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Retirement Planning for Gastroenterologists
Retirement planning starts the day we start our careers. Whenever we start any project, it is always worthwhile to learn how the project works, what we want to pursue and achieve with the project, how to exit the project, and when is the right time to exit.
As physicians, gastroenterologists go through several years of vigorous training, years spent studying, researching, practicing, and juggling between work and life, trying to lead a well-balanced life. With all the years of medical training, we do not get the same level of education in financial planning in order to attain financial stability, financial empowerment, or resources that we need to put in place for a successful retirement.
Many physicians like to work and provide services as long as they can, provided the physical and mental capacity permits. Retirement planning should start as early as possible — at your first job, with the first paycheck. Having a strategic plan and understanding several personal factors can help one make this journey successful.
Financial Planning
Financial planning starts with investments in 401k, IRA, defined benefit, and defined contribution plans, as early as possible and to the maximum extent possible. It is beneficial to contribute at the first opportunity and contribute enough to the employer retirement plan to earn the full employer match. Also consider capital investment opportunities that match your risk appetite and returns, as these compound and grow over time. This can be done by adjusting personal expenses and lifestyle, giving priority to savings and future wealth management, and auto-escalation of permitted retirement contributions annually.
Assessing your financial situation periodically to determine retirement needs based on how long you intend to work and preferred lifestyle post retirement (travel, leisurely activities, etc.) is important. It is also pertinent to align revenue earned, expenses made, and wealth saved to support post-retirement life. Consider hiring a financial advisor who has the best interests in your personal wealth management. These are usually found with reputable institutions at a fixed percentage cost. Finding a trustworthy knowledgeable advisor is the key. Learning from your colleagues, networking, and learning from friends in and out of healthcare are good resources to find the right financial advisor.
Healthcare expenses should be planned as well as part of financial planning. Short-term and long-term disability and long-term care expenses should be investigated when planning for healthcare needs.
Transition Planning
Timing of retirement is based on factors such as age, financial status, personal health and preferences. The transition can be facilitated by better communication with colleagues, partners, employer, staff, and patients. Identifying a successor and planning for continuity of care of the patients, such as transitioning patients to another provider, is important as well. This may involve hiring a new associate, merging with another practice, or selling the practice.
Healthcare Coverage
One of the biggest expenses with retirement is healthcare coverage. Healthcare coverage options need to be analyzed which may include Medicare eligibility, enrollment, potential needs after retirement, including preventative care, treatment of chronic conditions, long term care services, and unexpected health outcomes and consequences.
Lifestyle and Travel Planning
Reflect on the retirement lifestyle, hobbies, and passions to be explored. Some activities like volunteer work, continuing educational opportunities, and advisory work, will help maintain physical and mental health. Consider downsizing living arrangements to align with retirement lifestyle goals which may include relocating to a different area as it fits your needs.
Legal and Estate Planning
Review and update legal documents including power of attorney, healthcare directives, will, trusts, and periodically ensure that these documents reflect your wishes.
Professional Development
Retirement may not mean quitting work completely. Some may look at this as an opportunity for professional development and pivoting to a different career that suits their lifestyle and needs. Gastroenterologists may contribute to the field and stay connected by being mentors, advisors, or, industry partners; being involved in national organizations; leading purposeful projects; or teaching part-time or on a volunteer basis.
Emotional and Social Support
Being a physician and a leader on treatment teams after so many years, some may feel lonely and unproductive with a lack of purpose in retirement; while others are excited about the free time they gained to pursue other activities and projects.
The process can be emotionally challenging even for well-prepared individuals. Finding friends, family, and professionals who can support you through this process will be helpful as you go through the uncertainties, anxiety, and fear during this phase of life. Think of developing hobbies and interests and nurturing networks outside of work environment that will keep you engaged and content during this transition.
Gastroenterologists can plan for a financially secure, emotionally fulfilling, and professionally satisfying transition tailored to their needs and preferences. Seeking help from financial advisors, legal experts, mentors, and other professionals who can provide valuable advice, support, and guidance is crucial during this process.
Do what you love and love what you do.
Dr. Appalaneni is a gastroenterologist at Dayton Gastroenterology in Beavercreek, Ohio, and a clinical assistant professor at Boonshoft School of Medicine, Wright State University in Dayton, Ohio. This article is not a financial planning document, nor legal advice; these are the author’s learnings, experiences, and opinions and are not considered financial advice.
Retirement planning starts the day we start our careers. Whenever we start any project, it is always worthwhile to learn how the project works, what we want to pursue and achieve with the project, how to exit the project, and when is the right time to exit.
As physicians, gastroenterologists go through several years of vigorous training, years spent studying, researching, practicing, and juggling between work and life, trying to lead a well-balanced life. With all the years of medical training, we do not get the same level of education in financial planning in order to attain financial stability, financial empowerment, or resources that we need to put in place for a successful retirement.
Many physicians like to work and provide services as long as they can, provided the physical and mental capacity permits. Retirement planning should start as early as possible — at your first job, with the first paycheck. Having a strategic plan and understanding several personal factors can help one make this journey successful.
Financial Planning
Financial planning starts with investments in 401k, IRA, defined benefit, and defined contribution plans, as early as possible and to the maximum extent possible. It is beneficial to contribute at the first opportunity and contribute enough to the employer retirement plan to earn the full employer match. Also consider capital investment opportunities that match your risk appetite and returns, as these compound and grow over time. This can be done by adjusting personal expenses and lifestyle, giving priority to savings and future wealth management, and auto-escalation of permitted retirement contributions annually.
Assessing your financial situation periodically to determine retirement needs based on how long you intend to work and preferred lifestyle post retirement (travel, leisurely activities, etc.) is important. It is also pertinent to align revenue earned, expenses made, and wealth saved to support post-retirement life. Consider hiring a financial advisor who has the best interests in your personal wealth management. These are usually found with reputable institutions at a fixed percentage cost. Finding a trustworthy knowledgeable advisor is the key. Learning from your colleagues, networking, and learning from friends in and out of healthcare are good resources to find the right financial advisor.
Healthcare expenses should be planned as well as part of financial planning. Short-term and long-term disability and long-term care expenses should be investigated when planning for healthcare needs.
Transition Planning
Timing of retirement is based on factors such as age, financial status, personal health and preferences. The transition can be facilitated by better communication with colleagues, partners, employer, staff, and patients. Identifying a successor and planning for continuity of care of the patients, such as transitioning patients to another provider, is important as well. This may involve hiring a new associate, merging with another practice, or selling the practice.
Healthcare Coverage
One of the biggest expenses with retirement is healthcare coverage. Healthcare coverage options need to be analyzed which may include Medicare eligibility, enrollment, potential needs after retirement, including preventative care, treatment of chronic conditions, long term care services, and unexpected health outcomes and consequences.
Lifestyle and Travel Planning
Reflect on the retirement lifestyle, hobbies, and passions to be explored. Some activities like volunteer work, continuing educational opportunities, and advisory work, will help maintain physical and mental health. Consider downsizing living arrangements to align with retirement lifestyle goals which may include relocating to a different area as it fits your needs.
Legal and Estate Planning
Review and update legal documents including power of attorney, healthcare directives, will, trusts, and periodically ensure that these documents reflect your wishes.
Professional Development
Retirement may not mean quitting work completely. Some may look at this as an opportunity for professional development and pivoting to a different career that suits their lifestyle and needs. Gastroenterologists may contribute to the field and stay connected by being mentors, advisors, or, industry partners; being involved in national organizations; leading purposeful projects; or teaching part-time or on a volunteer basis.
Emotional and Social Support
Being a physician and a leader on treatment teams after so many years, some may feel lonely and unproductive with a lack of purpose in retirement; while others are excited about the free time they gained to pursue other activities and projects.
The process can be emotionally challenging even for well-prepared individuals. Finding friends, family, and professionals who can support you through this process will be helpful as you go through the uncertainties, anxiety, and fear during this phase of life. Think of developing hobbies and interests and nurturing networks outside of work environment that will keep you engaged and content during this transition.
Gastroenterologists can plan for a financially secure, emotionally fulfilling, and professionally satisfying transition tailored to their needs and preferences. Seeking help from financial advisors, legal experts, mentors, and other professionals who can provide valuable advice, support, and guidance is crucial during this process.
Do what you love and love what you do.
Dr. Appalaneni is a gastroenterologist at Dayton Gastroenterology in Beavercreek, Ohio, and a clinical assistant professor at Boonshoft School of Medicine, Wright State University in Dayton, Ohio. This article is not a financial planning document, nor legal advice; these are the author’s learnings, experiences, and opinions and are not considered financial advice.
Retirement planning starts the day we start our careers. Whenever we start any project, it is always worthwhile to learn how the project works, what we want to pursue and achieve with the project, how to exit the project, and when is the right time to exit.
As physicians, gastroenterologists go through several years of vigorous training, years spent studying, researching, practicing, and juggling between work and life, trying to lead a well-balanced life. With all the years of medical training, we do not get the same level of education in financial planning in order to attain financial stability, financial empowerment, or resources that we need to put in place for a successful retirement.
Many physicians like to work and provide services as long as they can, provided the physical and mental capacity permits. Retirement planning should start as early as possible — at your first job, with the first paycheck. Having a strategic plan and understanding several personal factors can help one make this journey successful.
Financial Planning
Financial planning starts with investments in 401k, IRA, defined benefit, and defined contribution plans, as early as possible and to the maximum extent possible. It is beneficial to contribute at the first opportunity and contribute enough to the employer retirement plan to earn the full employer match. Also consider capital investment opportunities that match your risk appetite and returns, as these compound and grow over time. This can be done by adjusting personal expenses and lifestyle, giving priority to savings and future wealth management, and auto-escalation of permitted retirement contributions annually.
Assessing your financial situation periodically to determine retirement needs based on how long you intend to work and preferred lifestyle post retirement (travel, leisurely activities, etc.) is important. It is also pertinent to align revenue earned, expenses made, and wealth saved to support post-retirement life. Consider hiring a financial advisor who has the best interests in your personal wealth management. These are usually found with reputable institutions at a fixed percentage cost. Finding a trustworthy knowledgeable advisor is the key. Learning from your colleagues, networking, and learning from friends in and out of healthcare are good resources to find the right financial advisor.
Healthcare expenses should be planned as well as part of financial planning. Short-term and long-term disability and long-term care expenses should be investigated when planning for healthcare needs.
Transition Planning
Timing of retirement is based on factors such as age, financial status, personal health and preferences. The transition can be facilitated by better communication with colleagues, partners, employer, staff, and patients. Identifying a successor and planning for continuity of care of the patients, such as transitioning patients to another provider, is important as well. This may involve hiring a new associate, merging with another practice, or selling the practice.
Healthcare Coverage
One of the biggest expenses with retirement is healthcare coverage. Healthcare coverage options need to be analyzed which may include Medicare eligibility, enrollment, potential needs after retirement, including preventative care, treatment of chronic conditions, long term care services, and unexpected health outcomes and consequences.
Lifestyle and Travel Planning
Reflect on the retirement lifestyle, hobbies, and passions to be explored. Some activities like volunteer work, continuing educational opportunities, and advisory work, will help maintain physical and mental health. Consider downsizing living arrangements to align with retirement lifestyle goals which may include relocating to a different area as it fits your needs.
Legal and Estate Planning
Review and update legal documents including power of attorney, healthcare directives, will, trusts, and periodically ensure that these documents reflect your wishes.
Professional Development
Retirement may not mean quitting work completely. Some may look at this as an opportunity for professional development and pivoting to a different career that suits their lifestyle and needs. Gastroenterologists may contribute to the field and stay connected by being mentors, advisors, or, industry partners; being involved in national organizations; leading purposeful projects; or teaching part-time or on a volunteer basis.
Emotional and Social Support
Being a physician and a leader on treatment teams after so many years, some may feel lonely and unproductive with a lack of purpose in retirement; while others are excited about the free time they gained to pursue other activities and projects.
The process can be emotionally challenging even for well-prepared individuals. Finding friends, family, and professionals who can support you through this process will be helpful as you go through the uncertainties, anxiety, and fear during this phase of life. Think of developing hobbies and interests and nurturing networks outside of work environment that will keep you engaged and content during this transition.
Gastroenterologists can plan for a financially secure, emotionally fulfilling, and professionally satisfying transition tailored to their needs and preferences. Seeking help from financial advisors, legal experts, mentors, and other professionals who can provide valuable advice, support, and guidance is crucial during this process.
Do what you love and love what you do.
Dr. Appalaneni is a gastroenterologist at Dayton Gastroenterology in Beavercreek, Ohio, and a clinical assistant professor at Boonshoft School of Medicine, Wright State University in Dayton, Ohio. This article is not a financial planning document, nor legal advice; these are the author’s learnings, experiences, and opinions and are not considered financial advice.
Navigating as a GI Locum: My Path and Guide to This Alternative Practice Model
My successful career in academic gastroenterology makes me a natural proponent of the academic model of practice. However, in my current role as a locum tenens, I have witnessed the versatility that locum assignments offer gastroenterologists, particularly when flexibility in their professional lives is paramount.
The locum tenens industry is a growing feature of the healthcare staffing landscape. My perspective is unique, transitioning from professor of medicine and chief of gastroenterology at an academic medical center to a self-employed locum gastroenterologist.
As chief, I hired locums to offer additional coverage to the faculty staffing as our division, inclusive of GI fellowship and endoscopy volume, expanded. I recruited, supervised, and assigned responsibilities to the locums. Not only were these physicians professional and competent, but they also contributed to my division’s forward evolution. Based on this experience, I was confident that I could successfully perform as a locum gastroenterologist myself.
My work as a locum these past 5 years has been a positive professional transition for me. I have enjoyed meeting and working with new colleagues, including international locums who travel to work in the United States. I have also witnessed how early-career and mid-career gastroenterologists have taken advantage of this flexible and well-remunerated work.
What It Entails to Be a Locum Tenens
I suspect you have been on the receiving end of emails and postcards from locum tenens companies recruiting for potential assignments and have wondered about the specifics. Essentially, a locum physician functions as an independent contractor who accepts a temporary position at a healthcare organization to provide clinical staffing support during periods of staffing disruption.
Assignments vary in geographic location, facility work site (outpatient vs inpatient), hours, required skills, cadence of assignment, and expected length of staffing need. The locum physician has complete control over selecting the assignment location, the intensity of responsibilities, and the time they wish to commit to the position. Temporal flexibility offers locums the opportunity to commit from a few weeks per year to a full-time commitment. Locums can also combine multiple assignments in different regions or states to match the targeted number of weeks they wish to commit to and the financial goal they have set.
I have met physicians working a few weeks a year during time off from their permanent jobs to supplement their incomes, as well as fully employed physicians leveraging locum placements to explore locations or practices that they have an interest in. Gastroenterologists facing planned or unplanned life events may find the role enticing as locum opportunities offer an elevated level of flexibility and autonomy.
The Role of the Locum Tenens Company
Locum tenens companies have arrangements with healthcare facilities to provide temporary staffing. They aim to recruit prospective physicians, establish a collaborative relationship, and align these physicians with a locum assignment that benefits all parties.
Once the physician has completed the company’s credentialing packet, the company facilitates credentialing for new state medical licensures and the specific healthcare facility. The company conducts all negotiations, communications, and financial arrangements between the locum physician and the facility. Locum physicians do not communicate directly with the facility, at least not initially. The company also provides medical malpractice coverage through an established insurance broker. The company arranges travel (flights, car rentals, and hotels) for the assignment, and the healthcare facility reimburses the company.
Lastly, the company arranges a phone interview between the locum physician and the facility’s gastroenterologist or medical director for a more detailed description of expected responsibilities and level of staffing for endoscopy before the locum physician decides whether the job is a “good fit” for their skills and objectives. It is critical at this point that the locum physician does their due diligence, asking thoughtful questions to ensure a comprehensive understanding of the role before committing.
What Does It Mean to Be an Independent Contractor
An independent contractor is contracted to perform work but is not an employee of an organization (ie, self-employed). This is an important distinction when it comes to the IRS, tax obligations, and allowable deductions.
Initially, this may seem confusing, but some websites review the specifics of these significant taxation differences. Because you are an independent contractor, your paycheck depicts your compensation without any deductions taken. At year’s end, you receive form 1099 rather than the more familiar W-2. The most critical difference is that as a W-2 employed person, you and the employer each contribute half of the obligated Social Security and Medicare taxes owed, but as an independent contractor you are required to pay the entire obligated Social Security and Medicare taxes.
Also important to consider is that although the locum tenens company facilitates necessary documentation, travel, and work schedules, you will be responsible for tracking your work-related finances, and maintaining your CME. This is not difficult but requires attention throughout the year and is manageable with a bit of organizing. A simple example is that meals are deductible on your taxes and can be easily tallied by the government’s per diem rate found at www.gsa.gov — so it is not necessary to save receipts. While it is important to become familiar with these financial nuances as they will affect your net income, they are not as intimidating or complex as you may initially believe.
Primary Benefits of Locum Tenens Assignments
In my experience, the benefits of working as a locum gastroenterologist include the opportunity to remain engaged in a gratifying career while having enhanced autonomy and flexibility. You can construct a schedule in a location most pleasing to you that fits your financial needs. You may work just a few weeks per year to full-time. You can uniquely plan for your desired personal time and alternative professional ambitions. If you choose to transition back to traditional full-time employment, the pivot remains feasible because you have demonstrated attractive professional attributes such as adaptability in different settings, maintenance of necessary skill sets, and collaboration with medical staffing of various complexities.
Quick Points to Consider
- Review the tax obligations and deductions before signing on to your first assignment.
- Healthcare benefits are not provided. If you must purchase healthcare, your healthcare premiums are 100% deductible.
- Malpractice insurance is provided through the locum tenens company.
- The points on flights, hotels, and car rentals remain in your accounts and can be used by you for personal travel in the future.
- You may be able to negotiate hourly rates and terms of responsibilities in certain instances. There’s no harm in requesting.
- Before accepting an assignment, review the website and location of the facility, accessibility to airports, frequency of flights, the physician directory, and services available.
- If your plans change and you are unable to complete a scheduled assignment previously confirmed, you must notify the locum tenens company within a specified window from the start date (usually 30 days) to avoid penalty.
Institutions utilizing locum physicians generally are doing so because their staffing is not optimal; for example, there may have been a transition in leadership or the facility may be located in a rural area. Self-awareness is key; recognize that you are essentially a guest who may need to adapt to the prevailing culture and make do with the resources at hand. You are not there to step in, innovate, or institute changes. Most often the office staff, nurses, and other physicians are very grateful that you are present and a part of the team.
Dr. Bartholomew is a gastroenterologist based in Sarasota, Florida. She has no conflicts to declare in relation to this article.
My successful career in academic gastroenterology makes me a natural proponent of the academic model of practice. However, in my current role as a locum tenens, I have witnessed the versatility that locum assignments offer gastroenterologists, particularly when flexibility in their professional lives is paramount.
The locum tenens industry is a growing feature of the healthcare staffing landscape. My perspective is unique, transitioning from professor of medicine and chief of gastroenterology at an academic medical center to a self-employed locum gastroenterologist.
As chief, I hired locums to offer additional coverage to the faculty staffing as our division, inclusive of GI fellowship and endoscopy volume, expanded. I recruited, supervised, and assigned responsibilities to the locums. Not only were these physicians professional and competent, but they also contributed to my division’s forward evolution. Based on this experience, I was confident that I could successfully perform as a locum gastroenterologist myself.
My work as a locum these past 5 years has been a positive professional transition for me. I have enjoyed meeting and working with new colleagues, including international locums who travel to work in the United States. I have also witnessed how early-career and mid-career gastroenterologists have taken advantage of this flexible and well-remunerated work.
What It Entails to Be a Locum Tenens
I suspect you have been on the receiving end of emails and postcards from locum tenens companies recruiting for potential assignments and have wondered about the specifics. Essentially, a locum physician functions as an independent contractor who accepts a temporary position at a healthcare organization to provide clinical staffing support during periods of staffing disruption.
Assignments vary in geographic location, facility work site (outpatient vs inpatient), hours, required skills, cadence of assignment, and expected length of staffing need. The locum physician has complete control over selecting the assignment location, the intensity of responsibilities, and the time they wish to commit to the position. Temporal flexibility offers locums the opportunity to commit from a few weeks per year to a full-time commitment. Locums can also combine multiple assignments in different regions or states to match the targeted number of weeks they wish to commit to and the financial goal they have set.
I have met physicians working a few weeks a year during time off from their permanent jobs to supplement their incomes, as well as fully employed physicians leveraging locum placements to explore locations or practices that they have an interest in. Gastroenterologists facing planned or unplanned life events may find the role enticing as locum opportunities offer an elevated level of flexibility and autonomy.
The Role of the Locum Tenens Company
Locum tenens companies have arrangements with healthcare facilities to provide temporary staffing. They aim to recruit prospective physicians, establish a collaborative relationship, and align these physicians with a locum assignment that benefits all parties.
Once the physician has completed the company’s credentialing packet, the company facilitates credentialing for new state medical licensures and the specific healthcare facility. The company conducts all negotiations, communications, and financial arrangements between the locum physician and the facility. Locum physicians do not communicate directly with the facility, at least not initially. The company also provides medical malpractice coverage through an established insurance broker. The company arranges travel (flights, car rentals, and hotels) for the assignment, and the healthcare facility reimburses the company.
Lastly, the company arranges a phone interview between the locum physician and the facility’s gastroenterologist or medical director for a more detailed description of expected responsibilities and level of staffing for endoscopy before the locum physician decides whether the job is a “good fit” for their skills and objectives. It is critical at this point that the locum physician does their due diligence, asking thoughtful questions to ensure a comprehensive understanding of the role before committing.
What Does It Mean to Be an Independent Contractor
An independent contractor is contracted to perform work but is not an employee of an organization (ie, self-employed). This is an important distinction when it comes to the IRS, tax obligations, and allowable deductions.
Initially, this may seem confusing, but some websites review the specifics of these significant taxation differences. Because you are an independent contractor, your paycheck depicts your compensation without any deductions taken. At year’s end, you receive form 1099 rather than the more familiar W-2. The most critical difference is that as a W-2 employed person, you and the employer each contribute half of the obligated Social Security and Medicare taxes owed, but as an independent contractor you are required to pay the entire obligated Social Security and Medicare taxes.
Also important to consider is that although the locum tenens company facilitates necessary documentation, travel, and work schedules, you will be responsible for tracking your work-related finances, and maintaining your CME. This is not difficult but requires attention throughout the year and is manageable with a bit of organizing. A simple example is that meals are deductible on your taxes and can be easily tallied by the government’s per diem rate found at www.gsa.gov — so it is not necessary to save receipts. While it is important to become familiar with these financial nuances as they will affect your net income, they are not as intimidating or complex as you may initially believe.
Primary Benefits of Locum Tenens Assignments
In my experience, the benefits of working as a locum gastroenterologist include the opportunity to remain engaged in a gratifying career while having enhanced autonomy and flexibility. You can construct a schedule in a location most pleasing to you that fits your financial needs. You may work just a few weeks per year to full-time. You can uniquely plan for your desired personal time and alternative professional ambitions. If you choose to transition back to traditional full-time employment, the pivot remains feasible because you have demonstrated attractive professional attributes such as adaptability in different settings, maintenance of necessary skill sets, and collaboration with medical staffing of various complexities.
Quick Points to Consider
- Review the tax obligations and deductions before signing on to your first assignment.
- Healthcare benefits are not provided. If you must purchase healthcare, your healthcare premiums are 100% deductible.
- Malpractice insurance is provided through the locum tenens company.
- The points on flights, hotels, and car rentals remain in your accounts and can be used by you for personal travel in the future.
- You may be able to negotiate hourly rates and terms of responsibilities in certain instances. There’s no harm in requesting.
- Before accepting an assignment, review the website and location of the facility, accessibility to airports, frequency of flights, the physician directory, and services available.
- If your plans change and you are unable to complete a scheduled assignment previously confirmed, you must notify the locum tenens company within a specified window from the start date (usually 30 days) to avoid penalty.
Institutions utilizing locum physicians generally are doing so because their staffing is not optimal; for example, there may have been a transition in leadership or the facility may be located in a rural area. Self-awareness is key; recognize that you are essentially a guest who may need to adapt to the prevailing culture and make do with the resources at hand. You are not there to step in, innovate, or institute changes. Most often the office staff, nurses, and other physicians are very grateful that you are present and a part of the team.
Dr. Bartholomew is a gastroenterologist based in Sarasota, Florida. She has no conflicts to declare in relation to this article.
My successful career in academic gastroenterology makes me a natural proponent of the academic model of practice. However, in my current role as a locum tenens, I have witnessed the versatility that locum assignments offer gastroenterologists, particularly when flexibility in their professional lives is paramount.
The locum tenens industry is a growing feature of the healthcare staffing landscape. My perspective is unique, transitioning from professor of medicine and chief of gastroenterology at an academic medical center to a self-employed locum gastroenterologist.
As chief, I hired locums to offer additional coverage to the faculty staffing as our division, inclusive of GI fellowship and endoscopy volume, expanded. I recruited, supervised, and assigned responsibilities to the locums. Not only were these physicians professional and competent, but they also contributed to my division’s forward evolution. Based on this experience, I was confident that I could successfully perform as a locum gastroenterologist myself.
My work as a locum these past 5 years has been a positive professional transition for me. I have enjoyed meeting and working with new colleagues, including international locums who travel to work in the United States. I have also witnessed how early-career and mid-career gastroenterologists have taken advantage of this flexible and well-remunerated work.
What It Entails to Be a Locum Tenens
I suspect you have been on the receiving end of emails and postcards from locum tenens companies recruiting for potential assignments and have wondered about the specifics. Essentially, a locum physician functions as an independent contractor who accepts a temporary position at a healthcare organization to provide clinical staffing support during periods of staffing disruption.
Assignments vary in geographic location, facility work site (outpatient vs inpatient), hours, required skills, cadence of assignment, and expected length of staffing need. The locum physician has complete control over selecting the assignment location, the intensity of responsibilities, and the time they wish to commit to the position. Temporal flexibility offers locums the opportunity to commit from a few weeks per year to a full-time commitment. Locums can also combine multiple assignments in different regions or states to match the targeted number of weeks they wish to commit to and the financial goal they have set.
I have met physicians working a few weeks a year during time off from their permanent jobs to supplement their incomes, as well as fully employed physicians leveraging locum placements to explore locations or practices that they have an interest in. Gastroenterologists facing planned or unplanned life events may find the role enticing as locum opportunities offer an elevated level of flexibility and autonomy.
The Role of the Locum Tenens Company
Locum tenens companies have arrangements with healthcare facilities to provide temporary staffing. They aim to recruit prospective physicians, establish a collaborative relationship, and align these physicians with a locum assignment that benefits all parties.
Once the physician has completed the company’s credentialing packet, the company facilitates credentialing for new state medical licensures and the specific healthcare facility. The company conducts all negotiations, communications, and financial arrangements between the locum physician and the facility. Locum physicians do not communicate directly with the facility, at least not initially. The company also provides medical malpractice coverage through an established insurance broker. The company arranges travel (flights, car rentals, and hotels) for the assignment, and the healthcare facility reimburses the company.
Lastly, the company arranges a phone interview between the locum physician and the facility’s gastroenterologist or medical director for a more detailed description of expected responsibilities and level of staffing for endoscopy before the locum physician decides whether the job is a “good fit” for their skills and objectives. It is critical at this point that the locum physician does their due diligence, asking thoughtful questions to ensure a comprehensive understanding of the role before committing.
What Does It Mean to Be an Independent Contractor
An independent contractor is contracted to perform work but is not an employee of an organization (ie, self-employed). This is an important distinction when it comes to the IRS, tax obligations, and allowable deductions.
Initially, this may seem confusing, but some websites review the specifics of these significant taxation differences. Because you are an independent contractor, your paycheck depicts your compensation without any deductions taken. At year’s end, you receive form 1099 rather than the more familiar W-2. The most critical difference is that as a W-2 employed person, you and the employer each contribute half of the obligated Social Security and Medicare taxes owed, but as an independent contractor you are required to pay the entire obligated Social Security and Medicare taxes.
Also important to consider is that although the locum tenens company facilitates necessary documentation, travel, and work schedules, you will be responsible for tracking your work-related finances, and maintaining your CME. This is not difficult but requires attention throughout the year and is manageable with a bit of organizing. A simple example is that meals are deductible on your taxes and can be easily tallied by the government’s per diem rate found at www.gsa.gov — so it is not necessary to save receipts. While it is important to become familiar with these financial nuances as they will affect your net income, they are not as intimidating or complex as you may initially believe.
Primary Benefits of Locum Tenens Assignments
In my experience, the benefits of working as a locum gastroenterologist include the opportunity to remain engaged in a gratifying career while having enhanced autonomy and flexibility. You can construct a schedule in a location most pleasing to you that fits your financial needs. You may work just a few weeks per year to full-time. You can uniquely plan for your desired personal time and alternative professional ambitions. If you choose to transition back to traditional full-time employment, the pivot remains feasible because you have demonstrated attractive professional attributes such as adaptability in different settings, maintenance of necessary skill sets, and collaboration with medical staffing of various complexities.
Quick Points to Consider
- Review the tax obligations and deductions before signing on to your first assignment.
- Healthcare benefits are not provided. If you must purchase healthcare, your healthcare premiums are 100% deductible.
- Malpractice insurance is provided through the locum tenens company.
- The points on flights, hotels, and car rentals remain in your accounts and can be used by you for personal travel in the future.
- You may be able to negotiate hourly rates and terms of responsibilities in certain instances. There’s no harm in requesting.
- Before accepting an assignment, review the website and location of the facility, accessibility to airports, frequency of flights, the physician directory, and services available.
- If your plans change and you are unable to complete a scheduled assignment previously confirmed, you must notify the locum tenens company within a specified window from the start date (usually 30 days) to avoid penalty.
Institutions utilizing locum physicians generally are doing so because their staffing is not optimal; for example, there may have been a transition in leadership or the facility may be located in a rural area. Self-awareness is key; recognize that you are essentially a guest who may need to adapt to the prevailing culture and make do with the resources at hand. You are not there to step in, innovate, or institute changes. Most often the office staff, nurses, and other physicians are very grateful that you are present and a part of the team.
Dr. Bartholomew is a gastroenterologist based in Sarasota, Florida. She has no conflicts to declare in relation to this article.
Gluconolactone
This derivative of oxidized glucose lactone is present naturally in bread, cheese, fruit juices, honey, tofu, and wine, and is used as a food additive in Europe.1,2 In dermatology, it is most often used in chemical peels.
Polyhydroxy acids (PHAs) were discovered about 3 decades ago to exert similar functions as alpha hydroxy acids without provoking sensory irritation reactions. Gluconolactone along with lactobionic acid were the identified PHAs and further characterized as delivering more humectant and moisturizing activity than alpha hydroxy acids and effective in combination with retinoic acid to treat adult acne and with retinyl acetate to confer antiaging benefits.3 It is typically added to products for its skin-conditioning qualities, resulting in smoother, brighter, more toned skin.4 This column focuses on recent studies using this bioactive agent for dermatologic purposes.
Split-Face Studies Show Various Benefits
In 2023, Jarząbek-Perz and colleagues conducted a split-face evaluation to assess the effects on various skin parameters (ie, hydration, pH, sebum, and transepidermal water loss [TEWL]) of gluconolactone and oxybrasion, compared with gluconolactone and microneedling. Twenty-one White women underwent a series of three split-face treatments at 1-week intervals. Chemical peels with 10% gluconolactone were performed on the whole face. The right side of the face was also treated with oxybrasion and the left with microneedle mesotherapy. Skin parameters were measured before the first and third treatments and 2 weeks following the final treatment. Photos were taken before and after the study. Both treatments resulted in improved hydration and reductions in sebum, pH, and TEWL. No statistically significant differences were noted between the treatment protocols. The researchers concluded that gluconolactone peels can be effectively combined with oxybrasion or microneedle mesotherapy to enhance skin hydration and to secure the hydrolipid barrier.5
Later that year, the same team evaluated pH, sebum levels, and TEWL before, during, and after several applications of 10% and 30% gluconolactone chemical peels in a split-face model in 16 female participants. The investigators conducted three procedures on both sides of the face, taking measurements on the forehead, periorbital area, on the cheek, and on the nose wing before, during, and 7 days after the final treatment. They found statistically significant improvements in sebum levels in the cheeks after the treatment series. Also, pH values were lower at each measurement site after each procedure. TEWL levels were significantly diminished around the eyes, as well as the left forehead and right cheek, with no significant discrepancy between gluconolactone concentrations. The researchers concluded that gluconolactone plays a major role in reducing cutaneous pH and TEWL and imparts a regulatory effect on sebum.1
Two years earlier, Jarząbek-Perz and colleagues assessed skin moisture in a split-face model in 16 healthy women after the application of 10% and 30% gluconolactone. Investigators measured skin moisture before and after each of three treatments and a week after the final treatment from the forehead, periorbital area, and on the cheek. They observed no significant discrepancies between the 10% and 30% formulations, but a significant elevation in facial skin hydration was found to be promoted by gluconolactone. The investigators concluded that gluconolactone is an effective moisturizer for care of dry skin.6
Topical Formulation
In 2023, Zerbinati and colleagues determined that a gluconolactone-based lotion that they had begun testing 2 years earlier was safe and effective for dermatologic applications, with the noncomedogenic formulation found suitable as an antiaging agent, particularly as it treats aging-related pore dilatation.7,8
Acne Treatment
In 2019, Kantikosum and colleagues conducted a double-blind, within-person comparative study to assess the efficacy of various cosmeceutical ingredients, including gluconolactone, glycolic acid, licochalcone A, and salicylic acid, combined with the acne treatment adapalene vs adapalene monotherapy for mild to moderate acne. Each of 25 subjects over 28 days applied a product mixed with 0.1% adapalene on one side of the face, and 0.1% adapalene alone on the other side of the face once nightly. The VISIA camera system spot score pointed to a statistically significant improvement on the combination sides. Differences in lesion reduction and severity were within acceptable margins, the authors reported. They concluded that the cosmeceutical combinations yielded similar benefits as adapalene alone, with the combination formulations decreasing acne complications.9
Potential Use as an Antifibrotic Agent
In 2018, Jayamani and colleagues investigated the antifibrotic characteristics of glucono-delta-lactone, a known acidifier, to ascertain if it could directly suppress collagen fibrils or even cause them to disintegrate. The researchers noted that collagen fibrillation is pH dependent, and that glucono-delta-lactone was found to exert a concentration-dependent suppression of fibrils and disintegration of preformed collagen fibrils with the antifibrotic function of the compound ascribed to its capacity to decrease pH. Further, glucono-delta-lactone appeared to emerge as an ideal antifibrotic agent as it left intact the triple helical structure of collagen after treatment. The investigators concluded that glucono-delta-lactone provides the foundation for developing antifibrotic agents intended to treat disorders characterized by collagen deposition.10
Conclusion
Gluconolactone emerged in the 1990s as a PHA useful in skin peels as an alternative to alpha hydroxy acids because of its nonirritating qualities. Since then, its soothing, hydrating, and, in particular, antiacne and antiaging qualities have become established. Wider applications of this versatile agent for dermatologic purposes are likely to be further investigated.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur in Miami. She founded the division of cosmetic dermatology at the University of Miami in 1997. The third edition of her bestselling textbook, “Cosmetic Dermatology,” was published in 2022. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Johnson & Johnson, and Burt’s Bees. She is the CEO of Skin Type Solutions, a SaaS company used to generate skin care routines in office and as a ecommerce solution. Write to her at dermnews@mdedge.com.
References
1. Jarząbek-Perz S et al. J Cosmet Dermatol. 2023 Dec;22(12):3305-3312..
2. Qin X et al. Front Physiol. 2022 Mar 14;13:856699.
3. Grimes PE et al. Cutis. 2004 Feb;73(2 Suppl):3-13.
4. Glaser DA. Facial Plast Surg Clin North Am. 2003 May;11(2):219-227.
5. Jarząbek-Perz S et al. Skin Res Technol. 2023 Jun;29(6):e13353.
6. Jarząbek-Perz S et al. Skin Res Technol. 2021 Sep;27(5):925-930.
7. Zerbinati N et al. Molecules. 2021 Dec 15;26(24):7592.
8. Zerbinati Net al. Pharmaceuticals (Basel). 2023 Apr 27;16(5):655.
9. Kantikosum K et al. Clin Cosmet Investig Dermatol. 2019 Feb 19;12:151-161.
10. Jayamani J et al. Int J Biol Macromol. 2018 Feb;107(Pt A):175-185.
This derivative of oxidized glucose lactone is present naturally in bread, cheese, fruit juices, honey, tofu, and wine, and is used as a food additive in Europe.1,2 In dermatology, it is most often used in chemical peels.
Polyhydroxy acids (PHAs) were discovered about 3 decades ago to exert similar functions as alpha hydroxy acids without provoking sensory irritation reactions. Gluconolactone along with lactobionic acid were the identified PHAs and further characterized as delivering more humectant and moisturizing activity than alpha hydroxy acids and effective in combination with retinoic acid to treat adult acne and with retinyl acetate to confer antiaging benefits.3 It is typically added to products for its skin-conditioning qualities, resulting in smoother, brighter, more toned skin.4 This column focuses on recent studies using this bioactive agent for dermatologic purposes.
Split-Face Studies Show Various Benefits
In 2023, Jarząbek-Perz and colleagues conducted a split-face evaluation to assess the effects on various skin parameters (ie, hydration, pH, sebum, and transepidermal water loss [TEWL]) of gluconolactone and oxybrasion, compared with gluconolactone and microneedling. Twenty-one White women underwent a series of three split-face treatments at 1-week intervals. Chemical peels with 10% gluconolactone were performed on the whole face. The right side of the face was also treated with oxybrasion and the left with microneedle mesotherapy. Skin parameters were measured before the first and third treatments and 2 weeks following the final treatment. Photos were taken before and after the study. Both treatments resulted in improved hydration and reductions in sebum, pH, and TEWL. No statistically significant differences were noted between the treatment protocols. The researchers concluded that gluconolactone peels can be effectively combined with oxybrasion or microneedle mesotherapy to enhance skin hydration and to secure the hydrolipid barrier.5
Later that year, the same team evaluated pH, sebum levels, and TEWL before, during, and after several applications of 10% and 30% gluconolactone chemical peels in a split-face model in 16 female participants. The investigators conducted three procedures on both sides of the face, taking measurements on the forehead, periorbital area, on the cheek, and on the nose wing before, during, and 7 days after the final treatment. They found statistically significant improvements in sebum levels in the cheeks after the treatment series. Also, pH values were lower at each measurement site after each procedure. TEWL levels were significantly diminished around the eyes, as well as the left forehead and right cheek, with no significant discrepancy between gluconolactone concentrations. The researchers concluded that gluconolactone plays a major role in reducing cutaneous pH and TEWL and imparts a regulatory effect on sebum.1
Two years earlier, Jarząbek-Perz and colleagues assessed skin moisture in a split-face model in 16 healthy women after the application of 10% and 30% gluconolactone. Investigators measured skin moisture before and after each of three treatments and a week after the final treatment from the forehead, periorbital area, and on the cheek. They observed no significant discrepancies between the 10% and 30% formulations, but a significant elevation in facial skin hydration was found to be promoted by gluconolactone. The investigators concluded that gluconolactone is an effective moisturizer for care of dry skin.6
Topical Formulation
In 2023, Zerbinati and colleagues determined that a gluconolactone-based lotion that they had begun testing 2 years earlier was safe and effective for dermatologic applications, with the noncomedogenic formulation found suitable as an antiaging agent, particularly as it treats aging-related pore dilatation.7,8
Acne Treatment
In 2019, Kantikosum and colleagues conducted a double-blind, within-person comparative study to assess the efficacy of various cosmeceutical ingredients, including gluconolactone, glycolic acid, licochalcone A, and salicylic acid, combined with the acne treatment adapalene vs adapalene monotherapy for mild to moderate acne. Each of 25 subjects over 28 days applied a product mixed with 0.1% adapalene on one side of the face, and 0.1% adapalene alone on the other side of the face once nightly. The VISIA camera system spot score pointed to a statistically significant improvement on the combination sides. Differences in lesion reduction and severity were within acceptable margins, the authors reported. They concluded that the cosmeceutical combinations yielded similar benefits as adapalene alone, with the combination formulations decreasing acne complications.9
Potential Use as an Antifibrotic Agent
In 2018, Jayamani and colleagues investigated the antifibrotic characteristics of glucono-delta-lactone, a known acidifier, to ascertain if it could directly suppress collagen fibrils or even cause them to disintegrate. The researchers noted that collagen fibrillation is pH dependent, and that glucono-delta-lactone was found to exert a concentration-dependent suppression of fibrils and disintegration of preformed collagen fibrils with the antifibrotic function of the compound ascribed to its capacity to decrease pH. Further, glucono-delta-lactone appeared to emerge as an ideal antifibrotic agent as it left intact the triple helical structure of collagen after treatment. The investigators concluded that glucono-delta-lactone provides the foundation for developing antifibrotic agents intended to treat disorders characterized by collagen deposition.10
Conclusion
Gluconolactone emerged in the 1990s as a PHA useful in skin peels as an alternative to alpha hydroxy acids because of its nonirritating qualities. Since then, its soothing, hydrating, and, in particular, antiacne and antiaging qualities have become established. Wider applications of this versatile agent for dermatologic purposes are likely to be further investigated.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur in Miami. She founded the division of cosmetic dermatology at the University of Miami in 1997. The third edition of her bestselling textbook, “Cosmetic Dermatology,” was published in 2022. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Johnson & Johnson, and Burt’s Bees. She is the CEO of Skin Type Solutions, a SaaS company used to generate skin care routines in office and as a ecommerce solution. Write to her at dermnews@mdedge.com.
References
1. Jarząbek-Perz S et al. J Cosmet Dermatol. 2023 Dec;22(12):3305-3312..
2. Qin X et al. Front Physiol. 2022 Mar 14;13:856699.
3. Grimes PE et al. Cutis. 2004 Feb;73(2 Suppl):3-13.
4. Glaser DA. Facial Plast Surg Clin North Am. 2003 May;11(2):219-227.
5. Jarząbek-Perz S et al. Skin Res Technol. 2023 Jun;29(6):e13353.
6. Jarząbek-Perz S et al. Skin Res Technol. 2021 Sep;27(5):925-930.
7. Zerbinati N et al. Molecules. 2021 Dec 15;26(24):7592.
8. Zerbinati Net al. Pharmaceuticals (Basel). 2023 Apr 27;16(5):655.
9. Kantikosum K et al. Clin Cosmet Investig Dermatol. 2019 Feb 19;12:151-161.
10. Jayamani J et al. Int J Biol Macromol. 2018 Feb;107(Pt A):175-185.
This derivative of oxidized glucose lactone is present naturally in bread, cheese, fruit juices, honey, tofu, and wine, and is used as a food additive in Europe.1,2 In dermatology, it is most often used in chemical peels.
Polyhydroxy acids (PHAs) were discovered about 3 decades ago to exert similar functions as alpha hydroxy acids without provoking sensory irritation reactions. Gluconolactone along with lactobionic acid were the identified PHAs and further characterized as delivering more humectant and moisturizing activity than alpha hydroxy acids and effective in combination with retinoic acid to treat adult acne and with retinyl acetate to confer antiaging benefits.3 It is typically added to products for its skin-conditioning qualities, resulting in smoother, brighter, more toned skin.4 This column focuses on recent studies using this bioactive agent for dermatologic purposes.
Split-Face Studies Show Various Benefits
In 2023, Jarząbek-Perz and colleagues conducted a split-face evaluation to assess the effects on various skin parameters (ie, hydration, pH, sebum, and transepidermal water loss [TEWL]) of gluconolactone and oxybrasion, compared with gluconolactone and microneedling. Twenty-one White women underwent a series of three split-face treatments at 1-week intervals. Chemical peels with 10% gluconolactone were performed on the whole face. The right side of the face was also treated with oxybrasion and the left with microneedle mesotherapy. Skin parameters were measured before the first and third treatments and 2 weeks following the final treatment. Photos were taken before and after the study. Both treatments resulted in improved hydration and reductions in sebum, pH, and TEWL. No statistically significant differences were noted between the treatment protocols. The researchers concluded that gluconolactone peels can be effectively combined with oxybrasion or microneedle mesotherapy to enhance skin hydration and to secure the hydrolipid barrier.5
Later that year, the same team evaluated pH, sebum levels, and TEWL before, during, and after several applications of 10% and 30% gluconolactone chemical peels in a split-face model in 16 female participants. The investigators conducted three procedures on both sides of the face, taking measurements on the forehead, periorbital area, on the cheek, and on the nose wing before, during, and 7 days after the final treatment. They found statistically significant improvements in sebum levels in the cheeks after the treatment series. Also, pH values were lower at each measurement site after each procedure. TEWL levels were significantly diminished around the eyes, as well as the left forehead and right cheek, with no significant discrepancy between gluconolactone concentrations. The researchers concluded that gluconolactone plays a major role in reducing cutaneous pH and TEWL and imparts a regulatory effect on sebum.1
Two years earlier, Jarząbek-Perz and colleagues assessed skin moisture in a split-face model in 16 healthy women after the application of 10% and 30% gluconolactone. Investigators measured skin moisture before and after each of three treatments and a week after the final treatment from the forehead, periorbital area, and on the cheek. They observed no significant discrepancies between the 10% and 30% formulations, but a significant elevation in facial skin hydration was found to be promoted by gluconolactone. The investigators concluded that gluconolactone is an effective moisturizer for care of dry skin.6
Topical Formulation
In 2023, Zerbinati and colleagues determined that a gluconolactone-based lotion that they had begun testing 2 years earlier was safe and effective for dermatologic applications, with the noncomedogenic formulation found suitable as an antiaging agent, particularly as it treats aging-related pore dilatation.7,8
Acne Treatment
In 2019, Kantikosum and colleagues conducted a double-blind, within-person comparative study to assess the efficacy of various cosmeceutical ingredients, including gluconolactone, glycolic acid, licochalcone A, and salicylic acid, combined with the acne treatment adapalene vs adapalene monotherapy for mild to moderate acne. Each of 25 subjects over 28 days applied a product mixed with 0.1% adapalene on one side of the face, and 0.1% adapalene alone on the other side of the face once nightly. The VISIA camera system spot score pointed to a statistically significant improvement on the combination sides. Differences in lesion reduction and severity were within acceptable margins, the authors reported. They concluded that the cosmeceutical combinations yielded similar benefits as adapalene alone, with the combination formulations decreasing acne complications.9
Potential Use as an Antifibrotic Agent
In 2018, Jayamani and colleagues investigated the antifibrotic characteristics of glucono-delta-lactone, a known acidifier, to ascertain if it could directly suppress collagen fibrils or even cause them to disintegrate. The researchers noted that collagen fibrillation is pH dependent, and that glucono-delta-lactone was found to exert a concentration-dependent suppression of fibrils and disintegration of preformed collagen fibrils with the antifibrotic function of the compound ascribed to its capacity to decrease pH. Further, glucono-delta-lactone appeared to emerge as an ideal antifibrotic agent as it left intact the triple helical structure of collagen after treatment. The investigators concluded that glucono-delta-lactone provides the foundation for developing antifibrotic agents intended to treat disorders characterized by collagen deposition.10
Conclusion
Gluconolactone emerged in the 1990s as a PHA useful in skin peels as an alternative to alpha hydroxy acids because of its nonirritating qualities. Since then, its soothing, hydrating, and, in particular, antiacne and antiaging qualities have become established. Wider applications of this versatile agent for dermatologic purposes are likely to be further investigated.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur in Miami. She founded the division of cosmetic dermatology at the University of Miami in 1997. The third edition of her bestselling textbook, “Cosmetic Dermatology,” was published in 2022. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Johnson & Johnson, and Burt’s Bees. She is the CEO of Skin Type Solutions, a SaaS company used to generate skin care routines in office and as a ecommerce solution. Write to her at dermnews@mdedge.com.
References
1. Jarząbek-Perz S et al. J Cosmet Dermatol. 2023 Dec;22(12):3305-3312..
2. Qin X et al. Front Physiol. 2022 Mar 14;13:856699.
3. Grimes PE et al. Cutis. 2004 Feb;73(2 Suppl):3-13.
4. Glaser DA. Facial Plast Surg Clin North Am. 2003 May;11(2):219-227.
5. Jarząbek-Perz S et al. Skin Res Technol. 2023 Jun;29(6):e13353.
6. Jarząbek-Perz S et al. Skin Res Technol. 2021 Sep;27(5):925-930.
7. Zerbinati N et al. Molecules. 2021 Dec 15;26(24):7592.
8. Zerbinati Net al. Pharmaceuticals (Basel). 2023 Apr 27;16(5):655.
9. Kantikosum K et al. Clin Cosmet Investig Dermatol. 2019 Feb 19;12:151-161.
10. Jayamani J et al. Int J Biol Macromol. 2018 Feb;107(Pt A):175-185.
The Rise of the Scribes
“We really aren’t taking care of records — we’re taking care of people.” — Dr. Lawrence Weed
What is the purpose of a progress note? Anyone? Yes, you there. “Insurance billing?” Yes, that’s a good one. Anyone else? “To remember what you did?” Excellent. Another? Yes, that’s right, for others to follow along in your care. These are all good reasons for a progress note to exist. But they aren’t the whole story. Let’s start at the beginning.
Charts were once a collection of paper sheets with handwritten notes. Sometimes illegible, sometimes beautiful, always efficient. A progress note back then could be just 10 characters, AK, LN2, X,X,X,X,X (with X’s marking nitrogen sprays). Then came the healthcare K-Pg event: the conversion to EMRs. Those doctors who survived evolved into computer programmers, creating blocks of text from a few keystrokes. But like toddler-sized Legos, the blocks made it impossible to build a note that is nuanced or precise. Worse yet, many notes consisting of blocks from one note added awkwardly to a new note, creating grotesque structures unrecognizable as anything that should exist in nature. Words and numbers, but no information.
Thanks to the eternity of EMR, these creations live on, hideous and useless. They waste not only the server’s energy but also our time. Few things are more maddening than scrolling to reach the bottom of another physician’s note only to find there is nothing there.
Whose fault is this? Anyone? Yes, that’s right, insurers. As there are probably no payers in this audience, let’s blame them. I agree, the crushing burden of documentation-to-get-reimbursed has forced us to create “notes” that add no value to us but add up points for us to get paid for them. CMS, payers, prior authorizations, and now even patients, it seems we are documenting for lots of people except for us. There isn’t time to satisfy all and this significant burden for every encounter is a proximate cause for doctors despair. Until now.
A fully formed, comprehensive, sometimes pretty note that satisfies all audiences. Dr. Larry Weed must be dancing in heaven. It was Dr. Weed who led us from the nicotine-stained logs of the 1950s to the powerful problem-based notes we use today, an innovation that rivals the stethoscope in its impact.
Professor Weed also predicted that computers would be important to capture and make sense of patient data, helping us make accurate diagnoses and efficient plans. Again, he was right. He would surely be advocating to take advantage of AI scribes’ marvelous ability to capture salient data and present it in the form of a problem-oriented medical record.
AI scribes will be ubiquitous soon; I’m fast and even for me they save time. They also allow, for the first time in a decade, to turn from the glow of a screen to actually face the patient – we no longer have to scribe and care simultaneously. Hallelujah. And yet, lest I disappoint you without a twist, it seems with AI scribes, like EMRs we lose a little something too.
Like self-driving cars or ChatGPT-generated letters, they remove cognitive loads. They are lovely when you have to multitask or are trying to recall a visit from hours (days) ago. Using them, you’ll feel faster, lighter, freer, happier. But what’s missing is the thinking. At the end, you have an exquisite note, but you didn’t write it. It has the salient points, but none of the mental work to create it. AI scribes subvert the valuable work of synthesis. That was the critical part of Dr. Weed’s discovery: writing problem-oriented notes helped us think better.
Writing allows for the friction that helps us process what is going on with a patient. It allows for the discovery of diagnoses and prompts plans. When I was an intern, one of my attendings would hand write notes, succinctly showing what he had observed and was thinking. He’d sketch diagrams in the chart, for example, to help illustrate how we’d work though the toxic, metabolic, and infectious etiologies of acute liver failure. Sublime.
The act of writing also helps remind us there is a person attached to these words. Like a handwritten sympathy card, it is intimate, human. Even using our EMR, I’d still often type sentences that help tell the patient’s story. “Her sister just died. Utterly devastated. I’ll forward chart to Bob (her PCP) to check in on her.” Or: “Scratch golfer wants to know why he is getting so many SCCs now. ‘Like bankruptcy, gradually then suddenly,’ I explained. I think I broke through.”
Since we’ve concluded the purpose of a note is mostly to capture data, AI scribes are a godsend. They do so with remarkable quality and efficiency. We’ll just have to remember if the diagnosis is unclear, then it might help to write the note out yourself. And even when done by the AI machine, we might add human touches now and again lest there be no art left in what we do.
“For sale. Sun hat. Never worn.”
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on X. Write to him at dermnews@mdedge.com.
“We really aren’t taking care of records — we’re taking care of people.” — Dr. Lawrence Weed
What is the purpose of a progress note? Anyone? Yes, you there. “Insurance billing?” Yes, that’s a good one. Anyone else? “To remember what you did?” Excellent. Another? Yes, that’s right, for others to follow along in your care. These are all good reasons for a progress note to exist. But they aren’t the whole story. Let’s start at the beginning.
Charts were once a collection of paper sheets with handwritten notes. Sometimes illegible, sometimes beautiful, always efficient. A progress note back then could be just 10 characters, AK, LN2, X,X,X,X,X (with X’s marking nitrogen sprays). Then came the healthcare K-Pg event: the conversion to EMRs. Those doctors who survived evolved into computer programmers, creating blocks of text from a few keystrokes. But like toddler-sized Legos, the blocks made it impossible to build a note that is nuanced or precise. Worse yet, many notes consisting of blocks from one note added awkwardly to a new note, creating grotesque structures unrecognizable as anything that should exist in nature. Words and numbers, but no information.
Thanks to the eternity of EMR, these creations live on, hideous and useless. They waste not only the server’s energy but also our time. Few things are more maddening than scrolling to reach the bottom of another physician’s note only to find there is nothing there.
Whose fault is this? Anyone? Yes, that’s right, insurers. As there are probably no payers in this audience, let’s blame them. I agree, the crushing burden of documentation-to-get-reimbursed has forced us to create “notes” that add no value to us but add up points for us to get paid for them. CMS, payers, prior authorizations, and now even patients, it seems we are documenting for lots of people except for us. There isn’t time to satisfy all and this significant burden for every encounter is a proximate cause for doctors despair. Until now.
A fully formed, comprehensive, sometimes pretty note that satisfies all audiences. Dr. Larry Weed must be dancing in heaven. It was Dr. Weed who led us from the nicotine-stained logs of the 1950s to the powerful problem-based notes we use today, an innovation that rivals the stethoscope in its impact.
Professor Weed also predicted that computers would be important to capture and make sense of patient data, helping us make accurate diagnoses and efficient plans. Again, he was right. He would surely be advocating to take advantage of AI scribes’ marvelous ability to capture salient data and present it in the form of a problem-oriented medical record.
AI scribes will be ubiquitous soon; I’m fast and even for me they save time. They also allow, for the first time in a decade, to turn from the glow of a screen to actually face the patient – we no longer have to scribe and care simultaneously. Hallelujah. And yet, lest I disappoint you without a twist, it seems with AI scribes, like EMRs we lose a little something too.
Like self-driving cars or ChatGPT-generated letters, they remove cognitive loads. They are lovely when you have to multitask or are trying to recall a visit from hours (days) ago. Using them, you’ll feel faster, lighter, freer, happier. But what’s missing is the thinking. At the end, you have an exquisite note, but you didn’t write it. It has the salient points, but none of the mental work to create it. AI scribes subvert the valuable work of synthesis. That was the critical part of Dr. Weed’s discovery: writing problem-oriented notes helped us think better.
Writing allows for the friction that helps us process what is going on with a patient. It allows for the discovery of diagnoses and prompts plans. When I was an intern, one of my attendings would hand write notes, succinctly showing what he had observed and was thinking. He’d sketch diagrams in the chart, for example, to help illustrate how we’d work though the toxic, metabolic, and infectious etiologies of acute liver failure. Sublime.
The act of writing also helps remind us there is a person attached to these words. Like a handwritten sympathy card, it is intimate, human. Even using our EMR, I’d still often type sentences that help tell the patient’s story. “Her sister just died. Utterly devastated. I’ll forward chart to Bob (her PCP) to check in on her.” Or: “Scratch golfer wants to know why he is getting so many SCCs now. ‘Like bankruptcy, gradually then suddenly,’ I explained. I think I broke through.”
Since we’ve concluded the purpose of a note is mostly to capture data, AI scribes are a godsend. They do so with remarkable quality and efficiency. We’ll just have to remember if the diagnosis is unclear, then it might help to write the note out yourself. And even when done by the AI machine, we might add human touches now and again lest there be no art left in what we do.
“For sale. Sun hat. Never worn.”
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on X. Write to him at dermnews@mdedge.com.
“We really aren’t taking care of records — we’re taking care of people.” — Dr. Lawrence Weed
What is the purpose of a progress note? Anyone? Yes, you there. “Insurance billing?” Yes, that’s a good one. Anyone else? “To remember what you did?” Excellent. Another? Yes, that’s right, for others to follow along in your care. These are all good reasons for a progress note to exist. But they aren’t the whole story. Let’s start at the beginning.
Charts were once a collection of paper sheets with handwritten notes. Sometimes illegible, sometimes beautiful, always efficient. A progress note back then could be just 10 characters, AK, LN2, X,X,X,X,X (with X’s marking nitrogen sprays). Then came the healthcare K-Pg event: the conversion to EMRs. Those doctors who survived evolved into computer programmers, creating blocks of text from a few keystrokes. But like toddler-sized Legos, the blocks made it impossible to build a note that is nuanced or precise. Worse yet, many notes consisting of blocks from one note added awkwardly to a new note, creating grotesque structures unrecognizable as anything that should exist in nature. Words and numbers, but no information.
Thanks to the eternity of EMR, these creations live on, hideous and useless. They waste not only the server’s energy but also our time. Few things are more maddening than scrolling to reach the bottom of another physician’s note only to find there is nothing there.
Whose fault is this? Anyone? Yes, that’s right, insurers. As there are probably no payers in this audience, let’s blame them. I agree, the crushing burden of documentation-to-get-reimbursed has forced us to create “notes” that add no value to us but add up points for us to get paid for them. CMS, payers, prior authorizations, and now even patients, it seems we are documenting for lots of people except for us. There isn’t time to satisfy all and this significant burden for every encounter is a proximate cause for doctors despair. Until now.
A fully formed, comprehensive, sometimes pretty note that satisfies all audiences. Dr. Larry Weed must be dancing in heaven. It was Dr. Weed who led us from the nicotine-stained logs of the 1950s to the powerful problem-based notes we use today, an innovation that rivals the stethoscope in its impact.
Professor Weed also predicted that computers would be important to capture and make sense of patient data, helping us make accurate diagnoses and efficient plans. Again, he was right. He would surely be advocating to take advantage of AI scribes’ marvelous ability to capture salient data and present it in the form of a problem-oriented medical record.
AI scribes will be ubiquitous soon; I’m fast and even for me they save time. They also allow, for the first time in a decade, to turn from the glow of a screen to actually face the patient – we no longer have to scribe and care simultaneously. Hallelujah. And yet, lest I disappoint you without a twist, it seems with AI scribes, like EMRs we lose a little something too.
Like self-driving cars or ChatGPT-generated letters, they remove cognitive loads. They are lovely when you have to multitask or are trying to recall a visit from hours (days) ago. Using them, you’ll feel faster, lighter, freer, happier. But what’s missing is the thinking. At the end, you have an exquisite note, but you didn’t write it. It has the salient points, but none of the mental work to create it. AI scribes subvert the valuable work of synthesis. That was the critical part of Dr. Weed’s discovery: writing problem-oriented notes helped us think better.
Writing allows for the friction that helps us process what is going on with a patient. It allows for the discovery of diagnoses and prompts plans. When I was an intern, one of my attendings would hand write notes, succinctly showing what he had observed and was thinking. He’d sketch diagrams in the chart, for example, to help illustrate how we’d work though the toxic, metabolic, and infectious etiologies of acute liver failure. Sublime.
The act of writing also helps remind us there is a person attached to these words. Like a handwritten sympathy card, it is intimate, human. Even using our EMR, I’d still often type sentences that help tell the patient’s story. “Her sister just died. Utterly devastated. I’ll forward chart to Bob (her PCP) to check in on her.” Or: “Scratch golfer wants to know why he is getting so many SCCs now. ‘Like bankruptcy, gradually then suddenly,’ I explained. I think I broke through.”
Since we’ve concluded the purpose of a note is mostly to capture data, AI scribes are a godsend. They do so with remarkable quality and efficiency. We’ll just have to remember if the diagnosis is unclear, then it might help to write the note out yourself. And even when done by the AI machine, we might add human touches now and again lest there be no art left in what we do.
“For sale. Sun hat. Never worn.”
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on X. Write to him at dermnews@mdedge.com.
How the New Vitamin D Guidelines Will, and Won’t, Change My Practice
Hi, everyone. I’m Dr. Kenny Lin. I am a family physician and associate director of the Lancaster General Hospital Family Medicine Residency, and I blog at Common Sense Family Doctor.
A few months ago, my health system added a clinical decision support function to our electronic health record to reduce inappropriate ordering of vitamin D levels. Clinicians are now required to select from a list of approved indications or diagnoses (including a history of vitamin D deficiency) before ordering the test.
Although I don’t know yet whether this process has had the desired effect, I felt that it was long overdue. Several years ago, I wrote an editorial that questioned the dramatic increase in vitamin D testing given the uncertainty about what level is adequate for good health and clinical trials showing that supplementing people with lower levels has no benefits for a variety of medical conditions. A more recent review of prospective studies of vitamin D supplements concluded that most correlations between vitamin D levels and outcomes in common and high-mortality conditions are unlikely to be causal.
A new Endocrine Society guideline recommends against routine measurement of vitamin D levels in healthy individuals. The guideline reinforces my current practice of not screening for vitamin D deficiency except in special situations, such as an individual with dark skin who works the night shift and rarely goes outdoors during daytime hours. But I haven’t been offering empirical vitamin D supplements to the four at-risk groups identified by the Endocrine Society: children, adults older than 75 years, pregnant patients, and adults with prediabetes. The evidence behind these recommendations merits a closer look.
In exclusively or primarily breastfed infants, I follow the American Academy of Pediatrics recommendation to prescribe a daily supplement containing 400 IU of vitamin D. However, the Endocrine Society found evidence from several studies conducted in other countries that continuing supplementation throughout childhood reduces the risk for rickets and possibly reduces the incidence of respiratory infections, with few adverse effects.
Many older women, and some older men, choose to take a calcium and vitamin D supplement for bone health, even though there is scant evidence that doing so prevents fractures in community-dwelling adults without osteoporosis. The Endocrine Society’s meta-analysis, however, found that 1000 adults aged 75 years or older who took an average of 900 IU of vitamin D daily for 2 years could expect to experience six fewer deaths than an identical group not taking supplements.
A typical prenatal vitamin contains 400 IU of vitamin D. Placebo-controlled trials reviewed by the Endocrine Society that gave an average of 2500 IU daily found statistically insignificant reductions in preeclampsia, intrauterine death, preterm birth, small for gestation age birth, and neonatal deaths.
Finally, the Endocrine Society’s recommendation for adults with prediabetes was based on 11 trials (three conducted in the United States) that tested a daily average of 3500 IU and found a slightly lower risk for progression to diabetes (24 fewer diagnoses of type 2 diabetes per 1000 persons) in the group who took supplements.
Of the four groups highlighted by the guideline, the strongest case for vitamin D supplements is in older adults — it’s hard to argue with lower mortality, even if the difference is small. Therefore, I will start suggesting that my patients over age 75 take a daily vitamin D supplement containing at least 800 IU if they aren’t already doing so.
On the other hand, I don’t plan to change my approach to pregnant patients (whose benefits in studies could have been due to chance), children after age 1 year (studies of children in other countries with different nutritional status may not apply to the United States), or adults with prediabetes (where we already have proven lifestyle interventions with much greater effects). In these cases, either I am unconvinced that the data support benefits for my patients, or I feel that the benefits of vitamin D supplements are small enough to be outweighed by potential harms, such as increased kidney stones.
Kenneth W. Lin, Associate Director, Family Medicine Residency Program, Lancaster General Hospital, Lancaster, Pennsylvania, has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Hi, everyone. I’m Dr. Kenny Lin. I am a family physician and associate director of the Lancaster General Hospital Family Medicine Residency, and I blog at Common Sense Family Doctor.
A few months ago, my health system added a clinical decision support function to our electronic health record to reduce inappropriate ordering of vitamin D levels. Clinicians are now required to select from a list of approved indications or diagnoses (including a history of vitamin D deficiency) before ordering the test.
Although I don’t know yet whether this process has had the desired effect, I felt that it was long overdue. Several years ago, I wrote an editorial that questioned the dramatic increase in vitamin D testing given the uncertainty about what level is adequate for good health and clinical trials showing that supplementing people with lower levels has no benefits for a variety of medical conditions. A more recent review of prospective studies of vitamin D supplements concluded that most correlations between vitamin D levels and outcomes in common and high-mortality conditions are unlikely to be causal.
A new Endocrine Society guideline recommends against routine measurement of vitamin D levels in healthy individuals. The guideline reinforces my current practice of not screening for vitamin D deficiency except in special situations, such as an individual with dark skin who works the night shift and rarely goes outdoors during daytime hours. But I haven’t been offering empirical vitamin D supplements to the four at-risk groups identified by the Endocrine Society: children, adults older than 75 years, pregnant patients, and adults with prediabetes. The evidence behind these recommendations merits a closer look.
In exclusively or primarily breastfed infants, I follow the American Academy of Pediatrics recommendation to prescribe a daily supplement containing 400 IU of vitamin D. However, the Endocrine Society found evidence from several studies conducted in other countries that continuing supplementation throughout childhood reduces the risk for rickets and possibly reduces the incidence of respiratory infections, with few adverse effects.
Many older women, and some older men, choose to take a calcium and vitamin D supplement for bone health, even though there is scant evidence that doing so prevents fractures in community-dwelling adults without osteoporosis. The Endocrine Society’s meta-analysis, however, found that 1000 adults aged 75 years or older who took an average of 900 IU of vitamin D daily for 2 years could expect to experience six fewer deaths than an identical group not taking supplements.
A typical prenatal vitamin contains 400 IU of vitamin D. Placebo-controlled trials reviewed by the Endocrine Society that gave an average of 2500 IU daily found statistically insignificant reductions in preeclampsia, intrauterine death, preterm birth, small for gestation age birth, and neonatal deaths.
Finally, the Endocrine Society’s recommendation for adults with prediabetes was based on 11 trials (three conducted in the United States) that tested a daily average of 3500 IU and found a slightly lower risk for progression to diabetes (24 fewer diagnoses of type 2 diabetes per 1000 persons) in the group who took supplements.
Of the four groups highlighted by the guideline, the strongest case for vitamin D supplements is in older adults — it’s hard to argue with lower mortality, even if the difference is small. Therefore, I will start suggesting that my patients over age 75 take a daily vitamin D supplement containing at least 800 IU if they aren’t already doing so.
On the other hand, I don’t plan to change my approach to pregnant patients (whose benefits in studies could have been due to chance), children after age 1 year (studies of children in other countries with different nutritional status may not apply to the United States), or adults with prediabetes (where we already have proven lifestyle interventions with much greater effects). In these cases, either I am unconvinced that the data support benefits for my patients, or I feel that the benefits of vitamin D supplements are small enough to be outweighed by potential harms, such as increased kidney stones.
Kenneth W. Lin, Associate Director, Family Medicine Residency Program, Lancaster General Hospital, Lancaster, Pennsylvania, has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Hi, everyone. I’m Dr. Kenny Lin. I am a family physician and associate director of the Lancaster General Hospital Family Medicine Residency, and I blog at Common Sense Family Doctor.
A few months ago, my health system added a clinical decision support function to our electronic health record to reduce inappropriate ordering of vitamin D levels. Clinicians are now required to select from a list of approved indications or diagnoses (including a history of vitamin D deficiency) before ordering the test.
Although I don’t know yet whether this process has had the desired effect, I felt that it was long overdue. Several years ago, I wrote an editorial that questioned the dramatic increase in vitamin D testing given the uncertainty about what level is adequate for good health and clinical trials showing that supplementing people with lower levels has no benefits for a variety of medical conditions. A more recent review of prospective studies of vitamin D supplements concluded that most correlations between vitamin D levels and outcomes in common and high-mortality conditions are unlikely to be causal.
A new Endocrine Society guideline recommends against routine measurement of vitamin D levels in healthy individuals. The guideline reinforces my current practice of not screening for vitamin D deficiency except in special situations, such as an individual with dark skin who works the night shift and rarely goes outdoors during daytime hours. But I haven’t been offering empirical vitamin D supplements to the four at-risk groups identified by the Endocrine Society: children, adults older than 75 years, pregnant patients, and adults with prediabetes. The evidence behind these recommendations merits a closer look.
In exclusively or primarily breastfed infants, I follow the American Academy of Pediatrics recommendation to prescribe a daily supplement containing 400 IU of vitamin D. However, the Endocrine Society found evidence from several studies conducted in other countries that continuing supplementation throughout childhood reduces the risk for rickets and possibly reduces the incidence of respiratory infections, with few adverse effects.
Many older women, and some older men, choose to take a calcium and vitamin D supplement for bone health, even though there is scant evidence that doing so prevents fractures in community-dwelling adults without osteoporosis. The Endocrine Society’s meta-analysis, however, found that 1000 adults aged 75 years or older who took an average of 900 IU of vitamin D daily for 2 years could expect to experience six fewer deaths than an identical group not taking supplements.
A typical prenatal vitamin contains 400 IU of vitamin D. Placebo-controlled trials reviewed by the Endocrine Society that gave an average of 2500 IU daily found statistically insignificant reductions in preeclampsia, intrauterine death, preterm birth, small for gestation age birth, and neonatal deaths.
Finally, the Endocrine Society’s recommendation for adults with prediabetes was based on 11 trials (three conducted in the United States) that tested a daily average of 3500 IU and found a slightly lower risk for progression to diabetes (24 fewer diagnoses of type 2 diabetes per 1000 persons) in the group who took supplements.
Of the four groups highlighted by the guideline, the strongest case for vitamin D supplements is in older adults — it’s hard to argue with lower mortality, even if the difference is small. Therefore, I will start suggesting that my patients over age 75 take a daily vitamin D supplement containing at least 800 IU if they aren’t already doing so.
On the other hand, I don’t plan to change my approach to pregnant patients (whose benefits in studies could have been due to chance), children after age 1 year (studies of children in other countries with different nutritional status may not apply to the United States), or adults with prediabetes (where we already have proven lifestyle interventions with much greater effects). In these cases, either I am unconvinced that the data support benefits for my patients, or I feel that the benefits of vitamin D supplements are small enough to be outweighed by potential harms, such as increased kidney stones.
Kenneth W. Lin, Associate Director, Family Medicine Residency Program, Lancaster General Hospital, Lancaster, Pennsylvania, has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
A young adult with a 1-year history of erythema, papules, and pustules on her cheeks and skin
. It typically presents with a sudden onset of papules, pustules, cysts, painful inflammatory nodules, and erythema on the centrofacial areas. The etiology is unknown but has been speculated to be hormone-related as it is more common in women and can be triggered by acute changes such as stress or medications.
Because of overlapping symptoms with other conditions, an accurate clinical assessment is crucial. Typically, there are no comedones and about half of the patients have a history of acne. Some cases have shown a possible link between pyoderma faciale with inflammatory bowel disease, thyroid disease and liver disease, highlighting the importance of considering these associations in treatment decisions.
Treatment options for pyoderma faciale include isotretinoin, corticosteroids, dapsone, and antibiotics such as doxycycline. Isotretinoin is usually the first-line treatment, with dapsone reserved for cases where other methods have failed. Despite concerns about isotretinoin exacerbating inflammatory bowel disease (IBD), there has been at least one reported case where a patient with ulcerative colitis who had pyoderma faciale that was successfully treated with isotretinoin with no adverse effects.
Isotretinoin has been shown to be effective in treating pyoderma faciale by significantly reducing inflammation and scarring. This is imperative because the scarring from pyoderma faciale can be disfiguring and psychologically harmful for patients. Therefore, an early diagnosis and effective treatment method are essential in preventing these scars and improving patients’ confidence and overall dermatological care.
This patient’s initial bacterial culture was negative. She was treated with a course of low dose isotretinoin. Prednisone was initiated two weeks before starting isotretinoin and then was tapered off during the first month of isotretinoin treatment. The patient was also started on spironolactone. The course of isotretinoin was 9 months. She has remained clear and still takes oral contraceptive pills and low dose spironolactone.
This case and the photos were submitted by Ms. Towe, Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, Florida, and Donna Bilu Martin, MD, of Premier Dermatology, MD, Aventura, Florida. The column was edited by Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to dermnews@mdedge.com.
References
Angileri L et al. J Dermatolog Treat. 2021 Feb;32(1):110-3. doi: 10.1080/09546634.2019.1628175.
Coutinho JC et al. An Bras Dermatol. 2016 Sep-Oct;91(5 suppl 1):151-3. doi: 10.1590/abd1806-4841.20164943.
Rosen T and Unkefer RP. Cutis. 1999 Aug;64(2):107-9.
. It typically presents with a sudden onset of papules, pustules, cysts, painful inflammatory nodules, and erythema on the centrofacial areas. The etiology is unknown but has been speculated to be hormone-related as it is more common in women and can be triggered by acute changes such as stress or medications.
Because of overlapping symptoms with other conditions, an accurate clinical assessment is crucial. Typically, there are no comedones and about half of the patients have a history of acne. Some cases have shown a possible link between pyoderma faciale with inflammatory bowel disease, thyroid disease and liver disease, highlighting the importance of considering these associations in treatment decisions.
Treatment options for pyoderma faciale include isotretinoin, corticosteroids, dapsone, and antibiotics such as doxycycline. Isotretinoin is usually the first-line treatment, with dapsone reserved for cases where other methods have failed. Despite concerns about isotretinoin exacerbating inflammatory bowel disease (IBD), there has been at least one reported case where a patient with ulcerative colitis who had pyoderma faciale that was successfully treated with isotretinoin with no adverse effects.
Isotretinoin has been shown to be effective in treating pyoderma faciale by significantly reducing inflammation and scarring. This is imperative because the scarring from pyoderma faciale can be disfiguring and psychologically harmful for patients. Therefore, an early diagnosis and effective treatment method are essential in preventing these scars and improving patients’ confidence and overall dermatological care.
This patient’s initial bacterial culture was negative. She was treated with a course of low dose isotretinoin. Prednisone was initiated two weeks before starting isotretinoin and then was tapered off during the first month of isotretinoin treatment. The patient was also started on spironolactone. The course of isotretinoin was 9 months. She has remained clear and still takes oral contraceptive pills and low dose spironolactone.
This case and the photos were submitted by Ms. Towe, Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, Florida, and Donna Bilu Martin, MD, of Premier Dermatology, MD, Aventura, Florida. The column was edited by Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to dermnews@mdedge.com.
References
Angileri L et al. J Dermatolog Treat. 2021 Feb;32(1):110-3. doi: 10.1080/09546634.2019.1628175.
Coutinho JC et al. An Bras Dermatol. 2016 Sep-Oct;91(5 suppl 1):151-3. doi: 10.1590/abd1806-4841.20164943.
Rosen T and Unkefer RP. Cutis. 1999 Aug;64(2):107-9.
. It typically presents with a sudden onset of papules, pustules, cysts, painful inflammatory nodules, and erythema on the centrofacial areas. The etiology is unknown but has been speculated to be hormone-related as it is more common in women and can be triggered by acute changes such as stress or medications.
Because of overlapping symptoms with other conditions, an accurate clinical assessment is crucial. Typically, there are no comedones and about half of the patients have a history of acne. Some cases have shown a possible link between pyoderma faciale with inflammatory bowel disease, thyroid disease and liver disease, highlighting the importance of considering these associations in treatment decisions.
Treatment options for pyoderma faciale include isotretinoin, corticosteroids, dapsone, and antibiotics such as doxycycline. Isotretinoin is usually the first-line treatment, with dapsone reserved for cases where other methods have failed. Despite concerns about isotretinoin exacerbating inflammatory bowel disease (IBD), there has been at least one reported case where a patient with ulcerative colitis who had pyoderma faciale that was successfully treated with isotretinoin with no adverse effects.
Isotretinoin has been shown to be effective in treating pyoderma faciale by significantly reducing inflammation and scarring. This is imperative because the scarring from pyoderma faciale can be disfiguring and psychologically harmful for patients. Therefore, an early diagnosis and effective treatment method are essential in preventing these scars and improving patients’ confidence and overall dermatological care.
This patient’s initial bacterial culture was negative. She was treated with a course of low dose isotretinoin. Prednisone was initiated two weeks before starting isotretinoin and then was tapered off during the first month of isotretinoin treatment. The patient was also started on spironolactone. The course of isotretinoin was 9 months. She has remained clear and still takes oral contraceptive pills and low dose spironolactone.
This case and the photos were submitted by Ms. Towe, Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, Florida, and Donna Bilu Martin, MD, of Premier Dermatology, MD, Aventura, Florida. The column was edited by Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to dermnews@mdedge.com.
References
Angileri L et al. J Dermatolog Treat. 2021 Feb;32(1):110-3. doi: 10.1080/09546634.2019.1628175.
Coutinho JC et al. An Bras Dermatol. 2016 Sep-Oct;91(5 suppl 1):151-3. doi: 10.1590/abd1806-4841.20164943.
Rosen T and Unkefer RP. Cutis. 1999 Aug;64(2):107-9.
Statins, Vitamin D, and Exercise in Older Adults
In this article, I will review several recently published articles and guidelines relevant to the care of older adults in primary care. The articles of interest address statins for primary prevention, vitamin D supplementation and testing, and physical activity for healthy aging.
Statins for Primary Prevention of Cardiovascular Disease
A common conundrum in primary care is whether an older adult should be on a statin for primary prevention. This question has been difficult to answer because of the underrepresentation of older adults in clinical trials that examine the effect of statins for primary prevention. A recent study by Xu et al. published in Annals of Internal Medicine sought to address this gap in knowledge, investigating the risks and benefits of statins for primary prevention for older adults.1
This study stratified participants by “old” (aged 75-84 years) and “very old” (85 years or older). In this study, older adults who had an indication for statins were initiated on statins and studied over a 5-year period and compared with age-matched cohorts not initiated on statin therapy. Participants with known cardiovascular disease at baseline were excluded. The outcomes of interest were major cardiovascular disease (CVD) (a composite of myocardial infarction, stroke, or heart failure), all-cause mortality, and adverse effect of drug therapy (myopathy or liver dysfunction).
The study found that among older adults aged 75-84, initiation of statin therapy led to a 1.2% risk reduction in major CVD over a 5-year period. For older adults aged 85 and greater, initiation of statins had an even larger impact, leading to a 4.4% risk reduction in major CVD over a 5-year period. The study found that there was no significant difference in adverse effects including myopathy or liver dysfunction in both age groups.
Statins, the study suggests, are appropriate and safe to initiate for primary prevention in older adults and can lead to substantial benefits in reduction of CVD. While time to benefit was not explicitly examined in this study, a prior study by Yourman et al. suggested that the time to benefit for statins for primary prevention in adults aged 50-75 would be least 2.5 years.2
My takeaway from these findings is to discuss statin initiation for primary prevention for older patients who are focused on longevity, have good functional status (often used in geriatrics as a proxy for prognosis), and are willing to accept more medications.
Empiric Vitamin D Supplementation in Adults over 75 Years
Vitamin D is one of the most common supplements taken by older adults but evidence supporting vitamin D supplementation is variable in published literature, as most data comes from observational trials. New guidelines from the Endocrine Society focused on developing recommendations for healthy individuals with data obtained from randomized controlled trials (RCTs) and large longitudinal observational trials with comparison groups if RCTs were not available. These guidelines recommend against empiric supplementation of vitamin D for healthy adults aged 18-74, excluding pregnant women and patients with high-risk diabetes.3
For older adults aged 75 or greater, empiric vitamin D supplementation is recommended because of the possible reduction of risk in all-cause mortality in this population. Of note, this was a grade 2 recommendation by the panel, indicating that the benefits of the treatment probably outweigh the risks. The panel stated that vitamin D supplementation could be delivered through fortified foods, multivitamins with vitamin D, or as a separate vitamin D supplement.
The dosage should remain within the recommended daily allowance outlined by the Institute of Medicine of 800 IU daily for adults over 70, and the panel recommends low-dose daily vitamin D supplementation over high-dose interval supplementation. The panel noted that routine screening of vitamin D levels should not be used to guide decision-making on whether to start supplementation, but vitamin D levels should be obtained for patients who have an indication for evaluation.
The reviewers highlight that these guidelines were developed for healthy individuals and are not applicable to those with conditions that warrant vitamin D evaluation. In my clinical practice, many of my patients have bone-mineral conditions and cognitive impairment that warrant evaluation. Based on these guidelines, I will consider empiric vitamin D supplementation more often for healthy patients aged 75 and older.
Sedentary Behaviors and Healthy Aging
Engaging inactive older adults in regular physical activity can be challenging, particularly as the pandemic has led to more pervasive social isolation and affected the availability of in-person exercise activities in the community. Physical activity is a key component of healthy aging and cognition, and its benefits should be a part of routine counseling for older adults.
An interesting recent study published in JAMA Network Open by Shi et al. evaluated the association of health behaviors and aging in female US nurses over a 20-year period.4 Surveys were administered to capture time spent in each behavior, such as being sedentary (TV watching, sitting at home or at work), light activity (walking around the house or at work), and moderate to vigorous activity (walking for exercise, lawn mowing). “Healthy aging” was defined by the absence of chronic conditions such as heart failure, and lack of physical, mental, and cognitive impairment.
The study found that participants who were more sedentary were less likely to age healthfully, with each additional 2 hours of TV watching per day associated with a 12% reduction in likelihood of healthy aging. Light physical activity was associated with a significant increase in healthy aging, with a 6% increase in the likelihood of healthy aging for each additional 2 hours of light activity. Each additional 1 hour of moderate to vigorous activity was associated with a 14% increase in the likelihood of healthy aging. These findings support discussions with patients that behavior change, even in small increments, can be beneficial in healthy aging.
References
1. Xu W et al. Ann Intern Med. 2024 Jun;177(6):701-10.
2. Yourman LC et al. JAMA Intern Med. 2021;181:179-85.
3. Demay MB et al. J Clin Endocrinol Metab. August 2024;109(8):1907-47.
4. Shi H et al. JAMA Netw Open. 2024;7(6):e2416300.
In this article, I will review several recently published articles and guidelines relevant to the care of older adults in primary care. The articles of interest address statins for primary prevention, vitamin D supplementation and testing, and physical activity for healthy aging.
Statins for Primary Prevention of Cardiovascular Disease
A common conundrum in primary care is whether an older adult should be on a statin for primary prevention. This question has been difficult to answer because of the underrepresentation of older adults in clinical trials that examine the effect of statins for primary prevention. A recent study by Xu et al. published in Annals of Internal Medicine sought to address this gap in knowledge, investigating the risks and benefits of statins for primary prevention for older adults.1
This study stratified participants by “old” (aged 75-84 years) and “very old” (85 years or older). In this study, older adults who had an indication for statins were initiated on statins and studied over a 5-year period and compared with age-matched cohorts not initiated on statin therapy. Participants with known cardiovascular disease at baseline were excluded. The outcomes of interest were major cardiovascular disease (CVD) (a composite of myocardial infarction, stroke, or heart failure), all-cause mortality, and adverse effect of drug therapy (myopathy or liver dysfunction).
The study found that among older adults aged 75-84, initiation of statin therapy led to a 1.2% risk reduction in major CVD over a 5-year period. For older adults aged 85 and greater, initiation of statins had an even larger impact, leading to a 4.4% risk reduction in major CVD over a 5-year period. The study found that there was no significant difference in adverse effects including myopathy or liver dysfunction in both age groups.
Statins, the study suggests, are appropriate and safe to initiate for primary prevention in older adults and can lead to substantial benefits in reduction of CVD. While time to benefit was not explicitly examined in this study, a prior study by Yourman et al. suggested that the time to benefit for statins for primary prevention in adults aged 50-75 would be least 2.5 years.2
My takeaway from these findings is to discuss statin initiation for primary prevention for older patients who are focused on longevity, have good functional status (often used in geriatrics as a proxy for prognosis), and are willing to accept more medications.
Empiric Vitamin D Supplementation in Adults over 75 Years
Vitamin D is one of the most common supplements taken by older adults but evidence supporting vitamin D supplementation is variable in published literature, as most data comes from observational trials. New guidelines from the Endocrine Society focused on developing recommendations for healthy individuals with data obtained from randomized controlled trials (RCTs) and large longitudinal observational trials with comparison groups if RCTs were not available. These guidelines recommend against empiric supplementation of vitamin D for healthy adults aged 18-74, excluding pregnant women and patients with high-risk diabetes.3
For older adults aged 75 or greater, empiric vitamin D supplementation is recommended because of the possible reduction of risk in all-cause mortality in this population. Of note, this was a grade 2 recommendation by the panel, indicating that the benefits of the treatment probably outweigh the risks. The panel stated that vitamin D supplementation could be delivered through fortified foods, multivitamins with vitamin D, or as a separate vitamin D supplement.
The dosage should remain within the recommended daily allowance outlined by the Institute of Medicine of 800 IU daily for adults over 70, and the panel recommends low-dose daily vitamin D supplementation over high-dose interval supplementation. The panel noted that routine screening of vitamin D levels should not be used to guide decision-making on whether to start supplementation, but vitamin D levels should be obtained for patients who have an indication for evaluation.
The reviewers highlight that these guidelines were developed for healthy individuals and are not applicable to those with conditions that warrant vitamin D evaluation. In my clinical practice, many of my patients have bone-mineral conditions and cognitive impairment that warrant evaluation. Based on these guidelines, I will consider empiric vitamin D supplementation more often for healthy patients aged 75 and older.
Sedentary Behaviors and Healthy Aging
Engaging inactive older adults in regular physical activity can be challenging, particularly as the pandemic has led to more pervasive social isolation and affected the availability of in-person exercise activities in the community. Physical activity is a key component of healthy aging and cognition, and its benefits should be a part of routine counseling for older adults.
An interesting recent study published in JAMA Network Open by Shi et al. evaluated the association of health behaviors and aging in female US nurses over a 20-year period.4 Surveys were administered to capture time spent in each behavior, such as being sedentary (TV watching, sitting at home or at work), light activity (walking around the house or at work), and moderate to vigorous activity (walking for exercise, lawn mowing). “Healthy aging” was defined by the absence of chronic conditions such as heart failure, and lack of physical, mental, and cognitive impairment.
The study found that participants who were more sedentary were less likely to age healthfully, with each additional 2 hours of TV watching per day associated with a 12% reduction in likelihood of healthy aging. Light physical activity was associated with a significant increase in healthy aging, with a 6% increase in the likelihood of healthy aging for each additional 2 hours of light activity. Each additional 1 hour of moderate to vigorous activity was associated with a 14% increase in the likelihood of healthy aging. These findings support discussions with patients that behavior change, even in small increments, can be beneficial in healthy aging.
References
1. Xu W et al. Ann Intern Med. 2024 Jun;177(6):701-10.
2. Yourman LC et al. JAMA Intern Med. 2021;181:179-85.
3. Demay MB et al. J Clin Endocrinol Metab. August 2024;109(8):1907-47.
4. Shi H et al. JAMA Netw Open. 2024;7(6):e2416300.
In this article, I will review several recently published articles and guidelines relevant to the care of older adults in primary care. The articles of interest address statins for primary prevention, vitamin D supplementation and testing, and physical activity for healthy aging.
Statins for Primary Prevention of Cardiovascular Disease
A common conundrum in primary care is whether an older adult should be on a statin for primary prevention. This question has been difficult to answer because of the underrepresentation of older adults in clinical trials that examine the effect of statins for primary prevention. A recent study by Xu et al. published in Annals of Internal Medicine sought to address this gap in knowledge, investigating the risks and benefits of statins for primary prevention for older adults.1
This study stratified participants by “old” (aged 75-84 years) and “very old” (85 years or older). In this study, older adults who had an indication for statins were initiated on statins and studied over a 5-year period and compared with age-matched cohorts not initiated on statin therapy. Participants with known cardiovascular disease at baseline were excluded. The outcomes of interest were major cardiovascular disease (CVD) (a composite of myocardial infarction, stroke, or heart failure), all-cause mortality, and adverse effect of drug therapy (myopathy or liver dysfunction).
The study found that among older adults aged 75-84, initiation of statin therapy led to a 1.2% risk reduction in major CVD over a 5-year period. For older adults aged 85 and greater, initiation of statins had an even larger impact, leading to a 4.4% risk reduction in major CVD over a 5-year period. The study found that there was no significant difference in adverse effects including myopathy or liver dysfunction in both age groups.
Statins, the study suggests, are appropriate and safe to initiate for primary prevention in older adults and can lead to substantial benefits in reduction of CVD. While time to benefit was not explicitly examined in this study, a prior study by Yourman et al. suggested that the time to benefit for statins for primary prevention in adults aged 50-75 would be least 2.5 years.2
My takeaway from these findings is to discuss statin initiation for primary prevention for older patients who are focused on longevity, have good functional status (often used in geriatrics as a proxy for prognosis), and are willing to accept more medications.
Empiric Vitamin D Supplementation in Adults over 75 Years
Vitamin D is one of the most common supplements taken by older adults but evidence supporting vitamin D supplementation is variable in published literature, as most data comes from observational trials. New guidelines from the Endocrine Society focused on developing recommendations for healthy individuals with data obtained from randomized controlled trials (RCTs) and large longitudinal observational trials with comparison groups if RCTs were not available. These guidelines recommend against empiric supplementation of vitamin D for healthy adults aged 18-74, excluding pregnant women and patients with high-risk diabetes.3
For older adults aged 75 or greater, empiric vitamin D supplementation is recommended because of the possible reduction of risk in all-cause mortality in this population. Of note, this was a grade 2 recommendation by the panel, indicating that the benefits of the treatment probably outweigh the risks. The panel stated that vitamin D supplementation could be delivered through fortified foods, multivitamins with vitamin D, or as a separate vitamin D supplement.
The dosage should remain within the recommended daily allowance outlined by the Institute of Medicine of 800 IU daily for adults over 70, and the panel recommends low-dose daily vitamin D supplementation over high-dose interval supplementation. The panel noted that routine screening of vitamin D levels should not be used to guide decision-making on whether to start supplementation, but vitamin D levels should be obtained for patients who have an indication for evaluation.
The reviewers highlight that these guidelines were developed for healthy individuals and are not applicable to those with conditions that warrant vitamin D evaluation. In my clinical practice, many of my patients have bone-mineral conditions and cognitive impairment that warrant evaluation. Based on these guidelines, I will consider empiric vitamin D supplementation more often for healthy patients aged 75 and older.
Sedentary Behaviors and Healthy Aging
Engaging inactive older adults in regular physical activity can be challenging, particularly as the pandemic has led to more pervasive social isolation and affected the availability of in-person exercise activities in the community. Physical activity is a key component of healthy aging and cognition, and its benefits should be a part of routine counseling for older adults.
An interesting recent study published in JAMA Network Open by Shi et al. evaluated the association of health behaviors and aging in female US nurses over a 20-year period.4 Surveys were administered to capture time spent in each behavior, such as being sedentary (TV watching, sitting at home or at work), light activity (walking around the house or at work), and moderate to vigorous activity (walking for exercise, lawn mowing). “Healthy aging” was defined by the absence of chronic conditions such as heart failure, and lack of physical, mental, and cognitive impairment.
The study found that participants who were more sedentary were less likely to age healthfully, with each additional 2 hours of TV watching per day associated with a 12% reduction in likelihood of healthy aging. Light physical activity was associated with a significant increase in healthy aging, with a 6% increase in the likelihood of healthy aging for each additional 2 hours of light activity. Each additional 1 hour of moderate to vigorous activity was associated with a 14% increase in the likelihood of healthy aging. These findings support discussions with patients that behavior change, even in small increments, can be beneficial in healthy aging.
References
1. Xu W et al. Ann Intern Med. 2024 Jun;177(6):701-10.
2. Yourman LC et al. JAMA Intern Med. 2021;181:179-85.
3. Demay MB et al. J Clin Endocrinol Metab. August 2024;109(8):1907-47.
4. Shi H et al. JAMA Netw Open. 2024;7(6):e2416300.
The Disturbing Sexual Trend With Real Health Consequences
This transcript has been edited for clarity.
Rachel S. Rubin, MD: I have an interesting topic for you — kind of shocking, actually. Some of you may have read a story earlier this year in The New York Times about the alarming rise among young people of choking or strangulation during sex. I spoke recently with Dr. Debby Herbenick about this concerning and violent trend. Dr. Herbenick is a well-known sexuality researcher and professor at the Indiana University School of Public Health. Welcome, Dr. Herbenick. Can you tell us about your research into this new trend?
Debby Herbenick, PhD: This is some of the most important research that I’ve done. I’ve been studying sexual behaviors and trends for about 14 years in terms of nationally representative studies that we do. Over time, we noticed a trend of increasing prevalence of rough sex practices.
Now, there’s always been a lot of sexual diversity in the world throughout history. But . The increase is mostly seen in teenagers and young adults.
We’ve done US nationally representative surveys as well as college campus representative surveys. We find that consistently across four campus representative surveys that 64% of women report having ever been choked during sex, and around 1 in 3 women (aged 18-24 years) throughout the whole country report having been choked during their most recent sexual activity with another person. They call it choking, but because it involves usually one hand — sometimes two hands or a forearm or an object, like a belt or a cord to tie around the neck — it is technically strangulation, because it’s external pressure to the neck to reduce or stop airflow or blood flow.
Dr. Rubin: These numbers are staggering, right? Everyone listening now is taking care of someone who has been strangled as a form of sexual pleasure. What does this mean from a safety perspective? And as doctors who are working these patients up for migraines and other health problems, what is the research showing?
Dr. Herbenick: We certainly are seeing people report recurrent headaches and ringing in the ears. There are things we’ve just barely scratched the surface on. Those of us working in this space believe that for anybody coming in for an unexplained stroke (for example, under age 50), you might consider some imaging to see if they have a dissection. We are hearing about people who, when you really probe to find out whether they’ve had pressure on the neck, they report that indeed that they have. So, we have to be thinking about neurologic symptoms. We know that they’re experiencing these at a pretty high rate.
For people who are engaging in these practices, they should know about the health risks, but we find that most don’t. They may have heard that if it’s really intense high pressure, that in rare cases people can die, but most have never heard of anything in between. So, they’re not necessarily connecting their voice hoarseness, or the recurrent headaches or the sensitivity to light they are having, to an experience of being choked. We need to be paying attention to neurologic symptoms.
Most physicians I speak with at conferences say that where they feel like they can step into this conversation is through anticipatory guidance and letting their patients know that they may have heard about this trend, and a lot of people are talking about the health consequences, and I want to share some information with you — not coming at it from a place of shame or judgment, but providing some information so that [patients] actually get some medical facts about this that could be lifesaving.
Dr. Rubin: I see such a big gap in my medical training. I was taught to say, “Hey, do you smoke, do you drink, do you do drugs? Do you have sex? Men, women, or both?”And that’s it. And then maybe use birth control, and don’t get an STD, thinking about herpes, syphilis, gonorrhea, and chlamydia. We weren’t really trained to talk to patients about what kind of sex they are having, or how to talk to patients in a way that is open-minded but also safety-conscious and how the concept of safe sex is more than wear a condom and use birth control.
This idea of rough sex practices and how to talk to teenagers — maybe our pediatricians should be talking about this. Where do we start in terms of how to bring up these conversations and with what level of detail?
Dr. Herbenick: We find that some young people are already being asked about some of the effects that might be showing on their bodies. It might be that their provider notices some bruising, or marks on their bodies from other types of rough sex practices like hitting and spanking. So that could be an entry point there. Choking is far more prevalent than slapping, so if you’re seeing some marks on the body, then it’s also a good time to ask about other practices they might be engaging in, especially higher risk ones like choking or strangulation. It’s offering some information and even saying, “Look, I’m not here to shame or judge you. I just want you to have some information about this” and giving them an opportunity to ask questions, too.
We have found that almost nobody talks with their nurse or doctor, even if they have symptoms after being choked or strangled during sex. Just 1% of women with choking-related symptoms, 7% of men, and far fewer trans and nonbinary young people report talking with a nurse or doctor, mostly because they say it doesn’t seem like a big deal. The symptoms got better quickly. Sometimes they’re afraid of being shamed for their sexual behavior, and that’s why they say they don’t talk with somebody.
They need some type of open-door anticipatory guidance as a way forward. Not everyone is comfortable directly asking whether a patient is engaging in this, but at least letting people know that you’ve heard of this behavior and providing some medical facts can give us a step forward with creating these conversations.
Dr. Rubin: Can you tell us where is this research going in terms of next steps? Other things that you’re looking at? And what are you excited about?
Dr. Herbenick: I’m excited about some work I did with a collaborator and colleague of mine, Dr. Keisuke Kawata, that he led a couple of years ago. He’s a neuroscientist. We were looking at potential cumulative effects on the brain. Now we’re taking some of that research into its next steps. We’re also doing more focused studies on other health consequences and hopefully finding out how we can test different educational messages and get people to learn more fact-based information about this, and then see if that is effective in prevention.
Dr. Rubin: It sounds like a public health campaign is really needed about how to get the word out there about the health consequences of these activities. We’re asking people often enough. In my clinic, I try to keep it open-ended — tell me what sex looks like. What does it look like, and what do you want it to look like? Because I see a lot of people with problems, but if they don’t bring it to me, I don’t necessarily bring it up to them. Until I heard your lecture, and I thought, oh my gosh, I’m not even asking the right questions. Are you hopeful that there will be more public health messaging out there?
Dr. Herbenick: I am. Years ago, when the child and adolescent choking game became a thing, the Centers for Disease Control and Prevention (CDC) issued reports about it and warnings to parents. And this is a far, far higher prevalence than that ever was. So, I would love to see organizations like the CDC and medical groups getting involved and educating their members and making statements. This is really impacting a huge generation of girls and women, because when it happens during sex between women and men, the choking is mostly happening to the girls and women. It’s also prevalent among sexual minority individuals. But we are talking about this whole generation of young women and what’s happening to their bodies and their brain health. We really need to step into this conversation.
Dr. Rubin: Very few of us are sexual medicine–trained physicians, and very few of us feel confident and comfortable talking about sexual health issues. But people are getting hurt. People are having real consequences of these behaviors because of our lack of education, knowledge, and even discussion around it. So thank you for doing this research, because had you not done this research, we wouldn’t have found out that 64% of people are engaging in these types of activities. That is not rare.
Dr. Rubin is an assistant clinical professor, Department of Urology, at Georgetown University, Washington. She reported conflicts of interest with Sprout, Maternal Medical, Absorption Pharmaceuticals, GSK, and Endo.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Rachel S. Rubin, MD: I have an interesting topic for you — kind of shocking, actually. Some of you may have read a story earlier this year in The New York Times about the alarming rise among young people of choking or strangulation during sex. I spoke recently with Dr. Debby Herbenick about this concerning and violent trend. Dr. Herbenick is a well-known sexuality researcher and professor at the Indiana University School of Public Health. Welcome, Dr. Herbenick. Can you tell us about your research into this new trend?
Debby Herbenick, PhD: This is some of the most important research that I’ve done. I’ve been studying sexual behaviors and trends for about 14 years in terms of nationally representative studies that we do. Over time, we noticed a trend of increasing prevalence of rough sex practices.
Now, there’s always been a lot of sexual diversity in the world throughout history. But . The increase is mostly seen in teenagers and young adults.
We’ve done US nationally representative surveys as well as college campus representative surveys. We find that consistently across four campus representative surveys that 64% of women report having ever been choked during sex, and around 1 in 3 women (aged 18-24 years) throughout the whole country report having been choked during their most recent sexual activity with another person. They call it choking, but because it involves usually one hand — sometimes two hands or a forearm or an object, like a belt or a cord to tie around the neck — it is technically strangulation, because it’s external pressure to the neck to reduce or stop airflow or blood flow.
Dr. Rubin: These numbers are staggering, right? Everyone listening now is taking care of someone who has been strangled as a form of sexual pleasure. What does this mean from a safety perspective? And as doctors who are working these patients up for migraines and other health problems, what is the research showing?
Dr. Herbenick: We certainly are seeing people report recurrent headaches and ringing in the ears. There are things we’ve just barely scratched the surface on. Those of us working in this space believe that for anybody coming in for an unexplained stroke (for example, under age 50), you might consider some imaging to see if they have a dissection. We are hearing about people who, when you really probe to find out whether they’ve had pressure on the neck, they report that indeed that they have. So, we have to be thinking about neurologic symptoms. We know that they’re experiencing these at a pretty high rate.
For people who are engaging in these practices, they should know about the health risks, but we find that most don’t. They may have heard that if it’s really intense high pressure, that in rare cases people can die, but most have never heard of anything in between. So, they’re not necessarily connecting their voice hoarseness, or the recurrent headaches or the sensitivity to light they are having, to an experience of being choked. We need to be paying attention to neurologic symptoms.
Most physicians I speak with at conferences say that where they feel like they can step into this conversation is through anticipatory guidance and letting their patients know that they may have heard about this trend, and a lot of people are talking about the health consequences, and I want to share some information with you — not coming at it from a place of shame or judgment, but providing some information so that [patients] actually get some medical facts about this that could be lifesaving.
Dr. Rubin: I see such a big gap in my medical training. I was taught to say, “Hey, do you smoke, do you drink, do you do drugs? Do you have sex? Men, women, or both?”And that’s it. And then maybe use birth control, and don’t get an STD, thinking about herpes, syphilis, gonorrhea, and chlamydia. We weren’t really trained to talk to patients about what kind of sex they are having, or how to talk to patients in a way that is open-minded but also safety-conscious and how the concept of safe sex is more than wear a condom and use birth control.
This idea of rough sex practices and how to talk to teenagers — maybe our pediatricians should be talking about this. Where do we start in terms of how to bring up these conversations and with what level of detail?
Dr. Herbenick: We find that some young people are already being asked about some of the effects that might be showing on their bodies. It might be that their provider notices some bruising, or marks on their bodies from other types of rough sex practices like hitting and spanking. So that could be an entry point there. Choking is far more prevalent than slapping, so if you’re seeing some marks on the body, then it’s also a good time to ask about other practices they might be engaging in, especially higher risk ones like choking or strangulation. It’s offering some information and even saying, “Look, I’m not here to shame or judge you. I just want you to have some information about this” and giving them an opportunity to ask questions, too.
We have found that almost nobody talks with their nurse or doctor, even if they have symptoms after being choked or strangled during sex. Just 1% of women with choking-related symptoms, 7% of men, and far fewer trans and nonbinary young people report talking with a nurse or doctor, mostly because they say it doesn’t seem like a big deal. The symptoms got better quickly. Sometimes they’re afraid of being shamed for their sexual behavior, and that’s why they say they don’t talk with somebody.
They need some type of open-door anticipatory guidance as a way forward. Not everyone is comfortable directly asking whether a patient is engaging in this, but at least letting people know that you’ve heard of this behavior and providing some medical facts can give us a step forward with creating these conversations.
Dr. Rubin: Can you tell us where is this research going in terms of next steps? Other things that you’re looking at? And what are you excited about?
Dr. Herbenick: I’m excited about some work I did with a collaborator and colleague of mine, Dr. Keisuke Kawata, that he led a couple of years ago. He’s a neuroscientist. We were looking at potential cumulative effects on the brain. Now we’re taking some of that research into its next steps. We’re also doing more focused studies on other health consequences and hopefully finding out how we can test different educational messages and get people to learn more fact-based information about this, and then see if that is effective in prevention.
Dr. Rubin: It sounds like a public health campaign is really needed about how to get the word out there about the health consequences of these activities. We’re asking people often enough. In my clinic, I try to keep it open-ended — tell me what sex looks like. What does it look like, and what do you want it to look like? Because I see a lot of people with problems, but if they don’t bring it to me, I don’t necessarily bring it up to them. Until I heard your lecture, and I thought, oh my gosh, I’m not even asking the right questions. Are you hopeful that there will be more public health messaging out there?
Dr. Herbenick: I am. Years ago, when the child and adolescent choking game became a thing, the Centers for Disease Control and Prevention (CDC) issued reports about it and warnings to parents. And this is a far, far higher prevalence than that ever was. So, I would love to see organizations like the CDC and medical groups getting involved and educating their members and making statements. This is really impacting a huge generation of girls and women, because when it happens during sex between women and men, the choking is mostly happening to the girls and women. It’s also prevalent among sexual minority individuals. But we are talking about this whole generation of young women and what’s happening to their bodies and their brain health. We really need to step into this conversation.
Dr. Rubin: Very few of us are sexual medicine–trained physicians, and very few of us feel confident and comfortable talking about sexual health issues. But people are getting hurt. People are having real consequences of these behaviors because of our lack of education, knowledge, and even discussion around it. So thank you for doing this research, because had you not done this research, we wouldn’t have found out that 64% of people are engaging in these types of activities. That is not rare.
Dr. Rubin is an assistant clinical professor, Department of Urology, at Georgetown University, Washington. She reported conflicts of interest with Sprout, Maternal Medical, Absorption Pharmaceuticals, GSK, and Endo.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Rachel S. Rubin, MD: I have an interesting topic for you — kind of shocking, actually. Some of you may have read a story earlier this year in The New York Times about the alarming rise among young people of choking or strangulation during sex. I spoke recently with Dr. Debby Herbenick about this concerning and violent trend. Dr. Herbenick is a well-known sexuality researcher and professor at the Indiana University School of Public Health. Welcome, Dr. Herbenick. Can you tell us about your research into this new trend?
Debby Herbenick, PhD: This is some of the most important research that I’ve done. I’ve been studying sexual behaviors and trends for about 14 years in terms of nationally representative studies that we do. Over time, we noticed a trend of increasing prevalence of rough sex practices.
Now, there’s always been a lot of sexual diversity in the world throughout history. But . The increase is mostly seen in teenagers and young adults.
We’ve done US nationally representative surveys as well as college campus representative surveys. We find that consistently across four campus representative surveys that 64% of women report having ever been choked during sex, and around 1 in 3 women (aged 18-24 years) throughout the whole country report having been choked during their most recent sexual activity with another person. They call it choking, but because it involves usually one hand — sometimes two hands or a forearm or an object, like a belt or a cord to tie around the neck — it is technically strangulation, because it’s external pressure to the neck to reduce or stop airflow or blood flow.
Dr. Rubin: These numbers are staggering, right? Everyone listening now is taking care of someone who has been strangled as a form of sexual pleasure. What does this mean from a safety perspective? And as doctors who are working these patients up for migraines and other health problems, what is the research showing?
Dr. Herbenick: We certainly are seeing people report recurrent headaches and ringing in the ears. There are things we’ve just barely scratched the surface on. Those of us working in this space believe that for anybody coming in for an unexplained stroke (for example, under age 50), you might consider some imaging to see if they have a dissection. We are hearing about people who, when you really probe to find out whether they’ve had pressure on the neck, they report that indeed that they have. So, we have to be thinking about neurologic symptoms. We know that they’re experiencing these at a pretty high rate.
For people who are engaging in these practices, they should know about the health risks, but we find that most don’t. They may have heard that if it’s really intense high pressure, that in rare cases people can die, but most have never heard of anything in between. So, they’re not necessarily connecting their voice hoarseness, or the recurrent headaches or the sensitivity to light they are having, to an experience of being choked. We need to be paying attention to neurologic symptoms.
Most physicians I speak with at conferences say that where they feel like they can step into this conversation is through anticipatory guidance and letting their patients know that they may have heard about this trend, and a lot of people are talking about the health consequences, and I want to share some information with you — not coming at it from a place of shame or judgment, but providing some information so that [patients] actually get some medical facts about this that could be lifesaving.
Dr. Rubin: I see such a big gap in my medical training. I was taught to say, “Hey, do you smoke, do you drink, do you do drugs? Do you have sex? Men, women, or both?”And that’s it. And then maybe use birth control, and don’t get an STD, thinking about herpes, syphilis, gonorrhea, and chlamydia. We weren’t really trained to talk to patients about what kind of sex they are having, or how to talk to patients in a way that is open-minded but also safety-conscious and how the concept of safe sex is more than wear a condom and use birth control.
This idea of rough sex practices and how to talk to teenagers — maybe our pediatricians should be talking about this. Where do we start in terms of how to bring up these conversations and with what level of detail?
Dr. Herbenick: We find that some young people are already being asked about some of the effects that might be showing on their bodies. It might be that their provider notices some bruising, or marks on their bodies from other types of rough sex practices like hitting and spanking. So that could be an entry point there. Choking is far more prevalent than slapping, so if you’re seeing some marks on the body, then it’s also a good time to ask about other practices they might be engaging in, especially higher risk ones like choking or strangulation. It’s offering some information and even saying, “Look, I’m not here to shame or judge you. I just want you to have some information about this” and giving them an opportunity to ask questions, too.
We have found that almost nobody talks with their nurse or doctor, even if they have symptoms after being choked or strangled during sex. Just 1% of women with choking-related symptoms, 7% of men, and far fewer trans and nonbinary young people report talking with a nurse or doctor, mostly because they say it doesn’t seem like a big deal. The symptoms got better quickly. Sometimes they’re afraid of being shamed for their sexual behavior, and that’s why they say they don’t talk with somebody.
They need some type of open-door anticipatory guidance as a way forward. Not everyone is comfortable directly asking whether a patient is engaging in this, but at least letting people know that you’ve heard of this behavior and providing some medical facts can give us a step forward with creating these conversations.
Dr. Rubin: Can you tell us where is this research going in terms of next steps? Other things that you’re looking at? And what are you excited about?
Dr. Herbenick: I’m excited about some work I did with a collaborator and colleague of mine, Dr. Keisuke Kawata, that he led a couple of years ago. He’s a neuroscientist. We were looking at potential cumulative effects on the brain. Now we’re taking some of that research into its next steps. We’re also doing more focused studies on other health consequences and hopefully finding out how we can test different educational messages and get people to learn more fact-based information about this, and then see if that is effective in prevention.
Dr. Rubin: It sounds like a public health campaign is really needed about how to get the word out there about the health consequences of these activities. We’re asking people often enough. In my clinic, I try to keep it open-ended — tell me what sex looks like. What does it look like, and what do you want it to look like? Because I see a lot of people with problems, but if they don’t bring it to me, I don’t necessarily bring it up to them. Until I heard your lecture, and I thought, oh my gosh, I’m not even asking the right questions. Are you hopeful that there will be more public health messaging out there?
Dr. Herbenick: I am. Years ago, when the child and adolescent choking game became a thing, the Centers for Disease Control and Prevention (CDC) issued reports about it and warnings to parents. And this is a far, far higher prevalence than that ever was. So, I would love to see organizations like the CDC and medical groups getting involved and educating their members and making statements. This is really impacting a huge generation of girls and women, because when it happens during sex between women and men, the choking is mostly happening to the girls and women. It’s also prevalent among sexual minority individuals. But we are talking about this whole generation of young women and what’s happening to their bodies and their brain health. We really need to step into this conversation.
Dr. Rubin: Very few of us are sexual medicine–trained physicians, and very few of us feel confident and comfortable talking about sexual health issues. But people are getting hurt. People are having real consequences of these behaviors because of our lack of education, knowledge, and even discussion around it. So thank you for doing this research, because had you not done this research, we wouldn’t have found out that 64% of people are engaging in these types of activities. That is not rare.
Dr. Rubin is an assistant clinical professor, Department of Urology, at Georgetown University, Washington. She reported conflicts of interest with Sprout, Maternal Medical, Absorption Pharmaceuticals, GSK, and Endo.
A version of this article first appeared on Medscape.com.
How to Get Patients Over a Weight Loss Plateau
This transcript has been edited for clarity.
On today’s edition of Beyond BMI, I’ll be discussing weight plateaus. This is something that our patients are very familiar with. Sometimes, they’re happy with their weight when they plateau; sometimes, they’re not. A weight plateau is simply a state of equilibrium.
There’s a common adage that the last 5 pounds are the hardest. When people decrease their calorie intake and increase their activity — as we instruct our patients to do to lose weight — the body starts to fight back because it believes this is a famine state. Our bodies feel that we are running around the jungle looking for food to help us survive a perceived famine state.
The body does a few things to help us keep weight on, and this is what leads to the frustration of not being able to lose those last 5 pounds. The first thing that happens in this process, which is called metabolic adaptation, is that when someone loses weight, the body naturally increases appetite signals from the brain, so the person becomes hungrier. Satiety signals from the stomach also decrease, so they feel more hungry and less full. And finally, stable fat cells form to allow the person to seek out more food without losing weight. This eventually leads the patient to regain weight, or they may plateau at a weight they’re not happy with.
I’m sure you’ve seen many studies looking at weight plateaus and the amount of weight loss people are able to achieve with diet, exercise, and behavior change alone vs the same lifestyle modifications plus medication. Studies show that patients who are taking anti-obesity medications achieve far more weight loss than do those who are not taking medications. The reason is related to the different mechanisms of action of the anti-obesity medications. Patients taking these medications are able to tolerate a lower caloric intake for a longer period of time, thus they’re able to burn more fat cells and lose more weight. Some medications perform this by decreasing appetite signals, so patients can continue to eat a small number of calories. Some medications affect the stability of fat cells. Some medications also increase satiety signals, so patients can move beyond that degree of metabolic adaptation and get beyond their previous plateau.
What can we do for patients who are frustrated with their weight plateau? I recommend taking a dive into their daily routine. Find out how many calories they are eating. Find out how much exercise they are doing and see whether there’s any room to reorganize the day or change their meals to create a caloric deficit. Are they eating things that are not filling enough, so they can’t get to the next meal without having a snack in between? We are looking at the quality of the meals as well and making sure there’s an adequate amount of protein and fiber in their meals to help with those increased appetite signals. We should also make sure these patients are getting adequate fluid intake.
These are all strategies that can help our patients try to get beyond their weight plateaus.
If the patient meets criteria for anti-obesity medication, which means a body mass index (BMI) of 27-29 with a weight-related comorbidity or BMI ≥ 30 with or without a comorbidity, you may want to consider anti-obesity medication to help that patient get beyond the plateau.
Plateaus will occur as a natural process because of the appetite signaling and hormonal changes that occur when patients lose weight from any modality. It’s important that we work with our patients to determine whether their weight plateau is due to metabolic adaptation. If they aren’t meeting their goals and they have weight-related comorbidities, we can use other available modalities to help those patients continue to lose weight. Of course, whenever we are prescribing a medication, we need to make sure that it is safe for the patient and the patient is on board with the potential side effects and risks. And we should always make sure our patients know we are their advocates in their weight journey.
Holly Lofton, clinical associate professor of surgery and medicine, NYU Langone Health, New York, NY, has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
On today’s edition of Beyond BMI, I’ll be discussing weight plateaus. This is something that our patients are very familiar with. Sometimes, they’re happy with their weight when they plateau; sometimes, they’re not. A weight plateau is simply a state of equilibrium.
There’s a common adage that the last 5 pounds are the hardest. When people decrease their calorie intake and increase their activity — as we instruct our patients to do to lose weight — the body starts to fight back because it believes this is a famine state. Our bodies feel that we are running around the jungle looking for food to help us survive a perceived famine state.
The body does a few things to help us keep weight on, and this is what leads to the frustration of not being able to lose those last 5 pounds. The first thing that happens in this process, which is called metabolic adaptation, is that when someone loses weight, the body naturally increases appetite signals from the brain, so the person becomes hungrier. Satiety signals from the stomach also decrease, so they feel more hungry and less full. And finally, stable fat cells form to allow the person to seek out more food without losing weight. This eventually leads the patient to regain weight, or they may plateau at a weight they’re not happy with.
I’m sure you’ve seen many studies looking at weight plateaus and the amount of weight loss people are able to achieve with diet, exercise, and behavior change alone vs the same lifestyle modifications plus medication. Studies show that patients who are taking anti-obesity medications achieve far more weight loss than do those who are not taking medications. The reason is related to the different mechanisms of action of the anti-obesity medications. Patients taking these medications are able to tolerate a lower caloric intake for a longer period of time, thus they’re able to burn more fat cells and lose more weight. Some medications perform this by decreasing appetite signals, so patients can continue to eat a small number of calories. Some medications affect the stability of fat cells. Some medications also increase satiety signals, so patients can move beyond that degree of metabolic adaptation and get beyond their previous plateau.
What can we do for patients who are frustrated with their weight plateau? I recommend taking a dive into their daily routine. Find out how many calories they are eating. Find out how much exercise they are doing and see whether there’s any room to reorganize the day or change their meals to create a caloric deficit. Are they eating things that are not filling enough, so they can’t get to the next meal without having a snack in between? We are looking at the quality of the meals as well and making sure there’s an adequate amount of protein and fiber in their meals to help with those increased appetite signals. We should also make sure these patients are getting adequate fluid intake.
These are all strategies that can help our patients try to get beyond their weight plateaus.
If the patient meets criteria for anti-obesity medication, which means a body mass index (BMI) of 27-29 with a weight-related comorbidity or BMI ≥ 30 with or without a comorbidity, you may want to consider anti-obesity medication to help that patient get beyond the plateau.
Plateaus will occur as a natural process because of the appetite signaling and hormonal changes that occur when patients lose weight from any modality. It’s important that we work with our patients to determine whether their weight plateau is due to metabolic adaptation. If they aren’t meeting their goals and they have weight-related comorbidities, we can use other available modalities to help those patients continue to lose weight. Of course, whenever we are prescribing a medication, we need to make sure that it is safe for the patient and the patient is on board with the potential side effects and risks. And we should always make sure our patients know we are their advocates in their weight journey.
Holly Lofton, clinical associate professor of surgery and medicine, NYU Langone Health, New York, NY, has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
On today’s edition of Beyond BMI, I’ll be discussing weight plateaus. This is something that our patients are very familiar with. Sometimes, they’re happy with their weight when they plateau; sometimes, they’re not. A weight plateau is simply a state of equilibrium.
There’s a common adage that the last 5 pounds are the hardest. When people decrease their calorie intake and increase their activity — as we instruct our patients to do to lose weight — the body starts to fight back because it believes this is a famine state. Our bodies feel that we are running around the jungle looking for food to help us survive a perceived famine state.
The body does a few things to help us keep weight on, and this is what leads to the frustration of not being able to lose those last 5 pounds. The first thing that happens in this process, which is called metabolic adaptation, is that when someone loses weight, the body naturally increases appetite signals from the brain, so the person becomes hungrier. Satiety signals from the stomach also decrease, so they feel more hungry and less full. And finally, stable fat cells form to allow the person to seek out more food without losing weight. This eventually leads the patient to regain weight, or they may plateau at a weight they’re not happy with.
I’m sure you’ve seen many studies looking at weight plateaus and the amount of weight loss people are able to achieve with diet, exercise, and behavior change alone vs the same lifestyle modifications plus medication. Studies show that patients who are taking anti-obesity medications achieve far more weight loss than do those who are not taking medications. The reason is related to the different mechanisms of action of the anti-obesity medications. Patients taking these medications are able to tolerate a lower caloric intake for a longer period of time, thus they’re able to burn more fat cells and lose more weight. Some medications perform this by decreasing appetite signals, so patients can continue to eat a small number of calories. Some medications affect the stability of fat cells. Some medications also increase satiety signals, so patients can move beyond that degree of metabolic adaptation and get beyond their previous plateau.
What can we do for patients who are frustrated with their weight plateau? I recommend taking a dive into their daily routine. Find out how many calories they are eating. Find out how much exercise they are doing and see whether there’s any room to reorganize the day or change their meals to create a caloric deficit. Are they eating things that are not filling enough, so they can’t get to the next meal without having a snack in between? We are looking at the quality of the meals as well and making sure there’s an adequate amount of protein and fiber in their meals to help with those increased appetite signals. We should also make sure these patients are getting adequate fluid intake.
These are all strategies that can help our patients try to get beyond their weight plateaus.
If the patient meets criteria for anti-obesity medication, which means a body mass index (BMI) of 27-29 with a weight-related comorbidity or BMI ≥ 30 with or without a comorbidity, you may want to consider anti-obesity medication to help that patient get beyond the plateau.
Plateaus will occur as a natural process because of the appetite signaling and hormonal changes that occur when patients lose weight from any modality. It’s important that we work with our patients to determine whether their weight plateau is due to metabolic adaptation. If they aren’t meeting their goals and they have weight-related comorbidities, we can use other available modalities to help those patients continue to lose weight. Of course, whenever we are prescribing a medication, we need to make sure that it is safe for the patient and the patient is on board with the potential side effects and risks. And we should always make sure our patients know we are their advocates in their weight journey.
Holly Lofton, clinical associate professor of surgery and medicine, NYU Langone Health, New York, NY, has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Avoid These Common Mistakes in Treating Hyperkalemia
Hyperkalemia tends to cause panic in healthcare professionals, and rightfully so. On a good day, it causes weakness in the legs; on a bad day, it causes cardiac arrest.
It makes sense that a high potassium level causes clinicians to feel a bit jumpy. This anxiety tends to result in treating the issue by overly restricting potassium in the diet. The problem with this method is that it should be temporary but often isn’t. There are only a few concerns that justify long-term potassium restriction.
As a dietitian, I have seen numerous patients with varying disease states who are terrified of potassium because they were never properly educated on the situation that required restriction or were never notified that their potassium was corrected.
I’ve seen patients whose potassium level hasn’t been elevated in years refuse banana bread because they were told that they could never eat a banana again. I’ve worked with patients who continued to needlessly restrict, which eventually led to hypokalemia.
Not only does this indicate ineffective education — banana bread is actually a low-potassium food at about 80 mg per slice — but also poor follow-up.
Potassium has been designated by the United States Department of Agriculture as a nutrient of public health concern due to its underconsumption in the general population. Although there is concern in the public health community that the current guidelines for potassium intake (3500-4700 mg/d) are unattainable, with some professionals arguing for lowering the standard, there remains significant deficiency in the general population. This deficiency has also been connected to increasing rates of hypertension and cardiovascular disease.
Nondietary Causes of Hyperkalemia
There are many causes of hyperkalemia, of which excessive potassium intake is only one, and an uncommon one at that. A high potassium level should resolve during the course of treatment for metabolic acidosis, hyperglycemia, and dehydration. We may also see resolution with medication changes. But the question remains: Are we relaying this information to patients?
Renal insufficiency is a common cause of hyperkalemia, but it is also a common cause of chronic constipation that can cause hyperkalemia as well. Are we addressing bowel movements with these patients? I often work with patients who aren’t having their bowel movements addressed until the patient themselves voices discomfort.
Depending upon the urgency of treatment, potassium restriction may be the most effective and efficient way to address an acutely elevated value. However, long-term potassium restriction may not be an appropriate intervention for all patients, even those with kidney conditions.
As a dietitian, I have seen many patients who overly restrict dietary potassium because they had one elevated value. These patients tend to view potassium as the enemy because they were never educated on the actual cause of their hyperkalemia. They were simply given a list of high-potassium foods and told to avoid them. A lack of follow-up education may cause them to avoid those foods forever.
Benefits of Potassium
The problem with this perpetual avoidance of high potassium foods is that a potassium-rich diet has been shown to be exceptionally beneficial.
Potassium exists in many forms in the Western diet: as a preservative and additive, a salt substitute, and naturally occurring in both animal and plant products. My concern regarding blanket potassium restriction is that potassium-rich plant and animal products can actually be beneficial, even to those with kidney and heart conditions who are most often advised to restrict its intake.
Adequate potassium intake can:
- Decrease blood pressure by increasing urinary excretion of sodium
- Improve nephrolithiasis by decreasing urinary excretion of calcium
- Decrease incidence of metabolic acidosis by providing precursors to bicarbonate that facilitate excretion of potassium
- Increase bone density in postmenopausal women
- Decrease risk for stroke and cardiovascular disease in the general population
One study found that metabolic acidosis can be corrected in patients with stage 4 chronic kidney disease, without hyperkalemia, by increasing fruit and vegetable intake when compared with those treated with bicarbonate alone, thus preserving kidney function.
Do I suggest encouraging a patient with acute hyperkalemia to eat a banana? Of course not. But I would suggest finding ways to work with patients who have chronic hyperkalemia to increase intake of potassium-rich plant foods to maintain homeostasis while liberalizing diet and preventing progression of chronic kidney disease.
When to Refer to a Dietitian
In patients for whom a potassium-restricted diet is a necessary long-term treatment of hyperkalemia, education with a registered dietitian can be beneficial. A registered dietitian has the time and expertise to address the areas in the diet where excessive potassium exists without forfeiting other nutritional benefits that come from whole foods like fruits, vegetables, lean protein, legumes, nuts, and seeds in a way that is both realistic and helpful. A dietitian can work with patients to reduce intake of potassium-containing salt substitutes, preservatives, and other additives while still encouraging a whole-food diet rich in antioxidants, fiber, and healthy fats.
Dietitians also provide education on serving size and methods to reduce potassium content of food.
For example, tomatoes are a high-potassium food at 300+ mg per medium-sized tomato. But how often does a patient eat a whole tomato? A slice of tomato on a sandwich or a handful of cherry tomatoes in a salad are actually low in potassium per serving and can provide additional nutrients like vitamin C, beta-carotene, and antioxidants like lycopene, which is linked to a decreased incidence of prostate cancer.
By incorporating the assistance of a registered dietitian into the treatment of chronic hyperkalemia, we can develop individualized restrictions that are realistic for the patient and tailored to their nutritional needs to promote optimal health and thus encourage continued compliance.
Ms. Winfree is a renal dietitian in private practice in Mary Esther, Florida. She disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
Hyperkalemia tends to cause panic in healthcare professionals, and rightfully so. On a good day, it causes weakness in the legs; on a bad day, it causes cardiac arrest.
It makes sense that a high potassium level causes clinicians to feel a bit jumpy. This anxiety tends to result in treating the issue by overly restricting potassium in the diet. The problem with this method is that it should be temporary but often isn’t. There are only a few concerns that justify long-term potassium restriction.
As a dietitian, I have seen numerous patients with varying disease states who are terrified of potassium because they were never properly educated on the situation that required restriction or were never notified that their potassium was corrected.
I’ve seen patients whose potassium level hasn’t been elevated in years refuse banana bread because they were told that they could never eat a banana again. I’ve worked with patients who continued to needlessly restrict, which eventually led to hypokalemia.
Not only does this indicate ineffective education — banana bread is actually a low-potassium food at about 80 mg per slice — but also poor follow-up.
Potassium has been designated by the United States Department of Agriculture as a nutrient of public health concern due to its underconsumption in the general population. Although there is concern in the public health community that the current guidelines for potassium intake (3500-4700 mg/d) are unattainable, with some professionals arguing for lowering the standard, there remains significant deficiency in the general population. This deficiency has also been connected to increasing rates of hypertension and cardiovascular disease.
Nondietary Causes of Hyperkalemia
There are many causes of hyperkalemia, of which excessive potassium intake is only one, and an uncommon one at that. A high potassium level should resolve during the course of treatment for metabolic acidosis, hyperglycemia, and dehydration. We may also see resolution with medication changes. But the question remains: Are we relaying this information to patients?
Renal insufficiency is a common cause of hyperkalemia, but it is also a common cause of chronic constipation that can cause hyperkalemia as well. Are we addressing bowel movements with these patients? I often work with patients who aren’t having their bowel movements addressed until the patient themselves voices discomfort.
Depending upon the urgency of treatment, potassium restriction may be the most effective and efficient way to address an acutely elevated value. However, long-term potassium restriction may not be an appropriate intervention for all patients, even those with kidney conditions.
As a dietitian, I have seen many patients who overly restrict dietary potassium because they had one elevated value. These patients tend to view potassium as the enemy because they were never educated on the actual cause of their hyperkalemia. They were simply given a list of high-potassium foods and told to avoid them. A lack of follow-up education may cause them to avoid those foods forever.
Benefits of Potassium
The problem with this perpetual avoidance of high potassium foods is that a potassium-rich diet has been shown to be exceptionally beneficial.
Potassium exists in many forms in the Western diet: as a preservative and additive, a salt substitute, and naturally occurring in both animal and plant products. My concern regarding blanket potassium restriction is that potassium-rich plant and animal products can actually be beneficial, even to those with kidney and heart conditions who are most often advised to restrict its intake.
Adequate potassium intake can:
- Decrease blood pressure by increasing urinary excretion of sodium
- Improve nephrolithiasis by decreasing urinary excretion of calcium
- Decrease incidence of metabolic acidosis by providing precursors to bicarbonate that facilitate excretion of potassium
- Increase bone density in postmenopausal women
- Decrease risk for stroke and cardiovascular disease in the general population
One study found that metabolic acidosis can be corrected in patients with stage 4 chronic kidney disease, without hyperkalemia, by increasing fruit and vegetable intake when compared with those treated with bicarbonate alone, thus preserving kidney function.
Do I suggest encouraging a patient with acute hyperkalemia to eat a banana? Of course not. But I would suggest finding ways to work with patients who have chronic hyperkalemia to increase intake of potassium-rich plant foods to maintain homeostasis while liberalizing diet and preventing progression of chronic kidney disease.
When to Refer to a Dietitian
In patients for whom a potassium-restricted diet is a necessary long-term treatment of hyperkalemia, education with a registered dietitian can be beneficial. A registered dietitian has the time and expertise to address the areas in the diet where excessive potassium exists without forfeiting other nutritional benefits that come from whole foods like fruits, vegetables, lean protein, legumes, nuts, and seeds in a way that is both realistic and helpful. A dietitian can work with patients to reduce intake of potassium-containing salt substitutes, preservatives, and other additives while still encouraging a whole-food diet rich in antioxidants, fiber, and healthy fats.
Dietitians also provide education on serving size and methods to reduce potassium content of food.
For example, tomatoes are a high-potassium food at 300+ mg per medium-sized tomato. But how often does a patient eat a whole tomato? A slice of tomato on a sandwich or a handful of cherry tomatoes in a salad are actually low in potassium per serving and can provide additional nutrients like vitamin C, beta-carotene, and antioxidants like lycopene, which is linked to a decreased incidence of prostate cancer.
By incorporating the assistance of a registered dietitian into the treatment of chronic hyperkalemia, we can develop individualized restrictions that are realistic for the patient and tailored to their nutritional needs to promote optimal health and thus encourage continued compliance.
Ms. Winfree is a renal dietitian in private practice in Mary Esther, Florida. She disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
Hyperkalemia tends to cause panic in healthcare professionals, and rightfully so. On a good day, it causes weakness in the legs; on a bad day, it causes cardiac arrest.
It makes sense that a high potassium level causes clinicians to feel a bit jumpy. This anxiety tends to result in treating the issue by overly restricting potassium in the diet. The problem with this method is that it should be temporary but often isn’t. There are only a few concerns that justify long-term potassium restriction.
As a dietitian, I have seen numerous patients with varying disease states who are terrified of potassium because they were never properly educated on the situation that required restriction or were never notified that their potassium was corrected.
I’ve seen patients whose potassium level hasn’t been elevated in years refuse banana bread because they were told that they could never eat a banana again. I’ve worked with patients who continued to needlessly restrict, which eventually led to hypokalemia.
Not only does this indicate ineffective education — banana bread is actually a low-potassium food at about 80 mg per slice — but also poor follow-up.
Potassium has been designated by the United States Department of Agriculture as a nutrient of public health concern due to its underconsumption in the general population. Although there is concern in the public health community that the current guidelines for potassium intake (3500-4700 mg/d) are unattainable, with some professionals arguing for lowering the standard, there remains significant deficiency in the general population. This deficiency has also been connected to increasing rates of hypertension and cardiovascular disease.
Nondietary Causes of Hyperkalemia
There are many causes of hyperkalemia, of which excessive potassium intake is only one, and an uncommon one at that. A high potassium level should resolve during the course of treatment for metabolic acidosis, hyperglycemia, and dehydration. We may also see resolution with medication changes. But the question remains: Are we relaying this information to patients?
Renal insufficiency is a common cause of hyperkalemia, but it is also a common cause of chronic constipation that can cause hyperkalemia as well. Are we addressing bowel movements with these patients? I often work with patients who aren’t having their bowel movements addressed until the patient themselves voices discomfort.
Depending upon the urgency of treatment, potassium restriction may be the most effective and efficient way to address an acutely elevated value. However, long-term potassium restriction may not be an appropriate intervention for all patients, even those with kidney conditions.
As a dietitian, I have seen many patients who overly restrict dietary potassium because they had one elevated value. These patients tend to view potassium as the enemy because they were never educated on the actual cause of their hyperkalemia. They were simply given a list of high-potassium foods and told to avoid them. A lack of follow-up education may cause them to avoid those foods forever.
Benefits of Potassium
The problem with this perpetual avoidance of high potassium foods is that a potassium-rich diet has been shown to be exceptionally beneficial.
Potassium exists in many forms in the Western diet: as a preservative and additive, a salt substitute, and naturally occurring in both animal and plant products. My concern regarding blanket potassium restriction is that potassium-rich plant and animal products can actually be beneficial, even to those with kidney and heart conditions who are most often advised to restrict its intake.
Adequate potassium intake can:
- Decrease blood pressure by increasing urinary excretion of sodium
- Improve nephrolithiasis by decreasing urinary excretion of calcium
- Decrease incidence of metabolic acidosis by providing precursors to bicarbonate that facilitate excretion of potassium
- Increase bone density in postmenopausal women
- Decrease risk for stroke and cardiovascular disease in the general population
One study found that metabolic acidosis can be corrected in patients with stage 4 chronic kidney disease, without hyperkalemia, by increasing fruit and vegetable intake when compared with those treated with bicarbonate alone, thus preserving kidney function.
Do I suggest encouraging a patient with acute hyperkalemia to eat a banana? Of course not. But I would suggest finding ways to work with patients who have chronic hyperkalemia to increase intake of potassium-rich plant foods to maintain homeostasis while liberalizing diet and preventing progression of chronic kidney disease.
When to Refer to a Dietitian
In patients for whom a potassium-restricted diet is a necessary long-term treatment of hyperkalemia, education with a registered dietitian can be beneficial. A registered dietitian has the time and expertise to address the areas in the diet where excessive potassium exists without forfeiting other nutritional benefits that come from whole foods like fruits, vegetables, lean protein, legumes, nuts, and seeds in a way that is both realistic and helpful. A dietitian can work with patients to reduce intake of potassium-containing salt substitutes, preservatives, and other additives while still encouraging a whole-food diet rich in antioxidants, fiber, and healthy fats.
Dietitians also provide education on serving size and methods to reduce potassium content of food.
For example, tomatoes are a high-potassium food at 300+ mg per medium-sized tomato. But how often does a patient eat a whole tomato? A slice of tomato on a sandwich or a handful of cherry tomatoes in a salad are actually low in potassium per serving and can provide additional nutrients like vitamin C, beta-carotene, and antioxidants like lycopene, which is linked to a decreased incidence of prostate cancer.
By incorporating the assistance of a registered dietitian into the treatment of chronic hyperkalemia, we can develop individualized restrictions that are realistic for the patient and tailored to their nutritional needs to promote optimal health and thus encourage continued compliance.
Ms. Winfree is a renal dietitian in private practice in Mary Esther, Florida. She disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.