Business of Medicine

In early 2020, Justin Bullock, MD, MPH, did what few, if any, resident physicians have done: He published an honest account in the New England Journal of Medicine of a would-be suicide attempt during medical training.

In the article, Dr. Bullock matter-of-factly laid out how, in 2019, intern-year night shifts contributed to a depressive episode. For Dr. Bullock, who has a bipolar disorder, sleep dysregulation can be deadly. He had a plan for completing suicide, and this wouldn’t have been his first attempt. Thanks to his history and openness about his condition, Dr. Bullock had an experienced care team that helped him get to a psychiatric hospital before anything happened. While there for around 5 days, he wrote the bulk of the NEJM article.

The article took Dr. Bullock’s impact nationwide. In the medical world, where mental illness is a serious problem but still deeply stigmatized, Dr. Bullock’s unblinking honesty on the issue is still radical to many. On Twitter and in interviews, Dr. Bullock is an unapologetic advocate for accommodations for people in medicine with mental illness. “One of the things that inspired me to speak out early on is that I feel I stand in a place of so much privilege,” Dr. Bullock told this news organization. “I often feel this sense of ... ‘you have to speak up, Justin; no one else can.’ ”

Dr. Bullock’s activism is especially noteworthy, given that he is still establishing his career. In August, while an internal medicine resident at the University of California, San Francisco, he received a lifetime teaching award from UCSF because he had received three prior teaching awards; a recognition like this is considered rare someone so early in their career. Now in his final year of residency, he actively researches medical education, advocates for mental health support, and is working to become a leading voice on related issues.

“It seems to be working,” his older sister, Jacquis Mahoney, RN, said during a visit to the UCSF campus. Instead of any awkwardness, everyone is thrilled to learn that she is Justin’s sister. “There’s a lot of pride and excitement.”
 

Suicide attempts during medical training

Now 28, Dr. Bullock grew up in Detroit, with his mom and two older sisters. His father was incarcerated for much of Dr. Bullock’s childhood, in part because of his own bipolar disorder not being well controlled, Dr. Bullock said.

When he was younger, Dr. Bullock was the peacekeeper in the house between his two sisters, said Ms. Mahoney: “Justin was always very delicate and kind.”

He played soccer and ran track but also loved math and science. While outwardly accumulating an impressive resume, Dr. Bullock was internally struggling. In high school, he made what he now calls an “immature” attempt at suicide after coming out as gay to his family. While Dr. Bullock said he doesn’t necessarily dwell on the discrimination he has faced as a gay, Black man, his awareness of how others perceive and treat him because of his identity increases the background stress present in his daily life.

After high school, Dr. Bullock went to MIT in Boston, where he continued running and studied chemical-biological engineering. During college, Dr. Bullock thought he was going to have to withdraw from MIT because of his depression. Thankfully, he received counseling from student services and advice from a track coach who sat him down and talked about pragmatic solutions, like medication. “That was life-changing,” said Dr. Bullock.

When trying to decide between engineering and medicine, Dr. Bullock realized he preferred contemplating medical problems to engineering ones. So he applied to medical school. Dr. Bullock eventually ended up at UCSF, where he was selected to participate in the Program in Medical Education for the Urban Underserved, a 5-year track at the college for students committed to working with underserved communities.

By the time Dr. Bullock got to medical school, he was feeling good. In consultation with his psychiatrist, he thought it worthwhile to take a break from his medications. At that time, his diagnosis was major depressive disorder and he had only had one serious depressive episode, which didn’t necessarily indicate that he would need medication long-term, he said. 

Dr. Bullock loved everything about medical school. “One day when I was in my first year of med school, I called my mom and said: ‘It’s like science summer camp but every day!’” he recalled.

Despite his enthusiasm, though, he began feeling something troubling. Recognizing the symptoms of early depression, Dr. Bullock restarted his medication. But this time, the same SSRI only made things worse. He went from sleeping 8 hours to 90 minutes a night. He felt angry. One day, he went on a furious 22-mile run. Plus, within the first 6 months of moving to San Francisco, Dr. Bullock was stopped by the police three different times while riding his bike. He attributes this to his race, which has only further added to his stress. In September 2015, during his second year of medical school, Dr. Bullock attempted suicide again. This time, he was intubated in the ED and rushed to the ICU.

He was given a new diagnosis: bipolar disorder. He changed medications and lived for a time with Ms. Mahoney and his other sister, who moved from Chicago to California to be with him. “My family has helped me a lot,” he said.

Dr. Bullock was initially not sure whether he would be able to return to school after his attempted suicide. Overall, UCSF was extremely supportive, he said. That came as a relief. Medical school was a grounding force in his life, not a destabilizing one: “If I had been pushed out, it would have been really harmful to me.”

Then Dr. Bullock started residency. The sleep disruption that comes with the night shift – the resident rite of passage – triggered another episode. At first, Dr. Bullock was overly productive; his mind was active and alert after staying up all night. He worked on new research during the day instead of sleeping. 

Sleep disturbance is a hallmark symptom of bipolar disorder. “Justin should never be on a 24-hour call,” said Lisa Meeks, PhD, associate professor of psychiatry and family medicine at the University of Colorado at Denver, Aurora, and a leading scholar on disability advocacy for medical trainees. When he started residency, Dr. Bullock was open with his program director about his diagnosis and sought accommodations to go to therapy each week. But he didn’t try to get out of night shifts or 24-hour calls, despite his care team urging him to do so. “I have this sense of wanting to tough it out,” he said. He also felt guilty making his peers take on his share of those challenging shifts.

In December 2019, Dr. Bullock was voluntarily hospitalized for a few days and started writing the article that would later appear in NEJM. In January, a friend and UCSF medical student completed suicide. In March, the same month his NEJM article came out, Dr. Bullock attempted suicide again. This time, he quickly recognized that he was making a mistake and called an ambulance. “For me, as far as suicide attempts go, it’s the most positive one.”
 

Advocating for changes in medical training

Throughout his medical training, Dr. Bullock was always open about his struggles with his peers and with the administration. He shared his suicidal thoughts at a Mental Illness Among Us event during medical school. His story resonated with peers who were surprised that Dr. Bullock, who was thriving academically, could be struggling emotionally. 

During residency, he led small group discussions and gave lectures at the medical school, including a talk about his attempts to create institutional change at UCSF, such as his public fight against the college’s Fitness for Duty (FFD) assessment process. That discussion earned him an Outstanding Lecturer award. Because it was the third award he had received from the medical school, Dr. Bullock also automatically earned a lifetime teaching award. When he told his mom, a teacher herself, about the award, she joked: “Are you old enough for ‘lifetime’ anything?”

Dr. Bullock has also spoken out and actively fought against the processes within the medical community that prevent people from coming forward until it is too late. Physicians and trainees often fear that if they seek mental health treatment, they will have to disclose that treatment to a potential employer or licensing board and then be barred from practicing medicine. Because he has been open about his mental health for so long, Dr. Bullock feels that he is in a position to push back against these norms. For example, in June he coauthored another article, this time for the Journal of Hospital Medicine, describing the traumatizing FFD assessment that followed his March 2020 suicide attempt.

In that article, Dr. Bullock wrote how no mental health professional served on the UCSF Physician Well Being Committee – comprising physicians and lawyers who evaluate physician impairment or potential physician impairment – that evaluated him. Dr. Bullock was referred to an outside psychiatrist. He also describes how he was forced to release all of his psychiatric records and undergo extensive drug testing, despite having no history of substance abuse. To return to work, he had to sign a contract, agreeing to be monitored and to attend a specific kind of therapy.

While steps like these can, in the right circumstances, protect both the public and doctors-in-training in important ways, they can also “be very punitive and isolating for someone going through a mental health crisis,” said Dr. Meeks. There were also no Black physicians or lawyers on the committee evaluating Dr. Bullock. “That was really egregious, when you look back.” Dr. Meeks is a coauthor on Dr. Bullock’s JHM article and a mentor and previous student disability officer at UCSF. 

Dr. Bullock raised objections to UCSF administrators about how he felt that the committee was discriminating against him because of his mental illness despite assurances from the director of his program that there have never been any performance or professionalism concerns with him. He said the administrators told him he was the first person to question the FFD process. This isn’t surprising, given that all the power in such situations usually lies with the hospital and the administrators, whereas the resident or physician is worried about losing their job and their license, said Dr. Meeks.

Dr. Bullock contends that he’s in a unique position to speak out, considering his stellar academic and work records, openness about his mental illness before a crisis, access to quality mental health care, and extensive personal network among the UCSF administration. “I know that I hold power within my institution; I spoke out because I could,” Dr. Bullock said. In addition to writing an article about his experience, Dr. Bullock shared his story with a task force appointed by the medical staff president to review the Physician Well-Being Committee and the overall FFD process. Even before Dr. Bullock shared his story with the public, the task force had already been appointed as a result of the increased concern about physician mental health during the ongoing COVID-19 pandemic, Michelle Guy, MD, clinical professor of medicine at UCSF, told this news organization. 

Elizabeth Fernandez, a UCSF senior public information representative, declined to comment on Dr. Bullock’s specific experience as reported in the JHM. “As with every hospital accredited by the Joint Commission, UCSF Medical Center has a Physician Well Being Committee that provides resources for physicians who may need help with chemical dependency or mental illness,” Ms. Fernandez said.

“Our goal through this program is always, first, to provide the compassion and assistance our physicians need to address the issues they face and continue to pursue their careers. This program is entirely voluntary and is bound by federal and state laws and regulations to protect the confidentiality of its participants, while ensuring that – first and foremost – no one is harmed by the situation, including the participant.”
 

Overcoming stigma to change the system

All of the attention – from national media outlets such as Vox to struggling peers and others – is fulfilling, Dr. Bullock said. But it can also be overwhelming. “I have definitely been praised as ‘Black excellence,’ and that definitely has added to the pressure to keep going ... to keep pushing at times,” he said.

Ms. Mahoney added: “He’s willing to sacrifice himself in order to make a difference. He would be a sacrificial lamb” for the Black community, the gay community, or any minority community.

Despite these concerns and his past suicide attempts, colleagues feel that Dr. Bullock is in a strong place to make decisions. “I trust Justin to put the boundaries up when they are needed and to engage in a way that feels comfortable for him,” said Ms. Meeks. “He is someone who has incredible self-awareness.”

Dr. Bullock’s history isn’t just something he overcame: It’s something that makes him a better, more empathetic doctor, said Ms. Mahoney. He knows what it’s like to be hospitalized, to deal with the frustration of insurance, to navigate the complexity of the health care system as a patient, or to be facing a deep internal darkness. He “can genuinely hold that person’s hand and say: ‘I know what you’re going through and we’re going to work through this day by day,’ ” she said. “That is something he can bring that no other physician can bring.”

In his advocacy on Twitter, in lectures, and in conversations with UCSF administrators, Dr. Bullock is pushing for board licensing questions to be reformed so physicians are no longer penalized for seeking mental health treatment. He would also like residency programs to make it easier and less stigmatizing for trainees to receive accommodations for a disability or mental illness.

“They say one person can’t change a system,” said Dr. Meeks, “but I do think Justin is calling an awful lot of attention to the system and I do think there will be changes because of his advocacy.”

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

In early 2020, Justin Bullock, MD, MPH, did what few, if any, resident physicians have done: He published an honest account in the New England Journal of Medicine of a would-be suicide attempt during medical training.

In the article, Dr. Bullock matter-of-factly laid out how, in 2019, intern-year night shifts contributed to a depressive episode. For Dr. Bullock, who has a bipolar disorder, sleep dysregulation can be deadly. He had a plan for completing suicide, and this wouldn’t have been his first attempt. Thanks to his history and openness about his condition, Dr. Bullock had an experienced care team that helped him get to a psychiatric hospital before anything happened. While there for around 5 days, he wrote the bulk of the NEJM article.

The article took Dr. Bullock’s impact nationwide. In the medical world, where mental illness is a serious problem but still deeply stigmatized, Dr. Bullock’s unblinking honesty on the issue is still radical to many. On Twitter and in interviews, Dr. Bullock is an unapologetic advocate for accommodations for people in medicine with mental illness. “One of the things that inspired me to speak out early on is that I feel I stand in a place of so much privilege,” Dr. Bullock told this news organization. “I often feel this sense of ... ‘you have to speak up, Justin; no one else can.’ ”

Dr. Bullock’s activism is especially noteworthy, given that he is still establishing his career. In August, while an internal medicine resident at the University of California, San Francisco, he received a lifetime teaching award from UCSF because he had received three prior teaching awards; a recognition like this is considered rare someone so early in their career. Now in his final year of residency, he actively researches medical education, advocates for mental health support, and is working to become a leading voice on related issues.

“It seems to be working,” his older sister, Jacquis Mahoney, RN, said during a visit to the UCSF campus. Instead of any awkwardness, everyone is thrilled to learn that she is Justin’s sister. “There’s a lot of pride and excitement.”
 

Suicide attempts during medical training

Now 28, Dr. Bullock grew up in Detroit, with his mom and two older sisters. His father was incarcerated for much of Dr. Bullock’s childhood, in part because of his own bipolar disorder not being well controlled, Dr. Bullock said.

When he was younger, Dr. Bullock was the peacekeeper in the house between his two sisters, said Ms. Mahoney: “Justin was always very delicate and kind.”

He played soccer and ran track but also loved math and science. While outwardly accumulating an impressive resume, Dr. Bullock was internally struggling. In high school, he made what he now calls an “immature” attempt at suicide after coming out as gay to his family. While Dr. Bullock said he doesn’t necessarily dwell on the discrimination he has faced as a gay, Black man, his awareness of how others perceive and treat him because of his identity increases the background stress present in his daily life.

After high school, Dr. Bullock went to MIT in Boston, where he continued running and studied chemical-biological engineering. During college, Dr. Bullock thought he was going to have to withdraw from MIT because of his depression. Thankfully, he received counseling from student services and advice from a track coach who sat him down and talked about pragmatic solutions, like medication. “That was life-changing,” said Dr. Bullock.

When trying to decide between engineering and medicine, Dr. Bullock realized he preferred contemplating medical problems to engineering ones. So he applied to medical school. Dr. Bullock eventually ended up at UCSF, where he was selected to participate in the Program in Medical Education for the Urban Underserved, a 5-year track at the college for students committed to working with underserved communities.

By the time Dr. Bullock got to medical school, he was feeling good. In consultation with his psychiatrist, he thought it worthwhile to take a break from his medications. At that time, his diagnosis was major depressive disorder and he had only had one serious depressive episode, which didn’t necessarily indicate that he would need medication long-term, he said. 

Dr. Bullock loved everything about medical school. “One day when I was in my first year of med school, I called my mom and said: ‘It’s like science summer camp but every day!’” he recalled.

Despite his enthusiasm, though, he began feeling something troubling. Recognizing the symptoms of early depression, Dr. Bullock restarted his medication. But this time, the same SSRI only made things worse. He went from sleeping 8 hours to 90 minutes a night. He felt angry. One day, he went on a furious 22-mile run. Plus, within the first 6 months of moving to San Francisco, Dr. Bullock was stopped by the police three different times while riding his bike. He attributes this to his race, which has only further added to his stress. In September 2015, during his second year of medical school, Dr. Bullock attempted suicide again. This time, he was intubated in the ED and rushed to the ICU.

He was given a new diagnosis: bipolar disorder. He changed medications and lived for a time with Ms. Mahoney and his other sister, who moved from Chicago to California to be with him. “My family has helped me a lot,” he said.

Dr. Bullock was initially not sure whether he would be able to return to school after his attempted suicide. Overall, UCSF was extremely supportive, he said. That came as a relief. Medical school was a grounding force in his life, not a destabilizing one: “If I had been pushed out, it would have been really harmful to me.”

Then Dr. Bullock started residency. The sleep disruption that comes with the night shift – the resident rite of passage – triggered another episode. At first, Dr. Bullock was overly productive; his mind was active and alert after staying up all night. He worked on new research during the day instead of sleeping. 

Sleep disturbance is a hallmark symptom of bipolar disorder. “Justin should never be on a 24-hour call,” said Lisa Meeks, PhD, associate professor of psychiatry and family medicine at the University of Colorado at Denver, Aurora, and a leading scholar on disability advocacy for medical trainees. When he started residency, Dr. Bullock was open with his program director about his diagnosis and sought accommodations to go to therapy each week. But he didn’t try to get out of night shifts or 24-hour calls, despite his care team urging him to do so. “I have this sense of wanting to tough it out,” he said. He also felt guilty making his peers take on his share of those challenging shifts.

In December 2019, Dr. Bullock was voluntarily hospitalized for a few days and started writing the article that would later appear in NEJM. In January, a friend and UCSF medical student completed suicide. In March, the same month his NEJM article came out, Dr. Bullock attempted suicide again. This time, he quickly recognized that he was making a mistake and called an ambulance. “For me, as far as suicide attempts go, it’s the most positive one.”
 

Advocating for changes in medical training

Throughout his medical training, Dr. Bullock was always open about his struggles with his peers and with the administration. He shared his suicidal thoughts at a Mental Illness Among Us event during medical school. His story resonated with peers who were surprised that Dr. Bullock, who was thriving academically, could be struggling emotionally. 

During residency, he led small group discussions and gave lectures at the medical school, including a talk about his attempts to create institutional change at UCSF, such as his public fight against the college’s Fitness for Duty (FFD) assessment process. That discussion earned him an Outstanding Lecturer award. Because it was the third award he had received from the medical school, Dr. Bullock also automatically earned a lifetime teaching award. When he told his mom, a teacher herself, about the award, she joked: “Are you old enough for ‘lifetime’ anything?”

Dr. Bullock has also spoken out and actively fought against the processes within the medical community that prevent people from coming forward until it is too late. Physicians and trainees often fear that if they seek mental health treatment, they will have to disclose that treatment to a potential employer or licensing board and then be barred from practicing medicine. Because he has been open about his mental health for so long, Dr. Bullock feels that he is in a position to push back against these norms. For example, in June he coauthored another article, this time for the Journal of Hospital Medicine, describing the traumatizing FFD assessment that followed his March 2020 suicide attempt.

In that article, Dr. Bullock wrote how no mental health professional served on the UCSF Physician Well Being Committee – comprising physicians and lawyers who evaluate physician impairment or potential physician impairment – that evaluated him. Dr. Bullock was referred to an outside psychiatrist. He also describes how he was forced to release all of his psychiatric records and undergo extensive drug testing, despite having no history of substance abuse. To return to work, he had to sign a contract, agreeing to be monitored and to attend a specific kind of therapy.

While steps like these can, in the right circumstances, protect both the public and doctors-in-training in important ways, they can also “be very punitive and isolating for someone going through a mental health crisis,” said Dr. Meeks. There were also no Black physicians or lawyers on the committee evaluating Dr. Bullock. “That was really egregious, when you look back.” Dr. Meeks is a coauthor on Dr. Bullock’s JHM article and a mentor and previous student disability officer at UCSF. 

Dr. Bullock raised objections to UCSF administrators about how he felt that the committee was discriminating against him because of his mental illness despite assurances from the director of his program that there have never been any performance or professionalism concerns with him. He said the administrators told him he was the first person to question the FFD process. This isn’t surprising, given that all the power in such situations usually lies with the hospital and the administrators, whereas the resident or physician is worried about losing their job and their license, said Dr. Meeks.

Dr. Bullock contends that he’s in a unique position to speak out, considering his stellar academic and work records, openness about his mental illness before a crisis, access to quality mental health care, and extensive personal network among the UCSF administration. “I know that I hold power within my institution; I spoke out because I could,” Dr. Bullock said. In addition to writing an article about his experience, Dr. Bullock shared his story with a task force appointed by the medical staff president to review the Physician Well-Being Committee and the overall FFD process. Even before Dr. Bullock shared his story with the public, the task force had already been appointed as a result of the increased concern about physician mental health during the ongoing COVID-19 pandemic, Michelle Guy, MD, clinical professor of medicine at UCSF, told this news organization. 

Elizabeth Fernandez, a UCSF senior public information representative, declined to comment on Dr. Bullock’s specific experience as reported in the JHM. “As with every hospital accredited by the Joint Commission, UCSF Medical Center has a Physician Well Being Committee that provides resources for physicians who may need help with chemical dependency or mental illness,” Ms. Fernandez said.

“Our goal through this program is always, first, to provide the compassion and assistance our physicians need to address the issues they face and continue to pursue their careers. This program is entirely voluntary and is bound by federal and state laws and regulations to protect the confidentiality of its participants, while ensuring that – first and foremost – no one is harmed by the situation, including the participant.”
 

Overcoming stigma to change the system

All of the attention – from national media outlets such as Vox to struggling peers and others – is fulfilling, Dr. Bullock said. But it can also be overwhelming. “I have definitely been praised as ‘Black excellence,’ and that definitely has added to the pressure to keep going ... to keep pushing at times,” he said.

Ms. Mahoney added: “He’s willing to sacrifice himself in order to make a difference. He would be a sacrificial lamb” for the Black community, the gay community, or any minority community.

Despite these concerns and his past suicide attempts, colleagues feel that Dr. Bullock is in a strong place to make decisions. “I trust Justin to put the boundaries up when they are needed and to engage in a way that feels comfortable for him,” said Ms. Meeks. “He is someone who has incredible self-awareness.”

Dr. Bullock’s history isn’t just something he overcame: It’s something that makes him a better, more empathetic doctor, said Ms. Mahoney. He knows what it’s like to be hospitalized, to deal with the frustration of insurance, to navigate the complexity of the health care system as a patient, or to be facing a deep internal darkness. He “can genuinely hold that person’s hand and say: ‘I know what you’re going through and we’re going to work through this day by day,’ ” she said. “That is something he can bring that no other physician can bring.”

In his advocacy on Twitter, in lectures, and in conversations with UCSF administrators, Dr. Bullock is pushing for board licensing questions to be reformed so physicians are no longer penalized for seeking mental health treatment. He would also like residency programs to make it easier and less stigmatizing for trainees to receive accommodations for a disability or mental illness.

“They say one person can’t change a system,” said Dr. Meeks, “but I do think Justin is calling an awful lot of attention to the system and I do think there will be changes because of his advocacy.”

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

In early 2020, Justin Bullock, MD, MPH, did what few, if any, resident physicians have done: He published an honest account in the New England Journal of Medicine of a would-be suicide attempt during medical training.

In the article, Dr. Bullock matter-of-factly laid out how, in 2019, intern-year night shifts contributed to a depressive episode. For Dr. Bullock, who has a bipolar disorder, sleep dysregulation can be deadly. He had a plan for completing suicide, and this wouldn’t have been his first attempt. Thanks to his history and openness about his condition, Dr. Bullock had an experienced care team that helped him get to a psychiatric hospital before anything happened. While there for around 5 days, he wrote the bulk of the NEJM article.

The article took Dr. Bullock’s impact nationwide. In the medical world, where mental illness is a serious problem but still deeply stigmatized, Dr. Bullock’s unblinking honesty on the issue is still radical to many. On Twitter and in interviews, Dr. Bullock is an unapologetic advocate for accommodations for people in medicine with mental illness. “One of the things that inspired me to speak out early on is that I feel I stand in a place of so much privilege,” Dr. Bullock told this news organization. “I often feel this sense of ... ‘you have to speak up, Justin; no one else can.’ ”

Dr. Bullock’s activism is especially noteworthy, given that he is still establishing his career. In August, while an internal medicine resident at the University of California, San Francisco, he received a lifetime teaching award from UCSF because he had received three prior teaching awards; a recognition like this is considered rare someone so early in their career. Now in his final year of residency, he actively researches medical education, advocates for mental health support, and is working to become a leading voice on related issues.

“It seems to be working,” his older sister, Jacquis Mahoney, RN, said during a visit to the UCSF campus. Instead of any awkwardness, everyone is thrilled to learn that she is Justin’s sister. “There’s a lot of pride and excitement.”
 

Suicide attempts during medical training

Now 28, Dr. Bullock grew up in Detroit, with his mom and two older sisters. His father was incarcerated for much of Dr. Bullock’s childhood, in part because of his own bipolar disorder not being well controlled, Dr. Bullock said.

When he was younger, Dr. Bullock was the peacekeeper in the house between his two sisters, said Ms. Mahoney: “Justin was always very delicate and kind.”

He played soccer and ran track but also loved math and science. While outwardly accumulating an impressive resume, Dr. Bullock was internally struggling. In high school, he made what he now calls an “immature” attempt at suicide after coming out as gay to his family. While Dr. Bullock said he doesn’t necessarily dwell on the discrimination he has faced as a gay, Black man, his awareness of how others perceive and treat him because of his identity increases the background stress present in his daily life.

After high school, Dr. Bullock went to MIT in Boston, where he continued running and studied chemical-biological engineering. During college, Dr. Bullock thought he was going to have to withdraw from MIT because of his depression. Thankfully, he received counseling from student services and advice from a track coach who sat him down and talked about pragmatic solutions, like medication. “That was life-changing,” said Dr. Bullock.

When trying to decide between engineering and medicine, Dr. Bullock realized he preferred contemplating medical problems to engineering ones. So he applied to medical school. Dr. Bullock eventually ended up at UCSF, where he was selected to participate in the Program in Medical Education for the Urban Underserved, a 5-year track at the college for students committed to working with underserved communities.

By the time Dr. Bullock got to medical school, he was feeling good. In consultation with his psychiatrist, he thought it worthwhile to take a break from his medications. At that time, his diagnosis was major depressive disorder and he had only had one serious depressive episode, which didn’t necessarily indicate that he would need medication long-term, he said. 

Dr. Bullock loved everything about medical school. “One day when I was in my first year of med school, I called my mom and said: ‘It’s like science summer camp but every day!’” he recalled.

Despite his enthusiasm, though, he began feeling something troubling. Recognizing the symptoms of early depression, Dr. Bullock restarted his medication. But this time, the same SSRI only made things worse. He went from sleeping 8 hours to 90 minutes a night. He felt angry. One day, he went on a furious 22-mile run. Plus, within the first 6 months of moving to San Francisco, Dr. Bullock was stopped by the police three different times while riding his bike. He attributes this to his race, which has only further added to his stress. In September 2015, during his second year of medical school, Dr. Bullock attempted suicide again. This time, he was intubated in the ED and rushed to the ICU.

He was given a new diagnosis: bipolar disorder. He changed medications and lived for a time with Ms. Mahoney and his other sister, who moved from Chicago to California to be with him. “My family has helped me a lot,” he said.

Dr. Bullock was initially not sure whether he would be able to return to school after his attempted suicide. Overall, UCSF was extremely supportive, he said. That came as a relief. Medical school was a grounding force in his life, not a destabilizing one: “If I had been pushed out, it would have been really harmful to me.”

Then Dr. Bullock started residency. The sleep disruption that comes with the night shift – the resident rite of passage – triggered another episode. At first, Dr. Bullock was overly productive; his mind was active and alert after staying up all night. He worked on new research during the day instead of sleeping. 

Sleep disturbance is a hallmark symptom of bipolar disorder. “Justin should never be on a 24-hour call,” said Lisa Meeks, PhD, associate professor of psychiatry and family medicine at the University of Colorado at Denver, Aurora, and a leading scholar on disability advocacy for medical trainees. When he started residency, Dr. Bullock was open with his program director about his diagnosis and sought accommodations to go to therapy each week. But he didn’t try to get out of night shifts or 24-hour calls, despite his care team urging him to do so. “I have this sense of wanting to tough it out,” he said. He also felt guilty making his peers take on his share of those challenging shifts.

In December 2019, Dr. Bullock was voluntarily hospitalized for a few days and started writing the article that would later appear in NEJM. In January, a friend and UCSF medical student completed suicide. In March, the same month his NEJM article came out, Dr. Bullock attempted suicide again. This time, he quickly recognized that he was making a mistake and called an ambulance. “For me, as far as suicide attempts go, it’s the most positive one.”
 

Advocating for changes in medical training

Throughout his medical training, Dr. Bullock was always open about his struggles with his peers and with the administration. He shared his suicidal thoughts at a Mental Illness Among Us event during medical school. His story resonated with peers who were surprised that Dr. Bullock, who was thriving academically, could be struggling emotionally. 

During residency, he led small group discussions and gave lectures at the medical school, including a talk about his attempts to create institutional change at UCSF, such as his public fight against the college’s Fitness for Duty (FFD) assessment process. That discussion earned him an Outstanding Lecturer award. Because it was the third award he had received from the medical school, Dr. Bullock also automatically earned a lifetime teaching award. When he told his mom, a teacher herself, about the award, she joked: “Are you old enough for ‘lifetime’ anything?”

Dr. Bullock has also spoken out and actively fought against the processes within the medical community that prevent people from coming forward until it is too late. Physicians and trainees often fear that if they seek mental health treatment, they will have to disclose that treatment to a potential employer or licensing board and then be barred from practicing medicine. Because he has been open about his mental health for so long, Dr. Bullock feels that he is in a position to push back against these norms. For example, in June he coauthored another article, this time for the Journal of Hospital Medicine, describing the traumatizing FFD assessment that followed his March 2020 suicide attempt.

In that article, Dr. Bullock wrote how no mental health professional served on the UCSF Physician Well Being Committee – comprising physicians and lawyers who evaluate physician impairment or potential physician impairment – that evaluated him. Dr. Bullock was referred to an outside psychiatrist. He also describes how he was forced to release all of his psychiatric records and undergo extensive drug testing, despite having no history of substance abuse. To return to work, he had to sign a contract, agreeing to be monitored and to attend a specific kind of therapy.

While steps like these can, in the right circumstances, protect both the public and doctors-in-training in important ways, they can also “be very punitive and isolating for someone going through a mental health crisis,” said Dr. Meeks. There were also no Black physicians or lawyers on the committee evaluating Dr. Bullock. “That was really egregious, when you look back.” Dr. Meeks is a coauthor on Dr. Bullock’s JHM article and a mentor and previous student disability officer at UCSF. 

Dr. Bullock raised objections to UCSF administrators about how he felt that the committee was discriminating against him because of his mental illness despite assurances from the director of his program that there have never been any performance or professionalism concerns with him. He said the administrators told him he was the first person to question the FFD process. This isn’t surprising, given that all the power in such situations usually lies with the hospital and the administrators, whereas the resident or physician is worried about losing their job and their license, said Dr. Meeks.

Dr. Bullock contends that he’s in a unique position to speak out, considering his stellar academic and work records, openness about his mental illness before a crisis, access to quality mental health care, and extensive personal network among the UCSF administration. “I know that I hold power within my institution; I spoke out because I could,” Dr. Bullock said. In addition to writing an article about his experience, Dr. Bullock shared his story with a task force appointed by the medical staff president to review the Physician Well-Being Committee and the overall FFD process. Even before Dr. Bullock shared his story with the public, the task force had already been appointed as a result of the increased concern about physician mental health during the ongoing COVID-19 pandemic, Michelle Guy, MD, clinical professor of medicine at UCSF, told this news organization. 

Elizabeth Fernandez, a UCSF senior public information representative, declined to comment on Dr. Bullock’s specific experience as reported in the JHM. “As with every hospital accredited by the Joint Commission, UCSF Medical Center has a Physician Well Being Committee that provides resources for physicians who may need help with chemical dependency or mental illness,” Ms. Fernandez said.

“Our goal through this program is always, first, to provide the compassion and assistance our physicians need to address the issues they face and continue to pursue their careers. This program is entirely voluntary and is bound by federal and state laws and regulations to protect the confidentiality of its participants, while ensuring that – first and foremost – no one is harmed by the situation, including the participant.”
 

Overcoming stigma to change the system

All of the attention – from national media outlets such as Vox to struggling peers and others – is fulfilling, Dr. Bullock said. But it can also be overwhelming. “I have definitely been praised as ‘Black excellence,’ and that definitely has added to the pressure to keep going ... to keep pushing at times,” he said.

Ms. Mahoney added: “He’s willing to sacrifice himself in order to make a difference. He would be a sacrificial lamb” for the Black community, the gay community, or any minority community.

Despite these concerns and his past suicide attempts, colleagues feel that Dr. Bullock is in a strong place to make decisions. “I trust Justin to put the boundaries up when they are needed and to engage in a way that feels comfortable for him,” said Ms. Meeks. “He is someone who has incredible self-awareness.”

Dr. Bullock’s history isn’t just something he overcame: It’s something that makes him a better, more empathetic doctor, said Ms. Mahoney. He knows what it’s like to be hospitalized, to deal with the frustration of insurance, to navigate the complexity of the health care system as a patient, or to be facing a deep internal darkness. He “can genuinely hold that person’s hand and say: ‘I know what you’re going through and we’re going to work through this day by day,’ ” she said. “That is something he can bring that no other physician can bring.”

In his advocacy on Twitter, in lectures, and in conversations with UCSF administrators, Dr. Bullock is pushing for board licensing questions to be reformed so physicians are no longer penalized for seeking mental health treatment. He would also like residency programs to make it easier and less stigmatizing for trainees to receive accommodations for a disability or mental illness.

“They say one person can’t change a system,” said Dr. Meeks, “but I do think Justin is calling an awful lot of attention to the system and I do think there will be changes because of his advocacy.”

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

Susan Haney, MD, a board-certified emergency physician in Coos Bay, Ore., was 2 years into her career when she had her first manic episode, likely a side effect of the steroid prednisone, which she had been prescribed for an asthma flare-up. Her boss at Bay Area Hospital told her that if she wanted to return to work, she would need to have written clearance from the medical board.

In retrospect, Dr. Haney says, “I don’t think they had any idea of what they would set in motion.”

Dr. Haney says the Oregon Medical Board posted her name and the nondisciplinary action on their website and in their newsletter. Her local newspaper read it and ran a story about her. “They effectively announced my mental illness to the general public despite my objections,” she says.

During the next decade, she had two more manic episodes, and more board investigations and actions followed. Despite being cleared for work each time, Dr. Haney says the board actions decimated her career in emergency medicine and her income, which is about half of what she would have earned by now. She is frustrated, sad, and angry about what happened but considers herself lucky to be practicing medicine in urgent care.
 

Being investigated is scary

After her first manic episode in 2006, Dr. Haney contacted the board’s medical director, a retired general surgeon, who told her the only way the board would authorize her return to work was if she agreed to open a board investigation.

She gave them the green light because she thought she had nothing to fear – she was cooperating fully and wasn’t impaired. Now Dr. Haney says she was naive. “The board is not your friend,” she says.

Dr. Haney was also anxious to return to work. She worked in a seven-person emergency department, and two colleagues were on maternity leave or medical leave.

“My colleagues kept calling asking me when I was going to return to work, and I kept saying, ‘I don’t know because the board won’t tell me,’ “ she says.

She was also feeling a lot of financial pressure. She was 2 years out of residency, owed $100,000 in student loans, and had just bought a house.

“I was really scared – I didn’t know how long this would last or if they would let me return to work. Early on, I even got a fitness for duty evaluation from the state’s consulting psychiatrist, who cleared me for work, and the board still wouldn’t let me return. They told me I had to go through their bureaucracy and a board meeting, which didn’t make sense to me.”

Dr. Haney consented to give the board’s investigative staff access to her medical records because she feared that if she challenged them, they would suspend or revoke her license immediately.

After investigating her for 4 months, the board cleared Dr. Haney to return to work at Bay Area Hospital. She agreed to the board’s “corrective action” terms: She would continue to receive psychiatric care, maintain a physician-patient relationship with a primary care physician, and enroll in the Health Physicians Program (HPP) for substance abuse monitoring.

Dr. Haney suspects that the board investigation damaged her reputation at work. “Before this, my work evaluations were consistently excellent. Afterwards, they were all adequate. I don’t think that was a coincidence.”
 

Worst time of her life

Five years later, after taking prednisone for another asthma flare-up, Dr. Haney had a more severe manic episode and was hospitalized.

The consulting psychiatrist who evaluated her reported her case to the medical board, stating she had bipolar disorder, was mentally incompetent, and shouldn’t be practicing medicine. The board opened a second investigation of her in 2012, which lasted 4 months.

Dr. Haney had quit her job at Bay Area Hospital in 2011 because she was pregnant and was planning to take a year off to care for the baby at home.

“That was the worst time of my life. I lost the baby at 4 months, I wasn’t working, and now I was under investigation by the board again,” she says.

The board issued an “interim stipulated order” that required that she be monitored regularly for mental illness and substance abuse by the Health Professionals Services Program (HPSP) for 2 years. “The board accused me of abusing prednisone, which I wasn’t. I was using it as prescribed and medically indicated,” she said.

The board order was reported to the National Practitioner Databank and is now permanently in her record. Although the board cleared her to work, she could not find a permanent job in a hospital emergency department.

“The repeated ‘nondisciplinary’ public board orders have had the same net impact on my career as if I had been disciplined for killing or harming my patients. For all intents and purposes, people treat it as a disciplinary action for the rest of your career,” she said.

To keep afloat financially, she found locum tenens work in local emergency departments until 2019.
 

Mental health toll

Dr. Haney feels that the stress of repeated board investigations has affected her mental health. “Both times this happened, it made my mental health worse, made the mania worse, and subsequent depression worse.”

Particularly distressing to her was the fact that the administrative staff who investigated her were attorneys and persons in law enforcement, rather than medical professionals with mental health training.

“I was required to disclose intimate personal details of my psychological and psychiatric history to anybody at the board who requested them. These investigators were asking me about my childhood history. That was traumatic and none of their business!”

Dr. Haney had quietly managed episodes of major depression since she was in her early 20s with the help of a psychiatrist. Her third episode of mania, which occurred in 2014, triggered a more severe depression, which she says deepened when she learned that the HPSP had notified the board about her manic symptoms and that she would not be released from the 2-year monitoring contract. When the board notified her 2 weeks later that they were opening another investigation, Dr. Haney says she had an emotional crisis, attempted suicide, and was briefly hospitalized. Several weeks later, she decided to take a mood stabilizer, which she continues to take.

The board’s 2015 corrective action agreement required Dr. Haney to practice medicine only in settings that the board’s medical director preapproved and to obtain a preapproved monitoring health care provider who would send quarterly reports to the medical director. Dr. Haney says the “nondisciplinary” action agreement was also reported to the National Practitioner Data Bank.

She also agreed to ongoing monitoring by the HPSP for mental illness and substance abuse, which involved random drug testing. When she didn’t call in one day in 2019 and missed a scheduled test, the board opened another investigation on her that lasted 7 months until July 2020. Dr. Haney said this was despite three subsequent negative tests.

Dr. Haney believes that the “open investigation” doomed a job offer from a hospital emergency department in the Virgin Islands. “I had passed all the required credentialing and explained previous board orders. They pulled the rug from under me 1 week before I was supposed to move there,” says Dr. Haney.

Her license was inactivated again because she hadn’t practiced medicine for a year, which she says was a new board policy. Although Dr. Haney says the medical director reactivated her license after talking with her, “By the time I was able to apply emergency medicine jobs, no one was interested in me anymore.”
 

Financial toll

Dr. Haney started her medical career when she was 42 as a second career. She says the board investigations and actions have resulted in a significant loss of work and income. “I have only worked 14 of the past 17 years as a doctor. I live cheaply because I never know how much longer my career will last,” says Dr. Haney.

The ordeal has devastated her finances. She has shelled out at least $200,000 in legal fees – she hired an attorney in 2007 and filed a lawsuit against the board in Oregon district court alleging that members had violated several of her rights. The district judge sided with the state medical board, and it was upheld on appeal in 2012, referring to state laws that gave the board absolute immunity from civil lawsuits. “I had no legal recourse to contest their decisions, no matter how injurious or unjust,” says Dr. Haney.

She has also shelled out at least $100,000 to be evaluated and monitored by the health physician program (now HPSP) for several years. Physicians who agree to be monitored by these health programs have to pay their fees. The board finally agreed last July to end her HPSP participation.

Dr. Haney also filed a complaint in 2007 with the federal Department of Health & Human Services Office for Civil Rights, alleging that the board violated her civil rights under the Americans with Disabilities Act. She says that her lawsuit and the OCR investigation of the board enabled her to withdraw from the HPP in good standing in 2008..
 

What would she have done differently?

She regrets not hiring an attorney earlier because “most likely the board action would not have been made public. It snowballed after that -- any mistake I made in my career was viewed in the lens of potential impairment.”

She also regrets telling her employer about the nature of her illness and reporting it to the board. A psychiatrist she saw later shared advice he gives to other patients who want to remain anonymous: get help but go out of town, use a false name, and pay cash.

“I wish I had that advice when all this started. That was the best way to protect my career,” says Dr. Haney.
 

Protecting the public?

The Oregon Medical Board declined to comment on Dr. Haney’s experience because investigations are confidential, but the executive director, Nicole Krishnaswami, JD, answered questions in an email about how the current board operates.

She says the board has 11 medical professionals and employs a medical director and expert consultants in specialty-specific fields. MDs with mental health training are involved in investigating/reviewing cases involving doctors with mental illnesses.

“State medical boards have a responsibility to protect and inform the public. State laws further require state agencies to provide access and transparency regarding the board’s official actions. If the board receives a complaint that a licensee is impaired and thus unable to safely practice, the board has a responsibility to investigate and ensure the licensee is practicing medicine safely,” Ms. Krishnaswami said.

The HPSP is the monitoring program established by state law to provide oversight in order to ensure that licensees are not practicing while impaired. HPSP is separate from the board and the board adopted a statement outlining its perspective on the program in support of doctors with substance abuse and mental health disorder.

The board also founded the Oregon Wellness Program, which provides free, confidential counseling to all Oregon-licensed physicians and physician assistants.
 

Stigma continues

Dr. Haney feels there is huge stigma associated with mental illness in the medical profession. “If I had cancer twice, I wouldn’t have been put in this position and would be at the peak of my career,” she says.

Nearly half of the 862 emergency medicine physicians surveyed last October said they were reluctant to seek mental health treatment. The reasons included fear of professional repercussions and stigma in the workplace. Several physicians said they were concerned about potentially having to report the treatment on medical license applications in the future, according to a survey by the American College of Emergency Physicians.

In addition, 26% of the more than 12,000 physicians who responded to a Medscape survey last year said they didn’t want to risk disclosure (20%) or that they distrusted mental health professionals (6%).
 

Another physician fights back

Steven Miles, MD, an award-winning professor emeritus of medicine and bioethics at the Center for Bioethics at the University of Minnesota, in Minneapolis, understands their reluctance. In 1996, he disclosed on his license renewal application that he had recently been diagnosed with a mainly depressive type of bipolar disorder and was in treatment. He had already told his employer, who was supportive.

That set off a 14-month investigation of him by the Minnesota Board of Medical Practice. Dr. Miles and his psychiatrist refused to release his confidential records to a panel of physicians, most of whom had no expertise in mental health care. He also filed a federal claim that the board’s requests violated the ADA, and he won the case.

“Had the board given me evidence of impaired ability to practice with ordinary skill and safety, I would have cooperated. Instead, they proposed a course of action, which would have degraded the privacy of my relationship with my psychiatrist and arguably increased the barrier to getting proper care and the risk of impairment,” he said.

The board kept renewing his license, and Dr. Miles continued to work full time. “I was empowered and protected by my stature in the field at the time my mental illness was diagnosed. Early-career physicians do not yet have that protection and should be very careful of disclosing, given the still widespread stigma of mental illnesses,” he said.
 

His advocacy led to changes

Dr. Miles went public to mobilize support for his ADA claim. He wrote editorials that were published in JAMA and Minnesota Medicine that refer to the American Psychiatric Association’s 1984 position paper, which says that the mandatory disclosure of the physician’s confidential medical record is without merit. Dr. Miles adds that major newspapers ran stories based on his editorials.

The board backed down after Dr. Miles won his ADA case, and it met with him. “I said this is not good stewardship of the medical profession; you are injuring doctors by keeping them from psychiatric care, which is out of line with the medical view of the treatability of depression and that needs to change,” he says.

Dr. Miles says he won a victory because his practice continued. “I also won a victory in the way the board was handling these questions, which was an opening salvo in a process that continues to this day.”

The original form asked whether he had ever been diagnosed with or treated for manic depression, schizophrenia, compulsive gambling, or other psychiatric conditions.

The revised form asks, “Do you have a physical or mental condition that would affect your ability, with or without reasonable accommodation, to provide appropriate care to patients and otherwise perform the essential functions of a practitioner in your area of practice without posing a health or safety risk to your patients? If yes, what accommodations would help you provide appropriate care to patients and perform other essential functions?”

Dr. Miles says that the final wording wasn’t ideal and that it was confusing to physicians. He says this prompted additional changes in wording by the board. Starting in January, applicants will be asked, “Do you currently have any condition that is not being appropriately treated that is likely to impair or adversely affect your ability to practice medicine with reasonable skill and safety in a competent, ethical, and professional manner?” the medical board’s executive director, Ruth M. Martinez, said in an email.

When asked whether the board still investigates physicians who reveal mental illnesses on licensing applications, Ms. Martinez responded, “All disclosures are evaluated to assure that the practitioner is qualified and safe to practice.”

This article was updated 11/4/21.

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

Susan Haney, MD, a board-certified emergency physician in Coos Bay, Ore., was 2 years into her career when she had her first manic episode, likely a side effect of the steroid prednisone, which she had been prescribed for an asthma flare-up. Her boss at Bay Area Hospital told her that if she wanted to return to work, she would need to have written clearance from the medical board.

In retrospect, Dr. Haney says, “I don’t think they had any idea of what they would set in motion.”

Dr. Haney says the Oregon Medical Board posted her name and the nondisciplinary action on their website and in their newsletter. Her local newspaper read it and ran a story about her. “They effectively announced my mental illness to the general public despite my objections,” she says.

During the next decade, she had two more manic episodes, and more board investigations and actions followed. Despite being cleared for work each time, Dr. Haney says the board actions decimated her career in emergency medicine and her income, which is about half of what she would have earned by now. She is frustrated, sad, and angry about what happened but considers herself lucky to be practicing medicine in urgent care.
 

Being investigated is scary

After her first manic episode in 2006, Dr. Haney contacted the board’s medical director, a retired general surgeon, who told her the only way the board would authorize her return to work was if she agreed to open a board investigation.

She gave them the green light because she thought she had nothing to fear – she was cooperating fully and wasn’t impaired. Now Dr. Haney says she was naive. “The board is not your friend,” she says.

Dr. Haney was also anxious to return to work. She worked in a seven-person emergency department, and two colleagues were on maternity leave or medical leave.

“My colleagues kept calling asking me when I was going to return to work, and I kept saying, ‘I don’t know because the board won’t tell me,’ “ she says.

She was also feeling a lot of financial pressure. She was 2 years out of residency, owed $100,000 in student loans, and had just bought a house.

“I was really scared – I didn’t know how long this would last or if they would let me return to work. Early on, I even got a fitness for duty evaluation from the state’s consulting psychiatrist, who cleared me for work, and the board still wouldn’t let me return. They told me I had to go through their bureaucracy and a board meeting, which didn’t make sense to me.”

Dr. Haney consented to give the board’s investigative staff access to her medical records because she feared that if she challenged them, they would suspend or revoke her license immediately.

After investigating her for 4 months, the board cleared Dr. Haney to return to work at Bay Area Hospital. She agreed to the board’s “corrective action” terms: She would continue to receive psychiatric care, maintain a physician-patient relationship with a primary care physician, and enroll in the Health Physicians Program (HPP) for substance abuse monitoring.

Dr. Haney suspects that the board investigation damaged her reputation at work. “Before this, my work evaluations were consistently excellent. Afterwards, they were all adequate. I don’t think that was a coincidence.”
 

Worst time of her life

Five years later, after taking prednisone for another asthma flare-up, Dr. Haney had a more severe manic episode and was hospitalized.

The consulting psychiatrist who evaluated her reported her case to the medical board, stating she had bipolar disorder, was mentally incompetent, and shouldn’t be practicing medicine. The board opened a second investigation of her in 2012, which lasted 4 months.

Dr. Haney had quit her job at Bay Area Hospital in 2011 because she was pregnant and was planning to take a year off to care for the baby at home.

“That was the worst time of my life. I lost the baby at 4 months, I wasn’t working, and now I was under investigation by the board again,” she says.

The board issued an “interim stipulated order” that required that she be monitored regularly for mental illness and substance abuse by the Health Professionals Services Program (HPSP) for 2 years. “The board accused me of abusing prednisone, which I wasn’t. I was using it as prescribed and medically indicated,” she said.

The board order was reported to the National Practitioner Databank and is now permanently in her record. Although the board cleared her to work, she could not find a permanent job in a hospital emergency department.

“The repeated ‘nondisciplinary’ public board orders have had the same net impact on my career as if I had been disciplined for killing or harming my patients. For all intents and purposes, people treat it as a disciplinary action for the rest of your career,” she said.

To keep afloat financially, she found locum tenens work in local emergency departments until 2019.
 

Mental health toll

Dr. Haney feels that the stress of repeated board investigations has affected her mental health. “Both times this happened, it made my mental health worse, made the mania worse, and subsequent depression worse.”

Particularly distressing to her was the fact that the administrative staff who investigated her were attorneys and persons in law enforcement, rather than medical professionals with mental health training.

“I was required to disclose intimate personal details of my psychological and psychiatric history to anybody at the board who requested them. These investigators were asking me about my childhood history. That was traumatic and none of their business!”

Dr. Haney had quietly managed episodes of major depression since she was in her early 20s with the help of a psychiatrist. Her third episode of mania, which occurred in 2014, triggered a more severe depression, which she says deepened when she learned that the HPSP had notified the board about her manic symptoms and that she would not be released from the 2-year monitoring contract. When the board notified her 2 weeks later that they were opening another investigation, Dr. Haney says she had an emotional crisis, attempted suicide, and was briefly hospitalized. Several weeks later, she decided to take a mood stabilizer, which she continues to take.

The board’s 2015 corrective action agreement required Dr. Haney to practice medicine only in settings that the board’s medical director preapproved and to obtain a preapproved monitoring health care provider who would send quarterly reports to the medical director. Dr. Haney says the “nondisciplinary” action agreement was also reported to the National Practitioner Data Bank.

She also agreed to ongoing monitoring by the HPSP for mental illness and substance abuse, which involved random drug testing. When she didn’t call in one day in 2019 and missed a scheduled test, the board opened another investigation on her that lasted 7 months until July 2020. Dr. Haney said this was despite three subsequent negative tests.

Dr. Haney believes that the “open investigation” doomed a job offer from a hospital emergency department in the Virgin Islands. “I had passed all the required credentialing and explained previous board orders. They pulled the rug from under me 1 week before I was supposed to move there,” says Dr. Haney.

Her license was inactivated again because she hadn’t practiced medicine for a year, which she says was a new board policy. Although Dr. Haney says the medical director reactivated her license after talking with her, “By the time I was able to apply emergency medicine jobs, no one was interested in me anymore.”
 

Financial toll

Dr. Haney started her medical career when she was 42 as a second career. She says the board investigations and actions have resulted in a significant loss of work and income. “I have only worked 14 of the past 17 years as a doctor. I live cheaply because I never know how much longer my career will last,” says Dr. Haney.

The ordeal has devastated her finances. She has shelled out at least $200,000 in legal fees – she hired an attorney in 2007 and filed a lawsuit against the board in Oregon district court alleging that members had violated several of her rights. The district judge sided with the state medical board, and it was upheld on appeal in 2012, referring to state laws that gave the board absolute immunity from civil lawsuits. “I had no legal recourse to contest their decisions, no matter how injurious or unjust,” says Dr. Haney.

She has also shelled out at least $100,000 to be evaluated and monitored by the health physician program (now HPSP) for several years. Physicians who agree to be monitored by these health programs have to pay their fees. The board finally agreed last July to end her HPSP participation.

Dr. Haney also filed a complaint in 2007 with the federal Department of Health & Human Services Office for Civil Rights, alleging that the board violated her civil rights under the Americans with Disabilities Act. She says that her lawsuit and the OCR investigation of the board enabled her to withdraw from the HPP in good standing in 2008..
 

What would she have done differently?

She regrets not hiring an attorney earlier because “most likely the board action would not have been made public. It snowballed after that -- any mistake I made in my career was viewed in the lens of potential impairment.”

She also regrets telling her employer about the nature of her illness and reporting it to the board. A psychiatrist she saw later shared advice he gives to other patients who want to remain anonymous: get help but go out of town, use a false name, and pay cash.

“I wish I had that advice when all this started. That was the best way to protect my career,” says Dr. Haney.
 

Protecting the public?

The Oregon Medical Board declined to comment on Dr. Haney’s experience because investigations are confidential, but the executive director, Nicole Krishnaswami, JD, answered questions in an email about how the current board operates.

She says the board has 11 medical professionals and employs a medical director and expert consultants in specialty-specific fields. MDs with mental health training are involved in investigating/reviewing cases involving doctors with mental illnesses.

“State medical boards have a responsibility to protect and inform the public. State laws further require state agencies to provide access and transparency regarding the board’s official actions. If the board receives a complaint that a licensee is impaired and thus unable to safely practice, the board has a responsibility to investigate and ensure the licensee is practicing medicine safely,” Ms. Krishnaswami said.

The HPSP is the monitoring program established by state law to provide oversight in order to ensure that licensees are not practicing while impaired. HPSP is separate from the board and the board adopted a statement outlining its perspective on the program in support of doctors with substance abuse and mental health disorder.

The board also founded the Oregon Wellness Program, which provides free, confidential counseling to all Oregon-licensed physicians and physician assistants.
 

Stigma continues

Dr. Haney feels there is huge stigma associated with mental illness in the medical profession. “If I had cancer twice, I wouldn’t have been put in this position and would be at the peak of my career,” she says.

Nearly half of the 862 emergency medicine physicians surveyed last October said they were reluctant to seek mental health treatment. The reasons included fear of professional repercussions and stigma in the workplace. Several physicians said they were concerned about potentially having to report the treatment on medical license applications in the future, according to a survey by the American College of Emergency Physicians.

In addition, 26% of the more than 12,000 physicians who responded to a Medscape survey last year said they didn’t want to risk disclosure (20%) or that they distrusted mental health professionals (6%).
 

Another physician fights back

Steven Miles, MD, an award-winning professor emeritus of medicine and bioethics at the Center for Bioethics at the University of Minnesota, in Minneapolis, understands their reluctance. In 1996, he disclosed on his license renewal application that he had recently been diagnosed with a mainly depressive type of bipolar disorder and was in treatment. He had already told his employer, who was supportive.

That set off a 14-month investigation of him by the Minnesota Board of Medical Practice. Dr. Miles and his psychiatrist refused to release his confidential records to a panel of physicians, most of whom had no expertise in mental health care. He also filed a federal claim that the board’s requests violated the ADA, and he won the case.

“Had the board given me evidence of impaired ability to practice with ordinary skill and safety, I would have cooperated. Instead, they proposed a course of action, which would have degraded the privacy of my relationship with my psychiatrist and arguably increased the barrier to getting proper care and the risk of impairment,” he said.

The board kept renewing his license, and Dr. Miles continued to work full time. “I was empowered and protected by my stature in the field at the time my mental illness was diagnosed. Early-career physicians do not yet have that protection and should be very careful of disclosing, given the still widespread stigma of mental illnesses,” he said.
 

His advocacy led to changes

Dr. Miles went public to mobilize support for his ADA claim. He wrote editorials that were published in JAMA and Minnesota Medicine that refer to the American Psychiatric Association’s 1984 position paper, which says that the mandatory disclosure of the physician’s confidential medical record is without merit. Dr. Miles adds that major newspapers ran stories based on his editorials.

The board backed down after Dr. Miles won his ADA case, and it met with him. “I said this is not good stewardship of the medical profession; you are injuring doctors by keeping them from psychiatric care, which is out of line with the medical view of the treatability of depression and that needs to change,” he says.

Dr. Miles says he won a victory because his practice continued. “I also won a victory in the way the board was handling these questions, which was an opening salvo in a process that continues to this day.”

The original form asked whether he had ever been diagnosed with or treated for manic depression, schizophrenia, compulsive gambling, or other psychiatric conditions.

The revised form asks, “Do you have a physical or mental condition that would affect your ability, with or without reasonable accommodation, to provide appropriate care to patients and otherwise perform the essential functions of a practitioner in your area of practice without posing a health or safety risk to your patients? If yes, what accommodations would help you provide appropriate care to patients and perform other essential functions?”

Dr. Miles says that the final wording wasn’t ideal and that it was confusing to physicians. He says this prompted additional changes in wording by the board. Starting in January, applicants will be asked, “Do you currently have any condition that is not being appropriately treated that is likely to impair or adversely affect your ability to practice medicine with reasonable skill and safety in a competent, ethical, and professional manner?” the medical board’s executive director, Ruth M. Martinez, said in an email.

When asked whether the board still investigates physicians who reveal mental illnesses on licensing applications, Ms. Martinez responded, “All disclosures are evaluated to assure that the practitioner is qualified and safe to practice.”

This article was updated 11/4/21.

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

Susan Haney, MD, a board-certified emergency physician in Coos Bay, Ore., was 2 years into her career when she had her first manic episode, likely a side effect of the steroid prednisone, which she had been prescribed for an asthma flare-up. Her boss at Bay Area Hospital told her that if she wanted to return to work, she would need to have written clearance from the medical board.

In retrospect, Dr. Haney says, “I don’t think they had any idea of what they would set in motion.”

Dr. Haney says the Oregon Medical Board posted her name and the nondisciplinary action on their website and in their newsletter. Her local newspaper read it and ran a story about her. “They effectively announced my mental illness to the general public despite my objections,” she says.

During the next decade, she had two more manic episodes, and more board investigations and actions followed. Despite being cleared for work each time, Dr. Haney says the board actions decimated her career in emergency medicine and her income, which is about half of what she would have earned by now. She is frustrated, sad, and angry about what happened but considers herself lucky to be practicing medicine in urgent care.
 

Being investigated is scary

After her first manic episode in 2006, Dr. Haney contacted the board’s medical director, a retired general surgeon, who told her the only way the board would authorize her return to work was if she agreed to open a board investigation.

She gave them the green light because she thought she had nothing to fear – she was cooperating fully and wasn’t impaired. Now Dr. Haney says she was naive. “The board is not your friend,” she says.

Dr. Haney was also anxious to return to work. She worked in a seven-person emergency department, and two colleagues were on maternity leave or medical leave.

“My colleagues kept calling asking me when I was going to return to work, and I kept saying, ‘I don’t know because the board won’t tell me,’ “ she says.

She was also feeling a lot of financial pressure. She was 2 years out of residency, owed $100,000 in student loans, and had just bought a house.

“I was really scared – I didn’t know how long this would last or if they would let me return to work. Early on, I even got a fitness for duty evaluation from the state’s consulting psychiatrist, who cleared me for work, and the board still wouldn’t let me return. They told me I had to go through their bureaucracy and a board meeting, which didn’t make sense to me.”

Dr. Haney consented to give the board’s investigative staff access to her medical records because she feared that if she challenged them, they would suspend or revoke her license immediately.

After investigating her for 4 months, the board cleared Dr. Haney to return to work at Bay Area Hospital. She agreed to the board’s “corrective action” terms: She would continue to receive psychiatric care, maintain a physician-patient relationship with a primary care physician, and enroll in the Health Physicians Program (HPP) for substance abuse monitoring.

Dr. Haney suspects that the board investigation damaged her reputation at work. “Before this, my work evaluations were consistently excellent. Afterwards, they were all adequate. I don’t think that was a coincidence.”
 

Worst time of her life

Five years later, after taking prednisone for another asthma flare-up, Dr. Haney had a more severe manic episode and was hospitalized.

The consulting psychiatrist who evaluated her reported her case to the medical board, stating she had bipolar disorder, was mentally incompetent, and shouldn’t be practicing medicine. The board opened a second investigation of her in 2012, which lasted 4 months.

Dr. Haney had quit her job at Bay Area Hospital in 2011 because she was pregnant and was planning to take a year off to care for the baby at home.

“That was the worst time of my life. I lost the baby at 4 months, I wasn’t working, and now I was under investigation by the board again,” she says.

The board issued an “interim stipulated order” that required that she be monitored regularly for mental illness and substance abuse by the Health Professionals Services Program (HPSP) for 2 years. “The board accused me of abusing prednisone, which I wasn’t. I was using it as prescribed and medically indicated,” she said.

The board order was reported to the National Practitioner Databank and is now permanently in her record. Although the board cleared her to work, she could not find a permanent job in a hospital emergency department.

“The repeated ‘nondisciplinary’ public board orders have had the same net impact on my career as if I had been disciplined for killing or harming my patients. For all intents and purposes, people treat it as a disciplinary action for the rest of your career,” she said.

To keep afloat financially, she found locum tenens work in local emergency departments until 2019.
 

Mental health toll

Dr. Haney feels that the stress of repeated board investigations has affected her mental health. “Both times this happened, it made my mental health worse, made the mania worse, and subsequent depression worse.”

Particularly distressing to her was the fact that the administrative staff who investigated her were attorneys and persons in law enforcement, rather than medical professionals with mental health training.

“I was required to disclose intimate personal details of my psychological and psychiatric history to anybody at the board who requested them. These investigators were asking me about my childhood history. That was traumatic and none of their business!”

Dr. Haney had quietly managed episodes of major depression since she was in her early 20s with the help of a psychiatrist. Her third episode of mania, which occurred in 2014, triggered a more severe depression, which she says deepened when she learned that the HPSP had notified the board about her manic symptoms and that she would not be released from the 2-year monitoring contract. When the board notified her 2 weeks later that they were opening another investigation, Dr. Haney says she had an emotional crisis, attempted suicide, and was briefly hospitalized. Several weeks later, she decided to take a mood stabilizer, which she continues to take.

The board’s 2015 corrective action agreement required Dr. Haney to practice medicine only in settings that the board’s medical director preapproved and to obtain a preapproved monitoring health care provider who would send quarterly reports to the medical director. Dr. Haney says the “nondisciplinary” action agreement was also reported to the National Practitioner Data Bank.

She also agreed to ongoing monitoring by the HPSP for mental illness and substance abuse, which involved random drug testing. When she didn’t call in one day in 2019 and missed a scheduled test, the board opened another investigation on her that lasted 7 months until July 2020. Dr. Haney said this was despite three subsequent negative tests.

Dr. Haney believes that the “open investigation” doomed a job offer from a hospital emergency department in the Virgin Islands. “I had passed all the required credentialing and explained previous board orders. They pulled the rug from under me 1 week before I was supposed to move there,” says Dr. Haney.

Her license was inactivated again because she hadn’t practiced medicine for a year, which she says was a new board policy. Although Dr. Haney says the medical director reactivated her license after talking with her, “By the time I was able to apply emergency medicine jobs, no one was interested in me anymore.”
 

Financial toll

Dr. Haney started her medical career when she was 42 as a second career. She says the board investigations and actions have resulted in a significant loss of work and income. “I have only worked 14 of the past 17 years as a doctor. I live cheaply because I never know how much longer my career will last,” says Dr. Haney.

The ordeal has devastated her finances. She has shelled out at least $200,000 in legal fees – she hired an attorney in 2007 and filed a lawsuit against the board in Oregon district court alleging that members had violated several of her rights. The district judge sided with the state medical board, and it was upheld on appeal in 2012, referring to state laws that gave the board absolute immunity from civil lawsuits. “I had no legal recourse to contest their decisions, no matter how injurious or unjust,” says Dr. Haney.

She has also shelled out at least $100,000 to be evaluated and monitored by the health physician program (now HPSP) for several years. Physicians who agree to be monitored by these health programs have to pay their fees. The board finally agreed last July to end her HPSP participation.

Dr. Haney also filed a complaint in 2007 with the federal Department of Health & Human Services Office for Civil Rights, alleging that the board violated her civil rights under the Americans with Disabilities Act. She says that her lawsuit and the OCR investigation of the board enabled her to withdraw from the HPP in good standing in 2008..
 

What would she have done differently?

She regrets not hiring an attorney earlier because “most likely the board action would not have been made public. It snowballed after that -- any mistake I made in my career was viewed in the lens of potential impairment.”

She also regrets telling her employer about the nature of her illness and reporting it to the board. A psychiatrist she saw later shared advice he gives to other patients who want to remain anonymous: get help but go out of town, use a false name, and pay cash.

“I wish I had that advice when all this started. That was the best way to protect my career,” says Dr. Haney.
 

Protecting the public?

The Oregon Medical Board declined to comment on Dr. Haney’s experience because investigations are confidential, but the executive director, Nicole Krishnaswami, JD, answered questions in an email about how the current board operates.

She says the board has 11 medical professionals and employs a medical director and expert consultants in specialty-specific fields. MDs with mental health training are involved in investigating/reviewing cases involving doctors with mental illnesses.

“State medical boards have a responsibility to protect and inform the public. State laws further require state agencies to provide access and transparency regarding the board’s official actions. If the board receives a complaint that a licensee is impaired and thus unable to safely practice, the board has a responsibility to investigate and ensure the licensee is practicing medicine safely,” Ms. Krishnaswami said.

The HPSP is the monitoring program established by state law to provide oversight in order to ensure that licensees are not practicing while impaired. HPSP is separate from the board and the board adopted a statement outlining its perspective on the program in support of doctors with substance abuse and mental health disorder.

The board also founded the Oregon Wellness Program, which provides free, confidential counseling to all Oregon-licensed physicians and physician assistants.
 

Stigma continues

Dr. Haney feels there is huge stigma associated with mental illness in the medical profession. “If I had cancer twice, I wouldn’t have been put in this position and would be at the peak of my career,” she says.

Nearly half of the 862 emergency medicine physicians surveyed last October said they were reluctant to seek mental health treatment. The reasons included fear of professional repercussions and stigma in the workplace. Several physicians said they were concerned about potentially having to report the treatment on medical license applications in the future, according to a survey by the American College of Emergency Physicians.

In addition, 26% of the more than 12,000 physicians who responded to a Medscape survey last year said they didn’t want to risk disclosure (20%) or that they distrusted mental health professionals (6%).
 

Another physician fights back

Steven Miles, MD, an award-winning professor emeritus of medicine and bioethics at the Center for Bioethics at the University of Minnesota, in Minneapolis, understands their reluctance. In 1996, he disclosed on his license renewal application that he had recently been diagnosed with a mainly depressive type of bipolar disorder and was in treatment. He had already told his employer, who was supportive.

That set off a 14-month investigation of him by the Minnesota Board of Medical Practice. Dr. Miles and his psychiatrist refused to release his confidential records to a panel of physicians, most of whom had no expertise in mental health care. He also filed a federal claim that the board’s requests violated the ADA, and he won the case.

“Had the board given me evidence of impaired ability to practice with ordinary skill and safety, I would have cooperated. Instead, they proposed a course of action, which would have degraded the privacy of my relationship with my psychiatrist and arguably increased the barrier to getting proper care and the risk of impairment,” he said.

The board kept renewing his license, and Dr. Miles continued to work full time. “I was empowered and protected by my stature in the field at the time my mental illness was diagnosed. Early-career physicians do not yet have that protection and should be very careful of disclosing, given the still widespread stigma of mental illnesses,” he said.
 

His advocacy led to changes

Dr. Miles went public to mobilize support for his ADA claim. He wrote editorials that were published in JAMA and Minnesota Medicine that refer to the American Psychiatric Association’s 1984 position paper, which says that the mandatory disclosure of the physician’s confidential medical record is without merit. Dr. Miles adds that major newspapers ran stories based on his editorials.

The board backed down after Dr. Miles won his ADA case, and it met with him. “I said this is not good stewardship of the medical profession; you are injuring doctors by keeping them from psychiatric care, which is out of line with the medical view of the treatability of depression and that needs to change,” he says.

Dr. Miles says he won a victory because his practice continued. “I also won a victory in the way the board was handling these questions, which was an opening salvo in a process that continues to this day.”

The original form asked whether he had ever been diagnosed with or treated for manic depression, schizophrenia, compulsive gambling, or other psychiatric conditions.

The revised form asks, “Do you have a physical or mental condition that would affect your ability, with or without reasonable accommodation, to provide appropriate care to patients and otherwise perform the essential functions of a practitioner in your area of practice without posing a health or safety risk to your patients? If yes, what accommodations would help you provide appropriate care to patients and perform other essential functions?”

Dr. Miles says that the final wording wasn’t ideal and that it was confusing to physicians. He says this prompted additional changes in wording by the board. Starting in January, applicants will be asked, “Do you currently have any condition that is not being appropriately treated that is likely to impair or adversely affect your ability to practice medicine with reasonable skill and safety in a competent, ethical, and professional manner?” the medical board’s executive director, Ruth M. Martinez, said in an email.

When asked whether the board still investigates physicians who reveal mental illnesses on licensing applications, Ms. Martinez responded, “All disclosures are evaluated to assure that the practitioner is qualified and safe to practice.”

This article was updated 11/4/21.

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

No, Mr. Bond, I expect you to die

Movie watching usually requires a certain suspension of disbelief, and it’s safe to say James Bond movies require this more than most. Between the impossible gadgets and ludicrous doomsday plans, very few have ever stopped to consider the health risks of the James Bond universe.

Tumisu/Pixabay

Now, however, Bond, James Bond, has met his most formidable opponent: Wouter Graumans, a graduate student in epidemiology from the Netherlands. During a foray to Burkina Faso to study infectious diseases, Mr. Graumans came down with a case of food poisoning, which led him to wonder how 007 is able to trot across this big world of ours without contracting so much as a sinus infection.

Because Mr. Graumans is a man of science and conviction, mere speculation wasn’t enough. He and a group of coauthors wrote an entire paper on the health risks of the James Bond universe.

Doing so required watching over 3,000 minutes of numerous movies and analyzing Bond’s 86 total trips to 46 different countries based on current Centers for Disease Control and Prevention advice for travel to those countries. Time which, the authors state in the abstract, “could easily have been spent on more pressing societal issues or forms of relaxation that are more acceptable in academic circles.”

Naturally, Mr. Bond’s line of work entails exposure to unpleasant things, such as poison, dehydration, heatstroke, and dangerous wildlife (everything from ticks to crocodiles), though oddly enough he never succumbs to any of it. He’s also curiously immune to hangovers, despite rarely drinking anything nonalcoholic. There are also less obvious risks: For one, 007 rarely washes his hands. During one movie, he handles raw chicken to lure away a pack of crocodiles but fails to wash his hands afterward, leaving him at risk for multiple food-borne illnesses.

Of course, we must address the elephant in the bedroom: Mr. Bond’s numerous, er, encounters with women. One would imagine the biggest risk to those women would be from the various STDs that likely course through Bond’s body, but of the 27% who died shortly after … encountering … him, all involved violence, with disease playing no obvious role. Who knows, maybe he’s clean? Stranger things have happened.

The timing of this article may seem a bit suspicious. Was it a PR stunt by the studio? Rest assured, the authors addressed this, noting that they received no funding for the study, and that, “given the futility of its academic value, this is deemed entirely appropriate by all authors.” We love when a punchline writes itself.
 

How to see Atlanta on $688.35 a day

The world is always changing, so we have to change with it. This week, LOTME becomes a travel guide, and our first stop is the Big A, the Big Peach, Dogwood City, Empire City of the South, Wakanda.

There’s lots to do in Atlanta: Celebrate a World Series win, visit the College Football Hall of Fame or the World of Coca Cola, or take the Stranger Things/Upside Down film locations tour. Serious adventurers, however, get out of the city and go to Emory Decatur Hospital in – you guessed it – Decatur (unofficial motto: “Everything is Greater in Decatur”).

©Getty Images

Find the emergency room and ask for Taylor Davis, who will be your personal guide. She’ll show you how to check in at the desk, sit in the waiting room for 7 hours, and then leave without seeing any medical personnel or receiving any sort of attention whatsoever. All the things she did when she went there in July for a head injury.

Ms. Davis told Fox5 Atlanta: “I didn’t get my vitals taken, nobody called my name. I wasn’t seen at all.”

But wait! There’s more! By booking your trip through LOTMEgo* and using the code “Decatur,” you’ll get the Taylor Davis special, which includes a bill/cover charge for $688.35 from the hospital. An Emory Healthcare patient financial services employee told Ms. Davis that “you get charged before you are seen. Not for being seen.”

If all this has you ready to hop in your car (really?), then check out LOTMEgo* on Twittbook and InstaTok. You’ll also find trick-or-treating tips and discounts on haunted hospital tours.

*Does not actually exist

Breaking down the hot flash

Do you ever wonder why we scramble for cold things when we’re feeling nauseous? Whether it’s the cool air that needs to hit your face in the car or a cold, damp towel on the back of your neck, scientists think it could possibly be an evolutionary mechanism at the cellular level.

Piqsels

Motion sickness it’s actually a battle of body temperature, according to an article from LiveScience. Capillaries in the skin dilate, allowing for more blood flow near the skin’s surface and causing core temperature to fall. Once body temperature drops, the hypothalamus, which regulates temperature, tries to do its job by raising body temperature. Thus the hot flash!

The cold compress and cool air help fight the battle by counteracting the hypothalamus, but why the drop in body temperature to begin with?

There are a few theories. Dr. Robert Glatter, an emergency physician at Lenox Hill Hospital in New York, told LiveScience that the lack of oxygen needed in body tissue to survive at lower temperatures could be making it difficult to get oxygen to the body when a person is ill, and is “more likely an adaptive response influenced by poorly understood mechanisms at the cellular level.”

Another theory is that the nausea and body temperature shift is the body’s natural response to help people vomit.

Then there’s the theory of “defensive hypothermia,” which suggests that cold sweats are a possible mechanism to conserve energy so the body can fight off an intruder, which was supported by a 2014 study and a 2016 review.

It’s another one of the body’s many survival tricks.
 

Teachers were right: Pupils can do the math

Teachers liked to preach that we wouldn’t have calculators with us all the time, but that wound up not being true. Our phones have calculators at the press of a button. But maybe even calculators aren’t always needed because our pupils do more math than you think.

pxfuel

The pupil light reflex – constrict in light and dilate in darkness – is well known, but recent work shows that pupil size is also regulated by cognitive and perceptual factors. By presenting subjects with images of various numbers of dots and measuring pupil size, the investigators were able to show “that numerical information is intrinsically related to perception,” lead author Dr. Elisa Castaldi of Florence University noted in a written statement.

The researchers found that pupils are responsible for important survival techniques. Coauthor David Burr of the University of Sydney and the University of Florence gave an evolutionary perspective: “When we look around, we spontaneously perceive the form, size, movement and colour of a scene. Equally spontaneously, we perceive the number of items before us. This ability, shared with most other animals, is an evolutionary fundamental: It reveals immediately important quantities, such as how many apples there are on the tree, or how many enemies are attacking.”

Useful information, indeed, but our pupils seem to be more interested in the quantity of beers in the refrigerator.

No, Mr. Bond, I expect you to die

Movie watching usually requires a certain suspension of disbelief, and it’s safe to say James Bond movies require this more than most. Between the impossible gadgets and ludicrous doomsday plans, very few have ever stopped to consider the health risks of the James Bond universe.

Tumisu/Pixabay

Now, however, Bond, James Bond, has met his most formidable opponent: Wouter Graumans, a graduate student in epidemiology from the Netherlands. During a foray to Burkina Faso to study infectious diseases, Mr. Graumans came down with a case of food poisoning, which led him to wonder how 007 is able to trot across this big world of ours without contracting so much as a sinus infection.

Because Mr. Graumans is a man of science and conviction, mere speculation wasn’t enough. He and a group of coauthors wrote an entire paper on the health risks of the James Bond universe.

Doing so required watching over 3,000 minutes of numerous movies and analyzing Bond’s 86 total trips to 46 different countries based on current Centers for Disease Control and Prevention advice for travel to those countries. Time which, the authors state in the abstract, “could easily have been spent on more pressing societal issues or forms of relaxation that are more acceptable in academic circles.”

Naturally, Mr. Bond’s line of work entails exposure to unpleasant things, such as poison, dehydration, heatstroke, and dangerous wildlife (everything from ticks to crocodiles), though oddly enough he never succumbs to any of it. He’s also curiously immune to hangovers, despite rarely drinking anything nonalcoholic. There are also less obvious risks: For one, 007 rarely washes his hands. During one movie, he handles raw chicken to lure away a pack of crocodiles but fails to wash his hands afterward, leaving him at risk for multiple food-borne illnesses.

Of course, we must address the elephant in the bedroom: Mr. Bond’s numerous, er, encounters with women. One would imagine the biggest risk to those women would be from the various STDs that likely course through Bond’s body, but of the 27% who died shortly after … encountering … him, all involved violence, with disease playing no obvious role. Who knows, maybe he’s clean? Stranger things have happened.

The timing of this article may seem a bit suspicious. Was it a PR stunt by the studio? Rest assured, the authors addressed this, noting that they received no funding for the study, and that, “given the futility of its academic value, this is deemed entirely appropriate by all authors.” We love when a punchline writes itself.
 

How to see Atlanta on $688.35 a day

The world is always changing, so we have to change with it. This week, LOTME becomes a travel guide, and our first stop is the Big A, the Big Peach, Dogwood City, Empire City of the South, Wakanda.

There’s lots to do in Atlanta: Celebrate a World Series win, visit the College Football Hall of Fame or the World of Coca Cola, or take the Stranger Things/Upside Down film locations tour. Serious adventurers, however, get out of the city and go to Emory Decatur Hospital in – you guessed it – Decatur (unofficial motto: “Everything is Greater in Decatur”).

©Getty Images

Find the emergency room and ask for Taylor Davis, who will be your personal guide. She’ll show you how to check in at the desk, sit in the waiting room for 7 hours, and then leave without seeing any medical personnel or receiving any sort of attention whatsoever. All the things she did when she went there in July for a head injury.

Ms. Davis told Fox5 Atlanta: “I didn’t get my vitals taken, nobody called my name. I wasn’t seen at all.”

But wait! There’s more! By booking your trip through LOTMEgo* and using the code “Decatur,” you’ll get the Taylor Davis special, which includes a bill/cover charge for $688.35 from the hospital. An Emory Healthcare patient financial services employee told Ms. Davis that “you get charged before you are seen. Not for being seen.”

If all this has you ready to hop in your car (really?), then check out LOTMEgo* on Twittbook and InstaTok. You’ll also find trick-or-treating tips and discounts on haunted hospital tours.

*Does not actually exist

Breaking down the hot flash

Do you ever wonder why we scramble for cold things when we’re feeling nauseous? Whether it’s the cool air that needs to hit your face in the car or a cold, damp towel on the back of your neck, scientists think it could possibly be an evolutionary mechanism at the cellular level.

Piqsels

Motion sickness it’s actually a battle of body temperature, according to an article from LiveScience. Capillaries in the skin dilate, allowing for more blood flow near the skin’s surface and causing core temperature to fall. Once body temperature drops, the hypothalamus, which regulates temperature, tries to do its job by raising body temperature. Thus the hot flash!

The cold compress and cool air help fight the battle by counteracting the hypothalamus, but why the drop in body temperature to begin with?

There are a few theories. Dr. Robert Glatter, an emergency physician at Lenox Hill Hospital in New York, told LiveScience that the lack of oxygen needed in body tissue to survive at lower temperatures could be making it difficult to get oxygen to the body when a person is ill, and is “more likely an adaptive response influenced by poorly understood mechanisms at the cellular level.”

Another theory is that the nausea and body temperature shift is the body’s natural response to help people vomit.

Then there’s the theory of “defensive hypothermia,” which suggests that cold sweats are a possible mechanism to conserve energy so the body can fight off an intruder, which was supported by a 2014 study and a 2016 review.

It’s another one of the body’s many survival tricks.
 

Teachers were right: Pupils can do the math

Teachers liked to preach that we wouldn’t have calculators with us all the time, but that wound up not being true. Our phones have calculators at the press of a button. But maybe even calculators aren’t always needed because our pupils do more math than you think.

pxfuel

The pupil light reflex – constrict in light and dilate in darkness – is well known, but recent work shows that pupil size is also regulated by cognitive and perceptual factors. By presenting subjects with images of various numbers of dots and measuring pupil size, the investigators were able to show “that numerical information is intrinsically related to perception,” lead author Dr. Elisa Castaldi of Florence University noted in a written statement.

The researchers found that pupils are responsible for important survival techniques. Coauthor David Burr of the University of Sydney and the University of Florence gave an evolutionary perspective: “When we look around, we spontaneously perceive the form, size, movement and colour of a scene. Equally spontaneously, we perceive the number of items before us. This ability, shared with most other animals, is an evolutionary fundamental: It reveals immediately important quantities, such as how many apples there are on the tree, or how many enemies are attacking.”

Useful information, indeed, but our pupils seem to be more interested in the quantity of beers in the refrigerator.

No, Mr. Bond, I expect you to die

Movie watching usually requires a certain suspension of disbelief, and it’s safe to say James Bond movies require this more than most. Between the impossible gadgets and ludicrous doomsday plans, very few have ever stopped to consider the health risks of the James Bond universe.

Tumisu/Pixabay

Now, however, Bond, James Bond, has met his most formidable opponent: Wouter Graumans, a graduate student in epidemiology from the Netherlands. During a foray to Burkina Faso to study infectious diseases, Mr. Graumans came down with a case of food poisoning, which led him to wonder how 007 is able to trot across this big world of ours without contracting so much as a sinus infection.

Because Mr. Graumans is a man of science and conviction, mere speculation wasn’t enough. He and a group of coauthors wrote an entire paper on the health risks of the James Bond universe.

Doing so required watching over 3,000 minutes of numerous movies and analyzing Bond’s 86 total trips to 46 different countries based on current Centers for Disease Control and Prevention advice for travel to those countries. Time which, the authors state in the abstract, “could easily have been spent on more pressing societal issues or forms of relaxation that are more acceptable in academic circles.”

Naturally, Mr. Bond’s line of work entails exposure to unpleasant things, such as poison, dehydration, heatstroke, and dangerous wildlife (everything from ticks to crocodiles), though oddly enough he never succumbs to any of it. He’s also curiously immune to hangovers, despite rarely drinking anything nonalcoholic. There are also less obvious risks: For one, 007 rarely washes his hands. During one movie, he handles raw chicken to lure away a pack of crocodiles but fails to wash his hands afterward, leaving him at risk for multiple food-borne illnesses.

Of course, we must address the elephant in the bedroom: Mr. Bond’s numerous, er, encounters with women. One would imagine the biggest risk to those women would be from the various STDs that likely course through Bond’s body, but of the 27% who died shortly after … encountering … him, all involved violence, with disease playing no obvious role. Who knows, maybe he’s clean? Stranger things have happened.

The timing of this article may seem a bit suspicious. Was it a PR stunt by the studio? Rest assured, the authors addressed this, noting that they received no funding for the study, and that, “given the futility of its academic value, this is deemed entirely appropriate by all authors.” We love when a punchline writes itself.
 

How to see Atlanta on $688.35 a day

The world is always changing, so we have to change with it. This week, LOTME becomes a travel guide, and our first stop is the Big A, the Big Peach, Dogwood City, Empire City of the South, Wakanda.

There’s lots to do in Atlanta: Celebrate a World Series win, visit the College Football Hall of Fame or the World of Coca Cola, or take the Stranger Things/Upside Down film locations tour. Serious adventurers, however, get out of the city and go to Emory Decatur Hospital in – you guessed it – Decatur (unofficial motto: “Everything is Greater in Decatur”).

©Getty Images

Find the emergency room and ask for Taylor Davis, who will be your personal guide. She’ll show you how to check in at the desk, sit in the waiting room for 7 hours, and then leave without seeing any medical personnel or receiving any sort of attention whatsoever. All the things she did when she went there in July for a head injury.

Ms. Davis told Fox5 Atlanta: “I didn’t get my vitals taken, nobody called my name. I wasn’t seen at all.”

But wait! There’s more! By booking your trip through LOTMEgo* and using the code “Decatur,” you’ll get the Taylor Davis special, which includes a bill/cover charge for $688.35 from the hospital. An Emory Healthcare patient financial services employee told Ms. Davis that “you get charged before you are seen. Not for being seen.”

If all this has you ready to hop in your car (really?), then check out LOTMEgo* on Twittbook and InstaTok. You’ll also find trick-or-treating tips and discounts on haunted hospital tours.

*Does not actually exist

Breaking down the hot flash

Do you ever wonder why we scramble for cold things when we’re feeling nauseous? Whether it’s the cool air that needs to hit your face in the car or a cold, damp towel on the back of your neck, scientists think it could possibly be an evolutionary mechanism at the cellular level.

Piqsels

Motion sickness it’s actually a battle of body temperature, according to an article from LiveScience. Capillaries in the skin dilate, allowing for more blood flow near the skin’s surface and causing core temperature to fall. Once body temperature drops, the hypothalamus, which regulates temperature, tries to do its job by raising body temperature. Thus the hot flash!

The cold compress and cool air help fight the battle by counteracting the hypothalamus, but why the drop in body temperature to begin with?

There are a few theories. Dr. Robert Glatter, an emergency physician at Lenox Hill Hospital in New York, told LiveScience that the lack of oxygen needed in body tissue to survive at lower temperatures could be making it difficult to get oxygen to the body when a person is ill, and is “more likely an adaptive response influenced by poorly understood mechanisms at the cellular level.”

Another theory is that the nausea and body temperature shift is the body’s natural response to help people vomit.

Then there’s the theory of “defensive hypothermia,” which suggests that cold sweats are a possible mechanism to conserve energy so the body can fight off an intruder, which was supported by a 2014 study and a 2016 review.

It’s another one of the body’s many survival tricks.
 

Teachers were right: Pupils can do the math

Teachers liked to preach that we wouldn’t have calculators with us all the time, but that wound up not being true. Our phones have calculators at the press of a button. But maybe even calculators aren’t always needed because our pupils do more math than you think.

pxfuel

The pupil light reflex – constrict in light and dilate in darkness – is well known, but recent work shows that pupil size is also regulated by cognitive and perceptual factors. By presenting subjects with images of various numbers of dots and measuring pupil size, the investigators were able to show “that numerical information is intrinsically related to perception,” lead author Dr. Elisa Castaldi of Florence University noted in a written statement.

The researchers found that pupils are responsible for important survival techniques. Coauthor David Burr of the University of Sydney and the University of Florence gave an evolutionary perspective: “When we look around, we spontaneously perceive the form, size, movement and colour of a scene. Equally spontaneously, we perceive the number of items before us. This ability, shared with most other animals, is an evolutionary fundamental: It reveals immediately important quantities, such as how many apples there are on the tree, or how many enemies are attacking.”

Useful information, indeed, but our pupils seem to be more interested in the quantity of beers in the refrigerator.

Financial hardship remains prevalent among pregnant and postpartum women, despite the implementation of the Affordable Care Act (ACA), according to new findings published in JAMA Network Open.

Nearly a quarter (24%) of pregnant and postpartum women reported having unmet health care needs, 60% had health care unaffordability, and 54% reported general financial stress. Notably, the type of insurance was associated with the ability to afford health care.

Those with private insurance, along with women with lower incomes, were more likely to experience unaffordable health care, compared to those covered by public insurance or who had higher incomes.

Senior study author Michelle H. Moniz, MD, assistant professor in the department of obstetrics and gynecology at the University of Michigan, Ann Arbor, was surprised by multiple study findings. “The prevalence of financial hardship overall, and the three individual indicators of hardship, did not change over time from 2013 to 2018,” she said. “The ACA was enacted just prior to the study period, and while this policy had many benefits for women – especially around increasing insurance coverage – it does not seem to have improved financial hardship among pregnant and postpartum women.”

She emphasized that two groups were at the highest risk of health care unaffordability: those with private insurance and those living on low incomes. “This is notable, as we often think of private insurance as offering ‘Cadillac coverage,’ but our prior work suggests that privately insured women have strikingly high out-of-pocket costs for pregnancy and childbirth-related care,” Dr. Moniz said.

These expenses include deductibles, copays, and coinsurance payments, which come to about $4,500 on average. Medicaid plans, in contrast, have exceedingly low out-of-pocket costs for pregnant and postpartum women. “Findings from the current study call for targeted policy interventions to alleviate financial strain and remove financial barriers to health care access for privately insured families,” she said. “Similarly, families living on lower incomes were also at high risk of health care unaffordability. This may be because even small out-of-pocket costs, or health care–associated costs, account for a larger share of the family’s income.”

This finding for lower-income women calls for targeted policy interventions. “Sliding-scale deductibles, for example, are one solution that might mitigate economic hardship and remove cost-related barriers to health care for pregnant and postpartum women,” Dr. Moniz added.

Health care unaffordability high

In this study, Dr. Moniz and colleagues evaluated the prevalence of financial hardship among peripartum women over time, and how it was affected by their income level and the type of insurance coverage.

They conducted a cross-sectional study that included peripartum women between the ages of 18 and 45 years who reported being currently pregnant or pregnant in the past 12 months. The women were all participants in the National Health Interview Survey, which covers the period from 2013 to 2018, and the data were analyzed from January to May 2021.

The cohort included 3,509 peripartum women, and was weighted to represent 1,050,789 women, with a mean age of 29 years. In 2018, an estimated 39,017 of 184,018 (21.2%) were Black; 36,045 (19.6%) were Hispanic; and 97,366 (52.9%) were White. In the latter years of the study period, the participants tended to be older, more highly educated, and less likely to lack insurance.

When the authors compared the unadjusted reported financial hardship outcome by each study year, unmet health care need (2013: 27.9% [95% confidence interval, 24.4%-31.7%]; 2018: 23.7% [95% CI, 19.5%-28.6%]), health care unaffordability (2013: 65.7% [95% CI, 61.1%-70.0%]; 2018: 58.8% [95% CI, 53.4%-64.0%]), and general financial stress (2013: 60.6% [95% CI, 55.2%-65.8%]; 2018: 53.8% [95% CI, 47.8%-59.8%]) remained largely unchanged between 2013 and 2018.

When they looked at the relationship between insurance type, income, and financial difficulties, some degree of financial hardship was common across all groups; private insurance: 63.8% [95% CI, 61.1%-66.6%]; with public insurance: 49.9% [95% CI, 46.4%-53.4%]; with no insurance: 81.8% [95% CI, 76.4%-87.3%]; with income < 400% of the federal poverty level (FPL): 65.5% [95% CI, 62.1%-66.9%]; with income at least 400% of the FPL: 49.3% [95% CI,44.7%-53.9%]).

Those without any insurance had the highest odds of reporting unmet health care needs (adjusted OR [aOR], 4.40; 95% CI, 3.23-6.00) and health care unaffordability (aOR, 5.18; 95% CI, 3.49-7.70) compared with women who received public insurance.

But while women with private insurance had lower odds of reporting unmet health care needs (aOR, 0.67; 95% CI, 0.52-0.87), they faced higher odds of reporting health care unaffordability (aOR, 1.88; 95% CI, 1.49-2.36) compared to women who had public insurance.

Those with household incomes of less than 400% of the FPL had higher odds of reporting unmet health care need (aOR,1.50; 95% CI, 1.08-2.08) and health care unaffordability (aOR, 1.98; 95% CI, 1.54-2.55) versus women whose household incomes were at least 400% of FPL. The odds of general financial stress did not significantly differ by insurance status/type or income level.

Weighing in on the data

Jamie Daw, PhD, assistant professor of health policy and management, Columbia University Mailman School of Public Health, New York, noted that many people think of private insurance as “good coverage.”

“But the portion of medical costs that patients are required to pay under private plans has risen dramatically over the past decade,” she said. “Over half of the U.S. workforce is now enrolled in high-deductible plans, where the average deductible was $4,500 in 2020. The private insurance of today does not provide sufficient financial protection for most families, who would need to have the liquid assets to cover childbirth.”

Another expert agreed that the high out-of-pocket costs for women with private health insurance were probably responsible for making peripartum health care more unaffordable. These included costs for pregnancy care as well as for maternal and infant care during and after childbirth.

“This study reporting the high unmet medical needs and unaffordability of health care for peripartum women further underscores that the U.S. health care system is not meeting the needs of pregnant women, mothers, and their newborn infants,” said Lois K. Lee, MD, associate professor of pediatrics and emergency medicine at Harvard Medical School and associate director for public policy at the Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion, Boston.

“It is imperative to optimize the health of pregnant mothers to optimize the health of infants, who are our future society,” she said. “Policies which would expand Medicaid coverage to a full 1-year postpartum across all states is one important strategy to improve health care access and affordability to peripartum women. However, this must be part of a multipronged approach addressing the social determinants of health, as insurance coverage alone will not fully address this important health issue of peripartum women, and their children.”

Dr Moniz reported receiving personal fees from the RAND Corporation, the Society of Family Planning outside the submitted work and grant K08 HS025465 from the Agency for Healthcare Research and Quality. Dr. Daw has no disclosures. Dr. Lee reports speaker fees from the American Academy of Pediatrics and SUNY Upstate Medical University. Coauthor Dr. Taylor was supported by the National Clinician Scholars Program at the University of Michigan. Dr Dalton was supported by grant R01 HS023784 from the Agency for Healthcare Research and Quality.
 

Financial hardship remains prevalent among pregnant and postpartum women, despite the implementation of the Affordable Care Act (ACA), according to new findings published in JAMA Network Open.

Nearly a quarter (24%) of pregnant and postpartum women reported having unmet health care needs, 60% had health care unaffordability, and 54% reported general financial stress. Notably, the type of insurance was associated with the ability to afford health care.

Those with private insurance, along with women with lower incomes, were more likely to experience unaffordable health care, compared to those covered by public insurance or who had higher incomes.

Senior study author Michelle H. Moniz, MD, assistant professor in the department of obstetrics and gynecology at the University of Michigan, Ann Arbor, was surprised by multiple study findings. “The prevalence of financial hardship overall, and the three individual indicators of hardship, did not change over time from 2013 to 2018,” she said. “The ACA was enacted just prior to the study period, and while this policy had many benefits for women – especially around increasing insurance coverage – it does not seem to have improved financial hardship among pregnant and postpartum women.”

She emphasized that two groups were at the highest risk of health care unaffordability: those with private insurance and those living on low incomes. “This is notable, as we often think of private insurance as offering ‘Cadillac coverage,’ but our prior work suggests that privately insured women have strikingly high out-of-pocket costs for pregnancy and childbirth-related care,” Dr. Moniz said.

These expenses include deductibles, copays, and coinsurance payments, which come to about $4,500 on average. Medicaid plans, in contrast, have exceedingly low out-of-pocket costs for pregnant and postpartum women. “Findings from the current study call for targeted policy interventions to alleviate financial strain and remove financial barriers to health care access for privately insured families,” she said. “Similarly, families living on lower incomes were also at high risk of health care unaffordability. This may be because even small out-of-pocket costs, or health care–associated costs, account for a larger share of the family’s income.”

This finding for lower-income women calls for targeted policy interventions. “Sliding-scale deductibles, for example, are one solution that might mitigate economic hardship and remove cost-related barriers to health care for pregnant and postpartum women,” Dr. Moniz added.

Health care unaffordability high

In this study, Dr. Moniz and colleagues evaluated the prevalence of financial hardship among peripartum women over time, and how it was affected by their income level and the type of insurance coverage.

They conducted a cross-sectional study that included peripartum women between the ages of 18 and 45 years who reported being currently pregnant or pregnant in the past 12 months. The women were all participants in the National Health Interview Survey, which covers the period from 2013 to 2018, and the data were analyzed from January to May 2021.

The cohort included 3,509 peripartum women, and was weighted to represent 1,050,789 women, with a mean age of 29 years. In 2018, an estimated 39,017 of 184,018 (21.2%) were Black; 36,045 (19.6%) were Hispanic; and 97,366 (52.9%) were White. In the latter years of the study period, the participants tended to be older, more highly educated, and less likely to lack insurance.

When the authors compared the unadjusted reported financial hardship outcome by each study year, unmet health care need (2013: 27.9% [95% confidence interval, 24.4%-31.7%]; 2018: 23.7% [95% CI, 19.5%-28.6%]), health care unaffordability (2013: 65.7% [95% CI, 61.1%-70.0%]; 2018: 58.8% [95% CI, 53.4%-64.0%]), and general financial stress (2013: 60.6% [95% CI, 55.2%-65.8%]; 2018: 53.8% [95% CI, 47.8%-59.8%]) remained largely unchanged between 2013 and 2018.

When they looked at the relationship between insurance type, income, and financial difficulties, some degree of financial hardship was common across all groups; private insurance: 63.8% [95% CI, 61.1%-66.6%]; with public insurance: 49.9% [95% CI, 46.4%-53.4%]; with no insurance: 81.8% [95% CI, 76.4%-87.3%]; with income < 400% of the federal poverty level (FPL): 65.5% [95% CI, 62.1%-66.9%]; with income at least 400% of the FPL: 49.3% [95% CI,44.7%-53.9%]).

Those without any insurance had the highest odds of reporting unmet health care needs (adjusted OR [aOR], 4.40; 95% CI, 3.23-6.00) and health care unaffordability (aOR, 5.18; 95% CI, 3.49-7.70) compared with women who received public insurance.

But while women with private insurance had lower odds of reporting unmet health care needs (aOR, 0.67; 95% CI, 0.52-0.87), they faced higher odds of reporting health care unaffordability (aOR, 1.88; 95% CI, 1.49-2.36) compared to women who had public insurance.

Those with household incomes of less than 400% of the FPL had higher odds of reporting unmet health care need (aOR,1.50; 95% CI, 1.08-2.08) and health care unaffordability (aOR, 1.98; 95% CI, 1.54-2.55) versus women whose household incomes were at least 400% of FPL. The odds of general financial stress did not significantly differ by insurance status/type or income level.

Weighing in on the data

Jamie Daw, PhD, assistant professor of health policy and management, Columbia University Mailman School of Public Health, New York, noted that many people think of private insurance as “good coverage.”

“But the portion of medical costs that patients are required to pay under private plans has risen dramatically over the past decade,” she said. “Over half of the U.S. workforce is now enrolled in high-deductible plans, where the average deductible was $4,500 in 2020. The private insurance of today does not provide sufficient financial protection for most families, who would need to have the liquid assets to cover childbirth.”

Another expert agreed that the high out-of-pocket costs for women with private health insurance were probably responsible for making peripartum health care more unaffordable. These included costs for pregnancy care as well as for maternal and infant care during and after childbirth.

“This study reporting the high unmet medical needs and unaffordability of health care for peripartum women further underscores that the U.S. health care system is not meeting the needs of pregnant women, mothers, and their newborn infants,” said Lois K. Lee, MD, associate professor of pediatrics and emergency medicine at Harvard Medical School and associate director for public policy at the Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion, Boston.

“It is imperative to optimize the health of pregnant mothers to optimize the health of infants, who are our future society,” she said. “Policies which would expand Medicaid coverage to a full 1-year postpartum across all states is one important strategy to improve health care access and affordability to peripartum women. However, this must be part of a multipronged approach addressing the social determinants of health, as insurance coverage alone will not fully address this important health issue of peripartum women, and their children.”

Dr Moniz reported receiving personal fees from the RAND Corporation, the Society of Family Planning outside the submitted work and grant K08 HS025465 from the Agency for Healthcare Research and Quality. Dr. Daw has no disclosures. Dr. Lee reports speaker fees from the American Academy of Pediatrics and SUNY Upstate Medical University. Coauthor Dr. Taylor was supported by the National Clinician Scholars Program at the University of Michigan. Dr Dalton was supported by grant R01 HS023784 from the Agency for Healthcare Research and Quality.
 

Financial hardship remains prevalent among pregnant and postpartum women, despite the implementation of the Affordable Care Act (ACA), according to new findings published in JAMA Network Open.

Nearly a quarter (24%) of pregnant and postpartum women reported having unmet health care needs, 60% had health care unaffordability, and 54% reported general financial stress. Notably, the type of insurance was associated with the ability to afford health care.

Those with private insurance, along with women with lower incomes, were more likely to experience unaffordable health care, compared to those covered by public insurance or who had higher incomes.

Senior study author Michelle H. Moniz, MD, assistant professor in the department of obstetrics and gynecology at the University of Michigan, Ann Arbor, was surprised by multiple study findings. “The prevalence of financial hardship overall, and the three individual indicators of hardship, did not change over time from 2013 to 2018,” she said. “The ACA was enacted just prior to the study period, and while this policy had many benefits for women – especially around increasing insurance coverage – it does not seem to have improved financial hardship among pregnant and postpartum women.”

She emphasized that two groups were at the highest risk of health care unaffordability: those with private insurance and those living on low incomes. “This is notable, as we often think of private insurance as offering ‘Cadillac coverage,’ but our prior work suggests that privately insured women have strikingly high out-of-pocket costs for pregnancy and childbirth-related care,” Dr. Moniz said.

These expenses include deductibles, copays, and coinsurance payments, which come to about $4,500 on average. Medicaid plans, in contrast, have exceedingly low out-of-pocket costs for pregnant and postpartum women. “Findings from the current study call for targeted policy interventions to alleviate financial strain and remove financial barriers to health care access for privately insured families,” she said. “Similarly, families living on lower incomes were also at high risk of health care unaffordability. This may be because even small out-of-pocket costs, or health care–associated costs, account for a larger share of the family’s income.”

This finding for lower-income women calls for targeted policy interventions. “Sliding-scale deductibles, for example, are one solution that might mitigate economic hardship and remove cost-related barriers to health care for pregnant and postpartum women,” Dr. Moniz added.

Health care unaffordability high

In this study, Dr. Moniz and colleagues evaluated the prevalence of financial hardship among peripartum women over time, and how it was affected by their income level and the type of insurance coverage.

They conducted a cross-sectional study that included peripartum women between the ages of 18 and 45 years who reported being currently pregnant or pregnant in the past 12 months. The women were all participants in the National Health Interview Survey, which covers the period from 2013 to 2018, and the data were analyzed from January to May 2021.

The cohort included 3,509 peripartum women, and was weighted to represent 1,050,789 women, with a mean age of 29 years. In 2018, an estimated 39,017 of 184,018 (21.2%) were Black; 36,045 (19.6%) were Hispanic; and 97,366 (52.9%) were White. In the latter years of the study period, the participants tended to be older, more highly educated, and less likely to lack insurance.

When the authors compared the unadjusted reported financial hardship outcome by each study year, unmet health care need (2013: 27.9% [95% confidence interval, 24.4%-31.7%]; 2018: 23.7% [95% CI, 19.5%-28.6%]), health care unaffordability (2013: 65.7% [95% CI, 61.1%-70.0%]; 2018: 58.8% [95% CI, 53.4%-64.0%]), and general financial stress (2013: 60.6% [95% CI, 55.2%-65.8%]; 2018: 53.8% [95% CI, 47.8%-59.8%]) remained largely unchanged between 2013 and 2018.

When they looked at the relationship between insurance type, income, and financial difficulties, some degree of financial hardship was common across all groups; private insurance: 63.8% [95% CI, 61.1%-66.6%]; with public insurance: 49.9% [95% CI, 46.4%-53.4%]; with no insurance: 81.8% [95% CI, 76.4%-87.3%]; with income < 400% of the federal poverty level (FPL): 65.5% [95% CI, 62.1%-66.9%]; with income at least 400% of the FPL: 49.3% [95% CI,44.7%-53.9%]).

Those without any insurance had the highest odds of reporting unmet health care needs (adjusted OR [aOR], 4.40; 95% CI, 3.23-6.00) and health care unaffordability (aOR, 5.18; 95% CI, 3.49-7.70) compared with women who received public insurance.

But while women with private insurance had lower odds of reporting unmet health care needs (aOR, 0.67; 95% CI, 0.52-0.87), they faced higher odds of reporting health care unaffordability (aOR, 1.88; 95% CI, 1.49-2.36) compared to women who had public insurance.

Those with household incomes of less than 400% of the FPL had higher odds of reporting unmet health care need (aOR,1.50; 95% CI, 1.08-2.08) and health care unaffordability (aOR, 1.98; 95% CI, 1.54-2.55) versus women whose household incomes were at least 400% of FPL. The odds of general financial stress did not significantly differ by insurance status/type or income level.

Weighing in on the data

Jamie Daw, PhD, assistant professor of health policy and management, Columbia University Mailman School of Public Health, New York, noted that many people think of private insurance as “good coverage.”

“But the portion of medical costs that patients are required to pay under private plans has risen dramatically over the past decade,” she said. “Over half of the U.S. workforce is now enrolled in high-deductible plans, where the average deductible was $4,500 in 2020. The private insurance of today does not provide sufficient financial protection for most families, who would need to have the liquid assets to cover childbirth.”

Another expert agreed that the high out-of-pocket costs for women with private health insurance were probably responsible for making peripartum health care more unaffordable. These included costs for pregnancy care as well as for maternal and infant care during and after childbirth.

“This study reporting the high unmet medical needs and unaffordability of health care for peripartum women further underscores that the U.S. health care system is not meeting the needs of pregnant women, mothers, and their newborn infants,” said Lois K. Lee, MD, associate professor of pediatrics and emergency medicine at Harvard Medical School and associate director for public policy at the Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion, Boston.

“It is imperative to optimize the health of pregnant mothers to optimize the health of infants, who are our future society,” she said. “Policies which would expand Medicaid coverage to a full 1-year postpartum across all states is one important strategy to improve health care access and affordability to peripartum women. However, this must be part of a multipronged approach addressing the social determinants of health, as insurance coverage alone will not fully address this important health issue of peripartum women, and their children.”

Dr Moniz reported receiving personal fees from the RAND Corporation, the Society of Family Planning outside the submitted work and grant K08 HS025465 from the Agency for Healthcare Research and Quality. Dr. Daw has no disclosures. Dr. Lee reports speaker fees from the American Academy of Pediatrics and SUNY Upstate Medical University. Coauthor Dr. Taylor was supported by the National Clinician Scholars Program at the University of Michigan. Dr Dalton was supported by grant R01 HS023784 from the Agency for Healthcare Research and Quality.
 

During over 3 hours of oral arguments on Nov. 1, a seeming majority of Supreme Court justices appeared receptive to blocking a Texas law that essentially bans abortion after 6 weeks.

They seemed less certain about whether the federal government — which is also challenging the law — was within its rights to sue Texas.

Senate Bill 8, which went into effect September 1, allows any private citizen to file suit anywhere in the state against anyone who performs, induces, or “aids or abets” an abortion. If successful in court, the plaintiff is entitled to at least $10,000 and does not have to pay attorneys’ fees; rather, defendants are required to pay all legal costs.

In September, most justices denied an emergency request to stop the law but agreed to quickly hear the challenges in person.

At the Nov. 1 hearing, it appeared that a few justices who had let the law stand — notably conservatives Amy Coney Barrett and Brett Kavanaugh — were now agreeing that its challengers, in particular the abortion provider Whole Woman’s Health, might have a legal basis to move forward.

“I think it’s pretty likely the Court is going to do something that allows ‘someone’s’ suit against SB 8 to go ahead,” tweeted Raffi Melkonian, a Houston attorney, after the hearing. “I don’t know when they’re going to do that.”

The Supreme Court usually issues its opinions months after arguments. Since these two challenges — Whole Woman’s Health v. Jackson and US v. Texas —  were heard on a faster schedule, there’s speculation that a decision could also come quickly.

“The court clearly is in a hurry,” wrote Florida State University law professor Mary Ziegler before the hearing in a post on court-tracking site SCOTUSblog. She said the court seems to be taking the abortion issue as seriously as most Americans, and that the justices could rule before it hears oral arguments on December 1 in a Mississippi case directly challenging Roe v. Wade.

In addition, data shows abortions have been severely curtailed in Texas since the law took effect — by as much as 50% according to researchers at the University of Texas at Austin. They reported that 2,164 abortions were provided in September 2021, compared with 4,313 in September 2020.

“The actual provisions in this law have prevented every woman in Texas from exercising a constitutional right as declared by this court,” said Justice Elena Kagan, clarifying that it was every woman who had not made a decision by 6 weeks.

“Usually, in these chilling effect cases, we’re kind of guessing,” she said. “Here, we’re not guessing. We know exactly what has happened as a result of this law. It has chilled everybody on the ground.”

Judge Edward Stone II, an attorney with the Texas Attorney General’s Office who argued for the state, denied Justice Kagan’s assertion.

Nineteen medical organizations, including the American Medical Association, American College of Obstetricians and Gynecologists, American Academy of Family Physicians, American Academy of Pediatrics, and the American College of Physicians, filed a friend of the court brief supporting both challenges, saying the Texas law allows legislators to interfere with the patient–doctor relationship and that it limits treatment options.

Texas argued that the only way to challenge the law at the federal level would be to be sued first.

Marc A. Hearron, a lawyer with the Center for Reproductive Rights who argued for Whole Woman’s Health, said that was untenable.

“What my friends on the other side are saying is that clinics should just violate the law,” and “subject themselves to the risk that they will be forced to close their doors,” said Mr. Hearron. 

But even if providers decide to violate the law, “they may not find physicians, nurses, ultrasound technicians, staff members willing to work behind the desk, because this law targets all of them,” he said.

Plus, clinics run the risk of becoming permanent defendants because the law does not prohibit multiple suits, he said.

Whole Woman’s Health asked the justices to stop the law by preventing the state’s clerks from filing cases.
 

Federal standing not as clear

The U.S. Department of Justice sued Texas on September 9, saying the law negated the constitutional right to an abortion.

“The Act is clearly unconstitutional under longstanding Supreme Court precedent,” Attorney General Merrick Garland said at the time.

At the court, U.S. Solicitor General Elizabeth B. Prelogar called it a “brazen attack” on the supremacy of federal law and said it would open the door to other states mounting similar challenges.

Justice Kagan seemed to agree.

“The entire point of this law, its purpose, and its effect is to find the chink in the armor of Ex parte Young,” a 1908 law that “set out a basic principle of how our government is supposed to work and how people can seek review of unconstitutional state laws,” she said, decrying that “after all these many years, some geniuses came up with a way to evade the commands of that decision.”

Judge Stone waved off the concerns. “Nothing in this law even pretends that Texas courts could evade that because it can’t,” he said.

“Essentially, we would be inviting states, all 50 of them, with respect to their unpreferred constitutional rights, to try to nullify the law — that this Court has laid down as to the content of those rights,” said Justice Kagan.

Justice Kavanaugh also seemed concerned about that possibility.

“It could be free speech rights. It could be free exercise of religion rights. It could be Second Amendment rights if this position is accepted here,” he said, citing a brief submitted by the Firearms Policy Coalition that supported the Whole Woman’s Health challenge.

Justice Neil Gorsuch seemed dubious that the Texas law would undercut anybody’s right to challenge.

“Often constitutional rights, of course, can only be enforced in a defensive posture, when an individual is faced either with potential liability, punitive damages, but also, of course, civil fines — fines and even criminal sanction, including prison time,” he said.

Judge Stone argued that the U.S. government is “not a proper plaintiff” and did not have the right to sue Texas or any of its officials because none were involved in enforcing the law. If the federal government didn’t like the law, it should ask Congress to fix it, said Judge Stone.

After the hearing, Texas Attorney General Ken Paxton reiterated that position.

“The Biden Administration does not have the power to sue a state, such as Texas, just because it disagrees with a state law that protects the unborn,” he said in a statement.

A ruling on the challenges will not put an end to the litigation over SB 8.

“Even if the Supreme Court does rule that the abortion provider plaintiffs are allowed to sue, it is likely that there will still need to be more litigation in a federal trial court before SB 8 is actually determined to be unconstitutional and is blocked by a court order,” wrote Ian Millhiser, a Supreme Court scholar, after the hearing.

A federal judge in Austin did approve the Department of Justice’s request for a temporary halt to the law in October, but days later, the Fifth Circuit Court of Appeals ruled it could go back into effect while the legal questions were being pondered in the courts.

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

During over 3 hours of oral arguments on Nov. 1, a seeming majority of Supreme Court justices appeared receptive to blocking a Texas law that essentially bans abortion after 6 weeks.

They seemed less certain about whether the federal government — which is also challenging the law — was within its rights to sue Texas.

Senate Bill 8, which went into effect September 1, allows any private citizen to file suit anywhere in the state against anyone who performs, induces, or “aids or abets” an abortion. If successful in court, the plaintiff is entitled to at least $10,000 and does not have to pay attorneys’ fees; rather, defendants are required to pay all legal costs.

In September, most justices denied an emergency request to stop the law but agreed to quickly hear the challenges in person.

At the Nov. 1 hearing, it appeared that a few justices who had let the law stand — notably conservatives Amy Coney Barrett and Brett Kavanaugh — were now agreeing that its challengers, in particular the abortion provider Whole Woman’s Health, might have a legal basis to move forward.

“I think it’s pretty likely the Court is going to do something that allows ‘someone’s’ suit against SB 8 to go ahead,” tweeted Raffi Melkonian, a Houston attorney, after the hearing. “I don’t know when they’re going to do that.”

The Supreme Court usually issues its opinions months after arguments. Since these two challenges — Whole Woman’s Health v. Jackson and US v. Texas —  were heard on a faster schedule, there’s speculation that a decision could also come quickly.

“The court clearly is in a hurry,” wrote Florida State University law professor Mary Ziegler before the hearing in a post on court-tracking site SCOTUSblog. She said the court seems to be taking the abortion issue as seriously as most Americans, and that the justices could rule before it hears oral arguments on December 1 in a Mississippi case directly challenging Roe v. Wade.

In addition, data shows abortions have been severely curtailed in Texas since the law took effect — by as much as 50% according to researchers at the University of Texas at Austin. They reported that 2,164 abortions were provided in September 2021, compared with 4,313 in September 2020.

“The actual provisions in this law have prevented every woman in Texas from exercising a constitutional right as declared by this court,” said Justice Elena Kagan, clarifying that it was every woman who had not made a decision by 6 weeks.

“Usually, in these chilling effect cases, we’re kind of guessing,” she said. “Here, we’re not guessing. We know exactly what has happened as a result of this law. It has chilled everybody on the ground.”

Judge Edward Stone II, an attorney with the Texas Attorney General’s Office who argued for the state, denied Justice Kagan’s assertion.

Nineteen medical organizations, including the American Medical Association, American College of Obstetricians and Gynecologists, American Academy of Family Physicians, American Academy of Pediatrics, and the American College of Physicians, filed a friend of the court brief supporting both challenges, saying the Texas law allows legislators to interfere with the patient–doctor relationship and that it limits treatment options.

Texas argued that the only way to challenge the law at the federal level would be to be sued first.

Marc A. Hearron, a lawyer with the Center for Reproductive Rights who argued for Whole Woman’s Health, said that was untenable.

“What my friends on the other side are saying is that clinics should just violate the law,” and “subject themselves to the risk that they will be forced to close their doors,” said Mr. Hearron. 

But even if providers decide to violate the law, “they may not find physicians, nurses, ultrasound technicians, staff members willing to work behind the desk, because this law targets all of them,” he said.

Plus, clinics run the risk of becoming permanent defendants because the law does not prohibit multiple suits, he said.

Whole Woman’s Health asked the justices to stop the law by preventing the state’s clerks from filing cases.
 

Federal standing not as clear

The U.S. Department of Justice sued Texas on September 9, saying the law negated the constitutional right to an abortion.

“The Act is clearly unconstitutional under longstanding Supreme Court precedent,” Attorney General Merrick Garland said at the time.

At the court, U.S. Solicitor General Elizabeth B. Prelogar called it a “brazen attack” on the supremacy of federal law and said it would open the door to other states mounting similar challenges.

Justice Kagan seemed to agree.

“The entire point of this law, its purpose, and its effect is to find the chink in the armor of Ex parte Young,” a 1908 law that “set out a basic principle of how our government is supposed to work and how people can seek review of unconstitutional state laws,” she said, decrying that “after all these many years, some geniuses came up with a way to evade the commands of that decision.”

Judge Stone waved off the concerns. “Nothing in this law even pretends that Texas courts could evade that because it can’t,” he said.

“Essentially, we would be inviting states, all 50 of them, with respect to their unpreferred constitutional rights, to try to nullify the law — that this Court has laid down as to the content of those rights,” said Justice Kagan.

Justice Kavanaugh also seemed concerned about that possibility.

“It could be free speech rights. It could be free exercise of religion rights. It could be Second Amendment rights if this position is accepted here,” he said, citing a brief submitted by the Firearms Policy Coalition that supported the Whole Woman’s Health challenge.

Justice Neil Gorsuch seemed dubious that the Texas law would undercut anybody’s right to challenge.

“Often constitutional rights, of course, can only be enforced in a defensive posture, when an individual is faced either with potential liability, punitive damages, but also, of course, civil fines — fines and even criminal sanction, including prison time,” he said.

Judge Stone argued that the U.S. government is “not a proper plaintiff” and did not have the right to sue Texas or any of its officials because none were involved in enforcing the law. If the federal government didn’t like the law, it should ask Congress to fix it, said Judge Stone.

After the hearing, Texas Attorney General Ken Paxton reiterated that position.

“The Biden Administration does not have the power to sue a state, such as Texas, just because it disagrees with a state law that protects the unborn,” he said in a statement.

A ruling on the challenges will not put an end to the litigation over SB 8.

“Even if the Supreme Court does rule that the abortion provider plaintiffs are allowed to sue, it is likely that there will still need to be more litigation in a federal trial court before SB 8 is actually determined to be unconstitutional and is blocked by a court order,” wrote Ian Millhiser, a Supreme Court scholar, after the hearing.

A federal judge in Austin did approve the Department of Justice’s request for a temporary halt to the law in October, but days later, the Fifth Circuit Court of Appeals ruled it could go back into effect while the legal questions were being pondered in the courts.

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

During over 3 hours of oral arguments on Nov. 1, a seeming majority of Supreme Court justices appeared receptive to blocking a Texas law that essentially bans abortion after 6 weeks.

They seemed less certain about whether the federal government — which is also challenging the law — was within its rights to sue Texas.

Senate Bill 8, which went into effect September 1, allows any private citizen to file suit anywhere in the state against anyone who performs, induces, or “aids or abets” an abortion. If successful in court, the plaintiff is entitled to at least $10,000 and does not have to pay attorneys’ fees; rather, defendants are required to pay all legal costs.

In September, most justices denied an emergency request to stop the law but agreed to quickly hear the challenges in person.

At the Nov. 1 hearing, it appeared that a few justices who had let the law stand — notably conservatives Amy Coney Barrett and Brett Kavanaugh — were now agreeing that its challengers, in particular the abortion provider Whole Woman’s Health, might have a legal basis to move forward.

“I think it’s pretty likely the Court is going to do something that allows ‘someone’s’ suit against SB 8 to go ahead,” tweeted Raffi Melkonian, a Houston attorney, after the hearing. “I don’t know when they’re going to do that.”

The Supreme Court usually issues its opinions months after arguments. Since these two challenges — Whole Woman’s Health v. Jackson and US v. Texas —  were heard on a faster schedule, there’s speculation that a decision could also come quickly.

“The court clearly is in a hurry,” wrote Florida State University law professor Mary Ziegler before the hearing in a post on court-tracking site SCOTUSblog. She said the court seems to be taking the abortion issue as seriously as most Americans, and that the justices could rule before it hears oral arguments on December 1 in a Mississippi case directly challenging Roe v. Wade.

In addition, data shows abortions have been severely curtailed in Texas since the law took effect — by as much as 50% according to researchers at the University of Texas at Austin. They reported that 2,164 abortions were provided in September 2021, compared with 4,313 in September 2020.

“The actual provisions in this law have prevented every woman in Texas from exercising a constitutional right as declared by this court,” said Justice Elena Kagan, clarifying that it was every woman who had not made a decision by 6 weeks.

“Usually, in these chilling effect cases, we’re kind of guessing,” she said. “Here, we’re not guessing. We know exactly what has happened as a result of this law. It has chilled everybody on the ground.”

Judge Edward Stone II, an attorney with the Texas Attorney General’s Office who argued for the state, denied Justice Kagan’s assertion.

Nineteen medical organizations, including the American Medical Association, American College of Obstetricians and Gynecologists, American Academy of Family Physicians, American Academy of Pediatrics, and the American College of Physicians, filed a friend of the court brief supporting both challenges, saying the Texas law allows legislators to interfere with the patient–doctor relationship and that it limits treatment options.

Texas argued that the only way to challenge the law at the federal level would be to be sued first.

Marc A. Hearron, a lawyer with the Center for Reproductive Rights who argued for Whole Woman’s Health, said that was untenable.

“What my friends on the other side are saying is that clinics should just violate the law,” and “subject themselves to the risk that they will be forced to close their doors,” said Mr. Hearron. 

But even if providers decide to violate the law, “they may not find physicians, nurses, ultrasound technicians, staff members willing to work behind the desk, because this law targets all of them,” he said.

Plus, clinics run the risk of becoming permanent defendants because the law does not prohibit multiple suits, he said.

Whole Woman’s Health asked the justices to stop the law by preventing the state’s clerks from filing cases.
 

Federal standing not as clear

The U.S. Department of Justice sued Texas on September 9, saying the law negated the constitutional right to an abortion.

“The Act is clearly unconstitutional under longstanding Supreme Court precedent,” Attorney General Merrick Garland said at the time.

At the court, U.S. Solicitor General Elizabeth B. Prelogar called it a “brazen attack” on the supremacy of federal law and said it would open the door to other states mounting similar challenges.

Justice Kagan seemed to agree.

“The entire point of this law, its purpose, and its effect is to find the chink in the armor of Ex parte Young,” a 1908 law that “set out a basic principle of how our government is supposed to work and how people can seek review of unconstitutional state laws,” she said, decrying that “after all these many years, some geniuses came up with a way to evade the commands of that decision.”

Judge Stone waved off the concerns. “Nothing in this law even pretends that Texas courts could evade that because it can’t,” he said.

“Essentially, we would be inviting states, all 50 of them, with respect to their unpreferred constitutional rights, to try to nullify the law — that this Court has laid down as to the content of those rights,” said Justice Kagan.

Justice Kavanaugh also seemed concerned about that possibility.

“It could be free speech rights. It could be free exercise of religion rights. It could be Second Amendment rights if this position is accepted here,” he said, citing a brief submitted by the Firearms Policy Coalition that supported the Whole Woman’s Health challenge.

Justice Neil Gorsuch seemed dubious that the Texas law would undercut anybody’s right to challenge.

“Often constitutional rights, of course, can only be enforced in a defensive posture, when an individual is faced either with potential liability, punitive damages, but also, of course, civil fines — fines and even criminal sanction, including prison time,” he said.

Judge Stone argued that the U.S. government is “not a proper plaintiff” and did not have the right to sue Texas or any of its officials because none were involved in enforcing the law. If the federal government didn’t like the law, it should ask Congress to fix it, said Judge Stone.

After the hearing, Texas Attorney General Ken Paxton reiterated that position.

“The Biden Administration does not have the power to sue a state, such as Texas, just because it disagrees with a state law that protects the unborn,” he said in a statement.

A ruling on the challenges will not put an end to the litigation over SB 8.

“Even if the Supreme Court does rule that the abortion provider plaintiffs are allowed to sue, it is likely that there will still need to be more litigation in a federal trial court before SB 8 is actually determined to be unconstitutional and is blocked by a court order,” wrote Ian Millhiser, a Supreme Court scholar, after the hearing.

A federal judge in Austin did approve the Department of Justice’s request for a temporary halt to the law in October, but days later, the Fifth Circuit Court of Appeals ruled it could go back into effect while the legal questions were being pondered in the courts.

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

My office’s storage room has an old bankers box, which has been there since I moved 8 years ago. Before that it was at my other office, behind an old desk. I had no idea what was in it, I always assumed office supplies, surplus drug company pens and sticky notes, who-knows-whats.

Last week I had one of those days where everyone cancels, so I decided to investigate the box.

It was packed with 10 years worth (2000-2010) of my secretary’s MRI scheduling sheets that had somehow escaped occasional shredding purges. So I sat down next to the office shredder to get rid of them.

As I fed the sheets in, the names jumped out at me. Some I have absolutely no recollection of. Others I still see today.

There were names of the long-deceased, bringing them back to me for the first time in years. There were others that I have no idea what happened to – they must have just stopped seeing me at some point, though for the life of me I can’t remember when, or why. Yet, in my mind, there they were, as if I’d just seen them yesterday. A few times I got curious enough to turn back to my computer and look up their charts, trying to remember their stories.

Then there were those I still remember clearly, every single detail of, in spite of the elapsed time. Something about their case or personality had indelibly etched them in my memory. A valuable lesson learned from them that had something or nothing to do with medicine that’s still with me.

Looking back, I’d guess I’ve seen roughly 15,000-20,000 patients over my career. Not nearly as many as my colleagues in general practice, but still quite a few. A decent sized basketball arena full.

The majority don’t stick with you. That’s the way it is in life. We meet a lot of people as we walk down the road, but generally only remember those walking with us for a good part of it.

The ones we didn’t know long – but who are still clearly remembered – are also valuable. In their own way, perhaps unknowingly, they made an impact that hopefully makes us better.

For that I’ll always be grateful to them.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

My office’s storage room has an old bankers box, which has been there since I moved 8 years ago. Before that it was at my other office, behind an old desk. I had no idea what was in it, I always assumed office supplies, surplus drug company pens and sticky notes, who-knows-whats.

Last week I had one of those days where everyone cancels, so I decided to investigate the box.

It was packed with 10 years worth (2000-2010) of my secretary’s MRI scheduling sheets that had somehow escaped occasional shredding purges. So I sat down next to the office shredder to get rid of them.

As I fed the sheets in, the names jumped out at me. Some I have absolutely no recollection of. Others I still see today.

There were names of the long-deceased, bringing them back to me for the first time in years. There were others that I have no idea what happened to – they must have just stopped seeing me at some point, though for the life of me I can’t remember when, or why. Yet, in my mind, there they were, as if I’d just seen them yesterday. A few times I got curious enough to turn back to my computer and look up their charts, trying to remember their stories.

Then there were those I still remember clearly, every single detail of, in spite of the elapsed time. Something about their case or personality had indelibly etched them in my memory. A valuable lesson learned from them that had something or nothing to do with medicine that’s still with me.

Looking back, I’d guess I’ve seen roughly 15,000-20,000 patients over my career. Not nearly as many as my colleagues in general practice, but still quite a few. A decent sized basketball arena full.

The majority don’t stick with you. That’s the way it is in life. We meet a lot of people as we walk down the road, but generally only remember those walking with us for a good part of it.

The ones we didn’t know long – but who are still clearly remembered – are also valuable. In their own way, perhaps unknowingly, they made an impact that hopefully makes us better.

For that I’ll always be grateful to them.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

My office’s storage room has an old bankers box, which has been there since I moved 8 years ago. Before that it was at my other office, behind an old desk. I had no idea what was in it, I always assumed office supplies, surplus drug company pens and sticky notes, who-knows-whats.

Last week I had one of those days where everyone cancels, so I decided to investigate the box.

It was packed with 10 years worth (2000-2010) of my secretary’s MRI scheduling sheets that had somehow escaped occasional shredding purges. So I sat down next to the office shredder to get rid of them.

As I fed the sheets in, the names jumped out at me. Some I have absolutely no recollection of. Others I still see today.

There were names of the long-deceased, bringing them back to me for the first time in years. There were others that I have no idea what happened to – they must have just stopped seeing me at some point, though for the life of me I can’t remember when, or why. Yet, in my mind, there they were, as if I’d just seen them yesterday. A few times I got curious enough to turn back to my computer and look up their charts, trying to remember their stories.

Then there were those I still remember clearly, every single detail of, in spite of the elapsed time. Something about their case or personality had indelibly etched them in my memory. A valuable lesson learned from them that had something or nothing to do with medicine that’s still with me.

Looking back, I’d guess I’ve seen roughly 15,000-20,000 patients over my career. Not nearly as many as my colleagues in general practice, but still quite a few. A decent sized basketball arena full.

The majority don’t stick with you. That’s the way it is in life. We meet a lot of people as we walk down the road, but generally only remember those walking with us for a good part of it.

The ones we didn’t know long – but who are still clearly remembered – are also valuable. In their own way, perhaps unknowingly, they made an impact that hopefully makes us better.

For that I’ll always be grateful to them.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Almost all physicians write prescriptions, and each prescription requires a physician to assess the risks and benefits of the drug. If an adverse drug reaction occurs, physicians may be called on to defend their risk-benefit assessment in court.

The assessment of risk is complicated when there is a boxed warning that describes potentially serious and life-threatening adverse reactions associated with a drug. Some of our most commonly prescribed drugs have boxed warnings, and drugs that were initially approved by the Food and Drug Administration without boxed warnings may have them added years later.

One serious problem with boxed warnings is that there are no reliable mechanisms for making sure that physicians are aware of them. The warnings are typically not seen by physicians as printed product labels, just as physicians often don’t see the pills and capsules that they prescribe. Pharmacists who receive packaged drugs from manufacturers may be the only ones to see an actual printed boxed warning, but even those pharmacists have little reason to read each label and note changes when handling many bulk packages.

This problem is aggravated by misperceptions that many physicians have about boxed warnings and the increasingly intense scrutiny given to them by mass media and the courts. Lawyers can use boxed warnings to make a drug look dangerous, even when it’s not, and to make physicians look reckless when prescribing it. Therefore, it is important for physicians to understand what boxed warnings are, what they are not, the problems they cause, and how to minimize these problems.
 

What is a ‘boxed warning’?

The marketing and sale of drugs in the United States requires approval by the FDA. Approval requires manufacturers to prepare a document containing “Full Prescribing Information” for the drug and to include a printed copy in every package of the drug that is sold. This document is commonly called a “package insert,” but the FDA designates this document as the manufacturer’s product “label.”

In 1979, the FDA began requiring some labels to appear within thick, black rectangular borders; these have come to be known as boxed warnings. Boxed warnings are usually placed at the beginning of a label. They may be added to the label of a previously approved drug already on the market or included in the product label when first approved and marketed.

The requirement for a boxed warning most often arises when a signal appears during review of postmarketing surveillance data suggesting a possible and plausible association between a drug and an adverse reaction. Warnings may also be initiated in response to petitions from public interest groups, or upon the discovery of serious toxicity in animals. Regardless of their origin, the intent of a boxed warning is to highlight information that may have important therapeutic consequences and warrants heightened awareness among physicians.
 

What a boxed warning is not

A boxed warning is not “issued” by the FDA; it is merely required by the FDA. Specific wording or a template may be suggested by the FDA, but product labels and boxed warnings are written and issued by the manufacturer. This distinction may seem minor, but extensive litigation has occurred over whether manufacturers have met their duty to warn consumers about possible risks when using their products, and this duty cannot be shifted to the FDA.

A boxed warning may not be added to a product label at the option of a manufacturer. The FDA allows a boxed warning only if it requires the warning, to preserve its impact. It should be noted that some medical information sources (e.g., PDR.net) may include a “BOXED WARNING” in their drug monographs, but monographs not written by a manufacturer are not regulated by the FDA, and the text of their boxed warnings do not always correspond to the boxed warning that was approved by the FDA.

A boxed warning is not an indication that revocation of FDA approval is being considered or that it is likely to be revoked. FDA approval is subject to ongoing review and may be revoked at any time, without a prior boxed warning.

A boxed warning is not the highest level of warning. The FDA may require a manufacturer to send out a “Dear Health Care Provider” (DHCP) letter when an even higher or more urgent level of warning is deemed necessary. DHCP letters are usually accompanied by revisions of the product label, but most label revisions – and even most boxed warnings – are not accompanied by DHCP letters.

A boxed warning is not a statement about causation. Most warnings describe an “association” between a drug and an adverse effect, or “increased risk,” or instances of a particular adverse effect that “have been reported” in persons taking a drug. The words in a boxed warning are carefully chosen and require careful reading; in most cases they refrain from stating that a drug actually causes an adverse effect. The postmarketing surveillance data on which most warnings are based generally cannot provide the kind of evidence required to establish causation, and an association may be nothing more than an uncommon manifestation of the disorder for which the drug has been prescribed.

A boxed warning is not a statement about the probability of an adverse reaction occurring. The requirement for a boxed warning correlates better to the new recognition of a possible association than to the probability of an association. For example, penicillin has long been known to cause fatal anaphylaxis in 1/100,000 first-time administrations, but it does not have a boxed warning. The adverse consequences described in boxed warnings are often far less frequent – so much so that most physicians will never see them.

A boxed warning does not define the standard of care. The warning is a requirement imposed on the manufacturer, not on the practice of medicine. For legal purposes, the “standard of care” for the practice of medicine is defined state by state and is typically cast in terms such as “what most physicians would do in similar circumstances.” Physicians often prescribe drugs in spite of boxed warnings, just as they often prescribe drugs for “off label” indications, always balancing risk versus benefit.

A boxed warning does not constitute a contraindication to the use of a medication. Some warnings state that a drug is contraindicated in some situations, but product labels have another mandated section for listing contraindications, and most boxed warnings have no corresponding entry in that section.

A boxed warning does not necessarily constitute current information, nor is it always updated when new or contrary information becomes available. Revisions to boxed warnings, and to product labels in general, are made only after detailed review at the FDA, and the process of deciding whether an existing boxed warning continues to be appropriate may divert limited regulatory resources from more urgent priorities. Consequently, revisions to a boxed warning may lag behind the data that justify a revision by months or years. Revisions may never occur if softening or eliminating a boxed warning is deemed to be not worth the cost by a manufacturer.
 

Boxed warning problems for physicians

There is no reliable mechanism for manufacturers or the FDA to communicate boxed warnings directly to physicians, so it’s not clear how physicians are expected to stay informed about the issuance or revision of boxed warnings. They may first learn about new or revised warnings in the mass media, which is paying ever-increasing attention to press releases from the FDA. However, it can be difficult for the media to accurately convey the subtle and complex nature of a boxed warning in nontechnical terms.

Many physicians subscribe to various medical news alerts and attend continuing medical education (CME) programs, which often do an excellent job of highlighting new warnings, while hospitals, clinics, and pharmacies may broadcast news about boxed warnings in newsletters or other notices. But these notifications are ephemeral and may be missed by physicians who are overwhelmed by email, notices, newsletters, and CME programs.

The warnings that pop up in electronic medical records systems are often so numerous that physicians become trained to ignore them. Printed advertisements in professional journals must include mandated boxed warnings, but their visibility is waning as physicians increasingly read journals online.

Another conundrum is how to inform the public about boxed warnings.

Manufacturers are prohibited from direct-to-consumer advertising of drugs with boxed warnings, although the warnings are easily found on the Internet. Some patients expect and welcome detailed information from their physicians, so it’s a good policy to always and repeatedly review this information with them, especially if they are members of an identified risk group. However, that policy may be counterproductive if it dissuades anxious patients from needed therapy despite risk-benefit considerations that strongly favor it. Boxed warnings are well known to have “spillover effects” in which the aspersions cast by a boxed warning for a relatively small subgroup of patients causes use of a drug to decline among all patients.

Compounding this conundrum is that physicians rarely have sufficient information to gauge the magnitude of a risk, given that boxed warnings are often based on information from surveillance systems that cannot accurately quantify the risk or even establish a causal relationship. The text of a boxed warning generally does not provide the information needed for evidence-based clinical practice such as a quantitative estimate of effect, information about source and trustworthiness of the evidence, and guidance on implementation. For these and other reasons, FDA policies about various boxed warnings have been the target of significant criticism.

Medication guides are one mechanism to address the challenge of informing patients about the risks of drugs they are taking. FDA-approved medication guides are available for most drugs dispensed as outpatient prescriptions, they’re written in plain language for the consumer, and they include paraphrased versions of any boxed warning. Ideally, patients review these guides with their physicians or pharmacists, but the guides may be lengthy and raise questions that may not be answerable (e.g., about incidence rates). Patients may decline to review this information when a drug is prescribed or dispensed, and they may discard printed copies given to them without reading.
 

What can physicians do to minimize boxed warning problems?

Physicians should periodically review the product labels for drugs they commonly prescribe, including drugs they’ve prescribed for a long time. Prescription renewal requests can be used as a prompt to check for changes in a patient’s condition or other medications that might place a patient in the target population of a boxed warning. Physicians can subscribe to newsletters that announce and discuss significant product label changes, including alerts directly from the FDA. Physicians may also enlist their office staff to find and review boxed warnings for drugs being prescribed, noting which ones should require a conversation with any patient who has been or will be receiving this drug. They may want to make explicit mention in their encounter record that a boxed warning, medication guide, or overall risk-benefit assessment has been discussed.

Summary

The nature of boxed warnings, the means by which they are disseminated, and their role in clinical practice are all in great need of improvement. Until that occurs, boxed warnings offer some, but only very limited, help to patients and physicians who struggle to understand the risks of medications.

Dr. Axelsen is professor in the departments of pharmacology, biochemistry, and biophysics, and of medicine, infectious diseases section, University of Pennsylvania, Philadelphia. He disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.

Almost all physicians write prescriptions, and each prescription requires a physician to assess the risks and benefits of the drug. If an adverse drug reaction occurs, physicians may be called on to defend their risk-benefit assessment in court.

The assessment of risk is complicated when there is a boxed warning that describes potentially serious and life-threatening adverse reactions associated with a drug. Some of our most commonly prescribed drugs have boxed warnings, and drugs that were initially approved by the Food and Drug Administration without boxed warnings may have them added years later.

One serious problem with boxed warnings is that there are no reliable mechanisms for making sure that physicians are aware of them. The warnings are typically not seen by physicians as printed product labels, just as physicians often don’t see the pills and capsules that they prescribe. Pharmacists who receive packaged drugs from manufacturers may be the only ones to see an actual printed boxed warning, but even those pharmacists have little reason to read each label and note changes when handling many bulk packages.

This problem is aggravated by misperceptions that many physicians have about boxed warnings and the increasingly intense scrutiny given to them by mass media and the courts. Lawyers can use boxed warnings to make a drug look dangerous, even when it’s not, and to make physicians look reckless when prescribing it. Therefore, it is important for physicians to understand what boxed warnings are, what they are not, the problems they cause, and how to minimize these problems.
 

What is a ‘boxed warning’?

The marketing and sale of drugs in the United States requires approval by the FDA. Approval requires manufacturers to prepare a document containing “Full Prescribing Information” for the drug and to include a printed copy in every package of the drug that is sold. This document is commonly called a “package insert,” but the FDA designates this document as the manufacturer’s product “label.”

In 1979, the FDA began requiring some labels to appear within thick, black rectangular borders; these have come to be known as boxed warnings. Boxed warnings are usually placed at the beginning of a label. They may be added to the label of a previously approved drug already on the market or included in the product label when first approved and marketed.

The requirement for a boxed warning most often arises when a signal appears during review of postmarketing surveillance data suggesting a possible and plausible association between a drug and an adverse reaction. Warnings may also be initiated in response to petitions from public interest groups, or upon the discovery of serious toxicity in animals. Regardless of their origin, the intent of a boxed warning is to highlight information that may have important therapeutic consequences and warrants heightened awareness among physicians.
 

What a boxed warning is not

A boxed warning is not “issued” by the FDA; it is merely required by the FDA. Specific wording or a template may be suggested by the FDA, but product labels and boxed warnings are written and issued by the manufacturer. This distinction may seem minor, but extensive litigation has occurred over whether manufacturers have met their duty to warn consumers about possible risks when using their products, and this duty cannot be shifted to the FDA.

A boxed warning may not be added to a product label at the option of a manufacturer. The FDA allows a boxed warning only if it requires the warning, to preserve its impact. It should be noted that some medical information sources (e.g., PDR.net) may include a “BOXED WARNING” in their drug monographs, but monographs not written by a manufacturer are not regulated by the FDA, and the text of their boxed warnings do not always correspond to the boxed warning that was approved by the FDA.

A boxed warning is not an indication that revocation of FDA approval is being considered or that it is likely to be revoked. FDA approval is subject to ongoing review and may be revoked at any time, without a prior boxed warning.

A boxed warning is not the highest level of warning. The FDA may require a manufacturer to send out a “Dear Health Care Provider” (DHCP) letter when an even higher or more urgent level of warning is deemed necessary. DHCP letters are usually accompanied by revisions of the product label, but most label revisions – and even most boxed warnings – are not accompanied by DHCP letters.

A boxed warning is not a statement about causation. Most warnings describe an “association” between a drug and an adverse effect, or “increased risk,” or instances of a particular adverse effect that “have been reported” in persons taking a drug. The words in a boxed warning are carefully chosen and require careful reading; in most cases they refrain from stating that a drug actually causes an adverse effect. The postmarketing surveillance data on which most warnings are based generally cannot provide the kind of evidence required to establish causation, and an association may be nothing more than an uncommon manifestation of the disorder for which the drug has been prescribed.

A boxed warning is not a statement about the probability of an adverse reaction occurring. The requirement for a boxed warning correlates better to the new recognition of a possible association than to the probability of an association. For example, penicillin has long been known to cause fatal anaphylaxis in 1/100,000 first-time administrations, but it does not have a boxed warning. The adverse consequences described in boxed warnings are often far less frequent – so much so that most physicians will never see them.

A boxed warning does not define the standard of care. The warning is a requirement imposed on the manufacturer, not on the practice of medicine. For legal purposes, the “standard of care” for the practice of medicine is defined state by state and is typically cast in terms such as “what most physicians would do in similar circumstances.” Physicians often prescribe drugs in spite of boxed warnings, just as they often prescribe drugs for “off label” indications, always balancing risk versus benefit.

A boxed warning does not constitute a contraindication to the use of a medication. Some warnings state that a drug is contraindicated in some situations, but product labels have another mandated section for listing contraindications, and most boxed warnings have no corresponding entry in that section.

A boxed warning does not necessarily constitute current information, nor is it always updated when new or contrary information becomes available. Revisions to boxed warnings, and to product labels in general, are made only after detailed review at the FDA, and the process of deciding whether an existing boxed warning continues to be appropriate may divert limited regulatory resources from more urgent priorities. Consequently, revisions to a boxed warning may lag behind the data that justify a revision by months or years. Revisions may never occur if softening or eliminating a boxed warning is deemed to be not worth the cost by a manufacturer.
 

Boxed warning problems for physicians

There is no reliable mechanism for manufacturers or the FDA to communicate boxed warnings directly to physicians, so it’s not clear how physicians are expected to stay informed about the issuance or revision of boxed warnings. They may first learn about new or revised warnings in the mass media, which is paying ever-increasing attention to press releases from the FDA. However, it can be difficult for the media to accurately convey the subtle and complex nature of a boxed warning in nontechnical terms.

Many physicians subscribe to various medical news alerts and attend continuing medical education (CME) programs, which often do an excellent job of highlighting new warnings, while hospitals, clinics, and pharmacies may broadcast news about boxed warnings in newsletters or other notices. But these notifications are ephemeral and may be missed by physicians who are overwhelmed by email, notices, newsletters, and CME programs.

The warnings that pop up in electronic medical records systems are often so numerous that physicians become trained to ignore them. Printed advertisements in professional journals must include mandated boxed warnings, but their visibility is waning as physicians increasingly read journals online.

Another conundrum is how to inform the public about boxed warnings.

Manufacturers are prohibited from direct-to-consumer advertising of drugs with boxed warnings, although the warnings are easily found on the Internet. Some patients expect and welcome detailed information from their physicians, so it’s a good policy to always and repeatedly review this information with them, especially if they are members of an identified risk group. However, that policy may be counterproductive if it dissuades anxious patients from needed therapy despite risk-benefit considerations that strongly favor it. Boxed warnings are well known to have “spillover effects” in which the aspersions cast by a boxed warning for a relatively small subgroup of patients causes use of a drug to decline among all patients.

Compounding this conundrum is that physicians rarely have sufficient information to gauge the magnitude of a risk, given that boxed warnings are often based on information from surveillance systems that cannot accurately quantify the risk or even establish a causal relationship. The text of a boxed warning generally does not provide the information needed for evidence-based clinical practice such as a quantitative estimate of effect, information about source and trustworthiness of the evidence, and guidance on implementation. For these and other reasons, FDA policies about various boxed warnings have been the target of significant criticism.

Medication guides are one mechanism to address the challenge of informing patients about the risks of drugs they are taking. FDA-approved medication guides are available for most drugs dispensed as outpatient prescriptions, they’re written in plain language for the consumer, and they include paraphrased versions of any boxed warning. Ideally, patients review these guides with their physicians or pharmacists, but the guides may be lengthy and raise questions that may not be answerable (e.g., about incidence rates). Patients may decline to review this information when a drug is prescribed or dispensed, and they may discard printed copies given to them without reading.
 

What can physicians do to minimize boxed warning problems?

Physicians should periodically review the product labels for drugs they commonly prescribe, including drugs they’ve prescribed for a long time. Prescription renewal requests can be used as a prompt to check for changes in a patient’s condition or other medications that might place a patient in the target population of a boxed warning. Physicians can subscribe to newsletters that announce and discuss significant product label changes, including alerts directly from the FDA. Physicians may also enlist their office staff to find and review boxed warnings for drugs being prescribed, noting which ones should require a conversation with any patient who has been or will be receiving this drug. They may want to make explicit mention in their encounter record that a boxed warning, medication guide, or overall risk-benefit assessment has been discussed.

Summary

The nature of boxed warnings, the means by which they are disseminated, and their role in clinical practice are all in great need of improvement. Until that occurs, boxed warnings offer some, but only very limited, help to patients and physicians who struggle to understand the risks of medications.

Dr. Axelsen is professor in the departments of pharmacology, biochemistry, and biophysics, and of medicine, infectious diseases section, University of Pennsylvania, Philadelphia. He disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.

Almost all physicians write prescriptions, and each prescription requires a physician to assess the risks and benefits of the drug. If an adverse drug reaction occurs, physicians may be called on to defend their risk-benefit assessment in court.

The assessment of risk is complicated when there is a boxed warning that describes potentially serious and life-threatening adverse reactions associated with a drug. Some of our most commonly prescribed drugs have boxed warnings, and drugs that were initially approved by the Food and Drug Administration without boxed warnings may have them added years later.

One serious problem with boxed warnings is that there are no reliable mechanisms for making sure that physicians are aware of them. The warnings are typically not seen by physicians as printed product labels, just as physicians often don’t see the pills and capsules that they prescribe. Pharmacists who receive packaged drugs from manufacturers may be the only ones to see an actual printed boxed warning, but even those pharmacists have little reason to read each label and note changes when handling many bulk packages.

This problem is aggravated by misperceptions that many physicians have about boxed warnings and the increasingly intense scrutiny given to them by mass media and the courts. Lawyers can use boxed warnings to make a drug look dangerous, even when it’s not, and to make physicians look reckless when prescribing it. Therefore, it is important for physicians to understand what boxed warnings are, what they are not, the problems they cause, and how to minimize these problems.
 

What is a ‘boxed warning’?

The marketing and sale of drugs in the United States requires approval by the FDA. Approval requires manufacturers to prepare a document containing “Full Prescribing Information” for the drug and to include a printed copy in every package of the drug that is sold. This document is commonly called a “package insert,” but the FDA designates this document as the manufacturer’s product “label.”

In 1979, the FDA began requiring some labels to appear within thick, black rectangular borders; these have come to be known as boxed warnings. Boxed warnings are usually placed at the beginning of a label. They may be added to the label of a previously approved drug already on the market or included in the product label when first approved and marketed.

The requirement for a boxed warning most often arises when a signal appears during review of postmarketing surveillance data suggesting a possible and plausible association between a drug and an adverse reaction. Warnings may also be initiated in response to petitions from public interest groups, or upon the discovery of serious toxicity in animals. Regardless of their origin, the intent of a boxed warning is to highlight information that may have important therapeutic consequences and warrants heightened awareness among physicians.
 

What a boxed warning is not

A boxed warning is not “issued” by the FDA; it is merely required by the FDA. Specific wording or a template may be suggested by the FDA, but product labels and boxed warnings are written and issued by the manufacturer. This distinction may seem minor, but extensive litigation has occurred over whether manufacturers have met their duty to warn consumers about possible risks when using their products, and this duty cannot be shifted to the FDA.

A boxed warning may not be added to a product label at the option of a manufacturer. The FDA allows a boxed warning only if it requires the warning, to preserve its impact. It should be noted that some medical information sources (e.g., PDR.net) may include a “BOXED WARNING” in their drug monographs, but monographs not written by a manufacturer are not regulated by the FDA, and the text of their boxed warnings do not always correspond to the boxed warning that was approved by the FDA.

A boxed warning is not an indication that revocation of FDA approval is being considered or that it is likely to be revoked. FDA approval is subject to ongoing review and may be revoked at any time, without a prior boxed warning.

A boxed warning is not the highest level of warning. The FDA may require a manufacturer to send out a “Dear Health Care Provider” (DHCP) letter when an even higher or more urgent level of warning is deemed necessary. DHCP letters are usually accompanied by revisions of the product label, but most label revisions – and even most boxed warnings – are not accompanied by DHCP letters.

A boxed warning is not a statement about causation. Most warnings describe an “association” between a drug and an adverse effect, or “increased risk,” or instances of a particular adverse effect that “have been reported” in persons taking a drug. The words in a boxed warning are carefully chosen and require careful reading; in most cases they refrain from stating that a drug actually causes an adverse effect. The postmarketing surveillance data on which most warnings are based generally cannot provide the kind of evidence required to establish causation, and an association may be nothing more than an uncommon manifestation of the disorder for which the drug has been prescribed.

A boxed warning is not a statement about the probability of an adverse reaction occurring. The requirement for a boxed warning correlates better to the new recognition of a possible association than to the probability of an association. For example, penicillin has long been known to cause fatal anaphylaxis in 1/100,000 first-time administrations, but it does not have a boxed warning. The adverse consequences described in boxed warnings are often far less frequent – so much so that most physicians will never see them.

A boxed warning does not define the standard of care. The warning is a requirement imposed on the manufacturer, not on the practice of medicine. For legal purposes, the “standard of care” for the practice of medicine is defined state by state and is typically cast in terms such as “what most physicians would do in similar circumstances.” Physicians often prescribe drugs in spite of boxed warnings, just as they often prescribe drugs for “off label” indications, always balancing risk versus benefit.

A boxed warning does not constitute a contraindication to the use of a medication. Some warnings state that a drug is contraindicated in some situations, but product labels have another mandated section for listing contraindications, and most boxed warnings have no corresponding entry in that section.

A boxed warning does not necessarily constitute current information, nor is it always updated when new or contrary information becomes available. Revisions to boxed warnings, and to product labels in general, are made only after detailed review at the FDA, and the process of deciding whether an existing boxed warning continues to be appropriate may divert limited regulatory resources from more urgent priorities. Consequently, revisions to a boxed warning may lag behind the data that justify a revision by months or years. Revisions may never occur if softening or eliminating a boxed warning is deemed to be not worth the cost by a manufacturer.
 

Boxed warning problems for physicians

There is no reliable mechanism for manufacturers or the FDA to communicate boxed warnings directly to physicians, so it’s not clear how physicians are expected to stay informed about the issuance or revision of boxed warnings. They may first learn about new or revised warnings in the mass media, which is paying ever-increasing attention to press releases from the FDA. However, it can be difficult for the media to accurately convey the subtle and complex nature of a boxed warning in nontechnical terms.

Many physicians subscribe to various medical news alerts and attend continuing medical education (CME) programs, which often do an excellent job of highlighting new warnings, while hospitals, clinics, and pharmacies may broadcast news about boxed warnings in newsletters or other notices. But these notifications are ephemeral and may be missed by physicians who are overwhelmed by email, notices, newsletters, and CME programs.

The warnings that pop up in electronic medical records systems are often so numerous that physicians become trained to ignore them. Printed advertisements in professional journals must include mandated boxed warnings, but their visibility is waning as physicians increasingly read journals online.

Another conundrum is how to inform the public about boxed warnings.

Manufacturers are prohibited from direct-to-consumer advertising of drugs with boxed warnings, although the warnings are easily found on the Internet. Some patients expect and welcome detailed information from their physicians, so it’s a good policy to always and repeatedly review this information with them, especially if they are members of an identified risk group. However, that policy may be counterproductive if it dissuades anxious patients from needed therapy despite risk-benefit considerations that strongly favor it. Boxed warnings are well known to have “spillover effects” in which the aspersions cast by a boxed warning for a relatively small subgroup of patients causes use of a drug to decline among all patients.

Compounding this conundrum is that physicians rarely have sufficient information to gauge the magnitude of a risk, given that boxed warnings are often based on information from surveillance systems that cannot accurately quantify the risk or even establish a causal relationship. The text of a boxed warning generally does not provide the information needed for evidence-based clinical practice such as a quantitative estimate of effect, information about source and trustworthiness of the evidence, and guidance on implementation. For these and other reasons, FDA policies about various boxed warnings have been the target of significant criticism.

Medication guides are one mechanism to address the challenge of informing patients about the risks of drugs they are taking. FDA-approved medication guides are available for most drugs dispensed as outpatient prescriptions, they’re written in plain language for the consumer, and they include paraphrased versions of any boxed warning. Ideally, patients review these guides with their physicians or pharmacists, but the guides may be lengthy and raise questions that may not be answerable (e.g., about incidence rates). Patients may decline to review this information when a drug is prescribed or dispensed, and they may discard printed copies given to them without reading.
 

What can physicians do to minimize boxed warning problems?

Physicians should periodically review the product labels for drugs they commonly prescribe, including drugs they’ve prescribed for a long time. Prescription renewal requests can be used as a prompt to check for changes in a patient’s condition or other medications that might place a patient in the target population of a boxed warning. Physicians can subscribe to newsletters that announce and discuss significant product label changes, including alerts directly from the FDA. Physicians may also enlist their office staff to find and review boxed warnings for drugs being prescribed, noting which ones should require a conversation with any patient who has been or will be receiving this drug. They may want to make explicit mention in their encounter record that a boxed warning, medication guide, or overall risk-benefit assessment has been discussed.

Summary

The nature of boxed warnings, the means by which they are disseminated, and their role in clinical practice are all in great need of improvement. Until that occurs, boxed warnings offer some, but only very limited, help to patients and physicians who struggle to understand the risks of medications.

Dr. Axelsen is professor in the departments of pharmacology, biochemistry, and biophysics, and of medicine, infectious diseases section, University of Pennsylvania, Philadelphia. He disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.

There are multiple benefits and few harms from sharing clinical notes in patients with mental illness, results of a poll of international experts show.

As of April 5, 2021, new federal rules in the United States mandate that all patients are offered online access to their electronic health record. 

“Given that sharing notes in psychiatry is likely to be more complicated than in some other specialties, we were unsure whether experts would consider the practice more harmful than beneficial,” Charlotte Blease, PhD, of Beth Israel Deaconess Medical Center in Boston, told this news organization.

“However, the results of our poll suggest clinicians’ anxieties about sharing mental health notes with patients may be misplaced. We found clear consensus among experts that the benefits of online access to clinical notes could outweigh the risks,” Dr. Blease said in a news release.

The study was published online in PLOS ONE.

Empowering patients

Investigators used an online Delphi poll, an established methodology used to investigate emerging health care policy – including in psychiatry – to solicit the views of an international panel of experts on the mental health effects of sharing clinical notes.

The panel included clinicians, chief medical information officers, patient advocates, and informatics experts with extensive experience and research knowledge about patient access to mental health notes.

There was consensus among the panel that offering online access to mental health notes could enhance patients’ understanding about their diagnosis, care plan, and rationale for treatments.

There was also consensus that access to clinical notes could enhance patient recall about what was communicated and improve mental health patients’ sense of control over their health care.

The panel also agreed that blocking mental health notes could lead to greater harms including increased feelings of stigmatization.

Confirmatory findings

The poll results support an earlier study by Dr. Blease and colleagues that evaluated the experiences of patients in accessing their online clinical notes. 

Among these patients with major depressive disorder, schizophrenia, schizoaffective disorder, or bipolar-related disorder, “access helped to clarify why medications had been prescribed, improved understanding about side effects, and 20% of patients reported doing a better job taking their meds as prescribed,” said Dr. Blease.

However, the expert panel in the Delphi poll predicted that with “open notes” some patients might demand changes to their clinical notes, and that mental health clinicians might be less detailed/accurate in documenting negative aspects of the patient relationship, details about patients’ personalities, or symptoms of paranoia in patients.

“If some patients feel more judged or offended by what they read, this may undermine the therapeutic relationship. We also need more research into the experiences of patients hospitalized for their care,” she added.

“In some clinical cases where there is more focus on emergency care than in forming a therapeutic relationship, for example emergency department visits, we know almost nothing about the risks and benefits associated with OpenNotes,” senior author John Torous, MD, with Beth Israel Deaconess Medical Center and Harvard Medical School, said in an interview.

“One thing is clear,” Dr. Blease said. “Patient access to their online medical records is now mainstream, and we need more clinician education on how to write notes that patients will read, and more guidance among patients on the benefits and risks of accessing their notes.”

Support for this research was provided by a J. F. Keane Scholar Award and a Swedish Research Council on Health, Working Life, and Welfare grant. The authors have disclosed no relevant financial relationships.

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

There are multiple benefits and few harms from sharing clinical notes in patients with mental illness, results of a poll of international experts show.

As of April 5, 2021, new federal rules in the United States mandate that all patients are offered online access to their electronic health record. 

“Given that sharing notes in psychiatry is likely to be more complicated than in some other specialties, we were unsure whether experts would consider the practice more harmful than beneficial,” Charlotte Blease, PhD, of Beth Israel Deaconess Medical Center in Boston, told this news organization.

“However, the results of our poll suggest clinicians’ anxieties about sharing mental health notes with patients may be misplaced. We found clear consensus among experts that the benefits of online access to clinical notes could outweigh the risks,” Dr. Blease said in a news release.

The study was published online in PLOS ONE.

Empowering patients

Investigators used an online Delphi poll, an established methodology used to investigate emerging health care policy – including in psychiatry – to solicit the views of an international panel of experts on the mental health effects of sharing clinical notes.

The panel included clinicians, chief medical information officers, patient advocates, and informatics experts with extensive experience and research knowledge about patient access to mental health notes.

There was consensus among the panel that offering online access to mental health notes could enhance patients’ understanding about their diagnosis, care plan, and rationale for treatments.

There was also consensus that access to clinical notes could enhance patient recall about what was communicated and improve mental health patients’ sense of control over their health care.

The panel also agreed that blocking mental health notes could lead to greater harms including increased feelings of stigmatization.

Confirmatory findings

The poll results support an earlier study by Dr. Blease and colleagues that evaluated the experiences of patients in accessing their online clinical notes. 

Among these patients with major depressive disorder, schizophrenia, schizoaffective disorder, or bipolar-related disorder, “access helped to clarify why medications had been prescribed, improved understanding about side effects, and 20% of patients reported doing a better job taking their meds as prescribed,” said Dr. Blease.

However, the expert panel in the Delphi poll predicted that with “open notes” some patients might demand changes to their clinical notes, and that mental health clinicians might be less detailed/accurate in documenting negative aspects of the patient relationship, details about patients’ personalities, or symptoms of paranoia in patients.

“If some patients feel more judged or offended by what they read, this may undermine the therapeutic relationship. We also need more research into the experiences of patients hospitalized for their care,” she added.

“In some clinical cases where there is more focus on emergency care than in forming a therapeutic relationship, for example emergency department visits, we know almost nothing about the risks and benefits associated with OpenNotes,” senior author John Torous, MD, with Beth Israel Deaconess Medical Center and Harvard Medical School, said in an interview.

“One thing is clear,” Dr. Blease said. “Patient access to their online medical records is now mainstream, and we need more clinician education on how to write notes that patients will read, and more guidance among patients on the benefits and risks of accessing their notes.”

Support for this research was provided by a J. F. Keane Scholar Award and a Swedish Research Council on Health, Working Life, and Welfare grant. The authors have disclosed no relevant financial relationships.

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

There are multiple benefits and few harms from sharing clinical notes in patients with mental illness, results of a poll of international experts show.

As of April 5, 2021, new federal rules in the United States mandate that all patients are offered online access to their electronic health record. 

“Given that sharing notes in psychiatry is likely to be more complicated than in some other specialties, we were unsure whether experts would consider the practice more harmful than beneficial,” Charlotte Blease, PhD, of Beth Israel Deaconess Medical Center in Boston, told this news organization.

“However, the results of our poll suggest clinicians’ anxieties about sharing mental health notes with patients may be misplaced. We found clear consensus among experts that the benefits of online access to clinical notes could outweigh the risks,” Dr. Blease said in a news release.

The study was published online in PLOS ONE.

Empowering patients

Investigators used an online Delphi poll, an established methodology used to investigate emerging health care policy – including in psychiatry – to solicit the views of an international panel of experts on the mental health effects of sharing clinical notes.

The panel included clinicians, chief medical information officers, patient advocates, and informatics experts with extensive experience and research knowledge about patient access to mental health notes.

There was consensus among the panel that offering online access to mental health notes could enhance patients’ understanding about their diagnosis, care plan, and rationale for treatments.

There was also consensus that access to clinical notes could enhance patient recall about what was communicated and improve mental health patients’ sense of control over their health care.

The panel also agreed that blocking mental health notes could lead to greater harms including increased feelings of stigmatization.

Confirmatory findings

The poll results support an earlier study by Dr. Blease and colleagues that evaluated the experiences of patients in accessing their online clinical notes. 

Among these patients with major depressive disorder, schizophrenia, schizoaffective disorder, or bipolar-related disorder, “access helped to clarify why medications had been prescribed, improved understanding about side effects, and 20% of patients reported doing a better job taking their meds as prescribed,” said Dr. Blease.

However, the expert panel in the Delphi poll predicted that with “open notes” some patients might demand changes to their clinical notes, and that mental health clinicians might be less detailed/accurate in documenting negative aspects of the patient relationship, details about patients’ personalities, or symptoms of paranoia in patients.

“If some patients feel more judged or offended by what they read, this may undermine the therapeutic relationship. We also need more research into the experiences of patients hospitalized for their care,” she added.

“In some clinical cases where there is more focus on emergency care than in forming a therapeutic relationship, for example emergency department visits, we know almost nothing about the risks and benefits associated with OpenNotes,” senior author John Torous, MD, with Beth Israel Deaconess Medical Center and Harvard Medical School, said in an interview.

“One thing is clear,” Dr. Blease said. “Patient access to their online medical records is now mainstream, and we need more clinician education on how to write notes that patients will read, and more guidance among patients on the benefits and risks of accessing their notes.”

Support for this research was provided by a J. F. Keane Scholar Award and a Swedish Research Council on Health, Working Life, and Welfare grant. The authors have disclosed no relevant financial relationships.

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

Nearly two-thirds of Americans are not confident that they understood their doctor’s recommendations and the health information they discussed with their doctor after a visit, according to a new survey.

Confusion over health information and doctor advice is even higher among people who care for patients than among those who don’t provide care to their loved ones, the nationally representative survey from the AHIMA Foundation found.

The survey also shows that 80% of Americans – and an even higher portion of caregivers – are likely to research medical recommendations online after a doctor’s visit. But 1 in 4 people don’t know how to access their own medical records or find it difficult to do so.

The findings reflect the same low level of health literacy in the U.S. population that earlier surveys did. The results also indicate that little has changed since the Department of Health and Human Services released a National Action Plan to Improve Health Literacy in 2010.

That plan emphasized the need to develop and share accurate health information that helps people make decisions; to promote changes in the health care system that improve health information, communication, informed decision-making, and access to health services; and to increase the sharing and use of evidence-based health literacy practices.

According to the AHIMA Foundation report, 62% of Americans are not sure they understand their doctor’s advice and the health information discussed during a visit. Twenty-four percent say they don’t comprehend any of it, and 31% can’t remember what was said during the visit. Fifteen percent of those surveyed said they were more confused about their health than they were before the encounter with their doctor.
 

Caregivers have special issues

Forty-three percent of Americans are caregivers, the report notes, and 91% of those play an active role in managing someone else’s health. Millennials (65%) and Gen Xers (50%) are significantly more likely than Gen Zers (39%) and Boomers (20%) to be a caregiver.

Most caregivers have concerns about their loved ones’ ability to manage their own health. Most of them believe that doctors provide enough information, but 38% don’t believe a doctor can communicate effectively with the patient if the caregiver is not present.

Forty-three percent of caretakers don’t think their loved ones can understand medical information on their own. On the other hand, caregivers are more likely than people who don’t provide care to say the doctor confused them and to research the doctor’s advice after an appointment.

For many patients and caregivers, communications break down when they are with their health care provider. Twenty-two percent of Americans say they do not feel comfortable asking their doctor certain health questions. This inability to have a satisfactory dialogue with their doctor means that many patients leave their appointments without getting clear answers to their questions (24%) or without having an opportunity to ask any questions at all (17%).

This is not surprising, considering that a 2018 study found that doctors spend only 11 seconds, on average, listening to patients before interrupting them.
 

Depending on the internet

Overall, the AHIMA survey found, 42% of Americans research their doctor’s recommendations after an appointment. A higher percentage of caregivers than noncaregiver peers do so (47% vs. 38%). Eighty percent of respondents say they are “likely” to research their doctor’s advice online after a visit.

When they have a medical problem or a question about their condition, just as many Americans (59%) turn to the internet for an answer as contact their doctor directly, the survey found. Twenty-nine percent of the respondents consult friends, family, or colleagues; 23% look up medical records if they’re easily accessible; 19% ask pharmacists for advice; and 6% call an unspecified 800 number.

Americans feel secure in the health information they find on the internet. Among those who go online to look up information, 86% are confident that it is credible. And 42% report feeling relieved that they can find a lot of information about their health concerns. Respondents also say that the information they gather allows them to feel more confident in their doctor’s recommendations (35%) and that they feel better after having learned more on the internet than their doctor had told them (39%). Men are more likely than women to say that their confidence in their doctor’s recommendations increased after doing online research (40% vs. 30%).
 

Access to health records

Access to medical records would help people better understand their condition or diagnosis. But nearly half of Americans (48%) admit they don’t usually review their medical records until long after an appointment, and 52% say they rarely access their records at all.

One in four Americans say that they don’t know where to go to access their health information or that they didn’t find the process easy. More than half of those who have never had to find their records think the process would be difficult if they had to try.

Eighty-one percent of Americans use an online platform or portal to access their medical records or health information. Two-thirds of Americans who use an online portal trust that their medical information is kept safe and not shared with other people or organizations.

Four in five respondents agree that if they had access to all of their health information, including medical records, recommendations, conditions, and test results, they’d see an improvement in their health management. Fifty-nine percent of them believe they’d also be more confident about understanding their health, and 47% say they’d have greater trust in their doctor’s recommendations. Higher percentages of caregivers than noncaregivers say the same.

Younger people, those with a high school degree or less, and those who earn less than $50,000 are less likely than older, better educated, and more affluent people to understand their doctor’s health information and to ask questions of their providers.

People of color struggle with their relationships with doctors, are less satisfied than white people with the information they receive during visits, and are more likely than white peers to feel that if they had access to all their health information, they’d manage their health better and be more confident in their doctors’ recommendations, the survey found.

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

Nearly two-thirds of Americans are not confident that they understood their doctor’s recommendations and the health information they discussed with their doctor after a visit, according to a new survey.

Confusion over health information and doctor advice is even higher among people who care for patients than among those who don’t provide care to their loved ones, the nationally representative survey from the AHIMA Foundation found.

The survey also shows that 80% of Americans – and an even higher portion of caregivers – are likely to research medical recommendations online after a doctor’s visit. But 1 in 4 people don’t know how to access their own medical records or find it difficult to do so.

The findings reflect the same low level of health literacy in the U.S. population that earlier surveys did. The results also indicate that little has changed since the Department of Health and Human Services released a National Action Plan to Improve Health Literacy in 2010.

That plan emphasized the need to develop and share accurate health information that helps people make decisions; to promote changes in the health care system that improve health information, communication, informed decision-making, and access to health services; and to increase the sharing and use of evidence-based health literacy practices.

According to the AHIMA Foundation report, 62% of Americans are not sure they understand their doctor’s advice and the health information discussed during a visit. Twenty-four percent say they don’t comprehend any of it, and 31% can’t remember what was said during the visit. Fifteen percent of those surveyed said they were more confused about their health than they were before the encounter with their doctor.
 

Caregivers have special issues

Forty-three percent of Americans are caregivers, the report notes, and 91% of those play an active role in managing someone else’s health. Millennials (65%) and Gen Xers (50%) are significantly more likely than Gen Zers (39%) and Boomers (20%) to be a caregiver.

Most caregivers have concerns about their loved ones’ ability to manage their own health. Most of them believe that doctors provide enough information, but 38% don’t believe a doctor can communicate effectively with the patient if the caregiver is not present.

Forty-three percent of caretakers don’t think their loved ones can understand medical information on their own. On the other hand, caregivers are more likely than people who don’t provide care to say the doctor confused them and to research the doctor’s advice after an appointment.

For many patients and caregivers, communications break down when they are with their health care provider. Twenty-two percent of Americans say they do not feel comfortable asking their doctor certain health questions. This inability to have a satisfactory dialogue with their doctor means that many patients leave their appointments without getting clear answers to their questions (24%) or without having an opportunity to ask any questions at all (17%).

This is not surprising, considering that a 2018 study found that doctors spend only 11 seconds, on average, listening to patients before interrupting them.
 

Depending on the internet

Overall, the AHIMA survey found, 42% of Americans research their doctor’s recommendations after an appointment. A higher percentage of caregivers than noncaregiver peers do so (47% vs. 38%). Eighty percent of respondents say they are “likely” to research their doctor’s advice online after a visit.

When they have a medical problem or a question about their condition, just as many Americans (59%) turn to the internet for an answer as contact their doctor directly, the survey found. Twenty-nine percent of the respondents consult friends, family, or colleagues; 23% look up medical records if they’re easily accessible; 19% ask pharmacists for advice; and 6% call an unspecified 800 number.

Americans feel secure in the health information they find on the internet. Among those who go online to look up information, 86% are confident that it is credible. And 42% report feeling relieved that they can find a lot of information about their health concerns. Respondents also say that the information they gather allows them to feel more confident in their doctor’s recommendations (35%) and that they feel better after having learned more on the internet than their doctor had told them (39%). Men are more likely than women to say that their confidence in their doctor’s recommendations increased after doing online research (40% vs. 30%).
 

Access to health records

Access to medical records would help people better understand their condition or diagnosis. But nearly half of Americans (48%) admit they don’t usually review their medical records until long after an appointment, and 52% say they rarely access their records at all.

One in four Americans say that they don’t know where to go to access their health information or that they didn’t find the process easy. More than half of those who have never had to find their records think the process would be difficult if they had to try.

Eighty-one percent of Americans use an online platform or portal to access their medical records or health information. Two-thirds of Americans who use an online portal trust that their medical information is kept safe and not shared with other people or organizations.

Four in five respondents agree that if they had access to all of their health information, including medical records, recommendations, conditions, and test results, they’d see an improvement in their health management. Fifty-nine percent of them believe they’d also be more confident about understanding their health, and 47% say they’d have greater trust in their doctor’s recommendations. Higher percentages of caregivers than noncaregivers say the same.

Younger people, those with a high school degree or less, and those who earn less than $50,000 are less likely than older, better educated, and more affluent people to understand their doctor’s health information and to ask questions of their providers.

People of color struggle with their relationships with doctors, are less satisfied than white people with the information they receive during visits, and are more likely than white peers to feel that if they had access to all their health information, they’d manage their health better and be more confident in their doctors’ recommendations, the survey found.

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

Nearly two-thirds of Americans are not confident that they understood their doctor’s recommendations and the health information they discussed with their doctor after a visit, according to a new survey.

Confusion over health information and doctor advice is even higher among people who care for patients than among those who don’t provide care to their loved ones, the nationally representative survey from the AHIMA Foundation found.

The survey also shows that 80% of Americans – and an even higher portion of caregivers – are likely to research medical recommendations online after a doctor’s visit. But 1 in 4 people don’t know how to access their own medical records or find it difficult to do so.

The findings reflect the same low level of health literacy in the U.S. population that earlier surveys did. The results also indicate that little has changed since the Department of Health and Human Services released a National Action Plan to Improve Health Literacy in 2010.

That plan emphasized the need to develop and share accurate health information that helps people make decisions; to promote changes in the health care system that improve health information, communication, informed decision-making, and access to health services; and to increase the sharing and use of evidence-based health literacy practices.

According to the AHIMA Foundation report, 62% of Americans are not sure they understand their doctor’s advice and the health information discussed during a visit. Twenty-four percent say they don’t comprehend any of it, and 31% can’t remember what was said during the visit. Fifteen percent of those surveyed said they were more confused about their health than they were before the encounter with their doctor.
 

Caregivers have special issues

Forty-three percent of Americans are caregivers, the report notes, and 91% of those play an active role in managing someone else’s health. Millennials (65%) and Gen Xers (50%) are significantly more likely than Gen Zers (39%) and Boomers (20%) to be a caregiver.

Most caregivers have concerns about their loved ones’ ability to manage their own health. Most of them believe that doctors provide enough information, but 38% don’t believe a doctor can communicate effectively with the patient if the caregiver is not present.

Forty-three percent of caretakers don’t think their loved ones can understand medical information on their own. On the other hand, caregivers are more likely than people who don’t provide care to say the doctor confused them and to research the doctor’s advice after an appointment.

For many patients and caregivers, communications break down when they are with their health care provider. Twenty-two percent of Americans say they do not feel comfortable asking their doctor certain health questions. This inability to have a satisfactory dialogue with their doctor means that many patients leave their appointments without getting clear answers to their questions (24%) or without having an opportunity to ask any questions at all (17%).

This is not surprising, considering that a 2018 study found that doctors spend only 11 seconds, on average, listening to patients before interrupting them.
 

Depending on the internet

Overall, the AHIMA survey found, 42% of Americans research their doctor’s recommendations after an appointment. A higher percentage of caregivers than noncaregiver peers do so (47% vs. 38%). Eighty percent of respondents say they are “likely” to research their doctor’s advice online after a visit.

When they have a medical problem or a question about their condition, just as many Americans (59%) turn to the internet for an answer as contact their doctor directly, the survey found. Twenty-nine percent of the respondents consult friends, family, or colleagues; 23% look up medical records if they’re easily accessible; 19% ask pharmacists for advice; and 6% call an unspecified 800 number.

Americans feel secure in the health information they find on the internet. Among those who go online to look up information, 86% are confident that it is credible. And 42% report feeling relieved that they can find a lot of information about their health concerns. Respondents also say that the information they gather allows them to feel more confident in their doctor’s recommendations (35%) and that they feel better after having learned more on the internet than their doctor had told them (39%). Men are more likely than women to say that their confidence in their doctor’s recommendations increased after doing online research (40% vs. 30%).
 

Access to health records

Access to medical records would help people better understand their condition or diagnosis. But nearly half of Americans (48%) admit they don’t usually review their medical records until long after an appointment, and 52% say they rarely access their records at all.

One in four Americans say that they don’t know where to go to access their health information or that they didn’t find the process easy. More than half of those who have never had to find their records think the process would be difficult if they had to try.

Eighty-one percent of Americans use an online platform or portal to access their medical records or health information. Two-thirds of Americans who use an online portal trust that their medical information is kept safe and not shared with other people or organizations.

Four in five respondents agree that if they had access to all of their health information, including medical records, recommendations, conditions, and test results, they’d see an improvement in their health management. Fifty-nine percent of them believe they’d also be more confident about understanding their health, and 47% say they’d have greater trust in their doctor’s recommendations. Higher percentages of caregivers than noncaregivers say the same.

Younger people, those with a high school degree or less, and those who earn less than $50,000 are less likely than older, better educated, and more affluent people to understand their doctor’s health information and to ask questions of their providers.

People of color struggle with their relationships with doctors, are less satisfied than white people with the information they receive during visits, and are more likely than white peers to feel that if they had access to all their health information, they’d manage their health better and be more confident in their doctors’ recommendations, the survey found.

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

Social media isn’t everyone’s cup of tea, but for those who want to become a significant influencer on Instagram, YouTube, TikTok, or other platforms, “you have to enjoy it,” Sandra Lee, MD, said during a virtual course on laser and aesthetic skin therapy.

“I admit that I’m somewhat obsessed with it. I kind of blame it on my work as a dermatologist, that I’m trying to grow my social media as well. It’s interesting to me, fascinating, and I want to understand it more. I think that’s the mindset you need to approach it with.”

Perhaps no other public figure in dermatology has enjoyed success in social media more than Dr. Lee, a board-certified dermatologist who practices in Upland, Calif. In the fall of 2014, she started using Instagram to provide followers a glimpse into her life as a dermatologist, everything from Mohs surgery and Botox to keloid removals and ear lobe repair surgeries. From this she formed her alter ego, “Dr. Pimple Popper,” and became a YouTube sensation, building 7.1 million subscribers over the course of a few years, amounting to 4.5 billion lifetime views. She also grew 12 million followers on TikTok, 4.4 million followers on Instagram, 3 million on Facebook, and more than 139,000 on Twitter. About 80% of her followers are women who range between 18 and 40 years of age.

During the meeting she offered five social media marketing tips for busy clinicians:

You have to ‘play’ to ‘win.’ Active participation in social media is required to develop followers. “You cannot delegate this content,” Dr. Lee said. “You can hire people to help you or leave the task to a social media-savvy medical assistant in your office, but the content should be your responsibility ultimately, because you are the physician,” she added. Not everyone chooses to participate in social media, but it’s also something not to shy away from out of intimidation. “There is some talent associated with it, but it takes a lot of persistence as well,” she said.

Patients come first. Protect them at all costs. Dr. Lee rarely posts the faces of patients she cares for unless they grant consent in advance. “I try to show the work that I do and the beauty of dermatology,” she said during the meeting, which was named “Laser & Aesthetic Skin Therapy: What’s the Truth?” and was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. She added that taking part in social media can help you improve communication skills by engaging with followers who like, share, or respond to the material posted. “When you look back at your posts objectively, you learn about yourself and how you relate to your patients,” she said. “It helps to hone my bedside manner and my skills as a dermatologist.”

Show that you are human. Many dermatologists and other “skin influencers” have established their presence on the Internet and may be direct competitors for patients, but that doesn’t mean you can’t establish your own identity. One way to stand out is by posting content related to your authentic self, such as a photo or video that shows you engaged in a hobby, dining at a favorite restaurant, or visiting a beloved vacation spot. “Your followers don’t want a robot, someone who thinks they’re amazing and can do everything,” said Dr. Lee, who stars in her own TV reality show on TLC. “Show that you have a funny side. You want them to fall in love with you and see a little bit of your world, whatever it might be. Charm the socks off of them.”

Entertain first, educate a close second. The main way you’re going to get people to follow and watch you is to provide some entertainment, “not at the expense of a patient or your practice, though,” she said. “Then you’re going to educate people. We dermatologists have something to teach the world because we are experts on skin, hair, and nails. You want to impart this knowledge in a way that captivates people.” It’s like the sense of accomplishment that comes from learning something new after reading a book or watching a movie, she explained. “You feel good about it, and you can take that knowledge with you somewhere else. I love it when kids come up to me and tell me they know what a lipoma is, what a cyst is, and what psoriasis is because they’ve seen my show, or because they follow me on social media. It’s wonderful because I can see that I’ve educated them.”

Be kind and don’t activate the trolls. Dr. Lee allows positivity and kindness to rule the day on her social media content. “This is what I try to relay to followers, but I also do not engage with the negativity,” she said. “Every now and then, there will be someone who tries to insult what you do or who insults you personally. If you engage with them, it almost invites them to do it more. It almost gives them the ability to fight with you. Try to stay above that; just put out goodness and kindness.”

Several years ago, YouTube and Instagram temporarily shut down Dr. Lee’s accounts because she posted graphic images of skin lesions and procedures – a practice that wasn’t so commonplace at the time. “Don’t just post a graphic image just to be graphic,” she advised. “Make sure it has an educational message associated with it. That will help to validate your content. Posting a warning sign that some images may be graphic could help, too.”

Dr. Lee reported having no relevant financial disclosures.

dbrunk@mdedge.com

Social media isn’t everyone’s cup of tea, but for those who want to become a significant influencer on Instagram, YouTube, TikTok, or other platforms, “you have to enjoy it,” Sandra Lee, MD, said during a virtual course on laser and aesthetic skin therapy.

“I admit that I’m somewhat obsessed with it. I kind of blame it on my work as a dermatologist, that I’m trying to grow my social media as well. It’s interesting to me, fascinating, and I want to understand it more. I think that’s the mindset you need to approach it with.”

Perhaps no other public figure in dermatology has enjoyed success in social media more than Dr. Lee, a board-certified dermatologist who practices in Upland, Calif. In the fall of 2014, she started using Instagram to provide followers a glimpse into her life as a dermatologist, everything from Mohs surgery and Botox to keloid removals and ear lobe repair surgeries. From this she formed her alter ego, “Dr. Pimple Popper,” and became a YouTube sensation, building 7.1 million subscribers over the course of a few years, amounting to 4.5 billion lifetime views. She also grew 12 million followers on TikTok, 4.4 million followers on Instagram, 3 million on Facebook, and more than 139,000 on Twitter. About 80% of her followers are women who range between 18 and 40 years of age.

During the meeting she offered five social media marketing tips for busy clinicians:

You have to ‘play’ to ‘win.’ Active participation in social media is required to develop followers. “You cannot delegate this content,” Dr. Lee said. “You can hire people to help you or leave the task to a social media-savvy medical assistant in your office, but the content should be your responsibility ultimately, because you are the physician,” she added. Not everyone chooses to participate in social media, but it’s also something not to shy away from out of intimidation. “There is some talent associated with it, but it takes a lot of persistence as well,” she said.

Patients come first. Protect them at all costs. Dr. Lee rarely posts the faces of patients she cares for unless they grant consent in advance. “I try to show the work that I do and the beauty of dermatology,” she said during the meeting, which was named “Laser & Aesthetic Skin Therapy: What’s the Truth?” and was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. She added that taking part in social media can help you improve communication skills by engaging with followers who like, share, or respond to the material posted. “When you look back at your posts objectively, you learn about yourself and how you relate to your patients,” she said. “It helps to hone my bedside manner and my skills as a dermatologist.”

Show that you are human. Many dermatologists and other “skin influencers” have established their presence on the Internet and may be direct competitors for patients, but that doesn’t mean you can’t establish your own identity. One way to stand out is by posting content related to your authentic self, such as a photo or video that shows you engaged in a hobby, dining at a favorite restaurant, or visiting a beloved vacation spot. “Your followers don’t want a robot, someone who thinks they’re amazing and can do everything,” said Dr. Lee, who stars in her own TV reality show on TLC. “Show that you have a funny side. You want them to fall in love with you and see a little bit of your world, whatever it might be. Charm the socks off of them.”

Entertain first, educate a close second. The main way you’re going to get people to follow and watch you is to provide some entertainment, “not at the expense of a patient or your practice, though,” she said. “Then you’re going to educate people. We dermatologists have something to teach the world because we are experts on skin, hair, and nails. You want to impart this knowledge in a way that captivates people.” It’s like the sense of accomplishment that comes from learning something new after reading a book or watching a movie, she explained. “You feel good about it, and you can take that knowledge with you somewhere else. I love it when kids come up to me and tell me they know what a lipoma is, what a cyst is, and what psoriasis is because they’ve seen my show, or because they follow me on social media. It’s wonderful because I can see that I’ve educated them.”

Be kind and don’t activate the trolls. Dr. Lee allows positivity and kindness to rule the day on her social media content. “This is what I try to relay to followers, but I also do not engage with the negativity,” she said. “Every now and then, there will be someone who tries to insult what you do or who insults you personally. If you engage with them, it almost invites them to do it more. It almost gives them the ability to fight with you. Try to stay above that; just put out goodness and kindness.”

Several years ago, YouTube and Instagram temporarily shut down Dr. Lee’s accounts because she posted graphic images of skin lesions and procedures – a practice that wasn’t so commonplace at the time. “Don’t just post a graphic image just to be graphic,” she advised. “Make sure it has an educational message associated with it. That will help to validate your content. Posting a warning sign that some images may be graphic could help, too.”

Dr. Lee reported having no relevant financial disclosures.

dbrunk@mdedge.com

Social media isn’t everyone’s cup of tea, but for those who want to become a significant influencer on Instagram, YouTube, TikTok, or other platforms, “you have to enjoy it,” Sandra Lee, MD, said during a virtual course on laser and aesthetic skin therapy.

“I admit that I’m somewhat obsessed with it. I kind of blame it on my work as a dermatologist, that I’m trying to grow my social media as well. It’s interesting to me, fascinating, and I want to understand it more. I think that’s the mindset you need to approach it with.”

Perhaps no other public figure in dermatology has enjoyed success in social media more than Dr. Lee, a board-certified dermatologist who practices in Upland, Calif. In the fall of 2014, she started using Instagram to provide followers a glimpse into her life as a dermatologist, everything from Mohs surgery and Botox to keloid removals and ear lobe repair surgeries. From this she formed her alter ego, “Dr. Pimple Popper,” and became a YouTube sensation, building 7.1 million subscribers over the course of a few years, amounting to 4.5 billion lifetime views. She also grew 12 million followers on TikTok, 4.4 million followers on Instagram, 3 million on Facebook, and more than 139,000 on Twitter. About 80% of her followers are women who range between 18 and 40 years of age.

During the meeting she offered five social media marketing tips for busy clinicians:

You have to ‘play’ to ‘win.’ Active participation in social media is required to develop followers. “You cannot delegate this content,” Dr. Lee said. “You can hire people to help you or leave the task to a social media-savvy medical assistant in your office, but the content should be your responsibility ultimately, because you are the physician,” she added. Not everyone chooses to participate in social media, but it’s also something not to shy away from out of intimidation. “There is some talent associated with it, but it takes a lot of persistence as well,” she said.

Patients come first. Protect them at all costs. Dr. Lee rarely posts the faces of patients she cares for unless they grant consent in advance. “I try to show the work that I do and the beauty of dermatology,” she said during the meeting, which was named “Laser & Aesthetic Skin Therapy: What’s the Truth?” and was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. She added that taking part in social media can help you improve communication skills by engaging with followers who like, share, or respond to the material posted. “When you look back at your posts objectively, you learn about yourself and how you relate to your patients,” she said. “It helps to hone my bedside manner and my skills as a dermatologist.”

Show that you are human. Many dermatologists and other “skin influencers” have established their presence on the Internet and may be direct competitors for patients, but that doesn’t mean you can’t establish your own identity. One way to stand out is by posting content related to your authentic self, such as a photo or video that shows you engaged in a hobby, dining at a favorite restaurant, or visiting a beloved vacation spot. “Your followers don’t want a robot, someone who thinks they’re amazing and can do everything,” said Dr. Lee, who stars in her own TV reality show on TLC. “Show that you have a funny side. You want them to fall in love with you and see a little bit of your world, whatever it might be. Charm the socks off of them.”

Entertain first, educate a close second. The main way you’re going to get people to follow and watch you is to provide some entertainment, “not at the expense of a patient or your practice, though,” she said. “Then you’re going to educate people. We dermatologists have something to teach the world because we are experts on skin, hair, and nails. You want to impart this knowledge in a way that captivates people.” It’s like the sense of accomplishment that comes from learning something new after reading a book or watching a movie, she explained. “You feel good about it, and you can take that knowledge with you somewhere else. I love it when kids come up to me and tell me they know what a lipoma is, what a cyst is, and what psoriasis is because they’ve seen my show, or because they follow me on social media. It’s wonderful because I can see that I’ve educated them.”

Be kind and don’t activate the trolls. Dr. Lee allows positivity and kindness to rule the day on her social media content. “This is what I try to relay to followers, but I also do not engage with the negativity,” she said. “Every now and then, there will be someone who tries to insult what you do or who insults you personally. If you engage with them, it almost invites them to do it more. It almost gives them the ability to fight with you. Try to stay above that; just put out goodness and kindness.”

Several years ago, YouTube and Instagram temporarily shut down Dr. Lee’s accounts because she posted graphic images of skin lesions and procedures – a practice that wasn’t so commonplace at the time. “Don’t just post a graphic image just to be graphic,” she advised. “Make sure it has an educational message associated with it. That will help to validate your content. Posting a warning sign that some images may be graphic could help, too.”

Dr. Lee reported having no relevant financial disclosures.

dbrunk@mdedge.com