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Study estimates carbon footprint reduction of virtual isotretinoin visits
: A reduction of 5,137 kg of greenhouse gas emissions in carbon dioxide equivalents.
In what they say is “one of the first studies to evaluate the environmental impact of any aspect of dermatology,” the authors of the retrospective cross-sectional study identified patients who had virtual visits for isotretinoin management between March 25 and May 29, 2020, – the period during which all such visits were conducted virtually in keeping with hospital recommendations to minimize the spread of COVID-19.
The investigators, from the department of dermatology and the department of civil and environmental engineering at West Virginia University, Morgantown, then counted the number of virtual visits that occurred during this period and through Dec. 1, 2020, (175 virtual visits), calculated the distance patients would have traveled round-trip had these visits been in-person, and converted miles saved into the environmental impact using U.S. Environmental Protection Agency and Federal Highway Administration data and relevant EPA standards.
Most patients had elected to continue virtual visits after May 29, the point at which patients were given the option to return to the WVUH clinic. (Patients who initiated treatment during the 2-month identification period were not included.)
The investigators determined that virtual management of isotretinoin saved a median of 37.8 miles per visit during the study period of March 25 to Dec. 1, and estimated that the virtual visits reduced total travel by 14,450 miles. For the analysis, patients were assumed to use light-duty vehicles.
In addition to calculating the reduction in emissions during the study period (5,137 kg of CO2equivalents) they used patient census data from 2019 to 2020 and data from the study period to project the mileage – and the associated emissions – that would be saved annually if all in-person visits for isotretinoin management occurred virtually.
Their calculation for a projected emissions reduction with 1 year of all-virtual isotretinoin management was 49,400 kg of greenhouse gas emissions in CO2equivalents. This is the emission load released when 24,690 kg of coal are burned or 6.3 million smartphones are charged, the researchers wrote.
“Considering that more than 1,000,000 prescriptions of isotretinoin are authorized annually in the United States, the environmental impact could be magnified if virtual delivery of isotretinoin care is adopted on a national scale,” they commented.“Given the serious consequences of global climate change, analysis of the environmental impact of all fields of medicine, including dermatology, is warranted,” they added.
The reduced greenhouse gas emissions are “definitely [being taken] into consideration for future decisions about virtual visits” in the department of dermatology, said Zachary Zinn, MD, residency director and associate professor in the department of dermatology at West Virginia University, Morgantown, who is the senior author of the study. “The main benefit of virtual care in my opinion,” he said in an interview, “is the potential to reduce our carbon footprint.”
Justin Lee, MD, an intern at WVU and the study’s first author, said that the research team was motivated to think about how they “could reduce the negative environmental impact of practicing dermatology” after they read a paper about the environmental impact of endoscopy, written by a gastroenterologist.
In the study, no pregnancies occurred and monthly tests were performed, but “formal assessment of pregnancy risk with virtual isotretinoin management would be warranted,” Dr. Lee and coauthors wrote, noting too that, while no differences were seen with respect to isotretinoin side effects, these were not formally analyzed.
Dr. Zinn said that he and colleagues at WVUH are currently conducting clinical trials to assess the quality and efficacy of virtual care for patients with acne, atopic dermatitis, and psoriasis. Delivering care virtually “will be easier to do if there are data supporting [its] quality and efficacy,” he said. Rosacea is another condition that may be amendable to virtual care, he noted.
Meanwhile, he said, isotretinoin management is “well suited” for virtual visits. When initiating isotretinoin treatment, Dr. Zinn now “proactively inquires” if patients would like to pursue their follow-up visits virtually. “I’ll note that it will save the time and decrease the burden of travel, including the financial cost as well as the environmental cost of travel,” he said, estimating that about half of their management visits are currently virtual.
Asked about the study, Misha Rosenbach, MD, associate professor of dermatology at the University of Pennsylvania, Philadelphia, said the reduced carbon footprint calculated by the researchers and its downstream health benefits “should be taken into consideration by [dermatology] departments, insurers and policymakers” when making decisions about teledermatology.
While environmental impact is “not something I think most institutions are considering for virtual versus in-person care, they should be. And some are,” said Dr. Rosenbach, a founder and cochair of the American Academy of Dermatology Expert Resource Group for Climate Change and Environmental Issues.
Limitations of the study include the generalizability of the results. The impact of virtual isotretinoin management “may be less in predominantly urban areas” than it is in predominately rural West Virginia, the study authors note. And in the case of West Virginia, travel to a local laboratory and pharmacy offsets some of the environmental benefits for the virtual care, they noted. Such travel wasn’t accounted for in the study, but it was found to be a fraction of travel to the WVU hospital clinic. (Patients traveled a median of 5.8 miles to a lab 2.4 times from March 25 to Dec. 1, 2020.)
Dr. Lee will start his dermatology residency at WVU next year. The study was funded by a grant from the U.S. National Science Foundation. The authors have no relevant conflicts of interest, according to Dr. Lee.
: A reduction of 5,137 kg of greenhouse gas emissions in carbon dioxide equivalents.
In what they say is “one of the first studies to evaluate the environmental impact of any aspect of dermatology,” the authors of the retrospective cross-sectional study identified patients who had virtual visits for isotretinoin management between March 25 and May 29, 2020, – the period during which all such visits were conducted virtually in keeping with hospital recommendations to minimize the spread of COVID-19.
The investigators, from the department of dermatology and the department of civil and environmental engineering at West Virginia University, Morgantown, then counted the number of virtual visits that occurred during this period and through Dec. 1, 2020, (175 virtual visits), calculated the distance patients would have traveled round-trip had these visits been in-person, and converted miles saved into the environmental impact using U.S. Environmental Protection Agency and Federal Highway Administration data and relevant EPA standards.
Most patients had elected to continue virtual visits after May 29, the point at which patients were given the option to return to the WVUH clinic. (Patients who initiated treatment during the 2-month identification period were not included.)
The investigators determined that virtual management of isotretinoin saved a median of 37.8 miles per visit during the study period of March 25 to Dec. 1, and estimated that the virtual visits reduced total travel by 14,450 miles. For the analysis, patients were assumed to use light-duty vehicles.
In addition to calculating the reduction in emissions during the study period (5,137 kg of CO2equivalents) they used patient census data from 2019 to 2020 and data from the study period to project the mileage – and the associated emissions – that would be saved annually if all in-person visits for isotretinoin management occurred virtually.
Their calculation for a projected emissions reduction with 1 year of all-virtual isotretinoin management was 49,400 kg of greenhouse gas emissions in CO2equivalents. This is the emission load released when 24,690 kg of coal are burned or 6.3 million smartphones are charged, the researchers wrote.
“Considering that more than 1,000,000 prescriptions of isotretinoin are authorized annually in the United States, the environmental impact could be magnified if virtual delivery of isotretinoin care is adopted on a national scale,” they commented.“Given the serious consequences of global climate change, analysis of the environmental impact of all fields of medicine, including dermatology, is warranted,” they added.
The reduced greenhouse gas emissions are “definitely [being taken] into consideration for future decisions about virtual visits” in the department of dermatology, said Zachary Zinn, MD, residency director and associate professor in the department of dermatology at West Virginia University, Morgantown, who is the senior author of the study. “The main benefit of virtual care in my opinion,” he said in an interview, “is the potential to reduce our carbon footprint.”
Justin Lee, MD, an intern at WVU and the study’s first author, said that the research team was motivated to think about how they “could reduce the negative environmental impact of practicing dermatology” after they read a paper about the environmental impact of endoscopy, written by a gastroenterologist.
In the study, no pregnancies occurred and monthly tests were performed, but “formal assessment of pregnancy risk with virtual isotretinoin management would be warranted,” Dr. Lee and coauthors wrote, noting too that, while no differences were seen with respect to isotretinoin side effects, these were not formally analyzed.
Dr. Zinn said that he and colleagues at WVUH are currently conducting clinical trials to assess the quality and efficacy of virtual care for patients with acne, atopic dermatitis, and psoriasis. Delivering care virtually “will be easier to do if there are data supporting [its] quality and efficacy,” he said. Rosacea is another condition that may be amendable to virtual care, he noted.
Meanwhile, he said, isotretinoin management is “well suited” for virtual visits. When initiating isotretinoin treatment, Dr. Zinn now “proactively inquires” if patients would like to pursue their follow-up visits virtually. “I’ll note that it will save the time and decrease the burden of travel, including the financial cost as well as the environmental cost of travel,” he said, estimating that about half of their management visits are currently virtual.
Asked about the study, Misha Rosenbach, MD, associate professor of dermatology at the University of Pennsylvania, Philadelphia, said the reduced carbon footprint calculated by the researchers and its downstream health benefits “should be taken into consideration by [dermatology] departments, insurers and policymakers” when making decisions about teledermatology.
While environmental impact is “not something I think most institutions are considering for virtual versus in-person care, they should be. And some are,” said Dr. Rosenbach, a founder and cochair of the American Academy of Dermatology Expert Resource Group for Climate Change and Environmental Issues.
Limitations of the study include the generalizability of the results. The impact of virtual isotretinoin management “may be less in predominantly urban areas” than it is in predominately rural West Virginia, the study authors note. And in the case of West Virginia, travel to a local laboratory and pharmacy offsets some of the environmental benefits for the virtual care, they noted. Such travel wasn’t accounted for in the study, but it was found to be a fraction of travel to the WVU hospital clinic. (Patients traveled a median of 5.8 miles to a lab 2.4 times from March 25 to Dec. 1, 2020.)
Dr. Lee will start his dermatology residency at WVU next year. The study was funded by a grant from the U.S. National Science Foundation. The authors have no relevant conflicts of interest, according to Dr. Lee.
: A reduction of 5,137 kg of greenhouse gas emissions in carbon dioxide equivalents.
In what they say is “one of the first studies to evaluate the environmental impact of any aspect of dermatology,” the authors of the retrospective cross-sectional study identified patients who had virtual visits for isotretinoin management between March 25 and May 29, 2020, – the period during which all such visits were conducted virtually in keeping with hospital recommendations to minimize the spread of COVID-19.
The investigators, from the department of dermatology and the department of civil and environmental engineering at West Virginia University, Morgantown, then counted the number of virtual visits that occurred during this period and through Dec. 1, 2020, (175 virtual visits), calculated the distance patients would have traveled round-trip had these visits been in-person, and converted miles saved into the environmental impact using U.S. Environmental Protection Agency and Federal Highway Administration data and relevant EPA standards.
Most patients had elected to continue virtual visits after May 29, the point at which patients were given the option to return to the WVUH clinic. (Patients who initiated treatment during the 2-month identification period were not included.)
The investigators determined that virtual management of isotretinoin saved a median of 37.8 miles per visit during the study period of March 25 to Dec. 1, and estimated that the virtual visits reduced total travel by 14,450 miles. For the analysis, patients were assumed to use light-duty vehicles.
In addition to calculating the reduction in emissions during the study period (5,137 kg of CO2equivalents) they used patient census data from 2019 to 2020 and data from the study period to project the mileage – and the associated emissions – that would be saved annually if all in-person visits for isotretinoin management occurred virtually.
Their calculation for a projected emissions reduction with 1 year of all-virtual isotretinoin management was 49,400 kg of greenhouse gas emissions in CO2equivalents. This is the emission load released when 24,690 kg of coal are burned or 6.3 million smartphones are charged, the researchers wrote.
“Considering that more than 1,000,000 prescriptions of isotretinoin are authorized annually in the United States, the environmental impact could be magnified if virtual delivery of isotretinoin care is adopted on a national scale,” they commented.“Given the serious consequences of global climate change, analysis of the environmental impact of all fields of medicine, including dermatology, is warranted,” they added.
The reduced greenhouse gas emissions are “definitely [being taken] into consideration for future decisions about virtual visits” in the department of dermatology, said Zachary Zinn, MD, residency director and associate professor in the department of dermatology at West Virginia University, Morgantown, who is the senior author of the study. “The main benefit of virtual care in my opinion,” he said in an interview, “is the potential to reduce our carbon footprint.”
Justin Lee, MD, an intern at WVU and the study’s first author, said that the research team was motivated to think about how they “could reduce the negative environmental impact of practicing dermatology” after they read a paper about the environmental impact of endoscopy, written by a gastroenterologist.
In the study, no pregnancies occurred and monthly tests were performed, but “formal assessment of pregnancy risk with virtual isotretinoin management would be warranted,” Dr. Lee and coauthors wrote, noting too that, while no differences were seen with respect to isotretinoin side effects, these were not formally analyzed.
Dr. Zinn said that he and colleagues at WVUH are currently conducting clinical trials to assess the quality and efficacy of virtual care for patients with acne, atopic dermatitis, and psoriasis. Delivering care virtually “will be easier to do if there are data supporting [its] quality and efficacy,” he said. Rosacea is another condition that may be amendable to virtual care, he noted.
Meanwhile, he said, isotretinoin management is “well suited” for virtual visits. When initiating isotretinoin treatment, Dr. Zinn now “proactively inquires” if patients would like to pursue their follow-up visits virtually. “I’ll note that it will save the time and decrease the burden of travel, including the financial cost as well as the environmental cost of travel,” he said, estimating that about half of their management visits are currently virtual.
Asked about the study, Misha Rosenbach, MD, associate professor of dermatology at the University of Pennsylvania, Philadelphia, said the reduced carbon footprint calculated by the researchers and its downstream health benefits “should be taken into consideration by [dermatology] departments, insurers and policymakers” when making decisions about teledermatology.
While environmental impact is “not something I think most institutions are considering for virtual versus in-person care, they should be. And some are,” said Dr. Rosenbach, a founder and cochair of the American Academy of Dermatology Expert Resource Group for Climate Change and Environmental Issues.
Limitations of the study include the generalizability of the results. The impact of virtual isotretinoin management “may be less in predominantly urban areas” than it is in predominately rural West Virginia, the study authors note. And in the case of West Virginia, travel to a local laboratory and pharmacy offsets some of the environmental benefits for the virtual care, they noted. Such travel wasn’t accounted for in the study, but it was found to be a fraction of travel to the WVU hospital clinic. (Patients traveled a median of 5.8 miles to a lab 2.4 times from March 25 to Dec. 1, 2020.)
Dr. Lee will start his dermatology residency at WVU next year. The study was funded by a grant from the U.S. National Science Foundation. The authors have no relevant conflicts of interest, according to Dr. Lee.
FROM PEDIATRIC DERMATOLOGY
Mayo Clinic again named best hospital in U.S. for gynecology
This year, the Mayo Clinic, Rochester, Minn. again ranked as the top hospital for gynecology, according to U.S. News and World Report, which released its annual rankings today.
The top five hospitals for gynecology were the same this year and were in the same order. In second place again this year was Memorial Sloan Kettering Cancer Center, New York, followed by the Cleveland Clinic, Brigham and Women’s Hospital, Boston, and the University of Texas MD Anderson Cancer Center, Houston.
Rounding out the top 10 were (6) Inova Fairfax Hospital, Falls Church, Virginia; (7) the University of Alabama at Birmingham Hospital; (8) Johns Hopkins Hospital, Baltimore, Maryland; and Massachusetts General Hospital, Boston, and Stanford Health Care–Stanford Hospital, Palo Alto, California, which tied for the ninth spot.
U.S. News compared more than 4,750 medical centers nationwide in 15 specialties. Of those, 531 were recognized as Best Regional Hospitals on the basis of their strong performance in multiple areas of care.
In 12 of the specialties, including gynecology, rankings are determined by a data-driven analysis that combines performance measures in structure, process, and outcomes. Rankings in three other specialties – ophthalmology, psychiatry, and rheumatology – rely on expert opinion alone, according to the U.S. News methodology report.
The top 20 hospitals overall were also named to the Honor Roll.
Mayo Clinic was again no. 1 on the honor roll, a ranking it has held for 6 years in a row, according to a press release.
In other top specialties, the University of Texas MD Anderson Cancer Center ranked no. 1 in cancer; the Cleveland Clinic is no. 1 in cardiology and heart surgery; and the Hospital for Special Surgery, New York, is no. 1 in orthopedics.
A full list of rankings is available on the magazine’s website.
A version of this article first appeared on Medscape.com.
This year, the Mayo Clinic, Rochester, Minn. again ranked as the top hospital for gynecology, according to U.S. News and World Report, which released its annual rankings today.
The top five hospitals for gynecology were the same this year and were in the same order. In second place again this year was Memorial Sloan Kettering Cancer Center, New York, followed by the Cleveland Clinic, Brigham and Women’s Hospital, Boston, and the University of Texas MD Anderson Cancer Center, Houston.
Rounding out the top 10 were (6) Inova Fairfax Hospital, Falls Church, Virginia; (7) the University of Alabama at Birmingham Hospital; (8) Johns Hopkins Hospital, Baltimore, Maryland; and Massachusetts General Hospital, Boston, and Stanford Health Care–Stanford Hospital, Palo Alto, California, which tied for the ninth spot.
U.S. News compared more than 4,750 medical centers nationwide in 15 specialties. Of those, 531 were recognized as Best Regional Hospitals on the basis of their strong performance in multiple areas of care.
In 12 of the specialties, including gynecology, rankings are determined by a data-driven analysis that combines performance measures in structure, process, and outcomes. Rankings in three other specialties – ophthalmology, psychiatry, and rheumatology – rely on expert opinion alone, according to the U.S. News methodology report.
The top 20 hospitals overall were also named to the Honor Roll.
Mayo Clinic was again no. 1 on the honor roll, a ranking it has held for 6 years in a row, according to a press release.
In other top specialties, the University of Texas MD Anderson Cancer Center ranked no. 1 in cancer; the Cleveland Clinic is no. 1 in cardiology and heart surgery; and the Hospital for Special Surgery, New York, is no. 1 in orthopedics.
A full list of rankings is available on the magazine’s website.
A version of this article first appeared on Medscape.com.
This year, the Mayo Clinic, Rochester, Minn. again ranked as the top hospital for gynecology, according to U.S. News and World Report, which released its annual rankings today.
The top five hospitals for gynecology were the same this year and were in the same order. In second place again this year was Memorial Sloan Kettering Cancer Center, New York, followed by the Cleveland Clinic, Brigham and Women’s Hospital, Boston, and the University of Texas MD Anderson Cancer Center, Houston.
Rounding out the top 10 were (6) Inova Fairfax Hospital, Falls Church, Virginia; (7) the University of Alabama at Birmingham Hospital; (8) Johns Hopkins Hospital, Baltimore, Maryland; and Massachusetts General Hospital, Boston, and Stanford Health Care–Stanford Hospital, Palo Alto, California, which tied for the ninth spot.
U.S. News compared more than 4,750 medical centers nationwide in 15 specialties. Of those, 531 were recognized as Best Regional Hospitals on the basis of their strong performance in multiple areas of care.
In 12 of the specialties, including gynecology, rankings are determined by a data-driven analysis that combines performance measures in structure, process, and outcomes. Rankings in three other specialties – ophthalmology, psychiatry, and rheumatology – rely on expert opinion alone, according to the U.S. News methodology report.
The top 20 hospitals overall were also named to the Honor Roll.
Mayo Clinic was again no. 1 on the honor roll, a ranking it has held for 6 years in a row, according to a press release.
In other top specialties, the University of Texas MD Anderson Cancer Center ranked no. 1 in cancer; the Cleveland Clinic is no. 1 in cardiology and heart surgery; and the Hospital for Special Surgery, New York, is no. 1 in orthopedics.
A full list of rankings is available on the magazine’s website.
A version of this article first appeared on Medscape.com.
Are you at legal risk for speaking at conferences?
When Jerry Gardner, MD, and a junior colleague received the acceptance notification for their abstract to be presented at Digestive Diseases Week® (DDW) 2021, a clause in the mandatory participation agreement gave Dr. Gardner pause. It required his colleague, as the submitting author, to completely accept any and all legal responsibility for any claims that might arise out of their presentation.
The clause was a red flag to Dr. Gardner, president of Science for Organizations, a Mill Valley, Calif.–based consulting firm. The gastroenterologist and former head of the digestive diseases branch at the National Institute of Diabetes and Digestive and Kidney Diseases – who has made hundreds of presentations and had participated in DDW for 40 years – had never encountered such a broad indemnity clause.
This news organization investigated just how risky it is to make a presentation at a conference – more than a dozen professional societies were contacted. Although DDW declined to discuss its agreement, Houston health care attorney Rachel V. Rose said that Dr. Gardner was smart to be cautious. “I would not sign that agreement. I have never seen anything that broad and all encompassing,” she said.
The DDW requirement “means that participants must put themselves at great potential financial risk in order to present their work,” Dr. Gardner said. He added that he and his colleague would not have submitted an abstract had they known about the indemnification clause up front.
Dr. Gardner advised his colleague not to sign the DDW agreement. She did not, and both missed the meeting.
Speakers ‘have to be careful’
Dr. Gardner may be an exception. How many doctors are willing to forgo a presentation because of a concern about something in an agreement?
John Mandrola, MD, said he operates under the assumption that if he does not sign the agreement, then he won’t be able to give his presentation. He admits that he generally just signs them and is careful with his presentations. “I’ve never really paid much attention to them,” said Dr. Mandrola, a cardiac electrophysiologist in Louisville, Ky., and chief cardiology correspondent for Medscape.
Not everyone takes that approach. “I do think that people read them, but they also take them with a grain of salt,” said E. Magnus Ohman, MBBS, professor of medicine at Duke University, Durham, N.C. He said he’s pragmatic and regards the agreements as a necessary evil in a litigious nation. Speakers “have to be careful, obviously,” Dr. Ohman said in an interview.
Some argue that the requirements are not only fair but also understandable. David Johnson, MD, a former president of the American College of Gastroenterology, said he has never had questions about agreements for meetings he has been involved with. “To me, this is not anything other than standard operating procedure,” he said.
Presenters participate by invitation, noted Dr. Johnson, a professor of medicine and chief of gastroenterology at the Eastern Virginia Medical School, Norfolk, who is a contributor to this news organization. “If they stand up and do something egregious, I would concur that the society should not be liable,” he said.
Big asks, big secrecy
Even for those who generally agree with Dr. Johnson’s position, it may be hard to completely understand what’s at stake without an attorney.
Although many declined to discuss their policies, a handful of professional societies provided their agreements for review. In general, the agreements appear to offer broad protection and rights to the organizers and large liability exposure for the participants. Participants are charged with a wide range of responsibilities, such as ensuring against copyright violations and intellectual property infringement, and that they also agree to unlimited use of their presentations and their name and likeness.
The American Academy of Neurology, which held its meeting virtually in 2021, required participants to indemnify the organization against all “losses, expenses, damages, or liabilities,” including “reasonable attorneys’ fees.” Federal employees, however, could opt out of indemnification.
The American Society of Clinical Oncology said that it does not usually require indemnification from its meeting participants. However, a spokesperson noted that ASCO did require participants at its 2021 virtual meeting to abide by the terms of use for content posted to the ASCO website. Those terms specify that users agree to indemnify ASCO from damages related to posts.
The American Psychiatric Association said it does not require any indemnification but did not make its agreement available. The American Academy of Pediatrics also said it did not require indemnification but would not share its agreement.
An American Diabetes Association spokesperson said that “every association is different in what they ask or require from speakers,” but would not share its requirements.
The American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the Endocrine Society all declined to participate.
The organizations that withheld agreements “probably don’t want anybody picking apart their documents,” said Kyle Claussen, CEO of the Resolve Physician Agency, which reviews employment contracts and other contracts for physicians. “The more fair a document, the more likely they would be willing to disclose that, because they have nothing to hide,” he said.
‘It’s all on you’
Requiring indemnification for any and all aspects of a presentation appears to be increasingly common, said the attorneys interviewed for this article. As organizations repackage meeting presentations for sale, they put the content further out into the world and for a longer period, which increases liability exposure.
“If I’m the attorney for DDW, I certainly think I’d want to have this in place,” said Mr. Claussen.
“It’s good business sense for them because it reduces their risk,” said Courtney H. A. Thompson, an attorney with Fredrikson & Byron in Minneapolis, who advises regional and national corporations and ad agencies on advertising, marketing, and trademark law. She also works with clients who speak at meetings and who thus encounter meeting agreements.
Ms. Thompson said indemnity clauses have become fairly common over the past decade, especially as more companies and organizations have sought to protect trademarks, copyrights, and intellectual property and to minimize litigation costs.
A conference organizer “doesn’t want a third party to come after them for intellectual property, privacy, or publicity right infringement based on the participation of the customer or, in this case, the speaker,” said Ms. Thompson.
The agreements also reflect America’s litigation-prone culture.
Dean Fanelli, a patent attorney in the Washington, D.C., office of Cooley LLP, said the agreements he’s been asked to sign as a speaker increasingly seem “overly lawyerly.”
Two decades ago, a speaker might have been asked to sign a paragraph or a one-page form. Now “they often look more like formalized legal agreements,” Mr. Fanelli told this news organization.
The DDW agreement, for instance, ran four pages and contained 21 detailed clauses.
The increasingly complicated agreements “are a little over the top,” said Mr. Fanelli. But as an attorney who works with clients in the pharmaceutical industry, he said he understands that meeting organizers want to protect their rights.
DDW’s main indemnification clause requires the participant to indemnify DDW and its agents, directors, and employees “against any and all claims, demands, causes of action, losses, damages, liabilities, costs, and expenses,” including attorneys’ fees “arising out of a claim, action or proceeding” based on a breach or “alleged breach” by the participant.
“You’re releasing this information to them and then you’re also giving them blanket indemnity back, saying if there’s any type of intellectual property violation on your end – if you’ve included any type of work that’s protected, if this causes any problems – it’s all on you,” said Mr. Claussen.
Other potential pitfalls
Aside from indemnification, participation agreements can contain other potentially worrisome clauses, including onerous terms for cancellation and reuse of content without remuneration.
DDW requires royalty-free licensing of a speaker’s content; the organization can reproduce it in perpetuity without royalties. Many organizations have such a clause in their agreements, including the AAN and the American College of Cardiology.
ASCO’s general authorization form for meeting participants requires that they assign to ASCO rights to their content “perpetually, irrevocably, worldwide and royalty free.” Participants can contact the organization if they seek to opt out, but it’s not clear whether ASCO grants such requests.
Participants in the upcoming American Heart Association annual meeting can deny permission to record their presentation. But if they allow recording and do not agree to assign all rights and copyright ownership to the AHA, the work will be excluded from publication in the meeting program, e-posters, and the meeting supplement in Circulation.
Mr. Claussen said granting royalty-free rights presents a conundrum. Having content reproduced in various formats “might be better for your personal brand,” but it’s not likely to result in any direct compensation and could increase liability exposure, he said.
How presenters must prepare
Mr. Claussen and Ms. Rose said speakers should be vigilant about their own rights and responsibilities, including ensuring that they do not violate copyrights or infringe on intellectual property rights.
“I would recommend that folks be meticulous about what is in their slide deck and materials,” said Ms. Thompson. He said that presenters should be sure they have the right to share material. Technologies crawl the internet seeking out infringement, which often leads to cease and desist letters from attorneys, she said.
It’s better to head off such a letter, Ms. Thompson said. “You need to defend it whether or not it’s a viable claim,” and that can be costly, she said.
Both Ms. Thompson and Mr. Fanelli also warn about disclosing anything that might be considered a trade secret. Many agreements prohibit presenters from engaging in commercial promotion, but if a talk includes information about a drug or device, the manufacturer will want to review the presentation before it’s made public, said Mr. Fanelli.
Many organizations prohibit attendees from photographing, recording, or tweeting at meetings and often require speakers to warn the audience about doing so. DDW goes further by holding presenters liable if someone violates the rule.
“That’s a huge problem,” said Dr. Mandrola. He noted that although it might be easy to police journalists attending a meeting, “it seems hard to enforce that rule amongst just regular attendees.”
Accept or negotiate?
Individuals who submit work to an organization might feel they must sign an agreement as is, especially if they are looking to advance their career or expand knowledge by presenting work at a meeting. But some attorneys said it might be possible to negotiate with meeting organizers.
“My personal opinion is that it never hurts to ask,” said Ms. Thompson. If she were speaking at a legal conference, she would mark up a contract and “see what happens.” The more times pushback is accepted – say, if it works with three out of five speaking engagements – the more it reduces overall liability exposure.
Mr. Fanelli, however, said that although he always reads over an agreement, he typically signs without negotiating. “I don’t usually worry about it because I’m just trying to talk at a particular seminar,” he said.
Prospective presenters “have to weigh that balance – do you want to talk at a seminar, or are you concerned about the legal issues?” said Mr. Fanelli.
If in doubt, talk with a lawyer.
“If you ever have a question on whether or not you should consult an attorney, the answer is always yes,” said Mr. Claussen. It would be “an ounce of prevention,” especially if it’s just a short agreement, he said.
Dr. Ohman, however, said that he believed “it would be fairly costly” and potentially unwieldy. “You can’t litigate everything in life,” he added.
As for Dr. Gardner, he said he would not be as likely to attend DDW in the future if he has to agree to cover any and all liability. “I can’t conceive of ever agreeing to personally indemnify DDW in order to make a presentation at the annual meeting,” he said.
A version of this article first appeared on Medscape.com.
When Jerry Gardner, MD, and a junior colleague received the acceptance notification for their abstract to be presented at Digestive Diseases Week® (DDW) 2021, a clause in the mandatory participation agreement gave Dr. Gardner pause. It required his colleague, as the submitting author, to completely accept any and all legal responsibility for any claims that might arise out of their presentation.
The clause was a red flag to Dr. Gardner, president of Science for Organizations, a Mill Valley, Calif.–based consulting firm. The gastroenterologist and former head of the digestive diseases branch at the National Institute of Diabetes and Digestive and Kidney Diseases – who has made hundreds of presentations and had participated in DDW for 40 years – had never encountered such a broad indemnity clause.
This news organization investigated just how risky it is to make a presentation at a conference – more than a dozen professional societies were contacted. Although DDW declined to discuss its agreement, Houston health care attorney Rachel V. Rose said that Dr. Gardner was smart to be cautious. “I would not sign that agreement. I have never seen anything that broad and all encompassing,” she said.
The DDW requirement “means that participants must put themselves at great potential financial risk in order to present their work,” Dr. Gardner said. He added that he and his colleague would not have submitted an abstract had they known about the indemnification clause up front.
Dr. Gardner advised his colleague not to sign the DDW agreement. She did not, and both missed the meeting.
Speakers ‘have to be careful’
Dr. Gardner may be an exception. How many doctors are willing to forgo a presentation because of a concern about something in an agreement?
John Mandrola, MD, said he operates under the assumption that if he does not sign the agreement, then he won’t be able to give his presentation. He admits that he generally just signs them and is careful with his presentations. “I’ve never really paid much attention to them,” said Dr. Mandrola, a cardiac electrophysiologist in Louisville, Ky., and chief cardiology correspondent for Medscape.
Not everyone takes that approach. “I do think that people read them, but they also take them with a grain of salt,” said E. Magnus Ohman, MBBS, professor of medicine at Duke University, Durham, N.C. He said he’s pragmatic and regards the agreements as a necessary evil in a litigious nation. Speakers “have to be careful, obviously,” Dr. Ohman said in an interview.
Some argue that the requirements are not only fair but also understandable. David Johnson, MD, a former president of the American College of Gastroenterology, said he has never had questions about agreements for meetings he has been involved with. “To me, this is not anything other than standard operating procedure,” he said.
Presenters participate by invitation, noted Dr. Johnson, a professor of medicine and chief of gastroenterology at the Eastern Virginia Medical School, Norfolk, who is a contributor to this news organization. “If they stand up and do something egregious, I would concur that the society should not be liable,” he said.
Big asks, big secrecy
Even for those who generally agree with Dr. Johnson’s position, it may be hard to completely understand what’s at stake without an attorney.
Although many declined to discuss their policies, a handful of professional societies provided their agreements for review. In general, the agreements appear to offer broad protection and rights to the organizers and large liability exposure for the participants. Participants are charged with a wide range of responsibilities, such as ensuring against copyright violations and intellectual property infringement, and that they also agree to unlimited use of their presentations and their name and likeness.
The American Academy of Neurology, which held its meeting virtually in 2021, required participants to indemnify the organization against all “losses, expenses, damages, or liabilities,” including “reasonable attorneys’ fees.” Federal employees, however, could opt out of indemnification.
The American Society of Clinical Oncology said that it does not usually require indemnification from its meeting participants. However, a spokesperson noted that ASCO did require participants at its 2021 virtual meeting to abide by the terms of use for content posted to the ASCO website. Those terms specify that users agree to indemnify ASCO from damages related to posts.
The American Psychiatric Association said it does not require any indemnification but did not make its agreement available. The American Academy of Pediatrics also said it did not require indemnification but would not share its agreement.
An American Diabetes Association spokesperson said that “every association is different in what they ask or require from speakers,” but would not share its requirements.
The American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the Endocrine Society all declined to participate.
The organizations that withheld agreements “probably don’t want anybody picking apart their documents,” said Kyle Claussen, CEO of the Resolve Physician Agency, which reviews employment contracts and other contracts for physicians. “The more fair a document, the more likely they would be willing to disclose that, because they have nothing to hide,” he said.
‘It’s all on you’
Requiring indemnification for any and all aspects of a presentation appears to be increasingly common, said the attorneys interviewed for this article. As organizations repackage meeting presentations for sale, they put the content further out into the world and for a longer period, which increases liability exposure.
“If I’m the attorney for DDW, I certainly think I’d want to have this in place,” said Mr. Claussen.
“It’s good business sense for them because it reduces their risk,” said Courtney H. A. Thompson, an attorney with Fredrikson & Byron in Minneapolis, who advises regional and national corporations and ad agencies on advertising, marketing, and trademark law. She also works with clients who speak at meetings and who thus encounter meeting agreements.
Ms. Thompson said indemnity clauses have become fairly common over the past decade, especially as more companies and organizations have sought to protect trademarks, copyrights, and intellectual property and to minimize litigation costs.
A conference organizer “doesn’t want a third party to come after them for intellectual property, privacy, or publicity right infringement based on the participation of the customer or, in this case, the speaker,” said Ms. Thompson.
The agreements also reflect America’s litigation-prone culture.
Dean Fanelli, a patent attorney in the Washington, D.C., office of Cooley LLP, said the agreements he’s been asked to sign as a speaker increasingly seem “overly lawyerly.”
Two decades ago, a speaker might have been asked to sign a paragraph or a one-page form. Now “they often look more like formalized legal agreements,” Mr. Fanelli told this news organization.
The DDW agreement, for instance, ran four pages and contained 21 detailed clauses.
The increasingly complicated agreements “are a little over the top,” said Mr. Fanelli. But as an attorney who works with clients in the pharmaceutical industry, he said he understands that meeting organizers want to protect their rights.
DDW’s main indemnification clause requires the participant to indemnify DDW and its agents, directors, and employees “against any and all claims, demands, causes of action, losses, damages, liabilities, costs, and expenses,” including attorneys’ fees “arising out of a claim, action or proceeding” based on a breach or “alleged breach” by the participant.
“You’re releasing this information to them and then you’re also giving them blanket indemnity back, saying if there’s any type of intellectual property violation on your end – if you’ve included any type of work that’s protected, if this causes any problems – it’s all on you,” said Mr. Claussen.
Other potential pitfalls
Aside from indemnification, participation agreements can contain other potentially worrisome clauses, including onerous terms for cancellation and reuse of content without remuneration.
DDW requires royalty-free licensing of a speaker’s content; the organization can reproduce it in perpetuity without royalties. Many organizations have such a clause in their agreements, including the AAN and the American College of Cardiology.
ASCO’s general authorization form for meeting participants requires that they assign to ASCO rights to their content “perpetually, irrevocably, worldwide and royalty free.” Participants can contact the organization if they seek to opt out, but it’s not clear whether ASCO grants such requests.
Participants in the upcoming American Heart Association annual meeting can deny permission to record their presentation. But if they allow recording and do not agree to assign all rights and copyright ownership to the AHA, the work will be excluded from publication in the meeting program, e-posters, and the meeting supplement in Circulation.
Mr. Claussen said granting royalty-free rights presents a conundrum. Having content reproduced in various formats “might be better for your personal brand,” but it’s not likely to result in any direct compensation and could increase liability exposure, he said.
How presenters must prepare
Mr. Claussen and Ms. Rose said speakers should be vigilant about their own rights and responsibilities, including ensuring that they do not violate copyrights or infringe on intellectual property rights.
“I would recommend that folks be meticulous about what is in their slide deck and materials,” said Ms. Thompson. He said that presenters should be sure they have the right to share material. Technologies crawl the internet seeking out infringement, which often leads to cease and desist letters from attorneys, she said.
It’s better to head off such a letter, Ms. Thompson said. “You need to defend it whether or not it’s a viable claim,” and that can be costly, she said.
Both Ms. Thompson and Mr. Fanelli also warn about disclosing anything that might be considered a trade secret. Many agreements prohibit presenters from engaging in commercial promotion, but if a talk includes information about a drug or device, the manufacturer will want to review the presentation before it’s made public, said Mr. Fanelli.
Many organizations prohibit attendees from photographing, recording, or tweeting at meetings and often require speakers to warn the audience about doing so. DDW goes further by holding presenters liable if someone violates the rule.
“That’s a huge problem,” said Dr. Mandrola. He noted that although it might be easy to police journalists attending a meeting, “it seems hard to enforce that rule amongst just regular attendees.”
Accept or negotiate?
Individuals who submit work to an organization might feel they must sign an agreement as is, especially if they are looking to advance their career or expand knowledge by presenting work at a meeting. But some attorneys said it might be possible to negotiate with meeting organizers.
“My personal opinion is that it never hurts to ask,” said Ms. Thompson. If she were speaking at a legal conference, she would mark up a contract and “see what happens.” The more times pushback is accepted – say, if it works with three out of five speaking engagements – the more it reduces overall liability exposure.
Mr. Fanelli, however, said that although he always reads over an agreement, he typically signs without negotiating. “I don’t usually worry about it because I’m just trying to talk at a particular seminar,” he said.
Prospective presenters “have to weigh that balance – do you want to talk at a seminar, or are you concerned about the legal issues?” said Mr. Fanelli.
If in doubt, talk with a lawyer.
“If you ever have a question on whether or not you should consult an attorney, the answer is always yes,” said Mr. Claussen. It would be “an ounce of prevention,” especially if it’s just a short agreement, he said.
Dr. Ohman, however, said that he believed “it would be fairly costly” and potentially unwieldy. “You can’t litigate everything in life,” he added.
As for Dr. Gardner, he said he would not be as likely to attend DDW in the future if he has to agree to cover any and all liability. “I can’t conceive of ever agreeing to personally indemnify DDW in order to make a presentation at the annual meeting,” he said.
A version of this article first appeared on Medscape.com.
When Jerry Gardner, MD, and a junior colleague received the acceptance notification for their abstract to be presented at Digestive Diseases Week® (DDW) 2021, a clause in the mandatory participation agreement gave Dr. Gardner pause. It required his colleague, as the submitting author, to completely accept any and all legal responsibility for any claims that might arise out of their presentation.
The clause was a red flag to Dr. Gardner, president of Science for Organizations, a Mill Valley, Calif.–based consulting firm. The gastroenterologist and former head of the digestive diseases branch at the National Institute of Diabetes and Digestive and Kidney Diseases – who has made hundreds of presentations and had participated in DDW for 40 years – had never encountered such a broad indemnity clause.
This news organization investigated just how risky it is to make a presentation at a conference – more than a dozen professional societies were contacted. Although DDW declined to discuss its agreement, Houston health care attorney Rachel V. Rose said that Dr. Gardner was smart to be cautious. “I would not sign that agreement. I have never seen anything that broad and all encompassing,” she said.
The DDW requirement “means that participants must put themselves at great potential financial risk in order to present their work,” Dr. Gardner said. He added that he and his colleague would not have submitted an abstract had they known about the indemnification clause up front.
Dr. Gardner advised his colleague not to sign the DDW agreement. She did not, and both missed the meeting.
Speakers ‘have to be careful’
Dr. Gardner may be an exception. How many doctors are willing to forgo a presentation because of a concern about something in an agreement?
John Mandrola, MD, said he operates under the assumption that if he does not sign the agreement, then he won’t be able to give his presentation. He admits that he generally just signs them and is careful with his presentations. “I’ve never really paid much attention to them,” said Dr. Mandrola, a cardiac electrophysiologist in Louisville, Ky., and chief cardiology correspondent for Medscape.
Not everyone takes that approach. “I do think that people read them, but they also take them with a grain of salt,” said E. Magnus Ohman, MBBS, professor of medicine at Duke University, Durham, N.C. He said he’s pragmatic and regards the agreements as a necessary evil in a litigious nation. Speakers “have to be careful, obviously,” Dr. Ohman said in an interview.
Some argue that the requirements are not only fair but also understandable. David Johnson, MD, a former president of the American College of Gastroenterology, said he has never had questions about agreements for meetings he has been involved with. “To me, this is not anything other than standard operating procedure,” he said.
Presenters participate by invitation, noted Dr. Johnson, a professor of medicine and chief of gastroenterology at the Eastern Virginia Medical School, Norfolk, who is a contributor to this news organization. “If they stand up and do something egregious, I would concur that the society should not be liable,” he said.
Big asks, big secrecy
Even for those who generally agree with Dr. Johnson’s position, it may be hard to completely understand what’s at stake without an attorney.
Although many declined to discuss their policies, a handful of professional societies provided their agreements for review. In general, the agreements appear to offer broad protection and rights to the organizers and large liability exposure for the participants. Participants are charged with a wide range of responsibilities, such as ensuring against copyright violations and intellectual property infringement, and that they also agree to unlimited use of their presentations and their name and likeness.
The American Academy of Neurology, which held its meeting virtually in 2021, required participants to indemnify the organization against all “losses, expenses, damages, or liabilities,” including “reasonable attorneys’ fees.” Federal employees, however, could opt out of indemnification.
The American Society of Clinical Oncology said that it does not usually require indemnification from its meeting participants. However, a spokesperson noted that ASCO did require participants at its 2021 virtual meeting to abide by the terms of use for content posted to the ASCO website. Those terms specify that users agree to indemnify ASCO from damages related to posts.
The American Psychiatric Association said it does not require any indemnification but did not make its agreement available. The American Academy of Pediatrics also said it did not require indemnification but would not share its agreement.
An American Diabetes Association spokesperson said that “every association is different in what they ask or require from speakers,” but would not share its requirements.
The American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the Endocrine Society all declined to participate.
The organizations that withheld agreements “probably don’t want anybody picking apart their documents,” said Kyle Claussen, CEO of the Resolve Physician Agency, which reviews employment contracts and other contracts for physicians. “The more fair a document, the more likely they would be willing to disclose that, because they have nothing to hide,” he said.
‘It’s all on you’
Requiring indemnification for any and all aspects of a presentation appears to be increasingly common, said the attorneys interviewed for this article. As organizations repackage meeting presentations for sale, they put the content further out into the world and for a longer period, which increases liability exposure.
“If I’m the attorney for DDW, I certainly think I’d want to have this in place,” said Mr. Claussen.
“It’s good business sense for them because it reduces their risk,” said Courtney H. A. Thompson, an attorney with Fredrikson & Byron in Minneapolis, who advises regional and national corporations and ad agencies on advertising, marketing, and trademark law. She also works with clients who speak at meetings and who thus encounter meeting agreements.
Ms. Thompson said indemnity clauses have become fairly common over the past decade, especially as more companies and organizations have sought to protect trademarks, copyrights, and intellectual property and to minimize litigation costs.
A conference organizer “doesn’t want a third party to come after them for intellectual property, privacy, or publicity right infringement based on the participation of the customer or, in this case, the speaker,” said Ms. Thompson.
The agreements also reflect America’s litigation-prone culture.
Dean Fanelli, a patent attorney in the Washington, D.C., office of Cooley LLP, said the agreements he’s been asked to sign as a speaker increasingly seem “overly lawyerly.”
Two decades ago, a speaker might have been asked to sign a paragraph or a one-page form. Now “they often look more like formalized legal agreements,” Mr. Fanelli told this news organization.
The DDW agreement, for instance, ran four pages and contained 21 detailed clauses.
The increasingly complicated agreements “are a little over the top,” said Mr. Fanelli. But as an attorney who works with clients in the pharmaceutical industry, he said he understands that meeting organizers want to protect their rights.
DDW’s main indemnification clause requires the participant to indemnify DDW and its agents, directors, and employees “against any and all claims, demands, causes of action, losses, damages, liabilities, costs, and expenses,” including attorneys’ fees “arising out of a claim, action or proceeding” based on a breach or “alleged breach” by the participant.
“You’re releasing this information to them and then you’re also giving them blanket indemnity back, saying if there’s any type of intellectual property violation on your end – if you’ve included any type of work that’s protected, if this causes any problems – it’s all on you,” said Mr. Claussen.
Other potential pitfalls
Aside from indemnification, participation agreements can contain other potentially worrisome clauses, including onerous terms for cancellation and reuse of content without remuneration.
DDW requires royalty-free licensing of a speaker’s content; the organization can reproduce it in perpetuity without royalties. Many organizations have such a clause in their agreements, including the AAN and the American College of Cardiology.
ASCO’s general authorization form for meeting participants requires that they assign to ASCO rights to their content “perpetually, irrevocably, worldwide and royalty free.” Participants can contact the organization if they seek to opt out, but it’s not clear whether ASCO grants such requests.
Participants in the upcoming American Heart Association annual meeting can deny permission to record their presentation. But if they allow recording and do not agree to assign all rights and copyright ownership to the AHA, the work will be excluded from publication in the meeting program, e-posters, and the meeting supplement in Circulation.
Mr. Claussen said granting royalty-free rights presents a conundrum. Having content reproduced in various formats “might be better for your personal brand,” but it’s not likely to result in any direct compensation and could increase liability exposure, he said.
How presenters must prepare
Mr. Claussen and Ms. Rose said speakers should be vigilant about their own rights and responsibilities, including ensuring that they do not violate copyrights or infringe on intellectual property rights.
“I would recommend that folks be meticulous about what is in their slide deck and materials,” said Ms. Thompson. He said that presenters should be sure they have the right to share material. Technologies crawl the internet seeking out infringement, which often leads to cease and desist letters from attorneys, she said.
It’s better to head off such a letter, Ms. Thompson said. “You need to defend it whether or not it’s a viable claim,” and that can be costly, she said.
Both Ms. Thompson and Mr. Fanelli also warn about disclosing anything that might be considered a trade secret. Many agreements prohibit presenters from engaging in commercial promotion, but if a talk includes information about a drug or device, the manufacturer will want to review the presentation before it’s made public, said Mr. Fanelli.
Many organizations prohibit attendees from photographing, recording, or tweeting at meetings and often require speakers to warn the audience about doing so. DDW goes further by holding presenters liable if someone violates the rule.
“That’s a huge problem,” said Dr. Mandrola. He noted that although it might be easy to police journalists attending a meeting, “it seems hard to enforce that rule amongst just regular attendees.”
Accept or negotiate?
Individuals who submit work to an organization might feel they must sign an agreement as is, especially if they are looking to advance their career or expand knowledge by presenting work at a meeting. But some attorneys said it might be possible to negotiate with meeting organizers.
“My personal opinion is that it never hurts to ask,” said Ms. Thompson. If she were speaking at a legal conference, she would mark up a contract and “see what happens.” The more times pushback is accepted – say, if it works with three out of five speaking engagements – the more it reduces overall liability exposure.
Mr. Fanelli, however, said that although he always reads over an agreement, he typically signs without negotiating. “I don’t usually worry about it because I’m just trying to talk at a particular seminar,” he said.
Prospective presenters “have to weigh that balance – do you want to talk at a seminar, or are you concerned about the legal issues?” said Mr. Fanelli.
If in doubt, talk with a lawyer.
“If you ever have a question on whether or not you should consult an attorney, the answer is always yes,” said Mr. Claussen. It would be “an ounce of prevention,” especially if it’s just a short agreement, he said.
Dr. Ohman, however, said that he believed “it would be fairly costly” and potentially unwieldy. “You can’t litigate everything in life,” he added.
As for Dr. Gardner, he said he would not be as likely to attend DDW in the future if he has to agree to cover any and all liability. “I can’t conceive of ever agreeing to personally indemnify DDW in order to make a presentation at the annual meeting,” he said.
A version of this article first appeared on Medscape.com.
MDs rebut claims of toxic culture after resident suicides
The tragic loss of three medical residents in our beloved South Bronx hospital shook us to the core. They were our colleagues and friends – promising young physicians whose lives and contributions to our hospital family will never be forgotten. We miss them and we grieve them.
We have been keenly aware of the growing trend of physician suicides across the country. That’s one of the reasons why, years ago, we established the nationally recognized Helping Healers Heal program across our health system and more recently expanded other mental health counseling and support to our frontline clinicians.
Our focus is wellness and prevention, as well as helping address the sadness, anxiety, and depression that so many of us experience after a traumatic event. During the surge of the COVID pandemic, these programs proved to be essential, as we expanded these services to all staff, not just those on the frontlines of patient care.
We share Dr. Pamela Wible’s concerns about the physician suicide crisis in this country. However, she misrepresented our residency program and made numerous statements that are false and simply hurtful.
Out of respect for our colleagues and their families, we cannot share everything that we know about this tragic and irreparable loss. But we must set the record straight about a number of incorrect references made by Dr. Wible:
1. We lost two residents to suicide. Though no less horrific, the third death was investigated and declared an accident by the police department.
2. Resident work hours and workload are closely monitored to follow guidance set by the New York State Department of Health and by ACGME. In fact, at the peak of the COVID pandemic, when we were caring for nearly 130 intubated patients at a time, we adopted a strict residency program schedule with built-in breaks and reduced shifts and hours. Even at that tasking time, no one worked more than 80 hours. Although the maximum number of patients assigned to an intern allowed by ACGME is 10, we rarely have more than five or six patients assigned to each of our interns.
3. We swiftly investigate any allegation and do not hesitate to take the appropriate action against anyone who does not honor our values of professionalism and respect.
4. Our ACGME survey results are close to the mean of all internal medicine residency programs in the country. The fact that the results range from 75% to 95% clearly indicates that residents respond independently, and there is no coaching.
5. No resident has ever been threatened to have their visa canceled or withdrawn. Never. And the implication that we were intolerant because of their nationality is reprehensible. At NYC Health + Hospitals, we celebrate diversity. We are deeply committed to serving everyone, regardless of where they come from, what language they speak, what religion they practice. If you spend one day, or one hour, in our facility, you will see and feel our pride and commitment to this mission. We take pride in the fact that our staff and residents reflect the diversity of the community we serve.
6. As for the allegations of “toxic culture at Lincoln” – many of our graduates chose to stay on as attendings, serve the local community, and train new residents. Out of the 67 attendings in our department, 24 are former graduates. They are being joined by another five graduates from this year’s graduating class. There is no better testament to how our graduates feel about our residency program, Department of Medicine, and Lincoln Hospital.
Dr. Wible poses a legitimate question: How to prevent another suicide. No one has the exact answer. But it is a question we will keep asking ourselves as we continue to do all we can to meet our residents’ needs, extend the social and mental health support they need to thrive, and provide the learning and training they need to offer the best care to our patients.
A version of this article first appeared on Medscape.com.
The tragic loss of three medical residents in our beloved South Bronx hospital shook us to the core. They were our colleagues and friends – promising young physicians whose lives and contributions to our hospital family will never be forgotten. We miss them and we grieve them.
We have been keenly aware of the growing trend of physician suicides across the country. That’s one of the reasons why, years ago, we established the nationally recognized Helping Healers Heal program across our health system and more recently expanded other mental health counseling and support to our frontline clinicians.
Our focus is wellness and prevention, as well as helping address the sadness, anxiety, and depression that so many of us experience after a traumatic event. During the surge of the COVID pandemic, these programs proved to be essential, as we expanded these services to all staff, not just those on the frontlines of patient care.
We share Dr. Pamela Wible’s concerns about the physician suicide crisis in this country. However, she misrepresented our residency program and made numerous statements that are false and simply hurtful.
Out of respect for our colleagues and their families, we cannot share everything that we know about this tragic and irreparable loss. But we must set the record straight about a number of incorrect references made by Dr. Wible:
1. We lost two residents to suicide. Though no less horrific, the third death was investigated and declared an accident by the police department.
2. Resident work hours and workload are closely monitored to follow guidance set by the New York State Department of Health and by ACGME. In fact, at the peak of the COVID pandemic, when we were caring for nearly 130 intubated patients at a time, we adopted a strict residency program schedule with built-in breaks and reduced shifts and hours. Even at that tasking time, no one worked more than 80 hours. Although the maximum number of patients assigned to an intern allowed by ACGME is 10, we rarely have more than five or six patients assigned to each of our interns.
3. We swiftly investigate any allegation and do not hesitate to take the appropriate action against anyone who does not honor our values of professionalism and respect.
4. Our ACGME survey results are close to the mean of all internal medicine residency programs in the country. The fact that the results range from 75% to 95% clearly indicates that residents respond independently, and there is no coaching.
5. No resident has ever been threatened to have their visa canceled or withdrawn. Never. And the implication that we were intolerant because of their nationality is reprehensible. At NYC Health + Hospitals, we celebrate diversity. We are deeply committed to serving everyone, regardless of where they come from, what language they speak, what religion they practice. If you spend one day, or one hour, in our facility, you will see and feel our pride and commitment to this mission. We take pride in the fact that our staff and residents reflect the diversity of the community we serve.
6. As for the allegations of “toxic culture at Lincoln” – many of our graduates chose to stay on as attendings, serve the local community, and train new residents. Out of the 67 attendings in our department, 24 are former graduates. They are being joined by another five graduates from this year’s graduating class. There is no better testament to how our graduates feel about our residency program, Department of Medicine, and Lincoln Hospital.
Dr. Wible poses a legitimate question: How to prevent another suicide. No one has the exact answer. But it is a question we will keep asking ourselves as we continue to do all we can to meet our residents’ needs, extend the social and mental health support they need to thrive, and provide the learning and training they need to offer the best care to our patients.
A version of this article first appeared on Medscape.com.
The tragic loss of three medical residents in our beloved South Bronx hospital shook us to the core. They were our colleagues and friends – promising young physicians whose lives and contributions to our hospital family will never be forgotten. We miss them and we grieve them.
We have been keenly aware of the growing trend of physician suicides across the country. That’s one of the reasons why, years ago, we established the nationally recognized Helping Healers Heal program across our health system and more recently expanded other mental health counseling and support to our frontline clinicians.
Our focus is wellness and prevention, as well as helping address the sadness, anxiety, and depression that so many of us experience after a traumatic event. During the surge of the COVID pandemic, these programs proved to be essential, as we expanded these services to all staff, not just those on the frontlines of patient care.
We share Dr. Pamela Wible’s concerns about the physician suicide crisis in this country. However, she misrepresented our residency program and made numerous statements that are false and simply hurtful.
Out of respect for our colleagues and their families, we cannot share everything that we know about this tragic and irreparable loss. But we must set the record straight about a number of incorrect references made by Dr. Wible:
1. We lost two residents to suicide. Though no less horrific, the third death was investigated and declared an accident by the police department.
2. Resident work hours and workload are closely monitored to follow guidance set by the New York State Department of Health and by ACGME. In fact, at the peak of the COVID pandemic, when we were caring for nearly 130 intubated patients at a time, we adopted a strict residency program schedule with built-in breaks and reduced shifts and hours. Even at that tasking time, no one worked more than 80 hours. Although the maximum number of patients assigned to an intern allowed by ACGME is 10, we rarely have more than five or six patients assigned to each of our interns.
3. We swiftly investigate any allegation and do not hesitate to take the appropriate action against anyone who does not honor our values of professionalism and respect.
4. Our ACGME survey results are close to the mean of all internal medicine residency programs in the country. The fact that the results range from 75% to 95% clearly indicates that residents respond independently, and there is no coaching.
5. No resident has ever been threatened to have their visa canceled or withdrawn. Never. And the implication that we were intolerant because of their nationality is reprehensible. At NYC Health + Hospitals, we celebrate diversity. We are deeply committed to serving everyone, regardless of where they come from, what language they speak, what religion they practice. If you spend one day, or one hour, in our facility, you will see and feel our pride and commitment to this mission. We take pride in the fact that our staff and residents reflect the diversity of the community we serve.
6. As for the allegations of “toxic culture at Lincoln” – many of our graduates chose to stay on as attendings, serve the local community, and train new residents. Out of the 67 attendings in our department, 24 are former graduates. They are being joined by another five graduates from this year’s graduating class. There is no better testament to how our graduates feel about our residency program, Department of Medicine, and Lincoln Hospital.
Dr. Wible poses a legitimate question: How to prevent another suicide. No one has the exact answer. But it is a question we will keep asking ourselves as we continue to do all we can to meet our residents’ needs, extend the social and mental health support they need to thrive, and provide the learning and training they need to offer the best care to our patients.
A version of this article first appeared on Medscape.com.
Former rheumatologist settles civil fraud claims for $2 million
A former rheumatologist in Billings, Mont., and his business have agreed to pay more than $2 million to settle civil claims for alleged False Claims Act violations, according to Acting U.S. Attorney for the District of Montana Leif M. Johnson.
Enrico Arguelles, MD, and his business, the Arthritis & Osteoporosis Center (AOC), which closed in September 2018, agreed to the settlement with the U.S. Attorney’s Office on July 14.
Under terms of the settlement, Dr. Arguelles and the AOC must pay $1,268,646 and relinquish any claim to $802,018 in Medicare payment suspensions held in escrow for AOC for the past 4 years by the Centers for Medicare and Medicaid Services.
Attempts to reach Dr. Arguelles or his attorney for comment were unsuccessful.
“This civil settlement resolves claims of improper medical treatments and false billing to a federal program. Over billed and unnecessary claims, like the ones at issue in this case, drive up the costs for providing care to the people who really need it,” Mr. Johnson said in a statement.
Among the allegations, related to diagnosis and treatment of RA, were improper billing for MRI scans, improper billing for patient visits, and administration of biologic infusions such as infliximab (Remicade) for some patients who did not have seronegative RA, from Jan. 1, 2015, to the closure of the AOC office in 2018, the press release from the Department of Justice stated.
The press release notes that the settlement is not an admission of liability by Dr. Arguelles or AOC, nor a concession by the United States that its case is not well founded.
Assistant U.S. Attorney Michael A. Kakuk represented the United States in the case, which was investigated by the U.S. Attorney’s Office’s Health Care Fraud Investigative Team, Department of Health & Human Services Office of Inspector General, and FBI.
Special Agent in Charge Curt L. Muller, of the HHS-OIG, said in the statement: “Working with our law enforcement partners, we will hold accountable individuals who provide medically unnecessary treatments and pass along the cost to taxpayers.”
According to the Billings Gazette, Dr. Arguelles’ offices in Billings were raided on March 31, 2017, by agents from the HHS-OIG, FBI, and Montana Medicaid Fraud Control Unit.
A spokesperson for the OIG did not disclose to the Gazette the nature of the raid or what, if anything, was found, as it was an open investigation.
In the month after the raid, the Gazette reported, the FBI set up a hotline for patients after a number of them began calling state and federal authorities with concerns “about the medical care they have received at Arthritis & Osteoporosis Center,” Katherine Harris, an OIG spokeswoman, said in a statement.
The settlement comes after the previous fiscal year saw significant recovery of funds for U.S. medical fraud cases.
As this news organization has reported, the OIG recently announced that it had won or negotiated more than $1.8 billion in health care fraud settlements over the past fiscal year. The Department of Justice opened 1,148 criminal health care fraud investigations and 1,079 civil health care fraud investigations from Oct. 1, 2019, to Sept. 30, 2020.
A version of this article first appeared on Medscape.com.
A former rheumatologist in Billings, Mont., and his business have agreed to pay more than $2 million to settle civil claims for alleged False Claims Act violations, according to Acting U.S. Attorney for the District of Montana Leif M. Johnson.
Enrico Arguelles, MD, and his business, the Arthritis & Osteoporosis Center (AOC), which closed in September 2018, agreed to the settlement with the U.S. Attorney’s Office on July 14.
Under terms of the settlement, Dr. Arguelles and the AOC must pay $1,268,646 and relinquish any claim to $802,018 in Medicare payment suspensions held in escrow for AOC for the past 4 years by the Centers for Medicare and Medicaid Services.
Attempts to reach Dr. Arguelles or his attorney for comment were unsuccessful.
“This civil settlement resolves claims of improper medical treatments and false billing to a federal program. Over billed and unnecessary claims, like the ones at issue in this case, drive up the costs for providing care to the people who really need it,” Mr. Johnson said in a statement.
Among the allegations, related to diagnosis and treatment of RA, were improper billing for MRI scans, improper billing for patient visits, and administration of biologic infusions such as infliximab (Remicade) for some patients who did not have seronegative RA, from Jan. 1, 2015, to the closure of the AOC office in 2018, the press release from the Department of Justice stated.
The press release notes that the settlement is not an admission of liability by Dr. Arguelles or AOC, nor a concession by the United States that its case is not well founded.
Assistant U.S. Attorney Michael A. Kakuk represented the United States in the case, which was investigated by the U.S. Attorney’s Office’s Health Care Fraud Investigative Team, Department of Health & Human Services Office of Inspector General, and FBI.
Special Agent in Charge Curt L. Muller, of the HHS-OIG, said in the statement: “Working with our law enforcement partners, we will hold accountable individuals who provide medically unnecessary treatments and pass along the cost to taxpayers.”
According to the Billings Gazette, Dr. Arguelles’ offices in Billings were raided on March 31, 2017, by agents from the HHS-OIG, FBI, and Montana Medicaid Fraud Control Unit.
A spokesperson for the OIG did not disclose to the Gazette the nature of the raid or what, if anything, was found, as it was an open investigation.
In the month after the raid, the Gazette reported, the FBI set up a hotline for patients after a number of them began calling state and federal authorities with concerns “about the medical care they have received at Arthritis & Osteoporosis Center,” Katherine Harris, an OIG spokeswoman, said in a statement.
The settlement comes after the previous fiscal year saw significant recovery of funds for U.S. medical fraud cases.
As this news organization has reported, the OIG recently announced that it had won or negotiated more than $1.8 billion in health care fraud settlements over the past fiscal year. The Department of Justice opened 1,148 criminal health care fraud investigations and 1,079 civil health care fraud investigations from Oct. 1, 2019, to Sept. 30, 2020.
A version of this article first appeared on Medscape.com.
A former rheumatologist in Billings, Mont., and his business have agreed to pay more than $2 million to settle civil claims for alleged False Claims Act violations, according to Acting U.S. Attorney for the District of Montana Leif M. Johnson.
Enrico Arguelles, MD, and his business, the Arthritis & Osteoporosis Center (AOC), which closed in September 2018, agreed to the settlement with the U.S. Attorney’s Office on July 14.
Under terms of the settlement, Dr. Arguelles and the AOC must pay $1,268,646 and relinquish any claim to $802,018 in Medicare payment suspensions held in escrow for AOC for the past 4 years by the Centers for Medicare and Medicaid Services.
Attempts to reach Dr. Arguelles or his attorney for comment were unsuccessful.
“This civil settlement resolves claims of improper medical treatments and false billing to a federal program. Over billed and unnecessary claims, like the ones at issue in this case, drive up the costs for providing care to the people who really need it,” Mr. Johnson said in a statement.
Among the allegations, related to diagnosis and treatment of RA, were improper billing for MRI scans, improper billing for patient visits, and administration of biologic infusions such as infliximab (Remicade) for some patients who did not have seronegative RA, from Jan. 1, 2015, to the closure of the AOC office in 2018, the press release from the Department of Justice stated.
The press release notes that the settlement is not an admission of liability by Dr. Arguelles or AOC, nor a concession by the United States that its case is not well founded.
Assistant U.S. Attorney Michael A. Kakuk represented the United States in the case, which was investigated by the U.S. Attorney’s Office’s Health Care Fraud Investigative Team, Department of Health & Human Services Office of Inspector General, and FBI.
Special Agent in Charge Curt L. Muller, of the HHS-OIG, said in the statement: “Working with our law enforcement partners, we will hold accountable individuals who provide medically unnecessary treatments and pass along the cost to taxpayers.”
According to the Billings Gazette, Dr. Arguelles’ offices in Billings were raided on March 31, 2017, by agents from the HHS-OIG, FBI, and Montana Medicaid Fraud Control Unit.
A spokesperson for the OIG did not disclose to the Gazette the nature of the raid or what, if anything, was found, as it was an open investigation.
In the month after the raid, the Gazette reported, the FBI set up a hotline for patients after a number of them began calling state and federal authorities with concerns “about the medical care they have received at Arthritis & Osteoporosis Center,” Katherine Harris, an OIG spokeswoman, said in a statement.
The settlement comes after the previous fiscal year saw significant recovery of funds for U.S. medical fraud cases.
As this news organization has reported, the OIG recently announced that it had won or negotiated more than $1.8 billion in health care fraud settlements over the past fiscal year. The Department of Justice opened 1,148 criminal health care fraud investigations and 1,079 civil health care fraud investigations from Oct. 1, 2019, to Sept. 30, 2020.
A version of this article first appeared on Medscape.com.
Direct oral anticoagulants: Competition brought no cost relief
Medicare Part D spending for oral anticoagulants has risen by almost 1,600% since 2011, while the number of users has increased by just 95%, according to a new study.
In 2011, the year after the first direct oral anticoagulant (DOACs) was approved, Medicare Part D spent $0.44 billion on all oral anticoagulants. By 2019, when there a total of four DOACs on the market, spending was $7.38 billion, an increase of 1,577%, Aaron Troy, MD, MPH, and Timothy S. Anderson, MD, MAS, said in JAMA Health Forum.
Over that same time, the number of beneficiaries using oral anticoagulants went from 2.68 million to 5.24 million, they said, based on data from the Medicare Part D Prescription Drug Event file.
“While higher prices for novel therapeutics like DOACs, which offer clear benefits, such as decreased drug-drug interactions and improved persistence, may partly reflect value and help drive innovation, the patterns and effects of spending on novel medications still merit attention,” they noted.
One pattern of use looked like this: 0.2 million Medicare beneficiaries took DOACs in 2011,compared with 3.5 million in 2019, while the number of warfarin users dropped from 2.48 million to 1.74 million, the investigators reported.
As for spending over the study period, the cost to treat one beneficiary with atrial fibrillation increased by 9.3% each year for apixaban (a DOAC that was the most popular oral anticoagulant in 2019), decreased 27.6% per year for generic warfarin, and increased 9.5% per year for rivaroxaban, said Dr. Troy and Dr. Anderson of Beth Israel Deaconess Medical Center, Boston.
Rising Part D enrollment had an effect on spending growth, as did increased use of oral anticoagulants in general. The introduction of competing DOACs, however, “did not substantially curb annual spending increases, suggesting a lack of price competition, which is consistent with trends observed in other therapeutic categories,” they wrote.
Dr. Anderson has received research grants from the National Institute on Aging and the American College of Cardiology outside of this study and honoraria from Alosa Health. No other disclosures were reported.
Medicare Part D spending for oral anticoagulants has risen by almost 1,600% since 2011, while the number of users has increased by just 95%, according to a new study.
In 2011, the year after the first direct oral anticoagulant (DOACs) was approved, Medicare Part D spent $0.44 billion on all oral anticoagulants. By 2019, when there a total of four DOACs on the market, spending was $7.38 billion, an increase of 1,577%, Aaron Troy, MD, MPH, and Timothy S. Anderson, MD, MAS, said in JAMA Health Forum.
Over that same time, the number of beneficiaries using oral anticoagulants went from 2.68 million to 5.24 million, they said, based on data from the Medicare Part D Prescription Drug Event file.
“While higher prices for novel therapeutics like DOACs, which offer clear benefits, such as decreased drug-drug interactions and improved persistence, may partly reflect value and help drive innovation, the patterns and effects of spending on novel medications still merit attention,” they noted.
One pattern of use looked like this: 0.2 million Medicare beneficiaries took DOACs in 2011,compared with 3.5 million in 2019, while the number of warfarin users dropped from 2.48 million to 1.74 million, the investigators reported.
As for spending over the study period, the cost to treat one beneficiary with atrial fibrillation increased by 9.3% each year for apixaban (a DOAC that was the most popular oral anticoagulant in 2019), decreased 27.6% per year for generic warfarin, and increased 9.5% per year for rivaroxaban, said Dr. Troy and Dr. Anderson of Beth Israel Deaconess Medical Center, Boston.
Rising Part D enrollment had an effect on spending growth, as did increased use of oral anticoagulants in general. The introduction of competing DOACs, however, “did not substantially curb annual spending increases, suggesting a lack of price competition, which is consistent with trends observed in other therapeutic categories,” they wrote.
Dr. Anderson has received research grants from the National Institute on Aging and the American College of Cardiology outside of this study and honoraria from Alosa Health. No other disclosures were reported.
Medicare Part D spending for oral anticoagulants has risen by almost 1,600% since 2011, while the number of users has increased by just 95%, according to a new study.
In 2011, the year after the first direct oral anticoagulant (DOACs) was approved, Medicare Part D spent $0.44 billion on all oral anticoagulants. By 2019, when there a total of four DOACs on the market, spending was $7.38 billion, an increase of 1,577%, Aaron Troy, MD, MPH, and Timothy S. Anderson, MD, MAS, said in JAMA Health Forum.
Over that same time, the number of beneficiaries using oral anticoagulants went from 2.68 million to 5.24 million, they said, based on data from the Medicare Part D Prescription Drug Event file.
“While higher prices for novel therapeutics like DOACs, which offer clear benefits, such as decreased drug-drug interactions and improved persistence, may partly reflect value and help drive innovation, the patterns and effects of spending on novel medications still merit attention,” they noted.
One pattern of use looked like this: 0.2 million Medicare beneficiaries took DOACs in 2011,compared with 3.5 million in 2019, while the number of warfarin users dropped from 2.48 million to 1.74 million, the investigators reported.
As for spending over the study period, the cost to treat one beneficiary with atrial fibrillation increased by 9.3% each year for apixaban (a DOAC that was the most popular oral anticoagulant in 2019), decreased 27.6% per year for generic warfarin, and increased 9.5% per year for rivaroxaban, said Dr. Troy and Dr. Anderson of Beth Israel Deaconess Medical Center, Boston.
Rising Part D enrollment had an effect on spending growth, as did increased use of oral anticoagulants in general. The introduction of competing DOACs, however, “did not substantially curb annual spending increases, suggesting a lack of price competition, which is consistent with trends observed in other therapeutic categories,” they wrote.
Dr. Anderson has received research grants from the National Institute on Aging and the American College of Cardiology outside of this study and honoraria from Alosa Health. No other disclosures were reported.
FROM JAMA HEALTH FORUM
Mayo, Cleveland Clinics top latest U.S. News & World Report hospital rankings
This year’s expanded report debuts new ratings for seven “important procedures and conditions to help patients, in consultation with their doctors, narrow down their choice of hospital based on the specific type of care they need,” Ben Harder, managing editor and chief of health analysis, said in a news release.
With new ratings for myocardial infarction, stroke, hip fracture, and back surgery (spinal fusion), the report now ranks 17 procedures and conditions.
Also new to the 2021 report, which marks the 32nd edition, is a look at racial disparities in health care and the inclusion of health equity measures alongside the hospital rankings.
The new measures examine whether the patients each hospital has treated reflect the racial and ethnic diversity of the surrounding community, among other aspects of health equity.
“At roughly four out of five hospitals, we found that the community’s minority residents were underrepresented among patients receiving services such as joint replacement, cancer surgery and common heart procedures,” Mr. Harder said.
“Against this backdrop, however, we found important exceptions – hospitals that provide care to a disproportionate share of their community’s minority residents. These metrics are just a beginning; we aim to expand on our measurement of health equity in the future,” Mr. Harder added.
Mayo and Cleveland Clinic remain tops
Following the Mayo Clinic, the Cleveland Clinic once again takes the No. 2 spot in the magazine’s latest annual honor roll of best hospitals, which highlights hospitals that deliver exceptional treatment across multiple areas of care.
UCLA Medical Center, Los Angeles, holds the No. 3 spot in 2021. In 2020, UCLA Medical Center and New York–Presbyterian Hospital–Columbia and Cornell, New York, sat in a tie at No. 4.
In 2021, Johns Hopkins Hospital, Baltimore, which held the No. 3 spot in 2020, drops to No. 4, while Massachusetts General Hospital in Boston takes the No. 5 spot, up from No. 6 in 2020.
Rounding out the top 10 (in order) are Cedars-Sinai Medical Center, Los Angeles; New York–Presbyterian Hospital–Columbia and Cornell, New York; NYU Langone Hospitals, New York; UCSF Medical Center, San Francisco; and Northwestern Memorial Hospital, Chicago.
2021-2022 Best Hospitals honor roll
1. Mayo Clinic, Rochester, Minn.
2. Cleveland Clinic, Cleveland
3. UCLA Medical Center, Los Angeles
4. Johns Hopkins Hospital, Baltimore
5. Massachusetts General Hospital, Boston
6. Cedars-Sinai Medical Center, San Francisco
7. New York–Presbyterian Hospital–Columbia and Cornell, New York
8. NYU Langone Hospitals, New York
9. UCSF Medical Center, San Francisco
10. Northwestern Memorial Hospital, Chicago
11. University of Michigan Hospitals–Michigan Medicine, Ann Arbor.
12. Stanford Health Care–Stanford Hospital, Palo Alto, Calif.
13. Hospitals of the University of Pennsylvania–Penn Presbyterian, Philadelphia
14. Brigham and Women’s Hospital, Boston
15. Mayo Clinic–Phoenix, Phoenix
16. Houston Methodist Hospital, Houston
17. (tie) Barnes-Jewish Hospital, St. Louis
17. (tie) Mount Sinai Hospital, New York Rush University Medical Center, Chicago
19. Rush University Medical Center, Chicago
20. Vanderbilt University Medical Center, Nashville, Tenn.
For the 2021-2022 rankings and ratings, the magazine compared more than 4,750 hospitals nationwide in 15 specialties and 17 procedures and conditions.
At least 2,039 hospitals received a high performance rating in at least one of the services rated; 11 hospitals received high performance in all 17. A total of 175 hospitals were nationally ranked in at least one specialty
For specialty rankings, the University of Texas MD Anderson Cancer Center continues to hold the No. 1 spot in cancer care, the Hospital for Special Surgery continues to be No. 1 in orthopedics, and the Cleveland Clinic continues to be No. 1 in cardiology and heart surgery.
Top five for cancer
1. University of Texas MD Anderson Cancer Center, Houston
2. Memorial Sloan Kettering Cancer Center, New York
3. Mayo Clinic, Rochester, Minn.
4. Dana-Farber/Brigham & Women’s Cancer Center, Boston
5. Cleveland Clinic, Cleveland
Top five for cardiology and heart surgery
1. Cleveland Clinic, Cleveland
2. Mayo Clinic, Rochester, Minn.
3. Cedars-Sinai Medical Center, Los Angeles
4. New York–Presbyterian Hospital–Columbia and Cornell, New York
5. NYU Langone Hospitals, New York
Top five for orthopedics
1. Hospital for Special Surgery, New York
2. Mayo Clinic, Rochester, Minn.
3. Cedars-Sinai Medical Center, Los Angeles
4. NYU Langone Orthopedic Hospital, New York
5. UCLA Medical Center, Los Angeles
The magazine noted that data for the 2021-2022 Best Hospitals rankings and ratings were not affected by the COVID-19 pandemic, which began after the end of the data collection period.
The methodologies used in determining the rankings are based largely on objective measures, such as risk-adjusted survival, discharge-to-home rates, volume, and quality of nursing, among other care-related indicators.
The full report is available online.
A version of this article first appeared on Medscape.com.
This year’s expanded report debuts new ratings for seven “important procedures and conditions to help patients, in consultation with their doctors, narrow down their choice of hospital based on the specific type of care they need,” Ben Harder, managing editor and chief of health analysis, said in a news release.
With new ratings for myocardial infarction, stroke, hip fracture, and back surgery (spinal fusion), the report now ranks 17 procedures and conditions.
Also new to the 2021 report, which marks the 32nd edition, is a look at racial disparities in health care and the inclusion of health equity measures alongside the hospital rankings.
The new measures examine whether the patients each hospital has treated reflect the racial and ethnic diversity of the surrounding community, among other aspects of health equity.
“At roughly four out of five hospitals, we found that the community’s minority residents were underrepresented among patients receiving services such as joint replacement, cancer surgery and common heart procedures,” Mr. Harder said.
“Against this backdrop, however, we found important exceptions – hospitals that provide care to a disproportionate share of their community’s minority residents. These metrics are just a beginning; we aim to expand on our measurement of health equity in the future,” Mr. Harder added.
Mayo and Cleveland Clinic remain tops
Following the Mayo Clinic, the Cleveland Clinic once again takes the No. 2 spot in the magazine’s latest annual honor roll of best hospitals, which highlights hospitals that deliver exceptional treatment across multiple areas of care.
UCLA Medical Center, Los Angeles, holds the No. 3 spot in 2021. In 2020, UCLA Medical Center and New York–Presbyterian Hospital–Columbia and Cornell, New York, sat in a tie at No. 4.
In 2021, Johns Hopkins Hospital, Baltimore, which held the No. 3 spot in 2020, drops to No. 4, while Massachusetts General Hospital in Boston takes the No. 5 spot, up from No. 6 in 2020.
Rounding out the top 10 (in order) are Cedars-Sinai Medical Center, Los Angeles; New York–Presbyterian Hospital–Columbia and Cornell, New York; NYU Langone Hospitals, New York; UCSF Medical Center, San Francisco; and Northwestern Memorial Hospital, Chicago.
2021-2022 Best Hospitals honor roll
1. Mayo Clinic, Rochester, Minn.
2. Cleveland Clinic, Cleveland
3. UCLA Medical Center, Los Angeles
4. Johns Hopkins Hospital, Baltimore
5. Massachusetts General Hospital, Boston
6. Cedars-Sinai Medical Center, San Francisco
7. New York–Presbyterian Hospital–Columbia and Cornell, New York
8. NYU Langone Hospitals, New York
9. UCSF Medical Center, San Francisco
10. Northwestern Memorial Hospital, Chicago
11. University of Michigan Hospitals–Michigan Medicine, Ann Arbor.
12. Stanford Health Care–Stanford Hospital, Palo Alto, Calif.
13. Hospitals of the University of Pennsylvania–Penn Presbyterian, Philadelphia
14. Brigham and Women’s Hospital, Boston
15. Mayo Clinic–Phoenix, Phoenix
16. Houston Methodist Hospital, Houston
17. (tie) Barnes-Jewish Hospital, St. Louis
17. (tie) Mount Sinai Hospital, New York Rush University Medical Center, Chicago
19. Rush University Medical Center, Chicago
20. Vanderbilt University Medical Center, Nashville, Tenn.
For the 2021-2022 rankings and ratings, the magazine compared more than 4,750 hospitals nationwide in 15 specialties and 17 procedures and conditions.
At least 2,039 hospitals received a high performance rating in at least one of the services rated; 11 hospitals received high performance in all 17. A total of 175 hospitals were nationally ranked in at least one specialty
For specialty rankings, the University of Texas MD Anderson Cancer Center continues to hold the No. 1 spot in cancer care, the Hospital for Special Surgery continues to be No. 1 in orthopedics, and the Cleveland Clinic continues to be No. 1 in cardiology and heart surgery.
Top five for cancer
1. University of Texas MD Anderson Cancer Center, Houston
2. Memorial Sloan Kettering Cancer Center, New York
3. Mayo Clinic, Rochester, Minn.
4. Dana-Farber/Brigham & Women’s Cancer Center, Boston
5. Cleveland Clinic, Cleveland
Top five for cardiology and heart surgery
1. Cleveland Clinic, Cleveland
2. Mayo Clinic, Rochester, Minn.
3. Cedars-Sinai Medical Center, Los Angeles
4. New York–Presbyterian Hospital–Columbia and Cornell, New York
5. NYU Langone Hospitals, New York
Top five for orthopedics
1. Hospital for Special Surgery, New York
2. Mayo Clinic, Rochester, Minn.
3. Cedars-Sinai Medical Center, Los Angeles
4. NYU Langone Orthopedic Hospital, New York
5. UCLA Medical Center, Los Angeles
The magazine noted that data for the 2021-2022 Best Hospitals rankings and ratings were not affected by the COVID-19 pandemic, which began after the end of the data collection period.
The methodologies used in determining the rankings are based largely on objective measures, such as risk-adjusted survival, discharge-to-home rates, volume, and quality of nursing, among other care-related indicators.
The full report is available online.
A version of this article first appeared on Medscape.com.
This year’s expanded report debuts new ratings for seven “important procedures and conditions to help patients, in consultation with their doctors, narrow down their choice of hospital based on the specific type of care they need,” Ben Harder, managing editor and chief of health analysis, said in a news release.
With new ratings for myocardial infarction, stroke, hip fracture, and back surgery (spinal fusion), the report now ranks 17 procedures and conditions.
Also new to the 2021 report, which marks the 32nd edition, is a look at racial disparities in health care and the inclusion of health equity measures alongside the hospital rankings.
The new measures examine whether the patients each hospital has treated reflect the racial and ethnic diversity of the surrounding community, among other aspects of health equity.
“At roughly four out of five hospitals, we found that the community’s minority residents were underrepresented among patients receiving services such as joint replacement, cancer surgery and common heart procedures,” Mr. Harder said.
“Against this backdrop, however, we found important exceptions – hospitals that provide care to a disproportionate share of their community’s minority residents. These metrics are just a beginning; we aim to expand on our measurement of health equity in the future,” Mr. Harder added.
Mayo and Cleveland Clinic remain tops
Following the Mayo Clinic, the Cleveland Clinic once again takes the No. 2 spot in the magazine’s latest annual honor roll of best hospitals, which highlights hospitals that deliver exceptional treatment across multiple areas of care.
UCLA Medical Center, Los Angeles, holds the No. 3 spot in 2021. In 2020, UCLA Medical Center and New York–Presbyterian Hospital–Columbia and Cornell, New York, sat in a tie at No. 4.
In 2021, Johns Hopkins Hospital, Baltimore, which held the No. 3 spot in 2020, drops to No. 4, while Massachusetts General Hospital in Boston takes the No. 5 spot, up from No. 6 in 2020.
Rounding out the top 10 (in order) are Cedars-Sinai Medical Center, Los Angeles; New York–Presbyterian Hospital–Columbia and Cornell, New York; NYU Langone Hospitals, New York; UCSF Medical Center, San Francisco; and Northwestern Memorial Hospital, Chicago.
2021-2022 Best Hospitals honor roll
1. Mayo Clinic, Rochester, Minn.
2. Cleveland Clinic, Cleveland
3. UCLA Medical Center, Los Angeles
4. Johns Hopkins Hospital, Baltimore
5. Massachusetts General Hospital, Boston
6. Cedars-Sinai Medical Center, San Francisco
7. New York–Presbyterian Hospital–Columbia and Cornell, New York
8. NYU Langone Hospitals, New York
9. UCSF Medical Center, San Francisco
10. Northwestern Memorial Hospital, Chicago
11. University of Michigan Hospitals–Michigan Medicine, Ann Arbor.
12. Stanford Health Care–Stanford Hospital, Palo Alto, Calif.
13. Hospitals of the University of Pennsylvania–Penn Presbyterian, Philadelphia
14. Brigham and Women’s Hospital, Boston
15. Mayo Clinic–Phoenix, Phoenix
16. Houston Methodist Hospital, Houston
17. (tie) Barnes-Jewish Hospital, St. Louis
17. (tie) Mount Sinai Hospital, New York Rush University Medical Center, Chicago
19. Rush University Medical Center, Chicago
20. Vanderbilt University Medical Center, Nashville, Tenn.
For the 2021-2022 rankings and ratings, the magazine compared more than 4,750 hospitals nationwide in 15 specialties and 17 procedures and conditions.
At least 2,039 hospitals received a high performance rating in at least one of the services rated; 11 hospitals received high performance in all 17. A total of 175 hospitals were nationally ranked in at least one specialty
For specialty rankings, the University of Texas MD Anderson Cancer Center continues to hold the No. 1 spot in cancer care, the Hospital for Special Surgery continues to be No. 1 in orthopedics, and the Cleveland Clinic continues to be No. 1 in cardiology and heart surgery.
Top five for cancer
1. University of Texas MD Anderson Cancer Center, Houston
2. Memorial Sloan Kettering Cancer Center, New York
3. Mayo Clinic, Rochester, Minn.
4. Dana-Farber/Brigham & Women’s Cancer Center, Boston
5. Cleveland Clinic, Cleveland
Top five for cardiology and heart surgery
1. Cleveland Clinic, Cleveland
2. Mayo Clinic, Rochester, Minn.
3. Cedars-Sinai Medical Center, Los Angeles
4. New York–Presbyterian Hospital–Columbia and Cornell, New York
5. NYU Langone Hospitals, New York
Top five for orthopedics
1. Hospital for Special Surgery, New York
2. Mayo Clinic, Rochester, Minn.
3. Cedars-Sinai Medical Center, Los Angeles
4. NYU Langone Orthopedic Hospital, New York
5. UCLA Medical Center, Los Angeles
The magazine noted that data for the 2021-2022 Best Hospitals rankings and ratings were not affected by the COVID-19 pandemic, which began after the end of the data collection period.
The methodologies used in determining the rankings are based largely on objective measures, such as risk-adjusted survival, discharge-to-home rates, volume, and quality of nursing, among other care-related indicators.
The full report is available online.
A version of this article first appeared on Medscape.com.
Time’s little reminders
I don’t see anyone under 18. After all, I’m not a child neurologist.
People will occasionally argue with this policy, claiming that it’s too rigid. Why not 17½? I know that some adult neurologists do see teenagers.
But not me. It’s easier to just have a solid line and stick by it.
So, by habit, I often note someone’s birthday on the schedule to make sure they’re old enough to see me. And, over the years, this has made me realize the passage of time more than a lot of things.
Not much changes in my office. I’ve been in the same building since 2013, had the same furniture for longer, and the same staff since 2004. So it’s easy to lose track of how long I’ve been doing this.
But when I started out I didn’t see anyone born after 1979. Today that’s crept up to 2003. How the hell did that happen?
With that came the even more sobering realization that my kids are now all old enough to be my patients.
Time flies by in this world. You do the same thing day in and day out, and suddenly you’re 20 years older and starting to think about retirement.
We all see ourselves in the mirror each day, but rarely notice the changes. Watching patients grow older, seeing the minimum birth year for them advance, even being surprised when a drug I thought had just come out is now generic – those are the reminders of time’s passage that get my attention at work.
Not that it’s a bad thing. After 20 years I still enjoy this job, and it allows me to support my family. I can’t ask for much more than that.
But each morning I scan through the names and birthdays on my schedule, and am amazed when I think about how clearly I remember my first day of medical school, college, and even high school like it had just happened.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I don’t see anyone under 18. After all, I’m not a child neurologist.
People will occasionally argue with this policy, claiming that it’s too rigid. Why not 17½? I know that some adult neurologists do see teenagers.
But not me. It’s easier to just have a solid line and stick by it.
So, by habit, I often note someone’s birthday on the schedule to make sure they’re old enough to see me. And, over the years, this has made me realize the passage of time more than a lot of things.
Not much changes in my office. I’ve been in the same building since 2013, had the same furniture for longer, and the same staff since 2004. So it’s easy to lose track of how long I’ve been doing this.
But when I started out I didn’t see anyone born after 1979. Today that’s crept up to 2003. How the hell did that happen?
With that came the even more sobering realization that my kids are now all old enough to be my patients.
Time flies by in this world. You do the same thing day in and day out, and suddenly you’re 20 years older and starting to think about retirement.
We all see ourselves in the mirror each day, but rarely notice the changes. Watching patients grow older, seeing the minimum birth year for them advance, even being surprised when a drug I thought had just come out is now generic – those are the reminders of time’s passage that get my attention at work.
Not that it’s a bad thing. After 20 years I still enjoy this job, and it allows me to support my family. I can’t ask for much more than that.
But each morning I scan through the names and birthdays on my schedule, and am amazed when I think about how clearly I remember my first day of medical school, college, and even high school like it had just happened.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I don’t see anyone under 18. After all, I’m not a child neurologist.
People will occasionally argue with this policy, claiming that it’s too rigid. Why not 17½? I know that some adult neurologists do see teenagers.
But not me. It’s easier to just have a solid line and stick by it.
So, by habit, I often note someone’s birthday on the schedule to make sure they’re old enough to see me. And, over the years, this has made me realize the passage of time more than a lot of things.
Not much changes in my office. I’ve been in the same building since 2013, had the same furniture for longer, and the same staff since 2004. So it’s easy to lose track of how long I’ve been doing this.
But when I started out I didn’t see anyone born after 1979. Today that’s crept up to 2003. How the hell did that happen?
With that came the even more sobering realization that my kids are now all old enough to be my patients.
Time flies by in this world. You do the same thing day in and day out, and suddenly you’re 20 years older and starting to think about retirement.
We all see ourselves in the mirror each day, but rarely notice the changes. Watching patients grow older, seeing the minimum birth year for them advance, even being surprised when a drug I thought had just come out is now generic – those are the reminders of time’s passage that get my attention at work.
Not that it’s a bad thing. After 20 years I still enjoy this job, and it allows me to support my family. I can’t ask for much more than that.
But each morning I scan through the names and birthdays on my schedule, and am amazed when I think about how clearly I remember my first day of medical school, college, and even high school like it had just happened.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
A clarion call for regulating PBMs: Health care groups, states push back on legal challenges
Mark Nelson, PharmD, recalls the anguish when a major pharmacy benefit manager (PBM) moved all veteran patients with prostate cancer at his facility from an effective medication to a pricier alternative therapy. “All of these patients were stable on their therapy and were extremely distraught about their medications being changed,” said Dr. Nelson, CEO of Northwest Medical Specialties in Washington State. While there was no clinical reason to change the medication, “our oncologists had no choice other than to comply,” he said.
It’s unclear why a PBM would switch to a more expensive medication that has no additional clinical benefit, he continued. “Why upset so many veterans? For what reason? We were not given a reason despite our very vocal protest.”
Angus B. Worthing, MD, sees these scenarios unfold every day in his rheumatology practice in the Washington, D.C., area. “In my clinic with 25 doctors, we have three full-time people that only handle PBMs,” he said in an interview. He and others in the medical community, as well as many states, have been pushing back on what they see as efforts by PBMs to raise drug prices and collect the profits at the expense of patients.
PCMA’s challenges against PBM law
The Pharmaceutical Care Management Association (PCMA), a trade group that represents PBMs, has sued at least a half dozen states on their ability to regulate PBMs. However, a landmark case in late 2020 (Pharmaceutical Care Management Association v. Rutledge) set a new precedent. Reversing a lower appeals court decision, the Supreme Court unanimously ruled in favor of allowing states to put in place fair regulation of these entities.
Dr. Worthing and others hope that the medical community and states can leverage this ruling in another lawsuit PCMA brought against North Dakota (PCMA v. Wehbi). PCMA filed this lawsuit in 2017, which challenges two statutes on PBM regulation. The group has issued similar legal challenges in Maine, the District of Columbia, Iowa, Oklahoma, and Arkansas with the Rutledge case.
“PBMs have become massive profit centers while (ironically) increasing patients’ out-of-pocket costs, interfering with doctor-patient relationships, and impairing patient access to appropriate treatment,” according to an amicus brief filed by The Alliance for Transparent & Affordable Prescriptions (ATAP), the Community Oncology Alliance (COA), and American Pharmacies, supporting North Dakota in the Wehbi case.
This is to ensure the case represents the voices of physicians, patients, nurses, and other stakeholders, and underscores PBM abuses, said Dr. Worthing, vice president of ATAP. He also serves as the American College of Rheumatology’s representative on ATAP’s Executive Committee.
PCMA did not respond to requests for comment. Its CEO and president, J.C. Scott, emphasizes that PBMs have a long track record of reducing drug costs for patients and plan sponsors. In 2021, PCMA released 21 policy solutions, a set of industry principles and a three-part policy platform, all with an aim to bring down costs and increase access to pharmaceutical care, according to the organization.
PCMA estimates that the strategies in its platform (updating Medicare Part D, accelerating value-based care, and eliminating anticompetitive ‘pay for delay’ agreements) would save the federal government a maximum of $398.7 billion over 10 years.
According to Wendy Hemmen, senior director with Texas Oncology in Dallas, PBMs do their own unique calculations to arrive at their cost reductions. “Essentially in a PBM, they use things that make their story. Numbers reported to plan sponsors and to the public are not audited and are usually in terms of percentages or a per member per month. Data points are moved around, dropped, or reclassified to make the story that the PBM needs to tell,” Ms. Hemmen said.
Amicus briefs dispute ERISA connection
North Dakota legislation prohibits PBMs from charging copays to patients that exceed the cost of a drug. It also prohibits gag clause provisions that restrict what pharmacists may discuss with patients. PBMs may charge fees based on performance metrics, but they must use nationally recognized metrics. Fees must be disclosed at the point of sale.
In its legal challenges, PCMA has asserted that state laws violate the preemption clause in the Employee Retirement Income Security Act (ERISA). “Federal preemption allows employers flexibility to administer innovative benefit plans in an environment of increasing health care costs. The court’s decision in Rutledge v. PCMA will either uphold or threaten these federal protections,” PCMA asserted in a statement issued in March 2020.
ATAP’s amicus brief, and another one filed by 34 attorneys general that supports the North Dakota statute to regulate PBMs, counter that this isn’t the case.
“First, PBM regulation (in its common and standard form) does not reference ERISA itself. These laws leave all plans on equal footing; they do not single out ERISA plans for preferred or disfavored coverage, and they do not change the playing field for ERISA plans alone ... Second, PBM regulation does not have any prohibited connection with ERISA plans,” noted authors in the ATAP brief.
PCMA has also included Medicare preemption in its arguments against PBM regulation. This is meritless, wrote the state attorneys general. “Medicare preempts state laws only if a Medicare ‘standard’ particularly addresses the subject of state regulation. Because the challenged North Dakota laws do not dictate plan benefits or conflict with a Medicare standard, they are not preempted.”
The auctioning of medications
PBMs in theory could use their market power to drive down costs by extracting discounts from drug makers and pharmacies. In reality, they retain any price concessions and discounts for themselves, ATAP’s brief continued.
A system that PBMs have put into place, called step therapy, is essentially an auction for the preferred spot that will be authorized and covered, Dr. Worthing explained.
PBMs create formularies through this auction. The highest rebate to the PBM earns the top spot in the auction and becomes the preferred drug. “That highest bid gets paid for by passing the cost along to patients and insurance plans, and PBMs pocket the profits. This provides an incentive for pharmaceutical manufacturers to raise prices,” he said.
Dr. Worthing has seen these practices trickle down and affect his patients. “Frequently, the medication I prescribe based on what’s best for the patient based on their disease activity, values, and medical history is often not covered because a different drug or portfolio of drugs has earned the top spot in step therapy. This is an extremely frustrating and cumbersome process that not only delays access to treatments but also provides an incentive for higher drug prices,” he said.
There are other ways in which PBMs get in the way of care, said Ms. Hemmen, whose facility serves complex-care oncology patients.
“PBMs force scripts out of higher-quality pharmacies that preserve unfragmented care. They incentivize plan sponsors to put programs into place that take away patient choice, fragment care, and drive scripts to their own owned pharmacies,” she said.
Rutledge case sets precedent
In the Rutledge case, PCMA had challenged an Arkansas law that forbid PBMs from paying local pharmacies at a lower rate than what the pharmacies were reimbursed to fill prescriptions. Although the 8th Circuit Court of Appeals agreed with PCMA, the Supreme Court ruled in favor of Arkansas in late 2020.
The appeals court also backed PCMA in PCMA v. Wehbi. However, the Supreme Court vacated this decision and remanded it back to the appeals court, asking for a reconsideration in wake of the outcome in Rutledge v. PCMA.
PCMA has argued that Rutledge was a narrow decision, limited to state laws that regulate PBM reimbursements, and that Rutledge has no bearing on North Dakota law.
While it’s unfortunate that PCMA is trying to delay implementation of sensible regulations, “a lot of us are happy that this issue is coming to light,” Dr. Worthing said. “As a rheumatologist and health policy advocate, exposing drug middlemen is the most important bipartisan issue in the country today because it gets at the core of making sure that sick people get access to the medications they need and reducing the budget of insurance carriers, hospitals, and the federal budget.”
The ATAP brief noted that 28 state attorneys general have filed suit against PBMs, “securing settlements compelling PBMs to correct deceptive trade practices.”
Many people at the state and local level were waiting for the Supreme Court to decide on Rutledge before enacting legislation and sensible regulations, and now they can go ahead and do it, said Dr. Worthing. “I expect to see this across the country as states look at budgets, and as patients bring personal stories to light. We look forward to states passing these kinds of laws to regulate PBMs.”
The ACR doesn’t anticipate a ruling in the Wehbi case until the spring of 2022.
Recent laws passed around PBMs and the pharmacy benefit are a good first step in holding PBMs accountable for quality of care and honoring patient choice, Ms. Hemmen said. The laws also begin to address the fiscal manipulations PBMs use to gain advantage and direct scripts to their own coffers, she added. However, this may not have enough teeth. “These state laws are coming from a provider perspective, and they don’t anticipate what PBMs will do in response. The PBMs are going to work around it.”
Mark Nelson, PharmD, recalls the anguish when a major pharmacy benefit manager (PBM) moved all veteran patients with prostate cancer at his facility from an effective medication to a pricier alternative therapy. “All of these patients were stable on their therapy and were extremely distraught about their medications being changed,” said Dr. Nelson, CEO of Northwest Medical Specialties in Washington State. While there was no clinical reason to change the medication, “our oncologists had no choice other than to comply,” he said.
It’s unclear why a PBM would switch to a more expensive medication that has no additional clinical benefit, he continued. “Why upset so many veterans? For what reason? We were not given a reason despite our very vocal protest.”
Angus B. Worthing, MD, sees these scenarios unfold every day in his rheumatology practice in the Washington, D.C., area. “In my clinic with 25 doctors, we have three full-time people that only handle PBMs,” he said in an interview. He and others in the medical community, as well as many states, have been pushing back on what they see as efforts by PBMs to raise drug prices and collect the profits at the expense of patients.
PCMA’s challenges against PBM law
The Pharmaceutical Care Management Association (PCMA), a trade group that represents PBMs, has sued at least a half dozen states on their ability to regulate PBMs. However, a landmark case in late 2020 (Pharmaceutical Care Management Association v. Rutledge) set a new precedent. Reversing a lower appeals court decision, the Supreme Court unanimously ruled in favor of allowing states to put in place fair regulation of these entities.
Dr. Worthing and others hope that the medical community and states can leverage this ruling in another lawsuit PCMA brought against North Dakota (PCMA v. Wehbi). PCMA filed this lawsuit in 2017, which challenges two statutes on PBM regulation. The group has issued similar legal challenges in Maine, the District of Columbia, Iowa, Oklahoma, and Arkansas with the Rutledge case.
“PBMs have become massive profit centers while (ironically) increasing patients’ out-of-pocket costs, interfering with doctor-patient relationships, and impairing patient access to appropriate treatment,” according to an amicus brief filed by The Alliance for Transparent & Affordable Prescriptions (ATAP), the Community Oncology Alliance (COA), and American Pharmacies, supporting North Dakota in the Wehbi case.
This is to ensure the case represents the voices of physicians, patients, nurses, and other stakeholders, and underscores PBM abuses, said Dr. Worthing, vice president of ATAP. He also serves as the American College of Rheumatology’s representative on ATAP’s Executive Committee.
PCMA did not respond to requests for comment. Its CEO and president, J.C. Scott, emphasizes that PBMs have a long track record of reducing drug costs for patients and plan sponsors. In 2021, PCMA released 21 policy solutions, a set of industry principles and a three-part policy platform, all with an aim to bring down costs and increase access to pharmaceutical care, according to the organization.
PCMA estimates that the strategies in its platform (updating Medicare Part D, accelerating value-based care, and eliminating anticompetitive ‘pay for delay’ agreements) would save the federal government a maximum of $398.7 billion over 10 years.
According to Wendy Hemmen, senior director with Texas Oncology in Dallas, PBMs do their own unique calculations to arrive at their cost reductions. “Essentially in a PBM, they use things that make their story. Numbers reported to plan sponsors and to the public are not audited and are usually in terms of percentages or a per member per month. Data points are moved around, dropped, or reclassified to make the story that the PBM needs to tell,” Ms. Hemmen said.
Amicus briefs dispute ERISA connection
North Dakota legislation prohibits PBMs from charging copays to patients that exceed the cost of a drug. It also prohibits gag clause provisions that restrict what pharmacists may discuss with patients. PBMs may charge fees based on performance metrics, but they must use nationally recognized metrics. Fees must be disclosed at the point of sale.
In its legal challenges, PCMA has asserted that state laws violate the preemption clause in the Employee Retirement Income Security Act (ERISA). “Federal preemption allows employers flexibility to administer innovative benefit plans in an environment of increasing health care costs. The court’s decision in Rutledge v. PCMA will either uphold or threaten these federal protections,” PCMA asserted in a statement issued in March 2020.
ATAP’s amicus brief, and another one filed by 34 attorneys general that supports the North Dakota statute to regulate PBMs, counter that this isn’t the case.
“First, PBM regulation (in its common and standard form) does not reference ERISA itself. These laws leave all plans on equal footing; they do not single out ERISA plans for preferred or disfavored coverage, and they do not change the playing field for ERISA plans alone ... Second, PBM regulation does not have any prohibited connection with ERISA plans,” noted authors in the ATAP brief.
PCMA has also included Medicare preemption in its arguments against PBM regulation. This is meritless, wrote the state attorneys general. “Medicare preempts state laws only if a Medicare ‘standard’ particularly addresses the subject of state regulation. Because the challenged North Dakota laws do not dictate plan benefits or conflict with a Medicare standard, they are not preempted.”
The auctioning of medications
PBMs in theory could use their market power to drive down costs by extracting discounts from drug makers and pharmacies. In reality, they retain any price concessions and discounts for themselves, ATAP’s brief continued.
A system that PBMs have put into place, called step therapy, is essentially an auction for the preferred spot that will be authorized and covered, Dr. Worthing explained.
PBMs create formularies through this auction. The highest rebate to the PBM earns the top spot in the auction and becomes the preferred drug. “That highest bid gets paid for by passing the cost along to patients and insurance plans, and PBMs pocket the profits. This provides an incentive for pharmaceutical manufacturers to raise prices,” he said.
Dr. Worthing has seen these practices trickle down and affect his patients. “Frequently, the medication I prescribe based on what’s best for the patient based on their disease activity, values, and medical history is often not covered because a different drug or portfolio of drugs has earned the top spot in step therapy. This is an extremely frustrating and cumbersome process that not only delays access to treatments but also provides an incentive for higher drug prices,” he said.
There are other ways in which PBMs get in the way of care, said Ms. Hemmen, whose facility serves complex-care oncology patients.
“PBMs force scripts out of higher-quality pharmacies that preserve unfragmented care. They incentivize plan sponsors to put programs into place that take away patient choice, fragment care, and drive scripts to their own owned pharmacies,” she said.
Rutledge case sets precedent
In the Rutledge case, PCMA had challenged an Arkansas law that forbid PBMs from paying local pharmacies at a lower rate than what the pharmacies were reimbursed to fill prescriptions. Although the 8th Circuit Court of Appeals agreed with PCMA, the Supreme Court ruled in favor of Arkansas in late 2020.
The appeals court also backed PCMA in PCMA v. Wehbi. However, the Supreme Court vacated this decision and remanded it back to the appeals court, asking for a reconsideration in wake of the outcome in Rutledge v. PCMA.
PCMA has argued that Rutledge was a narrow decision, limited to state laws that regulate PBM reimbursements, and that Rutledge has no bearing on North Dakota law.
While it’s unfortunate that PCMA is trying to delay implementation of sensible regulations, “a lot of us are happy that this issue is coming to light,” Dr. Worthing said. “As a rheumatologist and health policy advocate, exposing drug middlemen is the most important bipartisan issue in the country today because it gets at the core of making sure that sick people get access to the medications they need and reducing the budget of insurance carriers, hospitals, and the federal budget.”
The ATAP brief noted that 28 state attorneys general have filed suit against PBMs, “securing settlements compelling PBMs to correct deceptive trade practices.”
Many people at the state and local level were waiting for the Supreme Court to decide on Rutledge before enacting legislation and sensible regulations, and now they can go ahead and do it, said Dr. Worthing. “I expect to see this across the country as states look at budgets, and as patients bring personal stories to light. We look forward to states passing these kinds of laws to regulate PBMs.”
The ACR doesn’t anticipate a ruling in the Wehbi case until the spring of 2022.
Recent laws passed around PBMs and the pharmacy benefit are a good first step in holding PBMs accountable for quality of care and honoring patient choice, Ms. Hemmen said. The laws also begin to address the fiscal manipulations PBMs use to gain advantage and direct scripts to their own coffers, she added. However, this may not have enough teeth. “These state laws are coming from a provider perspective, and they don’t anticipate what PBMs will do in response. The PBMs are going to work around it.”
Mark Nelson, PharmD, recalls the anguish when a major pharmacy benefit manager (PBM) moved all veteran patients with prostate cancer at his facility from an effective medication to a pricier alternative therapy. “All of these patients were stable on their therapy and were extremely distraught about their medications being changed,” said Dr. Nelson, CEO of Northwest Medical Specialties in Washington State. While there was no clinical reason to change the medication, “our oncologists had no choice other than to comply,” he said.
It’s unclear why a PBM would switch to a more expensive medication that has no additional clinical benefit, he continued. “Why upset so many veterans? For what reason? We were not given a reason despite our very vocal protest.”
Angus B. Worthing, MD, sees these scenarios unfold every day in his rheumatology practice in the Washington, D.C., area. “In my clinic with 25 doctors, we have three full-time people that only handle PBMs,” he said in an interview. He and others in the medical community, as well as many states, have been pushing back on what they see as efforts by PBMs to raise drug prices and collect the profits at the expense of patients.
PCMA’s challenges against PBM law
The Pharmaceutical Care Management Association (PCMA), a trade group that represents PBMs, has sued at least a half dozen states on their ability to regulate PBMs. However, a landmark case in late 2020 (Pharmaceutical Care Management Association v. Rutledge) set a new precedent. Reversing a lower appeals court decision, the Supreme Court unanimously ruled in favor of allowing states to put in place fair regulation of these entities.
Dr. Worthing and others hope that the medical community and states can leverage this ruling in another lawsuit PCMA brought against North Dakota (PCMA v. Wehbi). PCMA filed this lawsuit in 2017, which challenges two statutes on PBM regulation. The group has issued similar legal challenges in Maine, the District of Columbia, Iowa, Oklahoma, and Arkansas with the Rutledge case.
“PBMs have become massive profit centers while (ironically) increasing patients’ out-of-pocket costs, interfering with doctor-patient relationships, and impairing patient access to appropriate treatment,” according to an amicus brief filed by The Alliance for Transparent & Affordable Prescriptions (ATAP), the Community Oncology Alliance (COA), and American Pharmacies, supporting North Dakota in the Wehbi case.
This is to ensure the case represents the voices of physicians, patients, nurses, and other stakeholders, and underscores PBM abuses, said Dr. Worthing, vice president of ATAP. He also serves as the American College of Rheumatology’s representative on ATAP’s Executive Committee.
PCMA did not respond to requests for comment. Its CEO and president, J.C. Scott, emphasizes that PBMs have a long track record of reducing drug costs for patients and plan sponsors. In 2021, PCMA released 21 policy solutions, a set of industry principles and a three-part policy platform, all with an aim to bring down costs and increase access to pharmaceutical care, according to the organization.
PCMA estimates that the strategies in its platform (updating Medicare Part D, accelerating value-based care, and eliminating anticompetitive ‘pay for delay’ agreements) would save the federal government a maximum of $398.7 billion over 10 years.
According to Wendy Hemmen, senior director with Texas Oncology in Dallas, PBMs do their own unique calculations to arrive at their cost reductions. “Essentially in a PBM, they use things that make their story. Numbers reported to plan sponsors and to the public are not audited and are usually in terms of percentages or a per member per month. Data points are moved around, dropped, or reclassified to make the story that the PBM needs to tell,” Ms. Hemmen said.
Amicus briefs dispute ERISA connection
North Dakota legislation prohibits PBMs from charging copays to patients that exceed the cost of a drug. It also prohibits gag clause provisions that restrict what pharmacists may discuss with patients. PBMs may charge fees based on performance metrics, but they must use nationally recognized metrics. Fees must be disclosed at the point of sale.
In its legal challenges, PCMA has asserted that state laws violate the preemption clause in the Employee Retirement Income Security Act (ERISA). “Federal preemption allows employers flexibility to administer innovative benefit plans in an environment of increasing health care costs. The court’s decision in Rutledge v. PCMA will either uphold or threaten these federal protections,” PCMA asserted in a statement issued in March 2020.
ATAP’s amicus brief, and another one filed by 34 attorneys general that supports the North Dakota statute to regulate PBMs, counter that this isn’t the case.
“First, PBM regulation (in its common and standard form) does not reference ERISA itself. These laws leave all plans on equal footing; they do not single out ERISA plans for preferred or disfavored coverage, and they do not change the playing field for ERISA plans alone ... Second, PBM regulation does not have any prohibited connection with ERISA plans,” noted authors in the ATAP brief.
PCMA has also included Medicare preemption in its arguments against PBM regulation. This is meritless, wrote the state attorneys general. “Medicare preempts state laws only if a Medicare ‘standard’ particularly addresses the subject of state regulation. Because the challenged North Dakota laws do not dictate plan benefits or conflict with a Medicare standard, they are not preempted.”
The auctioning of medications
PBMs in theory could use their market power to drive down costs by extracting discounts from drug makers and pharmacies. In reality, they retain any price concessions and discounts for themselves, ATAP’s brief continued.
A system that PBMs have put into place, called step therapy, is essentially an auction for the preferred spot that will be authorized and covered, Dr. Worthing explained.
PBMs create formularies through this auction. The highest rebate to the PBM earns the top spot in the auction and becomes the preferred drug. “That highest bid gets paid for by passing the cost along to patients and insurance plans, and PBMs pocket the profits. This provides an incentive for pharmaceutical manufacturers to raise prices,” he said.
Dr. Worthing has seen these practices trickle down and affect his patients. “Frequently, the medication I prescribe based on what’s best for the patient based on their disease activity, values, and medical history is often not covered because a different drug or portfolio of drugs has earned the top spot in step therapy. This is an extremely frustrating and cumbersome process that not only delays access to treatments but also provides an incentive for higher drug prices,” he said.
There are other ways in which PBMs get in the way of care, said Ms. Hemmen, whose facility serves complex-care oncology patients.
“PBMs force scripts out of higher-quality pharmacies that preserve unfragmented care. They incentivize plan sponsors to put programs into place that take away patient choice, fragment care, and drive scripts to their own owned pharmacies,” she said.
Rutledge case sets precedent
In the Rutledge case, PCMA had challenged an Arkansas law that forbid PBMs from paying local pharmacies at a lower rate than what the pharmacies were reimbursed to fill prescriptions. Although the 8th Circuit Court of Appeals agreed with PCMA, the Supreme Court ruled in favor of Arkansas in late 2020.
The appeals court also backed PCMA in PCMA v. Wehbi. However, the Supreme Court vacated this decision and remanded it back to the appeals court, asking for a reconsideration in wake of the outcome in Rutledge v. PCMA.
PCMA has argued that Rutledge was a narrow decision, limited to state laws that regulate PBM reimbursements, and that Rutledge has no bearing on North Dakota law.
While it’s unfortunate that PCMA is trying to delay implementation of sensible regulations, “a lot of us are happy that this issue is coming to light,” Dr. Worthing said. “As a rheumatologist and health policy advocate, exposing drug middlemen is the most important bipartisan issue in the country today because it gets at the core of making sure that sick people get access to the medications they need and reducing the budget of insurance carriers, hospitals, and the federal budget.”
The ATAP brief noted that 28 state attorneys general have filed suit against PBMs, “securing settlements compelling PBMs to correct deceptive trade practices.”
Many people at the state and local level were waiting for the Supreme Court to decide on Rutledge before enacting legislation and sensible regulations, and now they can go ahead and do it, said Dr. Worthing. “I expect to see this across the country as states look at budgets, and as patients bring personal stories to light. We look forward to states passing these kinds of laws to regulate PBMs.”
The ACR doesn’t anticipate a ruling in the Wehbi case until the spring of 2022.
Recent laws passed around PBMs and the pharmacy benefit are a good first step in holding PBMs accountable for quality of care and honoring patient choice, Ms. Hemmen said. The laws also begin to address the fiscal manipulations PBMs use to gain advantage and direct scripts to their own coffers, she added. However, this may not have enough teeth. “These state laws are coming from a provider perspective, and they don’t anticipate what PBMs will do in response. The PBMs are going to work around it.”
FM diversity has increased, but more physicians of color needed
The specialty has been on the path to a racially diverse workforce over the past few decades. Since family medicine is a discipline where doctors look not just at individual patients, but also at the health of the community, some family physicians see working in their specialty as a way to integrate public health with medicine to curb health inequities.
Maria Harsha Wusu, MD, MSEd, is an example of such a family physician.
Dr. Wusu, who is Black and of Japanese descent, chose to practice family medicine to address health in communities of color “which we know in the United States experience health inequities due to structural racism,” she said in an interview.
“It’s a discipline where you look at the health of the entire family and the community and you really look at the environmental, the political, the historical factors that are influencing the health of the community,” explained Dr. Wusu, who is currently the director of health equity at Morehouse School of Medicine, Atlanta. Family physicians are not just asking: “Does a patient have hypertension?” but also whether a patient has access to healthy food, green space and other things.
While the field of family medicine is more diverse in the 21st century than it was at its beginning, Dr. Wusu, who completed her residency in 2016, still faced challenges to achieving her goal of helping communities of color. These specifically stemmed from a lack of diversity among the people in the places where she studied to become a doctor and family physician.
There were moments when Dr. Wusu felt isolated while in medical school and residency, because so few students and faculty members she saw looked like her.
Plus, studies have shown that a racially and ethnically diverse physician workforce is necessary to address health inequities. Research published in 2018 in the Journal of Health Care for the Poor and Underserved, for example, found that underrepresented physicians are more likely to practice in underserved areas than their White peers.
“I went to medical school at a historically White institution, and so there were very few people who identified as what we would say are underrepresented minorities in medicine,” Dr. Wusu explained. “There are issues with both implicit and explicit racism, which I think could be echoed by colleagues across the country that are additional challenges that I think medical students, particularly students of color, experience during what is an already kind of challenging time of medical school and the rigorous training of residency.”
Ada Stewart, MD, FAAFP, president of the American Academy of Family Physicians, echoed Dr. Wusu’s medical school experience. Dr. Stewart, who finished her residency in 2003, said that, out of the 120 students in her graduating medical class, only 10 were Black.
Marginalized groups are still underrepresented in residences. According to data compiled by the Association of American Medical Colleges, only 9.3% of Black people, 10% of Latino, and 0.3% of Native Hawaiian or other Pacific Islanders are residents in family medicine residency programs in 2019-2020. Meanwhile, White residents make up 50.8% of the residency program.
“We really need to do all that we can to increase diversity within our medical schools and residencies,” Dr. Stewart said.
In regards to gender, there has been an increasing number of women in the family medicine specialty. A 2021 study found that the proportion of female physicians in family medicine has grown from 33.9% 2010 to 41.9% in 2020.
“There’s still room for growth and we have to change the system and those structures that created these problems,” noted Dr. Stewart.
The social responsibility of family medicine
The family medicine specialty was born during an era of protest of social change, alongside the Civil Rights Movement, the peace movement, and counterculture protests. In April 1966, 3 years before American Boards approved family practice as a new specialty; the National Commission on Community Health stated that every person should have a personal physician who is the “central point for the integration and continuity of all medical services to his patient.” They also said such physicians should be aware of the “many and varied social, emotional and environmental factors that influence the health of his patient and family.”
While the diversity of family medicine specialty has significantly increased since its beginnings, it continues to lag behind the general U.S. population. A 2018 study published in the Journal of the American Board of Family Medicine, which aggregated data from 1987 to 2017, found that the proportion of Black and Latino board certified family physicians increased from 1.3% to 7.8% and 2.3% to 9.1%, respectively, in 30 years.
A 2014 study included 2 decades worth of data from the U.S. Census and the Association of American Medical Colleges to examine trends in racial and ethnic composition among family medicine residents. The U.S. population increased from 9% to 17% for Latinos, 11.7% to 12.2% for Blacks/African Americans, and 0.87% to 0.89% for Native Americans from 1990 to 2012. Meanwhile, minority representation in family residencies increased 4.9% to 9.4% for Hispanics/Latinos, from 4.2% to 7.9% for Blacks/African Americans, and from 0.7% to 0.9% for Native Americans.
Furthermore, 13.4% of the U.S. population is Black and 18.5% of the population is Latino, while only 7.8% of family medicine residents in 2019 were Black and 9.1% of family medicine residents were Latino, according to a recent study published in Family Medicine.
Recruiting a diverse physician workforce
The AAFP has launched a few initiatives to increase diversity within the specialty. In 2017, the AAFP established the Center for Diversity and Health Equity, a center to address social determinants of health. The EveryONE Project, an initiative that’s part of the AAFP’s center, offers members education and resources to promote workforce diversity. Some of those resources include “The Ladder Program,” an initiative founded by an AAFP member which involves monthly meetings and events for students as young as 9 years old to introduce them to medicine at a young age.
“You can’t see what you don’t see,” noted Dr. Stewart, who is the first Black, female president of the AAFP, and the fourth woman in the role. “I really have seen how important it is to be a mentor and to be out there so that individuals who look like me can see that they too can become a family physician and be that member of their community.”
In addition to The Ladder Program, some other resources aimed at increasing diversity among family physicians include Tour for Diversity in Medicine and the Doctors Back to School Program.
The Tour for Diversity in Medicine involves a team of physicians, other clinicians and students hosting events nationwide for minority students to help them see a path to medicine and other health professions. Meanwhile, the AAFP’s Doctors Back to School Program involves family physicians visiting children at schools, clubs, community organizations, and other places to raise childhood awareness of family medicine and help them see their own potential in health care careers.
Dr. Stewart said these programs have been successful in increasing underrepresented groups.
“We are trying to see how best to measure their success,” the AAFP president said. “Looking at the high numbers of individuals who chose the specialty of family medicine last year is what I would deem a success.”
Dr. Wusu also believes outreach to children in elementary schools is important when it comes to increasing diversity in the family medicine specialty.
One organization that’s proving such outreach is the Student National Medical Association, a branch of the National Medical Association, which is a professional organization of Black physicians. This group’s initiative, the Health Professions Recruitment Exposure Programs, exposes teens to science-related activities while introducing them to careers in health professions. Another SMNA program, called Youth Science Enrichment Program, targets elementary and junior high school students.
Dr. Wusu led a 2019 project that focused on creating a more diverse family medicine residency program by developing and implementing a strategic plan for diversity recruitment, which involved increasing outreach to marginalized groups and revising interviews to minimize bias. In a paper published on the results of the initiative, Dr. Wusu and coauthors noted that, between 2014 and 2017, the total number of underrepresented minority applicants to the Boston Medical Center Family Medicine Residency Program increased by 80%. Before the intervention, the percentage of applicants who were part of an underrepresented group ranged from 0% to 20%. During the intervention, that range jumped to 25% to 50%, according to the paper.
While Dr. Wusu considers these programs to be beneficial for the specialty, she doesn’t believe they should be done in isolation. There should also be efforts to tackle lack of opportunities and structural racism.
“With any inequity, you have to address it on multiple levels,” Dr. Wusu explained. “It’s great that there has been recognition for a need for diversity in family medicine, but my hope is that the call for equity would reach beyond that.”
Fostering an inclusive environment
While family medicine has come a long way with regards to increasing the amount of underrepresented groups in its specialty, Stephen Richmond, MD, MPH, believes there also needs to be a focus on the infrastructure of support to help retain these physicians.
“The problem of diversity within family medicine and largely in other specialties cannot be summed up simply as a matter of poor representation. We must do be better to understand the lived experience of physicians of color, in particular Black physicians, once they arrive in the medical professional environment. Doing so will help institutions to provide that infrastructure of support – including antiracism policies and practices – that will enhance wellness and representation,” said Dr. Richmond, clinical assistant professor of medicine in the division of primary care and population health at Stanford (Calif.) University.
Dr. Wusu also suggested establishing an explicitly antiracist environment. This can be done in multiple ways, including by holding programs that acknowledge the impact of structural racism on both the patients, medical students and faculty, and by educating staff about the history of racism, she said.
Dr. Stewart and Dr. Wusu think the specialty has improved in its representation of minorities, but that it has a “long way to go.”
“I think family medicine is really one of the more inclusive specialties. I mean, it has higher numbers of Black and Brown residents and physicians than other specialties,” Dr. Wusu said. “We still have a very long way to go to be at numbers that match the general population. But I think, in that way, family medicine is a place where a lot of Black and Brown physicians can find a home.”
The specialty has been on the path to a racially diverse workforce over the past few decades. Since family medicine is a discipline where doctors look not just at individual patients, but also at the health of the community, some family physicians see working in their specialty as a way to integrate public health with medicine to curb health inequities.
Maria Harsha Wusu, MD, MSEd, is an example of such a family physician.
Dr. Wusu, who is Black and of Japanese descent, chose to practice family medicine to address health in communities of color “which we know in the United States experience health inequities due to structural racism,” she said in an interview.
“It’s a discipline where you look at the health of the entire family and the community and you really look at the environmental, the political, the historical factors that are influencing the health of the community,” explained Dr. Wusu, who is currently the director of health equity at Morehouse School of Medicine, Atlanta. Family physicians are not just asking: “Does a patient have hypertension?” but also whether a patient has access to healthy food, green space and other things.
While the field of family medicine is more diverse in the 21st century than it was at its beginning, Dr. Wusu, who completed her residency in 2016, still faced challenges to achieving her goal of helping communities of color. These specifically stemmed from a lack of diversity among the people in the places where she studied to become a doctor and family physician.
There were moments when Dr. Wusu felt isolated while in medical school and residency, because so few students and faculty members she saw looked like her.
Plus, studies have shown that a racially and ethnically diverse physician workforce is necessary to address health inequities. Research published in 2018 in the Journal of Health Care for the Poor and Underserved, for example, found that underrepresented physicians are more likely to practice in underserved areas than their White peers.
“I went to medical school at a historically White institution, and so there were very few people who identified as what we would say are underrepresented minorities in medicine,” Dr. Wusu explained. “There are issues with both implicit and explicit racism, which I think could be echoed by colleagues across the country that are additional challenges that I think medical students, particularly students of color, experience during what is an already kind of challenging time of medical school and the rigorous training of residency.”
Ada Stewart, MD, FAAFP, president of the American Academy of Family Physicians, echoed Dr. Wusu’s medical school experience. Dr. Stewart, who finished her residency in 2003, said that, out of the 120 students in her graduating medical class, only 10 were Black.
Marginalized groups are still underrepresented in residences. According to data compiled by the Association of American Medical Colleges, only 9.3% of Black people, 10% of Latino, and 0.3% of Native Hawaiian or other Pacific Islanders are residents in family medicine residency programs in 2019-2020. Meanwhile, White residents make up 50.8% of the residency program.
“We really need to do all that we can to increase diversity within our medical schools and residencies,” Dr. Stewart said.
In regards to gender, there has been an increasing number of women in the family medicine specialty. A 2021 study found that the proportion of female physicians in family medicine has grown from 33.9% 2010 to 41.9% in 2020.
“There’s still room for growth and we have to change the system and those structures that created these problems,” noted Dr. Stewart.
The social responsibility of family medicine
The family medicine specialty was born during an era of protest of social change, alongside the Civil Rights Movement, the peace movement, and counterculture protests. In April 1966, 3 years before American Boards approved family practice as a new specialty; the National Commission on Community Health stated that every person should have a personal physician who is the “central point for the integration and continuity of all medical services to his patient.” They also said such physicians should be aware of the “many and varied social, emotional and environmental factors that influence the health of his patient and family.”
While the diversity of family medicine specialty has significantly increased since its beginnings, it continues to lag behind the general U.S. population. A 2018 study published in the Journal of the American Board of Family Medicine, which aggregated data from 1987 to 2017, found that the proportion of Black and Latino board certified family physicians increased from 1.3% to 7.8% and 2.3% to 9.1%, respectively, in 30 years.
A 2014 study included 2 decades worth of data from the U.S. Census and the Association of American Medical Colleges to examine trends in racial and ethnic composition among family medicine residents. The U.S. population increased from 9% to 17% for Latinos, 11.7% to 12.2% for Blacks/African Americans, and 0.87% to 0.89% for Native Americans from 1990 to 2012. Meanwhile, minority representation in family residencies increased 4.9% to 9.4% for Hispanics/Latinos, from 4.2% to 7.9% for Blacks/African Americans, and from 0.7% to 0.9% for Native Americans.
Furthermore, 13.4% of the U.S. population is Black and 18.5% of the population is Latino, while only 7.8% of family medicine residents in 2019 were Black and 9.1% of family medicine residents were Latino, according to a recent study published in Family Medicine.
Recruiting a diverse physician workforce
The AAFP has launched a few initiatives to increase diversity within the specialty. In 2017, the AAFP established the Center for Diversity and Health Equity, a center to address social determinants of health. The EveryONE Project, an initiative that’s part of the AAFP’s center, offers members education and resources to promote workforce diversity. Some of those resources include “The Ladder Program,” an initiative founded by an AAFP member which involves monthly meetings and events for students as young as 9 years old to introduce them to medicine at a young age.
“You can’t see what you don’t see,” noted Dr. Stewart, who is the first Black, female president of the AAFP, and the fourth woman in the role. “I really have seen how important it is to be a mentor and to be out there so that individuals who look like me can see that they too can become a family physician and be that member of their community.”
In addition to The Ladder Program, some other resources aimed at increasing diversity among family physicians include Tour for Diversity in Medicine and the Doctors Back to School Program.
The Tour for Diversity in Medicine involves a team of physicians, other clinicians and students hosting events nationwide for minority students to help them see a path to medicine and other health professions. Meanwhile, the AAFP’s Doctors Back to School Program involves family physicians visiting children at schools, clubs, community organizations, and other places to raise childhood awareness of family medicine and help them see their own potential in health care careers.
Dr. Stewart said these programs have been successful in increasing underrepresented groups.
“We are trying to see how best to measure their success,” the AAFP president said. “Looking at the high numbers of individuals who chose the specialty of family medicine last year is what I would deem a success.”
Dr. Wusu also believes outreach to children in elementary schools is important when it comes to increasing diversity in the family medicine specialty.
One organization that’s proving such outreach is the Student National Medical Association, a branch of the National Medical Association, which is a professional organization of Black physicians. This group’s initiative, the Health Professions Recruitment Exposure Programs, exposes teens to science-related activities while introducing them to careers in health professions. Another SMNA program, called Youth Science Enrichment Program, targets elementary and junior high school students.
Dr. Wusu led a 2019 project that focused on creating a more diverse family medicine residency program by developing and implementing a strategic plan for diversity recruitment, which involved increasing outreach to marginalized groups and revising interviews to minimize bias. In a paper published on the results of the initiative, Dr. Wusu and coauthors noted that, between 2014 and 2017, the total number of underrepresented minority applicants to the Boston Medical Center Family Medicine Residency Program increased by 80%. Before the intervention, the percentage of applicants who were part of an underrepresented group ranged from 0% to 20%. During the intervention, that range jumped to 25% to 50%, according to the paper.
While Dr. Wusu considers these programs to be beneficial for the specialty, she doesn’t believe they should be done in isolation. There should also be efforts to tackle lack of opportunities and structural racism.
“With any inequity, you have to address it on multiple levels,” Dr. Wusu explained. “It’s great that there has been recognition for a need for diversity in family medicine, but my hope is that the call for equity would reach beyond that.”
Fostering an inclusive environment
While family medicine has come a long way with regards to increasing the amount of underrepresented groups in its specialty, Stephen Richmond, MD, MPH, believes there also needs to be a focus on the infrastructure of support to help retain these physicians.
“The problem of diversity within family medicine and largely in other specialties cannot be summed up simply as a matter of poor representation. We must do be better to understand the lived experience of physicians of color, in particular Black physicians, once they arrive in the medical professional environment. Doing so will help institutions to provide that infrastructure of support – including antiracism policies and practices – that will enhance wellness and representation,” said Dr. Richmond, clinical assistant professor of medicine in the division of primary care and population health at Stanford (Calif.) University.
Dr. Wusu also suggested establishing an explicitly antiracist environment. This can be done in multiple ways, including by holding programs that acknowledge the impact of structural racism on both the patients, medical students and faculty, and by educating staff about the history of racism, she said.
Dr. Stewart and Dr. Wusu think the specialty has improved in its representation of minorities, but that it has a “long way to go.”
“I think family medicine is really one of the more inclusive specialties. I mean, it has higher numbers of Black and Brown residents and physicians than other specialties,” Dr. Wusu said. “We still have a very long way to go to be at numbers that match the general population. But I think, in that way, family medicine is a place where a lot of Black and Brown physicians can find a home.”
The specialty has been on the path to a racially diverse workforce over the past few decades. Since family medicine is a discipline where doctors look not just at individual patients, but also at the health of the community, some family physicians see working in their specialty as a way to integrate public health with medicine to curb health inequities.
Maria Harsha Wusu, MD, MSEd, is an example of such a family physician.
Dr. Wusu, who is Black and of Japanese descent, chose to practice family medicine to address health in communities of color “which we know in the United States experience health inequities due to structural racism,” she said in an interview.
“It’s a discipline where you look at the health of the entire family and the community and you really look at the environmental, the political, the historical factors that are influencing the health of the community,” explained Dr. Wusu, who is currently the director of health equity at Morehouse School of Medicine, Atlanta. Family physicians are not just asking: “Does a patient have hypertension?” but also whether a patient has access to healthy food, green space and other things.
While the field of family medicine is more diverse in the 21st century than it was at its beginning, Dr. Wusu, who completed her residency in 2016, still faced challenges to achieving her goal of helping communities of color. These specifically stemmed from a lack of diversity among the people in the places where she studied to become a doctor and family physician.
There were moments when Dr. Wusu felt isolated while in medical school and residency, because so few students and faculty members she saw looked like her.
Plus, studies have shown that a racially and ethnically diverse physician workforce is necessary to address health inequities. Research published in 2018 in the Journal of Health Care for the Poor and Underserved, for example, found that underrepresented physicians are more likely to practice in underserved areas than their White peers.
“I went to medical school at a historically White institution, and so there were very few people who identified as what we would say are underrepresented minorities in medicine,” Dr. Wusu explained. “There are issues with both implicit and explicit racism, which I think could be echoed by colleagues across the country that are additional challenges that I think medical students, particularly students of color, experience during what is an already kind of challenging time of medical school and the rigorous training of residency.”
Ada Stewart, MD, FAAFP, president of the American Academy of Family Physicians, echoed Dr. Wusu’s medical school experience. Dr. Stewart, who finished her residency in 2003, said that, out of the 120 students in her graduating medical class, only 10 were Black.
Marginalized groups are still underrepresented in residences. According to data compiled by the Association of American Medical Colleges, only 9.3% of Black people, 10% of Latino, and 0.3% of Native Hawaiian or other Pacific Islanders are residents in family medicine residency programs in 2019-2020. Meanwhile, White residents make up 50.8% of the residency program.
“We really need to do all that we can to increase diversity within our medical schools and residencies,” Dr. Stewart said.
In regards to gender, there has been an increasing number of women in the family medicine specialty. A 2021 study found that the proportion of female physicians in family medicine has grown from 33.9% 2010 to 41.9% in 2020.
“There’s still room for growth and we have to change the system and those structures that created these problems,” noted Dr. Stewart.
The social responsibility of family medicine
The family medicine specialty was born during an era of protest of social change, alongside the Civil Rights Movement, the peace movement, and counterculture protests. In April 1966, 3 years before American Boards approved family practice as a new specialty; the National Commission on Community Health stated that every person should have a personal physician who is the “central point for the integration and continuity of all medical services to his patient.” They also said such physicians should be aware of the “many and varied social, emotional and environmental factors that influence the health of his patient and family.”
While the diversity of family medicine specialty has significantly increased since its beginnings, it continues to lag behind the general U.S. population. A 2018 study published in the Journal of the American Board of Family Medicine, which aggregated data from 1987 to 2017, found that the proportion of Black and Latino board certified family physicians increased from 1.3% to 7.8% and 2.3% to 9.1%, respectively, in 30 years.
A 2014 study included 2 decades worth of data from the U.S. Census and the Association of American Medical Colleges to examine trends in racial and ethnic composition among family medicine residents. The U.S. population increased from 9% to 17% for Latinos, 11.7% to 12.2% for Blacks/African Americans, and 0.87% to 0.89% for Native Americans from 1990 to 2012. Meanwhile, minority representation in family residencies increased 4.9% to 9.4% for Hispanics/Latinos, from 4.2% to 7.9% for Blacks/African Americans, and from 0.7% to 0.9% for Native Americans.
Furthermore, 13.4% of the U.S. population is Black and 18.5% of the population is Latino, while only 7.8% of family medicine residents in 2019 were Black and 9.1% of family medicine residents were Latino, according to a recent study published in Family Medicine.
Recruiting a diverse physician workforce
The AAFP has launched a few initiatives to increase diversity within the specialty. In 2017, the AAFP established the Center for Diversity and Health Equity, a center to address social determinants of health. The EveryONE Project, an initiative that’s part of the AAFP’s center, offers members education and resources to promote workforce diversity. Some of those resources include “The Ladder Program,” an initiative founded by an AAFP member which involves monthly meetings and events for students as young as 9 years old to introduce them to medicine at a young age.
“You can’t see what you don’t see,” noted Dr. Stewart, who is the first Black, female president of the AAFP, and the fourth woman in the role. “I really have seen how important it is to be a mentor and to be out there so that individuals who look like me can see that they too can become a family physician and be that member of their community.”
In addition to The Ladder Program, some other resources aimed at increasing diversity among family physicians include Tour for Diversity in Medicine and the Doctors Back to School Program.
The Tour for Diversity in Medicine involves a team of physicians, other clinicians and students hosting events nationwide for minority students to help them see a path to medicine and other health professions. Meanwhile, the AAFP’s Doctors Back to School Program involves family physicians visiting children at schools, clubs, community organizations, and other places to raise childhood awareness of family medicine and help them see their own potential in health care careers.
Dr. Stewart said these programs have been successful in increasing underrepresented groups.
“We are trying to see how best to measure their success,” the AAFP president said. “Looking at the high numbers of individuals who chose the specialty of family medicine last year is what I would deem a success.”
Dr. Wusu also believes outreach to children in elementary schools is important when it comes to increasing diversity in the family medicine specialty.
One organization that’s proving such outreach is the Student National Medical Association, a branch of the National Medical Association, which is a professional organization of Black physicians. This group’s initiative, the Health Professions Recruitment Exposure Programs, exposes teens to science-related activities while introducing them to careers in health professions. Another SMNA program, called Youth Science Enrichment Program, targets elementary and junior high school students.
Dr. Wusu led a 2019 project that focused on creating a more diverse family medicine residency program by developing and implementing a strategic plan for diversity recruitment, which involved increasing outreach to marginalized groups and revising interviews to minimize bias. In a paper published on the results of the initiative, Dr. Wusu and coauthors noted that, between 2014 and 2017, the total number of underrepresented minority applicants to the Boston Medical Center Family Medicine Residency Program increased by 80%. Before the intervention, the percentage of applicants who were part of an underrepresented group ranged from 0% to 20%. During the intervention, that range jumped to 25% to 50%, according to the paper.
While Dr. Wusu considers these programs to be beneficial for the specialty, she doesn’t believe they should be done in isolation. There should also be efforts to tackle lack of opportunities and structural racism.
“With any inequity, you have to address it on multiple levels,” Dr. Wusu explained. “It’s great that there has been recognition for a need for diversity in family medicine, but my hope is that the call for equity would reach beyond that.”
Fostering an inclusive environment
While family medicine has come a long way with regards to increasing the amount of underrepresented groups in its specialty, Stephen Richmond, MD, MPH, believes there also needs to be a focus on the infrastructure of support to help retain these physicians.
“The problem of diversity within family medicine and largely in other specialties cannot be summed up simply as a matter of poor representation. We must do be better to understand the lived experience of physicians of color, in particular Black physicians, once they arrive in the medical professional environment. Doing so will help institutions to provide that infrastructure of support – including antiracism policies and practices – that will enhance wellness and representation,” said Dr. Richmond, clinical assistant professor of medicine in the division of primary care and population health at Stanford (Calif.) University.
Dr. Wusu also suggested establishing an explicitly antiracist environment. This can be done in multiple ways, including by holding programs that acknowledge the impact of structural racism on both the patients, medical students and faculty, and by educating staff about the history of racism, she said.
Dr. Stewart and Dr. Wusu think the specialty has improved in its representation of minorities, but that it has a “long way to go.”
“I think family medicine is really one of the more inclusive specialties. I mean, it has higher numbers of Black and Brown residents and physicians than other specialties,” Dr. Wusu said. “We still have a very long way to go to be at numbers that match the general population. But I think, in that way, family medicine is a place where a lot of Black and Brown physicians can find a home.”