User login
How physicians can provide better care to transgender patients
People who identify as transgender experience many health disparities, in addition to lack of access to quality care. The most commonly cited barrier is the lack of providers who are knowledgeable about transgender health care, according to past surveys.
Even those who do seek care often have unpleasant experiences. A 2015 survey conducted by the National Center for Transgender Equality found that 33% of those who saw a health care provider reported at least one unfavorable experience related to being transgender, such as being verbally harassed or refused treatment because of their gender identity. In fact, 23% of those surveyed say they did not seek health care they needed in the past year because of fear of being mistreated as a transgender person.
This interview has been edited for length and clarity.
Question: Surveys have shown that many people who identify as transgender will seek only transition care, not primary or preventive care. Why is that?
Dr. Brandt: My answer is multifactorial. Transgender patients do seek primary care – just not as readily. There’s a lot of misconceptions about health care needs for the LGBT community in general. For example, lesbian or bisexual women may be not as well informed about the need for Pap smears compared with their heterosexual counterparts. These misconceptions are further exacerbated in the transgender community.
The fact that a lot of patients seek only transition-related care, but not preventive services, such as primary care and gynecologic care, is also related to fears of discrimination and lack of education of providers. These patients are afraid when they walk into an office that they will be misgendered or their physician won’t be familiar with their health care needs.
What can clinics and clinicians do to create a safe and welcoming environment?
Dr. Brandt: It starts with educating office staff about terminology and gender identities.
A key feature of our EHR is the sexual orientation and gender identity platform, which asks questions about a patient’s gender identity, sexual orientation, sex assigned at birth, and organ inventory. These data are then found in the patient information tab and are just as relevant as their insurance status, age, and date of birth.
There are many ways a doctor’s office can signal to patients that they are inclusive. They can hang LGBTQ-friendly flags or symbols or a sign saying, “We have an anti-discrimination policy” in the waiting room. A welcoming environment can also be achieved by revising patient questionnaires or forms so that they aren’t gender-specific or binary.
Given that the patient may have limited contact with a primary care clinician, how do you prioritize what you address during the visit?
Dr. Brandt: Similar to cisgender patients, it depends initially on the age of the patient and the reason for the visit. The priorities of an otherwise healthy transgender patient in their 20s are going to be largely the same as for a cisgender patient of the same age. As patients age in the primary care world, you’re addressing more issues, such as colorectal screening, lipid disorders, and mammograms, and that doesn’t change. For the most part, the problems that you address should be specific for that age group.
It becomes more complicated when you add in factors such as hormone therapy and whether patients have had any type of gender-affirming surgery. Those things can change the usual recommendations for screening or risk assessment. We try to figure out what routine health maintenance and cancer screening a patient needs based on age and risk factors, in addition to hormone status and surgical state.
Do you think that many physicians are educated about the care of underserved populations such as transgender patients?
Dr. Brandt: Yes and no. We are definitely getting better at it. For example, the American College of Obstetricians and Gynecologists published a committee opinion highlighting transgender care. So organizations are starting to prioritize these populations and recognize that they are, in fact, underserved and they have special health care needs.
However, the knowledge gaps are still pretty big. I get calls daily from providers asking questions about how to manage patients on hormones, or how to examine a patient who has undergone a vaginoplasty. I hear a lot of horror stories from transgender patients who had their hormones stopped for absurd and medically misinformed reasons.
But I definitely think it’s getting better and it’s being addressed at all levels – the medical school level, the residency level, and the attending level. It just takes time to inform people and for people to get used to the health care needs of these patients.
What should physicians keep in mind when treating patients who identify as transgender?
Dr. Brandt: First and foremost, understanding the terminology and the difference between gender identity, sex, and sexual orientation. Being familiar with that language and being able to speak that language very comfortably and not being awkward about it is a really important thing for primary care physicians and indeed any physician who treats transgender patients.
Physicians should also be aware that any underserved population has higher rates of mental health issues, such as depression and anxiety. Obviously, that goes along with being underserved and the stigma and the disparities that exist for these patients. Having providers educate themselves about what those disparities are and how they impact a patient’s daily life and health is paramount to knowing how to treat patients.
What are your top health concerns for these patients and how do you address them?
Dr. Brandt: I think mental health and safety is probably the number one for me. About 41% of transgender adults have attempted suicide. That number is roughly 51% in transgender youth. That is an astonishing number. These patients have much higher rates of domestic violence, intimate partner violence, and sexual assault, especially trans women and trans women of color. So understanding those statistics is huge.
Obesity, smoking, and substance abuse are my next three. Again, those are things that should be addressed at any visit, regardless of the gender identity or sexual orientation of the patient, but those rates are particularly high in this population.
Fertility and long-term care for patients should be addressed. Many patients who identify as transgender are told they can’t have a family. As a primary care physician, you may see a patient before they are seen by an ob.gyn. or surgeon. Talking about what a patient’s long-term life goals are with fertility and family planning, and what that looks like for them, is a big thing for me. Other providers may not feel that’s a concern, but I believe it should be discussed before initiation of hormone therapy, which can significantly impact fertility in some patients.
Are there nuances to the physical examination that primary care physicians should be aware of when dealing with transmasculine patients vs. transfeminine patients?
Dr. Brandt: Absolutely. And this interview can’t cover the scope of those nuances. An example that comes to mind is the genital exam. For transgender women who have undergone a vaginoplasty, the pelvic exam can be very affirming. Whereas for transgender men, a gynecologic exam can significantly exacerbate dysphoria and there are ways to conduct the exam to limit this discomfort and avoid creating a traumatic experience for the patient. It’s important to be aware that the genital exam, or any type of genitourinary exam, can be either affirming or not affirming.
Sexually transmitted infections are up in the general population, and the trans population is at even higher risk. What should physicians think about when they assess this risk?
Dr. Brandt: It’s really important for primary care clinicians and for gynecologists to learn to be comfortable talking about sexual practices, because what people do behind closed doors is really a key to how to counsel patients about safe sex.
People are well aware of the need to have safe sex. However, depending on the type of sex that you’re having, what body parts go where, what is truly safe can vary and people may not know, for example, to wear a condom when sex toys are involved or that a transgender male on testosterone can become pregnant during penile-vaginal intercourse. Providers really should be very educated on the array of sexual practices that people have and how to counsel them about those. They should know how to ask patients the gender identity of their sexual partners, the sexual orientation of their partners, and what parts go where during sex.
Providers should also talk to patients about PrEP [pre-exposure prophylaxis], whether they identify as cisgender or transgender. My trans patients tend to be a lot more educated about PrEP than other patients. It’s something that many of the residents, even in a standard gynecologic clinic, for example, don’t talk to cisgender patients about because of the stigma surrounding HIV. Many providers still think that the only people who are at risk for HIV are men who have sex with men. And while those rates are higher in some populations, depending on sexual practices, those aren’t the only patients who qualify for PrEP.
Overall, in order to counsel patients about STIs and safe sexual practices, providers should learn to be comfortable talking about sex.
Do you have any strategies on how to make the appointment more successful in addressing those issues?
Dr. Brandt: Bedside manner is a hard thing to teach, and comfort in talking about sex, gender identity, and sexual orientation can vary – but there are a lot of continuing medical education courses that physicians can utilize through the World Professional Association for Transgender Health.
If providers start to notice an influx of patients who identify as transgender or if they want to start seeing transgender patients, it’s really important for them to have that training before they start interacting with patients. In all of medicine, we sort of learn as we go, but this patient population has been subjected to discrimination, violence, error, and misgendering. They have dealt with providers who didn’t understand their health care needs. While this field is evolving, knowing how to appropriately address a patient (using their correct name, pronouns, etc.) is an absolute must.
That needs to be part of a provider’s routine vernacular and not something that they sort of stumble through. You can scare a patient away as soon as they walk into the office with an uneducated front desk staff and things that are seen in the office. Seeking out those educational tools, being aware of your own deficits as a provider and the educational needs of your office, and addressing those needs is really key.
A version of this article first appeared on Medscape.com.
People who identify as transgender experience many health disparities, in addition to lack of access to quality care. The most commonly cited barrier is the lack of providers who are knowledgeable about transgender health care, according to past surveys.
Even those who do seek care often have unpleasant experiences. A 2015 survey conducted by the National Center for Transgender Equality found that 33% of those who saw a health care provider reported at least one unfavorable experience related to being transgender, such as being verbally harassed or refused treatment because of their gender identity. In fact, 23% of those surveyed say they did not seek health care they needed in the past year because of fear of being mistreated as a transgender person.
This interview has been edited for length and clarity.
Question: Surveys have shown that many people who identify as transgender will seek only transition care, not primary or preventive care. Why is that?
Dr. Brandt: My answer is multifactorial. Transgender patients do seek primary care – just not as readily. There’s a lot of misconceptions about health care needs for the LGBT community in general. For example, lesbian or bisexual women may be not as well informed about the need for Pap smears compared with their heterosexual counterparts. These misconceptions are further exacerbated in the transgender community.
The fact that a lot of patients seek only transition-related care, but not preventive services, such as primary care and gynecologic care, is also related to fears of discrimination and lack of education of providers. These patients are afraid when they walk into an office that they will be misgendered or their physician won’t be familiar with their health care needs.
What can clinics and clinicians do to create a safe and welcoming environment?
Dr. Brandt: It starts with educating office staff about terminology and gender identities.
A key feature of our EHR is the sexual orientation and gender identity platform, which asks questions about a patient’s gender identity, sexual orientation, sex assigned at birth, and organ inventory. These data are then found in the patient information tab and are just as relevant as their insurance status, age, and date of birth.
There are many ways a doctor’s office can signal to patients that they are inclusive. They can hang LGBTQ-friendly flags or symbols or a sign saying, “We have an anti-discrimination policy” in the waiting room. A welcoming environment can also be achieved by revising patient questionnaires or forms so that they aren’t gender-specific or binary.
Given that the patient may have limited contact with a primary care clinician, how do you prioritize what you address during the visit?
Dr. Brandt: Similar to cisgender patients, it depends initially on the age of the patient and the reason for the visit. The priorities of an otherwise healthy transgender patient in their 20s are going to be largely the same as for a cisgender patient of the same age. As patients age in the primary care world, you’re addressing more issues, such as colorectal screening, lipid disorders, and mammograms, and that doesn’t change. For the most part, the problems that you address should be specific for that age group.
It becomes more complicated when you add in factors such as hormone therapy and whether patients have had any type of gender-affirming surgery. Those things can change the usual recommendations for screening or risk assessment. We try to figure out what routine health maintenance and cancer screening a patient needs based on age and risk factors, in addition to hormone status and surgical state.
Do you think that many physicians are educated about the care of underserved populations such as transgender patients?
Dr. Brandt: Yes and no. We are definitely getting better at it. For example, the American College of Obstetricians and Gynecologists published a committee opinion highlighting transgender care. So organizations are starting to prioritize these populations and recognize that they are, in fact, underserved and they have special health care needs.
However, the knowledge gaps are still pretty big. I get calls daily from providers asking questions about how to manage patients on hormones, or how to examine a patient who has undergone a vaginoplasty. I hear a lot of horror stories from transgender patients who had their hormones stopped for absurd and medically misinformed reasons.
But I definitely think it’s getting better and it’s being addressed at all levels – the medical school level, the residency level, and the attending level. It just takes time to inform people and for people to get used to the health care needs of these patients.
What should physicians keep in mind when treating patients who identify as transgender?
Dr. Brandt: First and foremost, understanding the terminology and the difference between gender identity, sex, and sexual orientation. Being familiar with that language and being able to speak that language very comfortably and not being awkward about it is a really important thing for primary care physicians and indeed any physician who treats transgender patients.
Physicians should also be aware that any underserved population has higher rates of mental health issues, such as depression and anxiety. Obviously, that goes along with being underserved and the stigma and the disparities that exist for these patients. Having providers educate themselves about what those disparities are and how they impact a patient’s daily life and health is paramount to knowing how to treat patients.
What are your top health concerns for these patients and how do you address them?
Dr. Brandt: I think mental health and safety is probably the number one for me. About 41% of transgender adults have attempted suicide. That number is roughly 51% in transgender youth. That is an astonishing number. These patients have much higher rates of domestic violence, intimate partner violence, and sexual assault, especially trans women and trans women of color. So understanding those statistics is huge.
Obesity, smoking, and substance abuse are my next three. Again, those are things that should be addressed at any visit, regardless of the gender identity or sexual orientation of the patient, but those rates are particularly high in this population.
Fertility and long-term care for patients should be addressed. Many patients who identify as transgender are told they can’t have a family. As a primary care physician, you may see a patient before they are seen by an ob.gyn. or surgeon. Talking about what a patient’s long-term life goals are with fertility and family planning, and what that looks like for them, is a big thing for me. Other providers may not feel that’s a concern, but I believe it should be discussed before initiation of hormone therapy, which can significantly impact fertility in some patients.
Are there nuances to the physical examination that primary care physicians should be aware of when dealing with transmasculine patients vs. transfeminine patients?
Dr. Brandt: Absolutely. And this interview can’t cover the scope of those nuances. An example that comes to mind is the genital exam. For transgender women who have undergone a vaginoplasty, the pelvic exam can be very affirming. Whereas for transgender men, a gynecologic exam can significantly exacerbate dysphoria and there are ways to conduct the exam to limit this discomfort and avoid creating a traumatic experience for the patient. It’s important to be aware that the genital exam, or any type of genitourinary exam, can be either affirming or not affirming.
Sexually transmitted infections are up in the general population, and the trans population is at even higher risk. What should physicians think about when they assess this risk?
Dr. Brandt: It’s really important for primary care clinicians and for gynecologists to learn to be comfortable talking about sexual practices, because what people do behind closed doors is really a key to how to counsel patients about safe sex.
People are well aware of the need to have safe sex. However, depending on the type of sex that you’re having, what body parts go where, what is truly safe can vary and people may not know, for example, to wear a condom when sex toys are involved or that a transgender male on testosterone can become pregnant during penile-vaginal intercourse. Providers really should be very educated on the array of sexual practices that people have and how to counsel them about those. They should know how to ask patients the gender identity of their sexual partners, the sexual orientation of their partners, and what parts go where during sex.
Providers should also talk to patients about PrEP [pre-exposure prophylaxis], whether they identify as cisgender or transgender. My trans patients tend to be a lot more educated about PrEP than other patients. It’s something that many of the residents, even in a standard gynecologic clinic, for example, don’t talk to cisgender patients about because of the stigma surrounding HIV. Many providers still think that the only people who are at risk for HIV are men who have sex with men. And while those rates are higher in some populations, depending on sexual practices, those aren’t the only patients who qualify for PrEP.
Overall, in order to counsel patients about STIs and safe sexual practices, providers should learn to be comfortable talking about sex.
Do you have any strategies on how to make the appointment more successful in addressing those issues?
Dr. Brandt: Bedside manner is a hard thing to teach, and comfort in talking about sex, gender identity, and sexual orientation can vary – but there are a lot of continuing medical education courses that physicians can utilize through the World Professional Association for Transgender Health.
If providers start to notice an influx of patients who identify as transgender or if they want to start seeing transgender patients, it’s really important for them to have that training before they start interacting with patients. In all of medicine, we sort of learn as we go, but this patient population has been subjected to discrimination, violence, error, and misgendering. They have dealt with providers who didn’t understand their health care needs. While this field is evolving, knowing how to appropriately address a patient (using their correct name, pronouns, etc.) is an absolute must.
That needs to be part of a provider’s routine vernacular and not something that they sort of stumble through. You can scare a patient away as soon as they walk into the office with an uneducated front desk staff and things that are seen in the office. Seeking out those educational tools, being aware of your own deficits as a provider and the educational needs of your office, and addressing those needs is really key.
A version of this article first appeared on Medscape.com.
People who identify as transgender experience many health disparities, in addition to lack of access to quality care. The most commonly cited barrier is the lack of providers who are knowledgeable about transgender health care, according to past surveys.
Even those who do seek care often have unpleasant experiences. A 2015 survey conducted by the National Center for Transgender Equality found that 33% of those who saw a health care provider reported at least one unfavorable experience related to being transgender, such as being verbally harassed or refused treatment because of their gender identity. In fact, 23% of those surveyed say they did not seek health care they needed in the past year because of fear of being mistreated as a transgender person.
This interview has been edited for length and clarity.
Question: Surveys have shown that many people who identify as transgender will seek only transition care, not primary or preventive care. Why is that?
Dr. Brandt: My answer is multifactorial. Transgender patients do seek primary care – just not as readily. There’s a lot of misconceptions about health care needs for the LGBT community in general. For example, lesbian or bisexual women may be not as well informed about the need for Pap smears compared with their heterosexual counterparts. These misconceptions are further exacerbated in the transgender community.
The fact that a lot of patients seek only transition-related care, but not preventive services, such as primary care and gynecologic care, is also related to fears of discrimination and lack of education of providers. These patients are afraid when they walk into an office that they will be misgendered or their physician won’t be familiar with their health care needs.
What can clinics and clinicians do to create a safe and welcoming environment?
Dr. Brandt: It starts with educating office staff about terminology and gender identities.
A key feature of our EHR is the sexual orientation and gender identity platform, which asks questions about a patient’s gender identity, sexual orientation, sex assigned at birth, and organ inventory. These data are then found in the patient information tab and are just as relevant as their insurance status, age, and date of birth.
There are many ways a doctor’s office can signal to patients that they are inclusive. They can hang LGBTQ-friendly flags or symbols or a sign saying, “We have an anti-discrimination policy” in the waiting room. A welcoming environment can also be achieved by revising patient questionnaires or forms so that they aren’t gender-specific or binary.
Given that the patient may have limited contact with a primary care clinician, how do you prioritize what you address during the visit?
Dr. Brandt: Similar to cisgender patients, it depends initially on the age of the patient and the reason for the visit. The priorities of an otherwise healthy transgender patient in their 20s are going to be largely the same as for a cisgender patient of the same age. As patients age in the primary care world, you’re addressing more issues, such as colorectal screening, lipid disorders, and mammograms, and that doesn’t change. For the most part, the problems that you address should be specific for that age group.
It becomes more complicated when you add in factors such as hormone therapy and whether patients have had any type of gender-affirming surgery. Those things can change the usual recommendations for screening or risk assessment. We try to figure out what routine health maintenance and cancer screening a patient needs based on age and risk factors, in addition to hormone status and surgical state.
Do you think that many physicians are educated about the care of underserved populations such as transgender patients?
Dr. Brandt: Yes and no. We are definitely getting better at it. For example, the American College of Obstetricians and Gynecologists published a committee opinion highlighting transgender care. So organizations are starting to prioritize these populations and recognize that they are, in fact, underserved and they have special health care needs.
However, the knowledge gaps are still pretty big. I get calls daily from providers asking questions about how to manage patients on hormones, or how to examine a patient who has undergone a vaginoplasty. I hear a lot of horror stories from transgender patients who had their hormones stopped for absurd and medically misinformed reasons.
But I definitely think it’s getting better and it’s being addressed at all levels – the medical school level, the residency level, and the attending level. It just takes time to inform people and for people to get used to the health care needs of these patients.
What should physicians keep in mind when treating patients who identify as transgender?
Dr. Brandt: First and foremost, understanding the terminology and the difference between gender identity, sex, and sexual orientation. Being familiar with that language and being able to speak that language very comfortably and not being awkward about it is a really important thing for primary care physicians and indeed any physician who treats transgender patients.
Physicians should also be aware that any underserved population has higher rates of mental health issues, such as depression and anxiety. Obviously, that goes along with being underserved and the stigma and the disparities that exist for these patients. Having providers educate themselves about what those disparities are and how they impact a patient’s daily life and health is paramount to knowing how to treat patients.
What are your top health concerns for these patients and how do you address them?
Dr. Brandt: I think mental health and safety is probably the number one for me. About 41% of transgender adults have attempted suicide. That number is roughly 51% in transgender youth. That is an astonishing number. These patients have much higher rates of domestic violence, intimate partner violence, and sexual assault, especially trans women and trans women of color. So understanding those statistics is huge.
Obesity, smoking, and substance abuse are my next three. Again, those are things that should be addressed at any visit, regardless of the gender identity or sexual orientation of the patient, but those rates are particularly high in this population.
Fertility and long-term care for patients should be addressed. Many patients who identify as transgender are told they can’t have a family. As a primary care physician, you may see a patient before they are seen by an ob.gyn. or surgeon. Talking about what a patient’s long-term life goals are with fertility and family planning, and what that looks like for them, is a big thing for me. Other providers may not feel that’s a concern, but I believe it should be discussed before initiation of hormone therapy, which can significantly impact fertility in some patients.
Are there nuances to the physical examination that primary care physicians should be aware of when dealing with transmasculine patients vs. transfeminine patients?
Dr. Brandt: Absolutely. And this interview can’t cover the scope of those nuances. An example that comes to mind is the genital exam. For transgender women who have undergone a vaginoplasty, the pelvic exam can be very affirming. Whereas for transgender men, a gynecologic exam can significantly exacerbate dysphoria and there are ways to conduct the exam to limit this discomfort and avoid creating a traumatic experience for the patient. It’s important to be aware that the genital exam, or any type of genitourinary exam, can be either affirming or not affirming.
Sexually transmitted infections are up in the general population, and the trans population is at even higher risk. What should physicians think about when they assess this risk?
Dr. Brandt: It’s really important for primary care clinicians and for gynecologists to learn to be comfortable talking about sexual practices, because what people do behind closed doors is really a key to how to counsel patients about safe sex.
People are well aware of the need to have safe sex. However, depending on the type of sex that you’re having, what body parts go where, what is truly safe can vary and people may not know, for example, to wear a condom when sex toys are involved or that a transgender male on testosterone can become pregnant during penile-vaginal intercourse. Providers really should be very educated on the array of sexual practices that people have and how to counsel them about those. They should know how to ask patients the gender identity of their sexual partners, the sexual orientation of their partners, and what parts go where during sex.
Providers should also talk to patients about PrEP [pre-exposure prophylaxis], whether they identify as cisgender or transgender. My trans patients tend to be a lot more educated about PrEP than other patients. It’s something that many of the residents, even in a standard gynecologic clinic, for example, don’t talk to cisgender patients about because of the stigma surrounding HIV. Many providers still think that the only people who are at risk for HIV are men who have sex with men. And while those rates are higher in some populations, depending on sexual practices, those aren’t the only patients who qualify for PrEP.
Overall, in order to counsel patients about STIs and safe sexual practices, providers should learn to be comfortable talking about sex.
Do you have any strategies on how to make the appointment more successful in addressing those issues?
Dr. Brandt: Bedside manner is a hard thing to teach, and comfort in talking about sex, gender identity, and sexual orientation can vary – but there are a lot of continuing medical education courses that physicians can utilize through the World Professional Association for Transgender Health.
If providers start to notice an influx of patients who identify as transgender or if they want to start seeing transgender patients, it’s really important for them to have that training before they start interacting with patients. In all of medicine, we sort of learn as we go, but this patient population has been subjected to discrimination, violence, error, and misgendering. They have dealt with providers who didn’t understand their health care needs. While this field is evolving, knowing how to appropriately address a patient (using their correct name, pronouns, etc.) is an absolute must.
That needs to be part of a provider’s routine vernacular and not something that they sort of stumble through. You can scare a patient away as soon as they walk into the office with an uneducated front desk staff and things that are seen in the office. Seeking out those educational tools, being aware of your own deficits as a provider and the educational needs of your office, and addressing those needs is really key.
A version of this article first appeared on Medscape.com.
Steroid-refractory pneumonitis from ICIs: Experience at major centers
Pneumonitis is an uncommon and potentially life-threatening complication of immune checkpoint inhibitor (ICI) therapy. A fraction of patients with ICI-related pneumonitis fail to respond to initial therapy with high-dose systemic steroids.
The recently published experiences at two major cancer centers shed light on the outcomes from treatment and can provide some advice to clinicians for dealing with affected patients.
The Johns Hopkins experience
Because ICI-related pneumonitis typically improves within 48-72 hours of steroid therapy, at Johns Hopkins University, Baltimore, steroid-refractory pneumonitis is defined as pneumonitis that demonstrates no clinical improvement after high-dose corticosteroids for 2-14 days. If the immune toxicity–specialized, multidisciplinary management team implements additional immunosuppressive therapy, that is regarded as confirmatory evidence.
Aanika Balaji, a medical student at Johns Hopkins University, and colleagues retrospectively summarized the clinical course of 12 patients with ICI-related pneumonitis between 2011 and 2020. Clinical improvement with subsequent treatment was evidenced by reduction in either level of care or oxygen requirements.
Three-quarters of the patients were current or former smokers, and the same proportion had lung cancer. Most patients (91.6%) had received chemotherapy, 58.3% had prior chest radiotherapy, and 58.3% had achieved partial response or stable disease with an ICI.
Steroid-refractory ICI-related pneumonitis developed between 40 and 127 days (median, 85 days) after the first dose of ICI therapy. Subsequent immunosuppressive management included IVIg, infliximab, or the combination, in addition to ICU-level supportive care.
Among the seven patients who received IVIg alone, two patients (29%) achieved clinical improvement and hospital discharge. The remainder died.
The two patients treated with infliximab and the three patients treated with sequential IVIg and infliximab died. All deaths were attributed to ICI-related pneumonitis or infectious complications.
Overall, clinically relevant findings were:
- Steroid-refractory ICI-related pneumonitis was seen in 18.5% of patients referred for multidisciplinary care.
- Steroid-refractory ICI-related pneumonitis occurred at a median of 85 days into a patient’s ICI treatment.
- Some patients improved clinically after IVIg therapy, but mortality was high overall.
- Infliximab therapy, alone or in combination with IVIg, was ineffective.
The Memorial Sloan Kettering experience
Jason Beattie, MD, of Memorial Sloan Kettering Cancer Center, New York, and colleagues performed a retrospective study of patients who had pneumonitis after ICI therapy and/or received immune modulator therapy after corticosteroids in the setting of ICI cancer treatment.
Manual record review was performed to exclude cases of pneumonitis from other causes. The period reviewed was roughly contemporaneous with the Johns Hopkins series.
Patients with ICI-related pneumonitis were divided into “steroid refractory” (i.e., no response to high-dose corticosteroids) or “steroid resistant” (i.e., initial response, followed by worsening) categories.
The researchers identified 26 patients with ICI-related pneumonitis, all of whom had advanced malignancy (8 lung cancer, 4 malignant melanoma, 4 renal cell cancer, and 10 “other” cancers).
A majority of patients (85%) were current or former smokers, 73% had received ICI monotherapy, 35% had received prior chest radiation at a median interval of 4.9 months prior to pneumonitis onset, and 27% had preexisting pulmonary disease.
Twelve patients (46%) had steroid-refractory ICI-related pneumonitis, and 14 (54%) had steroid-resistant ICI-related pneumonitis.
The two groups differed in time to pneumonitis onset (a median of 68 days in the refractory group and 182 days in the resistant group) and time to immune modulator therapy after beginning steroids (median 7 days and 2.9 months, respectively). In the steroid-refractory cases, pneumonitis was more severe.
In addition to corticosteroids, most patients received infliximab monotherapy or infliximab with mycophenolate mofetil. In contrast to the Johns Hopkins series, IVIg was not used in the Memorial Sloan Kettering cases.
Outcomes from immune modulators were graded based on clinical evidence (progress notes, oxygen requirements, level of care, radiologic information, etc.) of resolution of pneumonitis on imaging at least 8 weeks after cessation of steroids and immune modulator therapy, durable improvement for at least 8 weeks after immune modulator therapy, transient improvement followed by pneumonitis relapse or inadequate follow-up because of death or hospice referral, or no improvement.
Ten patients (38%) had durable improvement of ICI-related pneumonitis, of whom three (12%) had complete resolution. Two of the patients with complete resolution had steroid-refractory pneumonitis, both of whom had received infliximab followed by mycophenolate mofetil.
Among the seven patients with durable improvement, four remained alive on immune modulators. Time to resolution of pneumonitis was protracted, ranging from 2.3 months to 8.4 months in the steroid-refractory patients.
Durable response was less common with steroid-refractory (25%) than steroid-resistant (50%) disease, with a significant difference in 90-day survival of 25% and 71%, respectively.
Among the 13 (50%) patients with transient improvement in ICI-related pneumonitis, 8 ultimately died, either because of recurrent ICI-related pneumonitis or infection. All three patients with no improvement from immune modulators died.
The 90-day all-cause mortality was 50%, with durable pneumonitis improvement and freedom from severe infectious complications occurring in only about a third of patients.
Lessons for clinicians
The National Comprehensive Cancer Network, the Society for Immunotherapy of Cancer, and the European Society of Medical Oncology have all published guidelines and recommendations for immunosuppression for steroid-refractory adverse events from ICIs.
Unfortunately, there is little experience with steroid-unresponsive ICI-related pneumonitis. The ideal sequence, dose, and duration of additional immune modulator therapy for ICI-related pneumonitis are unclear and may differ from the approaches to other immune-related toxicities.
This is important because, as suggested in an editorial by Margaret Gatti-Mays, MD, and James L. Gulley, MD, PhD, it is likely that ICI-related pneumonitis will be seen more in routine practice than in clinical trial populations. In addition, across all tumor types, ICI-related pneumonitis is the most common cause of ICI-associated death from toxicity.
The retrospective studies from Johns Hopkins and Memorial Sloan Kettering constitute the largest published experience with ICI-related pneumonitis and yield important clinical insights.
Uniform definitions of potentially important patient subgroups (e.g., steroid refractory vs. steroid resistant) are needed. The steroid-refractory and steroid-resistant subgroups have distinctly different clinical features and outcomes. Uniformity in the subgroup definitions would be a useful starting point from both clinical and research perspectives.
Preferred treatment choices need to be tested systematically in multi-institutional studies. Any potential impact of treatment for ICI-related pneumonitis on antitumor immune control should be identified.
Endpoints of interest need to be defined and measured prospectively. All-cause mortality after 90 days is important, but, as the authors of both reviews noted, there are vitally important narratives and differences in functionality that are completely concealed by restricting the focus to mortality.
Potential causal relationships with antecedent exposure to tobacco, radiation, intrathoracic tumor burden, or other factors need to be defined.
Clinicians need predictive biomarkers for ICI-related pneumonitis (e.g., in peripheral blood, pulmonary function testing, or bronchoscopy specimens). At-risk patients may benefit from early intervention.
The limitations of single-institution record reviews in guiding real-world patient management notwithstanding, these reviews illustrate the value of registries and prospective studies to guide the path forward. Taking these next steps will ensure for our patients that the success of immune-targeted therapy against their cancer never becomes a Pyrrhic victory.
The Johns Hopkins investigators and the editorialists reported having no disclosures. The Memorial Sloan Kettering investigators disclosed relationships with Targeted Oncology, Merck, Array BioPharma, Novartis, and many other companies.
Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers, as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.
Pneumonitis is an uncommon and potentially life-threatening complication of immune checkpoint inhibitor (ICI) therapy. A fraction of patients with ICI-related pneumonitis fail to respond to initial therapy with high-dose systemic steroids.
The recently published experiences at two major cancer centers shed light on the outcomes from treatment and can provide some advice to clinicians for dealing with affected patients.
The Johns Hopkins experience
Because ICI-related pneumonitis typically improves within 48-72 hours of steroid therapy, at Johns Hopkins University, Baltimore, steroid-refractory pneumonitis is defined as pneumonitis that demonstrates no clinical improvement after high-dose corticosteroids for 2-14 days. If the immune toxicity–specialized, multidisciplinary management team implements additional immunosuppressive therapy, that is regarded as confirmatory evidence.
Aanika Balaji, a medical student at Johns Hopkins University, and colleagues retrospectively summarized the clinical course of 12 patients with ICI-related pneumonitis between 2011 and 2020. Clinical improvement with subsequent treatment was evidenced by reduction in either level of care or oxygen requirements.
Three-quarters of the patients were current or former smokers, and the same proportion had lung cancer. Most patients (91.6%) had received chemotherapy, 58.3% had prior chest radiotherapy, and 58.3% had achieved partial response or stable disease with an ICI.
Steroid-refractory ICI-related pneumonitis developed between 40 and 127 days (median, 85 days) after the first dose of ICI therapy. Subsequent immunosuppressive management included IVIg, infliximab, or the combination, in addition to ICU-level supportive care.
Among the seven patients who received IVIg alone, two patients (29%) achieved clinical improvement and hospital discharge. The remainder died.
The two patients treated with infliximab and the three patients treated with sequential IVIg and infliximab died. All deaths were attributed to ICI-related pneumonitis or infectious complications.
Overall, clinically relevant findings were:
- Steroid-refractory ICI-related pneumonitis was seen in 18.5% of patients referred for multidisciplinary care.
- Steroid-refractory ICI-related pneumonitis occurred at a median of 85 days into a patient’s ICI treatment.
- Some patients improved clinically after IVIg therapy, but mortality was high overall.
- Infliximab therapy, alone or in combination with IVIg, was ineffective.
The Memorial Sloan Kettering experience
Jason Beattie, MD, of Memorial Sloan Kettering Cancer Center, New York, and colleagues performed a retrospective study of patients who had pneumonitis after ICI therapy and/or received immune modulator therapy after corticosteroids in the setting of ICI cancer treatment.
Manual record review was performed to exclude cases of pneumonitis from other causes. The period reviewed was roughly contemporaneous with the Johns Hopkins series.
Patients with ICI-related pneumonitis were divided into “steroid refractory” (i.e., no response to high-dose corticosteroids) or “steroid resistant” (i.e., initial response, followed by worsening) categories.
The researchers identified 26 patients with ICI-related pneumonitis, all of whom had advanced malignancy (8 lung cancer, 4 malignant melanoma, 4 renal cell cancer, and 10 “other” cancers).
A majority of patients (85%) were current or former smokers, 73% had received ICI monotherapy, 35% had received prior chest radiation at a median interval of 4.9 months prior to pneumonitis onset, and 27% had preexisting pulmonary disease.
Twelve patients (46%) had steroid-refractory ICI-related pneumonitis, and 14 (54%) had steroid-resistant ICI-related pneumonitis.
The two groups differed in time to pneumonitis onset (a median of 68 days in the refractory group and 182 days in the resistant group) and time to immune modulator therapy after beginning steroids (median 7 days and 2.9 months, respectively). In the steroid-refractory cases, pneumonitis was more severe.
In addition to corticosteroids, most patients received infliximab monotherapy or infliximab with mycophenolate mofetil. In contrast to the Johns Hopkins series, IVIg was not used in the Memorial Sloan Kettering cases.
Outcomes from immune modulators were graded based on clinical evidence (progress notes, oxygen requirements, level of care, radiologic information, etc.) of resolution of pneumonitis on imaging at least 8 weeks after cessation of steroids and immune modulator therapy, durable improvement for at least 8 weeks after immune modulator therapy, transient improvement followed by pneumonitis relapse or inadequate follow-up because of death or hospice referral, or no improvement.
Ten patients (38%) had durable improvement of ICI-related pneumonitis, of whom three (12%) had complete resolution. Two of the patients with complete resolution had steroid-refractory pneumonitis, both of whom had received infliximab followed by mycophenolate mofetil.
Among the seven patients with durable improvement, four remained alive on immune modulators. Time to resolution of pneumonitis was protracted, ranging from 2.3 months to 8.4 months in the steroid-refractory patients.
Durable response was less common with steroid-refractory (25%) than steroid-resistant (50%) disease, with a significant difference in 90-day survival of 25% and 71%, respectively.
Among the 13 (50%) patients with transient improvement in ICI-related pneumonitis, 8 ultimately died, either because of recurrent ICI-related pneumonitis or infection. All three patients with no improvement from immune modulators died.
The 90-day all-cause mortality was 50%, with durable pneumonitis improvement and freedom from severe infectious complications occurring in only about a third of patients.
Lessons for clinicians
The National Comprehensive Cancer Network, the Society for Immunotherapy of Cancer, and the European Society of Medical Oncology have all published guidelines and recommendations for immunosuppression for steroid-refractory adverse events from ICIs.
Unfortunately, there is little experience with steroid-unresponsive ICI-related pneumonitis. The ideal sequence, dose, and duration of additional immune modulator therapy for ICI-related pneumonitis are unclear and may differ from the approaches to other immune-related toxicities.
This is important because, as suggested in an editorial by Margaret Gatti-Mays, MD, and James L. Gulley, MD, PhD, it is likely that ICI-related pneumonitis will be seen more in routine practice than in clinical trial populations. In addition, across all tumor types, ICI-related pneumonitis is the most common cause of ICI-associated death from toxicity.
The retrospective studies from Johns Hopkins and Memorial Sloan Kettering constitute the largest published experience with ICI-related pneumonitis and yield important clinical insights.
Uniform definitions of potentially important patient subgroups (e.g., steroid refractory vs. steroid resistant) are needed. The steroid-refractory and steroid-resistant subgroups have distinctly different clinical features and outcomes. Uniformity in the subgroup definitions would be a useful starting point from both clinical and research perspectives.
Preferred treatment choices need to be tested systematically in multi-institutional studies. Any potential impact of treatment for ICI-related pneumonitis on antitumor immune control should be identified.
Endpoints of interest need to be defined and measured prospectively. All-cause mortality after 90 days is important, but, as the authors of both reviews noted, there are vitally important narratives and differences in functionality that are completely concealed by restricting the focus to mortality.
Potential causal relationships with antecedent exposure to tobacco, radiation, intrathoracic tumor burden, or other factors need to be defined.
Clinicians need predictive biomarkers for ICI-related pneumonitis (e.g., in peripheral blood, pulmonary function testing, or bronchoscopy specimens). At-risk patients may benefit from early intervention.
The limitations of single-institution record reviews in guiding real-world patient management notwithstanding, these reviews illustrate the value of registries and prospective studies to guide the path forward. Taking these next steps will ensure for our patients that the success of immune-targeted therapy against their cancer never becomes a Pyrrhic victory.
The Johns Hopkins investigators and the editorialists reported having no disclosures. The Memorial Sloan Kettering investigators disclosed relationships with Targeted Oncology, Merck, Array BioPharma, Novartis, and many other companies.
Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers, as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.
Pneumonitis is an uncommon and potentially life-threatening complication of immune checkpoint inhibitor (ICI) therapy. A fraction of patients with ICI-related pneumonitis fail to respond to initial therapy with high-dose systemic steroids.
The recently published experiences at two major cancer centers shed light on the outcomes from treatment and can provide some advice to clinicians for dealing with affected patients.
The Johns Hopkins experience
Because ICI-related pneumonitis typically improves within 48-72 hours of steroid therapy, at Johns Hopkins University, Baltimore, steroid-refractory pneumonitis is defined as pneumonitis that demonstrates no clinical improvement after high-dose corticosteroids for 2-14 days. If the immune toxicity–specialized, multidisciplinary management team implements additional immunosuppressive therapy, that is regarded as confirmatory evidence.
Aanika Balaji, a medical student at Johns Hopkins University, and colleagues retrospectively summarized the clinical course of 12 patients with ICI-related pneumonitis between 2011 and 2020. Clinical improvement with subsequent treatment was evidenced by reduction in either level of care or oxygen requirements.
Three-quarters of the patients were current or former smokers, and the same proportion had lung cancer. Most patients (91.6%) had received chemotherapy, 58.3% had prior chest radiotherapy, and 58.3% had achieved partial response or stable disease with an ICI.
Steroid-refractory ICI-related pneumonitis developed between 40 and 127 days (median, 85 days) after the first dose of ICI therapy. Subsequent immunosuppressive management included IVIg, infliximab, or the combination, in addition to ICU-level supportive care.
Among the seven patients who received IVIg alone, two patients (29%) achieved clinical improvement and hospital discharge. The remainder died.
The two patients treated with infliximab and the three patients treated with sequential IVIg and infliximab died. All deaths were attributed to ICI-related pneumonitis or infectious complications.
Overall, clinically relevant findings were:
- Steroid-refractory ICI-related pneumonitis was seen in 18.5% of patients referred for multidisciplinary care.
- Steroid-refractory ICI-related pneumonitis occurred at a median of 85 days into a patient’s ICI treatment.
- Some patients improved clinically after IVIg therapy, but mortality was high overall.
- Infliximab therapy, alone or in combination with IVIg, was ineffective.
The Memorial Sloan Kettering experience
Jason Beattie, MD, of Memorial Sloan Kettering Cancer Center, New York, and colleagues performed a retrospective study of patients who had pneumonitis after ICI therapy and/or received immune modulator therapy after corticosteroids in the setting of ICI cancer treatment.
Manual record review was performed to exclude cases of pneumonitis from other causes. The period reviewed was roughly contemporaneous with the Johns Hopkins series.
Patients with ICI-related pneumonitis were divided into “steroid refractory” (i.e., no response to high-dose corticosteroids) or “steroid resistant” (i.e., initial response, followed by worsening) categories.
The researchers identified 26 patients with ICI-related pneumonitis, all of whom had advanced malignancy (8 lung cancer, 4 malignant melanoma, 4 renal cell cancer, and 10 “other” cancers).
A majority of patients (85%) were current or former smokers, 73% had received ICI monotherapy, 35% had received prior chest radiation at a median interval of 4.9 months prior to pneumonitis onset, and 27% had preexisting pulmonary disease.
Twelve patients (46%) had steroid-refractory ICI-related pneumonitis, and 14 (54%) had steroid-resistant ICI-related pneumonitis.
The two groups differed in time to pneumonitis onset (a median of 68 days in the refractory group and 182 days in the resistant group) and time to immune modulator therapy after beginning steroids (median 7 days and 2.9 months, respectively). In the steroid-refractory cases, pneumonitis was more severe.
In addition to corticosteroids, most patients received infliximab monotherapy or infliximab with mycophenolate mofetil. In contrast to the Johns Hopkins series, IVIg was not used in the Memorial Sloan Kettering cases.
Outcomes from immune modulators were graded based on clinical evidence (progress notes, oxygen requirements, level of care, radiologic information, etc.) of resolution of pneumonitis on imaging at least 8 weeks after cessation of steroids and immune modulator therapy, durable improvement for at least 8 weeks after immune modulator therapy, transient improvement followed by pneumonitis relapse or inadequate follow-up because of death or hospice referral, or no improvement.
Ten patients (38%) had durable improvement of ICI-related pneumonitis, of whom three (12%) had complete resolution. Two of the patients with complete resolution had steroid-refractory pneumonitis, both of whom had received infliximab followed by mycophenolate mofetil.
Among the seven patients with durable improvement, four remained alive on immune modulators. Time to resolution of pneumonitis was protracted, ranging from 2.3 months to 8.4 months in the steroid-refractory patients.
Durable response was less common with steroid-refractory (25%) than steroid-resistant (50%) disease, with a significant difference in 90-day survival of 25% and 71%, respectively.
Among the 13 (50%) patients with transient improvement in ICI-related pneumonitis, 8 ultimately died, either because of recurrent ICI-related pneumonitis or infection. All three patients with no improvement from immune modulators died.
The 90-day all-cause mortality was 50%, with durable pneumonitis improvement and freedom from severe infectious complications occurring in only about a third of patients.
Lessons for clinicians
The National Comprehensive Cancer Network, the Society for Immunotherapy of Cancer, and the European Society of Medical Oncology have all published guidelines and recommendations for immunosuppression for steroid-refractory adverse events from ICIs.
Unfortunately, there is little experience with steroid-unresponsive ICI-related pneumonitis. The ideal sequence, dose, and duration of additional immune modulator therapy for ICI-related pneumonitis are unclear and may differ from the approaches to other immune-related toxicities.
This is important because, as suggested in an editorial by Margaret Gatti-Mays, MD, and James L. Gulley, MD, PhD, it is likely that ICI-related pneumonitis will be seen more in routine practice than in clinical trial populations. In addition, across all tumor types, ICI-related pneumonitis is the most common cause of ICI-associated death from toxicity.
The retrospective studies from Johns Hopkins and Memorial Sloan Kettering constitute the largest published experience with ICI-related pneumonitis and yield important clinical insights.
Uniform definitions of potentially important patient subgroups (e.g., steroid refractory vs. steroid resistant) are needed. The steroid-refractory and steroid-resistant subgroups have distinctly different clinical features and outcomes. Uniformity in the subgroup definitions would be a useful starting point from both clinical and research perspectives.
Preferred treatment choices need to be tested systematically in multi-institutional studies. Any potential impact of treatment for ICI-related pneumonitis on antitumor immune control should be identified.
Endpoints of interest need to be defined and measured prospectively. All-cause mortality after 90 days is important, but, as the authors of both reviews noted, there are vitally important narratives and differences in functionality that are completely concealed by restricting the focus to mortality.
Potential causal relationships with antecedent exposure to tobacco, radiation, intrathoracic tumor burden, or other factors need to be defined.
Clinicians need predictive biomarkers for ICI-related pneumonitis (e.g., in peripheral blood, pulmonary function testing, or bronchoscopy specimens). At-risk patients may benefit from early intervention.
The limitations of single-institution record reviews in guiding real-world patient management notwithstanding, these reviews illustrate the value of registries and prospective studies to guide the path forward. Taking these next steps will ensure for our patients that the success of immune-targeted therapy against their cancer never becomes a Pyrrhic victory.
The Johns Hopkins investigators and the editorialists reported having no disclosures. The Memorial Sloan Kettering investigators disclosed relationships with Targeted Oncology, Merck, Array BioPharma, Novartis, and many other companies.
Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers, as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.
Moderate-to-vigorous physical activity is the answer to childhood obesity
There is no question that none of us, not just pediatricians, is doing a very good job of dealing with the obesity problem this nation faces. We can agree that a more active lifestyle that includes spells of vigorous activity is important for weight management. We know that in general overweight people sleep less than do those whose basal metabolic rate is normal. And, of course, we know that a diet high in calorie-dense foods is associated with unhealthy weight gain.
Not surprisingly, overweight individuals are usually struggling with all three of these challenges. They are less active, get too little sleep, and are ingesting a diet that is too calorie dense. In other words, they would benefit from a total lifestyle reboot. But you know as well as I do a change of that magnitude is much easier said than done. Few families can afford nor would they have the appetite for sending their children to a “fat camp” for 6 months with no guarantee of success.
Instead of throwing up our hands in the face of this monumental task or attacking it at close range, maybe we should aim our efforts at the risk associations that will yield the best results for our efforts. A group of researchers at the University of South Australia has just published a study in Pediatrics in which they provide some data that may help us target our interventions with obese and overweight children. The researchers did not investigate diet, but used accelerometers to determine how much time each child spent sleeping and a variety of activity levels. They then determined what effect changes in the child’s allocation of activity had on their adiposity.
The investigators found on a minute-to-minute basis that an increase in a child’s moderate-to-vigorous physical activity (MVPA) was up to six times more effective at influencing adiposity than was a decrease in sedentary time or an increase in sleep duration. For example, 17 minutes of MVPA had the same beneficial effect as 52 minutes more sleep or 56 minutes less sedentary time. Interestingly and somewhat surprisingly, the researchers found that light activity was positively associated with adiposity.
For those of us in primary care, this study from Australia suggests that our time (and the parents’ time) would be best spent figuring out how to include more MVPA in the child’s day and not focus so much on sleep duration and sedentary intervals.
However, before one can make any recommendation one must first have a clear understanding of how the child and his family spend the day. This process can be done in the office by interviewing the family. I have found that this is not as time consuming as one might think and often yields some valuable additional insight into the family’s dynamics. Sending the family home with an hourly log to be filled in or asking them to use a smartphone to record information will also work.
I must admit that at first I found the results of this study ran counter to my intuition. I have always felt that sleep is the linchpin to the solution of a variety of health style related problems. In my construct, more sleep has always been the first and easy answer and decreasing screen time the second. But, it turns out that increasing MVPA may give us the biggest bang for the buck. Which is fine with me.
The problem facing us is how we can be creative in adding that 20 minutes of vigorous activity. In most communities, we have allowed the school system to drop the ball. We can hope that this study will be confirmed or at least widely publicized. It feels like it is time to guarantee that every child gets a robust gym class every school day.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
There is no question that none of us, not just pediatricians, is doing a very good job of dealing with the obesity problem this nation faces. We can agree that a more active lifestyle that includes spells of vigorous activity is important for weight management. We know that in general overweight people sleep less than do those whose basal metabolic rate is normal. And, of course, we know that a diet high in calorie-dense foods is associated with unhealthy weight gain.
Not surprisingly, overweight individuals are usually struggling with all three of these challenges. They are less active, get too little sleep, and are ingesting a diet that is too calorie dense. In other words, they would benefit from a total lifestyle reboot. But you know as well as I do a change of that magnitude is much easier said than done. Few families can afford nor would they have the appetite for sending their children to a “fat camp” for 6 months with no guarantee of success.
Instead of throwing up our hands in the face of this monumental task or attacking it at close range, maybe we should aim our efforts at the risk associations that will yield the best results for our efforts. A group of researchers at the University of South Australia has just published a study in Pediatrics in which they provide some data that may help us target our interventions with obese and overweight children. The researchers did not investigate diet, but used accelerometers to determine how much time each child spent sleeping and a variety of activity levels. They then determined what effect changes in the child’s allocation of activity had on their adiposity.
The investigators found on a minute-to-minute basis that an increase in a child’s moderate-to-vigorous physical activity (MVPA) was up to six times more effective at influencing adiposity than was a decrease in sedentary time or an increase in sleep duration. For example, 17 minutes of MVPA had the same beneficial effect as 52 minutes more sleep or 56 minutes less sedentary time. Interestingly and somewhat surprisingly, the researchers found that light activity was positively associated with adiposity.
For those of us in primary care, this study from Australia suggests that our time (and the parents’ time) would be best spent figuring out how to include more MVPA in the child’s day and not focus so much on sleep duration and sedentary intervals.
However, before one can make any recommendation one must first have a clear understanding of how the child and his family spend the day. This process can be done in the office by interviewing the family. I have found that this is not as time consuming as one might think and often yields some valuable additional insight into the family’s dynamics. Sending the family home with an hourly log to be filled in or asking them to use a smartphone to record information will also work.
I must admit that at first I found the results of this study ran counter to my intuition. I have always felt that sleep is the linchpin to the solution of a variety of health style related problems. In my construct, more sleep has always been the first and easy answer and decreasing screen time the second. But, it turns out that increasing MVPA may give us the biggest bang for the buck. Which is fine with me.
The problem facing us is how we can be creative in adding that 20 minutes of vigorous activity. In most communities, we have allowed the school system to drop the ball. We can hope that this study will be confirmed or at least widely publicized. It feels like it is time to guarantee that every child gets a robust gym class every school day.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
There is no question that none of us, not just pediatricians, is doing a very good job of dealing with the obesity problem this nation faces. We can agree that a more active lifestyle that includes spells of vigorous activity is important for weight management. We know that in general overweight people sleep less than do those whose basal metabolic rate is normal. And, of course, we know that a diet high in calorie-dense foods is associated with unhealthy weight gain.
Not surprisingly, overweight individuals are usually struggling with all three of these challenges. They are less active, get too little sleep, and are ingesting a diet that is too calorie dense. In other words, they would benefit from a total lifestyle reboot. But you know as well as I do a change of that magnitude is much easier said than done. Few families can afford nor would they have the appetite for sending their children to a “fat camp” for 6 months with no guarantee of success.
Instead of throwing up our hands in the face of this monumental task or attacking it at close range, maybe we should aim our efforts at the risk associations that will yield the best results for our efforts. A group of researchers at the University of South Australia has just published a study in Pediatrics in which they provide some data that may help us target our interventions with obese and overweight children. The researchers did not investigate diet, but used accelerometers to determine how much time each child spent sleeping and a variety of activity levels. They then determined what effect changes in the child’s allocation of activity had on their adiposity.
The investigators found on a minute-to-minute basis that an increase in a child’s moderate-to-vigorous physical activity (MVPA) was up to six times more effective at influencing adiposity than was a decrease in sedentary time or an increase in sleep duration. For example, 17 minutes of MVPA had the same beneficial effect as 52 minutes more sleep or 56 minutes less sedentary time. Interestingly and somewhat surprisingly, the researchers found that light activity was positively associated with adiposity.
For those of us in primary care, this study from Australia suggests that our time (and the parents’ time) would be best spent figuring out how to include more MVPA in the child’s day and not focus so much on sleep duration and sedentary intervals.
However, before one can make any recommendation one must first have a clear understanding of how the child and his family spend the day. This process can be done in the office by interviewing the family. I have found that this is not as time consuming as one might think and often yields some valuable additional insight into the family’s dynamics. Sending the family home with an hourly log to be filled in or asking them to use a smartphone to record information will also work.
I must admit that at first I found the results of this study ran counter to my intuition. I have always felt that sleep is the linchpin to the solution of a variety of health style related problems. In my construct, more sleep has always been the first and easy answer and decreasing screen time the second. But, it turns out that increasing MVPA may give us the biggest bang for the buck. Which is fine with me.
The problem facing us is how we can be creative in adding that 20 minutes of vigorous activity. In most communities, we have allowed the school system to drop the ball. We can hope that this study will be confirmed or at least widely publicized. It feels like it is time to guarantee that every child gets a robust gym class every school day.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
Disparities and racism in health care
From Anarcha Westcott to George Floyd to the Atlanta massacre
The Atlanta spa massacre, the commencement of the George Floyd trial, and COVID-19 highlight societal inequalities and health disparities among minority groups. We can only hope that we have arrived at the tipping point to address historical institutional racism and structural violence in this country.
Admittedly, we, as health care professionals, have been at best apathetic and at worst complicit with this tragedy. Dr. James Sims, the father of gynecology, perfected his surgical techniques of vaginal fistula on slaves. Starting in 1845, he performed over thirty surgeries without anesthesia on Anarcha Westcott.1 Moreover, the past century was dotted with similar transgressions such as the Tuskegee Untreated Syphilis Experiment from 1932 to 1972, the use of the cells of Henrietta Lack in 1951, and the disproportionate lack of funding of sickle cell research.2 We must move from complicit/apathetic to being part of the discourse and solution.
The juxtaposition of George Floyd’s cry of “I can’t breathe” and the disproportionate way in which COVID-19 has affected Black communities and people of color highlights how deeply entrenched the problem of systemic racism is in this country. The innumerable reported hate crimes against Asian Americans stemming from xenophobia linked to the COVID-19 pandemic and the stereotyping of Hispanic Americans as criminals during the last U.S. administration demonstrate that all minority racial/ethnic groups are affected. As clinicians who care for the health of our communities and strive to reduce suffering, we have a responsibility to identify discrimination that exists in the health care system – ranging from subtle implicit bias to overt discrimination.3
Unconscious bias and its effect on diversity and inclusion has only recently been recognized and addressed in the realm of health care as applied to clinicians. This is key to structural racism as providers inadvertently use unconscious bias every day to make their medical decisions quick and efficient. As Dayna Bowen Matthews points out in her book, “Just Medicine,” “where health and health care are concerned, even when implicit biases are based on seemingly benign distinctions, or supported by apparently rational or widely held observations, these biases can cause grave individual, group, and societal harm that is commensurate to and even exceeds the harm caused by outright racism.” To deny the prejudices that providers have when making decisions for patients will perpetuate the racism and hinder our ability to overcome health inequity. Americans of racial and ethnic minorities have a higher incidence of chronic diseases and premature death when compared to white Americans.4 These disparities exist even when controlling for individual variations such as availability of health insurance, education, and socioeconomic status.5 Social determinants of health because of racial differences is often talked about as a cause of health care inequity, but given the evidence that providers play a much more active role in this, we need to become more comfortable with the discomfort of using the word “racism” if we intend to bring awareness and create change. 
In order to tackle structural racism in health care, organizations must take a multifaceted approach. Evidence-based strategies include: creation of an inclusive workforce, diversification of the workforce to better represent patient populations, and education/training on the effect of implicit bias on equitable health care.6 These aspirations can provide a framework for interventions at all levels of health care organizations.
The JEDI (justice, equity, diversity, and inclusion) committee of the section of hospital medicine at Wake Forest Baptist Health System came into existence in November 2019. The objective for JEDI was to use evidence-based methods to help create an environment that would lead to the creation of a diverse and inclusive hospital medicine group. Prior to establishing our committee, we interviewed providers from traditional minority groups who were part of our practice to bring clarity to the discrimination faced by our providers from colleagues, staff, and patients. The discrimination varied from microaggressions caused by implicit biases to macroaggression from overt discrimination. We initiated our work on this burning platform by following the evidence-based methods mentioned earlier.
Creation of an inclusive workforce. Our working committee included members of varied backgrounds and experiences who were passionate about enhancing equity while focusing on inclusion and wellness. The committee brainstormed ideas for interventions that could make a positive impact for our teammates. Individual providers voted to choose the interventions that would positively impact their inclusion and health. Using a validated survey,7 we were able to measure the degree of inclusion of our work group based on multiple demographics including age, gender, race/ethnicity, training (physician vs. APP), etc. Our intention is to complete the proposed interventions before remeasuring inclusion to understand the effect of our work.
Diversifying the workforce. Although our section of hospital medicine at Wake Forest Baptist Health System consists of providers self-identifying as people of color, we do not adequately mirror the racial composition of the population we serve. To achieve the desired result, we have made changes to our recruiting program. The section of hospital medicine visibly demonstrates our commitment to diversity and displays our values on our website. We intend for this to attract diverse individuals who would intend to be part of our group.
Education and training on impact of implicit bias on equitable health care. Implicit bias training will have to consist of actions that would help our clinicians recognize their own prejudices and find means to mitigate them. We have committed to bystander education that would give practice and words to our providers to speak up in situations where they see discrimination in the workplace that is directed against patients, staff, and colleagues. A series of open and honest conversations about racial and gender discrimination in health care that involves inviting accomplished speakers from around the country has been planned. Continued attention to opportunities to further awareness on this subject is vital.
On Jan. 6, 2021, a day that should have filled citizens with pride and hope with the election of the first Black minister and the first Jewish man to the U.S. Senate in a historically conservative state, as well as the confirmation of the election of a president who pledged to address racial disparities, we instead saw another stark reminder of where we came from and just how far we have to go. White supremacists incited by their perceived threat to a legacy of centuries of suppression transformed into a mob of insurrectionists, blatantly bearing Confederate and Nazi flags, and seemingly easily invaded and desecrated the U.S. Capitol. On March 16, 2021, a white male who was “having a bad day” ended the lives of eight individuals, including six Asian Americans.
These instances have brought forth the reality that many of our interventions have been directed towards subtle prejudices and microaggressions alone. We have skirted around calling out overt discrimination of minority groups and failed to openly acknowledge our own contribution to the problem. This newly found awareness has created an opportunity for more impactful work. The equitable delivery of health care is dependent on creating a patient-provider relationship based on trust; addressing overt discrimination respectfully; and overcoming unconscious bias.
While we have made the commitment to confront structural racism in our workplace and taken important steps to work towards this goal with the initiatives set forth by our JEDI committee, we certainly have a long way to go. George Floyd spent the last 8 minutes and 46 seconds of his life struggling to breathe and asking for his mother. Let’s not waste another second and instead be the change that we seek in health care.
Dr. Nagaraj is medical director, Hospital Medicine, at Lexington (N.C.) Medical Center, assistant professor at Wake Forest School of Medicine, and cochair, JEDI committee for diversity and inclusion, hospital medicine, at Wake Forest Baptist Health, Winston-Salem, NC. Ms. Haller is cochair, JEDI committee for diversity and inclusion, hospital medicine, Wake Forest Baptist Health. Dr. Huang is the executive medical director and service line director of general medicine and hospital medicine within the Wake Forest Baptist Health System and associate professor at Wake Forest School of Medicine. The authors would like to acknowledge Dr. Julie Freischlag, Dr. Kevin High, and Dr. David McIntosh at Wake Forest Baptist Health System for the support of the JEDI committee and the section on hospital medicine.
References
1. Holland B. The “father of modern gynecology” performed shocking experiments on enslaved women. History. 2017 Aug 29. www.history.com/news/the-father-of-modern-gynecology-performed-shocking-experiments-on-slaves.
2. Buseh AG et al. Community leaders’ perspectives on engaging African Americans in biobanks and other human genetics initiatives. J Community Genet. 2013 Oct;4(4):483-94. doi: 10.1007/s12687-013-0155-z.
3. National Center for Health Statistics. Health, United States, 2015: With special feature on racial and ethnic health disparities. 2016 May. www.cdc.gov/nchs/data/hus/hus15.pdf.
4. Bailey ZD et al. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017 Apr 8;389(10077):1453-63. doi: 10.1016/S0140-6736(17)30569-X.
5. Arvizo C and Garrison E. Diversity and inclusion: the role of unconscious bias on patient care, health outcomes and the workforce in obstetrics and gynaecology. Curr Opin Obstet Gynecol. 2019 Oct;31(5):356-62. doi: 10.1097/GCO.0000000000000566.
6. Chung BG et al. Work group inclusion: test of a scale and model. Group & Organization Management. 2020;45(1):75-102. doi: 10.1177/1059601119839858.
From Anarcha Westcott to George Floyd to the Atlanta massacre
From Anarcha Westcott to George Floyd to the Atlanta massacre
The Atlanta spa massacre, the commencement of the George Floyd trial, and COVID-19 highlight societal inequalities and health disparities among minority groups. We can only hope that we have arrived at the tipping point to address historical institutional racism and structural violence in this country.
Admittedly, we, as health care professionals, have been at best apathetic and at worst complicit with this tragedy. Dr. James Sims, the father of gynecology, perfected his surgical techniques of vaginal fistula on slaves. Starting in 1845, he performed over thirty surgeries without anesthesia on Anarcha Westcott.1 Moreover, the past century was dotted with similar transgressions such as the Tuskegee Untreated Syphilis Experiment from 1932 to 1972, the use of the cells of Henrietta Lack in 1951, and the disproportionate lack of funding of sickle cell research.2 We must move from complicit/apathetic to being part of the discourse and solution.
The juxtaposition of George Floyd’s cry of “I can’t breathe” and the disproportionate way in which COVID-19 has affected Black communities and people of color highlights how deeply entrenched the problem of systemic racism is in this country. The innumerable reported hate crimes against Asian Americans stemming from xenophobia linked to the COVID-19 pandemic and the stereotyping of Hispanic Americans as criminals during the last U.S. administration demonstrate that all minority racial/ethnic groups are affected. As clinicians who care for the health of our communities and strive to reduce suffering, we have a responsibility to identify discrimination that exists in the health care system – ranging from subtle implicit bias to overt discrimination.3
Unconscious bias and its effect on diversity and inclusion has only recently been recognized and addressed in the realm of health care as applied to clinicians. This is key to structural racism as providers inadvertently use unconscious bias every day to make their medical decisions quick and efficient. As Dayna Bowen Matthews points out in her book, “Just Medicine,” “where health and health care are concerned, even when implicit biases are based on seemingly benign distinctions, or supported by apparently rational or widely held observations, these biases can cause grave individual, group, and societal harm that is commensurate to and even exceeds the harm caused by outright racism.” To deny the prejudices that providers have when making decisions for patients will perpetuate the racism and hinder our ability to overcome health inequity. Americans of racial and ethnic minorities have a higher incidence of chronic diseases and premature death when compared to white Americans.4 These disparities exist even when controlling for individual variations such as availability of health insurance, education, and socioeconomic status.5 Social determinants of health because of racial differences is often talked about as a cause of health care inequity, but given the evidence that providers play a much more active role in this, we need to become more comfortable with the discomfort of using the word “racism” if we intend to bring awareness and create change.
In order to tackle structural racism in health care, organizations must take a multifaceted approach. Evidence-based strategies include: creation of an inclusive workforce, diversification of the workforce to better represent patient populations, and education/training on the effect of implicit bias on equitable health care.6 These aspirations can provide a framework for interventions at all levels of health care organizations.
The JEDI (justice, equity, diversity, and inclusion) committee of the section of hospital medicine at Wake Forest Baptist Health System came into existence in November 2019. The objective for JEDI was to use evidence-based methods to help create an environment that would lead to the creation of a diverse and inclusive hospital medicine group. Prior to establishing our committee, we interviewed providers from traditional minority groups who were part of our practice to bring clarity to the discrimination faced by our providers from colleagues, staff, and patients. The discrimination varied from microaggressions caused by implicit biases to macroaggression from overt discrimination. We initiated our work on this burning platform by following the evidence-based methods mentioned earlier.
Creation of an inclusive workforce. Our working committee included members of varied backgrounds and experiences who were passionate about enhancing equity while focusing on inclusion and wellness. The committee brainstormed ideas for interventions that could make a positive impact for our teammates. Individual providers voted to choose the interventions that would positively impact their inclusion and health. Using a validated survey,7 we were able to measure the degree of inclusion of our work group based on multiple demographics including age, gender, race/ethnicity, training (physician vs. APP), etc. Our intention is to complete the proposed interventions before remeasuring inclusion to understand the effect of our work.
Diversifying the workforce. Although our section of hospital medicine at Wake Forest Baptist Health System consists of providers self-identifying as people of color, we do not adequately mirror the racial composition of the population we serve. To achieve the desired result, we have made changes to our recruiting program. The section of hospital medicine visibly demonstrates our commitment to diversity and displays our values on our website. We intend for this to attract diverse individuals who would intend to be part of our group.
Education and training on impact of implicit bias on equitable health care. Implicit bias training will have to consist of actions that would help our clinicians recognize their own prejudices and find means to mitigate them. We have committed to bystander education that would give practice and words to our providers to speak up in situations where they see discrimination in the workplace that is directed against patients, staff, and colleagues. A series of open and honest conversations about racial and gender discrimination in health care that involves inviting accomplished speakers from around the country has been planned. Continued attention to opportunities to further awareness on this subject is vital.
On Jan. 6, 2021, a day that should have filled citizens with pride and hope with the election of the first Black minister and the first Jewish man to the U.S. Senate in a historically conservative state, as well as the confirmation of the election of a president who pledged to address racial disparities, we instead saw another stark reminder of where we came from and just how far we have to go. White supremacists incited by their perceived threat to a legacy of centuries of suppression transformed into a mob of insurrectionists, blatantly bearing Confederate and Nazi flags, and seemingly easily invaded and desecrated the U.S. Capitol. On March 16, 2021, a white male who was “having a bad day” ended the lives of eight individuals, including six Asian Americans.
These instances have brought forth the reality that many of our interventions have been directed towards subtle prejudices and microaggressions alone. We have skirted around calling out overt discrimination of minority groups and failed to openly acknowledge our own contribution to the problem. This newly found awareness has created an opportunity for more impactful work. The equitable delivery of health care is dependent on creating a patient-provider relationship based on trust; addressing overt discrimination respectfully; and overcoming unconscious bias.
While we have made the commitment to confront structural racism in our workplace and taken important steps to work towards this goal with the initiatives set forth by our JEDI committee, we certainly have a long way to go. George Floyd spent the last 8 minutes and 46 seconds of his life struggling to breathe and asking for his mother. Let’s not waste another second and instead be the change that we seek in health care.
Dr. Nagaraj is medical director, Hospital Medicine, at Lexington (N.C.) Medical Center, assistant professor at Wake Forest School of Medicine, and cochair, JEDI committee for diversity and inclusion, hospital medicine, at Wake Forest Baptist Health, Winston-Salem, NC. Ms. Haller is cochair, JEDI committee for diversity and inclusion, hospital medicine, Wake Forest Baptist Health. Dr. Huang is the executive medical director and service line director of general medicine and hospital medicine within the Wake Forest Baptist Health System and associate professor at Wake Forest School of Medicine. The authors would like to acknowledge Dr. Julie Freischlag, Dr. Kevin High, and Dr. David McIntosh at Wake Forest Baptist Health System for the support of the JEDI committee and the section on hospital medicine.
References
1. Holland B. The “father of modern gynecology” performed shocking experiments on enslaved women. History. 2017 Aug 29. www.history.com/news/the-father-of-modern-gynecology-performed-shocking-experiments-on-slaves.
2. Buseh AG et al. Community leaders’ perspectives on engaging African Americans in biobanks and other human genetics initiatives. J Community Genet. 2013 Oct;4(4):483-94. doi: 10.1007/s12687-013-0155-z.
3. National Center for Health Statistics. Health, United States, 2015: With special feature on racial and ethnic health disparities. 2016 May. www.cdc.gov/nchs/data/hus/hus15.pdf.
4. Bailey ZD et al. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017 Apr 8;389(10077):1453-63. doi: 10.1016/S0140-6736(17)30569-X.
5. Arvizo C and Garrison E. Diversity and inclusion: the role of unconscious bias on patient care, health outcomes and the workforce in obstetrics and gynaecology. Curr Opin Obstet Gynecol. 2019 Oct;31(5):356-62. doi: 10.1097/GCO.0000000000000566.
6. Chung BG et al. Work group inclusion: test of a scale and model. Group & Organization Management. 2020;45(1):75-102. doi: 10.1177/1059601119839858.
The Atlanta spa massacre, the commencement of the George Floyd trial, and COVID-19 highlight societal inequalities and health disparities among minority groups. We can only hope that we have arrived at the tipping point to address historical institutional racism and structural violence in this country.
Admittedly, we, as health care professionals, have been at best apathetic and at worst complicit with this tragedy. Dr. James Sims, the father of gynecology, perfected his surgical techniques of vaginal fistula on slaves. Starting in 1845, he performed over thirty surgeries without anesthesia on Anarcha Westcott.1 Moreover, the past century was dotted with similar transgressions such as the Tuskegee Untreated Syphilis Experiment from 1932 to 1972, the use of the cells of Henrietta Lack in 1951, and the disproportionate lack of funding of sickle cell research.2 We must move from complicit/apathetic to being part of the discourse and solution.
The juxtaposition of George Floyd’s cry of “I can’t breathe” and the disproportionate way in which COVID-19 has affected Black communities and people of color highlights how deeply entrenched the problem of systemic racism is in this country. The innumerable reported hate crimes against Asian Americans stemming from xenophobia linked to the COVID-19 pandemic and the stereotyping of Hispanic Americans as criminals during the last U.S. administration demonstrate that all minority racial/ethnic groups are affected. As clinicians who care for the health of our communities and strive to reduce suffering, we have a responsibility to identify discrimination that exists in the health care system – ranging from subtle implicit bias to overt discrimination.3
Unconscious bias and its effect on diversity and inclusion has only recently been recognized and addressed in the realm of health care as applied to clinicians. This is key to structural racism as providers inadvertently use unconscious bias every day to make their medical decisions quick and efficient. As Dayna Bowen Matthews points out in her book, “Just Medicine,” “where health and health care are concerned, even when implicit biases are based on seemingly benign distinctions, or supported by apparently rational or widely held observations, these biases can cause grave individual, group, and societal harm that is commensurate to and even exceeds the harm caused by outright racism.” To deny the prejudices that providers have when making decisions for patients will perpetuate the racism and hinder our ability to overcome health inequity. Americans of racial and ethnic minorities have a higher incidence of chronic diseases and premature death when compared to white Americans.4 These disparities exist even when controlling for individual variations such as availability of health insurance, education, and socioeconomic status.5 Social determinants of health because of racial differences is often talked about as a cause of health care inequity, but given the evidence that providers play a much more active role in this, we need to become more comfortable with the discomfort of using the word “racism” if we intend to bring awareness and create change.
In order to tackle structural racism in health care, organizations must take a multifaceted approach. Evidence-based strategies include: creation of an inclusive workforce, diversification of the workforce to better represent patient populations, and education/training on the effect of implicit bias on equitable health care.6 These aspirations can provide a framework for interventions at all levels of health care organizations.
The JEDI (justice, equity, diversity, and inclusion) committee of the section of hospital medicine at Wake Forest Baptist Health System came into existence in November 2019. The objective for JEDI was to use evidence-based methods to help create an environment that would lead to the creation of a diverse and inclusive hospital medicine group. Prior to establishing our committee, we interviewed providers from traditional minority groups who were part of our practice to bring clarity to the discrimination faced by our providers from colleagues, staff, and patients. The discrimination varied from microaggressions caused by implicit biases to macroaggression from overt discrimination. We initiated our work on this burning platform by following the evidence-based methods mentioned earlier.
Creation of an inclusive workforce. Our working committee included members of varied backgrounds and experiences who were passionate about enhancing equity while focusing on inclusion and wellness. The committee brainstormed ideas for interventions that could make a positive impact for our teammates. Individual providers voted to choose the interventions that would positively impact their inclusion and health. Using a validated survey,7 we were able to measure the degree of inclusion of our work group based on multiple demographics including age, gender, race/ethnicity, training (physician vs. APP), etc. Our intention is to complete the proposed interventions before remeasuring inclusion to understand the effect of our work.
Diversifying the workforce. Although our section of hospital medicine at Wake Forest Baptist Health System consists of providers self-identifying as people of color, we do not adequately mirror the racial composition of the population we serve. To achieve the desired result, we have made changes to our recruiting program. The section of hospital medicine visibly demonstrates our commitment to diversity and displays our values on our website. We intend for this to attract diverse individuals who would intend to be part of our group.
Education and training on impact of implicit bias on equitable health care. Implicit bias training will have to consist of actions that would help our clinicians recognize their own prejudices and find means to mitigate them. We have committed to bystander education that would give practice and words to our providers to speak up in situations where they see discrimination in the workplace that is directed against patients, staff, and colleagues. A series of open and honest conversations about racial and gender discrimination in health care that involves inviting accomplished speakers from around the country has been planned. Continued attention to opportunities to further awareness on this subject is vital.
On Jan. 6, 2021, a day that should have filled citizens with pride and hope with the election of the first Black minister and the first Jewish man to the U.S. Senate in a historically conservative state, as well as the confirmation of the election of a president who pledged to address racial disparities, we instead saw another stark reminder of where we came from and just how far we have to go. White supremacists incited by their perceived threat to a legacy of centuries of suppression transformed into a mob of insurrectionists, blatantly bearing Confederate and Nazi flags, and seemingly easily invaded and desecrated the U.S. Capitol. On March 16, 2021, a white male who was “having a bad day” ended the lives of eight individuals, including six Asian Americans.
These instances have brought forth the reality that many of our interventions have been directed towards subtle prejudices and microaggressions alone. We have skirted around calling out overt discrimination of minority groups and failed to openly acknowledge our own contribution to the problem. This newly found awareness has created an opportunity for more impactful work. The equitable delivery of health care is dependent on creating a patient-provider relationship based on trust; addressing overt discrimination respectfully; and overcoming unconscious bias.
While we have made the commitment to confront structural racism in our workplace and taken important steps to work towards this goal with the initiatives set forth by our JEDI committee, we certainly have a long way to go. George Floyd spent the last 8 minutes and 46 seconds of his life struggling to breathe and asking for his mother. Let’s not waste another second and instead be the change that we seek in health care.
Dr. Nagaraj is medical director, Hospital Medicine, at Lexington (N.C.) Medical Center, assistant professor at Wake Forest School of Medicine, and cochair, JEDI committee for diversity and inclusion, hospital medicine, at Wake Forest Baptist Health, Winston-Salem, NC. Ms. Haller is cochair, JEDI committee for diversity and inclusion, hospital medicine, Wake Forest Baptist Health. Dr. Huang is the executive medical director and service line director of general medicine and hospital medicine within the Wake Forest Baptist Health System and associate professor at Wake Forest School of Medicine. The authors would like to acknowledge Dr. Julie Freischlag, Dr. Kevin High, and Dr. David McIntosh at Wake Forest Baptist Health System for the support of the JEDI committee and the section on hospital medicine.
References
1. Holland B. The “father of modern gynecology” performed shocking experiments on enslaved women. History. 2017 Aug 29. www.history.com/news/the-father-of-modern-gynecology-performed-shocking-experiments-on-slaves.
2. Buseh AG et al. Community leaders’ perspectives on engaging African Americans in biobanks and other human genetics initiatives. J Community Genet. 2013 Oct;4(4):483-94. doi: 10.1007/s12687-013-0155-z.
3. National Center for Health Statistics. Health, United States, 2015: With special feature on racial and ethnic health disparities. 2016 May. www.cdc.gov/nchs/data/hus/hus15.pdf.
4. Bailey ZD et al. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017 Apr 8;389(10077):1453-63. doi: 10.1016/S0140-6736(17)30569-X.
5. Arvizo C and Garrison E. Diversity and inclusion: the role of unconscious bias on patient care, health outcomes and the workforce in obstetrics and gynaecology. Curr Opin Obstet Gynecol. 2019 Oct;31(5):356-62. doi: 10.1097/GCO.0000000000000566.
6. Chung BG et al. Work group inclusion: test of a scale and model. Group & Organization Management. 2020;45(1):75-102. doi: 10.1177/1059601119839858.
The COVID-19 push to evolve
Has anyone else noticed how slow it has been on your pediatric floors? Well, you are not alone.
The COVID pandemic has had a significant impact on health care volumes, with pediatric volumes decreasing across the nation. A Children’s Hospital Association CEO survey, currently unpublished, noted a 10%-20% decline in inpatient admissions and a 30%-50% decline in pediatric ED visits this past year. Even our usual respiratory surge has been disrupted. The rate of influenza tracked by the CDC is around 1%, compared with the usual seasonal flu baseline national rate of 2.6%. These COVID-related declines have occurred amidst the backdrop of already-decreasing inpatient admissions because of the great work of the pediatric hospital medicine (PHM) community in reducing unnecessary admissions and lengths of stay.
For many hospitals, several factors related to the pandemic have raised significant financial concerns. According to Becker Hospital Review, as of August 2020 over 500 hospitals had furloughed workers. While 26 of those hospitals had brought back workers by December 2020, many did not. Similar financial concerns were noted in a Kaufmann Hall report from January 2021, which showed a median drop of 55% in operating margins. The CARES Act helped reduce some of the detrimental impact on operating margins, but it did not diminish the added burden of personal protective equipment expenses, longer length of stay for COVID patients, and a reimbursement shift to more government payors and uninsured caused by pandemic-forced job losses.
COVID’s impact specific to pediatric hospital medicine has been substantial. A recent unpublished survey by the PHM Economics Research Collaborative (PERC) demonstrated how COVID has affected pediatric hospital medicine programs. Forty-five unique PHM programs from over 21 states responded, with 98% reporting a decrease in pediatric inpatient admissions as well as ED visits. About 11% reported temporary unit closures, while 51% of all programs reported staffing restrictions ranging from hiring freezes to downsizing the number of hospitalists in the group. Salaries decreased in 26% of reporting programs, and 20%-56% described reduced benefits, ranging from less CME/vacation time and stipends to retirement benefits. The three most frequent benefit losses included annual salary increases, educational stipends, and bonuses.
Community hospitals felt the palpable, financial strain of decreasing pediatric admissions well before the pandemic. Hospitals like MedStar Franklin Square Hospital in Baltimore and Harrington Hospital in Southbridge, Mass., had decided to close their pediatrics units before COVID hit. In a 2014 unpublished survey of 349 community PHM (CPHM) programs, 57% of respondents felt that finances and justification for a pediatric program were primary concerns.
Responding to financial stressors is not a novel challenge for CPHM programs. To keep these vital pediatric programs in place despite lower inpatient volumes, those of us in CPHM have learned many lessons over the years on how to adapt. Such adaptations have included diversification in procedures and multifloor coverage in the hospital. Voiding cystourethrogram catheterizations and circumcisions are now more commonly performed by CPHM providers, who may also cover multiple areas of the hospital, including the ED, NICU, and well-newborn nursery. Comanagement of subspecialty or surgical patients is yet another example of such diversification.
Furthermore, the PERC survey showed that some PHM programs temporarily covered pediatric ICUs and step-down units and began doing ED and urgent care coverage as primary providers Most programs reported no change in newborn visits while 16% reported an increase in newborn volume and 14% reported a decrease in newborn volume. My own health system was one of the groups that had an increase in newborn volume. This was caused by community pediatricians who had stopped coming in to see their own newborns. This coverage adjustment has yet to return to baseline and will likely become permanent.
There was a 11% increase from prepandemic baselines (from 9% to 20%) in programs doing telemedicine. Most respondents stated that they will continue to offer telemedicine with an additional 25% of programs considering starting. There was also a slight increase during the pandemic of coverage of mental health units (from 11% to 13%), which may have led 11% of respondents to consider the addition of this service. The survey also noted that about 28% of PHM programs performed circumcisions, frenectomies, and sedation prepandemic, and 14%-18% are considering adding these services.
Overall, the financial stressors are improving, but our need to adapt in PHM is more pressing than ever. The pandemic has given us the push for evolution and some opportunities that did not exist before. One is the use of telemedicine to expand our subspecialty support to community hospitals, as well as to children’s hospitals in areas where subspecialists are in short supply. These telemedicine consults are being reimbursed for the first time, which allows more access to these services.
With the pandemic, many hospitals are moving to single room occupancy models. Construction to add more beds is costly, and unnecessary if we can utilize community hospitals to keep appropriate patients in their home communities. The opportunity to partner with community hospital programs to provide telemedicine support should not be overlooked. This is also an opportunity for academic referral centers to have more open beds for critical care and highly specialized patients.
Another opportunity is to expand scope by changing age limits, as 18% of respondents to the PERC survey reported that they had started to care for adults since the pandemic. The Pediatric Overflow Planning Contingency Response Network (POPCoRN) has been a valuable resource for education on caring for adults, guidance on which patient populations are appropriate, and the resources needed to do this. While caring for older adults, even in their 90s, was a pandemic-related phenomenon, there is an opportunity to see if the age limit we care for should be raised to 21, or even 25, as some CPHM programs had been doing prepandemic.
Along with the expansion of age limits, there are many other areas of opportunity highlighted within the PERC survey. These include expanding coverage within pediatric ICUs, EDs, and urgent care areas, along with coverage of well newborns that were previously covered by community pediatricians. Also, the increase of mental health admissions is another area where PHM programs might expand their services.
While I hope the financial stressors improve, hope is not a plan and therefore we need to think and prepare for what the post-COVID future may look like. Some have predicted a rebound pediatric respiratory surge next year as the masks come off and children return to in-person learning and daycare. This may be true, but we would be foolish not to use lessons from the pandemic as well as the past to consider options in our toolkit to become more financially stable. POPCoRN, as well as the American Academy of Pediatrics’ listserv and subcommittees, have been a source of collaboration and shared knowledge during a time when we have needed to quickly respond to ever-changing information. These networks and information sharing should be leveraged once the dust settles for us to prepare for future challenges.
New innovations may arise as we look at how we address the growing need for mental health services and incorporate new procedures, like point of care ultrasound. As Charles Darwin said: “It is not the strongest of the species that survives nor the most intelligent that survives. It is the one that is most adaptable to change.” It is time for us to evolve.
Dr. Dias is a clinical associate professor of pediatrics at Yale University, New Haven, Conn., in the division of pediatric hospital medicine. She has practiced community pediatric hospital medicine for over 21 years in New Jersey, Pennsylvania, and Connecticut. She is the chair of the Education Working Group for the AAP’s section on hospital medicine’s subcommittee on community hospitalists as well as the cochair of the Community Hospital Operations Group of the POPCoRN network.
Has anyone else noticed how slow it has been on your pediatric floors? Well, you are not alone.
The COVID pandemic has had a significant impact on health care volumes, with pediatric volumes decreasing across the nation. A Children’s Hospital Association CEO survey, currently unpublished, noted a 10%-20% decline in inpatient admissions and a 30%-50% decline in pediatric ED visits this past year. Even our usual respiratory surge has been disrupted. The rate of influenza tracked by the CDC is around 1%, compared with the usual seasonal flu baseline national rate of 2.6%. These COVID-related declines have occurred amidst the backdrop of already-decreasing inpatient admissions because of the great work of the pediatric hospital medicine (PHM) community in reducing unnecessary admissions and lengths of stay.
For many hospitals, several factors related to the pandemic have raised significant financial concerns. According to Becker Hospital Review, as of August 2020 over 500 hospitals had furloughed workers. While 26 of those hospitals had brought back workers by December 2020, many did not. Similar financial concerns were noted in a Kaufmann Hall report from January 2021, which showed a median drop of 55% in operating margins. The CARES Act helped reduce some of the detrimental impact on operating margins, but it did not diminish the added burden of personal protective equipment expenses, longer length of stay for COVID patients, and a reimbursement shift to more government payors and uninsured caused by pandemic-forced job losses.
COVID’s impact specific to pediatric hospital medicine has been substantial. A recent unpublished survey by the PHM Economics Research Collaborative (PERC) demonstrated how COVID has affected pediatric hospital medicine programs. Forty-five unique PHM programs from over 21 states responded, with 98% reporting a decrease in pediatric inpatient admissions as well as ED visits. About 11% reported temporary unit closures, while 51% of all programs reported staffing restrictions ranging from hiring freezes to downsizing the number of hospitalists in the group. Salaries decreased in 26% of reporting programs, and 20%-56% described reduced benefits, ranging from less CME/vacation time and stipends to retirement benefits. The three most frequent benefit losses included annual salary increases, educational stipends, and bonuses.
Community hospitals felt the palpable, financial strain of decreasing pediatric admissions well before the pandemic. Hospitals like MedStar Franklin Square Hospital in Baltimore and Harrington Hospital in Southbridge, Mass., had decided to close their pediatrics units before COVID hit. In a 2014 unpublished survey of 349 community PHM (CPHM) programs, 57% of respondents felt that finances and justification for a pediatric program were primary concerns.
Responding to financial stressors is not a novel challenge for CPHM programs. To keep these vital pediatric programs in place despite lower inpatient volumes, those of us in CPHM have learned many lessons over the years on how to adapt. Such adaptations have included diversification in procedures and multifloor coverage in the hospital. Voiding cystourethrogram catheterizations and circumcisions are now more commonly performed by CPHM providers, who may also cover multiple areas of the hospital, including the ED, NICU, and well-newborn nursery. Comanagement of subspecialty or surgical patients is yet another example of such diversification.
Furthermore, the PERC survey showed that some PHM programs temporarily covered pediatric ICUs and step-down units and began doing ED and urgent care coverage as primary providers Most programs reported no change in newborn visits while 16% reported an increase in newborn volume and 14% reported a decrease in newborn volume. My own health system was one of the groups that had an increase in newborn volume. This was caused by community pediatricians who had stopped coming in to see their own newborns. This coverage adjustment has yet to return to baseline and will likely become permanent.
There was a 11% increase from prepandemic baselines (from 9% to 20%) in programs doing telemedicine. Most respondents stated that they will continue to offer telemedicine with an additional 25% of programs considering starting. There was also a slight increase during the pandemic of coverage of mental health units (from 11% to 13%), which may have led 11% of respondents to consider the addition of this service. The survey also noted that about 28% of PHM programs performed circumcisions, frenectomies, and sedation prepandemic, and 14%-18% are considering adding these services.
Overall, the financial stressors are improving, but our need to adapt in PHM is more pressing than ever. The pandemic has given us the push for evolution and some opportunities that did not exist before. One is the use of telemedicine to expand our subspecialty support to community hospitals, as well as to children’s hospitals in areas where subspecialists are in short supply. These telemedicine consults are being reimbursed for the first time, which allows more access to these services.
With the pandemic, many hospitals are moving to single room occupancy models. Construction to add more beds is costly, and unnecessary if we can utilize community hospitals to keep appropriate patients in their home communities. The opportunity to partner with community hospital programs to provide telemedicine support should not be overlooked. This is also an opportunity for academic referral centers to have more open beds for critical care and highly specialized patients.
Another opportunity is to expand scope by changing age limits, as 18% of respondents to the PERC survey reported that they had started to care for adults since the pandemic. The Pediatric Overflow Planning Contingency Response Network (POPCoRN) has been a valuable resource for education on caring for adults, guidance on which patient populations are appropriate, and the resources needed to do this. While caring for older adults, even in their 90s, was a pandemic-related phenomenon, there is an opportunity to see if the age limit we care for should be raised to 21, or even 25, as some CPHM programs had been doing prepandemic.
Along with the expansion of age limits, there are many other areas of opportunity highlighted within the PERC survey. These include expanding coverage within pediatric ICUs, EDs, and urgent care areas, along with coverage of well newborns that were previously covered by community pediatricians. Also, the increase of mental health admissions is another area where PHM programs might expand their services.
While I hope the financial stressors improve, hope is not a plan and therefore we need to think and prepare for what the post-COVID future may look like. Some have predicted a rebound pediatric respiratory surge next year as the masks come off and children return to in-person learning and daycare. This may be true, but we would be foolish not to use lessons from the pandemic as well as the past to consider options in our toolkit to become more financially stable. POPCoRN, as well as the American Academy of Pediatrics’ listserv and subcommittees, have been a source of collaboration and shared knowledge during a time when we have needed to quickly respond to ever-changing information. These networks and information sharing should be leveraged once the dust settles for us to prepare for future challenges.
New innovations may arise as we look at how we address the growing need for mental health services and incorporate new procedures, like point of care ultrasound. As Charles Darwin said: “It is not the strongest of the species that survives nor the most intelligent that survives. It is the one that is most adaptable to change.” It is time for us to evolve.
Dr. Dias is a clinical associate professor of pediatrics at Yale University, New Haven, Conn., in the division of pediatric hospital medicine. She has practiced community pediatric hospital medicine for over 21 years in New Jersey, Pennsylvania, and Connecticut. She is the chair of the Education Working Group for the AAP’s section on hospital medicine’s subcommittee on community hospitalists as well as the cochair of the Community Hospital Operations Group of the POPCoRN network.
Has anyone else noticed how slow it has been on your pediatric floors? Well, you are not alone.
The COVID pandemic has had a significant impact on health care volumes, with pediatric volumes decreasing across the nation. A Children’s Hospital Association CEO survey, currently unpublished, noted a 10%-20% decline in inpatient admissions and a 30%-50% decline in pediatric ED visits this past year. Even our usual respiratory surge has been disrupted. The rate of influenza tracked by the CDC is around 1%, compared with the usual seasonal flu baseline national rate of 2.6%. These COVID-related declines have occurred amidst the backdrop of already-decreasing inpatient admissions because of the great work of the pediatric hospital medicine (PHM) community in reducing unnecessary admissions and lengths of stay.
For many hospitals, several factors related to the pandemic have raised significant financial concerns. According to Becker Hospital Review, as of August 2020 over 500 hospitals had furloughed workers. While 26 of those hospitals had brought back workers by December 2020, many did not. Similar financial concerns were noted in a Kaufmann Hall report from January 2021, which showed a median drop of 55% in operating margins. The CARES Act helped reduce some of the detrimental impact on operating margins, but it did not diminish the added burden of personal protective equipment expenses, longer length of stay for COVID patients, and a reimbursement shift to more government payors and uninsured caused by pandemic-forced job losses.
COVID’s impact specific to pediatric hospital medicine has been substantial. A recent unpublished survey by the PHM Economics Research Collaborative (PERC) demonstrated how COVID has affected pediatric hospital medicine programs. Forty-five unique PHM programs from over 21 states responded, with 98% reporting a decrease in pediatric inpatient admissions as well as ED visits. About 11% reported temporary unit closures, while 51% of all programs reported staffing restrictions ranging from hiring freezes to downsizing the number of hospitalists in the group. Salaries decreased in 26% of reporting programs, and 20%-56% described reduced benefits, ranging from less CME/vacation time and stipends to retirement benefits. The three most frequent benefit losses included annual salary increases, educational stipends, and bonuses.
Community hospitals felt the palpable, financial strain of decreasing pediatric admissions well before the pandemic. Hospitals like MedStar Franklin Square Hospital in Baltimore and Harrington Hospital in Southbridge, Mass., had decided to close their pediatrics units before COVID hit. In a 2014 unpublished survey of 349 community PHM (CPHM) programs, 57% of respondents felt that finances and justification for a pediatric program were primary concerns.
Responding to financial stressors is not a novel challenge for CPHM programs. To keep these vital pediatric programs in place despite lower inpatient volumes, those of us in CPHM have learned many lessons over the years on how to adapt. Such adaptations have included diversification in procedures and multifloor coverage in the hospital. Voiding cystourethrogram catheterizations and circumcisions are now more commonly performed by CPHM providers, who may also cover multiple areas of the hospital, including the ED, NICU, and well-newborn nursery. Comanagement of subspecialty or surgical patients is yet another example of such diversification.
Furthermore, the PERC survey showed that some PHM programs temporarily covered pediatric ICUs and step-down units and began doing ED and urgent care coverage as primary providers Most programs reported no change in newborn visits while 16% reported an increase in newborn volume and 14% reported a decrease in newborn volume. My own health system was one of the groups that had an increase in newborn volume. This was caused by community pediatricians who had stopped coming in to see their own newborns. This coverage adjustment has yet to return to baseline and will likely become permanent.
There was a 11% increase from prepandemic baselines (from 9% to 20%) in programs doing telemedicine. Most respondents stated that they will continue to offer telemedicine with an additional 25% of programs considering starting. There was also a slight increase during the pandemic of coverage of mental health units (from 11% to 13%), which may have led 11% of respondents to consider the addition of this service. The survey also noted that about 28% of PHM programs performed circumcisions, frenectomies, and sedation prepandemic, and 14%-18% are considering adding these services.
Overall, the financial stressors are improving, but our need to adapt in PHM is more pressing than ever. The pandemic has given us the push for evolution and some opportunities that did not exist before. One is the use of telemedicine to expand our subspecialty support to community hospitals, as well as to children’s hospitals in areas where subspecialists are in short supply. These telemedicine consults are being reimbursed for the first time, which allows more access to these services.
With the pandemic, many hospitals are moving to single room occupancy models. Construction to add more beds is costly, and unnecessary if we can utilize community hospitals to keep appropriate patients in their home communities. The opportunity to partner with community hospital programs to provide telemedicine support should not be overlooked. This is also an opportunity for academic referral centers to have more open beds for critical care and highly specialized patients.
Another opportunity is to expand scope by changing age limits, as 18% of respondents to the PERC survey reported that they had started to care for adults since the pandemic. The Pediatric Overflow Planning Contingency Response Network (POPCoRN) has been a valuable resource for education on caring for adults, guidance on which patient populations are appropriate, and the resources needed to do this. While caring for older adults, even in their 90s, was a pandemic-related phenomenon, there is an opportunity to see if the age limit we care for should be raised to 21, or even 25, as some CPHM programs had been doing prepandemic.
Along with the expansion of age limits, there are many other areas of opportunity highlighted within the PERC survey. These include expanding coverage within pediatric ICUs, EDs, and urgent care areas, along with coverage of well newborns that were previously covered by community pediatricians. Also, the increase of mental health admissions is another area where PHM programs might expand their services.
While I hope the financial stressors improve, hope is not a plan and therefore we need to think and prepare for what the post-COVID future may look like. Some have predicted a rebound pediatric respiratory surge next year as the masks come off and children return to in-person learning and daycare. This may be true, but we would be foolish not to use lessons from the pandemic as well as the past to consider options in our toolkit to become more financially stable. POPCoRN, as well as the American Academy of Pediatrics’ listserv and subcommittees, have been a source of collaboration and shared knowledge during a time when we have needed to quickly respond to ever-changing information. These networks and information sharing should be leveraged once the dust settles for us to prepare for future challenges.
New innovations may arise as we look at how we address the growing need for mental health services and incorporate new procedures, like point of care ultrasound. As Charles Darwin said: “It is not the strongest of the species that survives nor the most intelligent that survives. It is the one that is most adaptable to change.” It is time for us to evolve.
Dr. Dias is a clinical associate professor of pediatrics at Yale University, New Haven, Conn., in the division of pediatric hospital medicine. She has practiced community pediatric hospital medicine for over 21 years in New Jersey, Pennsylvania, and Connecticut. She is the chair of the Education Working Group for the AAP’s section on hospital medicine’s subcommittee on community hospitalists as well as the cochair of the Community Hospital Operations Group of the POPCoRN network.
More than just 3 dogs: Is burnout getting in the way of knowing our patients?
Do you ever leave work thinking “Why do I always feel so tired after my shift?” “How can I overcome this fatigue?” “Is this what I expected?” “How can I get over the dread of so much administrative work when I want more time for my patients?” As clinicians, we face these and many other questions every day. These questions are the result of feeling entrapped in a health care system that has forgotten that clinicians need enough time to get to know and connect with their patients. Burnout is real, and relying on wellness activities is not sufficient to overcome it. Instead, taking the time for some introspection and self-reflection can help to overcome these difficulties.
A valuable lesson
Ten months into my intern year as a psychiatry resident, while on a busy night shift at the psychiatry emergency unit, an 86-year-old man arrived alone, hopeless, and with persistent death wishes. He needed to be heard and comforted by someone. Although he understood the nonnegotiable need to be hospitalized, he was extremely hesitant. But why? After all, he expressed wanting to get better and feared going back home alone, yet he was unwilling to be admitted to the hospital for acute care.
I knew I had to address the reason behind my patient’s ambivalence by further exploring his history. Nonetheless, my physician-in-training mind was battling feelings of stress secondary to what at the time seemed to be a never-ending to-do list full of nurses’ requests and patient-related tasks. Despite an unconscious temptation to rush through the history to please my go, go, go! trainee mind, I do not regret having taken the time to ask and address the often-feared “why.” Why was my patient reluctant to accept my recommendation?
To my surprise, it turned out to be an important matter. He said, “I have 3 dogs back home I don’t want to leave alone. They are the only living memory of my wife, who passed away 5 months ago. They help me stay alive.” I was struck by a feeling of empathy, but also guilt for having almost rushed through the history and not being thorough enough to ask why.
Take time to explore ‘why’
Do we really recognize the importance of being inquisitive in our history-taking? What might seem a simple matter to us (in my patient’s case, his 3 dogs were his main support system) can be a significant cause of a patient’s distress. A patients’ hesitancy to accept our recommendations can be secondary to reasons that unfortunately at times we only partially explore, or do not explore at all. Asking why can open Pandora’s box. It can uncover feelings and emotions such as frustration, anger, anxiety, and sorrow. It can also reveal uncertainties regarding topics such as race, gender identity, sexual orientation, socioeconomic status, and religion. We should be driven by humble curiosity, and tailor the interview by purposefully asking questions with the goal of learning and understanding our patients’ concerns. This practice serves to cultivate honest and trustworthy physician-patient relationships founded on empathy and respect.
If we know that obtaining an in-depth history is crucial for formulating a patient’s treatment plan, why do we sometimes fall in the trap of obtaining superficial ones, at times limiting ourselves to checklists? Reasons for not delving into our patients’ histories include (but are not limited to) an overload of patients, time constraints, a physician’s personal style, unconscious bias, suboptimal mentoring, and burnout. Of all these reasons, I worry the most about burnout. Physicians face insurmountable academic, institutional, and administrative demands. These constraints inarguably contribute to feeling rushed, and eventually possibly burned out.
Using self-reflection to prevent burnout
Physician burnout—as well as attempts to define, identify, target, and prevent it—has been on the rise in the past decades. If burnout affects the physician-patient relationship, we should make efforts to mitigate it. One should try to rely on internal, rather than external, influences to positively influence our delivery of care. One way to do this is by really getting to know the patient in front of us: a father, mother, brother, sister, member of the community, etc. Understanding our patient’s needs and concerns promotes empathy and connectedness. Another way is to exercise self-reflection by asking ourselves: How do I feel about the care I delivered today? Did I make an effort to fully understand my patients’ concerns? Did I make each patient feel understood? Was I rushing through the day, or was I mindful of the person in front of me? Did I deliver the care I wish I had received?
Although there are innumerable ways to target physician burnout, these self-reflections are quick, simple exercises that easily can be woven into a clinician’s busy schedule. The goal is to be mindful of improving the quality of our interactions with patients to ultimately cultivate our own well-being by potentiating a sense of fulfilment and satisfaction with our profession. I encourage clinicians to always go after the “why.” After all, why not? Thankfully, after some persuasion, my patient accepted voluntary admission, and arranged with neighbors to take care of his 3 dogs.
Do you ever leave work thinking “Why do I always feel so tired after my shift?” “How can I overcome this fatigue?” “Is this what I expected?” “How can I get over the dread of so much administrative work when I want more time for my patients?” As clinicians, we face these and many other questions every day. These questions are the result of feeling entrapped in a health care system that has forgotten that clinicians need enough time to get to know and connect with their patients. Burnout is real, and relying on wellness activities is not sufficient to overcome it. Instead, taking the time for some introspection and self-reflection can help to overcome these difficulties.
A valuable lesson
Ten months into my intern year as a psychiatry resident, while on a busy night shift at the psychiatry emergency unit, an 86-year-old man arrived alone, hopeless, and with persistent death wishes. He needed to be heard and comforted by someone. Although he understood the nonnegotiable need to be hospitalized, he was extremely hesitant. But why? After all, he expressed wanting to get better and feared going back home alone, yet he was unwilling to be admitted to the hospital for acute care.
I knew I had to address the reason behind my patient’s ambivalence by further exploring his history. Nonetheless, my physician-in-training mind was battling feelings of stress secondary to what at the time seemed to be a never-ending to-do list full of nurses’ requests and patient-related tasks. Despite an unconscious temptation to rush through the history to please my go, go, go! trainee mind, I do not regret having taken the time to ask and address the often-feared “why.” Why was my patient reluctant to accept my recommendation?
To my surprise, it turned out to be an important matter. He said, “I have 3 dogs back home I don’t want to leave alone. They are the only living memory of my wife, who passed away 5 months ago. They help me stay alive.” I was struck by a feeling of empathy, but also guilt for having almost rushed through the history and not being thorough enough to ask why.
Take time to explore ‘why’
Do we really recognize the importance of being inquisitive in our history-taking? What might seem a simple matter to us (in my patient’s case, his 3 dogs were his main support system) can be a significant cause of a patient’s distress. A patients’ hesitancy to accept our recommendations can be secondary to reasons that unfortunately at times we only partially explore, or do not explore at all. Asking why can open Pandora’s box. It can uncover feelings and emotions such as frustration, anger, anxiety, and sorrow. It can also reveal uncertainties regarding topics such as race, gender identity, sexual orientation, socioeconomic status, and religion. We should be driven by humble curiosity, and tailor the interview by purposefully asking questions with the goal of learning and understanding our patients’ concerns. This practice serves to cultivate honest and trustworthy physician-patient relationships founded on empathy and respect.
If we know that obtaining an in-depth history is crucial for formulating a patient’s treatment plan, why do we sometimes fall in the trap of obtaining superficial ones, at times limiting ourselves to checklists? Reasons for not delving into our patients’ histories include (but are not limited to) an overload of patients, time constraints, a physician’s personal style, unconscious bias, suboptimal mentoring, and burnout. Of all these reasons, I worry the most about burnout. Physicians face insurmountable academic, institutional, and administrative demands. These constraints inarguably contribute to feeling rushed, and eventually possibly burned out.
Using self-reflection to prevent burnout
Physician burnout—as well as attempts to define, identify, target, and prevent it—has been on the rise in the past decades. If burnout affects the physician-patient relationship, we should make efforts to mitigate it. One should try to rely on internal, rather than external, influences to positively influence our delivery of care. One way to do this is by really getting to know the patient in front of us: a father, mother, brother, sister, member of the community, etc. Understanding our patient’s needs and concerns promotes empathy and connectedness. Another way is to exercise self-reflection by asking ourselves: How do I feel about the care I delivered today? Did I make an effort to fully understand my patients’ concerns? Did I make each patient feel understood? Was I rushing through the day, or was I mindful of the person in front of me? Did I deliver the care I wish I had received?
Although there are innumerable ways to target physician burnout, these self-reflections are quick, simple exercises that easily can be woven into a clinician’s busy schedule. The goal is to be mindful of improving the quality of our interactions with patients to ultimately cultivate our own well-being by potentiating a sense of fulfilment and satisfaction with our profession. I encourage clinicians to always go after the “why.” After all, why not? Thankfully, after some persuasion, my patient accepted voluntary admission, and arranged with neighbors to take care of his 3 dogs.
Do you ever leave work thinking “Why do I always feel so tired after my shift?” “How can I overcome this fatigue?” “Is this what I expected?” “How can I get over the dread of so much administrative work when I want more time for my patients?” As clinicians, we face these and many other questions every day. These questions are the result of feeling entrapped in a health care system that has forgotten that clinicians need enough time to get to know and connect with their patients. Burnout is real, and relying on wellness activities is not sufficient to overcome it. Instead, taking the time for some introspection and self-reflection can help to overcome these difficulties.
A valuable lesson
Ten months into my intern year as a psychiatry resident, while on a busy night shift at the psychiatry emergency unit, an 86-year-old man arrived alone, hopeless, and with persistent death wishes. He needed to be heard and comforted by someone. Although he understood the nonnegotiable need to be hospitalized, he was extremely hesitant. But why? After all, he expressed wanting to get better and feared going back home alone, yet he was unwilling to be admitted to the hospital for acute care.
I knew I had to address the reason behind my patient’s ambivalence by further exploring his history. Nonetheless, my physician-in-training mind was battling feelings of stress secondary to what at the time seemed to be a never-ending to-do list full of nurses’ requests and patient-related tasks. Despite an unconscious temptation to rush through the history to please my go, go, go! trainee mind, I do not regret having taken the time to ask and address the often-feared “why.” Why was my patient reluctant to accept my recommendation?
To my surprise, it turned out to be an important matter. He said, “I have 3 dogs back home I don’t want to leave alone. They are the only living memory of my wife, who passed away 5 months ago. They help me stay alive.” I was struck by a feeling of empathy, but also guilt for having almost rushed through the history and not being thorough enough to ask why.
Take time to explore ‘why’
Do we really recognize the importance of being inquisitive in our history-taking? What might seem a simple matter to us (in my patient’s case, his 3 dogs were his main support system) can be a significant cause of a patient’s distress. A patients’ hesitancy to accept our recommendations can be secondary to reasons that unfortunately at times we only partially explore, or do not explore at all. Asking why can open Pandora’s box. It can uncover feelings and emotions such as frustration, anger, anxiety, and sorrow. It can also reveal uncertainties regarding topics such as race, gender identity, sexual orientation, socioeconomic status, and religion. We should be driven by humble curiosity, and tailor the interview by purposefully asking questions with the goal of learning and understanding our patients’ concerns. This practice serves to cultivate honest and trustworthy physician-patient relationships founded on empathy and respect.
If we know that obtaining an in-depth history is crucial for formulating a patient’s treatment plan, why do we sometimes fall in the trap of obtaining superficial ones, at times limiting ourselves to checklists? Reasons for not delving into our patients’ histories include (but are not limited to) an overload of patients, time constraints, a physician’s personal style, unconscious bias, suboptimal mentoring, and burnout. Of all these reasons, I worry the most about burnout. Physicians face insurmountable academic, institutional, and administrative demands. These constraints inarguably contribute to feeling rushed, and eventually possibly burned out.
Using self-reflection to prevent burnout
Physician burnout—as well as attempts to define, identify, target, and prevent it—has been on the rise in the past decades. If burnout affects the physician-patient relationship, we should make efforts to mitigate it. One should try to rely on internal, rather than external, influences to positively influence our delivery of care. One way to do this is by really getting to know the patient in front of us: a father, mother, brother, sister, member of the community, etc. Understanding our patient’s needs and concerns promotes empathy and connectedness. Another way is to exercise self-reflection by asking ourselves: How do I feel about the care I delivered today? Did I make an effort to fully understand my patients’ concerns? Did I make each patient feel understood? Was I rushing through the day, or was I mindful of the person in front of me? Did I deliver the care I wish I had received?
Although there are innumerable ways to target physician burnout, these self-reflections are quick, simple exercises that easily can be woven into a clinician’s busy schedule. The goal is to be mindful of improving the quality of our interactions with patients to ultimately cultivate our own well-being by potentiating a sense of fulfilment and satisfaction with our profession. I encourage clinicians to always go after the “why.” After all, why not? Thankfully, after some persuasion, my patient accepted voluntary admission, and arranged with neighbors to take care of his 3 dogs.
A resident’s guide to lithium
Lithium has been used in psychiatry for more than half a century and is considered the gold standard for treating acute mania and maintenance treatment of bipolar disorder.1 Evidence supports its use to reduce suicidal behavior and as an adjunctive treatment for major depressive disorder.2 However, lithium has fallen out of favor because of its narrow therapeutic index as well as the introduction of newer psychotropic medications that have a quicker onset of action and do not require strict blood monitoring. For residents early in their training, keeping track of the laboratory monitoring and medical screening can be confusing. Different institutions and countries have specific guidelines and recommendations for monitoring patients receiving lithium, which adds to the confusion.
We completed a literature review to develop clear and concise recommendations for lithium monitoring for residents in our psychiatry residency program. These recommendations outline screening at baseline and after patients treated with lithium achieve stability. Table 13-11 outlines medical screening parameters, including bloodwork, that should be completed before initiating treatment, and how often such screening should be repeated. Table 2 incorporates these parameters into progress notes in the electronic medical record to keep track of the laboratory values and when they were last drawn. Our aim is to help residents stay organized and prevent missed screenings.
How often should lithium levels be monitored?
After starting a patient on lithium, check the level within 5 to 7 days, and 5 to 7 days after each dose change. Draw the lithium level 10 to 14 hours after the patient’s last dose (12 hours is best).1 Because of dosage changes, lithium levels usually are monitored more frequently during the first 3 months of treatment until therapeutic levels are reached or symptoms are controlled. It is recommended to monitor lithium levels every 3 months for the first year and every 6 months after the first year of treatment once the patient is stable and considering age, medical health, and how consistently a patient reports symptoms/adverse effects.3,5 Continue monitoring levels every 3 months in older adults; in patients with renal dysfunction, thyroid dysfunction, hypercalcemia, or other significant medical comorbidities; and in those who are taking medications that affect lithium, such as pain medications (nonsteroidal anti-inflammatory drugs can raise lithium levels), certain antihypertensives (angiotensin-converting-enzyme inhibitors can raise lithium levels), and diuretics (thiazide diuretics can raise lithium levels; osmotic diuretics and carbonic anhydrase inhibitors can reduce lithium levels).1,3,5
Lithium levels could vary by up to 0.5 mEq/L during transition between manic, euthymic, and depressive states.12 On a consistent dosage, lithium levels decrease during mania because of hemodilution, and increase during depression secondary to physiological effects specific to these episodes.13,14
Recommendations for plasma lithium levels (trough levels)
Mania. Lithium levels of 0.8 to 1.2 mEq/L often are needed to achieve symptom control during manic episodes.15 As levels approach 1.5 mEq/L, patients are at increased risk for intolerable adverse effects (eg, nausea and vomiting) and toxicity.16,17 Adverse effects at higher levels may result in patients abruptly discontinuing lithium. Patients who experience mania before a depressive episode at illness onsettend to have a better treatment response with lithium.18 Lithium monotherapy has been shown to be less effective for acute mania than antipsychotics or combination therapies.19 Consider combining lithium with valproate or antipsychotics for patients who have tolerated lithium in the past and plan to use lithium for maintenance treatment.20
Maintenance. In adults, the lithium level should be 0.60 to 80mEq/L, but consider levels of 0.40 to 0.60 mEq/L in patients who have a good response to lithium but develop adverse effects at higher levels.21 For patients who do not respond to treatment, such as those with severe mania, maintenance levels can be increased to 0.76 to 0.90 mEq/L.22 These same recommendations for maintenance levels can be used for children and adolescents. In older adults, aim for maintenance levels of 0.4 to 0.6 mEq/L. For patients age 65 to 79, the maximum level is 0.7 to 0.8 mEq/L, and should not exceed 0.7 mEq/L in patients age >80. Lithium levels <0.4 mEq/L do not appear to be effective.21
Depression. Aim for a lithium level of 0.6 to 1.0 mEq/L for patients with depression.11
Continue to: Renal function monitoring frequency
Renal function monitoring frequency
Obtain a basic metabolic panel or comprehensive metabolic panel to establish baseline levels of creatinine, blood urea nitrogen (BUN), and estimated glomerular filtration rate (eGFR). Repeat testing at Week 12 and at 6 months to detect any changes. Renal function can be monitored every 6 to 12 months in stable patients, but should be closely watched when a patient’s clinical status changes.3 A new lower eGFR value after starting lithium therapy should be investigated with a repeat test in 2 weeks.23 Mild elevations in creatinine should be monitored, and further medical workup with a nephrologist is recommended for patients with a creatinine level ≥1.6 mg/dL.24 It is important to note that creatinine might remain within normal limits if there is considerable reduction in glomerular function. Creatinine levels could vary because of body mass and diet. Creatinine levels can be low in nonmuscular patients and elevated in patients who consume large amounts of protein.23,25
Ordering a basic metabolic panel also allows electrolyte monitoring. Hyponatremia and dehydration can lead to elevated lithium levels and result in toxicity; hypokalemia might increase the risk of lithium-induced cardiac toxicity. Monitor calcium (corrected serum calcium) because hypercalcemia has been seen in patients treated with lithium.
Thyroid function monitoring frequency
Obtain levels of thyroid-stimulating hormone with reflex to free T4 at baseline, 12 weeks, and 6 months. Monitor thyroid function every 6 to 12 months in stable patients and when a patient’s clinical status changes, such as with new reports of medical or psychiatric symptoms and when there is concern for thyroid dysfunction.3
Lithium and neurotoxicity
Lithium is known to have neurotoxic effects, such as effects on fast-acting neurons leading to dyscoordination or tremor, even at therapeutic levels.26 This is especially the case when lithium is combined with an antipsychotic,26,27 a combination that is used to treat bipolar I disorder with psychotic features. Older adults are at greater risk for neurotoxicity because of physiological changes associated with increasing age.28
Educate patients about adherence, diet, and exercise
Patients might stop taking their psychotropic medications when they start feeling better. Instruct patients to discuss discontinuation with the prescribing clinician before they stop any medication. Educate patients that rapidly discontinuing lithium therapy puts them at high risk of relapse29 and increases the risk of developing treatment-refractory symptoms.23,30 Emphasize the importance of staying hydrated and maintaining adequate sodium in their diet.17,31 Consuming excessive sodium can reduce lithium levels.17,32 Lithium levels could increase when patients experience excessive sweating, such as during exercise or being outside on warm days, because of sodium and volume loss.17,33
1. Tondo L, Alda M, Bauer M, et al. Clinical use of lithium salts: guide for users and prescribers. Int J Bipolar Disord. 2019;7(1):16. doi:10.1186/s40345-019-0151-2
2. Azab AN, Shnaider A, Osher Y, et al. Lithium nephrotoxicity. Int J Bipolar Disord. 2015;3(1):28. doi:10.1186/s40345-015-0028-y
3. American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry. 2002;159:1-50.
4. Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013. Bipolar Disord. 2013;15:1‐44. doi:10.1111/bdi.12025
5. National Collaborating Center for Mental Health (UK). Bipolar disorder: the NICE guideline on the assessment and management of bipolar disorder in adults, children and young people in primary and secondary care. The British Psychological Society and The Royal College of Psychiatrists; 2014.
6. Kupka R, Goossens P, van Bendegem M, et al. Multidisciplinaire richtlijn bipolaire stoornissen. Nederlandse Vereniging voor Psychiatrie (NVvP); 2015. Accessed August 10, 2020. http://www.nvvp.net/stream/richtlijn-bipolaire-stoornissen-2015
7. Malhi GS, Bassett D, Boyce P, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust N Z J Psychiatry. 2015;49:1087‐1206. doi:10.1177/0004867415617657
8. Nederlof M, Heerdink ER, Egberts ACG, et al. Monitoring of patients treated with lithium for bipolar disorder: an international survey. Int J Bipolar Disord. 2018;6(1):12. doi:10.1186/s40345-018-0120-1
9. Leo RJ, Sharma M, Chrostowski DA. A case of lithium-induced symptomatic hypercalcemia. Prim Care Companion J Clin Psychiatry. 2010;12(4):PCC.09l00917. doi:10.4088/PCC.09l00917yel
10. McHenry CR, Lee K. Lithium therapy and disorders of the parathyroid glands. Endocr Pract. 1996;2(2):103-109. doi:10.4158/EP.2.2.103
11. Stahl SM. The prescribers guide: Stahl’s essential psychopharmacology. 6th ed. Cambridge University Press; 2017.
12. Kukopulos A, Reginaldi D. Variations of serum lithium concentrations correlated with the phases of manic-depressive psychosis. Agressologie. 1978;19(D):219-222.
13. Rittmannsberger H, Malsiner-Walli G. Mood-dependent changes of serum lithium concentration in a rapid cycling patient maintained on stable doses of lithium carbonate. Bipolar Disord. 2013;15(3):333-337. doi:10.1111/bdi.12066
14. Hochman E, Weizman A, Valevski A, et al. Association between bipolar episodes and fluid and electrolyte homeostasis: a retrospective longitudinal study. Bipolar Disord. 2014;16(8):781-789. doi:10.1111/bdi.12248
15. Volkmann C, Bschor T, Köhler S. Lithium treatment over the lifespan in bipolar disorders. Front Psychiatry. 2020;11:377. doi: 10.3389/fpsyt.2020.00377
16. Boltan DD, Fenves AZ. Effectiveness of normal saline diuresis in treating lithium overdose. Proc (Bayl Univ Med Cent). 2008;21(3):261-263. doi:10.1080/08998280.2008.11928407
17. Sadock BJ, Saddock VA, Ruiz P. Kaplan and Sadock’s synopsis of psychiatry. 11th ed. Wolters Kluwer; 2014.
18. Tighe SK, Mahon PB, Potash JB. Predictors of lithium response in bipolar disorder. Ther Adv Chronic Dis. 2011;2(3):209-226. doi:10.1177/2040622311399173
19. Cipriani A, Barbui C, Salanti G, et al. Comparative efficacy and acceptability of antimanic drugs in acute mania: a multiple-treatments meta-analysis. Lancet. 2011;378(9799):1306-1315. doi:10.1016/S0140-6736(11)60873-8
20. Smith LA, Cornelius V, Tacchi MJ, et al. Acute bipolar mania: a systematic review and meta-analysis of co-therapy vs monotherapy. Acta Psychiatr Scand. 2016;115(1):12-20. doi:10.1111/j.1600-0447.2006.00912.x
21. Nolen WA, Licht RW, Young AH, et al; ISBD/IGSLI Task Force on the treatment with lithium. What is the optimal serum level for lithium in the maintenance treatment of bipolar disorder? A systematic review and recommendations from the ISBD/IGSLI Task Force on treatment with lithium. Bipolar Disord. 2019;21(5):394-409. doi:10.1111/bdi.12805
22. Maj M, Starace F, Nolfe G, et al. Minimum plasma lithium levels required for effective prophylaxis in DSM III bipolar disorder: a prospective study. Pharmacopsychiatry. 1986;19(6):420-423. doi:10.1055/s-2007-1017280
23. Gupta S, Kripalani M, Khastgir U, et al. Management of the renal adverse effects of lithium. Advances in Psychiatric Treatment. 2013;19(6):457-466. doi:10.1192/apt.bp.112.010306
24. Gitlin M. Lithium and the kidney: an updated review. Drug Saf. 1999;20(3):231-243. doi:10.2165/00002018-199920030-00004
25. Jefferson JW. A clinician’s guide to monitoring kidney function in lithium-treated patients. J Clin Psychiatry. 2010;71(9):1153-1157. doi:10.4088/JCP.09m05917yel
26. Shah VC, Kayathi P, Singh G, et al. Enhance your understanding of lithium neurotoxicity. Prim Care Companion CNS Disord. 2015;17(3):10.4088/PCC.14l01767. doi:10.4088/PCC.14l01767
27. Netto I, Phutane VH. Reversible lithium neurotoxicity: review of the literature. Prim Care Companion CNS Disord. 2012;14(1):PCC.11r01197. doi:10.4088/PCC.11r01197
28. Mohandas E, Rajmohan V. Lithium use in special populations. Indian J Psychiatry. 2007;49(3):211-218. doi:10.4103/0019-5545.37325
29. Gupta S, Khastgir U. Drug information update. Lithium and chronic kidney disease: debates and dilemmas. BJPsych Bull. 2017;41(4):216-220. doi:10.1192/pb.bp.116.054031
30. Post RM. Preventing the malignant transformation of bipolar disorder. JAMA. 2018;319(12):1197-1198. doi:10.1001/jama.2018.0322
31. Timmer RT, Sands JM. Lithium intoxication. J Am Soc Nephrol. 1999;10(3):666-674.
32. Demers RG, Heninger GR. Sodium intake and lithium treatment in mania. Am J Psychiatry. 1971;128(1):100-104. doi:10.1176/ajp.128.1.100
33. Hedya SA, Avula A, Swoboda HD. Lithium toxicity. In: StatPearls. StatPearls Publishing; 2020.
Lithium has been used in psychiatry for more than half a century and is considered the gold standard for treating acute mania and maintenance treatment of bipolar disorder.1 Evidence supports its use to reduce suicidal behavior and as an adjunctive treatment for major depressive disorder.2 However, lithium has fallen out of favor because of its narrow therapeutic index as well as the introduction of newer psychotropic medications that have a quicker onset of action and do not require strict blood monitoring. For residents early in their training, keeping track of the laboratory monitoring and medical screening can be confusing. Different institutions and countries have specific guidelines and recommendations for monitoring patients receiving lithium, which adds to the confusion.
We completed a literature review to develop clear and concise recommendations for lithium monitoring for residents in our psychiatry residency program. These recommendations outline screening at baseline and after patients treated with lithium achieve stability. Table 13-11 outlines medical screening parameters, including bloodwork, that should be completed before initiating treatment, and how often such screening should be repeated. Table 2 incorporates these parameters into progress notes in the electronic medical record to keep track of the laboratory values and when they were last drawn. Our aim is to help residents stay organized and prevent missed screenings.
How often should lithium levels be monitored?
After starting a patient on lithium, check the level within 5 to 7 days, and 5 to 7 days after each dose change. Draw the lithium level 10 to 14 hours after the patient’s last dose (12 hours is best).1 Because of dosage changes, lithium levels usually are monitored more frequently during the first 3 months of treatment until therapeutic levels are reached or symptoms are controlled. It is recommended to monitor lithium levels every 3 months for the first year and every 6 months after the first year of treatment once the patient is stable and considering age, medical health, and how consistently a patient reports symptoms/adverse effects.3,5 Continue monitoring levels every 3 months in older adults; in patients with renal dysfunction, thyroid dysfunction, hypercalcemia, or other significant medical comorbidities; and in those who are taking medications that affect lithium, such as pain medications (nonsteroidal anti-inflammatory drugs can raise lithium levels), certain antihypertensives (angiotensin-converting-enzyme inhibitors can raise lithium levels), and diuretics (thiazide diuretics can raise lithium levels; osmotic diuretics and carbonic anhydrase inhibitors can reduce lithium levels).1,3,5
Lithium levels could vary by up to 0.5 mEq/L during transition between manic, euthymic, and depressive states.12 On a consistent dosage, lithium levels decrease during mania because of hemodilution, and increase during depression secondary to physiological effects specific to these episodes.13,14
Recommendations for plasma lithium levels (trough levels)
Mania. Lithium levels of 0.8 to 1.2 mEq/L often are needed to achieve symptom control during manic episodes.15 As levels approach 1.5 mEq/L, patients are at increased risk for intolerable adverse effects (eg, nausea and vomiting) and toxicity.16,17 Adverse effects at higher levels may result in patients abruptly discontinuing lithium. Patients who experience mania before a depressive episode at illness onsettend to have a better treatment response with lithium.18 Lithium monotherapy has been shown to be less effective for acute mania than antipsychotics or combination therapies.19 Consider combining lithium with valproate or antipsychotics for patients who have tolerated lithium in the past and plan to use lithium for maintenance treatment.20
Maintenance. In adults, the lithium level should be 0.60 to 80mEq/L, but consider levels of 0.40 to 0.60 mEq/L in patients who have a good response to lithium but develop adverse effects at higher levels.21 For patients who do not respond to treatment, such as those with severe mania, maintenance levels can be increased to 0.76 to 0.90 mEq/L.22 These same recommendations for maintenance levels can be used for children and adolescents. In older adults, aim for maintenance levels of 0.4 to 0.6 mEq/L. For patients age 65 to 79, the maximum level is 0.7 to 0.8 mEq/L, and should not exceed 0.7 mEq/L in patients age >80. Lithium levels <0.4 mEq/L do not appear to be effective.21
Depression. Aim for a lithium level of 0.6 to 1.0 mEq/L for patients with depression.11
Continue to: Renal function monitoring frequency
Renal function monitoring frequency
Obtain a basic metabolic panel or comprehensive metabolic panel to establish baseline levels of creatinine, blood urea nitrogen (BUN), and estimated glomerular filtration rate (eGFR). Repeat testing at Week 12 and at 6 months to detect any changes. Renal function can be monitored every 6 to 12 months in stable patients, but should be closely watched when a patient’s clinical status changes.3 A new lower eGFR value after starting lithium therapy should be investigated with a repeat test in 2 weeks.23 Mild elevations in creatinine should be monitored, and further medical workup with a nephrologist is recommended for patients with a creatinine level ≥1.6 mg/dL.24 It is important to note that creatinine might remain within normal limits if there is considerable reduction in glomerular function. Creatinine levels could vary because of body mass and diet. Creatinine levels can be low in nonmuscular patients and elevated in patients who consume large amounts of protein.23,25
Ordering a basic metabolic panel also allows electrolyte monitoring. Hyponatremia and dehydration can lead to elevated lithium levels and result in toxicity; hypokalemia might increase the risk of lithium-induced cardiac toxicity. Monitor calcium (corrected serum calcium) because hypercalcemia has been seen in patients treated with lithium.
Thyroid function monitoring frequency
Obtain levels of thyroid-stimulating hormone with reflex to free T4 at baseline, 12 weeks, and 6 months. Monitor thyroid function every 6 to 12 months in stable patients and when a patient’s clinical status changes, such as with new reports of medical or psychiatric symptoms and when there is concern for thyroid dysfunction.3
Lithium and neurotoxicity
Lithium is known to have neurotoxic effects, such as effects on fast-acting neurons leading to dyscoordination or tremor, even at therapeutic levels.26 This is especially the case when lithium is combined with an antipsychotic,26,27 a combination that is used to treat bipolar I disorder with psychotic features. Older adults are at greater risk for neurotoxicity because of physiological changes associated with increasing age.28
Educate patients about adherence, diet, and exercise
Patients might stop taking their psychotropic medications when they start feeling better. Instruct patients to discuss discontinuation with the prescribing clinician before they stop any medication. Educate patients that rapidly discontinuing lithium therapy puts them at high risk of relapse29 and increases the risk of developing treatment-refractory symptoms.23,30 Emphasize the importance of staying hydrated and maintaining adequate sodium in their diet.17,31 Consuming excessive sodium can reduce lithium levels.17,32 Lithium levels could increase when patients experience excessive sweating, such as during exercise or being outside on warm days, because of sodium and volume loss.17,33
Lithium has been used in psychiatry for more than half a century and is considered the gold standard for treating acute mania and maintenance treatment of bipolar disorder.1 Evidence supports its use to reduce suicidal behavior and as an adjunctive treatment for major depressive disorder.2 However, lithium has fallen out of favor because of its narrow therapeutic index as well as the introduction of newer psychotropic medications that have a quicker onset of action and do not require strict blood monitoring. For residents early in their training, keeping track of the laboratory monitoring and medical screening can be confusing. Different institutions and countries have specific guidelines and recommendations for monitoring patients receiving lithium, which adds to the confusion.
We completed a literature review to develop clear and concise recommendations for lithium monitoring for residents in our psychiatry residency program. These recommendations outline screening at baseline and after patients treated with lithium achieve stability. Table 13-11 outlines medical screening parameters, including bloodwork, that should be completed before initiating treatment, and how often such screening should be repeated. Table 2 incorporates these parameters into progress notes in the electronic medical record to keep track of the laboratory values and when they were last drawn. Our aim is to help residents stay organized and prevent missed screenings.
How often should lithium levels be monitored?
After starting a patient on lithium, check the level within 5 to 7 days, and 5 to 7 days after each dose change. Draw the lithium level 10 to 14 hours after the patient’s last dose (12 hours is best).1 Because of dosage changes, lithium levels usually are monitored more frequently during the first 3 months of treatment until therapeutic levels are reached or symptoms are controlled. It is recommended to monitor lithium levels every 3 months for the first year and every 6 months after the first year of treatment once the patient is stable and considering age, medical health, and how consistently a patient reports symptoms/adverse effects.3,5 Continue monitoring levels every 3 months in older adults; in patients with renal dysfunction, thyroid dysfunction, hypercalcemia, or other significant medical comorbidities; and in those who are taking medications that affect lithium, such as pain medications (nonsteroidal anti-inflammatory drugs can raise lithium levels), certain antihypertensives (angiotensin-converting-enzyme inhibitors can raise lithium levels), and diuretics (thiazide diuretics can raise lithium levels; osmotic diuretics and carbonic anhydrase inhibitors can reduce lithium levels).1,3,5
Lithium levels could vary by up to 0.5 mEq/L during transition between manic, euthymic, and depressive states.12 On a consistent dosage, lithium levels decrease during mania because of hemodilution, and increase during depression secondary to physiological effects specific to these episodes.13,14
Recommendations for plasma lithium levels (trough levels)
Mania. Lithium levels of 0.8 to 1.2 mEq/L often are needed to achieve symptom control during manic episodes.15 As levels approach 1.5 mEq/L, patients are at increased risk for intolerable adverse effects (eg, nausea and vomiting) and toxicity.16,17 Adverse effects at higher levels may result in patients abruptly discontinuing lithium. Patients who experience mania before a depressive episode at illness onsettend to have a better treatment response with lithium.18 Lithium monotherapy has been shown to be less effective for acute mania than antipsychotics or combination therapies.19 Consider combining lithium with valproate or antipsychotics for patients who have tolerated lithium in the past and plan to use lithium for maintenance treatment.20
Maintenance. In adults, the lithium level should be 0.60 to 80mEq/L, but consider levels of 0.40 to 0.60 mEq/L in patients who have a good response to lithium but develop adverse effects at higher levels.21 For patients who do not respond to treatment, such as those with severe mania, maintenance levels can be increased to 0.76 to 0.90 mEq/L.22 These same recommendations for maintenance levels can be used for children and adolescents. In older adults, aim for maintenance levels of 0.4 to 0.6 mEq/L. For patients age 65 to 79, the maximum level is 0.7 to 0.8 mEq/L, and should not exceed 0.7 mEq/L in patients age >80. Lithium levels <0.4 mEq/L do not appear to be effective.21
Depression. Aim for a lithium level of 0.6 to 1.0 mEq/L for patients with depression.11
Continue to: Renal function monitoring frequency
Renal function monitoring frequency
Obtain a basic metabolic panel or comprehensive metabolic panel to establish baseline levels of creatinine, blood urea nitrogen (BUN), and estimated glomerular filtration rate (eGFR). Repeat testing at Week 12 and at 6 months to detect any changes. Renal function can be monitored every 6 to 12 months in stable patients, but should be closely watched when a patient’s clinical status changes.3 A new lower eGFR value after starting lithium therapy should be investigated with a repeat test in 2 weeks.23 Mild elevations in creatinine should be monitored, and further medical workup with a nephrologist is recommended for patients with a creatinine level ≥1.6 mg/dL.24 It is important to note that creatinine might remain within normal limits if there is considerable reduction in glomerular function. Creatinine levels could vary because of body mass and diet. Creatinine levels can be low in nonmuscular patients and elevated in patients who consume large amounts of protein.23,25
Ordering a basic metabolic panel also allows electrolyte monitoring. Hyponatremia and dehydration can lead to elevated lithium levels and result in toxicity; hypokalemia might increase the risk of lithium-induced cardiac toxicity. Monitor calcium (corrected serum calcium) because hypercalcemia has been seen in patients treated with lithium.
Thyroid function monitoring frequency
Obtain levels of thyroid-stimulating hormone with reflex to free T4 at baseline, 12 weeks, and 6 months. Monitor thyroid function every 6 to 12 months in stable patients and when a patient’s clinical status changes, such as with new reports of medical or psychiatric symptoms and when there is concern for thyroid dysfunction.3
Lithium and neurotoxicity
Lithium is known to have neurotoxic effects, such as effects on fast-acting neurons leading to dyscoordination or tremor, even at therapeutic levels.26 This is especially the case when lithium is combined with an antipsychotic,26,27 a combination that is used to treat bipolar I disorder with psychotic features. Older adults are at greater risk for neurotoxicity because of physiological changes associated with increasing age.28
Educate patients about adherence, diet, and exercise
Patients might stop taking their psychotropic medications when they start feeling better. Instruct patients to discuss discontinuation with the prescribing clinician before they stop any medication. Educate patients that rapidly discontinuing lithium therapy puts them at high risk of relapse29 and increases the risk of developing treatment-refractory symptoms.23,30 Emphasize the importance of staying hydrated and maintaining adequate sodium in their diet.17,31 Consuming excessive sodium can reduce lithium levels.17,32 Lithium levels could increase when patients experience excessive sweating, such as during exercise or being outside on warm days, because of sodium and volume loss.17,33
1. Tondo L, Alda M, Bauer M, et al. Clinical use of lithium salts: guide for users and prescribers. Int J Bipolar Disord. 2019;7(1):16. doi:10.1186/s40345-019-0151-2
2. Azab AN, Shnaider A, Osher Y, et al. Lithium nephrotoxicity. Int J Bipolar Disord. 2015;3(1):28. doi:10.1186/s40345-015-0028-y
3. American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry. 2002;159:1-50.
4. Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013. Bipolar Disord. 2013;15:1‐44. doi:10.1111/bdi.12025
5. National Collaborating Center for Mental Health (UK). Bipolar disorder: the NICE guideline on the assessment and management of bipolar disorder in adults, children and young people in primary and secondary care. The British Psychological Society and The Royal College of Psychiatrists; 2014.
6. Kupka R, Goossens P, van Bendegem M, et al. Multidisciplinaire richtlijn bipolaire stoornissen. Nederlandse Vereniging voor Psychiatrie (NVvP); 2015. Accessed August 10, 2020. http://www.nvvp.net/stream/richtlijn-bipolaire-stoornissen-2015
7. Malhi GS, Bassett D, Boyce P, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust N Z J Psychiatry. 2015;49:1087‐1206. doi:10.1177/0004867415617657
8. Nederlof M, Heerdink ER, Egberts ACG, et al. Monitoring of patients treated with lithium for bipolar disorder: an international survey. Int J Bipolar Disord. 2018;6(1):12. doi:10.1186/s40345-018-0120-1
9. Leo RJ, Sharma M, Chrostowski DA. A case of lithium-induced symptomatic hypercalcemia. Prim Care Companion J Clin Psychiatry. 2010;12(4):PCC.09l00917. doi:10.4088/PCC.09l00917yel
10. McHenry CR, Lee K. Lithium therapy and disorders of the parathyroid glands. Endocr Pract. 1996;2(2):103-109. doi:10.4158/EP.2.2.103
11. Stahl SM. The prescribers guide: Stahl’s essential psychopharmacology. 6th ed. Cambridge University Press; 2017.
12. Kukopulos A, Reginaldi D. Variations of serum lithium concentrations correlated with the phases of manic-depressive psychosis. Agressologie. 1978;19(D):219-222.
13. Rittmannsberger H, Malsiner-Walli G. Mood-dependent changes of serum lithium concentration in a rapid cycling patient maintained on stable doses of lithium carbonate. Bipolar Disord. 2013;15(3):333-337. doi:10.1111/bdi.12066
14. Hochman E, Weizman A, Valevski A, et al. Association between bipolar episodes and fluid and electrolyte homeostasis: a retrospective longitudinal study. Bipolar Disord. 2014;16(8):781-789. doi:10.1111/bdi.12248
15. Volkmann C, Bschor T, Köhler S. Lithium treatment over the lifespan in bipolar disorders. Front Psychiatry. 2020;11:377. doi: 10.3389/fpsyt.2020.00377
16. Boltan DD, Fenves AZ. Effectiveness of normal saline diuresis in treating lithium overdose. Proc (Bayl Univ Med Cent). 2008;21(3):261-263. doi:10.1080/08998280.2008.11928407
17. Sadock BJ, Saddock VA, Ruiz P. Kaplan and Sadock’s synopsis of psychiatry. 11th ed. Wolters Kluwer; 2014.
18. Tighe SK, Mahon PB, Potash JB. Predictors of lithium response in bipolar disorder. Ther Adv Chronic Dis. 2011;2(3):209-226. doi:10.1177/2040622311399173
19. Cipriani A, Barbui C, Salanti G, et al. Comparative efficacy and acceptability of antimanic drugs in acute mania: a multiple-treatments meta-analysis. Lancet. 2011;378(9799):1306-1315. doi:10.1016/S0140-6736(11)60873-8
20. Smith LA, Cornelius V, Tacchi MJ, et al. Acute bipolar mania: a systematic review and meta-analysis of co-therapy vs monotherapy. Acta Psychiatr Scand. 2016;115(1):12-20. doi:10.1111/j.1600-0447.2006.00912.x
21. Nolen WA, Licht RW, Young AH, et al; ISBD/IGSLI Task Force on the treatment with lithium. What is the optimal serum level for lithium in the maintenance treatment of bipolar disorder? A systematic review and recommendations from the ISBD/IGSLI Task Force on treatment with lithium. Bipolar Disord. 2019;21(5):394-409. doi:10.1111/bdi.12805
22. Maj M, Starace F, Nolfe G, et al. Minimum plasma lithium levels required for effective prophylaxis in DSM III bipolar disorder: a prospective study. Pharmacopsychiatry. 1986;19(6):420-423. doi:10.1055/s-2007-1017280
23. Gupta S, Kripalani M, Khastgir U, et al. Management of the renal adverse effects of lithium. Advances in Psychiatric Treatment. 2013;19(6):457-466. doi:10.1192/apt.bp.112.010306
24. Gitlin M. Lithium and the kidney: an updated review. Drug Saf. 1999;20(3):231-243. doi:10.2165/00002018-199920030-00004
25. Jefferson JW. A clinician’s guide to monitoring kidney function in lithium-treated patients. J Clin Psychiatry. 2010;71(9):1153-1157. doi:10.4088/JCP.09m05917yel
26. Shah VC, Kayathi P, Singh G, et al. Enhance your understanding of lithium neurotoxicity. Prim Care Companion CNS Disord. 2015;17(3):10.4088/PCC.14l01767. doi:10.4088/PCC.14l01767
27. Netto I, Phutane VH. Reversible lithium neurotoxicity: review of the literature. Prim Care Companion CNS Disord. 2012;14(1):PCC.11r01197. doi:10.4088/PCC.11r01197
28. Mohandas E, Rajmohan V. Lithium use in special populations. Indian J Psychiatry. 2007;49(3):211-218. doi:10.4103/0019-5545.37325
29. Gupta S, Khastgir U. Drug information update. Lithium and chronic kidney disease: debates and dilemmas. BJPsych Bull. 2017;41(4):216-220. doi:10.1192/pb.bp.116.054031
30. Post RM. Preventing the malignant transformation of bipolar disorder. JAMA. 2018;319(12):1197-1198. doi:10.1001/jama.2018.0322
31. Timmer RT, Sands JM. Lithium intoxication. J Am Soc Nephrol. 1999;10(3):666-674.
32. Demers RG, Heninger GR. Sodium intake and lithium treatment in mania. Am J Psychiatry. 1971;128(1):100-104. doi:10.1176/ajp.128.1.100
33. Hedya SA, Avula A, Swoboda HD. Lithium toxicity. In: StatPearls. StatPearls Publishing; 2020.
1. Tondo L, Alda M, Bauer M, et al. Clinical use of lithium salts: guide for users and prescribers. Int J Bipolar Disord. 2019;7(1):16. doi:10.1186/s40345-019-0151-2
2. Azab AN, Shnaider A, Osher Y, et al. Lithium nephrotoxicity. Int J Bipolar Disord. 2015;3(1):28. doi:10.1186/s40345-015-0028-y
3. American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry. 2002;159:1-50.
4. Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013. Bipolar Disord. 2013;15:1‐44. doi:10.1111/bdi.12025
5. National Collaborating Center for Mental Health (UK). Bipolar disorder: the NICE guideline on the assessment and management of bipolar disorder in adults, children and young people in primary and secondary care. The British Psychological Society and The Royal College of Psychiatrists; 2014.
6. Kupka R, Goossens P, van Bendegem M, et al. Multidisciplinaire richtlijn bipolaire stoornissen. Nederlandse Vereniging voor Psychiatrie (NVvP); 2015. Accessed August 10, 2020. http://www.nvvp.net/stream/richtlijn-bipolaire-stoornissen-2015
7. Malhi GS, Bassett D, Boyce P, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust N Z J Psychiatry. 2015;49:1087‐1206. doi:10.1177/0004867415617657
8. Nederlof M, Heerdink ER, Egberts ACG, et al. Monitoring of patients treated with lithium for bipolar disorder: an international survey. Int J Bipolar Disord. 2018;6(1):12. doi:10.1186/s40345-018-0120-1
9. Leo RJ, Sharma M, Chrostowski DA. A case of lithium-induced symptomatic hypercalcemia. Prim Care Companion J Clin Psychiatry. 2010;12(4):PCC.09l00917. doi:10.4088/PCC.09l00917yel
10. McHenry CR, Lee K. Lithium therapy and disorders of the parathyroid glands. Endocr Pract. 1996;2(2):103-109. doi:10.4158/EP.2.2.103
11. Stahl SM. The prescribers guide: Stahl’s essential psychopharmacology. 6th ed. Cambridge University Press; 2017.
12. Kukopulos A, Reginaldi D. Variations of serum lithium concentrations correlated with the phases of manic-depressive psychosis. Agressologie. 1978;19(D):219-222.
13. Rittmannsberger H, Malsiner-Walli G. Mood-dependent changes of serum lithium concentration in a rapid cycling patient maintained on stable doses of lithium carbonate. Bipolar Disord. 2013;15(3):333-337. doi:10.1111/bdi.12066
14. Hochman E, Weizman A, Valevski A, et al. Association between bipolar episodes and fluid and electrolyte homeostasis: a retrospective longitudinal study. Bipolar Disord. 2014;16(8):781-789. doi:10.1111/bdi.12248
15. Volkmann C, Bschor T, Köhler S. Lithium treatment over the lifespan in bipolar disorders. Front Psychiatry. 2020;11:377. doi: 10.3389/fpsyt.2020.00377
16. Boltan DD, Fenves AZ. Effectiveness of normal saline diuresis in treating lithium overdose. Proc (Bayl Univ Med Cent). 2008;21(3):261-263. doi:10.1080/08998280.2008.11928407
17. Sadock BJ, Saddock VA, Ruiz P. Kaplan and Sadock’s synopsis of psychiatry. 11th ed. Wolters Kluwer; 2014.
18. Tighe SK, Mahon PB, Potash JB. Predictors of lithium response in bipolar disorder. Ther Adv Chronic Dis. 2011;2(3):209-226. doi:10.1177/2040622311399173
19. Cipriani A, Barbui C, Salanti G, et al. Comparative efficacy and acceptability of antimanic drugs in acute mania: a multiple-treatments meta-analysis. Lancet. 2011;378(9799):1306-1315. doi:10.1016/S0140-6736(11)60873-8
20. Smith LA, Cornelius V, Tacchi MJ, et al. Acute bipolar mania: a systematic review and meta-analysis of co-therapy vs monotherapy. Acta Psychiatr Scand. 2016;115(1):12-20. doi:10.1111/j.1600-0447.2006.00912.x
21. Nolen WA, Licht RW, Young AH, et al; ISBD/IGSLI Task Force on the treatment with lithium. What is the optimal serum level for lithium in the maintenance treatment of bipolar disorder? A systematic review and recommendations from the ISBD/IGSLI Task Force on treatment with lithium. Bipolar Disord. 2019;21(5):394-409. doi:10.1111/bdi.12805
22. Maj M, Starace F, Nolfe G, et al. Minimum plasma lithium levels required for effective prophylaxis in DSM III bipolar disorder: a prospective study. Pharmacopsychiatry. 1986;19(6):420-423. doi:10.1055/s-2007-1017280
23. Gupta S, Kripalani M, Khastgir U, et al. Management of the renal adverse effects of lithium. Advances in Psychiatric Treatment. 2013;19(6):457-466. doi:10.1192/apt.bp.112.010306
24. Gitlin M. Lithium and the kidney: an updated review. Drug Saf. 1999;20(3):231-243. doi:10.2165/00002018-199920030-00004
25. Jefferson JW. A clinician’s guide to monitoring kidney function in lithium-treated patients. J Clin Psychiatry. 2010;71(9):1153-1157. doi:10.4088/JCP.09m05917yel
26. Shah VC, Kayathi P, Singh G, et al. Enhance your understanding of lithium neurotoxicity. Prim Care Companion CNS Disord. 2015;17(3):10.4088/PCC.14l01767. doi:10.4088/PCC.14l01767
27. Netto I, Phutane VH. Reversible lithium neurotoxicity: review of the literature. Prim Care Companion CNS Disord. 2012;14(1):PCC.11r01197. doi:10.4088/PCC.11r01197
28. Mohandas E, Rajmohan V. Lithium use in special populations. Indian J Psychiatry. 2007;49(3):211-218. doi:10.4103/0019-5545.37325
29. Gupta S, Khastgir U. Drug information update. Lithium and chronic kidney disease: debates and dilemmas. BJPsych Bull. 2017;41(4):216-220. doi:10.1192/pb.bp.116.054031
30. Post RM. Preventing the malignant transformation of bipolar disorder. JAMA. 2018;319(12):1197-1198. doi:10.1001/jama.2018.0322
31. Timmer RT, Sands JM. Lithium intoxication. J Am Soc Nephrol. 1999;10(3):666-674.
32. Demers RG, Heninger GR. Sodium intake and lithium treatment in mania. Am J Psychiatry. 1971;128(1):100-104. doi:10.1176/ajp.128.1.100
33. Hedya SA, Avula A, Swoboda HD. Lithium toxicity. In: StatPearls. StatPearls Publishing; 2020.
Today’s psychiatric neuroscience advances were science fiction during my residency
During my residency training years, I had many rosy and bold dreams about the future of psychiatry, hoping for many breakthroughs.
Early on, I decided to pursue an academic career, and specifically to focus on the neurobiology of schizophrenia, bipolar disorder, and other psychoses. I secured a neuroscience mentor, conducted a research project, and presented my findings at the American Psychiatric Association Annual Meeting. Although at the time everyone used the term “functional” to describe mental illnesses, I was convinced that they were all neurologic conditions, with prominent psychiatric manifestations. And I have been proven right.
After my residency, I eagerly pursued a neuroscience fellowship at the National Institutes of Health. My fantasy was that during my career as a psychiatric neuroscientist, brain exploration would uncover the many mysteries of psychiatric disorders. I was insightful enough to recognize that what I envisioned for the future of psychiatry qualified as science fiction, but I never stopped dreaming.
Today, the advances in psychiatric neuroscience that were unimaginable during my residency have become dazzling discoveries. My journey as a psychiatric neuroscientist has been more thrilling than I ever imagined. I recall doing postmortem research on the brains of hundreds of deceased psychiatric patients, noticing sulci widening and ventricular dilatation, and wondering whether one day we would be able to detect those atrophic changes while the patients were alive. Although I measured those changes in postmortem brains, I was cognizant that due to preservation artifacts, such measurements were less reliable than measurements of living brains.
And then the advent of neuroimaging fulfilled my fantasies. This began towards the end of my fellowship, and has exploded with neurobiologic findings throughout my academic career. Then came dramatic methodologies to probe brain molecular and cellular pathologies, followed by breakthrough clinical advances. Entirely new vistas of research into psychiatric brain disorders are opening every day. The exhilaration will never end!
From science fiction to clinical reality
Here is a quick outline of some of the “science fiction” of psychiatry that has come true since my training days. Back then, these discoveries were completely absent from the radar screen of psychiatry, when it was still a fledgling medical specialty struggling to emerge from the dominant yet nonempirical era of psychoanalysis.
Brain exploration methods. Unprecedented breakthroughs in computer technology have allowed psychiatric neuroscientists to create a new field of neuroimaging research that includes:
- cerebral blood flow (CBF)
- position emission tomography (PET)
- single photon emission computed tomography (SPECT).
Continue to: These functional neuroimaging...
These functional neuroimaging methods (using ionizing radiation) have enabled clinicians to see abnormal blood flow patterns in the brains of living patients. One of the earliest findings was hypofrontality in patients with schizophrenia, implicating frontal pathology in this severe brain disorder. PET was also used for dopamine and serotonin receptor imaging.
Computerized axia tomography. Compared with skull X-rays, CT (“CAT”) scans provided a more detailed view of brain tissue, and began a structural neuroimaging revolution that enriched psychiatric research, but also was applied to organs other than the brain.
Magnetic resonance imaging (MRI) became the “big kahuna” of neuroimaging when arrived in the early 1980s and quickly supplanted CT research because it is safer (no ionizing radiation, and it can be repeated multiple times with or without tasks). It also provided exquisite neuroanatomical details of brain tissue with stunning fidelity. Subsequently, several MRI techniques/software programs were developed that advanced research in psychiatry to multiple new frontiers, including:
- Morphological neuroimaging with MRI
- Magnetic resonance spectroscopy (MRS), which acts like a living, noninvasive biopsy of several chemicals (such as choline, lactate, glutamine, adenosine triphosphate, and the neuronal marker N-acetylcysteine) in a small volume (≤1 cc) of neural tissue in various regions
- Functional MRI (fMRI), which measures blood flow changes during actual or imagined tasks in the brains of patients vs healthy controls
- Diffusion tensor imaging (DTI), which evaluates the integrity of white matter (60% of brain volume, including 137,000 miles of myelinated fibers) by measuring the flow of water inside myelinated fibers (anisotropy and diffusivity). DTI of the corpus callosum, the largest brain commissure that is comprised of 200 million interhemispheric fibers, has revealed many abnormalities. This was one of the structures I investigated during my fellowship, including a histopathological study.1
All 4 of these neuroimaging techniques continue to generate a wealth of data about brain structure and function in psychosis, mood disorders, anxiety disorders, borderline personality disorder, obsessive-compulsive disorder, eating disorders, and substance use disorders. All these discoveries were utterly impossible to predict during my residency. I am proud to have published the first reports in the literature of ventricular enlargement in patients with bipolar disorder,2 cortical atrophy in schizophrenia and mania,3 reductions of hippocampal volume in patients with schizophrenia using MRS,4 and progressive brain atrophy in patients with schizophrenia.5 It is especially gratifying that I played a small role in translating my science fiction fantasies into clinical reality!
Other breakthrough methodologies that are advancing psychiatric neuroscience today but were science fiction during my residency days include:
- Pluripotent stem cells, which enable the de-differentiation of adult skin cells and then re-differentiating them into any type of cell, including neurons. This allows researchers to conduct studies on any patient’s brain cells without needing to do an invasive, high-risk brain biopsy. As a young resident, I would never have predicted that this virtual brain biopsy would be possible!
- Optogenetics, which enables controlling cell behavior using light and genetically encoded light-sensitive proteins. This triggered a cornucopia of neuroscience discoveries by using optogenetics to modulate cell-signaling cascades to understand cellular biology. Halorhodopsin and bacteriorhodopsin are used as tools to turn neurons off or on rapidly and safely.
- Genome-wide association studies (GWAS) have revolutionized the field of molecular neurogenetics and are enabling clinicians to detect risk genes by comparing the DNA samples of thousands of psychiatric patients with thousands of healthy controls. This is how several hundred risk genes have been identified for schizophrenia, bipolar disorder, autism spectrum disorder, and more to come.
- Clustered regularly interspaced short palindromic repeats (CRISPR) is a remarkable genetic “scissors” (that earned its inventors the 2020 Nobel Prize) that allows splicing out a disease gene and splicing in a normal gene. This will have an enormous future application in preventing an adulthood illness at its roots during fetal life. The future medical implications for psychiatric disorders are prodigious!
Continue to: Clinical advances
Clinical advances. Many therapies or approaches that did not exist during my residency (and how I dreamed about them back then!) are available to today’s clinicians. These include:
- Rapid-acting antidepressants that reverse severe and chronic depression and suicidal urges within a few hours or a couple of days. As a resident, I waited for weeks or months to see patients with depression reach the full remission that is now achieved practically the same day with IV ketamine, intranasal esketamine, IV scopolamine, and inhalable nitrous oxide. During my residency, the closest thing we had to a rapid-acting treatment for depression was electroconvulsive therapy (ECT), but that usually took 2 to 3 weeks. Psychiatric clinicians should never cease to appreciate how an intractable, treatment-refractory depression can rapidly be turned off like a light switch, restoring normal mood to desperately ill persons.
- Neuromodulation techniques are flourishing. Beyond ECT, transcranial magnetic stimulation (TMS), vagus nerve stimulation (VNS), transcranial direct current stimulation (tDCS), deep brain stimulation (DBS), low field magnetic stimulation (LFMS), magnetic seizure therapy (MST), near-infrared radiation (NIR), and focused ultrasound (FUS) are approved or under development, offering millions of patients with various neuropsychiatric disorders potential recovery not with pharmacotherapy, but via a brain-targeted approach.
- Telepsychiatry. Now taken for granted during the COVID-19 pandemic, telepsychiatry was completely unimaginable during my residency. Yes, we had phones, but not smartphones! The only “zoom” we knew was the furious sound of a sports car engine! To be able to see and evaluate a patient literally anywhere in the world was science fiction personified! Increased remote access to psychiatric care by patients everywhere is a truly remarkable advance that helped avoid a disastrous lack of psychiatric treatment during the current pandemic that brought in-person interactions between psychiatric physicians and their patients to a screeching halt.
- Neurobiologic effects of psychotherapy. Viewing psychotherapy as a neurobiologic treatment was totally unknown and unimaginable during my residency. I was heavily trained in various types of psychotherapies, but not once did any of my supervisors mention experiential neuroplasticity as a brain-altering process, or that psychotherapy changes brain structure, induces experimental neuroplasticity, and induces billions of dendritic spines in patients’ cortex and limbic structures, helping them connect the dots and develop new insights. No one knew that psychotherapy can mimic the neural effects of pharmacotherapy.
- Immunomodulatory effects of psychotherapy. It was completely unknown that psychotherapies such as cognitive-behavioral therapy can lower levels of inflammatory biomarkers in patients’ CSF and serum. Back then, no one imagined that psychotherapy had immunomodulatory effects. These discoveries are revolutionary for us psychiatrists and confirm the neurobiologic mechanisms of psychotherapy for every patient we treat.
- Epigenetics. This was rarely, if ever, mentioned when I was a resident. We knew from clinical studies that children who were abused or neglected often develop severe mood or psychotic disorders in adulthood. But we did not know that trauma modifies some genes via under- or overexpression, and that such epigenetic changes alter brain development towards psychopathology. The mysteries of psychiatric brain disorders generated by childhood trauma have been clarified by advances in epigenetics.
Aspirational, futuristic therapies. Even now, as a seasoned psychiatric neuroscientist, I continue to dream. Research is providing many clues for potentially radical psychiatric treatments that go beyond standard antipsychotics, antidepressants, mood stabilizers, or anxiolytics. But today, I fully expect that scientific dreams eventually come true through research. For example, the following neuroscientific therapeutics strategies may someday become routine in clinical practice:
- microglia inhibition
- mitochondria repair
- anti-apoptotic therapy
- white matter connectivity restoration
- neuroprotection (enhancing neurogenesis, increasing neurotropic factors, and enhancing synaptogenesis)
- reverse glutamate N-methyl-
d -aspartate hypofunction - prevent amyloid formation.
Data analysis breakthroughs. Side-by-side with the explosion of new findings and amassing mountains of data in psychiatric neuroscience, unprecedented and revolutionary data-management techniques have emerged to facilitate the herculean task of data analysis to extract the mythical needle in a haystack and derive the overall impact of masses of data. These techniques, whose names were not in our vocabulary during my residency days, include:
- machine learning
- artificial intelligence
- deep learning
- big data.
With the help of powerful computers and ingenious software, discovering critical nuggets of knowledge about the brain and predicting the best approaches to healing dysfunctional brains are now possible. Those powerful methods of analyzing massive data are the vehicles for transforming science fiction to reality by assembling the jigsaw puzzle(s) of the human brain, arguably the last frontier in medical science.
My life experiences as a psychiatric neuroscientist have convinced me that nothing is beyond the reach of scientific research. Unraveling the divine brain’s complexities will eventually become reality. So, let us never stop dreaming and fantasizing!
1. Nasrallah HA, McCalley-Whitters M, Bigelow LB, et al. A histological study of the corpus callosum in chronic schizophrenia. Psychiatry Res. 1983;8(4):251-260.
2. Nasrallah HA, McCalley-Whitters M, Jacoby CG. Cerebral ventricular enlargement in young manic males. A controlled CT study. J Affect Disord. 1982;4(1):15-19.
3. Nasrallah HA, McCalley-Whitters M, Jacoby CG. Cortical atrophy in schizophrenia and mania: a comparative CT study. J Clin Psychiatry. 1982;43(11):439-441.
4. Nasrallah HA, Skinner TE, Schmalbrock P, et al. Proton magnetic resonance spectroscopy (1H MRS) of the hippocampal formation in schizophrenia: a pilot study. Br J Psychiatry. 1994;165(4):481-485.
5. Nasrallah HA, Olson SC, McCalley-Whitters M, et al. Cerebral ventricular enlargement in schizophrenia. A preliminary follow-up study. Arch Gen Psychiatry. 1986;43(2):157-159.
During my residency training years, I had many rosy and bold dreams about the future of psychiatry, hoping for many breakthroughs.
Early on, I decided to pursue an academic career, and specifically to focus on the neurobiology of schizophrenia, bipolar disorder, and other psychoses. I secured a neuroscience mentor, conducted a research project, and presented my findings at the American Psychiatric Association Annual Meeting. Although at the time everyone used the term “functional” to describe mental illnesses, I was convinced that they were all neurologic conditions, with prominent psychiatric manifestations. And I have been proven right.
After my residency, I eagerly pursued a neuroscience fellowship at the National Institutes of Health. My fantasy was that during my career as a psychiatric neuroscientist, brain exploration would uncover the many mysteries of psychiatric disorders. I was insightful enough to recognize that what I envisioned for the future of psychiatry qualified as science fiction, but I never stopped dreaming.
Today, the advances in psychiatric neuroscience that were unimaginable during my residency have become dazzling discoveries. My journey as a psychiatric neuroscientist has been more thrilling than I ever imagined. I recall doing postmortem research on the brains of hundreds of deceased psychiatric patients, noticing sulci widening and ventricular dilatation, and wondering whether one day we would be able to detect those atrophic changes while the patients were alive. Although I measured those changes in postmortem brains, I was cognizant that due to preservation artifacts, such measurements were less reliable than measurements of living brains.
And then the advent of neuroimaging fulfilled my fantasies. This began towards the end of my fellowship, and has exploded with neurobiologic findings throughout my academic career. Then came dramatic methodologies to probe brain molecular and cellular pathologies, followed by breakthrough clinical advances. Entirely new vistas of research into psychiatric brain disorders are opening every day. The exhilaration will never end!
From science fiction to clinical reality
Here is a quick outline of some of the “science fiction” of psychiatry that has come true since my training days. Back then, these discoveries were completely absent from the radar screen of psychiatry, when it was still a fledgling medical specialty struggling to emerge from the dominant yet nonempirical era of psychoanalysis.
Brain exploration methods. Unprecedented breakthroughs in computer technology have allowed psychiatric neuroscientists to create a new field of neuroimaging research that includes:
- cerebral blood flow (CBF)
- position emission tomography (PET)
- single photon emission computed tomography (SPECT).
Continue to: These functional neuroimaging...
These functional neuroimaging methods (using ionizing radiation) have enabled clinicians to see abnormal blood flow patterns in the brains of living patients. One of the earliest findings was hypofrontality in patients with schizophrenia, implicating frontal pathology in this severe brain disorder. PET was also used for dopamine and serotonin receptor imaging.
Computerized axia tomography. Compared with skull X-rays, CT (“CAT”) scans provided a more detailed view of brain tissue, and began a structural neuroimaging revolution that enriched psychiatric research, but also was applied to organs other than the brain.
Magnetic resonance imaging (MRI) became the “big kahuna” of neuroimaging when arrived in the early 1980s and quickly supplanted CT research because it is safer (no ionizing radiation, and it can be repeated multiple times with or without tasks). It also provided exquisite neuroanatomical details of brain tissue with stunning fidelity. Subsequently, several MRI techniques/software programs were developed that advanced research in psychiatry to multiple new frontiers, including:
- Morphological neuroimaging with MRI
- Magnetic resonance spectroscopy (MRS), which acts like a living, noninvasive biopsy of several chemicals (such as choline, lactate, glutamine, adenosine triphosphate, and the neuronal marker N-acetylcysteine) in a small volume (≤1 cc) of neural tissue in various regions
- Functional MRI (fMRI), which measures blood flow changes during actual or imagined tasks in the brains of patients vs healthy controls
- Diffusion tensor imaging (DTI), which evaluates the integrity of white matter (60% of brain volume, including 137,000 miles of myelinated fibers) by measuring the flow of water inside myelinated fibers (anisotropy and diffusivity). DTI of the corpus callosum, the largest brain commissure that is comprised of 200 million interhemispheric fibers, has revealed many abnormalities. This was one of the structures I investigated during my fellowship, including a histopathological study.1
All 4 of these neuroimaging techniques continue to generate a wealth of data about brain structure and function in psychosis, mood disorders, anxiety disorders, borderline personality disorder, obsessive-compulsive disorder, eating disorders, and substance use disorders. All these discoveries were utterly impossible to predict during my residency. I am proud to have published the first reports in the literature of ventricular enlargement in patients with bipolar disorder,2 cortical atrophy in schizophrenia and mania,3 reductions of hippocampal volume in patients with schizophrenia using MRS,4 and progressive brain atrophy in patients with schizophrenia.5 It is especially gratifying that I played a small role in translating my science fiction fantasies into clinical reality!
Other breakthrough methodologies that are advancing psychiatric neuroscience today but were science fiction during my residency days include:
- Pluripotent stem cells, which enable the de-differentiation of adult skin cells and then re-differentiating them into any type of cell, including neurons. This allows researchers to conduct studies on any patient’s brain cells without needing to do an invasive, high-risk brain biopsy. As a young resident, I would never have predicted that this virtual brain biopsy would be possible!
- Optogenetics, which enables controlling cell behavior using light and genetically encoded light-sensitive proteins. This triggered a cornucopia of neuroscience discoveries by using optogenetics to modulate cell-signaling cascades to understand cellular biology. Halorhodopsin and bacteriorhodopsin are used as tools to turn neurons off or on rapidly and safely.
- Genome-wide association studies (GWAS) have revolutionized the field of molecular neurogenetics and are enabling clinicians to detect risk genes by comparing the DNA samples of thousands of psychiatric patients with thousands of healthy controls. This is how several hundred risk genes have been identified for schizophrenia, bipolar disorder, autism spectrum disorder, and more to come.
- Clustered regularly interspaced short palindromic repeats (CRISPR) is a remarkable genetic “scissors” (that earned its inventors the 2020 Nobel Prize) that allows splicing out a disease gene and splicing in a normal gene. This will have an enormous future application in preventing an adulthood illness at its roots during fetal life. The future medical implications for psychiatric disorders are prodigious!
Continue to: Clinical advances
Clinical advances. Many therapies or approaches that did not exist during my residency (and how I dreamed about them back then!) are available to today’s clinicians. These include:
- Rapid-acting antidepressants that reverse severe and chronic depression and suicidal urges within a few hours or a couple of days. As a resident, I waited for weeks or months to see patients with depression reach the full remission that is now achieved practically the same day with IV ketamine, intranasal esketamine, IV scopolamine, and inhalable nitrous oxide. During my residency, the closest thing we had to a rapid-acting treatment for depression was electroconvulsive therapy (ECT), but that usually took 2 to 3 weeks. Psychiatric clinicians should never cease to appreciate how an intractable, treatment-refractory depression can rapidly be turned off like a light switch, restoring normal mood to desperately ill persons.
- Neuromodulation techniques are flourishing. Beyond ECT, transcranial magnetic stimulation (TMS), vagus nerve stimulation (VNS), transcranial direct current stimulation (tDCS), deep brain stimulation (DBS), low field magnetic stimulation (LFMS), magnetic seizure therapy (MST), near-infrared radiation (NIR), and focused ultrasound (FUS) are approved or under development, offering millions of patients with various neuropsychiatric disorders potential recovery not with pharmacotherapy, but via a brain-targeted approach.
- Telepsychiatry. Now taken for granted during the COVID-19 pandemic, telepsychiatry was completely unimaginable during my residency. Yes, we had phones, but not smartphones! The only “zoom” we knew was the furious sound of a sports car engine! To be able to see and evaluate a patient literally anywhere in the world was science fiction personified! Increased remote access to psychiatric care by patients everywhere is a truly remarkable advance that helped avoid a disastrous lack of psychiatric treatment during the current pandemic that brought in-person interactions between psychiatric physicians and their patients to a screeching halt.
- Neurobiologic effects of psychotherapy. Viewing psychotherapy as a neurobiologic treatment was totally unknown and unimaginable during my residency. I was heavily trained in various types of psychotherapies, but not once did any of my supervisors mention experiential neuroplasticity as a brain-altering process, or that psychotherapy changes brain structure, induces experimental neuroplasticity, and induces billions of dendritic spines in patients’ cortex and limbic structures, helping them connect the dots and develop new insights. No one knew that psychotherapy can mimic the neural effects of pharmacotherapy.
- Immunomodulatory effects of psychotherapy. It was completely unknown that psychotherapies such as cognitive-behavioral therapy can lower levels of inflammatory biomarkers in patients’ CSF and serum. Back then, no one imagined that psychotherapy had immunomodulatory effects. These discoveries are revolutionary for us psychiatrists and confirm the neurobiologic mechanisms of psychotherapy for every patient we treat.
- Epigenetics. This was rarely, if ever, mentioned when I was a resident. We knew from clinical studies that children who were abused or neglected often develop severe mood or psychotic disorders in adulthood. But we did not know that trauma modifies some genes via under- or overexpression, and that such epigenetic changes alter brain development towards psychopathology. The mysteries of psychiatric brain disorders generated by childhood trauma have been clarified by advances in epigenetics.
Aspirational, futuristic therapies. Even now, as a seasoned psychiatric neuroscientist, I continue to dream. Research is providing many clues for potentially radical psychiatric treatments that go beyond standard antipsychotics, antidepressants, mood stabilizers, or anxiolytics. But today, I fully expect that scientific dreams eventually come true through research. For example, the following neuroscientific therapeutics strategies may someday become routine in clinical practice:
- microglia inhibition
- mitochondria repair
- anti-apoptotic therapy
- white matter connectivity restoration
- neuroprotection (enhancing neurogenesis, increasing neurotropic factors, and enhancing synaptogenesis)
- reverse glutamate N-methyl-
d -aspartate hypofunction - prevent amyloid formation.
Data analysis breakthroughs. Side-by-side with the explosion of new findings and amassing mountains of data in psychiatric neuroscience, unprecedented and revolutionary data-management techniques have emerged to facilitate the herculean task of data analysis to extract the mythical needle in a haystack and derive the overall impact of masses of data. These techniques, whose names were not in our vocabulary during my residency days, include:
- machine learning
- artificial intelligence
- deep learning
- big data.
With the help of powerful computers and ingenious software, discovering critical nuggets of knowledge about the brain and predicting the best approaches to healing dysfunctional brains are now possible. Those powerful methods of analyzing massive data are the vehicles for transforming science fiction to reality by assembling the jigsaw puzzle(s) of the human brain, arguably the last frontier in medical science.
My life experiences as a psychiatric neuroscientist have convinced me that nothing is beyond the reach of scientific research. Unraveling the divine brain’s complexities will eventually become reality. So, let us never stop dreaming and fantasizing!
During my residency training years, I had many rosy and bold dreams about the future of psychiatry, hoping for many breakthroughs.
Early on, I decided to pursue an academic career, and specifically to focus on the neurobiology of schizophrenia, bipolar disorder, and other psychoses. I secured a neuroscience mentor, conducted a research project, and presented my findings at the American Psychiatric Association Annual Meeting. Although at the time everyone used the term “functional” to describe mental illnesses, I was convinced that they were all neurologic conditions, with prominent psychiatric manifestations. And I have been proven right.
After my residency, I eagerly pursued a neuroscience fellowship at the National Institutes of Health. My fantasy was that during my career as a psychiatric neuroscientist, brain exploration would uncover the many mysteries of psychiatric disorders. I was insightful enough to recognize that what I envisioned for the future of psychiatry qualified as science fiction, but I never stopped dreaming.
Today, the advances in psychiatric neuroscience that were unimaginable during my residency have become dazzling discoveries. My journey as a psychiatric neuroscientist has been more thrilling than I ever imagined. I recall doing postmortem research on the brains of hundreds of deceased psychiatric patients, noticing sulci widening and ventricular dilatation, and wondering whether one day we would be able to detect those atrophic changes while the patients were alive. Although I measured those changes in postmortem brains, I was cognizant that due to preservation artifacts, such measurements were less reliable than measurements of living brains.
And then the advent of neuroimaging fulfilled my fantasies. This began towards the end of my fellowship, and has exploded with neurobiologic findings throughout my academic career. Then came dramatic methodologies to probe brain molecular and cellular pathologies, followed by breakthrough clinical advances. Entirely new vistas of research into psychiatric brain disorders are opening every day. The exhilaration will never end!
From science fiction to clinical reality
Here is a quick outline of some of the “science fiction” of psychiatry that has come true since my training days. Back then, these discoveries were completely absent from the radar screen of psychiatry, when it was still a fledgling medical specialty struggling to emerge from the dominant yet nonempirical era of psychoanalysis.
Brain exploration methods. Unprecedented breakthroughs in computer technology have allowed psychiatric neuroscientists to create a new field of neuroimaging research that includes:
- cerebral blood flow (CBF)
- position emission tomography (PET)
- single photon emission computed tomography (SPECT).
Continue to: These functional neuroimaging...
These functional neuroimaging methods (using ionizing radiation) have enabled clinicians to see abnormal blood flow patterns in the brains of living patients. One of the earliest findings was hypofrontality in patients with schizophrenia, implicating frontal pathology in this severe brain disorder. PET was also used for dopamine and serotonin receptor imaging.
Computerized axia tomography. Compared with skull X-rays, CT (“CAT”) scans provided a more detailed view of brain tissue, and began a structural neuroimaging revolution that enriched psychiatric research, but also was applied to organs other than the brain.
Magnetic resonance imaging (MRI) became the “big kahuna” of neuroimaging when arrived in the early 1980s and quickly supplanted CT research because it is safer (no ionizing radiation, and it can be repeated multiple times with or without tasks). It also provided exquisite neuroanatomical details of brain tissue with stunning fidelity. Subsequently, several MRI techniques/software programs were developed that advanced research in psychiatry to multiple new frontiers, including:
- Morphological neuroimaging with MRI
- Magnetic resonance spectroscopy (MRS), which acts like a living, noninvasive biopsy of several chemicals (such as choline, lactate, glutamine, adenosine triphosphate, and the neuronal marker N-acetylcysteine) in a small volume (≤1 cc) of neural tissue in various regions
- Functional MRI (fMRI), which measures blood flow changes during actual or imagined tasks in the brains of patients vs healthy controls
- Diffusion tensor imaging (DTI), which evaluates the integrity of white matter (60% of brain volume, including 137,000 miles of myelinated fibers) by measuring the flow of water inside myelinated fibers (anisotropy and diffusivity). DTI of the corpus callosum, the largest brain commissure that is comprised of 200 million interhemispheric fibers, has revealed many abnormalities. This was one of the structures I investigated during my fellowship, including a histopathological study.1
All 4 of these neuroimaging techniques continue to generate a wealth of data about brain structure and function in psychosis, mood disorders, anxiety disorders, borderline personality disorder, obsessive-compulsive disorder, eating disorders, and substance use disorders. All these discoveries were utterly impossible to predict during my residency. I am proud to have published the first reports in the literature of ventricular enlargement in patients with bipolar disorder,2 cortical atrophy in schizophrenia and mania,3 reductions of hippocampal volume in patients with schizophrenia using MRS,4 and progressive brain atrophy in patients with schizophrenia.5 It is especially gratifying that I played a small role in translating my science fiction fantasies into clinical reality!
Other breakthrough methodologies that are advancing psychiatric neuroscience today but were science fiction during my residency days include:
- Pluripotent stem cells, which enable the de-differentiation of adult skin cells and then re-differentiating them into any type of cell, including neurons. This allows researchers to conduct studies on any patient’s brain cells without needing to do an invasive, high-risk brain biopsy. As a young resident, I would never have predicted that this virtual brain biopsy would be possible!
- Optogenetics, which enables controlling cell behavior using light and genetically encoded light-sensitive proteins. This triggered a cornucopia of neuroscience discoveries by using optogenetics to modulate cell-signaling cascades to understand cellular biology. Halorhodopsin and bacteriorhodopsin are used as tools to turn neurons off or on rapidly and safely.
- Genome-wide association studies (GWAS) have revolutionized the field of molecular neurogenetics and are enabling clinicians to detect risk genes by comparing the DNA samples of thousands of psychiatric patients with thousands of healthy controls. This is how several hundred risk genes have been identified for schizophrenia, bipolar disorder, autism spectrum disorder, and more to come.
- Clustered regularly interspaced short palindromic repeats (CRISPR) is a remarkable genetic “scissors” (that earned its inventors the 2020 Nobel Prize) that allows splicing out a disease gene and splicing in a normal gene. This will have an enormous future application in preventing an adulthood illness at its roots during fetal life. The future medical implications for psychiatric disorders are prodigious!
Continue to: Clinical advances
Clinical advances. Many therapies or approaches that did not exist during my residency (and how I dreamed about them back then!) are available to today’s clinicians. These include:
- Rapid-acting antidepressants that reverse severe and chronic depression and suicidal urges within a few hours or a couple of days. As a resident, I waited for weeks or months to see patients with depression reach the full remission that is now achieved practically the same day with IV ketamine, intranasal esketamine, IV scopolamine, and inhalable nitrous oxide. During my residency, the closest thing we had to a rapid-acting treatment for depression was electroconvulsive therapy (ECT), but that usually took 2 to 3 weeks. Psychiatric clinicians should never cease to appreciate how an intractable, treatment-refractory depression can rapidly be turned off like a light switch, restoring normal mood to desperately ill persons.
- Neuromodulation techniques are flourishing. Beyond ECT, transcranial magnetic stimulation (TMS), vagus nerve stimulation (VNS), transcranial direct current stimulation (tDCS), deep brain stimulation (DBS), low field magnetic stimulation (LFMS), magnetic seizure therapy (MST), near-infrared radiation (NIR), and focused ultrasound (FUS) are approved or under development, offering millions of patients with various neuropsychiatric disorders potential recovery not with pharmacotherapy, but via a brain-targeted approach.
- Telepsychiatry. Now taken for granted during the COVID-19 pandemic, telepsychiatry was completely unimaginable during my residency. Yes, we had phones, but not smartphones! The only “zoom” we knew was the furious sound of a sports car engine! To be able to see and evaluate a patient literally anywhere in the world was science fiction personified! Increased remote access to psychiatric care by patients everywhere is a truly remarkable advance that helped avoid a disastrous lack of psychiatric treatment during the current pandemic that brought in-person interactions between psychiatric physicians and their patients to a screeching halt.
- Neurobiologic effects of psychotherapy. Viewing psychotherapy as a neurobiologic treatment was totally unknown and unimaginable during my residency. I was heavily trained in various types of psychotherapies, but not once did any of my supervisors mention experiential neuroplasticity as a brain-altering process, or that psychotherapy changes brain structure, induces experimental neuroplasticity, and induces billions of dendritic spines in patients’ cortex and limbic structures, helping them connect the dots and develop new insights. No one knew that psychotherapy can mimic the neural effects of pharmacotherapy.
- Immunomodulatory effects of psychotherapy. It was completely unknown that psychotherapies such as cognitive-behavioral therapy can lower levels of inflammatory biomarkers in patients’ CSF and serum. Back then, no one imagined that psychotherapy had immunomodulatory effects. These discoveries are revolutionary for us psychiatrists and confirm the neurobiologic mechanisms of psychotherapy for every patient we treat.
- Epigenetics. This was rarely, if ever, mentioned when I was a resident. We knew from clinical studies that children who were abused or neglected often develop severe mood or psychotic disorders in adulthood. But we did not know that trauma modifies some genes via under- or overexpression, and that such epigenetic changes alter brain development towards psychopathology. The mysteries of psychiatric brain disorders generated by childhood trauma have been clarified by advances in epigenetics.
Aspirational, futuristic therapies. Even now, as a seasoned psychiatric neuroscientist, I continue to dream. Research is providing many clues for potentially radical psychiatric treatments that go beyond standard antipsychotics, antidepressants, mood stabilizers, or anxiolytics. But today, I fully expect that scientific dreams eventually come true through research. For example, the following neuroscientific therapeutics strategies may someday become routine in clinical practice:
- microglia inhibition
- mitochondria repair
- anti-apoptotic therapy
- white matter connectivity restoration
- neuroprotection (enhancing neurogenesis, increasing neurotropic factors, and enhancing synaptogenesis)
- reverse glutamate N-methyl-
d -aspartate hypofunction - prevent amyloid formation.
Data analysis breakthroughs. Side-by-side with the explosion of new findings and amassing mountains of data in psychiatric neuroscience, unprecedented and revolutionary data-management techniques have emerged to facilitate the herculean task of data analysis to extract the mythical needle in a haystack and derive the overall impact of masses of data. These techniques, whose names were not in our vocabulary during my residency days, include:
- machine learning
- artificial intelligence
- deep learning
- big data.
With the help of powerful computers and ingenious software, discovering critical nuggets of knowledge about the brain and predicting the best approaches to healing dysfunctional brains are now possible. Those powerful methods of analyzing massive data are the vehicles for transforming science fiction to reality by assembling the jigsaw puzzle(s) of the human brain, arguably the last frontier in medical science.
My life experiences as a psychiatric neuroscientist have convinced me that nothing is beyond the reach of scientific research. Unraveling the divine brain’s complexities will eventually become reality. So, let us never stop dreaming and fantasizing!
1. Nasrallah HA, McCalley-Whitters M, Bigelow LB, et al. A histological study of the corpus callosum in chronic schizophrenia. Psychiatry Res. 1983;8(4):251-260.
2. Nasrallah HA, McCalley-Whitters M, Jacoby CG. Cerebral ventricular enlargement in young manic males. A controlled CT study. J Affect Disord. 1982;4(1):15-19.
3. Nasrallah HA, McCalley-Whitters M, Jacoby CG. Cortical atrophy in schizophrenia and mania: a comparative CT study. J Clin Psychiatry. 1982;43(11):439-441.
4. Nasrallah HA, Skinner TE, Schmalbrock P, et al. Proton magnetic resonance spectroscopy (1H MRS) of the hippocampal formation in schizophrenia: a pilot study. Br J Psychiatry. 1994;165(4):481-485.
5. Nasrallah HA, Olson SC, McCalley-Whitters M, et al. Cerebral ventricular enlargement in schizophrenia. A preliminary follow-up study. Arch Gen Psychiatry. 1986;43(2):157-159.
1. Nasrallah HA, McCalley-Whitters M, Bigelow LB, et al. A histological study of the corpus callosum in chronic schizophrenia. Psychiatry Res. 1983;8(4):251-260.
2. Nasrallah HA, McCalley-Whitters M, Jacoby CG. Cerebral ventricular enlargement in young manic males. A controlled CT study. J Affect Disord. 1982;4(1):15-19.
3. Nasrallah HA, McCalley-Whitters M, Jacoby CG. Cortical atrophy in schizophrenia and mania: a comparative CT study. J Clin Psychiatry. 1982;43(11):439-441.
4. Nasrallah HA, Skinner TE, Schmalbrock P, et al. Proton magnetic resonance spectroscopy (1H MRS) of the hippocampal formation in schizophrenia: a pilot study. Br J Psychiatry. 1994;165(4):481-485.
5. Nasrallah HA, Olson SC, McCalley-Whitters M, et al. Cerebral ventricular enlargement in schizophrenia. A preliminary follow-up study. Arch Gen Psychiatry. 1986;43(2):157-159.
High-dose lumateperone: A case report
Lumateperone is a novel antipsychotic that possesses a variety of unique receptor affinities. The recommended dose of lumateperone is 42 mg/d. In clinical trials, reductions in Positive and Negative Syndrome Scale scores observed with lumateperone, 28 mg/d and 84 mg/d, failed to separate from placebo.1 However, in these trials, safety profiles were similar for all 3 doses.
Despite the popular understanding of lumateperone’s “unexplained narrow therapeutic window,”2 we report the case of a patient with schizophrenia who responded well to lumateperone, 84 mg/d, without adverse effects or EKG changes.
Case report. Mr. W, age 26, has treatment-resistant schizophrenia (paranoid type). He failed to achieve remission on fluphenazine (10 to 25 mg/d), perphenazine (4 to 24 mg/d), risperidone (started at 4 mg/d and increased to 8 mg/d), and olanzapine (15, 20, and 25 mg/d). None of these medications eliminated his auditory or visual hallucinations. His response was most robust to perphenazine, as he reported a 50% reduction in the frequency of auditory hallucinations and a near-complete resolution of visual hallucinations (once or twice per week), but he never achieved full remission.
We started lumateperone, 42 mg/d, without a cross-taper. After 4 weeks of partial response, the patient escalated his dose to 84 mg/d on his own. At a follow-up visit 3.5 weeks after this self-directed dose increase, Mr. W reported a complete resolution of his auditory and visual hallucinations.
Six months later, Mr. W continued to receive lumateperone, 84 mg/d, without extrapyramidal symptoms, tardive dyskinesia, or other adverse effects. His QTc showed no significant change (410 ms vs 412 ms).
Although some studies indicate a possible “therapeutic window” for lumateperone dosing, clinicians should not deprive patients who partially respond to the recommended 42 mg/d dose of the opportunity for additional benefit through dose escalation. Due to the vagaries of psychiatric pathology, and unique profiles of metabolism and receptor sensitivity, there will always be patients who may require higher-than-recommended doses of lumateperone, as with all other agents.
1. Lieberman JA, Davis RE, Correll CU, et al. ITI-007 for the treatment of schizophrenia: a 4-week randomized, double-blind, controlled trial. Biol Psychiatry. 2016;79(12):952-961. doi: 10.1016/j.biopsych.2015.08.026
2. Kantrowitz JT. The potential role of lumateperone—something borrowed? something new? JAMA Psychiatry. 2020;77(4):343-344. doi:10.1001/jamapsychiatry.2019.4265
Lumateperone is a novel antipsychotic that possesses a variety of unique receptor affinities. The recommended dose of lumateperone is 42 mg/d. In clinical trials, reductions in Positive and Negative Syndrome Scale scores observed with lumateperone, 28 mg/d and 84 mg/d, failed to separate from placebo.1 However, in these trials, safety profiles were similar for all 3 doses.
Despite the popular understanding of lumateperone’s “unexplained narrow therapeutic window,”2 we report the case of a patient with schizophrenia who responded well to lumateperone, 84 mg/d, without adverse effects or EKG changes.
Case report. Mr. W, age 26, has treatment-resistant schizophrenia (paranoid type). He failed to achieve remission on fluphenazine (10 to 25 mg/d), perphenazine (4 to 24 mg/d), risperidone (started at 4 mg/d and increased to 8 mg/d), and olanzapine (15, 20, and 25 mg/d). None of these medications eliminated his auditory or visual hallucinations. His response was most robust to perphenazine, as he reported a 50% reduction in the frequency of auditory hallucinations and a near-complete resolution of visual hallucinations (once or twice per week), but he never achieved full remission.
We started lumateperone, 42 mg/d, without a cross-taper. After 4 weeks of partial response, the patient escalated his dose to 84 mg/d on his own. At a follow-up visit 3.5 weeks after this self-directed dose increase, Mr. W reported a complete resolution of his auditory and visual hallucinations.
Six months later, Mr. W continued to receive lumateperone, 84 mg/d, without extrapyramidal symptoms, tardive dyskinesia, or other adverse effects. His QTc showed no significant change (410 ms vs 412 ms).
Although some studies indicate a possible “therapeutic window” for lumateperone dosing, clinicians should not deprive patients who partially respond to the recommended 42 mg/d dose of the opportunity for additional benefit through dose escalation. Due to the vagaries of psychiatric pathology, and unique profiles of metabolism and receptor sensitivity, there will always be patients who may require higher-than-recommended doses of lumateperone, as with all other agents.
Lumateperone is a novel antipsychotic that possesses a variety of unique receptor affinities. The recommended dose of lumateperone is 42 mg/d. In clinical trials, reductions in Positive and Negative Syndrome Scale scores observed with lumateperone, 28 mg/d and 84 mg/d, failed to separate from placebo.1 However, in these trials, safety profiles were similar for all 3 doses.
Despite the popular understanding of lumateperone’s “unexplained narrow therapeutic window,”2 we report the case of a patient with schizophrenia who responded well to lumateperone, 84 mg/d, without adverse effects or EKG changes.
Case report. Mr. W, age 26, has treatment-resistant schizophrenia (paranoid type). He failed to achieve remission on fluphenazine (10 to 25 mg/d), perphenazine (4 to 24 mg/d), risperidone (started at 4 mg/d and increased to 8 mg/d), and olanzapine (15, 20, and 25 mg/d). None of these medications eliminated his auditory or visual hallucinations. His response was most robust to perphenazine, as he reported a 50% reduction in the frequency of auditory hallucinations and a near-complete resolution of visual hallucinations (once or twice per week), but he never achieved full remission.
We started lumateperone, 42 mg/d, without a cross-taper. After 4 weeks of partial response, the patient escalated his dose to 84 mg/d on his own. At a follow-up visit 3.5 weeks after this self-directed dose increase, Mr. W reported a complete resolution of his auditory and visual hallucinations.
Six months later, Mr. W continued to receive lumateperone, 84 mg/d, without extrapyramidal symptoms, tardive dyskinesia, or other adverse effects. His QTc showed no significant change (410 ms vs 412 ms).
Although some studies indicate a possible “therapeutic window” for lumateperone dosing, clinicians should not deprive patients who partially respond to the recommended 42 mg/d dose of the opportunity for additional benefit through dose escalation. Due to the vagaries of psychiatric pathology, and unique profiles of metabolism and receptor sensitivity, there will always be patients who may require higher-than-recommended doses of lumateperone, as with all other agents.
1. Lieberman JA, Davis RE, Correll CU, et al. ITI-007 for the treatment of schizophrenia: a 4-week randomized, double-blind, controlled trial. Biol Psychiatry. 2016;79(12):952-961. doi: 10.1016/j.biopsych.2015.08.026
2. Kantrowitz JT. The potential role of lumateperone—something borrowed? something new? JAMA Psychiatry. 2020;77(4):343-344. doi:10.1001/jamapsychiatry.2019.4265
1. Lieberman JA, Davis RE, Correll CU, et al. ITI-007 for the treatment of schizophrenia: a 4-week randomized, double-blind, controlled trial. Biol Psychiatry. 2016;79(12):952-961. doi: 10.1016/j.biopsych.2015.08.026
2. Kantrowitz JT. The potential role of lumateperone—something borrowed? something new? JAMA Psychiatry. 2020;77(4):343-344. doi:10.1001/jamapsychiatry.2019.4265
“Thank You for Not Letting Me Crash and Burn”: The Imperative of Quality Physician Onboarding to Foster Job Satisfaction, Strengthen Workplace Culture, and Advance the Quadruple Aim
From The Ohio State University College of Medicine Department of Family and Community Medicine, Columbus, OH (Candy Magaña, Jná Báez, Christine Junk, Drs. Ahmad, Conroy, and Olayiwola); The Ohio State University College of Medicine Center for Primary Care Innovation and Transformation (Candy Magaña, Jná Báez, and Dr. Olayiwola); and The Ohio State University Wexner Medical Center (Christine Harsh, Erica Esposito).
Much has been discussed about the growing crisis of professional dissatisfaction among physicians, with increasing efforts being made to incorporate physician wellness into health system strategies that move from the Triple to the Quadruple Aim.1 For many years, our health care system has been focused on improving the health of populations, optimizing the patient experience, and reducing the cost of care (Triple Aim). The inclusion of the fourth aim, improving the experience of the teams that deliver care, has become paramount in achieving the other aims.
An area often overlooked in this focus on wellness, however, is the importance of the earliest days of employment to shape and predict long-term career contentment. This is a missed opportunity, as data suggest that organizations with standardized onboarding programs boast a 62% increased productivity rate and a 50% greater retention rate among new hires.2,3 Moreover, a study by the International Institute for Management Development found that businesses lose an estimated $37 billion annually because employees do not fully understand their jobs.4 The report ties losses to “actions taken by employees who have misunderstood or misinterpreted company policies, business processes, job function, or a combination of the three.” Additionally, onboarding programs that focus strictly on technical or functional orientation tasks miss important opportunities for culture integration during the onboarding process.5 It is therefore imperative to look to effective models of employee onboarding to develop systems that position physicians and practices for success.
Challenges With Traditional Physician Onboarding
In recent years, the Department of Family and Community Medicine at The Ohio State University College of Medicine has experienced rapid organizational change. Like many primary care systems nationwide responding to disruption in health care and changing demands on the clinical workforce, the department has hired new leadership, revised strategic priorities, and witnessed an influx of faculty and staff. It has also planned an expansion of ambulatory services that will more than double the clinical workforce over the next 3 years. While an exciting time, there has been a growing need to align strategy, culture, and human capital during these changes.
As we entered this phase of transformation, we recognized that our highly individualized, ad hoc orientation system presented shortcomings. During the act of revamping our physician recruitment process, stakeholder workgroup members specifically noted that improvement efforts were needed regarding new physician orientation, as no consistent structures were previously in place. New physician orientation had been a major gap for years, resulting in dissatisfaction in the first few months of physician practice, early physician turnover, and staff frustration. For physicians, we continued to learn about their frustration and unanswered questions regarding expectations, norms, structures, and processes.
Many new hires were left with a kind of “trial by fire” entry into their roles. On the first day of clinic, a new physician would most likely need to simultaneously see patients, learn the nuances of the electronic health record (EHR), figure out where the break room was located, and quickly learn population health issues for the patients they were serving. Opportunities to meet key clinic site leadership would be at random, and new physicians might not have the opportunity to meet leadership or staff until months into their tenure; this did not allow for a sense of belonging or understanding of the many resources available to them. We learned that the quality of these ad hoc orientations also varied based on the experience and priorities of each practice’s clinic and administrative leaders, who themselves felt ill-equipped to provide a consistent, robust, and confidence-building experience. In addition, practice site management was rarely given advance time to prepare for the arrival of new physicians, which resulted in physicians perceiving practices to be unwelcoming and disorganized. Their first days were often spent with patients in clinic with no structured orientation and without understanding workflows or having systems practice knowledge.
Institutionally, the interview process satisfied some transfer of knowledge, but we were unclear of what was being consistently shared and understood in the multiple ambulatory locations where our physicians enter practice. More importantly, we knew we were missing a critical opportunity to use orientation to imbue other values of diversity and inclusion, health equity, and operational excellence into the workforce. Based on anecdotal insights from employees and our own review of successful onboarding approaches from other industries, we also knew a more structured welcoming process would predict greater long-term career satisfaction for physicians and create a foundation for providing optimal care for patients when clinical encounters began.
Reengineering Physician Onboarding
In 2019, our department developed a multipronged approach to physician onboarding, which is already paying dividends in easing acculturation and fostering team cohesion. The department tapped its Center for Primary Care Innovation and Transformation (PCIT) to direct this effort, based on its expertise in practice transformation, clinical transformation and adaptations, and workflow efficiency through process and quality improvement. The PCIT team provides support to the department and the entire health system focused on technology and innovation, health equity, and health care efficiency.6 They applied many of the tools used in the Clinical Transformation in Technology approach to lead this initiative.7
The PCIT team began identifying key stakeholders (department, clinical and ambulatory leadership, clinicians and clinical staff, community partners, human resources, and resident physicians), and then engaging those individuals in dialogue surrounding orientation needs. During scheduled in-person and virtual work sessions, stakeholders were asked to provide input on pain points for new physicians and clinic leadership and were then empowered to create an onboarding program. Applying health care quality improvement techniques, we leveraged workflow mapping, current and future state planning, and goal setting, led by the skilled process improvement and clinical transformation specialists. We coordinated a multidisciplinary process improvement team that included clinic administrators, medical directors, human resources, administrative staff, ambulatory and resident leadership, clinical leadership, and recruitment liaisons. This diverse group of leadership and staff was brought together to address these critical identified gaps and weaknesses in new physician onboarding.
Through a series of learning sessions, the workgroup provided input that was used to form an itemized physician onboarding schedule, which was then leveraged to develop Plan-Do-Study-Act (PDSA) cycles, collecting feedback in real time. Some issues that seem small can cause major distress for new physicians. For example, in our inaugural orientation implementation, a physician provided feedback that they wanted to obtain information on setting up their work email on their personal devices and was having considerable trouble figuring out how to do so. This particular topic was not initially included in the first iteration of the Department’s orientation program. We rapidly sought out different ways to embed that into the onboarding experience. The first PDSA involved integrating the university information technology team (IT) into the process but was not successful because it required extra work for the new physician and reliance on the IT schedule. The next attempt was to have IT train a department staff member, but again, this still required that the physician find time to connect with that staff member. Finally, we decided to obtain a useful tip sheet that clearly outlined the process and could be included in orientation materials. This gave the new physicians control over how and when they would work on this issue. Based on these learnings, this was incorporated as a standing agenda item and resource for incoming physicians.
Essential Elements of Effective Onboarding
The new physician onboarding program consists of 5 key elements: (1) 2-week acclimation period; (2) peer learning and connection; (3) training before beginning patient care; (4) standardization, transparency, and accountability in all processes; (5) ongoing feedback for continued program improvement with individual support (Figure).
The program begins with a 2-week period of intentional investment in individual success, during which time no patients are scheduled. In week 1, we work with new hires to set expectations for performance, understand departmental norms, and introduce culture. Physicians meet formally and informally with department and institutional leadership, as well as attend team meetings and trainings that include a range of administrative and compliance requirements, such as quality standards and expectations, compliance, billing and coding specific to family medicine, EHR management, and institutionally mandated orientations. We are also adding implicit bias and antiracism training during this period, which are essential to creating a culture of unity and belonging.
During week 2, we focus on clinic-level orientation, assigning new hires an orientation buddy and a department sponsor, such as a physician lead or medical director. Physicians spend time with leadership at their clinic as they nurture relationships important for mentorship, sponsorship, and peer support. They also meet care team members, including front desk associates, medical assistants, behavioral health clinicians, nutritionists, social workers, pharmacists, and other key colleagues and care team members. This introduces the physician to the clinical environment and physical space as well as acclimates the physician to workflows and feedback loops for regular interaction.
When physicians ultimately begin patient care, they begin with an expected productivity rate of 50%, followed by an expected productivity rate of 75%, and then an expected productivity rate of 100%. This steady increase occurs over 3 to 4 weeks depending on the physician’s comfort level. They are also provided monthly reports on work relative value unit performance so that they can track and adapt practice patterns as necessary.More details on the program can be found in Appendix 1.
Takeaways From the Implementation of the New Program
Give time for new physicians to focus on acclimating to the role and environment.
The initial 2-week period of transition—without direct patient care—ensures that physicians feel comfortable in their new ecosystem. This also supports personal transitions, as many new hires are managing relocation and acclimating themselves and their families to new settings. Even residents from our training program who returned as attending physicians found this flexibility and slow reentry essential. This also gives the clinic time to orient to an additional provider, nurture them into the team culture, and develop relationships with the care team.
Cultivate spaces for shared learning, problem-solving, and peer connection.
Orientation is delivered primarily through group learning sessions with cohorts of new physicians, thus developing spaces for networking, fostering psychological safety, encouraging personal and professional rapport, emphasizing interactive learning, and reinforcing scheduling blocks at the departmental level. New hires also participate in peer shadowing to develop clinical competencies and are assigned a workplace buddy to foster a sense of belonging and create opportunities for additional knowledge sharing and cross-training.
Strengthen physician knowledge base, confidence, and comfort in the workplace before beginning direct patient care.
Without fluency in the workflows, culture, and operations of a practice, the urgency to have physicians begin clinical care can result in frustration for the physician, patients, and clinical and administrative staff. Therefore, we complete essential training prior to seeing any patients. This includes clinical workflows, referral processes, use of alternate modalities of care (eg, telehealth, eConsults), billing protocols, population health training, patient resources, office resources, and other essential daily processes and tools. This creates efficiency in administrative management, increased productivity, and better understanding of resources available for patients’ medical, social, and behavioral needs when patient care begins.
Embrace standardization, transparency, and accountability in as many processes as possible.
Standardized knowledge-sharing and checklists are mandated at every step of the orientation process, requiring sign off from the physician lead, practice manager, and new physicians upon completion. This offers all parties the opportunity to play a role in the delivery of and accountability for skills transfer and empowers new hires to press pause if they feel unsure about any domain in the training. It is also essential in guaranteeing that all physicians—regardless of which ambulatory location they practice in—receive consistent information and expectations. A sample checklist can be found in Appendix 2.
Commit to collecting and acting on feedback for continued program improvement and individual support.
As physicians complete the program, it is necessary to create structures to measure and enhance its impact, as well as evaluate how physicians are faring following the program. Each physician completes surveys at the end of the orientation program, attends a 90-day post-program check-in with the department chair, and receives follow-up trainings on advanced topics as they become more deeply embedded in the organization.
Lessons Learned
Feedback from surveys and 90-day check-ins with leadership and physicians reflect a high degree of clarity on job roles and duties, a sense of team camaraderie, easier system navigation, and a strong sense of support. We do recognize that sustaining change takes time and our study is limited by data demonstrating the impact of these efforts. We look forward to sharing more robust data from surveys and qualitative interviews with physicians, clinical leadership, and staff in the future. Our team will conduct interviews at 90-day and 180-day checkpoints with new physicians who have gone through this program, followed by a check-in after 1 year. Additionally, new physicians as well as key stakeholders, such as physician leads, practice managers, and members of the recruitment team, have started to participate in short surveys. These are designed to better understand their experiences, what worked well, what can be improved, and the overall satisfaction of the physician and other members of the extended care team.
What follows are some comments made by the initial group of physicians that went through this program and participated in follow-up interviews:
“I really feel like part of a bigger team.”
“I knew exactly what do to when I walked into the exam room on clinic Day 1.”
“It was great to make deep connections during the early process of joining.”
“Having a buddy to direct questions and ideas to is amazing and empowering.”
“Even though the orientation was long, I felt that I learned so much that I would not have otherwise.”
“Thank you for not letting me crash and burn!”
“Great culture! I love understanding our values of health equity, diversity, and inclusion.”
In the months since our endeavor began, we have learned just how essential it is to fully and effectively integrate new hires into the organization for their own satisfaction and success—and ours. Indeed, we cannot expect to achieve the Quadruple Aim without investing in the kind of transparent and intentional orientation process that defines expectations, aligns cultural values, mitigates costly and stressful operational misunderstandings, and communicates to physicians that, not only do they belong, but their sense of belonging is our priority. While we have yet to understand the impact of this program on the fourth aim of the Quadruple Aim, we are hopeful that the benefits will be far-reaching.
It is our ultimate hope that programs like this: (1) give physicians the confidence needed to create impactful patient-centered experiences; (2) enable physicians to become more cost-effective and efficient in care delivery; (3) allow physicians to understand the populations they are serving and access tools available to mitigate health disparities and other barriers; and (4) improve the collective experience of every member of the care team, practice leadership, and clinician-patient partnership.
Corresponding author: J. Nwando Olayiwola, MD, MPH, FAAFP, The Ohio State University College of Medicine, Department of Family and Community Medicine, 2231 N High St, Ste 250, Columbus, OH 43210; nwando.olayiwola@osumc.edu.
Financial disclosures: None.
Keywords: physician onboarding; Quadruple Aim; leadership; clinician satisfaction; care team satisfaction.
1. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6): 573-576.
2. Maurer R. Onboarding key to retaining, engaging talent. Society for Human Resource Management. April 16, 2015. Accessed January 8, 2021. https://www.shrm.org/resourcesandtools/hr-topics/talent-acquisition/pages/onboarding-key-retaining-engaging-talent.aspx
3. Boston AG. New hire onboarding standardization and automation powers productivity gains. GlobeNewswire. March 8, 2011. Accessed January 8, 2021. http://www.globenewswire.com/news-release/2011/03/08/994239/0/en/New-Hire-Onboarding-Standardization-and-Automation-Powers-Productivity-Gains.html
4. $37 billion – US and UK business count the cost of employee misunderstanding. HR.com – Maximizing Human Potential. June 18, 2008. Accessed March 10, 2021. https://www.hr.com/en/communities/staffing_and_recruitment/37-billion---us-and-uk-businesses-count-the-cost-o_fhnduq4d.html
5. Employers risk driving new hires away with poor onboarding. Society for Human Resource Management. February 23, 2018. Accessed March 10, 2021. https://www.shrm.org/resourcesandtools/hr-topics/talent-acquisition/pages/employers-new-hires-poor-onboarding.aspx
6. Center for Primary Care Innovation and Transformation. The Ohio State University College of Medicine. Accessed January 8, 2021. https://wexnermedical.osu.edu/departments/family-medicine/pcit
7. Olayiwola, J.N. and Magaña, C. Clinical transformation in technology: a fresh change management approach for primary care. Harvard Health Policy Review. February 2, 2019. Accessed March 10, 2021. http://www.hhpronline.org/articles/2019/2/2/clinical-transformation-in-technology-a-fresh-change-management-approach-for-primary-care
From The Ohio State University College of Medicine Department of Family and Community Medicine, Columbus, OH (Candy Magaña, Jná Báez, Christine Junk, Drs. Ahmad, Conroy, and Olayiwola); The Ohio State University College of Medicine Center for Primary Care Innovation and Transformation (Candy Magaña, Jná Báez, and Dr. Olayiwola); and The Ohio State University Wexner Medical Center (Christine Harsh, Erica Esposito).
Much has been discussed about the growing crisis of professional dissatisfaction among physicians, with increasing efforts being made to incorporate physician wellness into health system strategies that move from the Triple to the Quadruple Aim.1 For many years, our health care system has been focused on improving the health of populations, optimizing the patient experience, and reducing the cost of care (Triple Aim). The inclusion of the fourth aim, improving the experience of the teams that deliver care, has become paramount in achieving the other aims.
An area often overlooked in this focus on wellness, however, is the importance of the earliest days of employment to shape and predict long-term career contentment. This is a missed opportunity, as data suggest that organizations with standardized onboarding programs boast a 62% increased productivity rate and a 50% greater retention rate among new hires.2,3 Moreover, a study by the International Institute for Management Development found that businesses lose an estimated $37 billion annually because employees do not fully understand their jobs.4 The report ties losses to “actions taken by employees who have misunderstood or misinterpreted company policies, business processes, job function, or a combination of the three.” Additionally, onboarding programs that focus strictly on technical or functional orientation tasks miss important opportunities for culture integration during the onboarding process.5 It is therefore imperative to look to effective models of employee onboarding to develop systems that position physicians and practices for success.
Challenges With Traditional Physician Onboarding
In recent years, the Department of Family and Community Medicine at The Ohio State University College of Medicine has experienced rapid organizational change. Like many primary care systems nationwide responding to disruption in health care and changing demands on the clinical workforce, the department has hired new leadership, revised strategic priorities, and witnessed an influx of faculty and staff. It has also planned an expansion of ambulatory services that will more than double the clinical workforce over the next 3 years. While an exciting time, there has been a growing need to align strategy, culture, and human capital during these changes.
As we entered this phase of transformation, we recognized that our highly individualized, ad hoc orientation system presented shortcomings. During the act of revamping our physician recruitment process, stakeholder workgroup members specifically noted that improvement efforts were needed regarding new physician orientation, as no consistent structures were previously in place. New physician orientation had been a major gap for years, resulting in dissatisfaction in the first few months of physician practice, early physician turnover, and staff frustration. For physicians, we continued to learn about their frustration and unanswered questions regarding expectations, norms, structures, and processes.
Many new hires were left with a kind of “trial by fire” entry into their roles. On the first day of clinic, a new physician would most likely need to simultaneously see patients, learn the nuances of the electronic health record (EHR), figure out where the break room was located, and quickly learn population health issues for the patients they were serving. Opportunities to meet key clinic site leadership would be at random, and new physicians might not have the opportunity to meet leadership or staff until months into their tenure; this did not allow for a sense of belonging or understanding of the many resources available to them. We learned that the quality of these ad hoc orientations also varied based on the experience and priorities of each practice’s clinic and administrative leaders, who themselves felt ill-equipped to provide a consistent, robust, and confidence-building experience. In addition, practice site management was rarely given advance time to prepare for the arrival of new physicians, which resulted in physicians perceiving practices to be unwelcoming and disorganized. Their first days were often spent with patients in clinic with no structured orientation and without understanding workflows or having systems practice knowledge.
Institutionally, the interview process satisfied some transfer of knowledge, but we were unclear of what was being consistently shared and understood in the multiple ambulatory locations where our physicians enter practice. More importantly, we knew we were missing a critical opportunity to use orientation to imbue other values of diversity and inclusion, health equity, and operational excellence into the workforce. Based on anecdotal insights from employees and our own review of successful onboarding approaches from other industries, we also knew a more structured welcoming process would predict greater long-term career satisfaction for physicians and create a foundation for providing optimal care for patients when clinical encounters began.
Reengineering Physician Onboarding
In 2019, our department developed a multipronged approach to physician onboarding, which is already paying dividends in easing acculturation and fostering team cohesion. The department tapped its Center for Primary Care Innovation and Transformation (PCIT) to direct this effort, based on its expertise in practice transformation, clinical transformation and adaptations, and workflow efficiency through process and quality improvement. The PCIT team provides support to the department and the entire health system focused on technology and innovation, health equity, and health care efficiency.6 They applied many of the tools used in the Clinical Transformation in Technology approach to lead this initiative.7
The PCIT team began identifying key stakeholders (department, clinical and ambulatory leadership, clinicians and clinical staff, community partners, human resources, and resident physicians), and then engaging those individuals in dialogue surrounding orientation needs. During scheduled in-person and virtual work sessions, stakeholders were asked to provide input on pain points for new physicians and clinic leadership and were then empowered to create an onboarding program. Applying health care quality improvement techniques, we leveraged workflow mapping, current and future state planning, and goal setting, led by the skilled process improvement and clinical transformation specialists. We coordinated a multidisciplinary process improvement team that included clinic administrators, medical directors, human resources, administrative staff, ambulatory and resident leadership, clinical leadership, and recruitment liaisons. This diverse group of leadership and staff was brought together to address these critical identified gaps and weaknesses in new physician onboarding.
Through a series of learning sessions, the workgroup provided input that was used to form an itemized physician onboarding schedule, which was then leveraged to develop Plan-Do-Study-Act (PDSA) cycles, collecting feedback in real time. Some issues that seem small can cause major distress for new physicians. For example, in our inaugural orientation implementation, a physician provided feedback that they wanted to obtain information on setting up their work email on their personal devices and was having considerable trouble figuring out how to do so. This particular topic was not initially included in the first iteration of the Department’s orientation program. We rapidly sought out different ways to embed that into the onboarding experience. The first PDSA involved integrating the university information technology team (IT) into the process but was not successful because it required extra work for the new physician and reliance on the IT schedule. The next attempt was to have IT train a department staff member, but again, this still required that the physician find time to connect with that staff member. Finally, we decided to obtain a useful tip sheet that clearly outlined the process and could be included in orientation materials. This gave the new physicians control over how and when they would work on this issue. Based on these learnings, this was incorporated as a standing agenda item and resource for incoming physicians.
Essential Elements of Effective Onboarding
The new physician onboarding program consists of 5 key elements: (1) 2-week acclimation period; (2) peer learning and connection; (3) training before beginning patient care; (4) standardization, transparency, and accountability in all processes; (5) ongoing feedback for continued program improvement with individual support (Figure).
The program begins with a 2-week period of intentional investment in individual success, during which time no patients are scheduled. In week 1, we work with new hires to set expectations for performance, understand departmental norms, and introduce culture. Physicians meet formally and informally with department and institutional leadership, as well as attend team meetings and trainings that include a range of administrative and compliance requirements, such as quality standards and expectations, compliance, billing and coding specific to family medicine, EHR management, and institutionally mandated orientations. We are also adding implicit bias and antiracism training during this period, which are essential to creating a culture of unity and belonging.
During week 2, we focus on clinic-level orientation, assigning new hires an orientation buddy and a department sponsor, such as a physician lead or medical director. Physicians spend time with leadership at their clinic as they nurture relationships important for mentorship, sponsorship, and peer support. They also meet care team members, including front desk associates, medical assistants, behavioral health clinicians, nutritionists, social workers, pharmacists, and other key colleagues and care team members. This introduces the physician to the clinical environment and physical space as well as acclimates the physician to workflows and feedback loops for regular interaction.
When physicians ultimately begin patient care, they begin with an expected productivity rate of 50%, followed by an expected productivity rate of 75%, and then an expected productivity rate of 100%. This steady increase occurs over 3 to 4 weeks depending on the physician’s comfort level. They are also provided monthly reports on work relative value unit performance so that they can track and adapt practice patterns as necessary.More details on the program can be found in Appendix 1.
Takeaways From the Implementation of the New Program
Give time for new physicians to focus on acclimating to the role and environment.
The initial 2-week period of transition—without direct patient care—ensures that physicians feel comfortable in their new ecosystem. This also supports personal transitions, as many new hires are managing relocation and acclimating themselves and their families to new settings. Even residents from our training program who returned as attending physicians found this flexibility and slow reentry essential. This also gives the clinic time to orient to an additional provider, nurture them into the team culture, and develop relationships with the care team.
Cultivate spaces for shared learning, problem-solving, and peer connection.
Orientation is delivered primarily through group learning sessions with cohorts of new physicians, thus developing spaces for networking, fostering psychological safety, encouraging personal and professional rapport, emphasizing interactive learning, and reinforcing scheduling blocks at the departmental level. New hires also participate in peer shadowing to develop clinical competencies and are assigned a workplace buddy to foster a sense of belonging and create opportunities for additional knowledge sharing and cross-training.
Strengthen physician knowledge base, confidence, and comfort in the workplace before beginning direct patient care.
Without fluency in the workflows, culture, and operations of a practice, the urgency to have physicians begin clinical care can result in frustration for the physician, patients, and clinical and administrative staff. Therefore, we complete essential training prior to seeing any patients. This includes clinical workflows, referral processes, use of alternate modalities of care (eg, telehealth, eConsults), billing protocols, population health training, patient resources, office resources, and other essential daily processes and tools. This creates efficiency in administrative management, increased productivity, and better understanding of resources available for patients’ medical, social, and behavioral needs when patient care begins.
Embrace standardization, transparency, and accountability in as many processes as possible.
Standardized knowledge-sharing and checklists are mandated at every step of the orientation process, requiring sign off from the physician lead, practice manager, and new physicians upon completion. This offers all parties the opportunity to play a role in the delivery of and accountability for skills transfer and empowers new hires to press pause if they feel unsure about any domain in the training. It is also essential in guaranteeing that all physicians—regardless of which ambulatory location they practice in—receive consistent information and expectations. A sample checklist can be found in Appendix 2.
Commit to collecting and acting on feedback for continued program improvement and individual support.
As physicians complete the program, it is necessary to create structures to measure and enhance its impact, as well as evaluate how physicians are faring following the program. Each physician completes surveys at the end of the orientation program, attends a 90-day post-program check-in with the department chair, and receives follow-up trainings on advanced topics as they become more deeply embedded in the organization.
Lessons Learned
Feedback from surveys and 90-day check-ins with leadership and physicians reflect a high degree of clarity on job roles and duties, a sense of team camaraderie, easier system navigation, and a strong sense of support. We do recognize that sustaining change takes time and our study is limited by data demonstrating the impact of these efforts. We look forward to sharing more robust data from surveys and qualitative interviews with physicians, clinical leadership, and staff in the future. Our team will conduct interviews at 90-day and 180-day checkpoints with new physicians who have gone through this program, followed by a check-in after 1 year. Additionally, new physicians as well as key stakeholders, such as physician leads, practice managers, and members of the recruitment team, have started to participate in short surveys. These are designed to better understand their experiences, what worked well, what can be improved, and the overall satisfaction of the physician and other members of the extended care team.
What follows are some comments made by the initial group of physicians that went through this program and participated in follow-up interviews:
“I really feel like part of a bigger team.”
“I knew exactly what do to when I walked into the exam room on clinic Day 1.”
“It was great to make deep connections during the early process of joining.”
“Having a buddy to direct questions and ideas to is amazing and empowering.”
“Even though the orientation was long, I felt that I learned so much that I would not have otherwise.”
“Thank you for not letting me crash and burn!”
“Great culture! I love understanding our values of health equity, diversity, and inclusion.”
In the months since our endeavor began, we have learned just how essential it is to fully and effectively integrate new hires into the organization for their own satisfaction and success—and ours. Indeed, we cannot expect to achieve the Quadruple Aim without investing in the kind of transparent and intentional orientation process that defines expectations, aligns cultural values, mitigates costly and stressful operational misunderstandings, and communicates to physicians that, not only do they belong, but their sense of belonging is our priority. While we have yet to understand the impact of this program on the fourth aim of the Quadruple Aim, we are hopeful that the benefits will be far-reaching.
It is our ultimate hope that programs like this: (1) give physicians the confidence needed to create impactful patient-centered experiences; (2) enable physicians to become more cost-effective and efficient in care delivery; (3) allow physicians to understand the populations they are serving and access tools available to mitigate health disparities and other barriers; and (4) improve the collective experience of every member of the care team, practice leadership, and clinician-patient partnership.
Corresponding author: J. Nwando Olayiwola, MD, MPH, FAAFP, The Ohio State University College of Medicine, Department of Family and Community Medicine, 2231 N High St, Ste 250, Columbus, OH 43210; nwando.olayiwola@osumc.edu.
Financial disclosures: None.
Keywords: physician onboarding; Quadruple Aim; leadership; clinician satisfaction; care team satisfaction.
From The Ohio State University College of Medicine Department of Family and Community Medicine, Columbus, OH (Candy Magaña, Jná Báez, Christine Junk, Drs. Ahmad, Conroy, and Olayiwola); The Ohio State University College of Medicine Center for Primary Care Innovation and Transformation (Candy Magaña, Jná Báez, and Dr. Olayiwola); and The Ohio State University Wexner Medical Center (Christine Harsh, Erica Esposito).
Much has been discussed about the growing crisis of professional dissatisfaction among physicians, with increasing efforts being made to incorporate physician wellness into health system strategies that move from the Triple to the Quadruple Aim.1 For many years, our health care system has been focused on improving the health of populations, optimizing the patient experience, and reducing the cost of care (Triple Aim). The inclusion of the fourth aim, improving the experience of the teams that deliver care, has become paramount in achieving the other aims.
An area often overlooked in this focus on wellness, however, is the importance of the earliest days of employment to shape and predict long-term career contentment. This is a missed opportunity, as data suggest that organizations with standardized onboarding programs boast a 62% increased productivity rate and a 50% greater retention rate among new hires.2,3 Moreover, a study by the International Institute for Management Development found that businesses lose an estimated $37 billion annually because employees do not fully understand their jobs.4 The report ties losses to “actions taken by employees who have misunderstood or misinterpreted company policies, business processes, job function, or a combination of the three.” Additionally, onboarding programs that focus strictly on technical or functional orientation tasks miss important opportunities for culture integration during the onboarding process.5 It is therefore imperative to look to effective models of employee onboarding to develop systems that position physicians and practices for success.
Challenges With Traditional Physician Onboarding
In recent years, the Department of Family and Community Medicine at The Ohio State University College of Medicine has experienced rapid organizational change. Like many primary care systems nationwide responding to disruption in health care and changing demands on the clinical workforce, the department has hired new leadership, revised strategic priorities, and witnessed an influx of faculty and staff. It has also planned an expansion of ambulatory services that will more than double the clinical workforce over the next 3 years. While an exciting time, there has been a growing need to align strategy, culture, and human capital during these changes.
As we entered this phase of transformation, we recognized that our highly individualized, ad hoc orientation system presented shortcomings. During the act of revamping our physician recruitment process, stakeholder workgroup members specifically noted that improvement efforts were needed regarding new physician orientation, as no consistent structures were previously in place. New physician orientation had been a major gap for years, resulting in dissatisfaction in the first few months of physician practice, early physician turnover, and staff frustration. For physicians, we continued to learn about their frustration and unanswered questions regarding expectations, norms, structures, and processes.
Many new hires were left with a kind of “trial by fire” entry into their roles. On the first day of clinic, a new physician would most likely need to simultaneously see patients, learn the nuances of the electronic health record (EHR), figure out where the break room was located, and quickly learn population health issues for the patients they were serving. Opportunities to meet key clinic site leadership would be at random, and new physicians might not have the opportunity to meet leadership or staff until months into their tenure; this did not allow for a sense of belonging or understanding of the many resources available to them. We learned that the quality of these ad hoc orientations also varied based on the experience and priorities of each practice’s clinic and administrative leaders, who themselves felt ill-equipped to provide a consistent, robust, and confidence-building experience. In addition, practice site management was rarely given advance time to prepare for the arrival of new physicians, which resulted in physicians perceiving practices to be unwelcoming and disorganized. Their first days were often spent with patients in clinic with no structured orientation and without understanding workflows or having systems practice knowledge.
Institutionally, the interview process satisfied some transfer of knowledge, but we were unclear of what was being consistently shared and understood in the multiple ambulatory locations where our physicians enter practice. More importantly, we knew we were missing a critical opportunity to use orientation to imbue other values of diversity and inclusion, health equity, and operational excellence into the workforce. Based on anecdotal insights from employees and our own review of successful onboarding approaches from other industries, we also knew a more structured welcoming process would predict greater long-term career satisfaction for physicians and create a foundation for providing optimal care for patients when clinical encounters began.
Reengineering Physician Onboarding
In 2019, our department developed a multipronged approach to physician onboarding, which is already paying dividends in easing acculturation and fostering team cohesion. The department tapped its Center for Primary Care Innovation and Transformation (PCIT) to direct this effort, based on its expertise in practice transformation, clinical transformation and adaptations, and workflow efficiency through process and quality improvement. The PCIT team provides support to the department and the entire health system focused on technology and innovation, health equity, and health care efficiency.6 They applied many of the tools used in the Clinical Transformation in Technology approach to lead this initiative.7
The PCIT team began identifying key stakeholders (department, clinical and ambulatory leadership, clinicians and clinical staff, community partners, human resources, and resident physicians), and then engaging those individuals in dialogue surrounding orientation needs. During scheduled in-person and virtual work sessions, stakeholders were asked to provide input on pain points for new physicians and clinic leadership and were then empowered to create an onboarding program. Applying health care quality improvement techniques, we leveraged workflow mapping, current and future state planning, and goal setting, led by the skilled process improvement and clinical transformation specialists. We coordinated a multidisciplinary process improvement team that included clinic administrators, medical directors, human resources, administrative staff, ambulatory and resident leadership, clinical leadership, and recruitment liaisons. This diverse group of leadership and staff was brought together to address these critical identified gaps and weaknesses in new physician onboarding.
Through a series of learning sessions, the workgroup provided input that was used to form an itemized physician onboarding schedule, which was then leveraged to develop Plan-Do-Study-Act (PDSA) cycles, collecting feedback in real time. Some issues that seem small can cause major distress for new physicians. For example, in our inaugural orientation implementation, a physician provided feedback that they wanted to obtain information on setting up their work email on their personal devices and was having considerable trouble figuring out how to do so. This particular topic was not initially included in the first iteration of the Department’s orientation program. We rapidly sought out different ways to embed that into the onboarding experience. The first PDSA involved integrating the university information technology team (IT) into the process but was not successful because it required extra work for the new physician and reliance on the IT schedule. The next attempt was to have IT train a department staff member, but again, this still required that the physician find time to connect with that staff member. Finally, we decided to obtain a useful tip sheet that clearly outlined the process and could be included in orientation materials. This gave the new physicians control over how and when they would work on this issue. Based on these learnings, this was incorporated as a standing agenda item and resource for incoming physicians.
Essential Elements of Effective Onboarding
The new physician onboarding program consists of 5 key elements: (1) 2-week acclimation period; (2) peer learning and connection; (3) training before beginning patient care; (4) standardization, transparency, and accountability in all processes; (5) ongoing feedback for continued program improvement with individual support (Figure).
The program begins with a 2-week period of intentional investment in individual success, during which time no patients are scheduled. In week 1, we work with new hires to set expectations for performance, understand departmental norms, and introduce culture. Physicians meet formally and informally with department and institutional leadership, as well as attend team meetings and trainings that include a range of administrative and compliance requirements, such as quality standards and expectations, compliance, billing and coding specific to family medicine, EHR management, and institutionally mandated orientations. We are also adding implicit bias and antiracism training during this period, which are essential to creating a culture of unity and belonging.
During week 2, we focus on clinic-level orientation, assigning new hires an orientation buddy and a department sponsor, such as a physician lead or medical director. Physicians spend time with leadership at their clinic as they nurture relationships important for mentorship, sponsorship, and peer support. They also meet care team members, including front desk associates, medical assistants, behavioral health clinicians, nutritionists, social workers, pharmacists, and other key colleagues and care team members. This introduces the physician to the clinical environment and physical space as well as acclimates the physician to workflows and feedback loops for regular interaction.
When physicians ultimately begin patient care, they begin with an expected productivity rate of 50%, followed by an expected productivity rate of 75%, and then an expected productivity rate of 100%. This steady increase occurs over 3 to 4 weeks depending on the physician’s comfort level. They are also provided monthly reports on work relative value unit performance so that they can track and adapt practice patterns as necessary.More details on the program can be found in Appendix 1.
Takeaways From the Implementation of the New Program
Give time for new physicians to focus on acclimating to the role and environment.
The initial 2-week period of transition—without direct patient care—ensures that physicians feel comfortable in their new ecosystem. This also supports personal transitions, as many new hires are managing relocation and acclimating themselves and their families to new settings. Even residents from our training program who returned as attending physicians found this flexibility and slow reentry essential. This also gives the clinic time to orient to an additional provider, nurture them into the team culture, and develop relationships with the care team.
Cultivate spaces for shared learning, problem-solving, and peer connection.
Orientation is delivered primarily through group learning sessions with cohorts of new physicians, thus developing spaces for networking, fostering psychological safety, encouraging personal and professional rapport, emphasizing interactive learning, and reinforcing scheduling blocks at the departmental level. New hires also participate in peer shadowing to develop clinical competencies and are assigned a workplace buddy to foster a sense of belonging and create opportunities for additional knowledge sharing and cross-training.
Strengthen physician knowledge base, confidence, and comfort in the workplace before beginning direct patient care.
Without fluency in the workflows, culture, and operations of a practice, the urgency to have physicians begin clinical care can result in frustration for the physician, patients, and clinical and administrative staff. Therefore, we complete essential training prior to seeing any patients. This includes clinical workflows, referral processes, use of alternate modalities of care (eg, telehealth, eConsults), billing protocols, population health training, patient resources, office resources, and other essential daily processes and tools. This creates efficiency in administrative management, increased productivity, and better understanding of resources available for patients’ medical, social, and behavioral needs when patient care begins.
Embrace standardization, transparency, and accountability in as many processes as possible.
Standardized knowledge-sharing and checklists are mandated at every step of the orientation process, requiring sign off from the physician lead, practice manager, and new physicians upon completion. This offers all parties the opportunity to play a role in the delivery of and accountability for skills transfer and empowers new hires to press pause if they feel unsure about any domain in the training. It is also essential in guaranteeing that all physicians—regardless of which ambulatory location they practice in—receive consistent information and expectations. A sample checklist can be found in Appendix 2.
Commit to collecting and acting on feedback for continued program improvement and individual support.
As physicians complete the program, it is necessary to create structures to measure and enhance its impact, as well as evaluate how physicians are faring following the program. Each physician completes surveys at the end of the orientation program, attends a 90-day post-program check-in with the department chair, and receives follow-up trainings on advanced topics as they become more deeply embedded in the organization.
Lessons Learned
Feedback from surveys and 90-day check-ins with leadership and physicians reflect a high degree of clarity on job roles and duties, a sense of team camaraderie, easier system navigation, and a strong sense of support. We do recognize that sustaining change takes time and our study is limited by data demonstrating the impact of these efforts. We look forward to sharing more robust data from surveys and qualitative interviews with physicians, clinical leadership, and staff in the future. Our team will conduct interviews at 90-day and 180-day checkpoints with new physicians who have gone through this program, followed by a check-in after 1 year. Additionally, new physicians as well as key stakeholders, such as physician leads, practice managers, and members of the recruitment team, have started to participate in short surveys. These are designed to better understand their experiences, what worked well, what can be improved, and the overall satisfaction of the physician and other members of the extended care team.
What follows are some comments made by the initial group of physicians that went through this program and participated in follow-up interviews:
“I really feel like part of a bigger team.”
“I knew exactly what do to when I walked into the exam room on clinic Day 1.”
“It was great to make deep connections during the early process of joining.”
“Having a buddy to direct questions and ideas to is amazing and empowering.”
“Even though the orientation was long, I felt that I learned so much that I would not have otherwise.”
“Thank you for not letting me crash and burn!”
“Great culture! I love understanding our values of health equity, diversity, and inclusion.”
In the months since our endeavor began, we have learned just how essential it is to fully and effectively integrate new hires into the organization for their own satisfaction and success—and ours. Indeed, we cannot expect to achieve the Quadruple Aim without investing in the kind of transparent and intentional orientation process that defines expectations, aligns cultural values, mitigates costly and stressful operational misunderstandings, and communicates to physicians that, not only do they belong, but their sense of belonging is our priority. While we have yet to understand the impact of this program on the fourth aim of the Quadruple Aim, we are hopeful that the benefits will be far-reaching.
It is our ultimate hope that programs like this: (1) give physicians the confidence needed to create impactful patient-centered experiences; (2) enable physicians to become more cost-effective and efficient in care delivery; (3) allow physicians to understand the populations they are serving and access tools available to mitigate health disparities and other barriers; and (4) improve the collective experience of every member of the care team, practice leadership, and clinician-patient partnership.
Corresponding author: J. Nwando Olayiwola, MD, MPH, FAAFP, The Ohio State University College of Medicine, Department of Family and Community Medicine, 2231 N High St, Ste 250, Columbus, OH 43210; nwando.olayiwola@osumc.edu.
Financial disclosures: None.
Keywords: physician onboarding; Quadruple Aim; leadership; clinician satisfaction; care team satisfaction.
1. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6): 573-576.
2. Maurer R. Onboarding key to retaining, engaging talent. Society for Human Resource Management. April 16, 2015. Accessed January 8, 2021. https://www.shrm.org/resourcesandtools/hr-topics/talent-acquisition/pages/onboarding-key-retaining-engaging-talent.aspx
3. Boston AG. New hire onboarding standardization and automation powers productivity gains. GlobeNewswire. March 8, 2011. Accessed January 8, 2021. http://www.globenewswire.com/news-release/2011/03/08/994239/0/en/New-Hire-Onboarding-Standardization-and-Automation-Powers-Productivity-Gains.html
4. $37 billion – US and UK business count the cost of employee misunderstanding. HR.com – Maximizing Human Potential. June 18, 2008. Accessed March 10, 2021. https://www.hr.com/en/communities/staffing_and_recruitment/37-billion---us-and-uk-businesses-count-the-cost-o_fhnduq4d.html
5. Employers risk driving new hires away with poor onboarding. Society for Human Resource Management. February 23, 2018. Accessed March 10, 2021. https://www.shrm.org/resourcesandtools/hr-topics/talent-acquisition/pages/employers-new-hires-poor-onboarding.aspx
6. Center for Primary Care Innovation and Transformation. The Ohio State University College of Medicine. Accessed January 8, 2021. https://wexnermedical.osu.edu/departments/family-medicine/pcit
7. Olayiwola, J.N. and Magaña, C. Clinical transformation in technology: a fresh change management approach for primary care. Harvard Health Policy Review. February 2, 2019. Accessed March 10, 2021. http://www.hhpronline.org/articles/2019/2/2/clinical-transformation-in-technology-a-fresh-change-management-approach-for-primary-care
1. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6): 573-576.
2. Maurer R. Onboarding key to retaining, engaging talent. Society for Human Resource Management. April 16, 2015. Accessed January 8, 2021. https://www.shrm.org/resourcesandtools/hr-topics/talent-acquisition/pages/onboarding-key-retaining-engaging-talent.aspx
3. Boston AG. New hire onboarding standardization and automation powers productivity gains. GlobeNewswire. March 8, 2011. Accessed January 8, 2021. http://www.globenewswire.com/news-release/2011/03/08/994239/0/en/New-Hire-Onboarding-Standardization-and-Automation-Powers-Productivity-Gains.html
4. $37 billion – US and UK business count the cost of employee misunderstanding. HR.com – Maximizing Human Potential. June 18, 2008. Accessed March 10, 2021. https://www.hr.com/en/communities/staffing_and_recruitment/37-billion---us-and-uk-businesses-count-the-cost-o_fhnduq4d.html
5. Employers risk driving new hires away with poor onboarding. Society for Human Resource Management. February 23, 2018. Accessed March 10, 2021. https://www.shrm.org/resourcesandtools/hr-topics/talent-acquisition/pages/employers-new-hires-poor-onboarding.aspx
6. Center for Primary Care Innovation and Transformation. The Ohio State University College of Medicine. Accessed January 8, 2021. https://wexnermedical.osu.edu/departments/family-medicine/pcit
7. Olayiwola, J.N. and Magaña, C. Clinical transformation in technology: a fresh change management approach for primary care. Harvard Health Policy Review. February 2, 2019. Accessed March 10, 2021. http://www.hhpronline.org/articles/2019/2/2/clinical-transformation-in-technology-a-fresh-change-management-approach-for-primary-care