Commentary

In the modern-day practice of medicine, turf wars are more common than one may realize. Presently, an ongoing battle over who should be prescribing and administering ketamine for novel treatment uses is being waged among psychiatrists, anesthesiologists, family physicians, and emergency physicians. Whoever emerges victorious will determine whether psychiatric care is administered in a safe and cost-effective manner, or if it will merely benefit the bottom line of the prescriber. In this article, we discuss how ketamine may have a role for treatment-resistant depression (TRD), and why psychiatrists are uniquely qualified to prescribe and administer this medication for this purpose.

New approaches to treatment-resistant depression

Antidepressant medications, long the mainstay of depression treatment, have been shown to be safe and relatively equally effective, with varying tolerability. However, 33% percent of patients do not achieve remission after 4 trials of antidepressant therapy.¹ Most antidepressant efficacy studies report remission rates of 35% to 40%,² which means many patients require subsequent switching and/or augmentation of their treatment.³ The STAR*D trial demonstrated that after 2 adequate antidepressant trials, the likelihood of remission diminishes.⁴

After a patient’s depression is found to be treatment-resistant, the onus of guiding treatment shifts away from the patient’s primary care physician to the more specialized psychiatrist. Few would question the suitability of a psychiatrist’s expertise in handling complicated and nuanced mental illness. In order to manage TRD, psychiatrists enter a terrain of emerging novel therapies with rapid onset, different mechanisms of action, and parenteral routes of administration.

One such therapy is esketamine, the S-enantiomer of ketamine. The FDA approved the intranasal (IN) formulation of esketamine in March 2019 after the medication had been designated as a breakthrough therapy for TRD in 2013 and studied in 6 Phase III clinical trials.⁵ The S-enantiomer of ketamine is known to bind to the N-methyl-D-aspartate receptor stronger than the R-enantiomer.⁶ The mechanism of action of both stereoisomers on other receptors, such as opioid and alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA), is the focus of intensive research and remains to be fully elucidated, but initial studies indicate rapid neuroplasticity and synaptogenesis.⁷ What is clear is that this new intervention can provide relief to patients with TRD via a pharmacologically distinct mechanism.⁸

Ketamine may be administered intranasally, intravenously, or orally. A meta-analysis aimed at assessing differences in ketamine efficacy for depression based on route of administration have shown that both IV and IN ketamine are effective, though it is not possible to draw conclusions regarding a direct comparison based on available data.⁹ Despite several landmark published studies, such as those by Zarate et al,¹⁰ IV ketamine is not FDA-approved for TRD.

Continue to: Why psychiatrists?

Psychiatrists have been prescribing IN esketamine, which is covered by most commercial insurances and administered in certified healthcare settings under a Risk Evaluation and Mitigation Strategy program.⁵ However, anesthesiologists and emergency physicians have opened a crop of boutique and concierge health clinics offering various “packages” of IV ketamine infusions for a slew of mental ailments, including depression, anxiety, bipolar disorder, and posttraumatic stress disorder.¹¹ Minimal investigation reveals that these services are being prescribed mainly by practitioners in fields other than psychiatry. Intravenous ketamine has long been used off-label as a treatment for depression not by psychiatrists but by practitioners of anesthesiology or emergency medicine. Although these clinicians are likely familiar with ketamine as an anesthetic, they have no foundation or expertise in the diagnosis and treatment of complex mood disorders. The FDA-approved indication for esketamine falls firmly in the realm of psychiatric treatment. Physicians who have not completed a psychiatry residency have neither the training nor experience necessary to determine whether a patient is a candidate for this treatment.

One potential adverse effect of ketamine is an emergence phenomenon, colloquially named a “K-hole,” that can induce symptoms of psychosis such as disturbing hallucinations. Patients who have a history of psychosis need to be carefully evaluated for appropriateness to receive this treatment.

Furthermore, ketamine treatments administered by physicians who are not psychiatrists are billed not through insurance but mostly via private pay. A patient may therefore be charged $350 to $1,000 per infusion, to be paid out of pocket.¹¹ Tally that up over the standard 6 to 12 initial treatment infusions, followed by maintenance infusions, and these patients with profound depression are potentially building up significant debt. Does this practice align with the ethical principles of autonomy, justice, beneficence, and nonmaleficence that all physicians swore to uphold? Will psychiatrists take a stand against the financial exploitation of a vulnerable group that is desperate to find any potential relief from their depression?

In the modern-day practice of medicine, turf wars are more common than one may realize. Presently, an ongoing battle over who should be prescribing and administering ketamine for novel treatment uses is being waged among psychiatrists, anesthesiologists, family physicians, and emergency physicians. Whoever emerges victorious will determine whether psychiatric care is administered in a safe and cost-effective manner, or if it will merely benefit the bottom line of the prescriber. In this article, we discuss how ketamine may have a role for treatment-resistant depression (TRD), and why psychiatrists are uniquely qualified to prescribe and administer this medication for this purpose.

New approaches to treatment-resistant depression

Antidepressant medications, long the mainstay of depression treatment, have been shown to be safe and relatively equally effective, with varying tolerability. However, 33% percent of patients do not achieve remission after 4 trials of antidepressant therapy.¹ Most antidepressant efficacy studies report remission rates of 35% to 40%,² which means many patients require subsequent switching and/or augmentation of their treatment.³ The STAR*D trial demonstrated that after 2 adequate antidepressant trials, the likelihood of remission diminishes.⁴

After a patient’s depression is found to be treatment-resistant, the onus of guiding treatment shifts away from the patient’s primary care physician to the more specialized psychiatrist. Few would question the suitability of a psychiatrist’s expertise in handling complicated and nuanced mental illness. In order to manage TRD, psychiatrists enter a terrain of emerging novel therapies with rapid onset, different mechanisms of action, and parenteral routes of administration.

One such therapy is esketamine, the S-enantiomer of ketamine. The FDA approved the intranasal (IN) formulation of esketamine in March 2019 after the medication had been designated as a breakthrough therapy for TRD in 2013 and studied in 6 Phase III clinical trials.⁵ The S-enantiomer of ketamine is known to bind to the N-methyl-D-aspartate receptor stronger than the R-enantiomer.⁶ The mechanism of action of both stereoisomers on other receptors, such as opioid and alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA), is the focus of intensive research and remains to be fully elucidated, but initial studies indicate rapid neuroplasticity and synaptogenesis.⁷ What is clear is that this new intervention can provide relief to patients with TRD via a pharmacologically distinct mechanism.⁸

Ketamine may be administered intranasally, intravenously, or orally. A meta-analysis aimed at assessing differences in ketamine efficacy for depression based on route of administration have shown that both IV and IN ketamine are effective, though it is not possible to draw conclusions regarding a direct comparison based on available data.⁹ Despite several landmark published studies, such as those by Zarate et al,¹⁰ IV ketamine is not FDA-approved for TRD.

Continue to: Why psychiatrists?

Psychiatrists have been prescribing IN esketamine, which is covered by most commercial insurances and administered in certified healthcare settings under a Risk Evaluation and Mitigation Strategy program.⁵ However, anesthesiologists and emergency physicians have opened a crop of boutique and concierge health clinics offering various “packages” of IV ketamine infusions for a slew of mental ailments, including depression, anxiety, bipolar disorder, and posttraumatic stress disorder.¹¹ Minimal investigation reveals that these services are being prescribed mainly by practitioners in fields other than psychiatry. Intravenous ketamine has long been used off-label as a treatment for depression not by psychiatrists but by practitioners of anesthesiology or emergency medicine. Although these clinicians are likely familiar with ketamine as an anesthetic, they have no foundation or expertise in the diagnosis and treatment of complex mood disorders. The FDA-approved indication for esketamine falls firmly in the realm of psychiatric treatment. Physicians who have not completed a psychiatry residency have neither the training nor experience necessary to determine whether a patient is a candidate for this treatment.

One potential adverse effect of ketamine is an emergence phenomenon, colloquially named a “K-hole,” that can induce symptoms of psychosis such as disturbing hallucinations. Patients who have a history of psychosis need to be carefully evaluated for appropriateness to receive this treatment.

Furthermore, ketamine treatments administered by physicians who are not psychiatrists are billed not through insurance but mostly via private pay. A patient may therefore be charged $350 to $1,000 per infusion, to be paid out of pocket.¹¹ Tally that up over the standard 6 to 12 initial treatment infusions, followed by maintenance infusions, and these patients with profound depression are potentially building up significant debt. Does this practice align with the ethical principles of autonomy, justice, beneficence, and nonmaleficence that all physicians swore to uphold? Will psychiatrists take a stand against the financial exploitation of a vulnerable group that is desperate to find any potential relief from their depression?

In the modern-day practice of medicine, turf wars are more common than one may realize. Presently, an ongoing battle over who should be prescribing and administering ketamine for novel treatment uses is being waged among psychiatrists, anesthesiologists, family physicians, and emergency physicians. Whoever emerges victorious will determine whether psychiatric care is administered in a safe and cost-effective manner, or if it will merely benefit the bottom line of the prescriber. In this article, we discuss how ketamine may have a role for treatment-resistant depression (TRD), and why psychiatrists are uniquely qualified to prescribe and administer this medication for this purpose.

New approaches to treatment-resistant depression

Antidepressant medications, long the mainstay of depression treatment, have been shown to be safe and relatively equally effective, with varying tolerability. However, 33% percent of patients do not achieve remission after 4 trials of antidepressant therapy.¹ Most antidepressant efficacy studies report remission rates of 35% to 40%,² which means many patients require subsequent switching and/or augmentation of their treatment.³ The STAR*D trial demonstrated that after 2 adequate antidepressant trials, the likelihood of remission diminishes.⁴

After a patient’s depression is found to be treatment-resistant, the onus of guiding treatment shifts away from the patient’s primary care physician to the more specialized psychiatrist. Few would question the suitability of a psychiatrist’s expertise in handling complicated and nuanced mental illness. In order to manage TRD, psychiatrists enter a terrain of emerging novel therapies with rapid onset, different mechanisms of action, and parenteral routes of administration.

One such therapy is esketamine, the S-enantiomer of ketamine. The FDA approved the intranasal (IN) formulation of esketamine in March 2019 after the medication had been designated as a breakthrough therapy for TRD in 2013 and studied in 6 Phase III clinical trials.⁵ The S-enantiomer of ketamine is known to bind to the N-methyl-D-aspartate receptor stronger than the R-enantiomer.⁶ The mechanism of action of both stereoisomers on other receptors, such as opioid and alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA), is the focus of intensive research and remains to be fully elucidated, but initial studies indicate rapid neuroplasticity and synaptogenesis.⁷ What is clear is that this new intervention can provide relief to patients with TRD via a pharmacologically distinct mechanism.⁸

Ketamine may be administered intranasally, intravenously, or orally. A meta-analysis aimed at assessing differences in ketamine efficacy for depression based on route of administration have shown that both IV and IN ketamine are effective, though it is not possible to draw conclusions regarding a direct comparison based on available data.⁹ Despite several landmark published studies, such as those by Zarate et al,¹⁰ IV ketamine is not FDA-approved for TRD.

Continue to: Why psychiatrists?

Psychiatrists have been prescribing IN esketamine, which is covered by most commercial insurances and administered in certified healthcare settings under a Risk Evaluation and Mitigation Strategy program.⁵ However, anesthesiologists and emergency physicians have opened a crop of boutique and concierge health clinics offering various “packages” of IV ketamine infusions for a slew of mental ailments, including depression, anxiety, bipolar disorder, and posttraumatic stress disorder.¹¹ Minimal investigation reveals that these services are being prescribed mainly by practitioners in fields other than psychiatry. Intravenous ketamine has long been used off-label as a treatment for depression not by psychiatrists but by practitioners of anesthesiology or emergency medicine. Although these clinicians are likely familiar with ketamine as an anesthetic, they have no foundation or expertise in the diagnosis and treatment of complex mood disorders. The FDA-approved indication for esketamine falls firmly in the realm of psychiatric treatment. Physicians who have not completed a psychiatry residency have neither the training nor experience necessary to determine whether a patient is a candidate for this treatment.

One potential adverse effect of ketamine is an emergence phenomenon, colloquially named a “K-hole,” that can induce symptoms of psychosis such as disturbing hallucinations. Patients who have a history of psychosis need to be carefully evaluated for appropriateness to receive this treatment.

Furthermore, ketamine treatments administered by physicians who are not psychiatrists are billed not through insurance but mostly via private pay. A patient may therefore be charged $350 to $1,000 per infusion, to be paid out of pocket.¹¹ Tally that up over the standard 6 to 12 initial treatment infusions, followed by maintenance infusions, and these patients with profound depression are potentially building up significant debt. Does this practice align with the ethical principles of autonomy, justice, beneficence, and nonmaleficence that all physicians swore to uphold? Will psychiatrists take a stand against the financial exploitation of a vulnerable group that is desperate to find any potential relief from their depression?

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.com.

The Accreditation Council for Graduate Medical Education (ACGME) is en­trusted with assuring that upon graduation every resident is a competent doctor, a trained professional, and prepared to practice in their own field at a level that assures patient safety and meets the standard of care. The American Board of Psychiatry and Neurology (ABPN) is a private company that sells certificates claiming to attest the capacity or competence of the doctor but does not make public the test questions or algorithms used to win its qualifications or approval. The certifying business and the newer Maintenance of Certification (MOC) process developed by ABPN have unfortunately been embraced by ACGME and many hospitals, despite the lack of any good scientific support that board certification or MOC are meaningful for quality of patient care or outcomes. By that I mean there is no evidence that the voluntary board certification process or MOC have been shown to produce better outcomes for patients, save money for the country drowning in an ocean of health care costs, or allow doctors to get paid at a higher level by insurers for the same billing codes compared with those who bill without possessing these qualifications. The only entity that “profits” from the board certification/MOC process is ABPN, a private corporation that is supposed to be a nonprofit, but was sitting on a treasury of more than $140M in assets in 2019,¹ with revenues growing annually. Including the interest earned on the investment and added revenues every year, the estimated total assets of ABPN will be in the range of $150M at the end of 2021!

Collaboration between ACGME and ABPN

The collaboration between ACGME and ABPN for graduate education for designing training programs for residents and fellows, with progressively increasing competencies and their assessments to dovetail with the board examinations offered by ABPN, sounds very legitimate. This arrangement is designed to enhance the quality of training and establish a minimum level of competence in each trainee who completes the training program. However, ACGME is catering to a monopoly recognized by the US Department of Justice (DOJ) Antitrust Division.² ACGME has not entertained other evaluators of competence to discourage competition to the monopolistic ABPN. ACGME is only involved with the accredited training programs and has no business in assessing the continued competence of graduated trainees after they leave the program, although most will voluntarily opt to become board-certified by ABPN. Maintenance of Certification definitely does not come within the purview of “graduate medical education” for ACGME to be getting drawn into this collaboration.

ACGME and ABPN are unregulated and are not member-driven. As such, they operate outside of any real oversight. Their power derives from the status given to them by hospitals, some insurers, and many of our colleagues, who fail to see the reality that they are nothing more than diploma shops.

I am board-certified in psychiatry and child and adolescent psychiatry, and I have participated in obtaining board certification by ABPN in 3 other subspecialties (geriatric, addiction, and forensic). I decided to not participate in MOC for the latter 3 subspecialty certifications beyond 10 and 20 years for my own practical reasons. Obviously, then, I am not at all against initial certifications in any specialty, nor am I opposed to practitioners keeping up with progress in their fields and maintaining their competence. I am opposed to the continued efforts to engage professionals to pay a high price for the repeated MOC, riding on the hard work and earnings of the graduated specialists and continuously suctioning their income over their careers, with no evidence that MOC measures clinical competence or patient outcomes of their subscribers, who pay a chunk of money to the American Board of Medical Specialties (ABMS)/ABPN annually and every 10 years.

MOC and the APA

Many American Psychiatric Association (APA) members are opposed to the APA giving ABPN a piggyback ride to accomplish this profit seeking. This is becoming obvious to many APA members, who see this as a great exploitation.

Over the last 6 years, physicians have begun to question the validity of board certification and MOC by ABPN, mostly as a response to ever-increasing costs to them and ever-increasing revenues to ABPN. While APA members have long pressed the APA to push back against ABPN, the APA Board of Trustees has done the opposite by accepting yearly “unrestricted educational grants” from ABPN. In this manner, ABPN has essentially silenced the APA and has made it ineffective as our member organization in what has become a fight against ABPN’s unchecked power, influence, and intrusion. Every poll conducted by every APA District Branch or subspecialty organization has shown widespread discontent and anger at the ABPN/MOC process and APA’s deliberate inaction. Even when the APA commissioned its own member survey on the topic, wrote the questions, picked who would get the survey, decided which responses to count, and determined what statistics to apply, the results were damning. Despite its obviously transparent machinations, the APA failed to glorify the MOC process.

Continue to: The APA's membership...

The APA’s membership is declining, and the Board of Trustee’s position on MOC is partly to blame. The APA is once again not listening to its members! As a membership-driven organization, the APA must not exclusively support and promote this commercial educational product termed MOC when other, less expensive alternatives are now available. The APA can easily endorse these alternatives, in addition to offering its own less expensive products for attesting maintenance of competence. The latter effort will help eliminate the monopoly held by ABMS/ABPN in this domain and please all members as well as the DOJ.

The APA’s failure to provide less expensive alternatives or at least endorse existing ones despite repeated requests from a large number of APA members has led to frustration and a surge of strong feelings that are expressed on the APA email listservs, and especially that of the MOC caucus. These expressions are legitimate and need to be publicized to the general membership. I have collected the opinions of various loyal, long-standing APA members and put together a separate, yet-unpublished article to drive home the point that APA has resisted breaking the monopoly of ABPN, which the DOJ would encourage organizations such as the APA to do. Instead, APA is acting as an enabler to ABPN to create a multi-million dollar (and eventually a billion dollar) monopolistic industry at their members’ expense, literally endangering the careers of members if they fail to participate when employed by institutions that overvalue the MOC offered by ABPN.

I believe the recent exhibition of “collaboration” between the APA and ABPN is not similar to that between ACGME and ABPN, but is a most blatant effort on the part of the APA to help ABPN build a billion-dollar educational industry over the next 10 to 15 years. One can easily lose sight of this and get lost in the intricacies of how candidates can maintain their competency by obtaining free CME credits. The APA is distracting its members by citing this. They will continue to pay a high price for certification and recertification, with no real discount.

Most of the APA’s 38,000 members are in the dark about the above-mentioned process. They need to do their own research, especially when there are alternatives to the ABPN’s MOC program. They need to insist that the APA stop exclusively promoting ABPN products, and publicize other, much cheaper, alternatives. It will please all APA members to see the ABPN’s monopoly vanish. This is especially the case for younger psychiatrists, who average nearly $250,000 in educational loans. They need to prevent the APA/ABPN collaboration from having a far-reaching effect on their careers and finances, with potentially destructive consequences for their families, employers and—most importantly—their patients. Even some state licensing boards are being tempted to buy into the illusion.

Stop this MOCkery.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.com.

The Accreditation Council for Graduate Medical Education (ACGME) is en­trusted with assuring that upon graduation every resident is a competent doctor, a trained professional, and prepared to practice in their own field at a level that assures patient safety and meets the standard of care. The American Board of Psychiatry and Neurology (ABPN) is a private company that sells certificates claiming to attest the capacity or competence of the doctor but does not make public the test questions or algorithms used to win its qualifications or approval. The certifying business and the newer Maintenance of Certification (MOC) process developed by ABPN have unfortunately been embraced by ACGME and many hospitals, despite the lack of any good scientific support that board certification or MOC are meaningful for quality of patient care or outcomes. By that I mean there is no evidence that the voluntary board certification process or MOC have been shown to produce better outcomes for patients, save money for the country drowning in an ocean of health care costs, or allow doctors to get paid at a higher level by insurers for the same billing codes compared with those who bill without possessing these qualifications. The only entity that “profits” from the board certification/MOC process is ABPN, a private corporation that is supposed to be a nonprofit, but was sitting on a treasury of more than $140M in assets in 2019,¹ with revenues growing annually. Including the interest earned on the investment and added revenues every year, the estimated total assets of ABPN will be in the range of $150M at the end of 2021!

Collaboration between ACGME and ABPN

The collaboration between ACGME and ABPN for graduate education for designing training programs for residents and fellows, with progressively increasing competencies and their assessments to dovetail with the board examinations offered by ABPN, sounds very legitimate. This arrangement is designed to enhance the quality of training and establish a minimum level of competence in each trainee who completes the training program. However, ACGME is catering to a monopoly recognized by the US Department of Justice (DOJ) Antitrust Division.² ACGME has not entertained other evaluators of competence to discourage competition to the monopolistic ABPN. ACGME is only involved with the accredited training programs and has no business in assessing the continued competence of graduated trainees after they leave the program, although most will voluntarily opt to become board-certified by ABPN. Maintenance of Certification definitely does not come within the purview of “graduate medical education” for ACGME to be getting drawn into this collaboration.

ACGME and ABPN are unregulated and are not member-driven. As such, they operate outside of any real oversight. Their power derives from the status given to them by hospitals, some insurers, and many of our colleagues, who fail to see the reality that they are nothing more than diploma shops.

I am board-certified in psychiatry and child and adolescent psychiatry, and I have participated in obtaining board certification by ABPN in 3 other subspecialties (geriatric, addiction, and forensic). I decided to not participate in MOC for the latter 3 subspecialty certifications beyond 10 and 20 years for my own practical reasons. Obviously, then, I am not at all against initial certifications in any specialty, nor am I opposed to practitioners keeping up with progress in their fields and maintaining their competence. I am opposed to the continued efforts to engage professionals to pay a high price for the repeated MOC, riding on the hard work and earnings of the graduated specialists and continuously suctioning their income over their careers, with no evidence that MOC measures clinical competence or patient outcomes of their subscribers, who pay a chunk of money to the American Board of Medical Specialties (ABMS)/ABPN annually and every 10 years.

MOC and the APA

Many American Psychiatric Association (APA) members are opposed to the APA giving ABPN a piggyback ride to accomplish this profit seeking. This is becoming obvious to many APA members, who see this as a great exploitation.

Over the last 6 years, physicians have begun to question the validity of board certification and MOC by ABPN, mostly as a response to ever-increasing costs to them and ever-increasing revenues to ABPN. While APA members have long pressed the APA to push back against ABPN, the APA Board of Trustees has done the opposite by accepting yearly “unrestricted educational grants” from ABPN. In this manner, ABPN has essentially silenced the APA and has made it ineffective as our member organization in what has become a fight against ABPN’s unchecked power, influence, and intrusion. Every poll conducted by every APA District Branch or subspecialty organization has shown widespread discontent and anger at the ABPN/MOC process and APA’s deliberate inaction. Even when the APA commissioned its own member survey on the topic, wrote the questions, picked who would get the survey, decided which responses to count, and determined what statistics to apply, the results were damning. Despite its obviously transparent machinations, the APA failed to glorify the MOC process.

Continue to: The APA's membership...

The APA’s membership is declining, and the Board of Trustee’s position on MOC is partly to blame. The APA is once again not listening to its members! As a membership-driven organization, the APA must not exclusively support and promote this commercial educational product termed MOC when other, less expensive alternatives are now available. The APA can easily endorse these alternatives, in addition to offering its own less expensive products for attesting maintenance of competence. The latter effort will help eliminate the monopoly held by ABMS/ABPN in this domain and please all members as well as the DOJ.

The APA’s failure to provide less expensive alternatives or at least endorse existing ones despite repeated requests from a large number of APA members has led to frustration and a surge of strong feelings that are expressed on the APA email listservs, and especially that of the MOC caucus. These expressions are legitimate and need to be publicized to the general membership. I have collected the opinions of various loyal, long-standing APA members and put together a separate, yet-unpublished article to drive home the point that APA has resisted breaking the monopoly of ABPN, which the DOJ would encourage organizations such as the APA to do. Instead, APA is acting as an enabler to ABPN to create a multi-million dollar (and eventually a billion dollar) monopolistic industry at their members’ expense, literally endangering the careers of members if they fail to participate when employed by institutions that overvalue the MOC offered by ABPN.

I believe the recent exhibition of “collaboration” between the APA and ABPN is not similar to that between ACGME and ABPN, but is a most blatant effort on the part of the APA to help ABPN build a billion-dollar educational industry over the next 10 to 15 years. One can easily lose sight of this and get lost in the intricacies of how candidates can maintain their competency by obtaining free CME credits. The APA is distracting its members by citing this. They will continue to pay a high price for certification and recertification, with no real discount.

Most of the APA’s 38,000 members are in the dark about the above-mentioned process. They need to do their own research, especially when there are alternatives to the ABPN’s MOC program. They need to insist that the APA stop exclusively promoting ABPN products, and publicize other, much cheaper, alternatives. It will please all APA members to see the ABPN’s monopoly vanish. This is especially the case for younger psychiatrists, who average nearly $250,000 in educational loans. They need to prevent the APA/ABPN collaboration from having a far-reaching effect on their careers and finances, with potentially destructive consequences for their families, employers and—most importantly—their patients. Even some state licensing boards are being tempted to buy into the illusion.

Stop this MOCkery.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.com.

The Accreditation Council for Graduate Medical Education (ACGME) is en­trusted with assuring that upon graduation every resident is a competent doctor, a trained professional, and prepared to practice in their own field at a level that assures patient safety and meets the standard of care. The American Board of Psychiatry and Neurology (ABPN) is a private company that sells certificates claiming to attest the capacity or competence of the doctor but does not make public the test questions or algorithms used to win its qualifications or approval. The certifying business and the newer Maintenance of Certification (MOC) process developed by ABPN have unfortunately been embraced by ACGME and many hospitals, despite the lack of any good scientific support that board certification or MOC are meaningful for quality of patient care or outcomes. By that I mean there is no evidence that the voluntary board certification process or MOC have been shown to produce better outcomes for patients, save money for the country drowning in an ocean of health care costs, or allow doctors to get paid at a higher level by insurers for the same billing codes compared with those who bill without possessing these qualifications. The only entity that “profits” from the board certification/MOC process is ABPN, a private corporation that is supposed to be a nonprofit, but was sitting on a treasury of more than $140M in assets in 2019,¹ with revenues growing annually. Including the interest earned on the investment and added revenues every year, the estimated total assets of ABPN will be in the range of $150M at the end of 2021!

Collaboration between ACGME and ABPN

The collaboration between ACGME and ABPN for graduate education for designing training programs for residents and fellows, with progressively increasing competencies and their assessments to dovetail with the board examinations offered by ABPN, sounds very legitimate. This arrangement is designed to enhance the quality of training and establish a minimum level of competence in each trainee who completes the training program. However, ACGME is catering to a monopoly recognized by the US Department of Justice (DOJ) Antitrust Division.² ACGME has not entertained other evaluators of competence to discourage competition to the monopolistic ABPN. ACGME is only involved with the accredited training programs and has no business in assessing the continued competence of graduated trainees after they leave the program, although most will voluntarily opt to become board-certified by ABPN. Maintenance of Certification definitely does not come within the purview of “graduate medical education” for ACGME to be getting drawn into this collaboration.

ACGME and ABPN are unregulated and are not member-driven. As such, they operate outside of any real oversight. Their power derives from the status given to them by hospitals, some insurers, and many of our colleagues, who fail to see the reality that they are nothing more than diploma shops.

I am board-certified in psychiatry and child and adolescent psychiatry, and I have participated in obtaining board certification by ABPN in 3 other subspecialties (geriatric, addiction, and forensic). I decided to not participate in MOC for the latter 3 subspecialty certifications beyond 10 and 20 years for my own practical reasons. Obviously, then, I am not at all against initial certifications in any specialty, nor am I opposed to practitioners keeping up with progress in their fields and maintaining their competence. I am opposed to the continued efforts to engage professionals to pay a high price for the repeated MOC, riding on the hard work and earnings of the graduated specialists and continuously suctioning their income over their careers, with no evidence that MOC measures clinical competence or patient outcomes of their subscribers, who pay a chunk of money to the American Board of Medical Specialties (ABMS)/ABPN annually and every 10 years.

MOC and the APA

Many American Psychiatric Association (APA) members are opposed to the APA giving ABPN a piggyback ride to accomplish this profit seeking. This is becoming obvious to many APA members, who see this as a great exploitation.

Over the last 6 years, physicians have begun to question the validity of board certification and MOC by ABPN, mostly as a response to ever-increasing costs to them and ever-increasing revenues to ABPN. While APA members have long pressed the APA to push back against ABPN, the APA Board of Trustees has done the opposite by accepting yearly “unrestricted educational grants” from ABPN. In this manner, ABPN has essentially silenced the APA and has made it ineffective as our member organization in what has become a fight against ABPN’s unchecked power, influence, and intrusion. Every poll conducted by every APA District Branch or subspecialty organization has shown widespread discontent and anger at the ABPN/MOC process and APA’s deliberate inaction. Even when the APA commissioned its own member survey on the topic, wrote the questions, picked who would get the survey, decided which responses to count, and determined what statistics to apply, the results were damning. Despite its obviously transparent machinations, the APA failed to glorify the MOC process.

Continue to: The APA's membership...

The APA’s membership is declining, and the Board of Trustee’s position on MOC is partly to blame. The APA is once again not listening to its members! As a membership-driven organization, the APA must not exclusively support and promote this commercial educational product termed MOC when other, less expensive alternatives are now available. The APA can easily endorse these alternatives, in addition to offering its own less expensive products for attesting maintenance of competence. The latter effort will help eliminate the monopoly held by ABMS/ABPN in this domain and please all members as well as the DOJ.

The APA’s failure to provide less expensive alternatives or at least endorse existing ones despite repeated requests from a large number of APA members has led to frustration and a surge of strong feelings that are expressed on the APA email listservs, and especially that of the MOC caucus. These expressions are legitimate and need to be publicized to the general membership. I have collected the opinions of various loyal, long-standing APA members and put together a separate, yet-unpublished article to drive home the point that APA has resisted breaking the monopoly of ABPN, which the DOJ would encourage organizations such as the APA to do. Instead, APA is acting as an enabler to ABPN to create a multi-million dollar (and eventually a billion dollar) monopolistic industry at their members’ expense, literally endangering the careers of members if they fail to participate when employed by institutions that overvalue the MOC offered by ABPN.

I believe the recent exhibition of “collaboration” between the APA and ABPN is not similar to that between ACGME and ABPN, but is a most blatant effort on the part of the APA to help ABPN build a billion-dollar educational industry over the next 10 to 15 years. One can easily lose sight of this and get lost in the intricacies of how candidates can maintain their competency by obtaining free CME credits. The APA is distracting its members by citing this. They will continue to pay a high price for certification and recertification, with no real discount.

Most of the APA’s 38,000 members are in the dark about the above-mentioned process. They need to do their own research, especially when there are alternatives to the ABPN’s MOC program. They need to insist that the APA stop exclusively promoting ABPN products, and publicize other, much cheaper, alternatives. It will please all APA members to see the ABPN’s monopoly vanish. This is especially the case for younger psychiatrists, who average nearly $250,000 in educational loans. They need to prevent the APA/ABPN collaboration from having a far-reaching effect on their careers and finances, with potentially destructive consequences for their families, employers and—most importantly—their patients. Even some state licensing boards are being tempted to buy into the illusion.

Stop this MOCkery.

This month, the current Editor-in-Chief and his Editorial Board will conclude our 5-year term. Megan Adams MD, JD, MSc, from the University of Michigan School of Medicine will assume my position. She has a stellar academic, research, and teaching record and is one of the best writers I know. She and her Board of Editors will carry on the tradition of GIHN.

The idea of an official newspaper of the AGA came from AGA staff in 2006. The goals of the newspaper were twofold: to communicate the latest news and information to practitioners to help them stay at the forefront of patient care and to develop another revenue stream for our society. The newspaper was launched in January 2007 with Charles Lightdale MD, AGAF, as the first editor and Colin W. Howden MD, AGAF, as the second (each with 5-year terms). While they wrote occasional editorials, I began writing 300-word essays for each issue. I have tried diligently to maintain a balanced viewpoint for all my editorials, although this has been difficult in the recent past and current national environment.

The paper evolved from a simple print publication to a multimedia communications vehicle that includes online-only content, videos, supplements, quizzes, and more. Last year, we published our first “Data Trends,” a supplement containing 10 or so brief articles written by content experts, covering current topics of high interest. As the paper evolved, we broadened our target audience to include research scientists, international practitioners and others interested in digestive diseases.

As I did last month, I would like to thank the AGA and Frontline Medical Communications staff for their dedication and constant work to bring you this newspaper.

Finally, I would like to pay tribute to Tadataka “Tachi” Yamada, who died this last month at the age of 76 years. He was one of the premier advocates for global health. His contributions to our field thru research, philanthropy, and leadership were enormous. We will miss him greatly.

John I Allen, MD, MBA, AGAF
Editor in Chief

This month, the current Editor-in-Chief and his Editorial Board will conclude our 5-year term. Megan Adams MD, JD, MSc, from the University of Michigan School of Medicine will assume my position. She has a stellar academic, research, and teaching record and is one of the best writers I know. She and her Board of Editors will carry on the tradition of GIHN.

The idea of an official newspaper of the AGA came from AGA staff in 2006. The goals of the newspaper were twofold: to communicate the latest news and information to practitioners to help them stay at the forefront of patient care and to develop another revenue stream for our society. The newspaper was launched in January 2007 with Charles Lightdale MD, AGAF, as the first editor and Colin W. Howden MD, AGAF, as the second (each with 5-year terms). While they wrote occasional editorials, I began writing 300-word essays for each issue. I have tried diligently to maintain a balanced viewpoint for all my editorials, although this has been difficult in the recent past and current national environment.

The paper evolved from a simple print publication to a multimedia communications vehicle that includes online-only content, videos, supplements, quizzes, and more. Last year, we published our first “Data Trends,” a supplement containing 10 or so brief articles written by content experts, covering current topics of high interest. As the paper evolved, we broadened our target audience to include research scientists, international practitioners and others interested in digestive diseases.

As I did last month, I would like to thank the AGA and Frontline Medical Communications staff for their dedication and constant work to bring you this newspaper.

Finally, I would like to pay tribute to Tadataka “Tachi” Yamada, who died this last month at the age of 76 years. He was one of the premier advocates for global health. His contributions to our field thru research, philanthropy, and leadership were enormous. We will miss him greatly.

John I Allen, MD, MBA, AGAF
Editor in Chief

This month, the current Editor-in-Chief and his Editorial Board will conclude our 5-year term. Megan Adams MD, JD, MSc, from the University of Michigan School of Medicine will assume my position. She has a stellar academic, research, and teaching record and is one of the best writers I know. She and her Board of Editors will carry on the tradition of GIHN.

The idea of an official newspaper of the AGA came from AGA staff in 2006. The goals of the newspaper were twofold: to communicate the latest news and information to practitioners to help them stay at the forefront of patient care and to develop another revenue stream for our society. The newspaper was launched in January 2007 with Charles Lightdale MD, AGAF, as the first editor and Colin W. Howden MD, AGAF, as the second (each with 5-year terms). While they wrote occasional editorials, I began writing 300-word essays for each issue. I have tried diligently to maintain a balanced viewpoint for all my editorials, although this has been difficult in the recent past and current national environment.

The paper evolved from a simple print publication to a multimedia communications vehicle that includes online-only content, videos, supplements, quizzes, and more. Last year, we published our first “Data Trends,” a supplement containing 10 or so brief articles written by content experts, covering current topics of high interest. As the paper evolved, we broadened our target audience to include research scientists, international practitioners and others interested in digestive diseases.

As I did last month, I would like to thank the AGA and Frontline Medical Communications staff for their dedication and constant work to bring you this newspaper.

Finally, I would like to pay tribute to Tadataka “Tachi” Yamada, who died this last month at the age of 76 years. He was one of the premier advocates for global health. His contributions to our field thru research, philanthropy, and leadership were enormous. We will miss him greatly.

John I Allen, MD, MBA, AGAF
Editor in Chief

Officer Scott Davis is a passionate man who thinks and talks quickly. As a member of the Special Events Team for Montgomery County, Maryland, he was already staging in Rockville, outside of Washington, D.C., when the call came in last Jan. 6 to move their unit to the U.S. Capitol. 

Courtesy Scott Davis

“It was surreal,” said Mr. Davis. “There were people from all different groups at the Capitol that day. Many people were trying to get out, but others surrounded us. They called us ‘human race traitors.’ And then I heard someone say, ‘It’s good you brought your shields, we’ll carry your bodies out on them.’”

Mr. Davis described hours of mayhem during which he was hit with bear spray, a brick, a chair, and a metal rod. One of the members of Mr. Davis’ unit remains on leave with a head injury nearly 9 months after the siege.  

“It went on for 3 hours, but it felt like 15 minutes. Then, all of a sudden, it was over.”

For the members of law enforcement at the Capitol that day, the repercussions are still being felt, perhaps most notably in the case of the four officers who subsequently died of suicide. Three of the officers were with the Metropolitan Police Department of the District of Columbia and one worked for the Capitol Police Department.

Police officers are subjected to traumas on a regular basis and often placed in circumstances where their lives are in danger. Yet four suicides within a short time – all connected to a single event – is particularly shocking and tragic, even more so for how little attention it has garnered to date.  
 

What contributes to the high rate of suicide among officers?

Scott Silverii, PhD, a former police officer and author of Broken and Blue: A Policeman’s Guide to Health, Hope, and Healing, commented that he “wouldn’t be surprised if there are more suicides to come.” This stems not only from the experiences of that day but also the elevated risk for suicide that law enforcement officers already experienced prior to the Capitol riots. Suicide remains a rare event, with a national all-population average of 13.9 per 100,000 citizens. But as Dr. Silverii noted, more officers die by suicide each year than are killed in the line of duty. 

“Suicide is a big part of police culture – officers are doers and fixers, and it is seen as being more honorable to take yourself out of the equation than it is to ask for help,” he said. “Most officers come in with past pain, and this is a situation where they are being overwhelmed and under-respected. At the same time, police culture is a closed culture, and it is not friendly to researchers.”

Another contributor is the frequency with which law enforcement officers are exposed to trauma, according to Vernon Herron, Director of Officer Safety and Wellness for the Baltimore City Police. 

“Suicide can be a direct result of trauma, and at some point you just can’t absorb it, and it leads to problems,” Mr. Herron said, citing the psychiatric and addiction issues that officers commonly experience.
 

Protecting the protectors

Mr. Herron and others are working to address these problems head-on.

“We are trying to identify employees exposed to trauma and to offer counseling and intervention,” he said, “Otherwise, everything else will fall short.”

Yet implementing such measures is no easy task, given the lack of a central oversight organization for law enforcement, said Sheldon Greenberg, PhD, a former police officer and professor of management in the School of Education at Johns Hopkins University, Baltimore.

“In the United States there is no such thing as ‘The Police.’ There is no one in a position to set policy, standards, or training mandates nationally,” he said. “There are approximately 18,000 police and sheriff departments in the country, and many of them are small. No one can compel law enforcement agencies to implement officer wellness and suicide prevention programs, make counseling available to officers, or train supervisors and peers to identify suicide ideation.”

Dr. Greenberg said a further barrier to helping police officers considering self-harm is posed by the fact that even if they do seek out counseling, there is no guarantee that it will remain confidential. 

“Support personnel have an obligation to report an officer who is thinking about committing suicide,” he said. “Many officers are concerned about this lack of confidentiality and that they may be branded if they seek help.”

Although Dr. Greenberg said many police officers are self-professed “action junkies,” even their unusually high capacity for stress is often tested by the realities of the job.  

“Increasing demands for service, shortages of personnel, misinformation about police, COVID-19, talk about restructuring policing with little concrete direction, increased exposure to violence, greater numbers of vulnerable people, and more take a toll over time,” he lamented. “In addition, we are in a recruiting crisis in law enforcement, and there are no standards to ensure the quality of psychological screening provided to applicants. Many officers will go through their entire career and never be screened again. We know little about the stresses and strains that officers bring to the job.”
 

After the siege

It is not clear how many police officers were present at the Capitol on Jan. 6. During the chaos of the day, reinforcements to the Capitol Police Department arrived from Washington D.C., Maryland, and Virginia, but no official numbers on responders were obtained; Mr. Davis thought it was likely that there were at least 1,000 law enforcement officers present. Those who did respond sustained an estimated 100 injuries, including an officer who died the next day. Of the officers who died by suicide, one died 3 days after, another died 9 days later, and two more died in July – numbers that contradict the notion that this is some coincidence. Officer Alexander Kettering, a colleague of Mr. Davis who has been with Montgomery County Police for 15 years, was among those tasked with protecting the Capitol on Jan. 6. The chaos, violence, and destruction of the day has stuck with him and continues to occupy his thoughts.

“I had a front-row seat to the whole thing. It was overwhelming, and I’ve never seen people this angry,” said Mr. Kettering. “There were people up on the veranda and on the scaffolding set up for the inauguration. They were smashing windows and throwing things into the crowd. It was insane. There were decent people coming up to us and saying they would pray for us, then others calling us traitors, telling us to stand down and join them.”

In the aftermath of the Capitol siege, Mr. Kettering watched in dismay as the narrative of the day’s events began to warp.

“At first there was a consensus that what happened was so wrong, and then the politics took over. People were saying it wasn’t as bad as the media said, that it really wasn’t that violent and those speaking out are traitors or political operatives. I relive it every day, and it’s hard to escape, even in casual conversation.”

He added that the days’ events were compounded by the already heightened tensions surrounding the national debate around policing.

“It’s been 18 months of stress, of anti-police movements, and there is a fine line between addressing police brutality and being anti-police,” Mr. Kettering said, noting that the aforementioned issues have all contributed to the ongoing struggles his fellow officers are experiencing. 

“It’s not a thing for cops to talk about how an event affected them,” he said. “A lot of officers have just shut down. People have careers and pensions to protect, and every time we stop a motorist, something could go wrong, even if we do everything right. There are mixed signals: They tell us, ‘Defend but don’t defend.’” 

His colleague, Mr. Davis, said that officers “need more support from politicians,” noting that he felt particularly insulted by a comment made by a Montgomery County public official who accused the officers present at the Capitol of racism. “And finally, we feel a little betrayed by the public.”
 

More questions than answers from the Capitol’s day of chaos

What about the events of Jan. 6 led to the suicides of four law enforcement officers and what can be done to prevent more deaths in the future? There are the individual factors of each man’s personal history, circumstances, and vulnerabilities, including the sense of being personally endangered, witnessing trauma, and direct injury – one officer who died of suicide had sustained a head injury that day.

We don’t know if the officers went into the event with preexisting mental illness or addiction or if the day’s events precipitated psychiatric episodes. And with all the partisan anger surrounding the presidential election, we don’t know if each officer’s political beliefs amplified his distress over what occurred in a social media climate where police are being faulted by all sides.

When multiple suicides occur in a community, there is always concern about a “copycat” phenomena. These concerns are made more difficult to address, however, given the police culture of taboo and stigma associated with getting professional help, difficulty accessing care, and career repercussions for speaking openly about suicidal thoughts and mental health issues.

Finally, there is the current political agenda that leaves officers feeling unsupported, fearful of negative outcomes, and unappreciated. The Capitol siege in particular embodied a great deal of national distress and confusion over basic issues of truth, justice, and perceptions of reality in our polarized society.  

Can we move to a place where those who enforce laws have easy access to treatment, free from stigma? Can we encourage a culture that does not tolerate brutality or racism, while also refusing to label all police as bad and lending support to their mission? Can we be more attuned to the repercussions of circumstances where officers are witnesses to trauma, are endangered themselves, and would benefit from acknowledgment of their distress? 

Time will tell if our anti-police pendulum swings back. In the meantime, these four suicides among people defending our country remain tragically overlooked.
 

Dinah Miller, MD, is coauthor of Committed: The Battle Over Involuntary Psychiatric Care (Johns Hopkins University Press, 2016). She has a private practice in Baltimore and is an assistant professor of psychiatry and behavioral sciences at Johns Hopkins University. A version of this article first appeared on Medscape.com.

Officer Scott Davis is a passionate man who thinks and talks quickly. As a member of the Special Events Team for Montgomery County, Maryland, he was already staging in Rockville, outside of Washington, D.C., when the call came in last Jan. 6 to move their unit to the U.S. Capitol. 

Courtesy Scott Davis

“It was surreal,” said Mr. Davis. “There were people from all different groups at the Capitol that day. Many people were trying to get out, but others surrounded us. They called us ‘human race traitors.’ And then I heard someone say, ‘It’s good you brought your shields, we’ll carry your bodies out on them.’”

Mr. Davis described hours of mayhem during which he was hit with bear spray, a brick, a chair, and a metal rod. One of the members of Mr. Davis’ unit remains on leave with a head injury nearly 9 months after the siege.  

“It went on for 3 hours, but it felt like 15 minutes. Then, all of a sudden, it was over.”

For the members of law enforcement at the Capitol that day, the repercussions are still being felt, perhaps most notably in the case of the four officers who subsequently died of suicide. Three of the officers were with the Metropolitan Police Department of the District of Columbia and one worked for the Capitol Police Department.

Police officers are subjected to traumas on a regular basis and often placed in circumstances where their lives are in danger. Yet four suicides within a short time – all connected to a single event – is particularly shocking and tragic, even more so for how little attention it has garnered to date.  
 

What contributes to the high rate of suicide among officers?

Scott Silverii, PhD, a former police officer and author of Broken and Blue: A Policeman’s Guide to Health, Hope, and Healing, commented that he “wouldn’t be surprised if there are more suicides to come.” This stems not only from the experiences of that day but also the elevated risk for suicide that law enforcement officers already experienced prior to the Capitol riots. Suicide remains a rare event, with a national all-population average of 13.9 per 100,000 citizens. But as Dr. Silverii noted, more officers die by suicide each year than are killed in the line of duty. 

“Suicide is a big part of police culture – officers are doers and fixers, and it is seen as being more honorable to take yourself out of the equation than it is to ask for help,” he said. “Most officers come in with past pain, and this is a situation where they are being overwhelmed and under-respected. At the same time, police culture is a closed culture, and it is not friendly to researchers.”

Another contributor is the frequency with which law enforcement officers are exposed to trauma, according to Vernon Herron, Director of Officer Safety and Wellness for the Baltimore City Police. 

“Suicide can be a direct result of trauma, and at some point you just can’t absorb it, and it leads to problems,” Mr. Herron said, citing the psychiatric and addiction issues that officers commonly experience.
 

Protecting the protectors

Mr. Herron and others are working to address these problems head-on.

“We are trying to identify employees exposed to trauma and to offer counseling and intervention,” he said, “Otherwise, everything else will fall short.”

Yet implementing such measures is no easy task, given the lack of a central oversight organization for law enforcement, said Sheldon Greenberg, PhD, a former police officer and professor of management in the School of Education at Johns Hopkins University, Baltimore.

“In the United States there is no such thing as ‘The Police.’ There is no one in a position to set policy, standards, or training mandates nationally,” he said. “There are approximately 18,000 police and sheriff departments in the country, and many of them are small. No one can compel law enforcement agencies to implement officer wellness and suicide prevention programs, make counseling available to officers, or train supervisors and peers to identify suicide ideation.”

Dr. Greenberg said a further barrier to helping police officers considering self-harm is posed by the fact that even if they do seek out counseling, there is no guarantee that it will remain confidential. 

“Support personnel have an obligation to report an officer who is thinking about committing suicide,” he said. “Many officers are concerned about this lack of confidentiality and that they may be branded if they seek help.”

Although Dr. Greenberg said many police officers are self-professed “action junkies,” even their unusually high capacity for stress is often tested by the realities of the job.  

“Increasing demands for service, shortages of personnel, misinformation about police, COVID-19, talk about restructuring policing with little concrete direction, increased exposure to violence, greater numbers of vulnerable people, and more take a toll over time,” he lamented. “In addition, we are in a recruiting crisis in law enforcement, and there are no standards to ensure the quality of psychological screening provided to applicants. Many officers will go through their entire career and never be screened again. We know little about the stresses and strains that officers bring to the job.”
 

After the siege

It is not clear how many police officers were present at the Capitol on Jan. 6. During the chaos of the day, reinforcements to the Capitol Police Department arrived from Washington D.C., Maryland, and Virginia, but no official numbers on responders were obtained; Mr. Davis thought it was likely that there were at least 1,000 law enforcement officers present. Those who did respond sustained an estimated 100 injuries, including an officer who died the next day. Of the officers who died by suicide, one died 3 days after, another died 9 days later, and two more died in July – numbers that contradict the notion that this is some coincidence. Officer Alexander Kettering, a colleague of Mr. Davis who has been with Montgomery County Police for 15 years, was among those tasked with protecting the Capitol on Jan. 6. The chaos, violence, and destruction of the day has stuck with him and continues to occupy his thoughts.

“I had a front-row seat to the whole thing. It was overwhelming, and I’ve never seen people this angry,” said Mr. Kettering. “There were people up on the veranda and on the scaffolding set up for the inauguration. They were smashing windows and throwing things into the crowd. It was insane. There were decent people coming up to us and saying they would pray for us, then others calling us traitors, telling us to stand down and join them.”

In the aftermath of the Capitol siege, Mr. Kettering watched in dismay as the narrative of the day’s events began to warp.

“At first there was a consensus that what happened was so wrong, and then the politics took over. People were saying it wasn’t as bad as the media said, that it really wasn’t that violent and those speaking out are traitors or political operatives. I relive it every day, and it’s hard to escape, even in casual conversation.”

He added that the days’ events were compounded by the already heightened tensions surrounding the national debate around policing.

“It’s been 18 months of stress, of anti-police movements, and there is a fine line between addressing police brutality and being anti-police,” Mr. Kettering said, noting that the aforementioned issues have all contributed to the ongoing struggles his fellow officers are experiencing. 

“It’s not a thing for cops to talk about how an event affected them,” he said. “A lot of officers have just shut down. People have careers and pensions to protect, and every time we stop a motorist, something could go wrong, even if we do everything right. There are mixed signals: They tell us, ‘Defend but don’t defend.’” 

His colleague, Mr. Davis, said that officers “need more support from politicians,” noting that he felt particularly insulted by a comment made by a Montgomery County public official who accused the officers present at the Capitol of racism. “And finally, we feel a little betrayed by the public.”
 

More questions than answers from the Capitol’s day of chaos

What about the events of Jan. 6 led to the suicides of four law enforcement officers and what can be done to prevent more deaths in the future? There are the individual factors of each man’s personal history, circumstances, and vulnerabilities, including the sense of being personally endangered, witnessing trauma, and direct injury – one officer who died of suicide had sustained a head injury that day.

We don’t know if the officers went into the event with preexisting mental illness or addiction or if the day’s events precipitated psychiatric episodes. And with all the partisan anger surrounding the presidential election, we don’t know if each officer’s political beliefs amplified his distress over what occurred in a social media climate where police are being faulted by all sides.

When multiple suicides occur in a community, there is always concern about a “copycat” phenomena. These concerns are made more difficult to address, however, given the police culture of taboo and stigma associated with getting professional help, difficulty accessing care, and career repercussions for speaking openly about suicidal thoughts and mental health issues.

Finally, there is the current political agenda that leaves officers feeling unsupported, fearful of negative outcomes, and unappreciated. The Capitol siege in particular embodied a great deal of national distress and confusion over basic issues of truth, justice, and perceptions of reality in our polarized society.  

Can we move to a place where those who enforce laws have easy access to treatment, free from stigma? Can we encourage a culture that does not tolerate brutality or racism, while also refusing to label all police as bad and lending support to their mission? Can we be more attuned to the repercussions of circumstances where officers are witnesses to trauma, are endangered themselves, and would benefit from acknowledgment of their distress? 

Time will tell if our anti-police pendulum swings back. In the meantime, these four suicides among people defending our country remain tragically overlooked.
 

Dinah Miller, MD, is coauthor of Committed: The Battle Over Involuntary Psychiatric Care (Johns Hopkins University Press, 2016). She has a private practice in Baltimore and is an assistant professor of psychiatry and behavioral sciences at Johns Hopkins University. A version of this article first appeared on Medscape.com.

Officer Scott Davis is a passionate man who thinks and talks quickly. As a member of the Special Events Team for Montgomery County, Maryland, he was already staging in Rockville, outside of Washington, D.C., when the call came in last Jan. 6 to move their unit to the U.S. Capitol. 

Courtesy Scott Davis

“It was surreal,” said Mr. Davis. “There were people from all different groups at the Capitol that day. Many people were trying to get out, but others surrounded us. They called us ‘human race traitors.’ And then I heard someone say, ‘It’s good you brought your shields, we’ll carry your bodies out on them.’”

Mr. Davis described hours of mayhem during which he was hit with bear spray, a brick, a chair, and a metal rod. One of the members of Mr. Davis’ unit remains on leave with a head injury nearly 9 months after the siege.  

“It went on for 3 hours, but it felt like 15 minutes. Then, all of a sudden, it was over.”

For the members of law enforcement at the Capitol that day, the repercussions are still being felt, perhaps most notably in the case of the four officers who subsequently died of suicide. Three of the officers were with the Metropolitan Police Department of the District of Columbia and one worked for the Capitol Police Department.

Police officers are subjected to traumas on a regular basis and often placed in circumstances where their lives are in danger. Yet four suicides within a short time – all connected to a single event – is particularly shocking and tragic, even more so for how little attention it has garnered to date.  
 

What contributes to the high rate of suicide among officers?

Scott Silverii, PhD, a former police officer and author of Broken and Blue: A Policeman’s Guide to Health, Hope, and Healing, commented that he “wouldn’t be surprised if there are more suicides to come.” This stems not only from the experiences of that day but also the elevated risk for suicide that law enforcement officers already experienced prior to the Capitol riots. Suicide remains a rare event, with a national all-population average of 13.9 per 100,000 citizens. But as Dr. Silverii noted, more officers die by suicide each year than are killed in the line of duty. 

“Suicide is a big part of police culture – officers are doers and fixers, and it is seen as being more honorable to take yourself out of the equation than it is to ask for help,” he said. “Most officers come in with past pain, and this is a situation where they are being overwhelmed and under-respected. At the same time, police culture is a closed culture, and it is not friendly to researchers.”

Another contributor is the frequency with which law enforcement officers are exposed to trauma, according to Vernon Herron, Director of Officer Safety and Wellness for the Baltimore City Police. 

“Suicide can be a direct result of trauma, and at some point you just can’t absorb it, and it leads to problems,” Mr. Herron said, citing the psychiatric and addiction issues that officers commonly experience.
 

Protecting the protectors

Mr. Herron and others are working to address these problems head-on.

“We are trying to identify employees exposed to trauma and to offer counseling and intervention,” he said, “Otherwise, everything else will fall short.”

Yet implementing such measures is no easy task, given the lack of a central oversight organization for law enforcement, said Sheldon Greenberg, PhD, a former police officer and professor of management in the School of Education at Johns Hopkins University, Baltimore.

“In the United States there is no such thing as ‘The Police.’ There is no one in a position to set policy, standards, or training mandates nationally,” he said. “There are approximately 18,000 police and sheriff departments in the country, and many of them are small. No one can compel law enforcement agencies to implement officer wellness and suicide prevention programs, make counseling available to officers, or train supervisors and peers to identify suicide ideation.”

Dr. Greenberg said a further barrier to helping police officers considering self-harm is posed by the fact that even if they do seek out counseling, there is no guarantee that it will remain confidential. 

“Support personnel have an obligation to report an officer who is thinking about committing suicide,” he said. “Many officers are concerned about this lack of confidentiality and that they may be branded if they seek help.”

Although Dr. Greenberg said many police officers are self-professed “action junkies,” even their unusually high capacity for stress is often tested by the realities of the job.  

“Increasing demands for service, shortages of personnel, misinformation about police, COVID-19, talk about restructuring policing with little concrete direction, increased exposure to violence, greater numbers of vulnerable people, and more take a toll over time,” he lamented. “In addition, we are in a recruiting crisis in law enforcement, and there are no standards to ensure the quality of psychological screening provided to applicants. Many officers will go through their entire career and never be screened again. We know little about the stresses and strains that officers bring to the job.”
 

After the siege

It is not clear how many police officers were present at the Capitol on Jan. 6. During the chaos of the day, reinforcements to the Capitol Police Department arrived from Washington D.C., Maryland, and Virginia, but no official numbers on responders were obtained; Mr. Davis thought it was likely that there were at least 1,000 law enforcement officers present. Those who did respond sustained an estimated 100 injuries, including an officer who died the next day. Of the officers who died by suicide, one died 3 days after, another died 9 days later, and two more died in July – numbers that contradict the notion that this is some coincidence. Officer Alexander Kettering, a colleague of Mr. Davis who has been with Montgomery County Police for 15 years, was among those tasked with protecting the Capitol on Jan. 6. The chaos, violence, and destruction of the day has stuck with him and continues to occupy his thoughts.

“I had a front-row seat to the whole thing. It was overwhelming, and I’ve never seen people this angry,” said Mr. Kettering. “There were people up on the veranda and on the scaffolding set up for the inauguration. They were smashing windows and throwing things into the crowd. It was insane. There were decent people coming up to us and saying they would pray for us, then others calling us traitors, telling us to stand down and join them.”

In the aftermath of the Capitol siege, Mr. Kettering watched in dismay as the narrative of the day’s events began to warp.

“At first there was a consensus that what happened was so wrong, and then the politics took over. People were saying it wasn’t as bad as the media said, that it really wasn’t that violent and those speaking out are traitors or political operatives. I relive it every day, and it’s hard to escape, even in casual conversation.”

He added that the days’ events were compounded by the already heightened tensions surrounding the national debate around policing.

“It’s been 18 months of stress, of anti-police movements, and there is a fine line between addressing police brutality and being anti-police,” Mr. Kettering said, noting that the aforementioned issues have all contributed to the ongoing struggles his fellow officers are experiencing. 

“It’s not a thing for cops to talk about how an event affected them,” he said. “A lot of officers have just shut down. People have careers and pensions to protect, and every time we stop a motorist, something could go wrong, even if we do everything right. There are mixed signals: They tell us, ‘Defend but don’t defend.’” 

His colleague, Mr. Davis, said that officers “need more support from politicians,” noting that he felt particularly insulted by a comment made by a Montgomery County public official who accused the officers present at the Capitol of racism. “And finally, we feel a little betrayed by the public.”
 

More questions than answers from the Capitol’s day of chaos

What about the events of Jan. 6 led to the suicides of four law enforcement officers and what can be done to prevent more deaths in the future? There are the individual factors of each man’s personal history, circumstances, and vulnerabilities, including the sense of being personally endangered, witnessing trauma, and direct injury – one officer who died of suicide had sustained a head injury that day.

We don’t know if the officers went into the event with preexisting mental illness or addiction or if the day’s events precipitated psychiatric episodes. And with all the partisan anger surrounding the presidential election, we don’t know if each officer’s political beliefs amplified his distress over what occurred in a social media climate where police are being faulted by all sides.

When multiple suicides occur in a community, there is always concern about a “copycat” phenomena. These concerns are made more difficult to address, however, given the police culture of taboo and stigma associated with getting professional help, difficulty accessing care, and career repercussions for speaking openly about suicidal thoughts and mental health issues.

Finally, there is the current political agenda that leaves officers feeling unsupported, fearful of negative outcomes, and unappreciated. The Capitol siege in particular embodied a great deal of national distress and confusion over basic issues of truth, justice, and perceptions of reality in our polarized society.  

Can we move to a place where those who enforce laws have easy access to treatment, free from stigma? Can we encourage a culture that does not tolerate brutality or racism, while also refusing to label all police as bad and lending support to their mission? Can we be more attuned to the repercussions of circumstances where officers are witnesses to trauma, are endangered themselves, and would benefit from acknowledgment of their distress? 

Time will tell if our anti-police pendulum swings back. In the meantime, these four suicides among people defending our country remain tragically overlooked.
 

Dinah Miller, MD, is coauthor of Committed: The Battle Over Involuntary Psychiatric Care (Johns Hopkins University Press, 2016). She has a private practice in Baltimore and is an assistant professor of psychiatry and behavioral sciences at Johns Hopkins University. A version of this article first appeared on Medscape.com.

After working two busy evening hospital shifts, I was eating breakfast with my children when I started reading about physicians confronted and verbally abused during school board meetings for advocating for face masks in school. The pandemic changed course with the Delta variant increasing hospitalizations, and it seems to me the public response to physicians and health care workers also changed.

During the first wave of the pandemic, public support accompanied health care workers’ sacrifices. Nightly applause rang through New York City, there were donations of food, and murals reflected public backing.

We as a nation rallied. We masked up and locked down. We produced vaccines. COVID cases decreased, and by spring, a hint of normalcy bloomed.

Then the virus changed, and the Delta variant spread. Pandemic fatigue set in. Health care workers asked for help with continued masking and increased vaccinations and instead were met with threats. The summer, already made difficult, makes the prospect of winter even more daunting.
 

This kind of abuse is persistent

Violence against health care workers is not a new dilemma. Stories abound of patients or family members physically attacking, verbally abusing, or harassing health care workers. A 2014 survey reported almost 80% of nurses attacked during their career. Data from the Bureau of Labor Statistics also reveals health care workers experience more nonfatal workplace violence, as compared with other professions.

Nurses, who often spend the most face-to-face time with patients, receive a litany of abuse. A 2019 nursing survey reported 59% of respondents experiencing verbal abuse from patients and more than 43% experiencing verbal abuse from patients’ families. Even more concerning is 23% of survey respondents reporting physical abuse, an increase from 20% in 2018.

Physicians, likewise, are not immune from the same maltreatment. A 2014 physician survey reported more than 71% of physicians in the United States have experienced at least one incident of workplace violence in their careers. Of the physician specialties, the highest rates of violence are in the emergency department and against less experienced physicians. This is likely caused by the higher rates of patient frustration in EDs as a result of long wait times, overcrowding, and boarding while awaiting an inpatient room.

These statistics are disheartening. However, what I find most discouraging is the almost submissive acceptance of this abuse in the health care field as almost 73% of health care workers feel that the abuse is part of the job.
 

COVID and the increase in violence against health care workers

The specter of COVID-19 has not only increased the problem of violence toward health care workers but has accelerated it at an alarming rate. As the Delta variant spreads, hospitals’ capacity to handle both COVID and non-COVID issues is further strained. Compounding this stress is the public’s pandemic fatigue and the ongoing battles with masking and vaccinations.

In San Antonio, health care workers faced verbal and physical abuse as they enforced masking and visitation restrictions for COVID patients. Online, health care workers, who advocate for masking or vaccination, are often subject to death threats, threats to family members, and verbal abuse on social media. Veiled threats of “we know who you are” and “we will find you” follow physicians who advocate for masking in schools.

This problem is not isolated to the United States. In Italy, a COVID patient spat at health care workers who asked them to wait, resulting in closure of an entire hospital ward. In the United Kingdom, health care workers were subject to the same abuse as those in San Antonio when trying to enforce masking in the hospital. In India, Pakistan, and Spain, a stigma exists against health care workers for being sources of contagion.

The presence of a growing divide between health care workers and those we serve threatens to undermine not only delivery of care but also our response to the pandemic. This is in addition to the mental health burden and compassion fatigue suffered by many health care workers who find their efforts in doubt. An already strained medical system will find it difficult to withstand the loss of its essential workforce.
 

Standing united against health care worker abuse

Despite the level of discord surrounding COVID-19, it is important that health care workers remain united. An effective response to the increase in violence toward health care workers will greatly depend on how we address the following.

First, we must actively work to combat the spread of misinformation that erodes the public trust in science and medicine. Transparency is paramount. Policy changes and plans for implementation should be open and free of political influence. This remains a challenge due to the CDC’s standing as both a federal and scientific institution. A steadfast and explicit presentation of scientific evidence by the CDC is a vital first step in repairing this trust.

In addition, we must become our own advocates. The passage of HR 1195, the Workplace Violence Prevention for Health Care and Social Service Workers Act, in the House of Representatives with bipartisan support is an indication that the time is ripe for sweeping change. Its supporters include the American Nurses Association, American Psychiatric Nurses Association, National Nurses United, and the American College of Emergency Physicians. Active opposition includes the American Hospital Association, which cites prohibitive cost as a source of objection.

HR 1195 now waits in the U.S. Senate for approval. We should alert local, state, and health system leadership to the violence against health care workers. We should demand increased protection for our most vulnerable colleagues in EDs and hospitals. Our advocacy will produce a paradigm shift away from the acceptance of this abuse.

Lastly, we must be mindful of compassion fatigue and health care worker burnout. Cynicism threatens to take away our greatest strengths of empathy and humanity. In our work environment, we must lift each other up and increase our awareness of when our colleagues need help. Self-care and creative outlets are encouraged. Admittedly, I am blogging as a personal safeguard against compassion fatigue and burnout.

The pandemic will have enduring implications both positive and negative. It is my hope that support for health care workers not only endures but is also enhanced long after the pandemic ends.

Giancarlo Toledanes, DO, is an assistant professor of pediatrics and a pediatric hospitalist at Texas Children’s Hospital and Baylor College of Medicine, both in Houston. He has no relevant financial conflicts of interest.

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

After working two busy evening hospital shifts, I was eating breakfast with my children when I started reading about physicians confronted and verbally abused during school board meetings for advocating for face masks in school. The pandemic changed course with the Delta variant increasing hospitalizations, and it seems to me the public response to physicians and health care workers also changed.

During the first wave of the pandemic, public support accompanied health care workers’ sacrifices. Nightly applause rang through New York City, there were donations of food, and murals reflected public backing.

We as a nation rallied. We masked up and locked down. We produced vaccines. COVID cases decreased, and by spring, a hint of normalcy bloomed.

Then the virus changed, and the Delta variant spread. Pandemic fatigue set in. Health care workers asked for help with continued masking and increased vaccinations and instead were met with threats. The summer, already made difficult, makes the prospect of winter even more daunting.
 

This kind of abuse is persistent

Violence against health care workers is not a new dilemma. Stories abound of patients or family members physically attacking, verbally abusing, or harassing health care workers. A 2014 survey reported almost 80% of nurses attacked during their career. Data from the Bureau of Labor Statistics also reveals health care workers experience more nonfatal workplace violence, as compared with other professions.

Nurses, who often spend the most face-to-face time with patients, receive a litany of abuse. A 2019 nursing survey reported 59% of respondents experiencing verbal abuse from patients and more than 43% experiencing verbal abuse from patients’ families. Even more concerning is 23% of survey respondents reporting physical abuse, an increase from 20% in 2018.

Physicians, likewise, are not immune from the same maltreatment. A 2014 physician survey reported more than 71% of physicians in the United States have experienced at least one incident of workplace violence in their careers. Of the physician specialties, the highest rates of violence are in the emergency department and against less experienced physicians. This is likely caused by the higher rates of patient frustration in EDs as a result of long wait times, overcrowding, and boarding while awaiting an inpatient room.

These statistics are disheartening. However, what I find most discouraging is the almost submissive acceptance of this abuse in the health care field as almost 73% of health care workers feel that the abuse is part of the job.
 

COVID and the increase in violence against health care workers

The specter of COVID-19 has not only increased the problem of violence toward health care workers but has accelerated it at an alarming rate. As the Delta variant spreads, hospitals’ capacity to handle both COVID and non-COVID issues is further strained. Compounding this stress is the public’s pandemic fatigue and the ongoing battles with masking and vaccinations.

In San Antonio, health care workers faced verbal and physical abuse as they enforced masking and visitation restrictions for COVID patients. Online, health care workers, who advocate for masking or vaccination, are often subject to death threats, threats to family members, and verbal abuse on social media. Veiled threats of “we know who you are” and “we will find you” follow physicians who advocate for masking in schools.

This problem is not isolated to the United States. In Italy, a COVID patient spat at health care workers who asked them to wait, resulting in closure of an entire hospital ward. In the United Kingdom, health care workers were subject to the same abuse as those in San Antonio when trying to enforce masking in the hospital. In India, Pakistan, and Spain, a stigma exists against health care workers for being sources of contagion.

The presence of a growing divide between health care workers and those we serve threatens to undermine not only delivery of care but also our response to the pandemic. This is in addition to the mental health burden and compassion fatigue suffered by many health care workers who find their efforts in doubt. An already strained medical system will find it difficult to withstand the loss of its essential workforce.
 

Standing united against health care worker abuse

Despite the level of discord surrounding COVID-19, it is important that health care workers remain united. An effective response to the increase in violence toward health care workers will greatly depend on how we address the following.

First, we must actively work to combat the spread of misinformation that erodes the public trust in science and medicine. Transparency is paramount. Policy changes and plans for implementation should be open and free of political influence. This remains a challenge due to the CDC’s standing as both a federal and scientific institution. A steadfast and explicit presentation of scientific evidence by the CDC is a vital first step in repairing this trust.

In addition, we must become our own advocates. The passage of HR 1195, the Workplace Violence Prevention for Health Care and Social Service Workers Act, in the House of Representatives with bipartisan support is an indication that the time is ripe for sweeping change. Its supporters include the American Nurses Association, American Psychiatric Nurses Association, National Nurses United, and the American College of Emergency Physicians. Active opposition includes the American Hospital Association, which cites prohibitive cost as a source of objection.

HR 1195 now waits in the U.S. Senate for approval. We should alert local, state, and health system leadership to the violence against health care workers. We should demand increased protection for our most vulnerable colleagues in EDs and hospitals. Our advocacy will produce a paradigm shift away from the acceptance of this abuse.

Lastly, we must be mindful of compassion fatigue and health care worker burnout. Cynicism threatens to take away our greatest strengths of empathy and humanity. In our work environment, we must lift each other up and increase our awareness of when our colleagues need help. Self-care and creative outlets are encouraged. Admittedly, I am blogging as a personal safeguard against compassion fatigue and burnout.

The pandemic will have enduring implications both positive and negative. It is my hope that support for health care workers not only endures but is also enhanced long after the pandemic ends.

Giancarlo Toledanes, DO, is an assistant professor of pediatrics and a pediatric hospitalist at Texas Children’s Hospital and Baylor College of Medicine, both in Houston. He has no relevant financial conflicts of interest.

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

After working two busy evening hospital shifts, I was eating breakfast with my children when I started reading about physicians confronted and verbally abused during school board meetings for advocating for face masks in school. The pandemic changed course with the Delta variant increasing hospitalizations, and it seems to me the public response to physicians and health care workers also changed.

During the first wave of the pandemic, public support accompanied health care workers’ sacrifices. Nightly applause rang through New York City, there were donations of food, and murals reflected public backing.

We as a nation rallied. We masked up and locked down. We produced vaccines. COVID cases decreased, and by spring, a hint of normalcy bloomed.

Then the virus changed, and the Delta variant spread. Pandemic fatigue set in. Health care workers asked for help with continued masking and increased vaccinations and instead were met with threats. The summer, already made difficult, makes the prospect of winter even more daunting.
 

This kind of abuse is persistent

Violence against health care workers is not a new dilemma. Stories abound of patients or family members physically attacking, verbally abusing, or harassing health care workers. A 2014 survey reported almost 80% of nurses attacked during their career. Data from the Bureau of Labor Statistics also reveals health care workers experience more nonfatal workplace violence, as compared with other professions.

Nurses, who often spend the most face-to-face time with patients, receive a litany of abuse. A 2019 nursing survey reported 59% of respondents experiencing verbal abuse from patients and more than 43% experiencing verbal abuse from patients’ families. Even more concerning is 23% of survey respondents reporting physical abuse, an increase from 20% in 2018.

Physicians, likewise, are not immune from the same maltreatment. A 2014 physician survey reported more than 71% of physicians in the United States have experienced at least one incident of workplace violence in their careers. Of the physician specialties, the highest rates of violence are in the emergency department and against less experienced physicians. This is likely caused by the higher rates of patient frustration in EDs as a result of long wait times, overcrowding, and boarding while awaiting an inpatient room.

These statistics are disheartening. However, what I find most discouraging is the almost submissive acceptance of this abuse in the health care field as almost 73% of health care workers feel that the abuse is part of the job.
 

COVID and the increase in violence against health care workers

The specter of COVID-19 has not only increased the problem of violence toward health care workers but has accelerated it at an alarming rate. As the Delta variant spreads, hospitals’ capacity to handle both COVID and non-COVID issues is further strained. Compounding this stress is the public’s pandemic fatigue and the ongoing battles with masking and vaccinations.

In San Antonio, health care workers faced verbal and physical abuse as they enforced masking and visitation restrictions for COVID patients. Online, health care workers, who advocate for masking or vaccination, are often subject to death threats, threats to family members, and verbal abuse on social media. Veiled threats of “we know who you are” and “we will find you” follow physicians who advocate for masking in schools.

This problem is not isolated to the United States. In Italy, a COVID patient spat at health care workers who asked them to wait, resulting in closure of an entire hospital ward. In the United Kingdom, health care workers were subject to the same abuse as those in San Antonio when trying to enforce masking in the hospital. In India, Pakistan, and Spain, a stigma exists against health care workers for being sources of contagion.

The presence of a growing divide between health care workers and those we serve threatens to undermine not only delivery of care but also our response to the pandemic. This is in addition to the mental health burden and compassion fatigue suffered by many health care workers who find their efforts in doubt. An already strained medical system will find it difficult to withstand the loss of its essential workforce.
 

Standing united against health care worker abuse

Despite the level of discord surrounding COVID-19, it is important that health care workers remain united. An effective response to the increase in violence toward health care workers will greatly depend on how we address the following.

First, we must actively work to combat the spread of misinformation that erodes the public trust in science and medicine. Transparency is paramount. Policy changes and plans for implementation should be open and free of political influence. This remains a challenge due to the CDC’s standing as both a federal and scientific institution. A steadfast and explicit presentation of scientific evidence by the CDC is a vital first step in repairing this trust.

In addition, we must become our own advocates. The passage of HR 1195, the Workplace Violence Prevention for Health Care and Social Service Workers Act, in the House of Representatives with bipartisan support is an indication that the time is ripe for sweeping change. Its supporters include the American Nurses Association, American Psychiatric Nurses Association, National Nurses United, and the American College of Emergency Physicians. Active opposition includes the American Hospital Association, which cites prohibitive cost as a source of objection.

HR 1195 now waits in the U.S. Senate for approval. We should alert local, state, and health system leadership to the violence against health care workers. We should demand increased protection for our most vulnerable colleagues in EDs and hospitals. Our advocacy will produce a paradigm shift away from the acceptance of this abuse.

Lastly, we must be mindful of compassion fatigue and health care worker burnout. Cynicism threatens to take away our greatest strengths of empathy and humanity. In our work environment, we must lift each other up and increase our awareness of when our colleagues need help. Self-care and creative outlets are encouraged. Admittedly, I am blogging as a personal safeguard against compassion fatigue and burnout.

The pandemic will have enduring implications both positive and negative. It is my hope that support for health care workers not only endures but is also enhanced long after the pandemic ends.

Giancarlo Toledanes, DO, is an assistant professor of pediatrics and a pediatric hospitalist at Texas Children’s Hospital and Baylor College of Medicine, both in Houston. He has no relevant financial conflicts of interest.

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

As politicians battle over masks and mandates, heated rhetoric has been used to describe the fourth heartbreaking surge in COVID as a “pandemic of the unvaccinated.”

While it may serve to further divide red and blue states, I disagree with the assertion that the current surge in cases is driven simply by the unvaccinated. Why? First, the premise would assume complete efficacy with our vaccinated population, which is statistically incorrect (at least 15 million of the U.S. population never completed a second round of injections), which means they were not considered “fully vaccinated.”

Alternately, we need to examine what has occurred in nations with significantly higher vaccination rates than ours (the United Kingdom and Israel) to realize that variants have overrun the dramatic success achieved in those countries as well. Israel, once considered to be the most vaccinated country in the world, is facing a brutal fourth wave of COVID that has sent the country spiraling into another heartbreaking lockdown.

The unvaccinated could hardly be blamed for what is happening in either of these highly vaccinated countries.
 

The concept of blame

So why use blame? It defeats the purpose of encouraging those who are hesitant or possibly misinformed or disenfranchised to move forward. It lacks compassion. It does not encompass the art and science of nursing (for example, the University of Southern Indiana), such as those that hospitals have used to frame optimal nursing care. I abhor the idea of labeling because it denies the prospect of future comprehension.

Labeling reminds me of one of the saddest cases in my career.
 

An unfortunate case

I was the nurse caring for a man from a motor vehicular accident where an entire family was brutally killed. My patient was alleged to be the cause, with a blood alcohol level of 0.40%+ post hydration, intubated and ventilated, with a flailed chest and multiple orthopedic injuries as well as blunt head trauma. He was secured to the bed with handcuffs, although that was unnecessary. Multiple times I was asked how I could possibly care for such an individual, by the police and even a few colleagues. But it was not my place to judge the man.

He was in pain, and he was dying. I comforted him for the 2 weeks it took his battered body to pass into the next realm. No one visited him except the police, eagerly waiting for the man to wake up to explain the tragic events that occurred. It was my job to ease what pain I could and protect him from labels. Did he deserve the labels? Who knew? I did not care. I cared about his writhing and his physical anguish.
 

The comparison

Blame did not help the situation then, nor does it help us move forward now. As nurses, we seek to work within a framework of understanding. As we tire of caring for thousands of COVID patients, we do not stop to ask if they “deserve” care or if they have taken precautions and lived reasonably prior to seeking assistance for disease. We would not be nurses if we did this.

Think about Gov. Greg Abbott, who has asked that Texans not be allowed to mandate masks for children returning to school. He has recently been diagnosed with COVID, despite assuring the public he is fully vaccinated. Politically, his diagnosis could be visualized as a fiasco for a purple state where he has been adamant in denying the efficacy of masks for children.

Yet, his diagnosis should not be fodder for the press. The first concern should be his health and well-being, similar for any man of his age and potential comorbidity.
 

Conclusion

We should be people first, human beings that remain interconnected by our need for care and survival, not conservatives, independents, or liberals, not “vaccinated or unvaccinated,” not seen as “breakthrough” infections, or the immunosuppressed possibly unable to mount a robust response to COVID.

Labels do not define the ability to effectively defeat coronavirus or variants, as highly vaccinated countries have demonstrated in recent months. We are in the midst of a global pandemic, and the battle is raging onward.

In fact, the longer this pandemic continues, the more likely it is we will need to live with this as an endemic disease, so we should stop blaming those who become ill and need support.

It could be any of us.

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

As politicians battle over masks and mandates, heated rhetoric has been used to describe the fourth heartbreaking surge in COVID as a “pandemic of the unvaccinated.”

While it may serve to further divide red and blue states, I disagree with the assertion that the current surge in cases is driven simply by the unvaccinated. Why? First, the premise would assume complete efficacy with our vaccinated population, which is statistically incorrect (at least 15 million of the U.S. population never completed a second round of injections), which means they were not considered “fully vaccinated.”

Alternately, we need to examine what has occurred in nations with significantly higher vaccination rates than ours (the United Kingdom and Israel) to realize that variants have overrun the dramatic success achieved in those countries as well. Israel, once considered to be the most vaccinated country in the world, is facing a brutal fourth wave of COVID that has sent the country spiraling into another heartbreaking lockdown.

The unvaccinated could hardly be blamed for what is happening in either of these highly vaccinated countries.
 

The concept of blame

So why use blame? It defeats the purpose of encouraging those who are hesitant or possibly misinformed or disenfranchised to move forward. It lacks compassion. It does not encompass the art and science of nursing (for example, the University of Southern Indiana), such as those that hospitals have used to frame optimal nursing care. I abhor the idea of labeling because it denies the prospect of future comprehension.

Labeling reminds me of one of the saddest cases in my career.
 

An unfortunate case

I was the nurse caring for a man from a motor vehicular accident where an entire family was brutally killed. My patient was alleged to be the cause, with a blood alcohol level of 0.40%+ post hydration, intubated and ventilated, with a flailed chest and multiple orthopedic injuries as well as blunt head trauma. He was secured to the bed with handcuffs, although that was unnecessary. Multiple times I was asked how I could possibly care for such an individual, by the police and even a few colleagues. But it was not my place to judge the man.

He was in pain, and he was dying. I comforted him for the 2 weeks it took his battered body to pass into the next realm. No one visited him except the police, eagerly waiting for the man to wake up to explain the tragic events that occurred. It was my job to ease what pain I could and protect him from labels. Did he deserve the labels? Who knew? I did not care. I cared about his writhing and his physical anguish.
 

The comparison

Blame did not help the situation then, nor does it help us move forward now. As nurses, we seek to work within a framework of understanding. As we tire of caring for thousands of COVID patients, we do not stop to ask if they “deserve” care or if they have taken precautions and lived reasonably prior to seeking assistance for disease. We would not be nurses if we did this.

Think about Gov. Greg Abbott, who has asked that Texans not be allowed to mandate masks for children returning to school. He has recently been diagnosed with COVID, despite assuring the public he is fully vaccinated. Politically, his diagnosis could be visualized as a fiasco for a purple state where he has been adamant in denying the efficacy of masks for children.

Yet, his diagnosis should not be fodder for the press. The first concern should be his health and well-being, similar for any man of his age and potential comorbidity.
 

Conclusion

We should be people first, human beings that remain interconnected by our need for care and survival, not conservatives, independents, or liberals, not “vaccinated or unvaccinated,” not seen as “breakthrough” infections, or the immunosuppressed possibly unable to mount a robust response to COVID.

Labels do not define the ability to effectively defeat coronavirus or variants, as highly vaccinated countries have demonstrated in recent months. We are in the midst of a global pandemic, and the battle is raging onward.

In fact, the longer this pandemic continues, the more likely it is we will need to live with this as an endemic disease, so we should stop blaming those who become ill and need support.

It could be any of us.

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

As politicians battle over masks and mandates, heated rhetoric has been used to describe the fourth heartbreaking surge in COVID as a “pandemic of the unvaccinated.”

While it may serve to further divide red and blue states, I disagree with the assertion that the current surge in cases is driven simply by the unvaccinated. Why? First, the premise would assume complete efficacy with our vaccinated population, which is statistically incorrect (at least 15 million of the U.S. population never completed a second round of injections), which means they were not considered “fully vaccinated.”

Alternately, we need to examine what has occurred in nations with significantly higher vaccination rates than ours (the United Kingdom and Israel) to realize that variants have overrun the dramatic success achieved in those countries as well. Israel, once considered to be the most vaccinated country in the world, is facing a brutal fourth wave of COVID that has sent the country spiraling into another heartbreaking lockdown.

The unvaccinated could hardly be blamed for what is happening in either of these highly vaccinated countries.
 

The concept of blame

So why use blame? It defeats the purpose of encouraging those who are hesitant or possibly misinformed or disenfranchised to move forward. It lacks compassion. It does not encompass the art and science of nursing (for example, the University of Southern Indiana), such as those that hospitals have used to frame optimal nursing care. I abhor the idea of labeling because it denies the prospect of future comprehension.

Labeling reminds me of one of the saddest cases in my career.
 

An unfortunate case

I was the nurse caring for a man from a motor vehicular accident where an entire family was brutally killed. My patient was alleged to be the cause, with a blood alcohol level of 0.40%+ post hydration, intubated and ventilated, with a flailed chest and multiple orthopedic injuries as well as blunt head trauma. He was secured to the bed with handcuffs, although that was unnecessary. Multiple times I was asked how I could possibly care for such an individual, by the police and even a few colleagues. But it was not my place to judge the man.

He was in pain, and he was dying. I comforted him for the 2 weeks it took his battered body to pass into the next realm. No one visited him except the police, eagerly waiting for the man to wake up to explain the tragic events that occurred. It was my job to ease what pain I could and protect him from labels. Did he deserve the labels? Who knew? I did not care. I cared about his writhing and his physical anguish.
 

The comparison

Blame did not help the situation then, nor does it help us move forward now. As nurses, we seek to work within a framework of understanding. As we tire of caring for thousands of COVID patients, we do not stop to ask if they “deserve” care or if they have taken precautions and lived reasonably prior to seeking assistance for disease. We would not be nurses if we did this.

Think about Gov. Greg Abbott, who has asked that Texans not be allowed to mandate masks for children returning to school. He has recently been diagnosed with COVID, despite assuring the public he is fully vaccinated. Politically, his diagnosis could be visualized as a fiasco for a purple state where he has been adamant in denying the efficacy of masks for children.

Yet, his diagnosis should not be fodder for the press. The first concern should be his health and well-being, similar for any man of his age and potential comorbidity.
 

Conclusion

We should be people first, human beings that remain interconnected by our need for care and survival, not conservatives, independents, or liberals, not “vaccinated or unvaccinated,” not seen as “breakthrough” infections, or the immunosuppressed possibly unable to mount a robust response to COVID.

Labels do not define the ability to effectively defeat coronavirus or variants, as highly vaccinated countries have demonstrated in recent months. We are in the midst of a global pandemic, and the battle is raging onward.

In fact, the longer this pandemic continues, the more likely it is we will need to live with this as an endemic disease, so we should stop blaming those who become ill and need support.

It could be any of us.

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

Since the reversal of the Medicare exclusion in 2014, the rates of gender-affirming surgery have increased markedly in the United States.¹ Gender-affirming mastectomy, otherwise known as “top surgery,” is one of the more commonly performed procedures; with 97% of patients having either undergone or expressed desire for the surgery.² The goals of this procedure are to remove all visible breast tissue and reconstruct the chest wall so it is more masculine in appearance. For transmasculine and nonbinary patients, this procedure is associated with significant improvements in mental health and quality of life.^3,4 While the mastectomy procedure is often performed by plastic surgeons, patients will see an ob.gyn. in the preoperative or postoperative period. Ob.gyns. should have a general understanding of the procedure, but most importantly know how to screen for breast cancer in patients who have undergone a gender-affirming mastectomy.

Providers will likely encounter transmasculine or nonbinary patients during annual screening examinations or for a preoperative exam. If a patient is seeking a preoperative risk assessment prior to undergoing a gender-affirming mastectomy, assessing a patient’s risk status for breast cancer is paramount. While testosterone therapy is no longer a prerequisite for gender-affirming mastectomies, documenting hormone use, age at initiation, and dosage is important.⁵ The overall effects of testosterone on breast tissue are inconsistent. However, studies have demonstrated that patients taking testosterone are not at an increased risk of breast cancer secondary to testosterone use.^5-7 Patients should be asked about a personal of family history of breast cancer, breast surgery, history of prior breast biopsies, parity, age at menarche, smoking status, and breastfeeding history if applicable. Patients with high-risk mutations or a strong family history of breast cancer should be referred to genetic counselors, surgical oncologists, and possibly undergo genetic testing.⁸ Before an examination, providers should counsel patients about the nature of the examination and use gender-neutral language such as “chest” to avoid exacerbating gender dysphoria.

It is important to educate transmasculine patients about their risk for the development of breast cancer after mastectomy. Larger-scale, population-based studies of breast cancer in the transgender population have reported an incidence of 5.9 per 100,000 patients-years and an overall incidence comparable to cisgender men in age-standardized national samples.^5-7 Unfortunately, data on the rates of breast cancer in transmasculine patients after gender-affirming mastectomy are limited, which makes defining postoperative guidelines challenging. Additionally, the amount of residual breast tissue remaining varies based on the surgeon and technique.

Several techniques are described for mastectomy procedures with differences that can affect the amount of residual breast tissue. The most common type of gender-affirming mastectomy is the double incision. With this procedure, the nipple-areolar complex is reduced in size, removed, and thinned to improve graft take. Dissection is then carried to the level of the breast capsule and the breast tissue and axillary tail are removed en bloc.⁵ During the dissection, the subcutaneous fat is left on the skin flap to provide appropriate contour and to avoid creating a concave-appearing chest wall. Prior to closure, the superior and inferior flaps are inspected for any visible residual breast tissue, which is removed if needed. In a circumareolar mastectomy, the nipple-areolar complex is also reduced but is preserved on a 1- to 1.5-cm-thick pedicle to maintain perfusion.⁵ The mastectomy is performed through an inferior periareolar incision and all visible breast tissue and the axillary tail are removed. Breast tissue specimens are sent for pathologic evaluation at the end of the procedure.

Following gender-affirming mastectomy, there is limited evidence to guide screening. During the patient visit, the provider should obtain a thorough history regarding mastectomy type, and if unknown, attempt to acquire the operative report detailing the procedure. For low-risk patients who undergo a subcutaneous mastectomy such as the double incision or circumareolar technique, screening mammography is not indicated nor is it technically feasible.⁹ For patients with a high-risk genetic mutation or a strong family history of breast cancer, monitoring with alternative modalities such as breast ultrasound or breast MRI may be beneficial, although there is no evidence to currently support this suggestion. Given the variety of surgical techniques of breast tissue removal, it is difficult to develop strong evidence-based guidelines. Annual chest wall examinations have been suggested as a screening modality; however, the clinical utility of clinical breast and chest exams has been debated and is no longer recommended as a screening method in cisgender patients.⁹ Clinicians can promote chest self-awareness and discuss the possibility of breast cancer in postmastectomy patients at annual examination visits. As research continues to resolve some of these unknowns, it is important that patients are informed of these areas of ambiguity and updated regarding any changes in screening recommendations.¹⁰

Dr. Brandt is an ob.gyn. and fellowship-trained gender affirming surgeon in West Reading, Pa.

References

1. American Society of Plastic Surgeons. 2018 plastic surgery statistics report. https://www.plasticsurgery.org/documents/News/Statistics/2018/plastic-surgery-statistics-full-report-2018.pdf. Accessed Aug. 20, 2021.

2. James SE et al. The report of the 2015 U.S. Transgender survey. Washington, D.C.: National Center for Transgender Equality, 2016.

3. Agarwal CA et al. J Plast Reconstr Aesthet Surg. 2018;71:651-7.

4. Poudrier G et al. Plast Reconstr Surg. 2018;80:679-83.

5. Salibian AA et al. Plast Reconstr Surg. 2020;147:213e-21e.

6. Gooren LJ et al. J Sex Med. 2013;10:3129-34.

7. Brown GR and Jones KT. Breast Cancer Res Treat. 2015;149:191-8.

8. Deutsch MF et al. Semin Reprod Med. 2017;35:434-41.

9. Phillips J et al. AJR Am J Roentgenol. 2014;202:1149-59.

10. Smith RA et al. CA Cancer J Clin. 2018;68:297-316.

Since the reversal of the Medicare exclusion in 2014, the rates of gender-affirming surgery have increased markedly in the United States.¹ Gender-affirming mastectomy, otherwise known as “top surgery,” is one of the more commonly performed procedures; with 97% of patients having either undergone or expressed desire for the surgery.² The goals of this procedure are to remove all visible breast tissue and reconstruct the chest wall so it is more masculine in appearance. For transmasculine and nonbinary patients, this procedure is associated with significant improvements in mental health and quality of life.^3,4 While the mastectomy procedure is often performed by plastic surgeons, patients will see an ob.gyn. in the preoperative or postoperative period. Ob.gyns. should have a general understanding of the procedure, but most importantly know how to screen for breast cancer in patients who have undergone a gender-affirming mastectomy.

Providers will likely encounter transmasculine or nonbinary patients during annual screening examinations or for a preoperative exam. If a patient is seeking a preoperative risk assessment prior to undergoing a gender-affirming mastectomy, assessing a patient’s risk status for breast cancer is paramount. While testosterone therapy is no longer a prerequisite for gender-affirming mastectomies, documenting hormone use, age at initiation, and dosage is important.⁵ The overall effects of testosterone on breast tissue are inconsistent. However, studies have demonstrated that patients taking testosterone are not at an increased risk of breast cancer secondary to testosterone use.^5-7 Patients should be asked about a personal of family history of breast cancer, breast surgery, history of prior breast biopsies, parity, age at menarche, smoking status, and breastfeeding history if applicable. Patients with high-risk mutations or a strong family history of breast cancer should be referred to genetic counselors, surgical oncologists, and possibly undergo genetic testing.⁸ Before an examination, providers should counsel patients about the nature of the examination and use gender-neutral language such as “chest” to avoid exacerbating gender dysphoria.

It is important to educate transmasculine patients about their risk for the development of breast cancer after mastectomy. Larger-scale, population-based studies of breast cancer in the transgender population have reported an incidence of 5.9 per 100,000 patients-years and an overall incidence comparable to cisgender men in age-standardized national samples.^5-7 Unfortunately, data on the rates of breast cancer in transmasculine patients after gender-affirming mastectomy are limited, which makes defining postoperative guidelines challenging. Additionally, the amount of residual breast tissue remaining varies based on the surgeon and technique.

Several techniques are described for mastectomy procedures with differences that can affect the amount of residual breast tissue. The most common type of gender-affirming mastectomy is the double incision. With this procedure, the nipple-areolar complex is reduced in size, removed, and thinned to improve graft take. Dissection is then carried to the level of the breast capsule and the breast tissue and axillary tail are removed en bloc.⁵ During the dissection, the subcutaneous fat is left on the skin flap to provide appropriate contour and to avoid creating a concave-appearing chest wall. Prior to closure, the superior and inferior flaps are inspected for any visible residual breast tissue, which is removed if needed. In a circumareolar mastectomy, the nipple-areolar complex is also reduced but is preserved on a 1- to 1.5-cm-thick pedicle to maintain perfusion.⁵ The mastectomy is performed through an inferior periareolar incision and all visible breast tissue and the axillary tail are removed. Breast tissue specimens are sent for pathologic evaluation at the end of the procedure.

Following gender-affirming mastectomy, there is limited evidence to guide screening. During the patient visit, the provider should obtain a thorough history regarding mastectomy type, and if unknown, attempt to acquire the operative report detailing the procedure. For low-risk patients who undergo a subcutaneous mastectomy such as the double incision or circumareolar technique, screening mammography is not indicated nor is it technically feasible.⁹ For patients with a high-risk genetic mutation or a strong family history of breast cancer, monitoring with alternative modalities such as breast ultrasound or breast MRI may be beneficial, although there is no evidence to currently support this suggestion. Given the variety of surgical techniques of breast tissue removal, it is difficult to develop strong evidence-based guidelines. Annual chest wall examinations have been suggested as a screening modality; however, the clinical utility of clinical breast and chest exams has been debated and is no longer recommended as a screening method in cisgender patients.⁹ Clinicians can promote chest self-awareness and discuss the possibility of breast cancer in postmastectomy patients at annual examination visits. As research continues to resolve some of these unknowns, it is important that patients are informed of these areas of ambiguity and updated regarding any changes in screening recommendations.¹⁰

Dr. Brandt is an ob.gyn. and fellowship-trained gender affirming surgeon in West Reading, Pa.

References

1. American Society of Plastic Surgeons. 2018 plastic surgery statistics report. https://www.plasticsurgery.org/documents/News/Statistics/2018/plastic-surgery-statistics-full-report-2018.pdf. Accessed Aug. 20, 2021.

2. James SE et al. The report of the 2015 U.S. Transgender survey. Washington, D.C.: National Center for Transgender Equality, 2016.

3. Agarwal CA et al. J Plast Reconstr Aesthet Surg. 2018;71:651-7.

4. Poudrier G et al. Plast Reconstr Surg. 2018;80:679-83.

5. Salibian AA et al. Plast Reconstr Surg. 2020;147:213e-21e.

6. Gooren LJ et al. J Sex Med. 2013;10:3129-34.

7. Brown GR and Jones KT. Breast Cancer Res Treat. 2015;149:191-8.

8. Deutsch MF et al. Semin Reprod Med. 2017;35:434-41.

9. Phillips J et al. AJR Am J Roentgenol. 2014;202:1149-59.

10. Smith RA et al. CA Cancer J Clin. 2018;68:297-316.

Since the reversal of the Medicare exclusion in 2014, the rates of gender-affirming surgery have increased markedly in the United States.¹ Gender-affirming mastectomy, otherwise known as “top surgery,” is one of the more commonly performed procedures; with 97% of patients having either undergone or expressed desire for the surgery.² The goals of this procedure are to remove all visible breast tissue and reconstruct the chest wall so it is more masculine in appearance. For transmasculine and nonbinary patients, this procedure is associated with significant improvements in mental health and quality of life.^3,4 While the mastectomy procedure is often performed by plastic surgeons, patients will see an ob.gyn. in the preoperative or postoperative period. Ob.gyns. should have a general understanding of the procedure, but most importantly know how to screen for breast cancer in patients who have undergone a gender-affirming mastectomy.

Providers will likely encounter transmasculine or nonbinary patients during annual screening examinations or for a preoperative exam. If a patient is seeking a preoperative risk assessment prior to undergoing a gender-affirming mastectomy, assessing a patient’s risk status for breast cancer is paramount. While testosterone therapy is no longer a prerequisite for gender-affirming mastectomies, documenting hormone use, age at initiation, and dosage is important.⁵ The overall effects of testosterone on breast tissue are inconsistent. However, studies have demonstrated that patients taking testosterone are not at an increased risk of breast cancer secondary to testosterone use.^5-7 Patients should be asked about a personal of family history of breast cancer, breast surgery, history of prior breast biopsies, parity, age at menarche, smoking status, and breastfeeding history if applicable. Patients with high-risk mutations or a strong family history of breast cancer should be referred to genetic counselors, surgical oncologists, and possibly undergo genetic testing.⁸ Before an examination, providers should counsel patients about the nature of the examination and use gender-neutral language such as “chest” to avoid exacerbating gender dysphoria.

It is important to educate transmasculine patients about their risk for the development of breast cancer after mastectomy. Larger-scale, population-based studies of breast cancer in the transgender population have reported an incidence of 5.9 per 100,000 patients-years and an overall incidence comparable to cisgender men in age-standardized national samples.^5-7 Unfortunately, data on the rates of breast cancer in transmasculine patients after gender-affirming mastectomy are limited, which makes defining postoperative guidelines challenging. Additionally, the amount of residual breast tissue remaining varies based on the surgeon and technique.

Several techniques are described for mastectomy procedures with differences that can affect the amount of residual breast tissue. The most common type of gender-affirming mastectomy is the double incision. With this procedure, the nipple-areolar complex is reduced in size, removed, and thinned to improve graft take. Dissection is then carried to the level of the breast capsule and the breast tissue and axillary tail are removed en bloc.⁵ During the dissection, the subcutaneous fat is left on the skin flap to provide appropriate contour and to avoid creating a concave-appearing chest wall. Prior to closure, the superior and inferior flaps are inspected for any visible residual breast tissue, which is removed if needed. In a circumareolar mastectomy, the nipple-areolar complex is also reduced but is preserved on a 1- to 1.5-cm-thick pedicle to maintain perfusion.⁵ The mastectomy is performed through an inferior periareolar incision and all visible breast tissue and the axillary tail are removed. Breast tissue specimens are sent for pathologic evaluation at the end of the procedure.

Following gender-affirming mastectomy, there is limited evidence to guide screening. During the patient visit, the provider should obtain a thorough history regarding mastectomy type, and if unknown, attempt to acquire the operative report detailing the procedure. For low-risk patients who undergo a subcutaneous mastectomy such as the double incision or circumareolar technique, screening mammography is not indicated nor is it technically feasible.⁹ For patients with a high-risk genetic mutation or a strong family history of breast cancer, monitoring with alternative modalities such as breast ultrasound or breast MRI may be beneficial, although there is no evidence to currently support this suggestion. Given the variety of surgical techniques of breast tissue removal, it is difficult to develop strong evidence-based guidelines. Annual chest wall examinations have been suggested as a screening modality; however, the clinical utility of clinical breast and chest exams has been debated and is no longer recommended as a screening method in cisgender patients.⁹ Clinicians can promote chest self-awareness and discuss the possibility of breast cancer in postmastectomy patients at annual examination visits. As research continues to resolve some of these unknowns, it is important that patients are informed of these areas of ambiguity and updated regarding any changes in screening recommendations.¹⁰

Dr. Brandt is an ob.gyn. and fellowship-trained gender affirming surgeon in West Reading, Pa.

References

1. American Society of Plastic Surgeons. 2018 plastic surgery statistics report. https://www.plasticsurgery.org/documents/News/Statistics/2018/plastic-surgery-statistics-full-report-2018.pdf. Accessed Aug. 20, 2021.

2. James SE et al. The report of the 2015 U.S. Transgender survey. Washington, D.C.: National Center for Transgender Equality, 2016.

3. Agarwal CA et al. J Plast Reconstr Aesthet Surg. 2018;71:651-7.

4. Poudrier G et al. Plast Reconstr Surg. 2018;80:679-83.

5. Salibian AA et al. Plast Reconstr Surg. 2020;147:213e-21e.

6. Gooren LJ et al. J Sex Med. 2013;10:3129-34.

7. Brown GR and Jones KT. Breast Cancer Res Treat. 2015;149:191-8.

8. Deutsch MF et al. Semin Reprod Med. 2017;35:434-41.

9. Phillips J et al. AJR Am J Roentgenol. 2014;202:1149-59.

10. Smith RA et al. CA Cancer J Clin. 2018;68:297-316.

In medical school, I remember thinking that telling a patient “you have cancer” would be the most professionally challenging phrase I would ever utter. And don’t get me wrong – it certainly isn’t easy; but, compared with telling someone “you are infertile,” it’s a cakewalk.

Maybe it’s because people “have” cancer and cancer is something you “fight.” Or maybe because, unlike infertility, cancer has become a part of public life (think lapel pins and support groups) and is now easier to accept. On the other hand, someone “is” infertile. The condition is a source of embarrassment for the couple and is often hidden from society.

Here’s another concerning point of contrast: While the overall rate of cancer death has declined since the early 1990s, infertility is increasing. Reports now show that one in six couples have problems conceiving and the use of assisted reproductive technologies is increasing by 5%-10% per year. Many theories exist to explain these trends, chief among them the rise in average maternal age and the increasing incidence of obesity, as well as various other male- and female-specific factors.

But interestingly, recent data suggest that the most male of all male-specific factors – total sperm count – may be specifically to blame.

According to a recent meta-analysis, the average total sperm count in men declined by 59.3% between 1973 and 2011. While these data certainly have limitations – including the exclusion of non-English publications, the reliance on total sperm count and not sperm motility, and the potential bias of those patients willing to give a semen sample – the overall trend nevertheless seems to be clearly downward. What’s more concerning, if you believe the data presented, is that there does not appear to be a leveling off of the downward curve in total sperm count.

Think about that last statement. At the current rate of decline, the average sperm count will be zero in 2045. One of the lead authors on the meta-analysis, Hagai Levine, MD, MPH, goes so far as to state, “We should hope for the best and prepare for the worst.”

As a matter of personal philosophy, I’m not a huge fan of end-of-the-world predictions because they tend not to come true (think Montanism back in the 2nd century; the 2012 Mayan calendar scare; or my personal favorite, the Prophet Hen of Leeds). On the other hand, the overall trend of decreased total sperm count in the English-speaking world seems to be true and it raises the interesting question of why.

According to the Mayo Clinic, causes of decreased sperm count include everything from anatomical factors (like varicoceles and ejaculatory issues) and lifestyle issues (such as recreational drugs, weight gain, and emotional stress) to environmental exposures (heavy metal or radiation). The senior author of the aforementioned meta-analysis, Shanna Swan, PhD, has championed another theory: the widespread exposure to endocrine-disrupting chemicals in everyday plastics.

It turns out that at least two chemicals used in the plastics industry, bisphenol A and phthalates, can mimic the effect of estrogen when ingested into the body. Even low levels of these chemicals in our bodies can lead to health problems.

Consider for a moment the presence of plastics in your life: the plastic wrappings on your food, plastic containers for shampoos and beauty products, and even the coatings of our oral supplements. A study by the Centers for Disease Control and Prevention looked at the urine of people participating in the National Health and Nutrition Examination Survey and found detectable concentrations of both of these chemicals in nearly all participants.

In 2045, I intend to be retired. But in the meantime, I think we all need to be aware of the potential impact that various endocrine-disrupting chemicals could be having on humanity. We need more research. If indeed the connection between endocrine disruptors and decreased sperm count is borne out, changes in our environmental exposure to these chemicals need to be made.

Henry Rosevear, MD, is a private-practice urologist based in Colorado Springs. He comes from a long line of doctors, but before entering medicine he served in the U.S. Navy as an officer aboard the USS Pittsburgh, a fast-attack submarine based out of New London, Conn. During his time in the Navy, he served in two deployments to the Persian Gulf, including combat experience as part of Operation Iraqi Freedom. Dr. Rosevear disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.

In medical school, I remember thinking that telling a patient “you have cancer” would be the most professionally challenging phrase I would ever utter. And don’t get me wrong – it certainly isn’t easy; but, compared with telling someone “you are infertile,” it’s a cakewalk.

Maybe it’s because people “have” cancer and cancer is something you “fight.” Or maybe because, unlike infertility, cancer has become a part of public life (think lapel pins and support groups) and is now easier to accept. On the other hand, someone “is” infertile. The condition is a source of embarrassment for the couple and is often hidden from society.

Here’s another concerning point of contrast: While the overall rate of cancer death has declined since the early 1990s, infertility is increasing. Reports now show that one in six couples have problems conceiving and the use of assisted reproductive technologies is increasing by 5%-10% per year. Many theories exist to explain these trends, chief among them the rise in average maternal age and the increasing incidence of obesity, as well as various other male- and female-specific factors.

But interestingly, recent data suggest that the most male of all male-specific factors – total sperm count – may be specifically to blame.

According to a recent meta-analysis, the average total sperm count in men declined by 59.3% between 1973 and 2011. While these data certainly have limitations – including the exclusion of non-English publications, the reliance on total sperm count and not sperm motility, and the potential bias of those patients willing to give a semen sample – the overall trend nevertheless seems to be clearly downward. What’s more concerning, if you believe the data presented, is that there does not appear to be a leveling off of the downward curve in total sperm count.

Think about that last statement. At the current rate of decline, the average sperm count will be zero in 2045. One of the lead authors on the meta-analysis, Hagai Levine, MD, MPH, goes so far as to state, “We should hope for the best and prepare for the worst.”

As a matter of personal philosophy, I’m not a huge fan of end-of-the-world predictions because they tend not to come true (think Montanism back in the 2nd century; the 2012 Mayan calendar scare; or my personal favorite, the Prophet Hen of Leeds). On the other hand, the overall trend of decreased total sperm count in the English-speaking world seems to be true and it raises the interesting question of why.

According to the Mayo Clinic, causes of decreased sperm count include everything from anatomical factors (like varicoceles and ejaculatory issues) and lifestyle issues (such as recreational drugs, weight gain, and emotional stress) to environmental exposures (heavy metal or radiation). The senior author of the aforementioned meta-analysis, Shanna Swan, PhD, has championed another theory: the widespread exposure to endocrine-disrupting chemicals in everyday plastics.

It turns out that at least two chemicals used in the plastics industry, bisphenol A and phthalates, can mimic the effect of estrogen when ingested into the body. Even low levels of these chemicals in our bodies can lead to health problems.

Consider for a moment the presence of plastics in your life: the plastic wrappings on your food, plastic containers for shampoos and beauty products, and even the coatings of our oral supplements. A study by the Centers for Disease Control and Prevention looked at the urine of people participating in the National Health and Nutrition Examination Survey and found detectable concentrations of both of these chemicals in nearly all participants.

In 2045, I intend to be retired. But in the meantime, I think we all need to be aware of the potential impact that various endocrine-disrupting chemicals could be having on humanity. We need more research. If indeed the connection between endocrine disruptors and decreased sperm count is borne out, changes in our environmental exposure to these chemicals need to be made.

Henry Rosevear, MD, is a private-practice urologist based in Colorado Springs. He comes from a long line of doctors, but before entering medicine he served in the U.S. Navy as an officer aboard the USS Pittsburgh, a fast-attack submarine based out of New London, Conn. During his time in the Navy, he served in two deployments to the Persian Gulf, including combat experience as part of Operation Iraqi Freedom. Dr. Rosevear disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.

In medical school, I remember thinking that telling a patient “you have cancer” would be the most professionally challenging phrase I would ever utter. And don’t get me wrong – it certainly isn’t easy; but, compared with telling someone “you are infertile,” it’s a cakewalk.

Maybe it’s because people “have” cancer and cancer is something you “fight.” Or maybe because, unlike infertility, cancer has become a part of public life (think lapel pins and support groups) and is now easier to accept. On the other hand, someone “is” infertile. The condition is a source of embarrassment for the couple and is often hidden from society.

Here’s another concerning point of contrast: While the overall rate of cancer death has declined since the early 1990s, infertility is increasing. Reports now show that one in six couples have problems conceiving and the use of assisted reproductive technologies is increasing by 5%-10% per year. Many theories exist to explain these trends, chief among them the rise in average maternal age and the increasing incidence of obesity, as well as various other male- and female-specific factors.

But interestingly, recent data suggest that the most male of all male-specific factors – total sperm count – may be specifically to blame.

According to a recent meta-analysis, the average total sperm count in men declined by 59.3% between 1973 and 2011. While these data certainly have limitations – including the exclusion of non-English publications, the reliance on total sperm count and not sperm motility, and the potential bias of those patients willing to give a semen sample – the overall trend nevertheless seems to be clearly downward. What’s more concerning, if you believe the data presented, is that there does not appear to be a leveling off of the downward curve in total sperm count.

Think about that last statement. At the current rate of decline, the average sperm count will be zero in 2045. One of the lead authors on the meta-analysis, Hagai Levine, MD, MPH, goes so far as to state, “We should hope for the best and prepare for the worst.”

As a matter of personal philosophy, I’m not a huge fan of end-of-the-world predictions because they tend not to come true (think Montanism back in the 2nd century; the 2012 Mayan calendar scare; or my personal favorite, the Prophet Hen of Leeds). On the other hand, the overall trend of decreased total sperm count in the English-speaking world seems to be true and it raises the interesting question of why.

According to the Mayo Clinic, causes of decreased sperm count include everything from anatomical factors (like varicoceles and ejaculatory issues) and lifestyle issues (such as recreational drugs, weight gain, and emotional stress) to environmental exposures (heavy metal or radiation). The senior author of the aforementioned meta-analysis, Shanna Swan, PhD, has championed another theory: the widespread exposure to endocrine-disrupting chemicals in everyday plastics.

It turns out that at least two chemicals used in the plastics industry, bisphenol A and phthalates, can mimic the effect of estrogen when ingested into the body. Even low levels of these chemicals in our bodies can lead to health problems.

Consider for a moment the presence of plastics in your life: the plastic wrappings on your food, plastic containers for shampoos and beauty products, and even the coatings of our oral supplements. A study by the Centers for Disease Control and Prevention looked at the urine of people participating in the National Health and Nutrition Examination Survey and found detectable concentrations of both of these chemicals in nearly all participants.

In 2045, I intend to be retired. But in the meantime, I think we all need to be aware of the potential impact that various endocrine-disrupting chemicals could be having on humanity. We need more research. If indeed the connection between endocrine disruptors and decreased sperm count is borne out, changes in our environmental exposure to these chemicals need to be made.

Henry Rosevear, MD, is a private-practice urologist based in Colorado Springs. He comes from a long line of doctors, but before entering medicine he served in the U.S. Navy as an officer aboard the USS Pittsburgh, a fast-attack submarine based out of New London, Conn. During his time in the Navy, he served in two deployments to the Persian Gulf, including combat experience as part of Operation Iraqi Freedom. Dr. Rosevear disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.

In this month’s column we continue to discuss recommendations from the gynecologic oncologist to the general gynecologist.

Don’t screen average-risk women for ovarian cancer.

Ovarian cancer is most often diagnosed at an advanced stage, which limits the curability of the disease. Consequently, there is a strong focus on attempting to diagnose the disease at earlier, more curable stages. This leads to the impulse by some well-intentioned providers to implement screening tests, such as ultrasounds and tumor markers, for all women. Unfortunately, the screening of “average risk” women for ovarian cancer is not recommended. Randomized controlled trials of tens of thousands of women have not observed a clinically significant decrease in ovarian cancer mortality with the addition of screening with tumor markers and ultrasound.¹ These studies did observe a false-positive rate of 5%. While that may seem like a low rate of false-positive testing, the definitive diagnostic test which follows is a major abdominal surgery (oophorectomy) and serious complications are encountered in 15% of patients undergoing surgery for false-positive ovarian cancer screening.¹ Therefore, quite simply, the harms are not balanced by benefits.

The key to offering patients appropriate and effective screening is case selection. It is important to identify which patients are at higher risk for ovarian cancer and offer those women testing for germline mutations and screening strategies. An important component of a well-woman visit is to take a thorough family history of cancer. Women are considered at high risk for having hereditary predisposition to ovarian cancer if they have a first- or second-degree relative with breast cancer younger than 45-50 years, or any age if Ashkenazi Jewish, triple-negative breast cancer younger than 60 years of age, two or more primary breast cancers with the first diagnosed at less than 50 years of age, male breast cancer, ovarian cancer, pancreatic cancer, a known BRCA 1/2 mutation, or a personal history of those same conditions. These women should be recommended to undergo genetic testing for BRCA 1, 2, and Lynch syndrome. They should not automatically be offered ovarian cancer screening. If a patient has a more remote family history for ovarian cancer, their personal risk may be somewhat elevated above the baseline population risk, however, not substantially enough to justify implementing screening in the absence of a confirmed genetic mutation.

While screening tests may not be appropriate for all patients, all patients should be asked about the early symptoms of ovarian cancer because these are consistently present, and frequently overlooked, prior to the eventual diagnosis of advanced disease. Those symptoms include abdominal discomfort, abdominal swelling and bloating, and urinary urgency.² Consider offering all patients a dedicated ovarian cancer specific review of systems that includes inquiries about these symptoms at their annual wellness visits.
 

Opt for vertical midline incisions when surgery is anticipated to be complex

What is the first thing gynecologic oncologists do when called in to assist in a difficult gynecologic procedure? Get better exposure. Exposure is the cornerstone of safe, effective surgery. Sometimes this simply means placing a more effective retractor. In other cases, it might mean extending the incision. However, if the incision is a low transverse incision (the go-to for many gynecologists because of its favorable cosmetic and pain-producing profile) this proves to be difficult. Attempting to assist in a complicated case, such as a frozen pelvis, severed ureter or rectal injury, through a pfannensteil incision can be extraordinarily difficult, and while these incisions can be extended by incising the rectus muscle bellies, upper abdominal visualization remains elusive in most patients. This is particularly problematic if the ureter or splenic flexure need to be mobilized, or if extensive lysis of adhesions is necessary to ensure there is no occult enterotomy. As my mentor Dr. John Soper once described to me: “It’s like trying to scratch your armpit by reaching through your fly.”

While pfannensteil incisions come naturally, and comfortably, to most gynecologists, likely because of their frequent application during cesarean section, all gynecologists should be confident in the steps and anatomy for vertical midline, or paramedian incisions. This is not only beneficial for complex gynecologic cases, but also in the event of vascular emergency. In the hands of an experienced abdominal/pelvic surgeon, the vertical midline incision is the quickest way to safely enter the abdomen, and provides the kind of exposure that may be critical in safely repairing or controlling hemorrhage from a major vessel.

While low transverse incisions may be more cosmetic, less painful, and associated with fewer wound complications, our first concern as surgeons should be mitigating complications. In situations where risks of complications are high, it is best to not handicap ourselves with the incision location. And always remember, wound complications are highest when a transverse incision needs to be converted to a vertical one with a “T.”
 

It’s not just about diagnosis of cancer, it’s also prevention

Detection of cancer is an important role of the obstetrician gynecologist. However, equally important is being able to seize opportunities for cancer prevention. Cervical, vulvar, endometrial and ovarian cancer are all known to have preventative strategies.

All patients up to the age of 45 should be offered vaccination against HPV. Initial indications for HPV vaccination were for women up to age 26; however, recent data support the safety and efficacy of the vaccine in older women.³ HPV vaccination is most effective at preventing cancer when administered prior to exposure (ideally age 9-11), leaving this in the hands of our pediatrician colleagues. However, we must be vigilant to inquire about vaccination status for all our patients and encourage vaccines for those who were missed earlier in their life.

Patients should be counseled regarding the significant risk reduction for cancer that is gained from use of oral hormonal contraceptives and progestin-releasing IUDs (especially for endometrial and ovarian cancers). Providing them with knowledge of this information when considering options for contraception or menstrual cycle management is important in their decision-making process.

Endometrial cancer incidence is sadly on the rise in the United States, likely secondary to increasing rates of obesity. Pregnancy is a time when many women begin to gain, and accumulate, weight and therefore obstetric providers have a unique opportunity to assist patients in strategies to normalize their weight after pregnancy. Many of my patients with endometrial cancer state that they have never heard that it is associated with obesity. This suggests that more can be done to educate patients on the carcinogenic effect of obesity (for both endometrial and breast cancer), which may aid in motivating change of modifiable behaviors.

The fallopian tubes are the source of many ovarian cancers and knowledge of this has led to the recommendation to perform opportunistic salpingectomy as a cancer risk-reducing strategy. Hysterectomy and sterilization procedures are most apropos for this modification. While prospective data to confirm a reduced risk of ovarian cancer with opportunistic salpingectomy are lacking, a reduced incidence of cancer has been observed when the tubes have been removed for indicated surgeries; there appear to be no significant deleterious sequelae.^4,5 A focus should be made on removal of the entire distal third of the tube, particularly the fimbriated ends, as this is the portion most implicated in malignancy.
 

Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She has no relevant disclosures. Contact her at obnews@mdedge.com.
 

References

1. Buys SS et al. JAMA. 2011;305(22):2295.

2. Goff BA et al. JAMA. 2004;291(22):2705.

3. Castellsagué X et al. Br J Cancer. 2011;105(1):28.

4. Yoon SH et al. Eur J Cancer. 2016 Mar;55:38-46.

5. Hanley GE et al. Am J Obstet Gynecol. 2018;219(2):172.

In this month’s column we continue to discuss recommendations from the gynecologic oncologist to the general gynecologist.

Don’t screen average-risk women for ovarian cancer.

Ovarian cancer is most often diagnosed at an advanced stage, which limits the curability of the disease. Consequently, there is a strong focus on attempting to diagnose the disease at earlier, more curable stages. This leads to the impulse by some well-intentioned providers to implement screening tests, such as ultrasounds and tumor markers, for all women. Unfortunately, the screening of “average risk” women for ovarian cancer is not recommended. Randomized controlled trials of tens of thousands of women have not observed a clinically significant decrease in ovarian cancer mortality with the addition of screening with tumor markers and ultrasound.¹ These studies did observe a false-positive rate of 5%. While that may seem like a low rate of false-positive testing, the definitive diagnostic test which follows is a major abdominal surgery (oophorectomy) and serious complications are encountered in 15% of patients undergoing surgery for false-positive ovarian cancer screening.¹ Therefore, quite simply, the harms are not balanced by benefits.

The key to offering patients appropriate and effective screening is case selection. It is important to identify which patients are at higher risk for ovarian cancer and offer those women testing for germline mutations and screening strategies. An important component of a well-woman visit is to take a thorough family history of cancer. Women are considered at high risk for having hereditary predisposition to ovarian cancer if they have a first- or second-degree relative with breast cancer younger than 45-50 years, or any age if Ashkenazi Jewish, triple-negative breast cancer younger than 60 years of age, two or more primary breast cancers with the first diagnosed at less than 50 years of age, male breast cancer, ovarian cancer, pancreatic cancer, a known BRCA 1/2 mutation, or a personal history of those same conditions. These women should be recommended to undergo genetic testing for BRCA 1, 2, and Lynch syndrome. They should not automatically be offered ovarian cancer screening. If a patient has a more remote family history for ovarian cancer, their personal risk may be somewhat elevated above the baseline population risk, however, not substantially enough to justify implementing screening in the absence of a confirmed genetic mutation.

While screening tests may not be appropriate for all patients, all patients should be asked about the early symptoms of ovarian cancer because these are consistently present, and frequently overlooked, prior to the eventual diagnosis of advanced disease. Those symptoms include abdominal discomfort, abdominal swelling and bloating, and urinary urgency.² Consider offering all patients a dedicated ovarian cancer specific review of systems that includes inquiries about these symptoms at their annual wellness visits.
 

Opt for vertical midline incisions when surgery is anticipated to be complex

What is the first thing gynecologic oncologists do when called in to assist in a difficult gynecologic procedure? Get better exposure. Exposure is the cornerstone of safe, effective surgery. Sometimes this simply means placing a more effective retractor. In other cases, it might mean extending the incision. However, if the incision is a low transverse incision (the go-to for many gynecologists because of its favorable cosmetic and pain-producing profile) this proves to be difficult. Attempting to assist in a complicated case, such as a frozen pelvis, severed ureter or rectal injury, through a pfannensteil incision can be extraordinarily difficult, and while these incisions can be extended by incising the rectus muscle bellies, upper abdominal visualization remains elusive in most patients. This is particularly problematic if the ureter or splenic flexure need to be mobilized, or if extensive lysis of adhesions is necessary to ensure there is no occult enterotomy. As my mentor Dr. John Soper once described to me: “It’s like trying to scratch your armpit by reaching through your fly.”

While pfannensteil incisions come naturally, and comfortably, to most gynecologists, likely because of their frequent application during cesarean section, all gynecologists should be confident in the steps and anatomy for vertical midline, or paramedian incisions. This is not only beneficial for complex gynecologic cases, but also in the event of vascular emergency. In the hands of an experienced abdominal/pelvic surgeon, the vertical midline incision is the quickest way to safely enter the abdomen, and provides the kind of exposure that may be critical in safely repairing or controlling hemorrhage from a major vessel.

While low transverse incisions may be more cosmetic, less painful, and associated with fewer wound complications, our first concern as surgeons should be mitigating complications. In situations where risks of complications are high, it is best to not handicap ourselves with the incision location. And always remember, wound complications are highest when a transverse incision needs to be converted to a vertical one with a “T.”
 

It’s not just about diagnosis of cancer, it’s also prevention

Detection of cancer is an important role of the obstetrician gynecologist. However, equally important is being able to seize opportunities for cancer prevention. Cervical, vulvar, endometrial and ovarian cancer are all known to have preventative strategies.

All patients up to the age of 45 should be offered vaccination against HPV. Initial indications for HPV vaccination were for women up to age 26; however, recent data support the safety and efficacy of the vaccine in older women.³ HPV vaccination is most effective at preventing cancer when administered prior to exposure (ideally age 9-11), leaving this in the hands of our pediatrician colleagues. However, we must be vigilant to inquire about vaccination status for all our patients and encourage vaccines for those who were missed earlier in their life.

Patients should be counseled regarding the significant risk reduction for cancer that is gained from use of oral hormonal contraceptives and progestin-releasing IUDs (especially for endometrial and ovarian cancers). Providing them with knowledge of this information when considering options for contraception or menstrual cycle management is important in their decision-making process.

Endometrial cancer incidence is sadly on the rise in the United States, likely secondary to increasing rates of obesity. Pregnancy is a time when many women begin to gain, and accumulate, weight and therefore obstetric providers have a unique opportunity to assist patients in strategies to normalize their weight after pregnancy. Many of my patients with endometrial cancer state that they have never heard that it is associated with obesity. This suggests that more can be done to educate patients on the carcinogenic effect of obesity (for both endometrial and breast cancer), which may aid in motivating change of modifiable behaviors.

The fallopian tubes are the source of many ovarian cancers and knowledge of this has led to the recommendation to perform opportunistic salpingectomy as a cancer risk-reducing strategy. Hysterectomy and sterilization procedures are most apropos for this modification. While prospective data to confirm a reduced risk of ovarian cancer with opportunistic salpingectomy are lacking, a reduced incidence of cancer has been observed when the tubes have been removed for indicated surgeries; there appear to be no significant deleterious sequelae.^4,5 A focus should be made on removal of the entire distal third of the tube, particularly the fimbriated ends, as this is the portion most implicated in malignancy.
 

Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She has no relevant disclosures. Contact her at obnews@mdedge.com.
 

References

1. Buys SS et al. JAMA. 2011;305(22):2295.

2. Goff BA et al. JAMA. 2004;291(22):2705.

3. Castellsagué X et al. Br J Cancer. 2011;105(1):28.

4. Yoon SH et al. Eur J Cancer. 2016 Mar;55:38-46.

5. Hanley GE et al. Am J Obstet Gynecol. 2018;219(2):172.

In this month’s column we continue to discuss recommendations from the gynecologic oncologist to the general gynecologist.

Don’t screen average-risk women for ovarian cancer.

Ovarian cancer is most often diagnosed at an advanced stage, which limits the curability of the disease. Consequently, there is a strong focus on attempting to diagnose the disease at earlier, more curable stages. This leads to the impulse by some well-intentioned providers to implement screening tests, such as ultrasounds and tumor markers, for all women. Unfortunately, the screening of “average risk” women for ovarian cancer is not recommended. Randomized controlled trials of tens of thousands of women have not observed a clinically significant decrease in ovarian cancer mortality with the addition of screening with tumor markers and ultrasound.¹ These studies did observe a false-positive rate of 5%. While that may seem like a low rate of false-positive testing, the definitive diagnostic test which follows is a major abdominal surgery (oophorectomy) and serious complications are encountered in 15% of patients undergoing surgery for false-positive ovarian cancer screening.¹ Therefore, quite simply, the harms are not balanced by benefits.

The key to offering patients appropriate and effective screening is case selection. It is important to identify which patients are at higher risk for ovarian cancer and offer those women testing for germline mutations and screening strategies. An important component of a well-woman visit is to take a thorough family history of cancer. Women are considered at high risk for having hereditary predisposition to ovarian cancer if they have a first- or second-degree relative with breast cancer younger than 45-50 years, or any age if Ashkenazi Jewish, triple-negative breast cancer younger than 60 years of age, two or more primary breast cancers with the first diagnosed at less than 50 years of age, male breast cancer, ovarian cancer, pancreatic cancer, a known BRCA 1/2 mutation, or a personal history of those same conditions. These women should be recommended to undergo genetic testing for BRCA 1, 2, and Lynch syndrome. They should not automatically be offered ovarian cancer screening. If a patient has a more remote family history for ovarian cancer, their personal risk may be somewhat elevated above the baseline population risk, however, not substantially enough to justify implementing screening in the absence of a confirmed genetic mutation.

While screening tests may not be appropriate for all patients, all patients should be asked about the early symptoms of ovarian cancer because these are consistently present, and frequently overlooked, prior to the eventual diagnosis of advanced disease. Those symptoms include abdominal discomfort, abdominal swelling and bloating, and urinary urgency.² Consider offering all patients a dedicated ovarian cancer specific review of systems that includes inquiries about these symptoms at their annual wellness visits.
 

Opt for vertical midline incisions when surgery is anticipated to be complex

What is the first thing gynecologic oncologists do when called in to assist in a difficult gynecologic procedure? Get better exposure. Exposure is the cornerstone of safe, effective surgery. Sometimes this simply means placing a more effective retractor. In other cases, it might mean extending the incision. However, if the incision is a low transverse incision (the go-to for many gynecologists because of its favorable cosmetic and pain-producing profile) this proves to be difficult. Attempting to assist in a complicated case, such as a frozen pelvis, severed ureter or rectal injury, through a pfannensteil incision can be extraordinarily difficult, and while these incisions can be extended by incising the rectus muscle bellies, upper abdominal visualization remains elusive in most patients. This is particularly problematic if the ureter or splenic flexure need to be mobilized, or if extensive lysis of adhesions is necessary to ensure there is no occult enterotomy. As my mentor Dr. John Soper once described to me: “It’s like trying to scratch your armpit by reaching through your fly.”

While pfannensteil incisions come naturally, and comfortably, to most gynecologists, likely because of their frequent application during cesarean section, all gynecologists should be confident in the steps and anatomy for vertical midline, or paramedian incisions. This is not only beneficial for complex gynecologic cases, but also in the event of vascular emergency. In the hands of an experienced abdominal/pelvic surgeon, the vertical midline incision is the quickest way to safely enter the abdomen, and provides the kind of exposure that may be critical in safely repairing or controlling hemorrhage from a major vessel.

While low transverse incisions may be more cosmetic, less painful, and associated with fewer wound complications, our first concern as surgeons should be mitigating complications. In situations where risks of complications are high, it is best to not handicap ourselves with the incision location. And always remember, wound complications are highest when a transverse incision needs to be converted to a vertical one with a “T.”
 

It’s not just about diagnosis of cancer, it’s also prevention

Detection of cancer is an important role of the obstetrician gynecologist. However, equally important is being able to seize opportunities for cancer prevention. Cervical, vulvar, endometrial and ovarian cancer are all known to have preventative strategies.

All patients up to the age of 45 should be offered vaccination against HPV. Initial indications for HPV vaccination were for women up to age 26; however, recent data support the safety and efficacy of the vaccine in older women.³ HPV vaccination is most effective at preventing cancer when administered prior to exposure (ideally age 9-11), leaving this in the hands of our pediatrician colleagues. However, we must be vigilant to inquire about vaccination status for all our patients and encourage vaccines for those who were missed earlier in their life.

Patients should be counseled regarding the significant risk reduction for cancer that is gained from use of oral hormonal contraceptives and progestin-releasing IUDs (especially for endometrial and ovarian cancers). Providing them with knowledge of this information when considering options for contraception or menstrual cycle management is important in their decision-making process.

Endometrial cancer incidence is sadly on the rise in the United States, likely secondary to increasing rates of obesity. Pregnancy is a time when many women begin to gain, and accumulate, weight and therefore obstetric providers have a unique opportunity to assist patients in strategies to normalize their weight after pregnancy. Many of my patients with endometrial cancer state that they have never heard that it is associated with obesity. This suggests that more can be done to educate patients on the carcinogenic effect of obesity (for both endometrial and breast cancer), which may aid in motivating change of modifiable behaviors.

The fallopian tubes are the source of many ovarian cancers and knowledge of this has led to the recommendation to perform opportunistic salpingectomy as a cancer risk-reducing strategy. Hysterectomy and sterilization procedures are most apropos for this modification. While prospective data to confirm a reduced risk of ovarian cancer with opportunistic salpingectomy are lacking, a reduced incidence of cancer has been observed when the tubes have been removed for indicated surgeries; there appear to be no significant deleterious sequelae.^4,5 A focus should be made on removal of the entire distal third of the tube, particularly the fimbriated ends, as this is the portion most implicated in malignancy.
 

Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She has no relevant disclosures. Contact her at obnews@mdedge.com.
 

References

1. Buys SS et al. JAMA. 2011;305(22):2295.

2. Goff BA et al. JAMA. 2004;291(22):2705.

3. Castellsagué X et al. Br J Cancer. 2011;105(1):28.

4. Yoon SH et al. Eur J Cancer. 2016 Mar;55:38-46.

5. Hanley GE et al. Am J Obstet Gynecol. 2018;219(2):172.