Business of Medicine

“A sad day. A new low point in the spiral of hate, violence, and lies. Behind every account, there is a person. Do not forget that. In loving memory,” a Twitter user wrote about the death of Lisa-Maria Kellermayr, MD.

“This outcome is very saddening indeed. It should cause everyone to reflect. About interactions in our society, about ‘social’ media, about tolerance, about consideration, and about freedom,” tweeted Dirk Heinrich, MD, chair of the Virchow Association.

The suspected suicide of Dr. Kellermayr, an Austrian vaccinator, is stirring emotions in Germany, too. The active exponent and supporter of COVID-19 measures had been seriously threatened by anti-vaxxers and pandemic deniers. Thousands of people in Vienna said goodbye to her with a solemn vigil. Dr. Kellermayr’s death raises the question of how life-threatening online hatred can be.

Dr. Kellermayr, a vaccination campaigner, had received hateful comments and death threats since the start of the pandemic. But a single post on Twitter changed everything. On Nov. 16, 2021, anti-vaxxers held a demonstration outside the Wels-Grieskirchen Hospital. Dr. Kellermayr tweeted in disgust, “Today in Wels: A demonstration by conspiracy theorists spills into the street under the gaze of the authorities and blocks both the main hospital entrance and the Red Cross ambulance exit.”

At the time of her tweet, Dr. Kellermayr was not aware of additional access that had been made available for ambulances. The police reacted to her tweet, calling it a “false report.” As Florian Klenk writes in the Austrian journal Falter, the police basically criticized Dr. Kellermayr publicly, including in front of the 12,000 Twitter users who follow the police on Twitter.

A screenshot of Dr. Kellermayr’s tweet and the authorities’ response went viral on relevant Telegram forums and triggered a flood of hatred. A COVID denier immediately posted her address online.

Dr. Kellermayr deleted her tweet and asked the police to also delete their tweet, but they did not respond, and the tweet remained online. The country physician was inundated with insults, slurs, and death threats. She was beset by alleged patients who came only to disrupt her work, take videos on their cell phones, and share the photos in anti-vaxxer groups. She privately paid for a security guard, who confiscated butterfly knives from multiple “patients” on their way into the waiting room. Dr. Kellermayr looked for help from the medical association, the police, and the Office for the Protection of the Constitution. She made her problem public.
 

Police recommend supervision

Dr. Kellermayr received emails in which the senders described in detail how they would kill her and her practice team. The physician took the threats seriously; the police did not. The officers investigated. With the evidence that the perpetrators were operating via the dark web, the officers insinuated to Dr. Kellermayr that it was not possible to find them, Klenk reported.

Dr. Kellermayr filed a complaint for the first time on Nov. 22, 2021. The law enforcement authorities in Upper Austria said they did not have domestic jurisdiction. The Austrian authorities launched another investigation. The German prosecution authorities joined the search for those posting death threats on social media. Even the Munich chief public prosecutor’s office and the Berlin public prosecutor’s office investigated the case.

According to some reports, Dr. Kellermayr did not receive police protection; a patrol was sent over from time to time. According to the police, she should “not be afraid,” and if she was, she should just call them. She was also advised to undergo supervision -- in other words, psychological treatment.

Those who had the power to help her provided no support. On the contrary, the spokesperson for the Upper Austria Police said in the Ö1 Mittagsjournal radio program that Dr. Kellermayr was “putting herself in the public eye for her own selfish benefit.” Even Peter Niedermoser, president of the Medical Association of Upper Austria, told the Austrian daily newspaper Standard, “I understand that you have to defend yourself, but it is a whole other question as to whether you have to discuss every topic to excess on Twitter. Sometimes it’s better to step away.”
 

Leaving Twitter

A German network specialist who hunts pedophiles online offered Dr. Kellermayr her help and was quickly on the trail of suspects, including a neo-Nazi from the Berlin area and a man from Upper Bavaria. Then the Office for the Protection of the Constitution stepped in. Omar Haijawi-Pirchner, head of the Austrian State Security and Intelligence Directorate, stated that the evidence provided by the network specialist would be pursued.

At the end of June, Dr. Kellermayr closed her practice. The situation was no longer tolerable for her staff, and the costs for security, €100,000 up to that point, were no longer manageable. At the start of July, she announced that she wanted to reopen the practice.

In her suicide note to the Upper Austria State Police Department, she wrote “that there was a lot of talking, but no one did anything.” In her letter to her medical association, she also made it clear that she had felt abandoned.

“Every suicide is a tragedy. This one more so: a woman in need was abandoned by the police and authorities. That is a social failure,” tweeted physicist and author Florian Aigner.

“Threatened. Ruined. Left alone by the state. Because she did her job. Because she got involved. Because she spread information. Because many want to be understanding for the self-styled ‘unconventional thinkers,’ the ‘Querdenker.’ Because many did not want to take the threat seriously. Because we tolerate them,” tweeted the intensive care physician Lämêth.

“Many colleagues using their real names get all of this outside of Twitter too: emails, phone calls, letters, or even visits by radical fanatics. If you are lucky, there is police protection, or a few reports, but often not a lot happens juridically,” tweeted Flow, anesthetist and emergency physician.

“More and more of the people who shaped Twitter by spreading reliable information voluntarily are now backing out. As long as the concept of freedom is abused here for hate and intimidation, individual responsibility can only mean self-defense. Sad,” wrote Christian Lübbers, MD, on Twitter. Since the ENT physician started vaccinating patients against COVID-19, he has been tormented with insults and death threats from anti-vaxxers and COVID deniers, this news organization has reported.

Examples of people who have backed out and deactivated their account are the virologist Isabella Eckerlek, MD, PhD, of the University of Geneva, and Natalie Grams, MD, spokesperson for the Information Network Homeopathy. For a long time, they spread information about COVID-19, corrected false assertions, and were increasingly faced with insults and hostility.

General practitioner Christian Kröner, MD, has repeatedly been the target of threats and insults and has been under police protection from time to time. He made a statement regarding Dr. Kellermayr’s death and has shut down his account for the first time following multiple instances of hostility.
 

Harassment continues

The hatred, harassment, and slander have not stopped, even after Dr. Kellermayr’s death. Harald Laatsch, who sits in the Berlin house of representatives for the Alternative for Germany party, commented that it seems “much more likely that she could no longer live with the heavy guilt of being a vaccine propagandist.”

“It is repulsive how the Querdenker deride a medical colleague who was driven to death by harassment and violence. She lost her life by saving the lives of others. Others are continuing her work. The state must protect people like her,” tweeted Karl Lauterbach, MD, PhD, who has also been overrun with hate campaigns by Querdenker and COVID deniers.

The page “Ich habe mitgemacht” – Das Archiv für Corona-Unrecht [“I Joined In” – The Archive for COVID Injustice] probably did not help to deescalate the situation on Twitter. Anonymous archivists there collect allegedly ostracizing quotes and share them, along with names. The context in which these statements were given at the time is not mentioned. Some politicians and journalists have given this online pillory the name, “We joined in! We have ostracized, defamed...”

Being humiliated and defamed is par for the course for those who spread information across social media. As doctor and politician Rainer Röver, MD, wrote, “Whoever is involved in spreading information, science, fighting against fake news, and protecting the patients, pupils, clients, or mandates entrusted to them is being shouted down, threatened in writing, or driven to suicide.” The lying, baiting mob is taking over sovereignty of the discussion. According to Röver, the politicians are doing nothing “to actually put a stop to the violent mob.”

For some time now, the Federal Criminal Police Office (BKA) of Germany has considered anti-vaxxers or COVID deniers as a “relevant risk” in connection with attacks on vaccination centers or medical practices.
 

Increasing aggression

At the start of November last year, participants at the 125th German Medical Assembly demanded that violence against health care professionals be outlawed, Mark Berger, deputy spokesperson of the German Medical Association (BÄK), recollected. At the assembly, various medical associations shared reports of an increase in aggression during the pandemic.

The State Medical Chamber of Physicians of Saxony confirmed threats of violence against physicians, death threats against employees of the Vaccination Committee of Saxony, and criminal damage to medical practices that administer vaccinations. Physicians who administer vaccines in schools receive abuse.

Owing to the increasing amount of aggression, the State Medical Association of Thuringia has set up a special email address as a first point of contact to report violence for those who are affected. “In recent months, we have received a large number of reports from physicians who have received threatening letters in relation to the COVID vaccination, or letters purporting to be liability information or notices of liability,” explained the association. In the cases of which the association becomes aware, a criminal charge is issued most of the time. The investigative proceedings are ongoing.

The State Medical Association of Hesse has devised a reporting form with which it can obtain information on the forms of violence inflicted against physicians and their teams. The reporting is anonymous, and the data are statistically analyzed.

Peter Bobbert, MD, PhD, president of the Berlin Medical Association, provided reports of threat scenarios, “the kind and frequency of which we have never experienced.” He received many messages from physicians asking for help because they had received threatening letters or because their addresses had been posted on social networks.

To date, there have only been isolated cases, said Oliver Erens, MD, spokesperson of the State Medical Association of Baden-Württemberg. “But it is true that some colleagues have already had these kinds of experiences.” Those affected have primarily reported “discussions, debates, and verbal altercations with patients on the topic of the COVID vaccination, compliance with the mask mandate, and other COVID-containment measures – definitely with a high potential for aggression from some of the patients,” said Dr. Erens. Cases of physical violence have not been reported to date.

Above all, there has been a need for advice over the phone, predominantly in the legal department of the regional medical associations. “All physicians and their teams are being recommended by their associations to consistently prosecute any cases of threat of, or use of, violence against them,” Dr. Erens said. In October 2021, the University of Heidelberg started a study on the victimization of physicians. The analysis is ongoing.
 

Staying on Twitter

Lübbers considered leaving Twitter but decided against it. “I decided not to do it and to carry on spreading information about pseudo-medicine and vaccination. I see this as necessary civic courage and will not give way to hate,” Lübbers tweeted.

As understandable as any departure is, “we must not surrender Twitter to the trolls and harassers. Who is still here? #Iamstaying,” wrote Flow. Others wrote, “I will stay on Twitter as a physician. With my real name, too. [...] We must not surrender it to the Querdenker, idiots, Nazis, and enemies of freedom.”

“We need people to share information, we need voices of reason, just as Kellermayr was. How can you say that it would be better to remain silent? Does everyone who is against idiocy, Querdenker, and conspiracy theorists now have to remain silent?” asked Janos Hegedüs, MD, in his podcast.

Hegedüs, who uncovers fake news about COVID-19 and vaccination, was and remains a frequent target of insults and threats. His attempts to take action against them has had only limited success. His conclusion is sobering. “If you decide to spread information, you should know: You are alone. You will get all of the hate and when you have a problem with it, no one will help you.”

Media attorney Chan-jo Jun, who for many years has taken a stand against hate and harassment, has deactivated his Twitter account. However, this is not a retreat, as he clarified in an interview with the German radio station Deutschlandfunk. “I do not intend to give up the fight against hate, harassment, and misinformation, but I will do it in a different place.”

He sees Dr. Kellermayr’s death as a turning point. “I thought that we had learned something after Lübcke [i.e., politician Walter Lübcke, who was murdered by a neo-Nazi]. But we are seeing that the death of a political opponent is not just the goal, but also a success for the other side. And that is shocking.”

The judicial means of taking action against hate are still not effective, said Mr. Jun. He also sees the platform operators as responsible, since they are not obliged to remove unlawful content. “German law and the German constitution hold no sway on Twitter.”
 

Right-wing extremism

What happened to Lisa-Maria Kellermayr is the same as targeted terrorism. An organized group set out to annihilate her. Social psychologist Pia Lamberty has spoken, in the context of COVID, about a pandemic of violence, the threatening nature of which has barely been recognized, both in the virtual and analog world.

In an article for the Jüdische Allgemeine, Dr. Lamberty criticizes the fact that “the mistakes made with Pegida [i.e., a far-right, Islamophobic political movement in Germany] are being made once again” in the classification of Querdenker and COVID deniers. From the very start, the protests against the COVID measures have been a rallying point in the mobilization of right-wing extremists. “The Querdenker movement is unifying radical, right-wing extremist elements. Antisemitism and racism were always welcome.” Still, the right-wing extremist motivation has not been clearly labeled as such.

The classification is not just a question of statistics. “It is also about analyzing the potential for danger and deriving political measures from this. And there is an urgent need for action here: The right-wing extremists will utilize the climate crisis, but also the war in Ukraine, attacks against refugees, and LGBTQ rights for further mobilization. Rather than the state, the focus of the attacks will be people who are labeled as the bogeyman. This also must be clearly labeled for what it is,” said Dr. Lamberty.
She wrote on Twitter, “The COVID-related attacks that took place in the last two years will not simply stop, they will shift. If we do not want more and more people to stop expressing themselves publicly, something urgently has to happen.” She added, “Once more: The next few months will be very difficult. This will probably also be accompanied by an increased level of threat for socially engaged people. More protection is urgently required.”

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

This article was translated from the Medscape German edition.

“A sad day. A new low point in the spiral of hate, violence, and lies. Behind every account, there is a person. Do not forget that. In loving memory,” a Twitter user wrote about the death of Lisa-Maria Kellermayr, MD.

“This outcome is very saddening indeed. It should cause everyone to reflect. About interactions in our society, about ‘social’ media, about tolerance, about consideration, and about freedom,” tweeted Dirk Heinrich, MD, chair of the Virchow Association.

The suspected suicide of Dr. Kellermayr, an Austrian vaccinator, is stirring emotions in Germany, too. The active exponent and supporter of COVID-19 measures had been seriously threatened by anti-vaxxers and pandemic deniers. Thousands of people in Vienna said goodbye to her with a solemn vigil. Dr. Kellermayr’s death raises the question of how life-threatening online hatred can be.

Dr. Kellermayr, a vaccination campaigner, had received hateful comments and death threats since the start of the pandemic. But a single post on Twitter changed everything. On Nov. 16, 2021, anti-vaxxers held a demonstration outside the Wels-Grieskirchen Hospital. Dr. Kellermayr tweeted in disgust, “Today in Wels: A demonstration by conspiracy theorists spills into the street under the gaze of the authorities and blocks both the main hospital entrance and the Red Cross ambulance exit.”

At the time of her tweet, Dr. Kellermayr was not aware of additional access that had been made available for ambulances. The police reacted to her tweet, calling it a “false report.” As Florian Klenk writes in the Austrian journal Falter, the police basically criticized Dr. Kellermayr publicly, including in front of the 12,000 Twitter users who follow the police on Twitter.

A screenshot of Dr. Kellermayr’s tweet and the authorities’ response went viral on relevant Telegram forums and triggered a flood of hatred. A COVID denier immediately posted her address online.

Dr. Kellermayr deleted her tweet and asked the police to also delete their tweet, but they did not respond, and the tweet remained online. The country physician was inundated with insults, slurs, and death threats. She was beset by alleged patients who came only to disrupt her work, take videos on their cell phones, and share the photos in anti-vaxxer groups. She privately paid for a security guard, who confiscated butterfly knives from multiple “patients” on their way into the waiting room. Dr. Kellermayr looked for help from the medical association, the police, and the Office for the Protection of the Constitution. She made her problem public.
 

Police recommend supervision

Dr. Kellermayr received emails in which the senders described in detail how they would kill her and her practice team. The physician took the threats seriously; the police did not. The officers investigated. With the evidence that the perpetrators were operating via the dark web, the officers insinuated to Dr. Kellermayr that it was not possible to find them, Klenk reported.

Dr. Kellermayr filed a complaint for the first time on Nov. 22, 2021. The law enforcement authorities in Upper Austria said they did not have domestic jurisdiction. The Austrian authorities launched another investigation. The German prosecution authorities joined the search for those posting death threats on social media. Even the Munich chief public prosecutor’s office and the Berlin public prosecutor’s office investigated the case.

According to some reports, Dr. Kellermayr did not receive police protection; a patrol was sent over from time to time. According to the police, she should “not be afraid,” and if she was, she should just call them. She was also advised to undergo supervision -- in other words, psychological treatment.

Those who had the power to help her provided no support. On the contrary, the spokesperson for the Upper Austria Police said in the Ö1 Mittagsjournal radio program that Dr. Kellermayr was “putting herself in the public eye for her own selfish benefit.” Even Peter Niedermoser, president of the Medical Association of Upper Austria, told the Austrian daily newspaper Standard, “I understand that you have to defend yourself, but it is a whole other question as to whether you have to discuss every topic to excess on Twitter. Sometimes it’s better to step away.”
 

Leaving Twitter

A German network specialist who hunts pedophiles online offered Dr. Kellermayr her help and was quickly on the trail of suspects, including a neo-Nazi from the Berlin area and a man from Upper Bavaria. Then the Office for the Protection of the Constitution stepped in. Omar Haijawi-Pirchner, head of the Austrian State Security and Intelligence Directorate, stated that the evidence provided by the network specialist would be pursued.

At the end of June, Dr. Kellermayr closed her practice. The situation was no longer tolerable for her staff, and the costs for security, €100,000 up to that point, were no longer manageable. At the start of July, she announced that she wanted to reopen the practice.

In her suicide note to the Upper Austria State Police Department, she wrote “that there was a lot of talking, but no one did anything.” In her letter to her medical association, she also made it clear that she had felt abandoned.

“Every suicide is a tragedy. This one more so: a woman in need was abandoned by the police and authorities. That is a social failure,” tweeted physicist and author Florian Aigner.

“Threatened. Ruined. Left alone by the state. Because she did her job. Because she got involved. Because she spread information. Because many want to be understanding for the self-styled ‘unconventional thinkers,’ the ‘Querdenker.’ Because many did not want to take the threat seriously. Because we tolerate them,” tweeted the intensive care physician Lämêth.

“Many colleagues using their real names get all of this outside of Twitter too: emails, phone calls, letters, or even visits by radical fanatics. If you are lucky, there is police protection, or a few reports, but often not a lot happens juridically,” tweeted Flow, anesthetist and emergency physician.

“More and more of the people who shaped Twitter by spreading reliable information voluntarily are now backing out. As long as the concept of freedom is abused here for hate and intimidation, individual responsibility can only mean self-defense. Sad,” wrote Christian Lübbers, MD, on Twitter. Since the ENT physician started vaccinating patients against COVID-19, he has been tormented with insults and death threats from anti-vaxxers and COVID deniers, this news organization has reported.

Examples of people who have backed out and deactivated their account are the virologist Isabella Eckerlek, MD, PhD, of the University of Geneva, and Natalie Grams, MD, spokesperson for the Information Network Homeopathy. For a long time, they spread information about COVID-19, corrected false assertions, and were increasingly faced with insults and hostility.

General practitioner Christian Kröner, MD, has repeatedly been the target of threats and insults and has been under police protection from time to time. He made a statement regarding Dr. Kellermayr’s death and has shut down his account for the first time following multiple instances of hostility.
 

Harassment continues

The hatred, harassment, and slander have not stopped, even after Dr. Kellermayr’s death. Harald Laatsch, who sits in the Berlin house of representatives for the Alternative for Germany party, commented that it seems “much more likely that she could no longer live with the heavy guilt of being a vaccine propagandist.”

“It is repulsive how the Querdenker deride a medical colleague who was driven to death by harassment and violence. She lost her life by saving the lives of others. Others are continuing her work. The state must protect people like her,” tweeted Karl Lauterbach, MD, PhD, who has also been overrun with hate campaigns by Querdenker and COVID deniers.

The page “Ich habe mitgemacht” – Das Archiv für Corona-Unrecht [“I Joined In” – The Archive for COVID Injustice] probably did not help to deescalate the situation on Twitter. Anonymous archivists there collect allegedly ostracizing quotes and share them, along with names. The context in which these statements were given at the time is not mentioned. Some politicians and journalists have given this online pillory the name, “We joined in! We have ostracized, defamed...”

Being humiliated and defamed is par for the course for those who spread information across social media. As doctor and politician Rainer Röver, MD, wrote, “Whoever is involved in spreading information, science, fighting against fake news, and protecting the patients, pupils, clients, or mandates entrusted to them is being shouted down, threatened in writing, or driven to suicide.” The lying, baiting mob is taking over sovereignty of the discussion. According to Röver, the politicians are doing nothing “to actually put a stop to the violent mob.”

For some time now, the Federal Criminal Police Office (BKA) of Germany has considered anti-vaxxers or COVID deniers as a “relevant risk” in connection with attacks on vaccination centers or medical practices.
 

Increasing aggression

At the start of November last year, participants at the 125th German Medical Assembly demanded that violence against health care professionals be outlawed, Mark Berger, deputy spokesperson of the German Medical Association (BÄK), recollected. At the assembly, various medical associations shared reports of an increase in aggression during the pandemic.

The State Medical Chamber of Physicians of Saxony confirmed threats of violence against physicians, death threats against employees of the Vaccination Committee of Saxony, and criminal damage to medical practices that administer vaccinations. Physicians who administer vaccines in schools receive abuse.

Owing to the increasing amount of aggression, the State Medical Association of Thuringia has set up a special email address as a first point of contact to report violence for those who are affected. “In recent months, we have received a large number of reports from physicians who have received threatening letters in relation to the COVID vaccination, or letters purporting to be liability information or notices of liability,” explained the association. In the cases of which the association becomes aware, a criminal charge is issued most of the time. The investigative proceedings are ongoing.

The State Medical Association of Hesse has devised a reporting form with which it can obtain information on the forms of violence inflicted against physicians and their teams. The reporting is anonymous, and the data are statistically analyzed.

Peter Bobbert, MD, PhD, president of the Berlin Medical Association, provided reports of threat scenarios, “the kind and frequency of which we have never experienced.” He received many messages from physicians asking for help because they had received threatening letters or because their addresses had been posted on social networks.

To date, there have only been isolated cases, said Oliver Erens, MD, spokesperson of the State Medical Association of Baden-Württemberg. “But it is true that some colleagues have already had these kinds of experiences.” Those affected have primarily reported “discussions, debates, and verbal altercations with patients on the topic of the COVID vaccination, compliance with the mask mandate, and other COVID-containment measures – definitely with a high potential for aggression from some of the patients,” said Dr. Erens. Cases of physical violence have not been reported to date.

Above all, there has been a need for advice over the phone, predominantly in the legal department of the regional medical associations. “All physicians and their teams are being recommended by their associations to consistently prosecute any cases of threat of, or use of, violence against them,” Dr. Erens said. In October 2021, the University of Heidelberg started a study on the victimization of physicians. The analysis is ongoing.
 

Staying on Twitter

Lübbers considered leaving Twitter but decided against it. “I decided not to do it and to carry on spreading information about pseudo-medicine and vaccination. I see this as necessary civic courage and will not give way to hate,” Lübbers tweeted.

As understandable as any departure is, “we must not surrender Twitter to the trolls and harassers. Who is still here? #Iamstaying,” wrote Flow. Others wrote, “I will stay on Twitter as a physician. With my real name, too. [...] We must not surrender it to the Querdenker, idiots, Nazis, and enemies of freedom.”

“We need people to share information, we need voices of reason, just as Kellermayr was. How can you say that it would be better to remain silent? Does everyone who is against idiocy, Querdenker, and conspiracy theorists now have to remain silent?” asked Janos Hegedüs, MD, in his podcast.

Hegedüs, who uncovers fake news about COVID-19 and vaccination, was and remains a frequent target of insults and threats. His attempts to take action against them has had only limited success. His conclusion is sobering. “If you decide to spread information, you should know: You are alone. You will get all of the hate and when you have a problem with it, no one will help you.”

Media attorney Chan-jo Jun, who for many years has taken a stand against hate and harassment, has deactivated his Twitter account. However, this is not a retreat, as he clarified in an interview with the German radio station Deutschlandfunk. “I do not intend to give up the fight against hate, harassment, and misinformation, but I will do it in a different place.”

He sees Dr. Kellermayr’s death as a turning point. “I thought that we had learned something after Lübcke [i.e., politician Walter Lübcke, who was murdered by a neo-Nazi]. But we are seeing that the death of a political opponent is not just the goal, but also a success for the other side. And that is shocking.”

The judicial means of taking action against hate are still not effective, said Mr. Jun. He also sees the platform operators as responsible, since they are not obliged to remove unlawful content. “German law and the German constitution hold no sway on Twitter.”
 

Right-wing extremism

What happened to Lisa-Maria Kellermayr is the same as targeted terrorism. An organized group set out to annihilate her. Social psychologist Pia Lamberty has spoken, in the context of COVID, about a pandemic of violence, the threatening nature of which has barely been recognized, both in the virtual and analog world.

In an article for the Jüdische Allgemeine, Dr. Lamberty criticizes the fact that “the mistakes made with Pegida [i.e., a far-right, Islamophobic political movement in Germany] are being made once again” in the classification of Querdenker and COVID deniers. From the very start, the protests against the COVID measures have been a rallying point in the mobilization of right-wing extremists. “The Querdenker movement is unifying radical, right-wing extremist elements. Antisemitism and racism were always welcome.” Still, the right-wing extremist motivation has not been clearly labeled as such.

The classification is not just a question of statistics. “It is also about analyzing the potential for danger and deriving political measures from this. And there is an urgent need for action here: The right-wing extremists will utilize the climate crisis, but also the war in Ukraine, attacks against refugees, and LGBTQ rights for further mobilization. Rather than the state, the focus of the attacks will be people who are labeled as the bogeyman. This also must be clearly labeled for what it is,” said Dr. Lamberty.
She wrote on Twitter, “The COVID-related attacks that took place in the last two years will not simply stop, they will shift. If we do not want more and more people to stop expressing themselves publicly, something urgently has to happen.” She added, “Once more: The next few months will be very difficult. This will probably also be accompanied by an increased level of threat for socially engaged people. More protection is urgently required.”

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

This article was translated from the Medscape German edition.

“A sad day. A new low point in the spiral of hate, violence, and lies. Behind every account, there is a person. Do not forget that. In loving memory,” a Twitter user wrote about the death of Lisa-Maria Kellermayr, MD.

“This outcome is very saddening indeed. It should cause everyone to reflect. About interactions in our society, about ‘social’ media, about tolerance, about consideration, and about freedom,” tweeted Dirk Heinrich, MD, chair of the Virchow Association.

The suspected suicide of Dr. Kellermayr, an Austrian vaccinator, is stirring emotions in Germany, too. The active exponent and supporter of COVID-19 measures had been seriously threatened by anti-vaxxers and pandemic deniers. Thousands of people in Vienna said goodbye to her with a solemn vigil. Dr. Kellermayr’s death raises the question of how life-threatening online hatred can be.

Dr. Kellermayr, a vaccination campaigner, had received hateful comments and death threats since the start of the pandemic. But a single post on Twitter changed everything. On Nov. 16, 2021, anti-vaxxers held a demonstration outside the Wels-Grieskirchen Hospital. Dr. Kellermayr tweeted in disgust, “Today in Wels: A demonstration by conspiracy theorists spills into the street under the gaze of the authorities and blocks both the main hospital entrance and the Red Cross ambulance exit.”

At the time of her tweet, Dr. Kellermayr was not aware of additional access that had been made available for ambulances. The police reacted to her tweet, calling it a “false report.” As Florian Klenk writes in the Austrian journal Falter, the police basically criticized Dr. Kellermayr publicly, including in front of the 12,000 Twitter users who follow the police on Twitter.

A screenshot of Dr. Kellermayr’s tweet and the authorities’ response went viral on relevant Telegram forums and triggered a flood of hatred. A COVID denier immediately posted her address online.

Dr. Kellermayr deleted her tweet and asked the police to also delete their tweet, but they did not respond, and the tweet remained online. The country physician was inundated with insults, slurs, and death threats. She was beset by alleged patients who came only to disrupt her work, take videos on their cell phones, and share the photos in anti-vaxxer groups. She privately paid for a security guard, who confiscated butterfly knives from multiple “patients” on their way into the waiting room. Dr. Kellermayr looked for help from the medical association, the police, and the Office for the Protection of the Constitution. She made her problem public.
 

Police recommend supervision

Dr. Kellermayr received emails in which the senders described in detail how they would kill her and her practice team. The physician took the threats seriously; the police did not. The officers investigated. With the evidence that the perpetrators were operating via the dark web, the officers insinuated to Dr. Kellermayr that it was not possible to find them, Klenk reported.

Dr. Kellermayr filed a complaint for the first time on Nov. 22, 2021. The law enforcement authorities in Upper Austria said they did not have domestic jurisdiction. The Austrian authorities launched another investigation. The German prosecution authorities joined the search for those posting death threats on social media. Even the Munich chief public prosecutor’s office and the Berlin public prosecutor’s office investigated the case.

According to some reports, Dr. Kellermayr did not receive police protection; a patrol was sent over from time to time. According to the police, she should “not be afraid,” and if she was, she should just call them. She was also advised to undergo supervision -- in other words, psychological treatment.

Those who had the power to help her provided no support. On the contrary, the spokesperson for the Upper Austria Police said in the Ö1 Mittagsjournal radio program that Dr. Kellermayr was “putting herself in the public eye for her own selfish benefit.” Even Peter Niedermoser, president of the Medical Association of Upper Austria, told the Austrian daily newspaper Standard, “I understand that you have to defend yourself, but it is a whole other question as to whether you have to discuss every topic to excess on Twitter. Sometimes it’s better to step away.”
 

Leaving Twitter

A German network specialist who hunts pedophiles online offered Dr. Kellermayr her help and was quickly on the trail of suspects, including a neo-Nazi from the Berlin area and a man from Upper Bavaria. Then the Office for the Protection of the Constitution stepped in. Omar Haijawi-Pirchner, head of the Austrian State Security and Intelligence Directorate, stated that the evidence provided by the network specialist would be pursued.

At the end of June, Dr. Kellermayr closed her practice. The situation was no longer tolerable for her staff, and the costs for security, €100,000 up to that point, were no longer manageable. At the start of July, she announced that she wanted to reopen the practice.

In her suicide note to the Upper Austria State Police Department, she wrote “that there was a lot of talking, but no one did anything.” In her letter to her medical association, she also made it clear that she had felt abandoned.

“Every suicide is a tragedy. This one more so: a woman in need was abandoned by the police and authorities. That is a social failure,” tweeted physicist and author Florian Aigner.

“Threatened. Ruined. Left alone by the state. Because she did her job. Because she got involved. Because she spread information. Because many want to be understanding for the self-styled ‘unconventional thinkers,’ the ‘Querdenker.’ Because many did not want to take the threat seriously. Because we tolerate them,” tweeted the intensive care physician Lämêth.

“Many colleagues using their real names get all of this outside of Twitter too: emails, phone calls, letters, or even visits by radical fanatics. If you are lucky, there is police protection, or a few reports, but often not a lot happens juridically,” tweeted Flow, anesthetist and emergency physician.

“More and more of the people who shaped Twitter by spreading reliable information voluntarily are now backing out. As long as the concept of freedom is abused here for hate and intimidation, individual responsibility can only mean self-defense. Sad,” wrote Christian Lübbers, MD, on Twitter. Since the ENT physician started vaccinating patients against COVID-19, he has been tormented with insults and death threats from anti-vaxxers and COVID deniers, this news organization has reported.

Examples of people who have backed out and deactivated their account are the virologist Isabella Eckerlek, MD, PhD, of the University of Geneva, and Natalie Grams, MD, spokesperson for the Information Network Homeopathy. For a long time, they spread information about COVID-19, corrected false assertions, and were increasingly faced with insults and hostility.

General practitioner Christian Kröner, MD, has repeatedly been the target of threats and insults and has been under police protection from time to time. He made a statement regarding Dr. Kellermayr’s death and has shut down his account for the first time following multiple instances of hostility.
 

Harassment continues

The hatred, harassment, and slander have not stopped, even after Dr. Kellermayr’s death. Harald Laatsch, who sits in the Berlin house of representatives for the Alternative for Germany party, commented that it seems “much more likely that she could no longer live with the heavy guilt of being a vaccine propagandist.”

“It is repulsive how the Querdenker deride a medical colleague who was driven to death by harassment and violence. She lost her life by saving the lives of others. Others are continuing her work. The state must protect people like her,” tweeted Karl Lauterbach, MD, PhD, who has also been overrun with hate campaigns by Querdenker and COVID deniers.

The page “Ich habe mitgemacht” – Das Archiv für Corona-Unrecht [“I Joined In” – The Archive for COVID Injustice] probably did not help to deescalate the situation on Twitter. Anonymous archivists there collect allegedly ostracizing quotes and share them, along with names. The context in which these statements were given at the time is not mentioned. Some politicians and journalists have given this online pillory the name, “We joined in! We have ostracized, defamed...”

Being humiliated and defamed is par for the course for those who spread information across social media. As doctor and politician Rainer Röver, MD, wrote, “Whoever is involved in spreading information, science, fighting against fake news, and protecting the patients, pupils, clients, or mandates entrusted to them is being shouted down, threatened in writing, or driven to suicide.” The lying, baiting mob is taking over sovereignty of the discussion. According to Röver, the politicians are doing nothing “to actually put a stop to the violent mob.”

For some time now, the Federal Criminal Police Office (BKA) of Germany has considered anti-vaxxers or COVID deniers as a “relevant risk” in connection with attacks on vaccination centers or medical practices.
 

Increasing aggression

At the start of November last year, participants at the 125th German Medical Assembly demanded that violence against health care professionals be outlawed, Mark Berger, deputy spokesperson of the German Medical Association (BÄK), recollected. At the assembly, various medical associations shared reports of an increase in aggression during the pandemic.

The State Medical Chamber of Physicians of Saxony confirmed threats of violence against physicians, death threats against employees of the Vaccination Committee of Saxony, and criminal damage to medical practices that administer vaccinations. Physicians who administer vaccines in schools receive abuse.

Owing to the increasing amount of aggression, the State Medical Association of Thuringia has set up a special email address as a first point of contact to report violence for those who are affected. “In recent months, we have received a large number of reports from physicians who have received threatening letters in relation to the COVID vaccination, or letters purporting to be liability information or notices of liability,” explained the association. In the cases of which the association becomes aware, a criminal charge is issued most of the time. The investigative proceedings are ongoing.

The State Medical Association of Hesse has devised a reporting form with which it can obtain information on the forms of violence inflicted against physicians and their teams. The reporting is anonymous, and the data are statistically analyzed.

Peter Bobbert, MD, PhD, president of the Berlin Medical Association, provided reports of threat scenarios, “the kind and frequency of which we have never experienced.” He received many messages from physicians asking for help because they had received threatening letters or because their addresses had been posted on social networks.

To date, there have only been isolated cases, said Oliver Erens, MD, spokesperson of the State Medical Association of Baden-Württemberg. “But it is true that some colleagues have already had these kinds of experiences.” Those affected have primarily reported “discussions, debates, and verbal altercations with patients on the topic of the COVID vaccination, compliance with the mask mandate, and other COVID-containment measures – definitely with a high potential for aggression from some of the patients,” said Dr. Erens. Cases of physical violence have not been reported to date.

Above all, there has been a need for advice over the phone, predominantly in the legal department of the regional medical associations. “All physicians and their teams are being recommended by their associations to consistently prosecute any cases of threat of, or use of, violence against them,” Dr. Erens said. In October 2021, the University of Heidelberg started a study on the victimization of physicians. The analysis is ongoing.
 

Staying on Twitter

Lübbers considered leaving Twitter but decided against it. “I decided not to do it and to carry on spreading information about pseudo-medicine and vaccination. I see this as necessary civic courage and will not give way to hate,” Lübbers tweeted.

As understandable as any departure is, “we must not surrender Twitter to the trolls and harassers. Who is still here? #Iamstaying,” wrote Flow. Others wrote, “I will stay on Twitter as a physician. With my real name, too. [...] We must not surrender it to the Querdenker, idiots, Nazis, and enemies of freedom.”

“We need people to share information, we need voices of reason, just as Kellermayr was. How can you say that it would be better to remain silent? Does everyone who is against idiocy, Querdenker, and conspiracy theorists now have to remain silent?” asked Janos Hegedüs, MD, in his podcast.

Hegedüs, who uncovers fake news about COVID-19 and vaccination, was and remains a frequent target of insults and threats. His attempts to take action against them has had only limited success. His conclusion is sobering. “If you decide to spread information, you should know: You are alone. You will get all of the hate and when you have a problem with it, no one will help you.”

Media attorney Chan-jo Jun, who for many years has taken a stand against hate and harassment, has deactivated his Twitter account. However, this is not a retreat, as he clarified in an interview with the German radio station Deutschlandfunk. “I do not intend to give up the fight against hate, harassment, and misinformation, but I will do it in a different place.”

He sees Dr. Kellermayr’s death as a turning point. “I thought that we had learned something after Lübcke [i.e., politician Walter Lübcke, who was murdered by a neo-Nazi]. But we are seeing that the death of a political opponent is not just the goal, but also a success for the other side. And that is shocking.”

The judicial means of taking action against hate are still not effective, said Mr. Jun. He also sees the platform operators as responsible, since they are not obliged to remove unlawful content. “German law and the German constitution hold no sway on Twitter.”
 

Right-wing extremism

What happened to Lisa-Maria Kellermayr is the same as targeted terrorism. An organized group set out to annihilate her. Social psychologist Pia Lamberty has spoken, in the context of COVID, about a pandemic of violence, the threatening nature of which has barely been recognized, both in the virtual and analog world.

In an article for the Jüdische Allgemeine, Dr. Lamberty criticizes the fact that “the mistakes made with Pegida [i.e., a far-right, Islamophobic political movement in Germany] are being made once again” in the classification of Querdenker and COVID deniers. From the very start, the protests against the COVID measures have been a rallying point in the mobilization of right-wing extremists. “The Querdenker movement is unifying radical, right-wing extremist elements. Antisemitism and racism were always welcome.” Still, the right-wing extremist motivation has not been clearly labeled as such.

The classification is not just a question of statistics. “It is also about analyzing the potential for danger and deriving political measures from this. And there is an urgent need for action here: The right-wing extremists will utilize the climate crisis, but also the war in Ukraine, attacks against refugees, and LGBTQ rights for further mobilization. Rather than the state, the focus of the attacks will be people who are labeled as the bogeyman. This also must be clearly labeled for what it is,” said Dr. Lamberty.
She wrote on Twitter, “The COVID-related attacks that took place in the last two years will not simply stop, they will shift. If we do not want more and more people to stop expressing themselves publicly, something urgently has to happen.” She added, “Once more: The next few months will be very difficult. This will probably also be accompanied by an increased level of threat for socially engaged people. More protection is urgently required.”

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

This article was translated from the Medscape German edition.

It seems that everyone’s nerves are on edge right now, and people are often behaving in surprising ways. Physicians are no exception.

“The days of surgeons throwing retractors across the OR and screaming at nurses and medical students are hopefully gone now,” said Barron Lerner, MD, PhD, professor of medicine at New York University Langone Health and author of “The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics” (Boston: Beacon Press, 2014). “We’re not going to tolerate that as an institution.”

But, Dr. Lerner said, bad behavior still happens. And according to a recent Medscape survey, it seems to be on the rise.

For the 2022 Physicians Behaving Badly Report, more than 1,500 physicians shared how often they see fellow doctors misbehaving in person or on social media, and shared some of the worse behavior they’ve seen.

Though misconduct is still relatively uncommon among doctors, and most physicians say they’re proud of the high standards and attitudes of their colleagues, respondents to the survey did say that they’re seeing more frequent incidents of other doctors acting disrespectfully toward patients and coworkers, taking too casual an approach to patient privacy, and even acting angrily or aggressively at work. While the uptick is not substantial, it’s nonetheless worrying.

“I have increased concern for my colleagues,” said Drew Ramsey, MD, an assistant clinical professor of psychiatry at Columbia University, New York. “People forget that COVID has made the physician workplace incredibly stressful. Physicians are struggling with their mental health.”
 

Bullying and harassment top bad behavior

When it comes to what kind of bad behavior was reported, bullying or harassing clinicians and staff was the runaway winner, with 86% of respondents saying they’d seen this type of behavior at work at some time. Making fun of or disparaging patients behind their backs was a close second, at 82%.

Dr. Ramsey thinks that these figures may reflect a deeper understanding of and sensitivity to harassment and bullying. “Five years ago, we weren’t talking about microaggression,” he said. This heightened awareness might explain the fact that doctors reported witnessing physicians mistreating other medical personnel and/or bullying or harassing patients somewhat more often than in 2021’s report.

Docs were caught using racist language by 55% of respondents, and 44% reported seeing colleagues becoming physically aggressive with patients, clinicians, or staff. Other disturbing behaviors respondents witnessed included bullying or harassing patients (45%), inebriation at work (43%), lying about credentials (34%), trying to date a patient (30%), and committing a crime, such as embezzling or stealing (27%).

Women were seen misbehaving about one-third as often as their male counterparts. This could be because women are more likely to seek help, rather than the bottle, when the stress piles up. “Some misbehavior stems from alcohol abuse, and a higher percentage of men have an alcoholism problem,” Dr. Ramsey pointed out. “Also, male physicians have historically been reluctant to seek mental health assistance.”
 

Speaking up

Doctors are behaving badly slightly more often, and their colleagues are slightly more willing to speak up about that behavior. In 2021, 35% of physicians said they did nothing upon witnessing inappropriate behavior. In 2022’s survey, that number fell to 29%.

Respondents largely agreed (49%) that doctors should be verbally warned when they’ve behaved badly at work, yet only 39% reported speaking to a colleague who acted inappropriately, and only 27% reported the bad behavior to an authority.

Dr. Lerner pointed out that it is very difficult for doctors to speak up, even though they know they should. There are several reasons for their reticence.

“For one thing, we all have bad days, and the reporting physician may worry that he or she could do something similar in the future,” he said. “Also, there is the liability question. A doctor might think: ‘What if I’m wrong? What if I think someone has a drinking problem and they don’t, or I can’t prove it?’ If you’re the doctor who reported the misbehavior, you’re potentially opening a can of worms. So there’s all sorts of reasons people convince themselves they don’t have to report it.” But, he added, “if you see it and don’t report it, you’re in the wrong.”
 

Off the job

Work isn’t the only place where doctors observe their colleagues misbehaving. About 66% of respondents had seen disparaging behavior, and 42% had heard racist language, away from the hospital or clinic, according to the survey.

Bullying and harassment weren’t limited to work, either, with 45% reporting seeing a colleague engage in this behavior off campus, and 52% reporting witnessing a colleague inebriated in public. That’s actually down from 2021 when 58% of respondents said they witnessed inebriated doctors in public.

The public sphere has broadened in recent years to include social media, and there, too, doctors sometimes behave badly. However, 47% of doctors surveyed said they saw more inappropriate behavior in person than on social media.

When doctors do act out online, they make the same mistakes other professionals make. One respondent reported seeing a fellow physician “copying and posting an interoffice memo from work and badmouthing the company and the person who wrote the memo.” Another said: “Someone got fired and stalked the supervisor and posted aggressive things.”

Not all social media transgressions were work related. One respondent reported that “a physician posted pictures of herself at a bar with multiple ER staff members, without masks during COVID restriction,” and another reported a colleague posting “unbelievable, antiscientific information expressed as valid, factual material.”

Though posting nonfactual, unscientific, and potentially unsafe information is clearly an ethics violation, Dr. Lerner said, the boundaries around posting personal peccadillos are less clear. This is a part of “digital professionalism,” he explained, adding that there is a broad range of opinions on this. “I think it’s important to discuss these things. Interestingly, while the rules for behavior at the hospital have become more strict, the culture has become less strict.”

As one respondent put it: “What exactly is bad behavior? If you’re saying physicians should be allowed to sexually assault people and use drugs, then no. Can they wear a tiny bathing suit on vacation and drink cocktails with friends? Yeah.”

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

It seems that everyone’s nerves are on edge right now, and people are often behaving in surprising ways. Physicians are no exception.

“The days of surgeons throwing retractors across the OR and screaming at nurses and medical students are hopefully gone now,” said Barron Lerner, MD, PhD, professor of medicine at New York University Langone Health and author of “The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics” (Boston: Beacon Press, 2014). “We’re not going to tolerate that as an institution.”

But, Dr. Lerner said, bad behavior still happens. And according to a recent Medscape survey, it seems to be on the rise.

For the 2022 Physicians Behaving Badly Report, more than 1,500 physicians shared how often they see fellow doctors misbehaving in person or on social media, and shared some of the worse behavior they’ve seen.

Though misconduct is still relatively uncommon among doctors, and most physicians say they’re proud of the high standards and attitudes of their colleagues, respondents to the survey did say that they’re seeing more frequent incidents of other doctors acting disrespectfully toward patients and coworkers, taking too casual an approach to patient privacy, and even acting angrily or aggressively at work. While the uptick is not substantial, it’s nonetheless worrying.

“I have increased concern for my colleagues,” said Drew Ramsey, MD, an assistant clinical professor of psychiatry at Columbia University, New York. “People forget that COVID has made the physician workplace incredibly stressful. Physicians are struggling with their mental health.”
 

Bullying and harassment top bad behavior

When it comes to what kind of bad behavior was reported, bullying or harassing clinicians and staff was the runaway winner, with 86% of respondents saying they’d seen this type of behavior at work at some time. Making fun of or disparaging patients behind their backs was a close second, at 82%.

Dr. Ramsey thinks that these figures may reflect a deeper understanding of and sensitivity to harassment and bullying. “Five years ago, we weren’t talking about microaggression,” he said. This heightened awareness might explain the fact that doctors reported witnessing physicians mistreating other medical personnel and/or bullying or harassing patients somewhat more often than in 2021’s report.

Docs were caught using racist language by 55% of respondents, and 44% reported seeing colleagues becoming physically aggressive with patients, clinicians, or staff. Other disturbing behaviors respondents witnessed included bullying or harassing patients (45%), inebriation at work (43%), lying about credentials (34%), trying to date a patient (30%), and committing a crime, such as embezzling or stealing (27%).

Women were seen misbehaving about one-third as often as their male counterparts. This could be because women are more likely to seek help, rather than the bottle, when the stress piles up. “Some misbehavior stems from alcohol abuse, and a higher percentage of men have an alcoholism problem,” Dr. Ramsey pointed out. “Also, male physicians have historically been reluctant to seek mental health assistance.”
 

Speaking up

Doctors are behaving badly slightly more often, and their colleagues are slightly more willing to speak up about that behavior. In 2021, 35% of physicians said they did nothing upon witnessing inappropriate behavior. In 2022’s survey, that number fell to 29%.

Respondents largely agreed (49%) that doctors should be verbally warned when they’ve behaved badly at work, yet only 39% reported speaking to a colleague who acted inappropriately, and only 27% reported the bad behavior to an authority.

Dr. Lerner pointed out that it is very difficult for doctors to speak up, even though they know they should. There are several reasons for their reticence.

“For one thing, we all have bad days, and the reporting physician may worry that he or she could do something similar in the future,” he said. “Also, there is the liability question. A doctor might think: ‘What if I’m wrong? What if I think someone has a drinking problem and they don’t, or I can’t prove it?’ If you’re the doctor who reported the misbehavior, you’re potentially opening a can of worms. So there’s all sorts of reasons people convince themselves they don’t have to report it.” But, he added, “if you see it and don’t report it, you’re in the wrong.”
 

Off the job

Work isn’t the only place where doctors observe their colleagues misbehaving. About 66% of respondents had seen disparaging behavior, and 42% had heard racist language, away from the hospital or clinic, according to the survey.

Bullying and harassment weren’t limited to work, either, with 45% reporting seeing a colleague engage in this behavior off campus, and 52% reporting witnessing a colleague inebriated in public. That’s actually down from 2021 when 58% of respondents said they witnessed inebriated doctors in public.

The public sphere has broadened in recent years to include social media, and there, too, doctors sometimes behave badly. However, 47% of doctors surveyed said they saw more inappropriate behavior in person than on social media.

When doctors do act out online, they make the same mistakes other professionals make. One respondent reported seeing a fellow physician “copying and posting an interoffice memo from work and badmouthing the company and the person who wrote the memo.” Another said: “Someone got fired and stalked the supervisor and posted aggressive things.”

Not all social media transgressions were work related. One respondent reported that “a physician posted pictures of herself at a bar with multiple ER staff members, without masks during COVID restriction,” and another reported a colleague posting “unbelievable, antiscientific information expressed as valid, factual material.”

Though posting nonfactual, unscientific, and potentially unsafe information is clearly an ethics violation, Dr. Lerner said, the boundaries around posting personal peccadillos are less clear. This is a part of “digital professionalism,” he explained, adding that there is a broad range of opinions on this. “I think it’s important to discuss these things. Interestingly, while the rules for behavior at the hospital have become more strict, the culture has become less strict.”

As one respondent put it: “What exactly is bad behavior? If you’re saying physicians should be allowed to sexually assault people and use drugs, then no. Can they wear a tiny bathing suit on vacation and drink cocktails with friends? Yeah.”

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

It seems that everyone’s nerves are on edge right now, and people are often behaving in surprising ways. Physicians are no exception.

“The days of surgeons throwing retractors across the OR and screaming at nurses and medical students are hopefully gone now,” said Barron Lerner, MD, PhD, professor of medicine at New York University Langone Health and author of “The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics” (Boston: Beacon Press, 2014). “We’re not going to tolerate that as an institution.”

But, Dr. Lerner said, bad behavior still happens. And according to a recent Medscape survey, it seems to be on the rise.

For the 2022 Physicians Behaving Badly Report, more than 1,500 physicians shared how often they see fellow doctors misbehaving in person or on social media, and shared some of the worse behavior they’ve seen.

Though misconduct is still relatively uncommon among doctors, and most physicians say they’re proud of the high standards and attitudes of their colleagues, respondents to the survey did say that they’re seeing more frequent incidents of other doctors acting disrespectfully toward patients and coworkers, taking too casual an approach to patient privacy, and even acting angrily or aggressively at work. While the uptick is not substantial, it’s nonetheless worrying.

“I have increased concern for my colleagues,” said Drew Ramsey, MD, an assistant clinical professor of psychiatry at Columbia University, New York. “People forget that COVID has made the physician workplace incredibly stressful. Physicians are struggling with their mental health.”
 

Bullying and harassment top bad behavior

When it comes to what kind of bad behavior was reported, bullying or harassing clinicians and staff was the runaway winner, with 86% of respondents saying they’d seen this type of behavior at work at some time. Making fun of or disparaging patients behind their backs was a close second, at 82%.

Dr. Ramsey thinks that these figures may reflect a deeper understanding of and sensitivity to harassment and bullying. “Five years ago, we weren’t talking about microaggression,” he said. This heightened awareness might explain the fact that doctors reported witnessing physicians mistreating other medical personnel and/or bullying or harassing patients somewhat more often than in 2021’s report.

Docs were caught using racist language by 55% of respondents, and 44% reported seeing colleagues becoming physically aggressive with patients, clinicians, or staff. Other disturbing behaviors respondents witnessed included bullying or harassing patients (45%), inebriation at work (43%), lying about credentials (34%), trying to date a patient (30%), and committing a crime, such as embezzling or stealing (27%).

Women were seen misbehaving about one-third as often as their male counterparts. This could be because women are more likely to seek help, rather than the bottle, when the stress piles up. “Some misbehavior stems from alcohol abuse, and a higher percentage of men have an alcoholism problem,” Dr. Ramsey pointed out. “Also, male physicians have historically been reluctant to seek mental health assistance.”
 

Speaking up

Doctors are behaving badly slightly more often, and their colleagues are slightly more willing to speak up about that behavior. In 2021, 35% of physicians said they did nothing upon witnessing inappropriate behavior. In 2022’s survey, that number fell to 29%.

Respondents largely agreed (49%) that doctors should be verbally warned when they’ve behaved badly at work, yet only 39% reported speaking to a colleague who acted inappropriately, and only 27% reported the bad behavior to an authority.

Dr. Lerner pointed out that it is very difficult for doctors to speak up, even though they know they should. There are several reasons for their reticence.

“For one thing, we all have bad days, and the reporting physician may worry that he or she could do something similar in the future,” he said. “Also, there is the liability question. A doctor might think: ‘What if I’m wrong? What if I think someone has a drinking problem and they don’t, or I can’t prove it?’ If you’re the doctor who reported the misbehavior, you’re potentially opening a can of worms. So there’s all sorts of reasons people convince themselves they don’t have to report it.” But, he added, “if you see it and don’t report it, you’re in the wrong.”
 

Off the job

Work isn’t the only place where doctors observe their colleagues misbehaving. About 66% of respondents had seen disparaging behavior, and 42% had heard racist language, away from the hospital or clinic, according to the survey.

Bullying and harassment weren’t limited to work, either, with 45% reporting seeing a colleague engage in this behavior off campus, and 52% reporting witnessing a colleague inebriated in public. That’s actually down from 2021 when 58% of respondents said they witnessed inebriated doctors in public.

The public sphere has broadened in recent years to include social media, and there, too, doctors sometimes behave badly. However, 47% of doctors surveyed said they saw more inappropriate behavior in person than on social media.

When doctors do act out online, they make the same mistakes other professionals make. One respondent reported seeing a fellow physician “copying and posting an interoffice memo from work and badmouthing the company and the person who wrote the memo.” Another said: “Someone got fired and stalked the supervisor and posted aggressive things.”

Not all social media transgressions were work related. One respondent reported that “a physician posted pictures of herself at a bar with multiple ER staff members, without masks during COVID restriction,” and another reported a colleague posting “unbelievable, antiscientific information expressed as valid, factual material.”

Though posting nonfactual, unscientific, and potentially unsafe information is clearly an ethics violation, Dr. Lerner said, the boundaries around posting personal peccadillos are less clear. This is a part of “digital professionalism,” he explained, adding that there is a broad range of opinions on this. “I think it’s important to discuss these things. Interestingly, while the rules for behavior at the hospital have become more strict, the culture has become less strict.”

As one respondent put it: “What exactly is bad behavior? If you’re saying physicians should be allowed to sexually assault people and use drugs, then no. Can they wear a tiny bathing suit on vacation and drink cocktails with friends? Yeah.”

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

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

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

The gray wave

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

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

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

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

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

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

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

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

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

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

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

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

Tracking a growing group

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

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

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

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

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

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

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

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

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

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

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

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

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

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

MD bias against the elderly?

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

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

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

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

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

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

COVID-19 and centenarians

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

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

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

Don’t mess with success

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

Opinions differ on how to approach screening for centenarians.

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

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

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

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

Avoid the ED

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

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

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

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

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

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

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

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

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

These patients often are subject to trauma from falls.

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

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

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

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

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

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

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

Dementia dilemma

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

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

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

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

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

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

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

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

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

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

‘They’ve already won’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The gray wave

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

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

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

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

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

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

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

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

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

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

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

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

Tracking a growing group

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

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

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

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

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

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

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

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

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

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

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

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

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

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

MD bias against the elderly?

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

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

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

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

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

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

COVID-19 and centenarians

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

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

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

Don’t mess with success

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

Opinions differ on how to approach screening for centenarians.

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

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

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

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

Avoid the ED

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

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

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

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

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

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

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

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

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

These patients often are subject to trauma from falls.

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

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

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

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

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

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

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

Dementia dilemma

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

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

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

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

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

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

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

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

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

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

‘They’ve already won’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The gray wave

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

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

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

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

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

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

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

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

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

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

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

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

Tracking a growing group

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

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

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

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

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

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

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

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

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

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

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

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

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

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

MD bias against the elderly?

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

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

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

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

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

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

COVID-19 and centenarians

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

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

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

Don’t mess with success

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

Opinions differ on how to approach screening for centenarians.

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

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

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

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

Avoid the ED

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

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

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

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

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

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

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

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

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

These patients often are subject to trauma from falls.

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

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

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

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

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

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

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

Dementia dilemma

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

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

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

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

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

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

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

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

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

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

‘They’ve already won’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rural patients with early onset dementia are more likely than urban patients to rely solely on primary care physicians or nurse practitioners for the initial diagnosis and treatment of the disease, a new study has found.

Patients in rural areas are also less likely to see psychologists and undergo neuropsychological testing, according to the study, published in JAMA Network Open.

Patients who forgo such specialist visits and testing may be missing information about their condition that could help them prepare for changes in job responsibilities and future care decisions, said Wendy Yi Xu, PhD, of The Ohio State University, Columbus, who led the research.

“A lot of them are still in the workforce,” Dr. Xu said. Patients in the study were an average age of 56 years, well before the conventional age of retirement.
 

Location, location, location

To examine rural versus urban differences in the use of diagnostic tests and health care visits for early onset Alzheimer’s disease and related dementias, Dr. Xu and colleagues analyzed commercial claims data from 2012-2018. They identified more than 71,000 patients aged 40-64 years with those conditions and focused on health care use by 7,311 patients in urban areas and 1,119 in rural areas within 90 days of a new dementia diagnosis.

The proportion who received neuropsychological testing was 19% among urban patients and 16% among rural patients. Psychological assessments, which are less specialized and detailed than neuropsychological testing, and brain imaging occurred at similar rates in both groups. Similar proportions of rural and urban patients visited neurologists (17.7% and 17.96%, respectively) and psychiatrists (6.02% and 6.47%).

But more urban patients than rural patients visited a psychologist, at 19% versus 15%, according to the researchers.

Approximately 18% of patients in rural areas saw a primary care provider without visiting other specialists, compared with 13% in urban areas.

The researchers found that rural patients were significantly less likely to undergo neuropsychological testing (odds ratio, 0.83; 95% confidence interval, 0.70-0.98) or see a psychologist (OR, 0.72; 95% CI, 0.60-0.85).

Similarly, rural patients had significantly higher odds of having only primary care providers involved in the diagnosis of dementia and symptom management (OR, 1.40; 95% CI, 1.19-1.66).
 

Addressing workforce deficiencies

More primary care training in dementia care and collaboration with specialist colleagues could help address differences in care, Dr. Xu’s group writes. Such efforts are already underway.

In 2018, the Alzheimer’s Association launched telementoring programs focused on dementia care using the Project ECHO (Extension for Community Healthcare Outcomes) model. Researchers originally developed Project ECHO at the University of New Mexico in 2003 to teach primary care clinicians in remote settings how to treat patients infected with the hepatitis C virus.

With the Alzheimer’s and Dementia Care ECHO Program for Clinicians, primary care clinicians can participate in interactive case-based video conferencing sessions to better understand dementia and how to provide high-quality care in community settings, according to the association.

The program covers guidelines for diagnosis, disclosure, and follow-up; the initiation of care planning; managing disease-related challenges; and resources for patients and caregivers.

Since 2018, nearly 100 primary care practices in the United States have completed training in dementia care using Project ECHO, said Morgan Daven, vice president of health systems for the Alzheimer’s Association. Many cases featured in the program are challenging, he added.

“With primary care being on the front lines, it is really important that primary care physicians are equipped to do what they can to detect or diagnose and know when to refer,” Mr. Daven said.

The association has compiled other resources for clinicians as well.

A 2020 report from the association examined the role that primary care physicians play in dementia care. One survey found that 82% of primary care physicians consider themselves on the front lines of providing care for patients with dementia.

Meanwhile, about half say medical professionals are not prepared to meet rising demands associated with Alzheimer’s disease and dementia care.

Mr. Daven said the geographic disparities Dr. Xu and colleagues found are unsurprising. More than half of primary care physicians who care for people with Alzheimer’s disease say dementia specialists in their communities cannot meet demand. The problem is more urgent in rural areas. Roughly half of nonmetropolitan counties in the United States lack a practicing psychologist, according to a 2018 study published in the American Journal of Preventive Medicine.

“We really need to approach this on both sides – build the capacity in primary care, but we also need to address the dementia care specialty shortages,” Mr. Daven said.

The lack of obvious differences in access to neurologists in the new study “was surprising, given the more than fourfold difference between urban and rural areas in the supply of neurologists,” the researchers note. Health plans may maintain more access to neurologists than psychologists because of relatively higher reimbursement for neurologists, they observed.

One of the study coauthors disclosed ties to Aveanna Healthcare, a company that delivers home health and hospice care.

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

Rural patients with early onset dementia are more likely than urban patients to rely solely on primary care physicians or nurse practitioners for the initial diagnosis and treatment of the disease, a new study has found.

Patients in rural areas are also less likely to see psychologists and undergo neuropsychological testing, according to the study, published in JAMA Network Open.

Patients who forgo such specialist visits and testing may be missing information about their condition that could help them prepare for changes in job responsibilities and future care decisions, said Wendy Yi Xu, PhD, of The Ohio State University, Columbus, who led the research.

“A lot of them are still in the workforce,” Dr. Xu said. Patients in the study were an average age of 56 years, well before the conventional age of retirement.
 

Location, location, location

To examine rural versus urban differences in the use of diagnostic tests and health care visits for early onset Alzheimer’s disease and related dementias, Dr. Xu and colleagues analyzed commercial claims data from 2012-2018. They identified more than 71,000 patients aged 40-64 years with those conditions and focused on health care use by 7,311 patients in urban areas and 1,119 in rural areas within 90 days of a new dementia diagnosis.

The proportion who received neuropsychological testing was 19% among urban patients and 16% among rural patients. Psychological assessments, which are less specialized and detailed than neuropsychological testing, and brain imaging occurred at similar rates in both groups. Similar proportions of rural and urban patients visited neurologists (17.7% and 17.96%, respectively) and psychiatrists (6.02% and 6.47%).

But more urban patients than rural patients visited a psychologist, at 19% versus 15%, according to the researchers.

Approximately 18% of patients in rural areas saw a primary care provider without visiting other specialists, compared with 13% in urban areas.

The researchers found that rural patients were significantly less likely to undergo neuropsychological testing (odds ratio, 0.83; 95% confidence interval, 0.70-0.98) or see a psychologist (OR, 0.72; 95% CI, 0.60-0.85).

Similarly, rural patients had significantly higher odds of having only primary care providers involved in the diagnosis of dementia and symptom management (OR, 1.40; 95% CI, 1.19-1.66).
 

Addressing workforce deficiencies

More primary care training in dementia care and collaboration with specialist colleagues could help address differences in care, Dr. Xu’s group writes. Such efforts are already underway.

In 2018, the Alzheimer’s Association launched telementoring programs focused on dementia care using the Project ECHO (Extension for Community Healthcare Outcomes) model. Researchers originally developed Project ECHO at the University of New Mexico in 2003 to teach primary care clinicians in remote settings how to treat patients infected with the hepatitis C virus.

With the Alzheimer’s and Dementia Care ECHO Program for Clinicians, primary care clinicians can participate in interactive case-based video conferencing sessions to better understand dementia and how to provide high-quality care in community settings, according to the association.

The program covers guidelines for diagnosis, disclosure, and follow-up; the initiation of care planning; managing disease-related challenges; and resources for patients and caregivers.

Since 2018, nearly 100 primary care practices in the United States have completed training in dementia care using Project ECHO, said Morgan Daven, vice president of health systems for the Alzheimer’s Association. Many cases featured in the program are challenging, he added.

“With primary care being on the front lines, it is really important that primary care physicians are equipped to do what they can to detect or diagnose and know when to refer,” Mr. Daven said.

The association has compiled other resources for clinicians as well.

A 2020 report from the association examined the role that primary care physicians play in dementia care. One survey found that 82% of primary care physicians consider themselves on the front lines of providing care for patients with dementia.

Meanwhile, about half say medical professionals are not prepared to meet rising demands associated with Alzheimer’s disease and dementia care.

Mr. Daven said the geographic disparities Dr. Xu and colleagues found are unsurprising. More than half of primary care physicians who care for people with Alzheimer’s disease say dementia specialists in their communities cannot meet demand. The problem is more urgent in rural areas. Roughly half of nonmetropolitan counties in the United States lack a practicing psychologist, according to a 2018 study published in the American Journal of Preventive Medicine.

“We really need to approach this on both sides – build the capacity in primary care, but we also need to address the dementia care specialty shortages,” Mr. Daven said.

The lack of obvious differences in access to neurologists in the new study “was surprising, given the more than fourfold difference between urban and rural areas in the supply of neurologists,” the researchers note. Health plans may maintain more access to neurologists than psychologists because of relatively higher reimbursement for neurologists, they observed.

One of the study coauthors disclosed ties to Aveanna Healthcare, a company that delivers home health and hospice care.

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

Rural patients with early onset dementia are more likely than urban patients to rely solely on primary care physicians or nurse practitioners for the initial diagnosis and treatment of the disease, a new study has found.

Patients in rural areas are also less likely to see psychologists and undergo neuropsychological testing, according to the study, published in JAMA Network Open.

Patients who forgo such specialist visits and testing may be missing information about their condition that could help them prepare for changes in job responsibilities and future care decisions, said Wendy Yi Xu, PhD, of The Ohio State University, Columbus, who led the research.

“A lot of them are still in the workforce,” Dr. Xu said. Patients in the study were an average age of 56 years, well before the conventional age of retirement.
 

Location, location, location

To examine rural versus urban differences in the use of diagnostic tests and health care visits for early onset Alzheimer’s disease and related dementias, Dr. Xu and colleagues analyzed commercial claims data from 2012-2018. They identified more than 71,000 patients aged 40-64 years with those conditions and focused on health care use by 7,311 patients in urban areas and 1,119 in rural areas within 90 days of a new dementia diagnosis.

The proportion who received neuropsychological testing was 19% among urban patients and 16% among rural patients. Psychological assessments, which are less specialized and detailed than neuropsychological testing, and brain imaging occurred at similar rates in both groups. Similar proportions of rural and urban patients visited neurologists (17.7% and 17.96%, respectively) and psychiatrists (6.02% and 6.47%).

But more urban patients than rural patients visited a psychologist, at 19% versus 15%, according to the researchers.

Approximately 18% of patients in rural areas saw a primary care provider without visiting other specialists, compared with 13% in urban areas.

The researchers found that rural patients were significantly less likely to undergo neuropsychological testing (odds ratio, 0.83; 95% confidence interval, 0.70-0.98) or see a psychologist (OR, 0.72; 95% CI, 0.60-0.85).

Similarly, rural patients had significantly higher odds of having only primary care providers involved in the diagnosis of dementia and symptom management (OR, 1.40; 95% CI, 1.19-1.66).
 

Addressing workforce deficiencies

More primary care training in dementia care and collaboration with specialist colleagues could help address differences in care, Dr. Xu’s group writes. Such efforts are already underway.

In 2018, the Alzheimer’s Association launched telementoring programs focused on dementia care using the Project ECHO (Extension for Community Healthcare Outcomes) model. Researchers originally developed Project ECHO at the University of New Mexico in 2003 to teach primary care clinicians in remote settings how to treat patients infected with the hepatitis C virus.

With the Alzheimer’s and Dementia Care ECHO Program for Clinicians, primary care clinicians can participate in interactive case-based video conferencing sessions to better understand dementia and how to provide high-quality care in community settings, according to the association.

The program covers guidelines for diagnosis, disclosure, and follow-up; the initiation of care planning; managing disease-related challenges; and resources for patients and caregivers.

Since 2018, nearly 100 primary care practices in the United States have completed training in dementia care using Project ECHO, said Morgan Daven, vice president of health systems for the Alzheimer’s Association. Many cases featured in the program are challenging, he added.

“With primary care being on the front lines, it is really important that primary care physicians are equipped to do what they can to detect or diagnose and know when to refer,” Mr. Daven said.

The association has compiled other resources for clinicians as well.

A 2020 report from the association examined the role that primary care physicians play in dementia care. One survey found that 82% of primary care physicians consider themselves on the front lines of providing care for patients with dementia.

Meanwhile, about half say medical professionals are not prepared to meet rising demands associated with Alzheimer’s disease and dementia care.

Mr. Daven said the geographic disparities Dr. Xu and colleagues found are unsurprising. More than half of primary care physicians who care for people with Alzheimer’s disease say dementia specialists in their communities cannot meet demand. The problem is more urgent in rural areas. Roughly half of nonmetropolitan counties in the United States lack a practicing psychologist, according to a 2018 study published in the American Journal of Preventive Medicine.

“We really need to approach this on both sides – build the capacity in primary care, but we also need to address the dementia care specialty shortages,” Mr. Daven said.

The lack of obvious differences in access to neurologists in the new study “was surprising, given the more than fourfold difference between urban and rural areas in the supply of neurologists,” the researchers note. Health plans may maintain more access to neurologists than psychologists because of relatively higher reimbursement for neurologists, they observed.

One of the study coauthors disclosed ties to Aveanna Healthcare, a company that delivers home health and hospice care.

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

In the same year that Howard Tucker, MD, began practicing neurology, the average loaf of bread cost 13 cents, the microwave oven became commercially available, and Jackie Robinson took the field for the Brooklyn Dodgers as the first Black person to play Major League Baseball.

Since 1947, Dr. Tucker has witnessed major changes in health care, from President Harry S. Truman proposing a national health care plan to Congress to the current day, when patients carry their digital records around with them.

Dr. Tucker has been a resident of Cleveland Heights, Ohio, since 1922, the year he was born. He is now in his 75th year of practicing neurology and is currently teaching residents and practicing medicine at St. Vincent Charity Medical Center in Cleveland.

After graduating high school in 1940, Dr. Tucker attended Ohio State University, Columbus, where he received his undergraduate and medical degrees. During the Korean War, he served as chief neurologist for the Atlantic fleet at a U.S. Naval Hospital in Philadelphia. Following the war, he completed his residency at the Cleveland Clinic and trained at the Neurological Institute of New York.

Dr. Tucker chose to return to Cleveland, where he practiced at the University Hospitals Cleveland Medical Center and Hillcrest Hospital for several decades.

Not content with just a medical degree, at the age of 67, Dr. Tucker attended Cleveland State University Cleveland Marshall College of Law. In 1989, he received his Juris Doctor degree and passed the Ohio bar examination.

And as if that weren’t enough career accomplishments, Guinness World Records dubbed him the world’s oldest practicing doctor at 98 years and 231 days. Dr. Tucker continues to practice into his 100th year. He celebrated his birthday in July.

Owing to the compelling and inspiring nature of his upbringing, Dr. Tucker has become the subject of a feature documentary film entitled “What’s Next?” The film is currently in production. It is being produced by his grandson, Austin Tucker, and is directed by Taylor Taglianetti.

This news organization recently spoke with Dr. Tucker about his life’s work in medicine.

Question: Why did you choose neurology?

Dr. Tucker: Well, I think I was just fascinated with medicine from about the seventh or eighth grade. I chose my specialty because it was a very cerebral one in those days. It was an intellectual pursuit. It was before the CAT scan, and you had to work hard to make a diagnosis. You even had to look at the spinal fluid. You had to look at EEGs, and it was a very detailed history taking.

Question: How has neurology changed since you started practicing?

Dr. Tucker: The MRI came in, so we don’t have to use spinal taps anymore. Lumbar puncture fluid and EEG aren’t needed as often either. Now we use EEG for convulsive disorders, but rarely when we suspect tumors like we used to. Also, when I was in med school, they said to use Dilaudid; don’t use morphine. And now, you can’t even find Dilaudin in emergency rooms anymore.

Question: How has medicine overall changed since you started practicing?

Dr. Tucker: Computers have made everything a different specialty.

In the old days, we would see a patient, call the referring doctor, and discuss [the case] with them in a very pleasant way. Now, when you call a doctor, he’ll say to you, “Let me read your note,” and that’s the end of it. He doesn’t want to talk to you. Medicine has changed dramatically.

It used to be a very warm relationship between you and your patients. You looked at your patient, you studied their expressions, and now you look at the screen and very rarely look at the patient.

Question: Why do you still enjoy practicing medicine?

Dr. Tucker: The challenge, the excitement of patients, and now I’m doing a lot of teaching, and I do love that part, too.

I teach neurology to residents and medical students that rotate through. When I retired from the Cleveland Clinic, 2 months of retirement was too much for me, so I went back to St. Vincent. It’s a smaller hospital but still has good residents and good teaching.

Question: What lessons do you teach to your residents?

Dr. Tucker: I ask my residents and physicians to think through a problem before they look at the CAT scan and imaging studies. Think through it, then you’ll know what questions you want to ask specifically before you even examine the patient, know exactly what you are going to find.

The complete neurological examination, aside from taking the history and checking mental status, is 5 minutes. You have them walk, check for excessive finger tapping, have them touch their nose, check their reflexes, check their strength – it’s over. That doesn’t take much time if you know what you’re looking for.

Residents say to me all the time, “55-year-old man, CAT scan shows ...” I have to say to them: “Slow down. Let’s talk about this first.”

Question: What advice do you have for physicians and medical students?

Dr. Tucker: Take a very careful history. Know the course of the illness. Make sure you have a diagnosis in your head and, specifically for medical residents, ask questions. You have to be smarter than the patients are, you have to know what to ask.

If someone hits their head on their steering wheel, they don’t know that they’ve lost their sense of smell. You have to ask that specifically, hence, why you have to be smarter than they are. Take a careful history before you do imaging studies.

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

In the same year that Howard Tucker, MD, began practicing neurology, the average loaf of bread cost 13 cents, the microwave oven became commercially available, and Jackie Robinson took the field for the Brooklyn Dodgers as the first Black person to play Major League Baseball.

Since 1947, Dr. Tucker has witnessed major changes in health care, from President Harry S. Truman proposing a national health care plan to Congress to the current day, when patients carry their digital records around with them.

Dr. Tucker has been a resident of Cleveland Heights, Ohio, since 1922, the year he was born. He is now in his 75th year of practicing neurology and is currently teaching residents and practicing medicine at St. Vincent Charity Medical Center in Cleveland.

After graduating high school in 1940, Dr. Tucker attended Ohio State University, Columbus, where he received his undergraduate and medical degrees. During the Korean War, he served as chief neurologist for the Atlantic fleet at a U.S. Naval Hospital in Philadelphia. Following the war, he completed his residency at the Cleveland Clinic and trained at the Neurological Institute of New York.

Dr. Tucker chose to return to Cleveland, where he practiced at the University Hospitals Cleveland Medical Center and Hillcrest Hospital for several decades.

Not content with just a medical degree, at the age of 67, Dr. Tucker attended Cleveland State University Cleveland Marshall College of Law. In 1989, he received his Juris Doctor degree and passed the Ohio bar examination.

And as if that weren’t enough career accomplishments, Guinness World Records dubbed him the world’s oldest practicing doctor at 98 years and 231 days. Dr. Tucker continues to practice into his 100th year. He celebrated his birthday in July.

Owing to the compelling and inspiring nature of his upbringing, Dr. Tucker has become the subject of a feature documentary film entitled “What’s Next?” The film is currently in production. It is being produced by his grandson, Austin Tucker, and is directed by Taylor Taglianetti.

This news organization recently spoke with Dr. Tucker about his life’s work in medicine.

Question: Why did you choose neurology?

Dr. Tucker: Well, I think I was just fascinated with medicine from about the seventh or eighth grade. I chose my specialty because it was a very cerebral one in those days. It was an intellectual pursuit. It was before the CAT scan, and you had to work hard to make a diagnosis. You even had to look at the spinal fluid. You had to look at EEGs, and it was a very detailed history taking.

Question: How has neurology changed since you started practicing?

Dr. Tucker: The MRI came in, so we don’t have to use spinal taps anymore. Lumbar puncture fluid and EEG aren’t needed as often either. Now we use EEG for convulsive disorders, but rarely when we suspect tumors like we used to. Also, when I was in med school, they said to use Dilaudid; don’t use morphine. And now, you can’t even find Dilaudin in emergency rooms anymore.

Question: How has medicine overall changed since you started practicing?

Dr. Tucker: Computers have made everything a different specialty.

In the old days, we would see a patient, call the referring doctor, and discuss [the case] with them in a very pleasant way. Now, when you call a doctor, he’ll say to you, “Let me read your note,” and that’s the end of it. He doesn’t want to talk to you. Medicine has changed dramatically.

It used to be a very warm relationship between you and your patients. You looked at your patient, you studied their expressions, and now you look at the screen and very rarely look at the patient.

Question: Why do you still enjoy practicing medicine?

Dr. Tucker: The challenge, the excitement of patients, and now I’m doing a lot of teaching, and I do love that part, too.

I teach neurology to residents and medical students that rotate through. When I retired from the Cleveland Clinic, 2 months of retirement was too much for me, so I went back to St. Vincent. It’s a smaller hospital but still has good residents and good teaching.

Question: What lessons do you teach to your residents?

Dr. Tucker: I ask my residents and physicians to think through a problem before they look at the CAT scan and imaging studies. Think through it, then you’ll know what questions you want to ask specifically before you even examine the patient, know exactly what you are going to find.

The complete neurological examination, aside from taking the history and checking mental status, is 5 minutes. You have them walk, check for excessive finger tapping, have them touch their nose, check their reflexes, check their strength – it’s over. That doesn’t take much time if you know what you’re looking for.

Residents say to me all the time, “55-year-old man, CAT scan shows ...” I have to say to them: “Slow down. Let’s talk about this first.”

Question: What advice do you have for physicians and medical students?

Dr. Tucker: Take a very careful history. Know the course of the illness. Make sure you have a diagnosis in your head and, specifically for medical residents, ask questions. You have to be smarter than the patients are, you have to know what to ask.

If someone hits their head on their steering wheel, they don’t know that they’ve lost their sense of smell. You have to ask that specifically, hence, why you have to be smarter than they are. Take a careful history before you do imaging studies.

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

In the same year that Howard Tucker, MD, began practicing neurology, the average loaf of bread cost 13 cents, the microwave oven became commercially available, and Jackie Robinson took the field for the Brooklyn Dodgers as the first Black person to play Major League Baseball.

Since 1947, Dr. Tucker has witnessed major changes in health care, from President Harry S. Truman proposing a national health care plan to Congress to the current day, when patients carry their digital records around with them.

Dr. Tucker has been a resident of Cleveland Heights, Ohio, since 1922, the year he was born. He is now in his 75th year of practicing neurology and is currently teaching residents and practicing medicine at St. Vincent Charity Medical Center in Cleveland.

After graduating high school in 1940, Dr. Tucker attended Ohio State University, Columbus, where he received his undergraduate and medical degrees. During the Korean War, he served as chief neurologist for the Atlantic fleet at a U.S. Naval Hospital in Philadelphia. Following the war, he completed his residency at the Cleveland Clinic and trained at the Neurological Institute of New York.

Dr. Tucker chose to return to Cleveland, where he practiced at the University Hospitals Cleveland Medical Center and Hillcrest Hospital for several decades.

Not content with just a medical degree, at the age of 67, Dr. Tucker attended Cleveland State University Cleveland Marshall College of Law. In 1989, he received his Juris Doctor degree and passed the Ohio bar examination.

And as if that weren’t enough career accomplishments, Guinness World Records dubbed him the world’s oldest practicing doctor at 98 years and 231 days. Dr. Tucker continues to practice into his 100th year. He celebrated his birthday in July.

Owing to the compelling and inspiring nature of his upbringing, Dr. Tucker has become the subject of a feature documentary film entitled “What’s Next?” The film is currently in production. It is being produced by his grandson, Austin Tucker, and is directed by Taylor Taglianetti.

This news organization recently spoke with Dr. Tucker about his life’s work in medicine.

Question: Why did you choose neurology?

Dr. Tucker: Well, I think I was just fascinated with medicine from about the seventh or eighth grade. I chose my specialty because it was a very cerebral one in those days. It was an intellectual pursuit. It was before the CAT scan, and you had to work hard to make a diagnosis. You even had to look at the spinal fluid. You had to look at EEGs, and it was a very detailed history taking.

Question: How has neurology changed since you started practicing?

Dr. Tucker: The MRI came in, so we don’t have to use spinal taps anymore. Lumbar puncture fluid and EEG aren’t needed as often either. Now we use EEG for convulsive disorders, but rarely when we suspect tumors like we used to. Also, when I was in med school, they said to use Dilaudid; don’t use morphine. And now, you can’t even find Dilaudin in emergency rooms anymore.

Question: How has medicine overall changed since you started practicing?

Dr. Tucker: Computers have made everything a different specialty.

In the old days, we would see a patient, call the referring doctor, and discuss [the case] with them in a very pleasant way. Now, when you call a doctor, he’ll say to you, “Let me read your note,” and that’s the end of it. He doesn’t want to talk to you. Medicine has changed dramatically.

It used to be a very warm relationship between you and your patients. You looked at your patient, you studied their expressions, and now you look at the screen and very rarely look at the patient.

Question: Why do you still enjoy practicing medicine?

Dr. Tucker: The challenge, the excitement of patients, and now I’m doing a lot of teaching, and I do love that part, too.

I teach neurology to residents and medical students that rotate through. When I retired from the Cleveland Clinic, 2 months of retirement was too much for me, so I went back to St. Vincent. It’s a smaller hospital but still has good residents and good teaching.

Question: What lessons do you teach to your residents?

Dr. Tucker: I ask my residents and physicians to think through a problem before they look at the CAT scan and imaging studies. Think through it, then you’ll know what questions you want to ask specifically before you even examine the patient, know exactly what you are going to find.

The complete neurological examination, aside from taking the history and checking mental status, is 5 minutes. You have them walk, check for excessive finger tapping, have them touch their nose, check their reflexes, check their strength – it’s over. That doesn’t take much time if you know what you’re looking for.

Residents say to me all the time, “55-year-old man, CAT scan shows ...” I have to say to them: “Slow down. Let’s talk about this first.”

Question: What advice do you have for physicians and medical students?

Dr. Tucker: Take a very careful history. Know the course of the illness. Make sure you have a diagnosis in your head and, specifically for medical residents, ask questions. You have to be smarter than the patients are, you have to know what to ask.

If someone hits their head on their steering wheel, they don’t know that they’ve lost their sense of smell. You have to ask that specifically, hence, why you have to be smarter than they are. Take a careful history before you do imaging studies.

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

The James Webb Space Telescope (JWST) is an engineering marvel. Costing over $10 billion, it should be. The project cost overrun was 900%. The launch was delayed by more than a decade. The Human Genome Project from 1990 to 2003 was completed slightly ahead of schedule and for less than the $4-$5 billion original estimates. This HGP success story is partly because of private entrepreneurial involvement. The Superconducting Super Collider in Texas spent $2 billion but never got off the ground. Successfully shepherding huge public projects like these involves the art of politics and management as well as science.

Whatever the earlier missteps, the JWST project is now performing above expectations. It has launched, taken up residence a million miles from Earth, deployed its mirrors (a process that had more than 300 possible single points of failure, any one of which would reduce the thing to scrap metal), and been calibrated. The JWST has even been dented by a micrometeoroid – sort of like a parking lot ding on the door of your brand new car. The first images are visually amazing and producing new scientific insights. This is a pinnacle of scientific achievement.

What characteristics enable such an achievement? How do we foster those same characteristics in the practice of medicine and medical research? Will the success of the JWST increase and restore the public’s trust in science and scientists?

After all the bickering over vaccines and masks for the past 2+ years, medical science could use a boost. The gravitas of scientists, and indeed all experts, has diminished over the 5 decades since humans walked on the moon. It has been harmed by mercenary scientists who sought to sow doubt about whether smoking caused cancer and whether fossil fuels created climate change. No proof was needed, just doubt.

The trust in science has also been harmed by the vast amount of published medical research that is wrong. An effort was made 20 years ago to rid research of the bias of taking money from drug companies. To my observation, that change produced only a small benefit that has been overwhelmed by the unintended harms. The large, well-funded academic labs of full-time researchers have been replaced with unfunded, undertrained, and inadequately supported part-time junior faculty trying to publish enough articles to be promoted. In my opinion, this change is worse than funding from Big Pharma. (Disclosure – I worked in industry prior to graduate school.)

The pressure to publish reduces skepticism, so more incorrect data are published. The small size of these amateur studies produces unconvincing conclusions that feed an industry of meta-analysis that tries to overcome the deficiencies of the individual studies. This fragmented, biased approach is not how you build, launch, deploy, and operate the JWST, which requires very high reliability.

This approach is not working well for pediatrics either. I look at the history of the recommended workup of the febrile young infant from the 1980s until today. I see constant changes to the guidelines but no real progress toward a validated, evidence-based approach. A similar history is behind treatment of neonatal hyperbilirubinemia. In the 1994 publication, there was a movement toward being less aggressive. The 2004 and 2009 editions increased the frequency of screening and phototherapy. Now, the 2022 guidelines have moved in the direction we were headed in the 1990s. The workup of infants and children with possible urinary tract infections has undergone a similar trajectory. So has the screening for neonatal herpes infections. The practice changes are more like Brownian motion than real progress. This inconsistency has led me to be skeptical of the process the American Academy of Pediatrics uses to create guidelines.

Part of solving complex problems is allowing all stakeholders’ voices to be heard. On Jan. 28, 1986, seconds after liftoff, the space shuttle Challenger exploded. In the aftermath, it was determined that some engineers had expressed concern about the very cold weather that morning. The rubber in the O-ring would not be as flexible as designed. Their objection was not listened to. The O-ring failed, the fuel tank exploded, and the ship and crew were lost. It is a lesson many engineers of my generation took to heart. Do not suppress voices.

For example, 1 year ago (September 2021), the Royal Australian and New Zealand College of Psychiatrists published a position statement, “Recognising and addressing the mental health needs of people experiencing gender dysphoria/gender incongruence.” The statement expressed concern about the marked increase in incidence of rapid-onset gender dysphoria and therefore urged more thorough assessment by psychiatry before embarking on puberty-blocking therapies. The RANZCP position is at variance with recent trends in the United States. The topic was censored at the 2021 AAP national conference. Lately, I have heard the words disinformation and homophobic used to describe my RANZCP colleagues. I have been comparing AAP, Britain’s National Institute for Health and Care Excellence, and Royal Children’s Hospital Melbourne guidelines for 20 years. The variation is enlightening. I do not know the correct answer to treating gender dysphoria, but I know suppressing viewpoints and debate leads to exploding spaceships.
 

Dr. Powell is a retired pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

The James Webb Space Telescope (JWST) is an engineering marvel. Costing over $10 billion, it should be. The project cost overrun was 900%. The launch was delayed by more than a decade. The Human Genome Project from 1990 to 2003 was completed slightly ahead of schedule and for less than the $4-$5 billion original estimates. This HGP success story is partly because of private entrepreneurial involvement. The Superconducting Super Collider in Texas spent $2 billion but never got off the ground. Successfully shepherding huge public projects like these involves the art of politics and management as well as science.

Whatever the earlier missteps, the JWST project is now performing above expectations. It has launched, taken up residence a million miles from Earth, deployed its mirrors (a process that had more than 300 possible single points of failure, any one of which would reduce the thing to scrap metal), and been calibrated. The JWST has even been dented by a micrometeoroid – sort of like a parking lot ding on the door of your brand new car. The first images are visually amazing and producing new scientific insights. This is a pinnacle of scientific achievement.

What characteristics enable such an achievement? How do we foster those same characteristics in the practice of medicine and medical research? Will the success of the JWST increase and restore the public’s trust in science and scientists?

After all the bickering over vaccines and masks for the past 2+ years, medical science could use a boost. The gravitas of scientists, and indeed all experts, has diminished over the 5 decades since humans walked on the moon. It has been harmed by mercenary scientists who sought to sow doubt about whether smoking caused cancer and whether fossil fuels created climate change. No proof was needed, just doubt.

The trust in science has also been harmed by the vast amount of published medical research that is wrong. An effort was made 20 years ago to rid research of the bias of taking money from drug companies. To my observation, that change produced only a small benefit that has been overwhelmed by the unintended harms. The large, well-funded academic labs of full-time researchers have been replaced with unfunded, undertrained, and inadequately supported part-time junior faculty trying to publish enough articles to be promoted. In my opinion, this change is worse than funding from Big Pharma. (Disclosure – I worked in industry prior to graduate school.)

The pressure to publish reduces skepticism, so more incorrect data are published. The small size of these amateur studies produces unconvincing conclusions that feed an industry of meta-analysis that tries to overcome the deficiencies of the individual studies. This fragmented, biased approach is not how you build, launch, deploy, and operate the JWST, which requires very high reliability.

This approach is not working well for pediatrics either. I look at the history of the recommended workup of the febrile young infant from the 1980s until today. I see constant changes to the guidelines but no real progress toward a validated, evidence-based approach. A similar history is behind treatment of neonatal hyperbilirubinemia. In the 1994 publication, there was a movement toward being less aggressive. The 2004 and 2009 editions increased the frequency of screening and phototherapy. Now, the 2022 guidelines have moved in the direction we were headed in the 1990s. The workup of infants and children with possible urinary tract infections has undergone a similar trajectory. So has the screening for neonatal herpes infections. The practice changes are more like Brownian motion than real progress. This inconsistency has led me to be skeptical of the process the American Academy of Pediatrics uses to create guidelines.

Part of solving complex problems is allowing all stakeholders’ voices to be heard. On Jan. 28, 1986, seconds after liftoff, the space shuttle Challenger exploded. In the aftermath, it was determined that some engineers had expressed concern about the very cold weather that morning. The rubber in the O-ring would not be as flexible as designed. Their objection was not listened to. The O-ring failed, the fuel tank exploded, and the ship and crew were lost. It is a lesson many engineers of my generation took to heart. Do not suppress voices.

For example, 1 year ago (September 2021), the Royal Australian and New Zealand College of Psychiatrists published a position statement, “Recognising and addressing the mental health needs of people experiencing gender dysphoria/gender incongruence.” The statement expressed concern about the marked increase in incidence of rapid-onset gender dysphoria and therefore urged more thorough assessment by psychiatry before embarking on puberty-blocking therapies. The RANZCP position is at variance with recent trends in the United States. The topic was censored at the 2021 AAP national conference. Lately, I have heard the words disinformation and homophobic used to describe my RANZCP colleagues. I have been comparing AAP, Britain’s National Institute for Health and Care Excellence, and Royal Children’s Hospital Melbourne guidelines for 20 years. The variation is enlightening. I do not know the correct answer to treating gender dysphoria, but I know suppressing viewpoints and debate leads to exploding spaceships.
 

Dr. Powell is a retired pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

The James Webb Space Telescope (JWST) is an engineering marvel. Costing over $10 billion, it should be. The project cost overrun was 900%. The launch was delayed by more than a decade. The Human Genome Project from 1990 to 2003 was completed slightly ahead of schedule and for less than the $4-$5 billion original estimates. This HGP success story is partly because of private entrepreneurial involvement. The Superconducting Super Collider in Texas spent $2 billion but never got off the ground. Successfully shepherding huge public projects like these involves the art of politics and management as well as science.

Whatever the earlier missteps, the JWST project is now performing above expectations. It has launched, taken up residence a million miles from Earth, deployed its mirrors (a process that had more than 300 possible single points of failure, any one of which would reduce the thing to scrap metal), and been calibrated. The JWST has even been dented by a micrometeoroid – sort of like a parking lot ding on the door of your brand new car. The first images are visually amazing and producing new scientific insights. This is a pinnacle of scientific achievement.

What characteristics enable such an achievement? How do we foster those same characteristics in the practice of medicine and medical research? Will the success of the JWST increase and restore the public’s trust in science and scientists?

After all the bickering over vaccines and masks for the past 2+ years, medical science could use a boost. The gravitas of scientists, and indeed all experts, has diminished over the 5 decades since humans walked on the moon. It has been harmed by mercenary scientists who sought to sow doubt about whether smoking caused cancer and whether fossil fuels created climate change. No proof was needed, just doubt.

The trust in science has also been harmed by the vast amount of published medical research that is wrong. An effort was made 20 years ago to rid research of the bias of taking money from drug companies. To my observation, that change produced only a small benefit that has been overwhelmed by the unintended harms. The large, well-funded academic labs of full-time researchers have been replaced with unfunded, undertrained, and inadequately supported part-time junior faculty trying to publish enough articles to be promoted. In my opinion, this change is worse than funding from Big Pharma. (Disclosure – I worked in industry prior to graduate school.)

The pressure to publish reduces skepticism, so more incorrect data are published. The small size of these amateur studies produces unconvincing conclusions that feed an industry of meta-analysis that tries to overcome the deficiencies of the individual studies. This fragmented, biased approach is not how you build, launch, deploy, and operate the JWST, which requires very high reliability.

This approach is not working well for pediatrics either. I look at the history of the recommended workup of the febrile young infant from the 1980s until today. I see constant changes to the guidelines but no real progress toward a validated, evidence-based approach. A similar history is behind treatment of neonatal hyperbilirubinemia. In the 1994 publication, there was a movement toward being less aggressive. The 2004 and 2009 editions increased the frequency of screening and phototherapy. Now, the 2022 guidelines have moved in the direction we were headed in the 1990s. The workup of infants and children with possible urinary tract infections has undergone a similar trajectory. So has the screening for neonatal herpes infections. The practice changes are more like Brownian motion than real progress. This inconsistency has led me to be skeptical of the process the American Academy of Pediatrics uses to create guidelines.

Part of solving complex problems is allowing all stakeholders’ voices to be heard. On Jan. 28, 1986, seconds after liftoff, the space shuttle Challenger exploded. In the aftermath, it was determined that some engineers had expressed concern about the very cold weather that morning. The rubber in the O-ring would not be as flexible as designed. Their objection was not listened to. The O-ring failed, the fuel tank exploded, and the ship and crew were lost. It is a lesson many engineers of my generation took to heart. Do not suppress voices.

For example, 1 year ago (September 2021), the Royal Australian and New Zealand College of Psychiatrists published a position statement, “Recognising and addressing the mental health needs of people experiencing gender dysphoria/gender incongruence.” The statement expressed concern about the marked increase in incidence of rapid-onset gender dysphoria and therefore urged more thorough assessment by psychiatry before embarking on puberty-blocking therapies. The RANZCP position is at variance with recent trends in the United States. The topic was censored at the 2021 AAP national conference. Lately, I have heard the words disinformation and homophobic used to describe my RANZCP colleagues. I have been comparing AAP, Britain’s National Institute for Health and Care Excellence, and Royal Children’s Hospital Melbourne guidelines for 20 years. The variation is enlightening. I do not know the correct answer to treating gender dysphoria, but I know suppressing viewpoints and debate leads to exploding spaceships.
 

Dr. Powell is a retired pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.

It used to be the treatment of “last resort” but for competitive athletes, intravenous nutrition is threatening to become the norm, despite no scientific evidence that it works, or is safe, warned experts.

In their editorial, published online in the British Journal of Sports Medicine, experts urged the “food first” and “no needle” messages – that are taught in sports nutrition courses around the world – need to be amplified among all athletes and their support teams to “stop this trend in its tracks”.

The international group of authors, including experts from St Mary’s University, London; University College London; and University of Bath (England), who regularly interact with professional team players in European and American leagues and their support teams, said they have become increasingly aware of the practice.

Although it’s not known exactly how common the practice is, they pointed out that, anecdotally, some players are hooked up to intravenous nutrition drips as often as every week as part of a pre- or postgame routine.
 

‘Drip-bars’ easily accessible but devoid of regulation

Intravenous nutrition has traditionally been reserved for serious clinical conditions – such as anaemia – symptoms caused by nutrient deficiencies, or to correct severe dehydration caused by marathon running in, for example, a desert.

A ban on needle use by athletes at the Olympic Games has been in place for all recent Games except for appropriate medical use, and where a therapeutic use exemption is obtained, explained the authors.

However, “so-called ‘drip bars’ and concierge IV nutrition services are now easily accessible,” they said. These claim to boost health and performance, restore hydration, and speed up recovery, by offering a menu of B vitamins, amino acids, glutathione, vitamin C, and electrolytes, and potentially boosting levels beyond any therapeutic range.

However, they are “devoid of regulation” and for players or practitioners there is no official guidance on their use.
 

Physical and reputational risks

Bypassing the gut-liver axis risks nutrient toxicity warned the authors, and “appears foolhardy” unless there is a “significant clinical rationale.” They highlighted that they had noted vitamin B6 and vitamin B12 levels often “beyond the measurement range of the laboratory” in a subgroup of professional players. They pointed out how long-term effects of too much vitamin B6 include peripheral neuropathy, and that athletes regularly receiving parenteral iron “risk liver disease.”

“Given that the long-term effects of supratherapeutic doses of B vitamins and other nutrients are unknown in athletes, it does not appear to be worth the risk, especially given the lack of evidence-based benefits,” they said. They added that there is also the risk related to venous access, including “infection and thromboembolic complications.”

Additionally, a shift away from “what works” according to scientific standards to that which is “unproven” puts the reputation of sport at risk, and also puts athletes at risk of antidoping violation, they cautioned.

Figures on the prevalence of intravenous nutrition need to be gathered in tandem with governing bodies and players’ associations in the professional leagues providing guidance on the potential risks of intravenous nutrition use, recommended the authors.

The ‘food first’ and ‘no needle’ messages need to be amplified among all athletes and multidisciplinary support teams, they emphasised, to avoid what was previously a ‘last resort’ treatment becoming “normal without scientific evidence of benefit”.

A version of this article first appeared on Medscape UK.

It used to be the treatment of “last resort” but for competitive athletes, intravenous nutrition is threatening to become the norm, despite no scientific evidence that it works, or is safe, warned experts.

In their editorial, published online in the British Journal of Sports Medicine, experts urged the “food first” and “no needle” messages – that are taught in sports nutrition courses around the world – need to be amplified among all athletes and their support teams to “stop this trend in its tracks”.

The international group of authors, including experts from St Mary’s University, London; University College London; and University of Bath (England), who regularly interact with professional team players in European and American leagues and their support teams, said they have become increasingly aware of the practice.

Although it’s not known exactly how common the practice is, they pointed out that, anecdotally, some players are hooked up to intravenous nutrition drips as often as every week as part of a pre- or postgame routine.
 

‘Drip-bars’ easily accessible but devoid of regulation

Intravenous nutrition has traditionally been reserved for serious clinical conditions – such as anaemia – symptoms caused by nutrient deficiencies, or to correct severe dehydration caused by marathon running in, for example, a desert.

A ban on needle use by athletes at the Olympic Games has been in place for all recent Games except for appropriate medical use, and where a therapeutic use exemption is obtained, explained the authors.

However, “so-called ‘drip bars’ and concierge IV nutrition services are now easily accessible,” they said. These claim to boost health and performance, restore hydration, and speed up recovery, by offering a menu of B vitamins, amino acids, glutathione, vitamin C, and electrolytes, and potentially boosting levels beyond any therapeutic range.

However, they are “devoid of regulation” and for players or practitioners there is no official guidance on their use.
 

Physical and reputational risks

Bypassing the gut-liver axis risks nutrient toxicity warned the authors, and “appears foolhardy” unless there is a “significant clinical rationale.” They highlighted that they had noted vitamin B6 and vitamin B12 levels often “beyond the measurement range of the laboratory” in a subgroup of professional players. They pointed out how long-term effects of too much vitamin B6 include peripheral neuropathy, and that athletes regularly receiving parenteral iron “risk liver disease.”

“Given that the long-term effects of supratherapeutic doses of B vitamins and other nutrients are unknown in athletes, it does not appear to be worth the risk, especially given the lack of evidence-based benefits,” they said. They added that there is also the risk related to venous access, including “infection and thromboembolic complications.”

Additionally, a shift away from “what works” according to scientific standards to that which is “unproven” puts the reputation of sport at risk, and also puts athletes at risk of antidoping violation, they cautioned.

Figures on the prevalence of intravenous nutrition need to be gathered in tandem with governing bodies and players’ associations in the professional leagues providing guidance on the potential risks of intravenous nutrition use, recommended the authors.

The ‘food first’ and ‘no needle’ messages need to be amplified among all athletes and multidisciplinary support teams, they emphasised, to avoid what was previously a ‘last resort’ treatment becoming “normal without scientific evidence of benefit”.

A version of this article first appeared on Medscape UK.

It used to be the treatment of “last resort” but for competitive athletes, intravenous nutrition is threatening to become the norm, despite no scientific evidence that it works, or is safe, warned experts.

In their editorial, published online in the British Journal of Sports Medicine, experts urged the “food first” and “no needle” messages – that are taught in sports nutrition courses around the world – need to be amplified among all athletes and their support teams to “stop this trend in its tracks”.

The international group of authors, including experts from St Mary’s University, London; University College London; and University of Bath (England), who regularly interact with professional team players in European and American leagues and their support teams, said they have become increasingly aware of the practice.

Although it’s not known exactly how common the practice is, they pointed out that, anecdotally, some players are hooked up to intravenous nutrition drips as often as every week as part of a pre- or postgame routine.
 

‘Drip-bars’ easily accessible but devoid of regulation

Intravenous nutrition has traditionally been reserved for serious clinical conditions – such as anaemia – symptoms caused by nutrient deficiencies, or to correct severe dehydration caused by marathon running in, for example, a desert.

A ban on needle use by athletes at the Olympic Games has been in place for all recent Games except for appropriate medical use, and where a therapeutic use exemption is obtained, explained the authors.

However, “so-called ‘drip bars’ and concierge IV nutrition services are now easily accessible,” they said. These claim to boost health and performance, restore hydration, and speed up recovery, by offering a menu of B vitamins, amino acids, glutathione, vitamin C, and electrolytes, and potentially boosting levels beyond any therapeutic range.

However, they are “devoid of regulation” and for players or practitioners there is no official guidance on their use.
 

Physical and reputational risks

Bypassing the gut-liver axis risks nutrient toxicity warned the authors, and “appears foolhardy” unless there is a “significant clinical rationale.” They highlighted that they had noted vitamin B6 and vitamin B12 levels often “beyond the measurement range of the laboratory” in a subgroup of professional players. They pointed out how long-term effects of too much vitamin B6 include peripheral neuropathy, and that athletes regularly receiving parenteral iron “risk liver disease.”

“Given that the long-term effects of supratherapeutic doses of B vitamins and other nutrients are unknown in athletes, it does not appear to be worth the risk, especially given the lack of evidence-based benefits,” they said. They added that there is also the risk related to venous access, including “infection and thromboembolic complications.”

Additionally, a shift away from “what works” according to scientific standards to that which is “unproven” puts the reputation of sport at risk, and also puts athletes at risk of antidoping violation, they cautioned.

Figures on the prevalence of intravenous nutrition need to be gathered in tandem with governing bodies and players’ associations in the professional leagues providing guidance on the potential risks of intravenous nutrition use, recommended the authors.

The ‘food first’ and ‘no needle’ messages need to be amplified among all athletes and multidisciplinary support teams, they emphasised, to avoid what was previously a ‘last resort’ treatment becoming “normal without scientific evidence of benefit”.

A version of this article first appeared on Medscape UK.

Five years ago, Kay Dean relied upon Yelp! and Google reviews in her search for a doctor in her area. After finding a physician with fairly high reviews, Ms. Dean was shocked when her personal experience was significantly worse than patients on the review platforms.

Following her experience, Ms. Dean, a former federal government investigator, became skeptical and used her skills to investigate the practice on all review platforms. She uncovered that the practice had a review from an individual who was involved in a review trading group on Facebook, where organizations openly barter their services in exchange for positive reviews fraud.

“I discovered that the online review world was just saturated with fake reviews, much more so than I think most people are aware ... and law enforcement regulators aren’t doing anything to address the problem,” said Ms. Dean. “In this online space, it’s the Wild West; cheating is rewarded.”

Ms. Dean decided to take matters into her own hands. She created a YouTube channel called Fake Review Watch, where she exposes real businesses and their attempts to dupe potential consumers with fake positive reviews.

For example, one video analyzes an orthopedic surgeon in Manhattan with an abundance of five-star reviews. Through her detailed analysis, Ms. Dean created a spreadsheet of the 26 alleged patients of the orthopedic surgeon that had submitted glowing reviews. She looked into other businesses that the individuals had left reviews for and found a significant amount of overlap.

According to the video, 19 of the doctor’s reviewers had left high reviews for the same moving company in Las Vegas, and 18 of them reviewed the same locksmith in Texas. Overall, eight of the patients reviewed the same mover, locksmith, and hotel in New Zealand.
 

A matter of trust

Ms. Dean expressed the gravity of this phenomenon, especially in health care, as patients often head online first when searching for care options. Based on a survey by Software Advice, about 84% of patients use online reviews to assess a physician, and 77% use review sites as the first step in finding a doctor.

Patient trust has continued to diminish in recent years, particularly following the pandemic. In a 2021 global ranking of trust levels towards health care by country, the U.S. health care system ranked 19th, far below those of several developing countries.

Owing to the rise of fake patient reviews and their inscrutable nature, Ms. Dean advises staying away from online review platforms. Instead, she suggests sticking to the old-fashioned method of getting recommendations from friends and relatives, not virtual people.

Ms. Dean explained a few indicators that she looks for when trying to identify a fake review.

“The business has all five-star reviews, negative reviews are followed by five-star reviews, or the business has an abnormal number of positive reviews in a short period of time,” she noted. “Some businesses try to bury legitimate negative reviews by obtaining more recent, fake, positive ones. The recent reviews will contradict the specific criticisms in the negative review.”

She warned that consumers should not give credibility to reviews simply because the reviewer is dubbed “Elite” or a Google Local Guide, because she has seen plenty of these individuals posting fake reviews.

Unfortunately, review platforms haven’t been doing much self-policing. Google and Healthgrades have a series of policies against fake engagement, impersonation, misinformation, and misrepresentation, according to their websites. However, the only consequence of these violations is review removal.

Both Yelp! and Google say they have automated software that distinguishes real versus fake reviews. When Yelp! uncovers users engaging in compensation review activity, it removes their reviews, closes their account, and blocks those users from creating future Yelp! accounts.
 

Physicians’ basis

Moreover, physicians purchasing fake reviews create an unfair environment for those physicians who choose to be ethical and honest with patients.

“I think there’s an erosion of business ethics because cheating is rewarded. You can’t compete in an environment where your competition is allowed to accumulate numerous fake reviews while you’re still trying to fill chairs in your business,” said Ms. Dean. “Your competition is then getting the business because the tech companies are allowing this fraud.”

Family physician and practice owner Mike Woo-Ming, MD, MPH, provides career coaching for physicians, including maintaining a good reputation – in-person and online. He has seen physicians bumping up their own five-star reviews personally as well as posting negative reviews for their competition.

“I’ve seen where they’re going to lose business, as many practices were affected through COVID,” he said. “Business owners can become desperate and may decide to start posting or buying reviews because they know people will choose certain services these days based upon reviews.”

Dr. Woo-Ming expressed his frustration with fellow physicians who give in to purchasing fake reviews, because the patients have no idea whether reviews are genuine or not.

To encourage genuine positive reviews, Dr. Woo-Ming’s practice uses a third-party app system that sends patients a follow-up email or text asking about their experience with a link to review sites.

“Honest reviews are a reflection of what I can do to improve my business. At the end of the day, if you’re truly providing great service and you’re helping people by providing great medical care, those are going to win out,” he said. “I would rather, as a responsible practice owner, improve the experience and outcome for the patient.”

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

Five years ago, Kay Dean relied upon Yelp! and Google reviews in her search for a doctor in her area. After finding a physician with fairly high reviews, Ms. Dean was shocked when her personal experience was significantly worse than patients on the review platforms.

Following her experience, Ms. Dean, a former federal government investigator, became skeptical and used her skills to investigate the practice on all review platforms. She uncovered that the practice had a review from an individual who was involved in a review trading group on Facebook, where organizations openly barter their services in exchange for positive reviews fraud.

“I discovered that the online review world was just saturated with fake reviews, much more so than I think most people are aware ... and law enforcement regulators aren’t doing anything to address the problem,” said Ms. Dean. “In this online space, it’s the Wild West; cheating is rewarded.”

Ms. Dean decided to take matters into her own hands. She created a YouTube channel called Fake Review Watch, where she exposes real businesses and their attempts to dupe potential consumers with fake positive reviews.

For example, one video analyzes an orthopedic surgeon in Manhattan with an abundance of five-star reviews. Through her detailed analysis, Ms. Dean created a spreadsheet of the 26 alleged patients of the orthopedic surgeon that had submitted glowing reviews. She looked into other businesses that the individuals had left reviews for and found a significant amount of overlap.

According to the video, 19 of the doctor’s reviewers had left high reviews for the same moving company in Las Vegas, and 18 of them reviewed the same locksmith in Texas. Overall, eight of the patients reviewed the same mover, locksmith, and hotel in New Zealand.
 

A matter of trust

Ms. Dean expressed the gravity of this phenomenon, especially in health care, as patients often head online first when searching for care options. Based on a survey by Software Advice, about 84% of patients use online reviews to assess a physician, and 77% use review sites as the first step in finding a doctor.

Patient trust has continued to diminish in recent years, particularly following the pandemic. In a 2021 global ranking of trust levels towards health care by country, the U.S. health care system ranked 19th, far below those of several developing countries.

Owing to the rise of fake patient reviews and their inscrutable nature, Ms. Dean advises staying away from online review platforms. Instead, she suggests sticking to the old-fashioned method of getting recommendations from friends and relatives, not virtual people.

Ms. Dean explained a few indicators that she looks for when trying to identify a fake review.

“The business has all five-star reviews, negative reviews are followed by five-star reviews, or the business has an abnormal number of positive reviews in a short period of time,” she noted. “Some businesses try to bury legitimate negative reviews by obtaining more recent, fake, positive ones. The recent reviews will contradict the specific criticisms in the negative review.”

She warned that consumers should not give credibility to reviews simply because the reviewer is dubbed “Elite” or a Google Local Guide, because she has seen plenty of these individuals posting fake reviews.

Unfortunately, review platforms haven’t been doing much self-policing. Google and Healthgrades have a series of policies against fake engagement, impersonation, misinformation, and misrepresentation, according to their websites. However, the only consequence of these violations is review removal.

Both Yelp! and Google say they have automated software that distinguishes real versus fake reviews. When Yelp! uncovers users engaging in compensation review activity, it removes their reviews, closes their account, and blocks those users from creating future Yelp! accounts.
 

Physicians’ basis

Moreover, physicians purchasing fake reviews create an unfair environment for those physicians who choose to be ethical and honest with patients.

“I think there’s an erosion of business ethics because cheating is rewarded. You can’t compete in an environment where your competition is allowed to accumulate numerous fake reviews while you’re still trying to fill chairs in your business,” said Ms. Dean. “Your competition is then getting the business because the tech companies are allowing this fraud.”

Family physician and practice owner Mike Woo-Ming, MD, MPH, provides career coaching for physicians, including maintaining a good reputation – in-person and online. He has seen physicians bumping up their own five-star reviews personally as well as posting negative reviews for their competition.

“I’ve seen where they’re going to lose business, as many practices were affected through COVID,” he said. “Business owners can become desperate and may decide to start posting or buying reviews because they know people will choose certain services these days based upon reviews.”

Dr. Woo-Ming expressed his frustration with fellow physicians who give in to purchasing fake reviews, because the patients have no idea whether reviews are genuine or not.

To encourage genuine positive reviews, Dr. Woo-Ming’s practice uses a third-party app system that sends patients a follow-up email or text asking about their experience with a link to review sites.

“Honest reviews are a reflection of what I can do to improve my business. At the end of the day, if you’re truly providing great service and you’re helping people by providing great medical care, those are going to win out,” he said. “I would rather, as a responsible practice owner, improve the experience and outcome for the patient.”

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

Five years ago, Kay Dean relied upon Yelp! and Google reviews in her search for a doctor in her area. After finding a physician with fairly high reviews, Ms. Dean was shocked when her personal experience was significantly worse than patients on the review platforms.

Following her experience, Ms. Dean, a former federal government investigator, became skeptical and used her skills to investigate the practice on all review platforms. She uncovered that the practice had a review from an individual who was involved in a review trading group on Facebook, where organizations openly barter their services in exchange for positive reviews fraud.

“I discovered that the online review world was just saturated with fake reviews, much more so than I think most people are aware ... and law enforcement regulators aren’t doing anything to address the problem,” said Ms. Dean. “In this online space, it’s the Wild West; cheating is rewarded.”

Ms. Dean decided to take matters into her own hands. She created a YouTube channel called Fake Review Watch, where she exposes real businesses and their attempts to dupe potential consumers with fake positive reviews.

For example, one video analyzes an orthopedic surgeon in Manhattan with an abundance of five-star reviews. Through her detailed analysis, Ms. Dean created a spreadsheet of the 26 alleged patients of the orthopedic surgeon that had submitted glowing reviews. She looked into other businesses that the individuals had left reviews for and found a significant amount of overlap.

According to the video, 19 of the doctor’s reviewers had left high reviews for the same moving company in Las Vegas, and 18 of them reviewed the same locksmith in Texas. Overall, eight of the patients reviewed the same mover, locksmith, and hotel in New Zealand.
 

A matter of trust

Ms. Dean expressed the gravity of this phenomenon, especially in health care, as patients often head online first when searching for care options. Based on a survey by Software Advice, about 84% of patients use online reviews to assess a physician, and 77% use review sites as the first step in finding a doctor.

Patient trust has continued to diminish in recent years, particularly following the pandemic. In a 2021 global ranking of trust levels towards health care by country, the U.S. health care system ranked 19th, far below those of several developing countries.

Owing to the rise of fake patient reviews and their inscrutable nature, Ms. Dean advises staying away from online review platforms. Instead, she suggests sticking to the old-fashioned method of getting recommendations from friends and relatives, not virtual people.

Ms. Dean explained a few indicators that she looks for when trying to identify a fake review.

“The business has all five-star reviews, negative reviews are followed by five-star reviews, or the business has an abnormal number of positive reviews in a short period of time,” she noted. “Some businesses try to bury legitimate negative reviews by obtaining more recent, fake, positive ones. The recent reviews will contradict the specific criticisms in the negative review.”

She warned that consumers should not give credibility to reviews simply because the reviewer is dubbed “Elite” or a Google Local Guide, because she has seen plenty of these individuals posting fake reviews.

Unfortunately, review platforms haven’t been doing much self-policing. Google and Healthgrades have a series of policies against fake engagement, impersonation, misinformation, and misrepresentation, according to their websites. However, the only consequence of these violations is review removal.

Both Yelp! and Google say they have automated software that distinguishes real versus fake reviews. When Yelp! uncovers users engaging in compensation review activity, it removes their reviews, closes their account, and blocks those users from creating future Yelp! accounts.
 

Physicians’ basis

Moreover, physicians purchasing fake reviews create an unfair environment for those physicians who choose to be ethical and honest with patients.

“I think there’s an erosion of business ethics because cheating is rewarded. You can’t compete in an environment where your competition is allowed to accumulate numerous fake reviews while you’re still trying to fill chairs in your business,” said Ms. Dean. “Your competition is then getting the business because the tech companies are allowing this fraud.”

Family physician and practice owner Mike Woo-Ming, MD, MPH, provides career coaching for physicians, including maintaining a good reputation – in-person and online. He has seen physicians bumping up their own five-star reviews personally as well as posting negative reviews for their competition.

“I’ve seen where they’re going to lose business, as many practices were affected through COVID,” he said. “Business owners can become desperate and may decide to start posting or buying reviews because they know people will choose certain services these days based upon reviews.”

Dr. Woo-Ming expressed his frustration with fellow physicians who give in to purchasing fake reviews, because the patients have no idea whether reviews are genuine or not.

To encourage genuine positive reviews, Dr. Woo-Ming’s practice uses a third-party app system that sends patients a follow-up email or text asking about their experience with a link to review sites.

“Honest reviews are a reflection of what I can do to improve my business. At the end of the day, if you’re truly providing great service and you’re helping people by providing great medical care, those are going to win out,” he said. “I would rather, as a responsible practice owner, improve the experience and outcome for the patient.”

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

People dealing with hearing loss will be able to buy hearing aids without a doctor’s prescription as soon as mid-October.

The White House announced today that the Food and Drug Administration will move forward with plans to make hearing aids available over the counter in pharmacies, other retail locations, and online.

This major milestone aims to make hearing aids easier to buy and more affordable, potentially saving families thousands of dollars.

An estimated 28.8 million U.S. adults could benefit from using hearing aids, according to numbers from the National Institute on Deafness and Other Communication Disorders. But only about 16% of people aged 20-69 years who could be helped by hearing aids have ever used them.

The risk for hearing loss increases with age. Among Americans ages 70 and older, only 30% who could hear better with these devices have ever used them, the institute reports.

Once the FDA final rule takes effect, Americans with mild to moderate hearing loss will be able to buy a hearing aid without a doctor’s exam, prescription, or fitting adjustment.

President Joe Biden announced in 2021 he intended to allow hearing aids to be sold over the counter without a prescription to increase competition among manufacturers. Congress also passed bipartisan legislation in 2017 requiring the FDA to create a new category for hearing aids sold directly to consumers. Some devices intended for minors or people with severe hearing loss will remain available only with a prescription.

“This action makes good on my commitment to lower costs for American families, delivering nearly $3,000 in savings to American families for a pair of hearing aids and giving people more choices to improve their health and wellbeing,” the president said in a statement announcing the news.

The new over-the-counter hearing aids will be considered medical devices. To avoid confusion, the FDA explains the differences between hearing aids and personal sound amplification products (PSAPs). For example, PSAPs are considered electronic devices designed for people with normal hearing to use in certain situations, like birdwatching or hunting.

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

People dealing with hearing loss will be able to buy hearing aids without a doctor’s prescription as soon as mid-October.

The White House announced today that the Food and Drug Administration will move forward with plans to make hearing aids available over the counter in pharmacies, other retail locations, and online.

This major milestone aims to make hearing aids easier to buy and more affordable, potentially saving families thousands of dollars.

An estimated 28.8 million U.S. adults could benefit from using hearing aids, according to numbers from the National Institute on Deafness and Other Communication Disorders. But only about 16% of people aged 20-69 years who could be helped by hearing aids have ever used them.

The risk for hearing loss increases with age. Among Americans ages 70 and older, only 30% who could hear better with these devices have ever used them, the institute reports.

Once the FDA final rule takes effect, Americans with mild to moderate hearing loss will be able to buy a hearing aid without a doctor’s exam, prescription, or fitting adjustment.

President Joe Biden announced in 2021 he intended to allow hearing aids to be sold over the counter without a prescription to increase competition among manufacturers. Congress also passed bipartisan legislation in 2017 requiring the FDA to create a new category for hearing aids sold directly to consumers. Some devices intended for minors or people with severe hearing loss will remain available only with a prescription.

“This action makes good on my commitment to lower costs for American families, delivering nearly $3,000 in savings to American families for a pair of hearing aids and giving people more choices to improve their health and wellbeing,” the president said in a statement announcing the news.

The new over-the-counter hearing aids will be considered medical devices. To avoid confusion, the FDA explains the differences between hearing aids and personal sound amplification products (PSAPs). For example, PSAPs are considered electronic devices designed for people with normal hearing to use in certain situations, like birdwatching or hunting.

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

People dealing with hearing loss will be able to buy hearing aids without a doctor’s prescription as soon as mid-October.

The White House announced today that the Food and Drug Administration will move forward with plans to make hearing aids available over the counter in pharmacies, other retail locations, and online.

This major milestone aims to make hearing aids easier to buy and more affordable, potentially saving families thousands of dollars.

An estimated 28.8 million U.S. adults could benefit from using hearing aids, according to numbers from the National Institute on Deafness and Other Communication Disorders. But only about 16% of people aged 20-69 years who could be helped by hearing aids have ever used them.

The risk for hearing loss increases with age. Among Americans ages 70 and older, only 30% who could hear better with these devices have ever used them, the institute reports.

Once the FDA final rule takes effect, Americans with mild to moderate hearing loss will be able to buy a hearing aid without a doctor’s exam, prescription, or fitting adjustment.

President Joe Biden announced in 2021 he intended to allow hearing aids to be sold over the counter without a prescription to increase competition among manufacturers. Congress also passed bipartisan legislation in 2017 requiring the FDA to create a new category for hearing aids sold directly to consumers. Some devices intended for minors or people with severe hearing loss will remain available only with a prescription.

“This action makes good on my commitment to lower costs for American families, delivering nearly $3,000 in savings to American families for a pair of hearing aids and giving people more choices to improve their health and wellbeing,” the president said in a statement announcing the news.

The new over-the-counter hearing aids will be considered medical devices. To avoid confusion, the FDA explains the differences between hearing aids and personal sound amplification products (PSAPs). For example, PSAPs are considered electronic devices designed for people with normal hearing to use in certain situations, like birdwatching or hunting.

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

Last year brought welcome relief to psychiatrists, with incomes generally rising as practices reopened after COVID-19 restrictions lifted and patients ventured out of their homes.

Psychiatrists’ average annual income rose to $287,000, according to the Medscape Psychiatrist Wealth and Debt Report 2022. That is up about 4% from $275,000, which was listed in last year’s report.

However, psychiatrists still rank in the bottom third of all specialties when it comes to physicians’ income.

According to the overall Medscape Physician Wealth and Debt Report 2022, the highest-paying speciality is plastic surgery ($576,000), followed by orthopedics ($557,000) and cardiology ($490,000).

The lowest-paying areas of medicine are family medicine ($255,000), pediatrics ($244,000), and public health and preventive medicine ($243,000).

The report is based on responses from more than 13,000 physicians in 29 specialties. All were surveyed between Oct. 5, 2021 and Jan. 19, 2022.
 

Money-conscious?

Similar to last year’s report, three-quarters of psychiatrists have not done anything to reduce major expenses. Those who have taken cost-cutting measures cited deferring or refinancing loans, moving to a different home, or changing cars as ways to do so.

Most psychiatrists (80%) reported having avoided major financial losses, which is up slightly from last year (76%). Only 6% of psychiatrists (9% last year) reported monetary losses because of issues at their medical practice.

One-quarter reported having a stock or corporate investment go south, which is about the same as last year. In addition, 42% said that they have yet to make a particular investment mistake and 19% said that they have not made any investments.

This year, a somewhat smaller percentage of psychiatrists reported keeping their rates of saving in after-tax accounts level or at increased rates, compared with last year (47% vs. 52%).

About 28% of psychiatrists do not regularly put money into after-tax savings accounts, compared with 25% of physicians overall.

The vast majority said that they kept up with bills amid COVID, as they also did last year.

The percentage of psychiatrists who paid mortgages or other bills late during the pandemic is about the same this year as last year (3% and 5%, respectively).

That is in contrast to one 2021 industry survey, which showed that 46% of Americans missed one or more rent or mortgage payments because of COVID.

Other key findings from Medscape’s latest psychiatrist wealth and debt report include that:

• 61% live in a home of 3,000 square feet or less, which is greater that the current average size of a U.S. house (2,261 square feet)
• 22% have one or two credit cards and 42% have five or more credit cards, while the average American has four cards
• 63% differ in opinion, at least sporadically, with their significant other about spending. A Northwestern Mutual study showed that across the country, around 1 in 4 couples argue about money at least once a month.

In addition, 70% of psychiatrists said that they typically tip at least the recommended 20% for decent service, which is somewhat more generous than the average physician (64%).

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

Last year brought welcome relief to psychiatrists, with incomes generally rising as practices reopened after COVID-19 restrictions lifted and patients ventured out of their homes.

Psychiatrists’ average annual income rose to $287,000, according to the Medscape Psychiatrist Wealth and Debt Report 2022. That is up about 4% from $275,000, which was listed in last year’s report.

However, psychiatrists still rank in the bottom third of all specialties when it comes to physicians’ income.

According to the overall Medscape Physician Wealth and Debt Report 2022, the highest-paying speciality is plastic surgery ($576,000), followed by orthopedics ($557,000) and cardiology ($490,000).

The lowest-paying areas of medicine are family medicine ($255,000), pediatrics ($244,000), and public health and preventive medicine ($243,000).

The report is based on responses from more than 13,000 physicians in 29 specialties. All were surveyed between Oct. 5, 2021 and Jan. 19, 2022.
 

Money-conscious?

Similar to last year’s report, three-quarters of psychiatrists have not done anything to reduce major expenses. Those who have taken cost-cutting measures cited deferring or refinancing loans, moving to a different home, or changing cars as ways to do so.

Most psychiatrists (80%) reported having avoided major financial losses, which is up slightly from last year (76%). Only 6% of psychiatrists (9% last year) reported monetary losses because of issues at their medical practice.

One-quarter reported having a stock or corporate investment go south, which is about the same as last year. In addition, 42% said that they have yet to make a particular investment mistake and 19% said that they have not made any investments.

This year, a somewhat smaller percentage of psychiatrists reported keeping their rates of saving in after-tax accounts level or at increased rates, compared with last year (47% vs. 52%).

About 28% of psychiatrists do not regularly put money into after-tax savings accounts, compared with 25% of physicians overall.

The vast majority said that they kept up with bills amid COVID, as they also did last year.

The percentage of psychiatrists who paid mortgages or other bills late during the pandemic is about the same this year as last year (3% and 5%, respectively).

That is in contrast to one 2021 industry survey, which showed that 46% of Americans missed one or more rent or mortgage payments because of COVID.

Other key findings from Medscape’s latest psychiatrist wealth and debt report include that:

• 61% live in a home of 3,000 square feet or less, which is greater that the current average size of a U.S. house (2,261 square feet)
• 22% have one or two credit cards and 42% have five or more credit cards, while the average American has four cards
• 63% differ in opinion, at least sporadically, with their significant other about spending. A Northwestern Mutual study showed that across the country, around 1 in 4 couples argue about money at least once a month.

In addition, 70% of psychiatrists said that they typically tip at least the recommended 20% for decent service, which is somewhat more generous than the average physician (64%).

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

Last year brought welcome relief to psychiatrists, with incomes generally rising as practices reopened after COVID-19 restrictions lifted and patients ventured out of their homes.

Psychiatrists’ average annual income rose to $287,000, according to the Medscape Psychiatrist Wealth and Debt Report 2022. That is up about 4% from $275,000, which was listed in last year’s report.

However, psychiatrists still rank in the bottom third of all specialties when it comes to physicians’ income.

According to the overall Medscape Physician Wealth and Debt Report 2022, the highest-paying speciality is plastic surgery ($576,000), followed by orthopedics ($557,000) and cardiology ($490,000).

The lowest-paying areas of medicine are family medicine ($255,000), pediatrics ($244,000), and public health and preventive medicine ($243,000).

The report is based on responses from more than 13,000 physicians in 29 specialties. All were surveyed between Oct. 5, 2021 and Jan. 19, 2022.
 

Money-conscious?

Similar to last year’s report, three-quarters of psychiatrists have not done anything to reduce major expenses. Those who have taken cost-cutting measures cited deferring or refinancing loans, moving to a different home, or changing cars as ways to do so.

Most psychiatrists (80%) reported having avoided major financial losses, which is up slightly from last year (76%). Only 6% of psychiatrists (9% last year) reported monetary losses because of issues at their medical practice.

One-quarter reported having a stock or corporate investment go south, which is about the same as last year. In addition, 42% said that they have yet to make a particular investment mistake and 19% said that they have not made any investments.

This year, a somewhat smaller percentage of psychiatrists reported keeping their rates of saving in after-tax accounts level or at increased rates, compared with last year (47% vs. 52%).

About 28% of psychiatrists do not regularly put money into after-tax savings accounts, compared with 25% of physicians overall.

The vast majority said that they kept up with bills amid COVID, as they also did last year.

The percentage of psychiatrists who paid mortgages or other bills late during the pandemic is about the same this year as last year (3% and 5%, respectively).

That is in contrast to one 2021 industry survey, which showed that 46% of Americans missed one or more rent or mortgage payments because of COVID.

Other key findings from Medscape’s latest psychiatrist wealth and debt report include that:

• 61% live in a home of 3,000 square feet or less, which is greater that the current average size of a U.S. house (2,261 square feet)
• 22% have one or two credit cards and 42% have five or more credit cards, while the average American has four cards
• 63% differ in opinion, at least sporadically, with their significant other about spending. A Northwestern Mutual study showed that across the country, around 1 in 4 couples argue about money at least once a month.

In addition, 70% of psychiatrists said that they typically tip at least the recommended 20% for decent service, which is somewhat more generous than the average physician (64%).

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