Mixed Topics

If the pandemic served as a window into our health, what it revealed was a U.S. population that is not only sick but also seemingly only getting sicker. Life expectancy is falling precipitously. Three-fourths of Americans are overweight or obese, half have diabetes or prediabetes, and a majority are metabolically unhealthy. Furthermore, the rates of allergic, inflammatory, and autoimmune diseases are rising at rates of 3%-9% per year in the West, far faster than the speed of genetic change in this population.

Of course, diet and lifestyle are major factors behind such trends, but a grossly underappreciated driver in what ails us is the role of environmental toxins and endocrine-disrupting chemicals. In years past, these factors have largely evaded the traditional Western medical establishment; however, mounting evidence now supports their significance in fertility, metabolic health, and cancer.

Although several industrial chemicals and toxins have been identified as carcinogens and have subsequently been regulated, many more remain persistent in the environment and continue to be freely used. It is therefore incumbent upon both the general public and clinicians to be knowledgeable about these exposures. Here, we review some of the most common exposures and the substantial health risks associated with them, along with some general guidance around best practices for how to minimize exposure.
 

Microplastics

“Microplastics” is a term used to describe small fragments or particles of plastic breakdown or microbeads from household or personal care products, measuring less than 5 mm in length.

Plastic waste is accumulating at alarming and devastating proportions – by 2050, it is estimated that by weight, there will be more plastic than fish in the oceans. That translates into hundreds of thousands of tons of microplastics and trillions of these particles in the seas. A recent study demonstrated that microplastics were present in the bloodstream in the majority of 22 otherwise healthy participants.

Since the 1950s, plastic exposure has been shown to promote tumorigenesis in animal studies, and in vitro studies have demonstrated the toxicity of microplastics at the cellular level. However, it is not well known whether the plastic itself is toxic or if it simply serves as a carrier for other environmental toxins to bioaccumulate.

According to Tasha Stoiber, a senior scientist at the Environmental Working Group, “Microplastics have been widely detected in fish and seafood, as well as other products like bottled water, beer, honey, and tap water.” The EWG states there are no formal advisories on fish consumption to avoid exposure to microplastics at the moment.

Pressure also is mounting for a ban on microbeads in personal care products.

Until such bans are put in place, it is advised to avoid single-use plastics, favor reusable tote bags for grocery shopping rather than plastic bags, and opt for loose leaf tea or paper tea bags rather than mesh-based alternatives.
 

Phthalates

Phthalates are chemicals used to make plastics soft and durable, as well as to bind fragrances. They are commonly found in household items such as vinyl (for example, flooring, shower curtains) and fragrances, air fresheners, and perfumes.

Phthalates are known hormone-disrupting chemicals, exposure to which has been associated with abnormal sexual and brain development in children, as well as lower levels of testosterone in men. Exposures are thought to occur via inhalation, ingestion, and skin contact; however, fasting studies demonstrate that a majority of exposure is probably food related.

To avoid phthalate exposures, recommendations include avoiding polyvinyl chloride plastics (particularly food containers, plastic wrap, and children’s toys), which are identifiable by the recycle code number 3, as well as air fresheners and fragranced products.

The EWG’s Skin Deep database provides an important resource on phthalate-free personal care products.

Despite pressure from consumer advocacy groups, the U.S. Food and Drug Administration has not yet banned phthalates in food packaging.
 

Bisphenol A (BPA)

BPA is a chemical additive used to make clear and hard polycarbonate plastics, as well as epoxy and thermal papers. BPA is one of the highest-volume chemicals, with roughly 6 billion pounds produced each year. BPA is traditionally found in many clear plastic bottles and sippy cups, as well as in the lining of canned foods.

Structurally, BPA acts as an estrogen mimetic and has been associated with cardiovascular disease, obesity, and male sexual dysfunction. Since 2012, BPA has been banned in sippy cups and baby bottles, but there is some debate as to whether its replacements (bisphenol S and bisphenol F) are any safer; they appear to have similar hormonal effects as BPA.

As with phthalates, the majority of ingestion is thought to be food related. BPA has been found in more than 90% of a representative study population in the United States.

Guidance advises avoiding polycarbonate plastics (identifiable with the recycling code number 7), as well as avoiding handling thermal papers such as tickets and receipts, if possible. Food and beverages should be stored in glass or stainless steel. If plastic must be used, opt for polycarbonate- and polyvinyl chloride–free plastics, and food and beverages should never be reheated in plastic containers or wrapping. Canned foods should ideally be avoided, particularly canned tunas and condensed soups. If canned products are bought, they should ideally be BPA free.
 

Dioxins and polychlorinated biphenyls (PCBs)

Dioxins are mainly the byproducts of industrial practices; they are released after incineration, trash burning, and fires. PCBs, which are somewhat structurally related to dioxins, were previously found in products such as flame retardants and coolants. Dioxins and PCBs are often grouped in the same category under the umbrella term “persistent organic pollutants” because they break down slowly and remain in the environment even after emissions have been curbed.

Tetrachlorodibenzodioxin, perhaps the best-known dioxin, is a known carcinogen. Dioxins also have been associated with a host of health implications in development, immunity, and reproductive and endocrine systems. Higher levels of PCB exposure have also been associated with an increased risk for mortality from cardiovascular disease.

Notably, dioxin emissions have been reduced by 90% since the 1980s, and the U.S. Environmental Protection Agency has banned the use of PCBs in industrial manufacturing since 1979. However, environmental dioxins and PCBs still enter the food chain and accumulate in fat.

The best ways to avoid exposures are through limiting meat, fish, and dairy consumption and trimming the skin and fat from meats. The level of dioxins and PCBs found in meat, eggs, fish, and dairy are approximately 5-10 times higher than they are in plant-based foods. Research has shown that farmed salmon is likely to be the most PCB-contaminated protein source in the U.S. diet; however, newer forms of land-based and sustainable aquaculture probably avoid this exposure.
 

Pesticides

The growth of modern monoculture agriculture in the United States over the past century has coincided with a dramatic surge in the use of industrial pesticides. In fact, over 90% of the U.S. population have pesticides in their urine and blood, regardless of where they live. Exposures are thought to be food related.

Approximately 1 billion pounds of pesticides are used annually in the United States, including nearly 300 million pounds of glyphosate, which has been identified as a probable carcinogen by European agencies. The EPA has not yet reached this conclusion, although the matter is currently being litigated.

A large European prospective cohort trial demonstrated a lower risk for cancer in those with a greater frequency of self-reported organic food consumption. In addition to cancer risk, relatively elevated blood levels of a pesticide known as beta-hexachlorocyclohexane (B-HCH) are associated with higher all-cause mortality. Also, exposure to DDE – a metabolite of DDT, a chlorinated pesticide heavily used in the 1940s-1960s that still persists in the environment today – has been shown to increase the risk for Alzheimer’s-type dementia as well as overall cognitive decline.

Because these chlorinated pesticides are often fat soluble, they seem to accumulate in animal products. Therefore, people consuming a vegetarian diet have been found to have lower levels of B-HCH. This has led to the recommendation that consumers of produce should favor organic over conventional, if possible. Here too, the EWG provides an important resource to consumers in the form of shopper guides regarding pesticides in produce.
 

Per- and polyfluoroalkyl substances (PFAS)

PFAS are a group of fluorinated compounds discovered in the 1930s. Their chemical composition includes a durable carbon-fluoride bond, giving them a persistence within the environment that has led to their being referred to as “forever chemicals.”

PFAS have been detected in the blood of 98% of Americans, and in the rainwater of locations as far afield as Tibet and Antarctica. Even low levels of exposure have been associated with an increased risk for cancer, liver disease, low birth weight, and hormonal disruption.

The properties of PFAS also make them both durable at very high heat and water repellent. Notoriously, the chemical was used by 3M to make Scotchgard for carpets and fabrics and by Dupont to make Teflon for nonstick coating of pots and pans. Although perfluorooctanoic acid (PFOA) was removed from nonstick cookware in 2013, PFAS – a family of thousands of synthetic compounds – remain common in fast-food packaging, water- and stain-repellent clothing, firefighting foam, and personal care products. PFAS are released into the environment during the breakdown of these consumer and industrial products, as well as from dumping from waste facilities.

Alarmingly, the EWG notes that up to 200 million Americans may be exposed to PFAS in their drinking water. In March 2021, the EPA announced that they will be regulating PFAS in drinking water; however, the regulations have not been finalized. Currently, it is up to individual states to test for its presence in the water. The EWG has compiled a map of all known PFAS contamination sites.

To avoid or prevent exposures from PFAS, recommendations include filtering tap water with either reverse osmosis or activated carbon filters, as well as avoiding fast food and carry-out food, if possible, and consumer products labeled as “water resistant,” “stain-resistant,” and “nonstick.”

In a testament to how harmful these chemicals are, the EPA recently revised their lifetime health advisories for PFAS, such as PFOA, to 0.004 parts per trillion, which is more than 10,000 times smaller than the previous limit of 70 parts per trillion. The EPA also has proposed formally designating certain PFAS chemicals as “hazardous substances.”

Dr. Goel, clinical assistant professor of medicine at Weill Cornell Medicine, New York, has disclosed no relevant financial relationships. A version of this article originally appeared on Medscape.com.

If the pandemic served as a window into our health, what it revealed was a U.S. population that is not only sick but also seemingly only getting sicker. Life expectancy is falling precipitously. Three-fourths of Americans are overweight or obese, half have diabetes or prediabetes, and a majority are metabolically unhealthy. Furthermore, the rates of allergic, inflammatory, and autoimmune diseases are rising at rates of 3%-9% per year in the West, far faster than the speed of genetic change in this population.

Of course, diet and lifestyle are major factors behind such trends, but a grossly underappreciated driver in what ails us is the role of environmental toxins and endocrine-disrupting chemicals. In years past, these factors have largely evaded the traditional Western medical establishment; however, mounting evidence now supports their significance in fertility, metabolic health, and cancer.

Although several industrial chemicals and toxins have been identified as carcinogens and have subsequently been regulated, many more remain persistent in the environment and continue to be freely used. It is therefore incumbent upon both the general public and clinicians to be knowledgeable about these exposures. Here, we review some of the most common exposures and the substantial health risks associated with them, along with some general guidance around best practices for how to minimize exposure.
 

Microplastics

“Microplastics” is a term used to describe small fragments or particles of plastic breakdown or microbeads from household or personal care products, measuring less than 5 mm in length.

Plastic waste is accumulating at alarming and devastating proportions – by 2050, it is estimated that by weight, there will be more plastic than fish in the oceans. That translates into hundreds of thousands of tons of microplastics and trillions of these particles in the seas. A recent study demonstrated that microplastics were present in the bloodstream in the majority of 22 otherwise healthy participants.

Since the 1950s, plastic exposure has been shown to promote tumorigenesis in animal studies, and in vitro studies have demonstrated the toxicity of microplastics at the cellular level. However, it is not well known whether the plastic itself is toxic or if it simply serves as a carrier for other environmental toxins to bioaccumulate.

According to Tasha Stoiber, a senior scientist at the Environmental Working Group, “Microplastics have been widely detected in fish and seafood, as well as other products like bottled water, beer, honey, and tap water.” The EWG states there are no formal advisories on fish consumption to avoid exposure to microplastics at the moment.

Pressure also is mounting for a ban on microbeads in personal care products.

Until such bans are put in place, it is advised to avoid single-use plastics, favor reusable tote bags for grocery shopping rather than plastic bags, and opt for loose leaf tea or paper tea bags rather than mesh-based alternatives.
 

Phthalates

Phthalates are chemicals used to make plastics soft and durable, as well as to bind fragrances. They are commonly found in household items such as vinyl (for example, flooring, shower curtains) and fragrances, air fresheners, and perfumes.

Phthalates are known hormone-disrupting chemicals, exposure to which has been associated with abnormal sexual and brain development in children, as well as lower levels of testosterone in men. Exposures are thought to occur via inhalation, ingestion, and skin contact; however, fasting studies demonstrate that a majority of exposure is probably food related.

To avoid phthalate exposures, recommendations include avoiding polyvinyl chloride plastics (particularly food containers, plastic wrap, and children’s toys), which are identifiable by the recycle code number 3, as well as air fresheners and fragranced products.

The EWG’s Skin Deep database provides an important resource on phthalate-free personal care products.

Despite pressure from consumer advocacy groups, the U.S. Food and Drug Administration has not yet banned phthalates in food packaging.
 

Bisphenol A (BPA)

BPA is a chemical additive used to make clear and hard polycarbonate plastics, as well as epoxy and thermal papers. BPA is one of the highest-volume chemicals, with roughly 6 billion pounds produced each year. BPA is traditionally found in many clear plastic bottles and sippy cups, as well as in the lining of canned foods.

Structurally, BPA acts as an estrogen mimetic and has been associated with cardiovascular disease, obesity, and male sexual dysfunction. Since 2012, BPA has been banned in sippy cups and baby bottles, but there is some debate as to whether its replacements (bisphenol S and bisphenol F) are any safer; they appear to have similar hormonal effects as BPA.

As with phthalates, the majority of ingestion is thought to be food related. BPA has been found in more than 90% of a representative study population in the United States.

Guidance advises avoiding polycarbonate plastics (identifiable with the recycling code number 7), as well as avoiding handling thermal papers such as tickets and receipts, if possible. Food and beverages should be stored in glass or stainless steel. If plastic must be used, opt for polycarbonate- and polyvinyl chloride–free plastics, and food and beverages should never be reheated in plastic containers or wrapping. Canned foods should ideally be avoided, particularly canned tunas and condensed soups. If canned products are bought, they should ideally be BPA free.
 

Dioxins and polychlorinated biphenyls (PCBs)

Dioxins are mainly the byproducts of industrial practices; they are released after incineration, trash burning, and fires. PCBs, which are somewhat structurally related to dioxins, were previously found in products such as flame retardants and coolants. Dioxins and PCBs are often grouped in the same category under the umbrella term “persistent organic pollutants” because they break down slowly and remain in the environment even after emissions have been curbed.

Tetrachlorodibenzodioxin, perhaps the best-known dioxin, is a known carcinogen. Dioxins also have been associated with a host of health implications in development, immunity, and reproductive and endocrine systems. Higher levels of PCB exposure have also been associated with an increased risk for mortality from cardiovascular disease.

Notably, dioxin emissions have been reduced by 90% since the 1980s, and the U.S. Environmental Protection Agency has banned the use of PCBs in industrial manufacturing since 1979. However, environmental dioxins and PCBs still enter the food chain and accumulate in fat.

The best ways to avoid exposures are through limiting meat, fish, and dairy consumption and trimming the skin and fat from meats. The level of dioxins and PCBs found in meat, eggs, fish, and dairy are approximately 5-10 times higher than they are in plant-based foods. Research has shown that farmed salmon is likely to be the most PCB-contaminated protein source in the U.S. diet; however, newer forms of land-based and sustainable aquaculture probably avoid this exposure.
 

Pesticides

The growth of modern monoculture agriculture in the United States over the past century has coincided with a dramatic surge in the use of industrial pesticides. In fact, over 90% of the U.S. population have pesticides in their urine and blood, regardless of where they live. Exposures are thought to be food related.

Approximately 1 billion pounds of pesticides are used annually in the United States, including nearly 300 million pounds of glyphosate, which has been identified as a probable carcinogen by European agencies. The EPA has not yet reached this conclusion, although the matter is currently being litigated.

A large European prospective cohort trial demonstrated a lower risk for cancer in those with a greater frequency of self-reported organic food consumption. In addition to cancer risk, relatively elevated blood levels of a pesticide known as beta-hexachlorocyclohexane (B-HCH) are associated with higher all-cause mortality. Also, exposure to DDE – a metabolite of DDT, a chlorinated pesticide heavily used in the 1940s-1960s that still persists in the environment today – has been shown to increase the risk for Alzheimer’s-type dementia as well as overall cognitive decline.

Because these chlorinated pesticides are often fat soluble, they seem to accumulate in animal products. Therefore, people consuming a vegetarian diet have been found to have lower levels of B-HCH. This has led to the recommendation that consumers of produce should favor organic over conventional, if possible. Here too, the EWG provides an important resource to consumers in the form of shopper guides regarding pesticides in produce.
 

Per- and polyfluoroalkyl substances (PFAS)

PFAS are a group of fluorinated compounds discovered in the 1930s. Their chemical composition includes a durable carbon-fluoride bond, giving them a persistence within the environment that has led to their being referred to as “forever chemicals.”

PFAS have been detected in the blood of 98% of Americans, and in the rainwater of locations as far afield as Tibet and Antarctica. Even low levels of exposure have been associated with an increased risk for cancer, liver disease, low birth weight, and hormonal disruption.

The properties of PFAS also make them both durable at very high heat and water repellent. Notoriously, the chemical was used by 3M to make Scotchgard for carpets and fabrics and by Dupont to make Teflon for nonstick coating of pots and pans. Although perfluorooctanoic acid (PFOA) was removed from nonstick cookware in 2013, PFAS – a family of thousands of synthetic compounds – remain common in fast-food packaging, water- and stain-repellent clothing, firefighting foam, and personal care products. PFAS are released into the environment during the breakdown of these consumer and industrial products, as well as from dumping from waste facilities.

Alarmingly, the EWG notes that up to 200 million Americans may be exposed to PFAS in their drinking water. In March 2021, the EPA announced that they will be regulating PFAS in drinking water; however, the regulations have not been finalized. Currently, it is up to individual states to test for its presence in the water. The EWG has compiled a map of all known PFAS contamination sites.

To avoid or prevent exposures from PFAS, recommendations include filtering tap water with either reverse osmosis or activated carbon filters, as well as avoiding fast food and carry-out food, if possible, and consumer products labeled as “water resistant,” “stain-resistant,” and “nonstick.”

In a testament to how harmful these chemicals are, the EPA recently revised their lifetime health advisories for PFAS, such as PFOA, to 0.004 parts per trillion, which is more than 10,000 times smaller than the previous limit of 70 parts per trillion. The EPA also has proposed formally designating certain PFAS chemicals as “hazardous substances.”

Dr. Goel, clinical assistant professor of medicine at Weill Cornell Medicine, New York, has disclosed no relevant financial relationships. A version of this article originally appeared on Medscape.com.

If the pandemic served as a window into our health, what it revealed was a U.S. population that is not only sick but also seemingly only getting sicker. Life expectancy is falling precipitously. Three-fourths of Americans are overweight or obese, half have diabetes or prediabetes, and a majority are metabolically unhealthy. Furthermore, the rates of allergic, inflammatory, and autoimmune diseases are rising at rates of 3%-9% per year in the West, far faster than the speed of genetic change in this population.

Of course, diet and lifestyle are major factors behind such trends, but a grossly underappreciated driver in what ails us is the role of environmental toxins and endocrine-disrupting chemicals. In years past, these factors have largely evaded the traditional Western medical establishment; however, mounting evidence now supports their significance in fertility, metabolic health, and cancer.

Although several industrial chemicals and toxins have been identified as carcinogens and have subsequently been regulated, many more remain persistent in the environment and continue to be freely used. It is therefore incumbent upon both the general public and clinicians to be knowledgeable about these exposures. Here, we review some of the most common exposures and the substantial health risks associated with them, along with some general guidance around best practices for how to minimize exposure.
 

Microplastics

“Microplastics” is a term used to describe small fragments or particles of plastic breakdown or microbeads from household or personal care products, measuring less than 5 mm in length.

Plastic waste is accumulating at alarming and devastating proportions – by 2050, it is estimated that by weight, there will be more plastic than fish in the oceans. That translates into hundreds of thousands of tons of microplastics and trillions of these particles in the seas. A recent study demonstrated that microplastics were present in the bloodstream in the majority of 22 otherwise healthy participants.

Since the 1950s, plastic exposure has been shown to promote tumorigenesis in animal studies, and in vitro studies have demonstrated the toxicity of microplastics at the cellular level. However, it is not well known whether the plastic itself is toxic or if it simply serves as a carrier for other environmental toxins to bioaccumulate.

According to Tasha Stoiber, a senior scientist at the Environmental Working Group, “Microplastics have been widely detected in fish and seafood, as well as other products like bottled water, beer, honey, and tap water.” The EWG states there are no formal advisories on fish consumption to avoid exposure to microplastics at the moment.

Pressure also is mounting for a ban on microbeads in personal care products.

Until such bans are put in place, it is advised to avoid single-use plastics, favor reusable tote bags for grocery shopping rather than plastic bags, and opt for loose leaf tea or paper tea bags rather than mesh-based alternatives.
 

Phthalates

Phthalates are chemicals used to make plastics soft and durable, as well as to bind fragrances. They are commonly found in household items such as vinyl (for example, flooring, shower curtains) and fragrances, air fresheners, and perfumes.

Phthalates are known hormone-disrupting chemicals, exposure to which has been associated with abnormal sexual and brain development in children, as well as lower levels of testosterone in men. Exposures are thought to occur via inhalation, ingestion, and skin contact; however, fasting studies demonstrate that a majority of exposure is probably food related.

To avoid phthalate exposures, recommendations include avoiding polyvinyl chloride plastics (particularly food containers, plastic wrap, and children’s toys), which are identifiable by the recycle code number 3, as well as air fresheners and fragranced products.

The EWG’s Skin Deep database provides an important resource on phthalate-free personal care products.

Despite pressure from consumer advocacy groups, the U.S. Food and Drug Administration has not yet banned phthalates in food packaging.
 

Bisphenol A (BPA)

BPA is a chemical additive used to make clear and hard polycarbonate plastics, as well as epoxy and thermal papers. BPA is one of the highest-volume chemicals, with roughly 6 billion pounds produced each year. BPA is traditionally found in many clear plastic bottles and sippy cups, as well as in the lining of canned foods.

Structurally, BPA acts as an estrogen mimetic and has been associated with cardiovascular disease, obesity, and male sexual dysfunction. Since 2012, BPA has been banned in sippy cups and baby bottles, but there is some debate as to whether its replacements (bisphenol S and bisphenol F) are any safer; they appear to have similar hormonal effects as BPA.

As with phthalates, the majority of ingestion is thought to be food related. BPA has been found in more than 90% of a representative study population in the United States.

Guidance advises avoiding polycarbonate plastics (identifiable with the recycling code number 7), as well as avoiding handling thermal papers such as tickets and receipts, if possible. Food and beverages should be stored in glass or stainless steel. If plastic must be used, opt for polycarbonate- and polyvinyl chloride–free plastics, and food and beverages should never be reheated in plastic containers or wrapping. Canned foods should ideally be avoided, particularly canned tunas and condensed soups. If canned products are bought, they should ideally be BPA free.
 

Dioxins and polychlorinated biphenyls (PCBs)

Dioxins are mainly the byproducts of industrial practices; they are released after incineration, trash burning, and fires. PCBs, which are somewhat structurally related to dioxins, were previously found in products such as flame retardants and coolants. Dioxins and PCBs are often grouped in the same category under the umbrella term “persistent organic pollutants” because they break down slowly and remain in the environment even after emissions have been curbed.

Tetrachlorodibenzodioxin, perhaps the best-known dioxin, is a known carcinogen. Dioxins also have been associated with a host of health implications in development, immunity, and reproductive and endocrine systems. Higher levels of PCB exposure have also been associated with an increased risk for mortality from cardiovascular disease.

Notably, dioxin emissions have been reduced by 90% since the 1980s, and the U.S. Environmental Protection Agency has banned the use of PCBs in industrial manufacturing since 1979. However, environmental dioxins and PCBs still enter the food chain and accumulate in fat.

The best ways to avoid exposures are through limiting meat, fish, and dairy consumption and trimming the skin and fat from meats. The level of dioxins and PCBs found in meat, eggs, fish, and dairy are approximately 5-10 times higher than they are in plant-based foods. Research has shown that farmed salmon is likely to be the most PCB-contaminated protein source in the U.S. diet; however, newer forms of land-based and sustainable aquaculture probably avoid this exposure.
 

Pesticides

The growth of modern monoculture agriculture in the United States over the past century has coincided with a dramatic surge in the use of industrial pesticides. In fact, over 90% of the U.S. population have pesticides in their urine and blood, regardless of where they live. Exposures are thought to be food related.

Approximately 1 billion pounds of pesticides are used annually in the United States, including nearly 300 million pounds of glyphosate, which has been identified as a probable carcinogen by European agencies. The EPA has not yet reached this conclusion, although the matter is currently being litigated.

A large European prospective cohort trial demonstrated a lower risk for cancer in those with a greater frequency of self-reported organic food consumption. In addition to cancer risk, relatively elevated blood levels of a pesticide known as beta-hexachlorocyclohexane (B-HCH) are associated with higher all-cause mortality. Also, exposure to DDE – a metabolite of DDT, a chlorinated pesticide heavily used in the 1940s-1960s that still persists in the environment today – has been shown to increase the risk for Alzheimer’s-type dementia as well as overall cognitive decline.

Because these chlorinated pesticides are often fat soluble, they seem to accumulate in animal products. Therefore, people consuming a vegetarian diet have been found to have lower levels of B-HCH. This has led to the recommendation that consumers of produce should favor organic over conventional, if possible. Here too, the EWG provides an important resource to consumers in the form of shopper guides regarding pesticides in produce.
 

Per- and polyfluoroalkyl substances (PFAS)

PFAS are a group of fluorinated compounds discovered in the 1930s. Their chemical composition includes a durable carbon-fluoride bond, giving them a persistence within the environment that has led to their being referred to as “forever chemicals.”

PFAS have been detected in the blood of 98% of Americans, and in the rainwater of locations as far afield as Tibet and Antarctica. Even low levels of exposure have been associated with an increased risk for cancer, liver disease, low birth weight, and hormonal disruption.

The properties of PFAS also make them both durable at very high heat and water repellent. Notoriously, the chemical was used by 3M to make Scotchgard for carpets and fabrics and by Dupont to make Teflon for nonstick coating of pots and pans. Although perfluorooctanoic acid (PFOA) was removed from nonstick cookware in 2013, PFAS – a family of thousands of synthetic compounds – remain common in fast-food packaging, water- and stain-repellent clothing, firefighting foam, and personal care products. PFAS are released into the environment during the breakdown of these consumer and industrial products, as well as from dumping from waste facilities.

Alarmingly, the EWG notes that up to 200 million Americans may be exposed to PFAS in their drinking water. In March 2021, the EPA announced that they will be regulating PFAS in drinking water; however, the regulations have not been finalized. Currently, it is up to individual states to test for its presence in the water. The EWG has compiled a map of all known PFAS contamination sites.

To avoid or prevent exposures from PFAS, recommendations include filtering tap water with either reverse osmosis or activated carbon filters, as well as avoiding fast food and carry-out food, if possible, and consumer products labeled as “water resistant,” “stain-resistant,” and “nonstick.”

In a testament to how harmful these chemicals are, the EPA recently revised their lifetime health advisories for PFAS, such as PFOA, to 0.004 parts per trillion, which is more than 10,000 times smaller than the previous limit of 70 parts per trillion. The EPA also has proposed formally designating certain PFAS chemicals as “hazardous substances.”

Dr. Goel, clinical assistant professor of medicine at Weill Cornell Medicine, New York, has disclosed no relevant financial relationships. A version of this article originally appeared on Medscape.com.

An investigational smartphone app that delivers cognitive behavioral therapy (CBT) to people with type 2 diabetes led to a significant 10 percentage point cut in the incidence of antihyperglycemic-drug intensification during 6 months’ follow-up, when compared with a control phone app, in the CBT app’s pivotal trial with 669 randomized patients.

Previously reported results from this trial, called BT-001, showed that people randomized to use the CBT app had a significant average 0.4 percentage point reduction in hemoglobin A1c, compared with controls, after 90 days for the trial’s primary endpoint, and a significant 0.29 percentage point reduction in A1c, compared with controls, after 180 days.

The new finding, that these incremental drops in A1c occurred while the control patients also received significantly more intensification of their antihyperglycemic medication, provides further evidence for the efficacy of the CBT app, said Marc P. Bonaca, MD, in a press conference organized by the American College of Cardiology in advance of its upcoming joint scientific sessions.

The CBT app “significantly reduced A1c despite less intensification of antihyperglycemic therapy,” noted Dr. Bonaca, a vascular medicine specialist and executive director of CPC Clinical Research, an academic research organization created by and affiliated with the University of Colorado at Denver, Aurora.

Based on positive safety and efficacy findings from the primary-endpoint phase of the BT-001 trial, reported in Diabetes Care, the company developing the CBT app, Better Therapeutics, said in a statement that the U.S. Food and Drug Administration accepted the company’s application for de novo classification and marketing approval of the app, also called BT-001. If the agency grants this classification and marketing approval, the company plans to sell the app on a prescription basis for use by people with type 2 diabetes.


 

CBT app gives patients problem-solving skills

CBT gives people with type 2 diabetes a way to better understand their unhelpful behaviors and motivations and teaches them problem-solving skills. Providing this counseling via an app addresses the challenge of making the intervention scalable to a broad range of patients, Dr. Bonaca explained.

“Clinicians are frustrated by trying to produce behavioral change” in patients. The BT-001 app “provides a new avenue to treatment,” an approach that clinicians have been “very receptive” to using “once they understand the mechanism,” Dr. Bonaca said during the press conference. “The effect at 90 days was very similar to what a drug would do. It’s not just drugs any more” for treating people with type 2 diabetes, he declared.

“CBT is an empirically supported psychotherapy for a variety of emotional disorders, and it has been adapted to target specific emotional distress in the context of chronic illness,” commented Amit Shapira, PhD, a clinical psychologist at the Joslin Diabetes Center in Boston who has not been involved in the BT-001 studies. A CBT protocol designed for diabetes, CBT for Adherence and Depression “has been shown to have a positive impact on depression symptoms and glycemic control in adults with type 2 diabetes,” Dr. Shapira noted in an interview.

“Once a physician explains this [CBT] app and patients understand how to use it, then patients will be happy to use it,” commented Julia Grapsa, MD, PhD, a cardiologist at St. Thomas Hospital in London, who moderated the press conference. “We may see an explosion of apps like this one, designed to help better control” other chronic disorders, such as elevated blood pressure or abnormal lipid levels, Dr. Grapsa predicted. “I’m very optimistic that these apps have a great future in health care.”
 

Forty percent relative cut in new antihyperglycemic drug use

The BT-001 study randomized 669 adults with smartphone access and type 2 diabetes at any of six U.S. sites. The enrolled patients had type 2 diabetes for an average of 11 years, and an A1c of 7%-10.9% with an average level of 8.2%. Participants had to be on a stable medication regimen for at least 3 months but not using prandial insulin, and their treatment regimens could undergo adjustment during the trial. At baseline, each subject was on an average of 2.1 antihyperglycemic medications, including 90% on metformin and 42% on a sulfonylurea.

The new results reported by Dr. Bonaca showed that, during follow-up, people using the app had a 14.4% rate of antihyperglycemic drug intensification compared with a 24.4% rate among the controls, a roughly 40% relative decrease in new antihyperglycemic medication use. In addition, among those using insulin at baseline, 3.8% of controls increased their insulin dose, compared with 1.5% of those using the CBT app, while insulin doses decreased in 0.9% of the control subjects and in 2.2% of those using the BT-001 app.

Further study findings, first reported by Dr. Bonaca at the American Heart Association scientific sessions in late 2022, also showed a clear dose-response pattern for the CBT app: the more CBT lessons a person completed, the greater their reduction in A1c over 180 days of app use. People who used the app fewer than 10 times had an average reduction from baseline in their A1c of less than 0.1 percentage points. Among those who used the app 10-20 times (a subgroup with roughly one-third of the people randomized to app use), average A1c reduction increased to about 0.4 percentage points, and among those who used the app more than 20 times (also about one-third of the intervention group), the average A1c reduction from baseline was about 0.6 percentage points.

“It would be interesting to learn more about the adults who engaged with the app” and had a higher use rate “to provide more targeted care” with the app to people who match the profiles of those who were more likely to use the app during the trial, said Dr. Shapira.

This “clear” dose-response relationship “was one of the most exciting findings. It helps validate the mechanism,” Dr. Bonaca said during the press conference. “We’re now modeling which patients were the most engaged” with using the app, and “looking at ways to increase app engagement.”

Better Therapeutics also announced, in December 2022, results from a separate, uncontrolled study of a similar CBT app in 19 people with nonalcoholic fatty liver disease and nonalcoholic steatohepatitis. The findings showed that use of the tested app linked with an average 16% drop from baseline in liver fat content as measured by MRI, as well as other improvements in markers of hepatic function. The company said in a statement that based on these findings it planned to apply for breakthrough-device designation with the FDA for use of a liver-specific CBT app in people with nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.

The BT-001 trial was sponsored by Better Therapeutics, the company developing the app. CPC Clinical Research receives research and consulting funding from numerous companies. Dr. Bonaca has been a consultant to Audentes, and is a stockholder of Medtronic and Pfizer. Dr. Shapira and Dr. Grapsa had no disclosures.

An investigational smartphone app that delivers cognitive behavioral therapy (CBT) to people with type 2 diabetes led to a significant 10 percentage point cut in the incidence of antihyperglycemic-drug intensification during 6 months’ follow-up, when compared with a control phone app, in the CBT app’s pivotal trial with 669 randomized patients.

Previously reported results from this trial, called BT-001, showed that people randomized to use the CBT app had a significant average 0.4 percentage point reduction in hemoglobin A1c, compared with controls, after 90 days for the trial’s primary endpoint, and a significant 0.29 percentage point reduction in A1c, compared with controls, after 180 days.

The new finding, that these incremental drops in A1c occurred while the control patients also received significantly more intensification of their antihyperglycemic medication, provides further evidence for the efficacy of the CBT app, said Marc P. Bonaca, MD, in a press conference organized by the American College of Cardiology in advance of its upcoming joint scientific sessions.

The CBT app “significantly reduced A1c despite less intensification of antihyperglycemic therapy,” noted Dr. Bonaca, a vascular medicine specialist and executive director of CPC Clinical Research, an academic research organization created by and affiliated with the University of Colorado at Denver, Aurora.

Based on positive safety and efficacy findings from the primary-endpoint phase of the BT-001 trial, reported in Diabetes Care, the company developing the CBT app, Better Therapeutics, said in a statement that the U.S. Food and Drug Administration accepted the company’s application for de novo classification and marketing approval of the app, also called BT-001. If the agency grants this classification and marketing approval, the company plans to sell the app on a prescription basis for use by people with type 2 diabetes.


 

CBT app gives patients problem-solving skills

CBT gives people with type 2 diabetes a way to better understand their unhelpful behaviors and motivations and teaches them problem-solving skills. Providing this counseling via an app addresses the challenge of making the intervention scalable to a broad range of patients, Dr. Bonaca explained.

“Clinicians are frustrated by trying to produce behavioral change” in patients. The BT-001 app “provides a new avenue to treatment,” an approach that clinicians have been “very receptive” to using “once they understand the mechanism,” Dr. Bonaca said during the press conference. “The effect at 90 days was very similar to what a drug would do. It’s not just drugs any more” for treating people with type 2 diabetes, he declared.

“CBT is an empirically supported psychotherapy for a variety of emotional disorders, and it has been adapted to target specific emotional distress in the context of chronic illness,” commented Amit Shapira, PhD, a clinical psychologist at the Joslin Diabetes Center in Boston who has not been involved in the BT-001 studies. A CBT protocol designed for diabetes, CBT for Adherence and Depression “has been shown to have a positive impact on depression symptoms and glycemic control in adults with type 2 diabetes,” Dr. Shapira noted in an interview.

“Once a physician explains this [CBT] app and patients understand how to use it, then patients will be happy to use it,” commented Julia Grapsa, MD, PhD, a cardiologist at St. Thomas Hospital in London, who moderated the press conference. “We may see an explosion of apps like this one, designed to help better control” other chronic disorders, such as elevated blood pressure or abnormal lipid levels, Dr. Grapsa predicted. “I’m very optimistic that these apps have a great future in health care.”
 

Forty percent relative cut in new antihyperglycemic drug use

The BT-001 study randomized 669 adults with smartphone access and type 2 diabetes at any of six U.S. sites. The enrolled patients had type 2 diabetes for an average of 11 years, and an A1c of 7%-10.9% with an average level of 8.2%. Participants had to be on a stable medication regimen for at least 3 months but not using prandial insulin, and their treatment regimens could undergo adjustment during the trial. At baseline, each subject was on an average of 2.1 antihyperglycemic medications, including 90% on metformin and 42% on a sulfonylurea.

The new results reported by Dr. Bonaca showed that, during follow-up, people using the app had a 14.4% rate of antihyperglycemic drug intensification compared with a 24.4% rate among the controls, a roughly 40% relative decrease in new antihyperglycemic medication use. In addition, among those using insulin at baseline, 3.8% of controls increased their insulin dose, compared with 1.5% of those using the CBT app, while insulin doses decreased in 0.9% of the control subjects and in 2.2% of those using the BT-001 app.

Further study findings, first reported by Dr. Bonaca at the American Heart Association scientific sessions in late 2022, also showed a clear dose-response pattern for the CBT app: the more CBT lessons a person completed, the greater their reduction in A1c over 180 days of app use. People who used the app fewer than 10 times had an average reduction from baseline in their A1c of less than 0.1 percentage points. Among those who used the app 10-20 times (a subgroup with roughly one-third of the people randomized to app use), average A1c reduction increased to about 0.4 percentage points, and among those who used the app more than 20 times (also about one-third of the intervention group), the average A1c reduction from baseline was about 0.6 percentage points.

“It would be interesting to learn more about the adults who engaged with the app” and had a higher use rate “to provide more targeted care” with the app to people who match the profiles of those who were more likely to use the app during the trial, said Dr. Shapira.

This “clear” dose-response relationship “was one of the most exciting findings. It helps validate the mechanism,” Dr. Bonaca said during the press conference. “We’re now modeling which patients were the most engaged” with using the app, and “looking at ways to increase app engagement.”

Better Therapeutics also announced, in December 2022, results from a separate, uncontrolled study of a similar CBT app in 19 people with nonalcoholic fatty liver disease and nonalcoholic steatohepatitis. The findings showed that use of the tested app linked with an average 16% drop from baseline in liver fat content as measured by MRI, as well as other improvements in markers of hepatic function. The company said in a statement that based on these findings it planned to apply for breakthrough-device designation with the FDA for use of a liver-specific CBT app in people with nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.

The BT-001 trial was sponsored by Better Therapeutics, the company developing the app. CPC Clinical Research receives research and consulting funding from numerous companies. Dr. Bonaca has been a consultant to Audentes, and is a stockholder of Medtronic and Pfizer. Dr. Shapira and Dr. Grapsa had no disclosures.

An investigational smartphone app that delivers cognitive behavioral therapy (CBT) to people with type 2 diabetes led to a significant 10 percentage point cut in the incidence of antihyperglycemic-drug intensification during 6 months’ follow-up, when compared with a control phone app, in the CBT app’s pivotal trial with 669 randomized patients.

Previously reported results from this trial, called BT-001, showed that people randomized to use the CBT app had a significant average 0.4 percentage point reduction in hemoglobin A1c, compared with controls, after 90 days for the trial’s primary endpoint, and a significant 0.29 percentage point reduction in A1c, compared with controls, after 180 days.

The new finding, that these incremental drops in A1c occurred while the control patients also received significantly more intensification of their antihyperglycemic medication, provides further evidence for the efficacy of the CBT app, said Marc P. Bonaca, MD, in a press conference organized by the American College of Cardiology in advance of its upcoming joint scientific sessions.

The CBT app “significantly reduced A1c despite less intensification of antihyperglycemic therapy,” noted Dr. Bonaca, a vascular medicine specialist and executive director of CPC Clinical Research, an academic research organization created by and affiliated with the University of Colorado at Denver, Aurora.

Based on positive safety and efficacy findings from the primary-endpoint phase of the BT-001 trial, reported in Diabetes Care, the company developing the CBT app, Better Therapeutics, said in a statement that the U.S. Food and Drug Administration accepted the company’s application for de novo classification and marketing approval of the app, also called BT-001. If the agency grants this classification and marketing approval, the company plans to sell the app on a prescription basis for use by people with type 2 diabetes.


 

CBT app gives patients problem-solving skills

CBT gives people with type 2 diabetes a way to better understand their unhelpful behaviors and motivations and teaches them problem-solving skills. Providing this counseling via an app addresses the challenge of making the intervention scalable to a broad range of patients, Dr. Bonaca explained.

“Clinicians are frustrated by trying to produce behavioral change” in patients. The BT-001 app “provides a new avenue to treatment,” an approach that clinicians have been “very receptive” to using “once they understand the mechanism,” Dr. Bonaca said during the press conference. “The effect at 90 days was very similar to what a drug would do. It’s not just drugs any more” for treating people with type 2 diabetes, he declared.

“CBT is an empirically supported psychotherapy for a variety of emotional disorders, and it has been adapted to target specific emotional distress in the context of chronic illness,” commented Amit Shapira, PhD, a clinical psychologist at the Joslin Diabetes Center in Boston who has not been involved in the BT-001 studies. A CBT protocol designed for diabetes, CBT for Adherence and Depression “has been shown to have a positive impact on depression symptoms and glycemic control in adults with type 2 diabetes,” Dr. Shapira noted in an interview.

“Once a physician explains this [CBT] app and patients understand how to use it, then patients will be happy to use it,” commented Julia Grapsa, MD, PhD, a cardiologist at St. Thomas Hospital in London, who moderated the press conference. “We may see an explosion of apps like this one, designed to help better control” other chronic disorders, such as elevated blood pressure or abnormal lipid levels, Dr. Grapsa predicted. “I’m very optimistic that these apps have a great future in health care.”
 

Forty percent relative cut in new antihyperglycemic drug use

The BT-001 study randomized 669 adults with smartphone access and type 2 diabetes at any of six U.S. sites. The enrolled patients had type 2 diabetes for an average of 11 years, and an A1c of 7%-10.9% with an average level of 8.2%. Participants had to be on a stable medication regimen for at least 3 months but not using prandial insulin, and their treatment regimens could undergo adjustment during the trial. At baseline, each subject was on an average of 2.1 antihyperglycemic medications, including 90% on metformin and 42% on a sulfonylurea.

The new results reported by Dr. Bonaca showed that, during follow-up, people using the app had a 14.4% rate of antihyperglycemic drug intensification compared with a 24.4% rate among the controls, a roughly 40% relative decrease in new antihyperglycemic medication use. In addition, among those using insulin at baseline, 3.8% of controls increased their insulin dose, compared with 1.5% of those using the CBT app, while insulin doses decreased in 0.9% of the control subjects and in 2.2% of those using the BT-001 app.

Further study findings, first reported by Dr. Bonaca at the American Heart Association scientific sessions in late 2022, also showed a clear dose-response pattern for the CBT app: the more CBT lessons a person completed, the greater their reduction in A1c over 180 days of app use. People who used the app fewer than 10 times had an average reduction from baseline in their A1c of less than 0.1 percentage points. Among those who used the app 10-20 times (a subgroup with roughly one-third of the people randomized to app use), average A1c reduction increased to about 0.4 percentage points, and among those who used the app more than 20 times (also about one-third of the intervention group), the average A1c reduction from baseline was about 0.6 percentage points.

“It would be interesting to learn more about the adults who engaged with the app” and had a higher use rate “to provide more targeted care” with the app to people who match the profiles of those who were more likely to use the app during the trial, said Dr. Shapira.

This “clear” dose-response relationship “was one of the most exciting findings. It helps validate the mechanism,” Dr. Bonaca said during the press conference. “We’re now modeling which patients were the most engaged” with using the app, and “looking at ways to increase app engagement.”

Better Therapeutics also announced, in December 2022, results from a separate, uncontrolled study of a similar CBT app in 19 people with nonalcoholic fatty liver disease and nonalcoholic steatohepatitis. The findings showed that use of the tested app linked with an average 16% drop from baseline in liver fat content as measured by MRI, as well as other improvements in markers of hepatic function. The company said in a statement that based on these findings it planned to apply for breakthrough-device designation with the FDA for use of a liver-specific CBT app in people with nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.

The BT-001 trial was sponsored by Better Therapeutics, the company developing the app. CPC Clinical Research receives research and consulting funding from numerous companies. Dr. Bonaca has been a consultant to Audentes, and is a stockholder of Medtronic and Pfizer. Dr. Shapira and Dr. Grapsa had no disclosures.

There are times when, as health care providers dealing with the stress of the profession, many doctors feel that tapping into a higher purpose – or even praying – might be a helpful way to cope.

Whether you’re spiritual, religious – or neither – the Medscape Physician Lifestyle & Happiness Report 2023 asked if you have a religious or spiritual belief. Turns out 69% of physicians shared that they have a spiritual or religious practice.
 

Tapping into the universe

Nick Shamie, MD, an orthopedic surgeon specializing in spine surgery at University of California, Los Angeles, says the constant challenges of making life-and-death decisions offer an opportunity to check in with a higher power.

“Sometimes when I’m going into a tough surgery or have a tough situation, I pause and think about how this isn’t about me and the situation I’m in,” says Dr. Shamie, whose family is Muslim. “It’s about the whole universe. I feel like someone, or some being, is looking over my shoulders, and if my intentions are good, I’ll be fine. The person I’m going to take care of will be fine. That’s how I use my faith.”

Having a belief in something greater than herself also fuels Jill Carnahan, MD, a family medicine physician and functional medicine expert in Boulder, Colo.

“This is key for me as a physician,” says Dr. Carnahan, author of “Unexpected: Finding Resilience Through Functional Medicine, Science, and Faith.” “I urge physicians to think about their source of strength. That’s not necessarily even religious. It could be meditation or being in nature.”

Dr. Carnahan likes to share with patients that there are lessons that can come from being ill – whether treating ill patients or struggling with one’s own illness.

“I like to teach this idea of illness as a teacher,” says Dr. Carnahan, who has Crohn’s disease and is a cancer survivor. “This is tough, but what you’re saying here is that there is meaning or purpose to this experience. It brings awareness to your life that may not have been there before.”

Often illness is our body’s way of getting our attention that our life, relationships, or work needs adjustment. Illness can be a reminder to make changes. “For example, a diagnosis of autoimmunity may be a reminder to take better care of ourselves, or a diagnosis of cancer may cause us to get out of an unhealthy relationship or change jobs to do something more fulfilling, as we have increased awareness of the brevity of life.”

When patients are affected by illness, pain, reduced functionality, and even imminent death, understanding the experience is difficult, and finding any purpose in it may seem impossible. Still, studies show that those who find meaning in the experience cope better with their illness.

Finding that meaning may be a strong driver of survival and may be positively related to hope, belief, and happiness.
 

Spirituality supports patients

Even if you’re not religious yourself, it can be helpful to support a patient who opts to pray before an arduous procedure, says Sharyar Baradaran, DDS, a periodontist specializing in gum surgery in Beverly Hills, Calif.

“I’ve had patients who go into meditation mode, or they say a prayer before I start surgery,” he says. “I take that opportunity to connect. In that instance, we hold hands. I want them to know that I understand what they’re going through and how they’re trying to find the courage to undergo surgery.”

When Dr. Shamie was a child, his father described religion as embodying the basic tenet of being good to others. “I’ve taken that to heart,” he says. “All religions, all faiths have that as a central premise.”

These doctors agree that when you take the time to stop and hold a patient’s hand, bow your head during their prayer, or acknowledge or speak for a few moments about their faith, especially during a health crisis, surgery, or challenging diagnosis, patients appreciate it and develop an even deeper connection with you.

Dr. Baradaran believes spirituality can play an important role in how health care providers care for patients. Though it may not be widely discussed or reported, and physicians may find little time and space to address patients’ spiritual needs, there is growing sensitivity regarding spirituality in health care. One study found that while physicians understand its importance, nurses are more apt to integrate spirituality into practice.

“No matter the religion, if you’re spiritual, it means you’re listening and being respectful,” says Dr. Baradaran, who is Jewish. “There are times that I’m not familiar with the prayers my patients are saying, but I always take them in, absorb them, and respect them. This allows me to have a deeper connection with them, which is wonderful.”

Dr. Shamie says that he turns to his faith in good times as well as tough ones.

“I see a lot of people who are dealing with very difficult situations, and it’s not their choice to be in this position,” he says. “At those moments, I think to myself how fortunate I am that I’m not experiencing what this individual or family is going through. I do thank God at that time. I appreciate the life I have, and when I witness hardships, it resets my appreciation.”

For Dr. Carnahan, faith is about becoming comfortable with the inevitable uncertainty of life. It’s also about finding ways to tap into the day’s stresses.

“As physicians, we’re workaholics, and one in four of us are burnt out,” she says. “One solution that really works is to step back from the day-to-day grind and find time to pray or meditate or be in nature.”

There are times when a tragedy occurs, and despite your most intense efforts, a patient may die. Those experiences can be crushing to a physician. However, to guide you through the loss of a patient or the daily juggles of managing your practice, Dr. Carnahan suggests finding time every morning to focus on the day ahead and how you connect with the universe.

“I take 15 minutes in the morning and think about how I will bring love to the world,” she says. “If you look for the miracles and the good and the unexpected, that gratitude shift allows your mind to be transformed by what’s happening. It’s often in those moments that you’ll realize again why you went into medicine in the first place.”
 

Doctors without faith

So, what does this mean if you’re among the 25% of physicians in the Medscape report who do not have a religious or spiritual leaning and aren’t apt to be spiritually minded when it comes to your patients? An article on KevinMD.com points out that atheist physicians are often in the closet about their atheism because they usually bow their heads or keep a respectful silence when a patient or their family offers a prayer request before surgery or a prayer of thanks after a procedure.

The retired atheist physician who wrote the piece reminds us that nonreligious doctors are good people with a high moral compass who may not believe in an afterlife. However, that means they try to make their patients’ quality of life the best they can.

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

There are times when, as health care providers dealing with the stress of the profession, many doctors feel that tapping into a higher purpose – or even praying – might be a helpful way to cope.

Whether you’re spiritual, religious – or neither – the Medscape Physician Lifestyle & Happiness Report 2023 asked if you have a religious or spiritual belief. Turns out 69% of physicians shared that they have a spiritual or religious practice.
 

Tapping into the universe

Nick Shamie, MD, an orthopedic surgeon specializing in spine surgery at University of California, Los Angeles, says the constant challenges of making life-and-death decisions offer an opportunity to check in with a higher power.

“Sometimes when I’m going into a tough surgery or have a tough situation, I pause and think about how this isn’t about me and the situation I’m in,” says Dr. Shamie, whose family is Muslim. “It’s about the whole universe. I feel like someone, or some being, is looking over my shoulders, and if my intentions are good, I’ll be fine. The person I’m going to take care of will be fine. That’s how I use my faith.”

Having a belief in something greater than herself also fuels Jill Carnahan, MD, a family medicine physician and functional medicine expert in Boulder, Colo.

“This is key for me as a physician,” says Dr. Carnahan, author of “Unexpected: Finding Resilience Through Functional Medicine, Science, and Faith.” “I urge physicians to think about their source of strength. That’s not necessarily even religious. It could be meditation or being in nature.”

Dr. Carnahan likes to share with patients that there are lessons that can come from being ill – whether treating ill patients or struggling with one’s own illness.

“I like to teach this idea of illness as a teacher,” says Dr. Carnahan, who has Crohn’s disease and is a cancer survivor. “This is tough, but what you’re saying here is that there is meaning or purpose to this experience. It brings awareness to your life that may not have been there before.”

Often illness is our body’s way of getting our attention that our life, relationships, or work needs adjustment. Illness can be a reminder to make changes. “For example, a diagnosis of autoimmunity may be a reminder to take better care of ourselves, or a diagnosis of cancer may cause us to get out of an unhealthy relationship or change jobs to do something more fulfilling, as we have increased awareness of the brevity of life.”

When patients are affected by illness, pain, reduced functionality, and even imminent death, understanding the experience is difficult, and finding any purpose in it may seem impossible. Still, studies show that those who find meaning in the experience cope better with their illness.

Finding that meaning may be a strong driver of survival and may be positively related to hope, belief, and happiness.
 

Spirituality supports patients

Even if you’re not religious yourself, it can be helpful to support a patient who opts to pray before an arduous procedure, says Sharyar Baradaran, DDS, a periodontist specializing in gum surgery in Beverly Hills, Calif.

“I’ve had patients who go into meditation mode, or they say a prayer before I start surgery,” he says. “I take that opportunity to connect. In that instance, we hold hands. I want them to know that I understand what they’re going through and how they’re trying to find the courage to undergo surgery.”

When Dr. Shamie was a child, his father described religion as embodying the basic tenet of being good to others. “I’ve taken that to heart,” he says. “All religions, all faiths have that as a central premise.”

These doctors agree that when you take the time to stop and hold a patient’s hand, bow your head during their prayer, or acknowledge or speak for a few moments about their faith, especially during a health crisis, surgery, or challenging diagnosis, patients appreciate it and develop an even deeper connection with you.

Dr. Baradaran believes spirituality can play an important role in how health care providers care for patients. Though it may not be widely discussed or reported, and physicians may find little time and space to address patients’ spiritual needs, there is growing sensitivity regarding spirituality in health care. One study found that while physicians understand its importance, nurses are more apt to integrate spirituality into practice.

“No matter the religion, if you’re spiritual, it means you’re listening and being respectful,” says Dr. Baradaran, who is Jewish. “There are times that I’m not familiar with the prayers my patients are saying, but I always take them in, absorb them, and respect them. This allows me to have a deeper connection with them, which is wonderful.”

Dr. Shamie says that he turns to his faith in good times as well as tough ones.

“I see a lot of people who are dealing with very difficult situations, and it’s not their choice to be in this position,” he says. “At those moments, I think to myself how fortunate I am that I’m not experiencing what this individual or family is going through. I do thank God at that time. I appreciate the life I have, and when I witness hardships, it resets my appreciation.”

For Dr. Carnahan, faith is about becoming comfortable with the inevitable uncertainty of life. It’s also about finding ways to tap into the day’s stresses.

“As physicians, we’re workaholics, and one in four of us are burnt out,” she says. “One solution that really works is to step back from the day-to-day grind and find time to pray or meditate or be in nature.”

There are times when a tragedy occurs, and despite your most intense efforts, a patient may die. Those experiences can be crushing to a physician. However, to guide you through the loss of a patient or the daily juggles of managing your practice, Dr. Carnahan suggests finding time every morning to focus on the day ahead and how you connect with the universe.

“I take 15 minutes in the morning and think about how I will bring love to the world,” she says. “If you look for the miracles and the good and the unexpected, that gratitude shift allows your mind to be transformed by what’s happening. It’s often in those moments that you’ll realize again why you went into medicine in the first place.”
 

Doctors without faith

So, what does this mean if you’re among the 25% of physicians in the Medscape report who do not have a religious or spiritual leaning and aren’t apt to be spiritually minded when it comes to your patients? An article on KevinMD.com points out that atheist physicians are often in the closet about their atheism because they usually bow their heads or keep a respectful silence when a patient or their family offers a prayer request before surgery or a prayer of thanks after a procedure.

The retired atheist physician who wrote the piece reminds us that nonreligious doctors are good people with a high moral compass who may not believe in an afterlife. However, that means they try to make their patients’ quality of life the best they can.

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

There are times when, as health care providers dealing with the stress of the profession, many doctors feel that tapping into a higher purpose – or even praying – might be a helpful way to cope.

Whether you’re spiritual, religious – or neither – the Medscape Physician Lifestyle & Happiness Report 2023 asked if you have a religious or spiritual belief. Turns out 69% of physicians shared that they have a spiritual or religious practice.
 

Tapping into the universe

Nick Shamie, MD, an orthopedic surgeon specializing in spine surgery at University of California, Los Angeles, says the constant challenges of making life-and-death decisions offer an opportunity to check in with a higher power.

“Sometimes when I’m going into a tough surgery or have a tough situation, I pause and think about how this isn’t about me and the situation I’m in,” says Dr. Shamie, whose family is Muslim. “It’s about the whole universe. I feel like someone, or some being, is looking over my shoulders, and if my intentions are good, I’ll be fine. The person I’m going to take care of will be fine. That’s how I use my faith.”

Having a belief in something greater than herself also fuels Jill Carnahan, MD, a family medicine physician and functional medicine expert in Boulder, Colo.

“This is key for me as a physician,” says Dr. Carnahan, author of “Unexpected: Finding Resilience Through Functional Medicine, Science, and Faith.” “I urge physicians to think about their source of strength. That’s not necessarily even religious. It could be meditation or being in nature.”

Dr. Carnahan likes to share with patients that there are lessons that can come from being ill – whether treating ill patients or struggling with one’s own illness.

“I like to teach this idea of illness as a teacher,” says Dr. Carnahan, who has Crohn’s disease and is a cancer survivor. “This is tough, but what you’re saying here is that there is meaning or purpose to this experience. It brings awareness to your life that may not have been there before.”

Often illness is our body’s way of getting our attention that our life, relationships, or work needs adjustment. Illness can be a reminder to make changes. “For example, a diagnosis of autoimmunity may be a reminder to take better care of ourselves, or a diagnosis of cancer may cause us to get out of an unhealthy relationship or change jobs to do something more fulfilling, as we have increased awareness of the brevity of life.”

When patients are affected by illness, pain, reduced functionality, and even imminent death, understanding the experience is difficult, and finding any purpose in it may seem impossible. Still, studies show that those who find meaning in the experience cope better with their illness.

Finding that meaning may be a strong driver of survival and may be positively related to hope, belief, and happiness.
 

Spirituality supports patients

Even if you’re not religious yourself, it can be helpful to support a patient who opts to pray before an arduous procedure, says Sharyar Baradaran, DDS, a periodontist specializing in gum surgery in Beverly Hills, Calif.

“I’ve had patients who go into meditation mode, or they say a prayer before I start surgery,” he says. “I take that opportunity to connect. In that instance, we hold hands. I want them to know that I understand what they’re going through and how they’re trying to find the courage to undergo surgery.”

When Dr. Shamie was a child, his father described religion as embodying the basic tenet of being good to others. “I’ve taken that to heart,” he says. “All religions, all faiths have that as a central premise.”

These doctors agree that when you take the time to stop and hold a patient’s hand, bow your head during their prayer, or acknowledge or speak for a few moments about their faith, especially during a health crisis, surgery, or challenging diagnosis, patients appreciate it and develop an even deeper connection with you.

Dr. Baradaran believes spirituality can play an important role in how health care providers care for patients. Though it may not be widely discussed or reported, and physicians may find little time and space to address patients’ spiritual needs, there is growing sensitivity regarding spirituality in health care. One study found that while physicians understand its importance, nurses are more apt to integrate spirituality into practice.

“No matter the religion, if you’re spiritual, it means you’re listening and being respectful,” says Dr. Baradaran, who is Jewish. “There are times that I’m not familiar with the prayers my patients are saying, but I always take them in, absorb them, and respect them. This allows me to have a deeper connection with them, which is wonderful.”

Dr. Shamie says that he turns to his faith in good times as well as tough ones.

“I see a lot of people who are dealing with very difficult situations, and it’s not their choice to be in this position,” he says. “At those moments, I think to myself how fortunate I am that I’m not experiencing what this individual or family is going through. I do thank God at that time. I appreciate the life I have, and when I witness hardships, it resets my appreciation.”

For Dr. Carnahan, faith is about becoming comfortable with the inevitable uncertainty of life. It’s also about finding ways to tap into the day’s stresses.

“As physicians, we’re workaholics, and one in four of us are burnt out,” she says. “One solution that really works is to step back from the day-to-day grind and find time to pray or meditate or be in nature.”

There are times when a tragedy occurs, and despite your most intense efforts, a patient may die. Those experiences can be crushing to a physician. However, to guide you through the loss of a patient or the daily juggles of managing your practice, Dr. Carnahan suggests finding time every morning to focus on the day ahead and how you connect with the universe.

“I take 15 minutes in the morning and think about how I will bring love to the world,” she says. “If you look for the miracles and the good and the unexpected, that gratitude shift allows your mind to be transformed by what’s happening. It’s often in those moments that you’ll realize again why you went into medicine in the first place.”
 

Doctors without faith

So, what does this mean if you’re among the 25% of physicians in the Medscape report who do not have a religious or spiritual leaning and aren’t apt to be spiritually minded when it comes to your patients? An article on KevinMD.com points out that atheist physicians are often in the closet about their atheism because they usually bow their heads or keep a respectful silence when a patient or their family offers a prayer request before surgery or a prayer of thanks after a procedure.

The retired atheist physician who wrote the piece reminds us that nonreligious doctors are good people with a high moral compass who may not believe in an afterlife. However, that means they try to make their patients’ quality of life the best they can.

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

New VA rule proposes to eliminate many copays for Native American veteran.

The US Department of Veterans Affairs (VA) has proposed a new rule that would waive medical copayments incurred on or after January 5, 2022, for eligible American Indian and Alaska Native (AI/AN) veterans.

The policy is intended to encourage veterans to seek regular primary care treatment, the VA says. “It’s no mystery to a lot of people that health care is sometimes hard to come by in many Native American communities,” Travis Trueblood, director of the VA Office of Tribal Health, told reporters in January. “So, this effort by VA will enhance getting people into the facilities, helping them feel welcome and getting them to use those benefits that they've earned.”

Copayments for more than 3 visits to community-based urgent care in any calendar year would still be required. Follow-up care provided by a VA-authorized primary care provider would be exempt from copays. Members of federally recognized tribes are already exempt from copays at Indian Health Service clinics.

Eligibility may be based in part on documentation issued by AI/AN tribal governments to show tribal membership. The VA has proposed the documentation requirement “as this recognizes tribal sovereignty and promotes the Nation-to-Nation relationship that exists between the United States and tribal governments.” The requirement, the notice says, is consistent with the preferences of tribal leaders.

The regulation implements a requirement in the Johnny Isakson and David P. Roe, MD, Veterans Health Care and Benefits Improvement Act of 2020, which prohibited the VA from collecting copayments from AI/AN veterans for hospital care or medical services. Senator Jon Tester (D-MT), chair of the Senate Veterans’ Affairs Committee, and Senator Jerry Moran (R-KS) introduced legislation in 2020 to enact the new policy in January 2022 , which is why the rule is retroactive.

Congress passed the measure as part of a package of veterans’ legislation at the end of 2020, and then-President Donald Trump signed it into law in January 2021. Trueblood said the nature of the federal rulemaking process makes it hard to say exactly when the change will take effect, but that no veteran will be turned away from VA care for not making a copayment, even before the rule is finalized. The VA plans to reimburse eligible veterans who received care in the past year for copayment costs.

“I’m encouraged to see VA answering my call to implement the law and remove burdensome copayments for Native veterans accessing their earned health care,” said Tester in a press release. “The fact is Native veterans have bravely answered the call to duty for generations. And I’ll continue to hold VA accountable in delivering these veterans their long-overdue support.”

New VA rule proposes to eliminate many copays for Native American veteran.

The US Department of Veterans Affairs (VA) has proposed a new rule that would waive medical copayments incurred on or after January 5, 2022, for eligible American Indian and Alaska Native (AI/AN) veterans.

The policy is intended to encourage veterans to seek regular primary care treatment, the VA says. “It’s no mystery to a lot of people that health care is sometimes hard to come by in many Native American communities,” Travis Trueblood, director of the VA Office of Tribal Health, told reporters in January. “So, this effort by VA will enhance getting people into the facilities, helping them feel welcome and getting them to use those benefits that they've earned.”

Copayments for more than 3 visits to community-based urgent care in any calendar year would still be required. Follow-up care provided by a VA-authorized primary care provider would be exempt from copays. Members of federally recognized tribes are already exempt from copays at Indian Health Service clinics.

Eligibility may be based in part on documentation issued by AI/AN tribal governments to show tribal membership. The VA has proposed the documentation requirement “as this recognizes tribal sovereignty and promotes the Nation-to-Nation relationship that exists between the United States and tribal governments.” The requirement, the notice says, is consistent with the preferences of tribal leaders.

The regulation implements a requirement in the Johnny Isakson and David P. Roe, MD, Veterans Health Care and Benefits Improvement Act of 2020, which prohibited the VA from collecting copayments from AI/AN veterans for hospital care or medical services. Senator Jon Tester (D-MT), chair of the Senate Veterans’ Affairs Committee, and Senator Jerry Moran (R-KS) introduced legislation in 2020 to enact the new policy in January 2022 , which is why the rule is retroactive.

Congress passed the measure as part of a package of veterans’ legislation at the end of 2020, and then-President Donald Trump signed it into law in January 2021. Trueblood said the nature of the federal rulemaking process makes it hard to say exactly when the change will take effect, but that no veteran will be turned away from VA care for not making a copayment, even before the rule is finalized. The VA plans to reimburse eligible veterans who received care in the past year for copayment costs.

“I’m encouraged to see VA answering my call to implement the law and remove burdensome copayments for Native veterans accessing their earned health care,” said Tester in a press release. “The fact is Native veterans have bravely answered the call to duty for generations. And I’ll continue to hold VA accountable in delivering these veterans their long-overdue support.”

New VA rule proposes to eliminate many copays for Native American veteran.

The US Department of Veterans Affairs (VA) has proposed a new rule that would waive medical copayments incurred on or after January 5, 2022, for eligible American Indian and Alaska Native (AI/AN) veterans.

The policy is intended to encourage veterans to seek regular primary care treatment, the VA says. “It’s no mystery to a lot of people that health care is sometimes hard to come by in many Native American communities,” Travis Trueblood, director of the VA Office of Tribal Health, told reporters in January. “So, this effort by VA will enhance getting people into the facilities, helping them feel welcome and getting them to use those benefits that they've earned.”

Copayments for more than 3 visits to community-based urgent care in any calendar year would still be required. Follow-up care provided by a VA-authorized primary care provider would be exempt from copays. Members of federally recognized tribes are already exempt from copays at Indian Health Service clinics.

Eligibility may be based in part on documentation issued by AI/AN tribal governments to show tribal membership. The VA has proposed the documentation requirement “as this recognizes tribal sovereignty and promotes the Nation-to-Nation relationship that exists between the United States and tribal governments.” The requirement, the notice says, is consistent with the preferences of tribal leaders.

The regulation implements a requirement in the Johnny Isakson and David P. Roe, MD, Veterans Health Care and Benefits Improvement Act of 2020, which prohibited the VA from collecting copayments from AI/AN veterans for hospital care or medical services. Senator Jon Tester (D-MT), chair of the Senate Veterans’ Affairs Committee, and Senator Jerry Moran (R-KS) introduced legislation in 2020 to enact the new policy in January 2022 , which is why the rule is retroactive.

Congress passed the measure as part of a package of veterans’ legislation at the end of 2020, and then-President Donald Trump signed it into law in January 2021. Trueblood said the nature of the federal rulemaking process makes it hard to say exactly when the change will take effect, but that no veteran will be turned away from VA care for not making a copayment, even before the rule is finalized. The VA plans to reimburse eligible veterans who received care in the past year for copayment costs.

“I’m encouraged to see VA answering my call to implement the law and remove burdensome copayments for Native veterans accessing their earned health care,” said Tester in a press release. “The fact is Native veterans have bravely answered the call to duty for generations. And I’ll continue to hold VA accountable in delivering these veterans their long-overdue support.”

One-eyed, one-horned, flying purple veggie eater

Big Fruits and Vegetables is at it again. You notice how they’re always like “Oh, vegetables are good for your health,” and “Eating fruits every day makes you live longer,” but come on. It’s a marketing ploy, leading us astray from our personal savior, McDonald’s.

PxHere

Just look at this latest bit of research: According to researchers from Finland, eating purple vegetables can protect against diabetes. Considering nearly 40 million Americans have diabetes (and nearly 100 million have prediabetes), anything to reduce the incidence of diabetes (people with diabetes account for one-fourth of every dollar spent in U.S. health care) would be beneficial. So, let’s humor the fruits and veggies people this time and hear them out.

It all comes down to a chemical called anthocyanin, which is a pigment that gives fruits and vegetables such as blueberries, radishes, and red cabbages their purplish color. Anthocyanin also has probiotic and anti-inflammatory effects, meaning it can help improve intestinal lining health and regulate glucose and lipid metabolic pathways. Obviously, good things if you want to avoid diabetes.

The investigators also found that, while standard anthocyanin was beneficial, acylated anthocyanin (which has an acyl group added to the sugar molecules of anthocyanin) is really what you want to go for. The acylated version, found in abundance in purple potatoes, purple carrots, radishes, and red cabbages, is tougher to digest, but the positive effects it has in the body are enhanced over the standard version.

Now, this all a compelling bit of research, but at the end of the day, you’re still eating fruits and vegetables, and we are red-blooded Americans here. We don’t do healthy foods. Although, if you were to dye our burgers with anthocyanin and make them purple, you’d have our attention. Purple is our favorite color.
 

Manuka honey better as building material than antibiotic

Milk, according to the old saying, builds strong bones, but when it comes to patients with bone loss caused by various medical reasons, researchers found that manuka honey, produced only in New Zealand and some parts of Australia, may also do the job. They soaked collagen scaffolds used for bone implants in various concentrations of the honey and found that 5% led to higher mineral formation and osteoprotegerin production, which suggests increased bone production.

Marley Dewey

But, and this is a pretty big one, the other half of the study – testing manuka honey’s ability to ward off bacteria – wasn’t so successful. Bone implants, apparently, count for almost half of all hospital-acquired infections, which obviously can put a damper on the healing process. The hope was that a biomaterial would be more effective than something like metal in lessening bacteria formation. Nope.

When the researchers soaked paper disks in honey and added them to cultures of Pseudomonas aeruginosa and Staphylococcus aureus, none of the various concentrations stopped bacterial growth in the scaffolding, even when they added antibiotics.

The sticky conclusion, you could say, is more bitter than sweet.
 

It may sound like Korn, but can it play ‘Freak on a Leash’?

Like all right-thinking Americans, we love corn, corn-based products, and almost corn. Corn on the cob grilled in the husk? Mmm. Plus, we’re big fans of the band Korn. Also, we once had a reporter here named Tim Kirn. And don’t even get us started with Karn. Best Family Feud host ever.

Quorn

But what about Quorn? Oh sure, the fungi-based meat alternative is full of yummy mycoprotein, but can it prevent colorectal cancer? Can we add Quorn to our favorites list? Let’s see what Science has to say.

Researchers at Northumbria University in Newcastle upon Tyne, England, fed a group of 20 men some meat (240 g/day) for 2 weeks – hopefully, they were allowed to eat some other food as well – and then gave them the same amount of Quorn, excuse us, fungi-derived mycoprotein equivalents, for 2 more weeks, with a 4-week washout period in between.

Levels of cancer-causing chemicals known as genotoxins fell significantly in the mycoprotein phase but rose during the meat phase. The mycoprotein diet also improved gut health “by increasing the abundance of protective bacteria such as Lactobacilli, Roseburia, and Akkermansia, which are associated with offering protection against chemically induced tumours, inflammation and bowel cancer,” they said in a statement from the university.

The meat phase, on the other hand, resulted in an increase in “gut bacteria linked with issues such as cancer, cardiovascular diseases, weight gain and other negative health outcomes,” they noted.

Science, then, seems to approve of Quorn, and that’s good enough for us. We’re adding Quorn to our diet, starting with a fungi-derived mycoproteinburger tonight while we’re watching the Cornell Big Red take the court against their archrivals, the Big Green of Dartmouth College. GO RED!

One-eyed, one-horned, flying purple veggie eater

Big Fruits and Vegetables is at it again. You notice how they’re always like “Oh, vegetables are good for your health,” and “Eating fruits every day makes you live longer,” but come on. It’s a marketing ploy, leading us astray from our personal savior, McDonald’s.

PxHere

Just look at this latest bit of research: According to researchers from Finland, eating purple vegetables can protect against diabetes. Considering nearly 40 million Americans have diabetes (and nearly 100 million have prediabetes), anything to reduce the incidence of diabetes (people with diabetes account for one-fourth of every dollar spent in U.S. health care) would be beneficial. So, let’s humor the fruits and veggies people this time and hear them out.

It all comes down to a chemical called anthocyanin, which is a pigment that gives fruits and vegetables such as blueberries, radishes, and red cabbages their purplish color. Anthocyanin also has probiotic and anti-inflammatory effects, meaning it can help improve intestinal lining health and regulate glucose and lipid metabolic pathways. Obviously, good things if you want to avoid diabetes.

The investigators also found that, while standard anthocyanin was beneficial, acylated anthocyanin (which has an acyl group added to the sugar molecules of anthocyanin) is really what you want to go for. The acylated version, found in abundance in purple potatoes, purple carrots, radishes, and red cabbages, is tougher to digest, but the positive effects it has in the body are enhanced over the standard version.

Now, this all a compelling bit of research, but at the end of the day, you’re still eating fruits and vegetables, and we are red-blooded Americans here. We don’t do healthy foods. Although, if you were to dye our burgers with anthocyanin and make them purple, you’d have our attention. Purple is our favorite color.
 

Manuka honey better as building material than antibiotic

Milk, according to the old saying, builds strong bones, but when it comes to patients with bone loss caused by various medical reasons, researchers found that manuka honey, produced only in New Zealand and some parts of Australia, may also do the job. They soaked collagen scaffolds used for bone implants in various concentrations of the honey and found that 5% led to higher mineral formation and osteoprotegerin production, which suggests increased bone production.

Marley Dewey

But, and this is a pretty big one, the other half of the study – testing manuka honey’s ability to ward off bacteria – wasn’t so successful. Bone implants, apparently, count for almost half of all hospital-acquired infections, which obviously can put a damper on the healing process. The hope was that a biomaterial would be more effective than something like metal in lessening bacteria formation. Nope.

When the researchers soaked paper disks in honey and added them to cultures of Pseudomonas aeruginosa and Staphylococcus aureus, none of the various concentrations stopped bacterial growth in the scaffolding, even when they added antibiotics.

The sticky conclusion, you could say, is more bitter than sweet.
 

It may sound like Korn, but can it play ‘Freak on a Leash’?

Like all right-thinking Americans, we love corn, corn-based products, and almost corn. Corn on the cob grilled in the husk? Mmm. Plus, we’re big fans of the band Korn. Also, we once had a reporter here named Tim Kirn. And don’t even get us started with Karn. Best Family Feud host ever.

Quorn

But what about Quorn? Oh sure, the fungi-based meat alternative is full of yummy mycoprotein, but can it prevent colorectal cancer? Can we add Quorn to our favorites list? Let’s see what Science has to say.

Researchers at Northumbria University in Newcastle upon Tyne, England, fed a group of 20 men some meat (240 g/day) for 2 weeks – hopefully, they were allowed to eat some other food as well – and then gave them the same amount of Quorn, excuse us, fungi-derived mycoprotein equivalents, for 2 more weeks, with a 4-week washout period in between.

Levels of cancer-causing chemicals known as genotoxins fell significantly in the mycoprotein phase but rose during the meat phase. The mycoprotein diet also improved gut health “by increasing the abundance of protective bacteria such as Lactobacilli, Roseburia, and Akkermansia, which are associated with offering protection against chemically induced tumours, inflammation and bowel cancer,” they said in a statement from the university.

The meat phase, on the other hand, resulted in an increase in “gut bacteria linked with issues such as cancer, cardiovascular diseases, weight gain and other negative health outcomes,” they noted.

Science, then, seems to approve of Quorn, and that’s good enough for us. We’re adding Quorn to our diet, starting with a fungi-derived mycoproteinburger tonight while we’re watching the Cornell Big Red take the court against their archrivals, the Big Green of Dartmouth College. GO RED!

One-eyed, one-horned, flying purple veggie eater

Big Fruits and Vegetables is at it again. You notice how they’re always like “Oh, vegetables are good for your health,” and “Eating fruits every day makes you live longer,” but come on. It’s a marketing ploy, leading us astray from our personal savior, McDonald’s.

PxHere

Just look at this latest bit of research: According to researchers from Finland, eating purple vegetables can protect against diabetes. Considering nearly 40 million Americans have diabetes (and nearly 100 million have prediabetes), anything to reduce the incidence of diabetes (people with diabetes account for one-fourth of every dollar spent in U.S. health care) would be beneficial. So, let’s humor the fruits and veggies people this time and hear them out.

It all comes down to a chemical called anthocyanin, which is a pigment that gives fruits and vegetables such as blueberries, radishes, and red cabbages their purplish color. Anthocyanin also has probiotic and anti-inflammatory effects, meaning it can help improve intestinal lining health and regulate glucose and lipid metabolic pathways. Obviously, good things if you want to avoid diabetes.

The investigators also found that, while standard anthocyanin was beneficial, acylated anthocyanin (which has an acyl group added to the sugar molecules of anthocyanin) is really what you want to go for. The acylated version, found in abundance in purple potatoes, purple carrots, radishes, and red cabbages, is tougher to digest, but the positive effects it has in the body are enhanced over the standard version.

Now, this all a compelling bit of research, but at the end of the day, you’re still eating fruits and vegetables, and we are red-blooded Americans here. We don’t do healthy foods. Although, if you were to dye our burgers with anthocyanin and make them purple, you’d have our attention. Purple is our favorite color.
 

Manuka honey better as building material than antibiotic

Milk, according to the old saying, builds strong bones, but when it comes to patients with bone loss caused by various medical reasons, researchers found that manuka honey, produced only in New Zealand and some parts of Australia, may also do the job. They soaked collagen scaffolds used for bone implants in various concentrations of the honey and found that 5% led to higher mineral formation and osteoprotegerin production, which suggests increased bone production.

Marley Dewey

But, and this is a pretty big one, the other half of the study – testing manuka honey’s ability to ward off bacteria – wasn’t so successful. Bone implants, apparently, count for almost half of all hospital-acquired infections, which obviously can put a damper on the healing process. The hope was that a biomaterial would be more effective than something like metal in lessening bacteria formation. Nope.

When the researchers soaked paper disks in honey and added them to cultures of Pseudomonas aeruginosa and Staphylococcus aureus, none of the various concentrations stopped bacterial growth in the scaffolding, even when they added antibiotics.

The sticky conclusion, you could say, is more bitter than sweet.
 

It may sound like Korn, but can it play ‘Freak on a Leash’?

Like all right-thinking Americans, we love corn, corn-based products, and almost corn. Corn on the cob grilled in the husk? Mmm. Plus, we’re big fans of the band Korn. Also, we once had a reporter here named Tim Kirn. And don’t even get us started with Karn. Best Family Feud host ever.

Quorn

But what about Quorn? Oh sure, the fungi-based meat alternative is full of yummy mycoprotein, but can it prevent colorectal cancer? Can we add Quorn to our favorites list? Let’s see what Science has to say.

Researchers at Northumbria University in Newcastle upon Tyne, England, fed a group of 20 men some meat (240 g/day) for 2 weeks – hopefully, they were allowed to eat some other food as well – and then gave them the same amount of Quorn, excuse us, fungi-derived mycoprotein equivalents, for 2 more weeks, with a 4-week washout period in between.

Levels of cancer-causing chemicals known as genotoxins fell significantly in the mycoprotein phase but rose during the meat phase. The mycoprotein diet also improved gut health “by increasing the abundance of protective bacteria such as Lactobacilli, Roseburia, and Akkermansia, which are associated with offering protection against chemically induced tumours, inflammation and bowel cancer,” they said in a statement from the university.

The meat phase, on the other hand, resulted in an increase in “gut bacteria linked with issues such as cancer, cardiovascular diseases, weight gain and other negative health outcomes,” they noted.

Science, then, seems to approve of Quorn, and that’s good enough for us. We’re adding Quorn to our diet, starting with a fungi-derived mycoproteinburger tonight while we’re watching the Cornell Big Red take the court against their archrivals, the Big Green of Dartmouth College. GO RED!

Doctors and their family members are less likely than other people to follow guidelines for taking medication, according to a study by economic professors from the Massachusetts Institute of Technology, Cambridge; Stanford (Calif.) University; and the George Gund Professor of Economics and Business Administration at Harvard University, Boston.

What to know

• Doctors’ medical knowledge may influence them and their families to often ignore medical advice while the rest of the population adheres to general medication guidelines.
• Of the 63 guidelines used in the study, doctors and their families followed the standards less than a third of the time.
• The difference in adherence to guidelines between experts and nonexperts is largest with respect to antibiotics, in which doctors and their families are 5.2 percentage points less in compliance than everyone else.
• Doctors could be more likely to prescribe broader-spectrum antibiotics for themselves and their families, whereas most patients receive more narrow-spectrum antibiotics.
• Many members of the general public don’t understand medical guidelines, finding them too complex to follow, and many people don’t trust their doctors.

This is a summary of the article, “A Taste of Their Own Medicine: Guideline Adherence and Access to Expertise,” published in the American Economic Review: Insights on December 13, 2022. The full article can be found on aeaweb.org.

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

Doctors and their family members are less likely than other people to follow guidelines for taking medication, according to a study by economic professors from the Massachusetts Institute of Technology, Cambridge; Stanford (Calif.) University; and the George Gund Professor of Economics and Business Administration at Harvard University, Boston.

What to know

• Doctors’ medical knowledge may influence them and their families to often ignore medical advice while the rest of the population adheres to general medication guidelines.
• Of the 63 guidelines used in the study, doctors and their families followed the standards less than a third of the time.
• The difference in adherence to guidelines between experts and nonexperts is largest with respect to antibiotics, in which doctors and their families are 5.2 percentage points less in compliance than everyone else.
• Doctors could be more likely to prescribe broader-spectrum antibiotics for themselves and their families, whereas most patients receive more narrow-spectrum antibiotics.
• Many members of the general public don’t understand medical guidelines, finding them too complex to follow, and many people don’t trust their doctors.

This is a summary of the article, “A Taste of Their Own Medicine: Guideline Adherence and Access to Expertise,” published in the American Economic Review: Insights on December 13, 2022. The full article can be found on aeaweb.org.

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

Doctors and their family members are less likely than other people to follow guidelines for taking medication, according to a study by economic professors from the Massachusetts Institute of Technology, Cambridge; Stanford (Calif.) University; and the George Gund Professor of Economics and Business Administration at Harvard University, Boston.

What to know

• Doctors’ medical knowledge may influence them and their families to often ignore medical advice while the rest of the population adheres to general medication guidelines.
• Of the 63 guidelines used in the study, doctors and their families followed the standards less than a third of the time.
• The difference in adherence to guidelines between experts and nonexperts is largest with respect to antibiotics, in which doctors and their families are 5.2 percentage points less in compliance than everyone else.
• Doctors could be more likely to prescribe broader-spectrum antibiotics for themselves and their families, whereas most patients receive more narrow-spectrum antibiotics.
• Many members of the general public don’t understand medical guidelines, finding them too complex to follow, and many people don’t trust their doctors.

This is a summary of the article, “A Taste of Their Own Medicine: Guideline Adherence and Access to Expertise,” published in the American Economic Review: Insights on December 13, 2022. The full article can be found on aeaweb.org.

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

When New York oncologist Gabriel Sara, MD, approached the French actress and film director Emmanuelle Bercot after a screening of one of her films in Manhattan, he was thinking big.

He never dreamed she would think bigger.  

“I thought maybe she will do a movie about some of my beliefs,” he said.

“Ma’am, would you like to go in the trenches of cancer?” he asked her, inviting her to tour the oncology department at Mount Sinai West.

Whether it was the Lebanese-born doctor’s Parisian French, his gentle, double-handed handshake, or the perpetual twinkle in his eye, something convinced Ms. Bercot to go. After the visit, she decided to base an entire film on the doctor’s philosophy about death, and she even cast him as one of the leads.

With no formal training in acting, “it’s incredible and prodigious what he did,” Ms. Bercot said in an interview at the 2021 Cannes Film Festival, where the film, “Peaceful” (“De Son Vivant”) premiered.

“This is a guy we took from his cancer ward to a film set, and he was able to be as real and authentic as he is in his doctor’s office,” she said.

Dr. Sara said that authenticity came easily, given that “a lot of my dialogue – maybe most – came from things I shared with Emmanuelle,” he said in an interview with this news organization. “She took the information from me, and she created the whole story. She studied my character and came up with really all the messages that I was hoping to share.”

He said that acting alongside professionals was not intimidating once he realized he was simply playing himself. “At some point ... it clicked in my head. Let me stop acting – I should just be me,” he recalled.

“Peaceful,” performed in French with English subtitles, was nominated for Best Film at the 2022 Lumières Awards.

It tells the story of a 39-year-old man (played by French actor Benoît Magimel) diagnosed with stage 4 pancreatic cancer and the journey, along with his mother (played by renowned actress Catherine Deneuve), through diagnosis, denial, and eventual acceptance of his death.

It is also the story of an oncologist, played by Dr. Sara as himself, who takes his patient by the hand, and refuses to sugarcoat the truth, because he believes that it is only by facing the facts that patients can continue to live – and then die – in peace.

“You’ll never hear me say I’ll cure your cancer. I’d be a liar if I did,” he tells his patient in the film.

“Patients put their life in your hands, so if you don’t tell them the truth you are betraying them,” he explained in the interview. “I have refused to see patients whose family did not allow them to come to the consultation to hear the truth. ... Nobody hears the truth and feels great about it the next day, but the truth helps them focus on what they need to deal with. And once they focus, they’re in control ... a big part of what is terrible for patients is that loss of control.”

The approach may sound harsh, but it is conveyed tenderly in the film. “[Your mother] thinks that half-truths will hurt you half as much,” he tells his patient gently, but “the scariest thing is realizing someone is lying to you. ... We have a tough journey ahead, there’s no room for lies. ... For me, truth is nonnegotiable.”  

Dr. Sara is brimming with stories of real-life patients whose lives were enriched and empowered by the clarity they gained in knowing the full truth.

However, not all oncologists agree with his style.

After screenings of the film in other parts of the world, and even in the United States, he has encountered some physicians who strongly disagree with his uncompromising honesty. “You always have somebody who says you know, in America, you will receive the truth but not in our culture – people are not used to it. I hear this all the time,” he said.

“And a long time ago, I decided I’m not going to accept that conversation. Truth works with all patients across all cultures,” Dr. Sara insisted.

“However, as caregivers, we have to be sensitive and present to the kind of culture we are dealing with. The content has to be always 100% honest but we adapt our language to the cultural and emotional state of the patient in order to successfully transmit the message,” he added.

Helping patients digest the news of their diagnosis and prognosis has been Dr. Sara’s recipe for his own survival at work. Now 68 and recently retired as medical director of the chemotherapy infusion suite and executive director of the patient services initiative at Mount Sinai West, he says he emerged from 40 years of practice without burning out by learning to step in time with each patient.

“My recipe for it is tango,” he said. Regular tango performances on his cancer ward were among his many real-life techniques that Ms. Bercot incorporated into the film. “I feel that we have to dance closely with our patients’ emotion,” he explained. “We have to feel our patients’ emotion and work with that. If you don’t move in harmony with your partner, you trip together and both of you will fall,” he told an audience after a screening of his film in New York City.

“I completely try to isolate my mind from anything else in order to be with the patient – this is what presence is about for me – to be right there for them, close to them. To spend that whole moment with them. That’s what will make the consultation really helpful, and will make me feel that I can move to the next page without feeling exhausted from the first one.”

A key scene in the film comes after the patient’s mother is stunned to discover a cheerful tango performance on her son’s ward, and confronts the doctor angrily.

“It’s like I’m abandoning him,” she says tearfully, when the doctor urges her to accept that her son’s chemotherapy is no longer working and let him live what life he has left.

“Give him permission to go,” he urges her. “It would be your greatest gift of love.”

Dr. Sara encourages a similar approach in his staff. He warns them about the “hero syndrome,” in which dying patients are made to feel they need to “hang on” and “fight” for the sake of their caregivers and families.

“The patient never asked to be the hero, but our attitude is telling him that he’s the hero,” he says in the film. “That puts him in an intolerable impasse because he figures that if he gives up, if he dies, he’s betraying his fans. He needs the exact opposite: to be set free. He needs the permission to die. That permission is given by two people: his doctor and his family.”

Of course, not all cancer patients have such a dim prognosis, and Dr. Sara is the first to forge ahead if he feels it’s appropriate. “If, if there is no option for them, I’m going to be aggressive to protect them. But when there is a curable disease, I will go broke to try to treat my patient. I’m willing to give them toxic drugs and hold their hand, get them through the storm if I believe it’s going to cure what they have, and I will coach them to accept being sick.”

He also believes in physical contact with the patient. “If we have some intimacy with the patient, we can at least palpate the kind of person they are,” he said. But his wife Nada pointed out that physical examinations can sometimes make patients nervous. “She told me, if you have a tie, they might have fun looking at it.” Thus began Dr. Sara’s collection of about 30 fun ties decorated with unicorns or jellyfish tailored to various patients’ preferences.

In the film, his patient teases him about this quirk, but Dr. Sara insists it is a small gesture that carries meaning. “One patient told me a story about lovebugs. She would see them in her kitchen when she was feeling well – so lovebugs became a sign of hope for her. I was telling the story to my wife ... so she got me a tie with lovebugs on it, and my patient was so happy when she saw me wearing that.”

In the film – and in real life – Dr. Sara often played guitar at breakfast music sessions with his staff in which he encouraged them to express their feelings about patients’ struggles. “If you cry, don’t be ashamed. Your patient will feel you’re with him,” he said in the film. In the final scenes, wearing a cloud-covered tie, he says goodbye to his patient with tears in his eyes. “They [the tears] are sincere,” he recalled. “Because I really felt I was looking at a dying patient. I really did.”

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

When New York oncologist Gabriel Sara, MD, approached the French actress and film director Emmanuelle Bercot after a screening of one of her films in Manhattan, he was thinking big.

He never dreamed she would think bigger.  

“I thought maybe she will do a movie about some of my beliefs,” he said.

“Ma’am, would you like to go in the trenches of cancer?” he asked her, inviting her to tour the oncology department at Mount Sinai West.

Whether it was the Lebanese-born doctor’s Parisian French, his gentle, double-handed handshake, or the perpetual twinkle in his eye, something convinced Ms. Bercot to go. After the visit, she decided to base an entire film on the doctor’s philosophy about death, and she even cast him as one of the leads.

With no formal training in acting, “it’s incredible and prodigious what he did,” Ms. Bercot said in an interview at the 2021 Cannes Film Festival, where the film, “Peaceful” (“De Son Vivant”) premiered.

“This is a guy we took from his cancer ward to a film set, and he was able to be as real and authentic as he is in his doctor’s office,” she said.

Dr. Sara said that authenticity came easily, given that “a lot of my dialogue – maybe most – came from things I shared with Emmanuelle,” he said in an interview with this news organization. “She took the information from me, and she created the whole story. She studied my character and came up with really all the messages that I was hoping to share.”

He said that acting alongside professionals was not intimidating once he realized he was simply playing himself. “At some point ... it clicked in my head. Let me stop acting – I should just be me,” he recalled.

“Peaceful,” performed in French with English subtitles, was nominated for Best Film at the 2022 Lumières Awards.

It tells the story of a 39-year-old man (played by French actor Benoît Magimel) diagnosed with stage 4 pancreatic cancer and the journey, along with his mother (played by renowned actress Catherine Deneuve), through diagnosis, denial, and eventual acceptance of his death.

It is also the story of an oncologist, played by Dr. Sara as himself, who takes his patient by the hand, and refuses to sugarcoat the truth, because he believes that it is only by facing the facts that patients can continue to live – and then die – in peace.

“You’ll never hear me say I’ll cure your cancer. I’d be a liar if I did,” he tells his patient in the film.

“Patients put their life in your hands, so if you don’t tell them the truth you are betraying them,” he explained in the interview. “I have refused to see patients whose family did not allow them to come to the consultation to hear the truth. ... Nobody hears the truth and feels great about it the next day, but the truth helps them focus on what they need to deal with. And once they focus, they’re in control ... a big part of what is terrible for patients is that loss of control.”

The approach may sound harsh, but it is conveyed tenderly in the film. “[Your mother] thinks that half-truths will hurt you half as much,” he tells his patient gently, but “the scariest thing is realizing someone is lying to you. ... We have a tough journey ahead, there’s no room for lies. ... For me, truth is nonnegotiable.”  

Dr. Sara is brimming with stories of real-life patients whose lives were enriched and empowered by the clarity they gained in knowing the full truth.

However, not all oncologists agree with his style.

After screenings of the film in other parts of the world, and even in the United States, he has encountered some physicians who strongly disagree with his uncompromising honesty. “You always have somebody who says you know, in America, you will receive the truth but not in our culture – people are not used to it. I hear this all the time,” he said.

“And a long time ago, I decided I’m not going to accept that conversation. Truth works with all patients across all cultures,” Dr. Sara insisted.

“However, as caregivers, we have to be sensitive and present to the kind of culture we are dealing with. The content has to be always 100% honest but we adapt our language to the cultural and emotional state of the patient in order to successfully transmit the message,” he added.

Helping patients digest the news of their diagnosis and prognosis has been Dr. Sara’s recipe for his own survival at work. Now 68 and recently retired as medical director of the chemotherapy infusion suite and executive director of the patient services initiative at Mount Sinai West, he says he emerged from 40 years of practice without burning out by learning to step in time with each patient.

“My recipe for it is tango,” he said. Regular tango performances on his cancer ward were among his many real-life techniques that Ms. Bercot incorporated into the film. “I feel that we have to dance closely with our patients’ emotion,” he explained. “We have to feel our patients’ emotion and work with that. If you don’t move in harmony with your partner, you trip together and both of you will fall,” he told an audience after a screening of his film in New York City.

“I completely try to isolate my mind from anything else in order to be with the patient – this is what presence is about for me – to be right there for them, close to them. To spend that whole moment with them. That’s what will make the consultation really helpful, and will make me feel that I can move to the next page without feeling exhausted from the first one.”

A key scene in the film comes after the patient’s mother is stunned to discover a cheerful tango performance on her son’s ward, and confronts the doctor angrily.

“It’s like I’m abandoning him,” she says tearfully, when the doctor urges her to accept that her son’s chemotherapy is no longer working and let him live what life he has left.

“Give him permission to go,” he urges her. “It would be your greatest gift of love.”

Dr. Sara encourages a similar approach in his staff. He warns them about the “hero syndrome,” in which dying patients are made to feel they need to “hang on” and “fight” for the sake of their caregivers and families.

“The patient never asked to be the hero, but our attitude is telling him that he’s the hero,” he says in the film. “That puts him in an intolerable impasse because he figures that if he gives up, if he dies, he’s betraying his fans. He needs the exact opposite: to be set free. He needs the permission to die. That permission is given by two people: his doctor and his family.”

Of course, not all cancer patients have such a dim prognosis, and Dr. Sara is the first to forge ahead if he feels it’s appropriate. “If, if there is no option for them, I’m going to be aggressive to protect them. But when there is a curable disease, I will go broke to try to treat my patient. I’m willing to give them toxic drugs and hold their hand, get them through the storm if I believe it’s going to cure what they have, and I will coach them to accept being sick.”

He also believes in physical contact with the patient. “If we have some intimacy with the patient, we can at least palpate the kind of person they are,” he said. But his wife Nada pointed out that physical examinations can sometimes make patients nervous. “She told me, if you have a tie, they might have fun looking at it.” Thus began Dr. Sara’s collection of about 30 fun ties decorated with unicorns or jellyfish tailored to various patients’ preferences.

In the film, his patient teases him about this quirk, but Dr. Sara insists it is a small gesture that carries meaning. “One patient told me a story about lovebugs. She would see them in her kitchen when she was feeling well – so lovebugs became a sign of hope for her. I was telling the story to my wife ... so she got me a tie with lovebugs on it, and my patient was so happy when she saw me wearing that.”

In the film – and in real life – Dr. Sara often played guitar at breakfast music sessions with his staff in which he encouraged them to express their feelings about patients’ struggles. “If you cry, don’t be ashamed. Your patient will feel you’re with him,” he said in the film. In the final scenes, wearing a cloud-covered tie, he says goodbye to his patient with tears in his eyes. “They [the tears] are sincere,” he recalled. “Because I really felt I was looking at a dying patient. I really did.”

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

When New York oncologist Gabriel Sara, MD, approached the French actress and film director Emmanuelle Bercot after a screening of one of her films in Manhattan, he was thinking big.

He never dreamed she would think bigger.  

“I thought maybe she will do a movie about some of my beliefs,” he said.

“Ma’am, would you like to go in the trenches of cancer?” he asked her, inviting her to tour the oncology department at Mount Sinai West.

Whether it was the Lebanese-born doctor’s Parisian French, his gentle, double-handed handshake, or the perpetual twinkle in his eye, something convinced Ms. Bercot to go. After the visit, she decided to base an entire film on the doctor’s philosophy about death, and she even cast him as one of the leads.

With no formal training in acting, “it’s incredible and prodigious what he did,” Ms. Bercot said in an interview at the 2021 Cannes Film Festival, where the film, “Peaceful” (“De Son Vivant”) premiered.

“This is a guy we took from his cancer ward to a film set, and he was able to be as real and authentic as he is in his doctor’s office,” she said.

Dr. Sara said that authenticity came easily, given that “a lot of my dialogue – maybe most – came from things I shared with Emmanuelle,” he said in an interview with this news organization. “She took the information from me, and she created the whole story. She studied my character and came up with really all the messages that I was hoping to share.”

He said that acting alongside professionals was not intimidating once he realized he was simply playing himself. “At some point ... it clicked in my head. Let me stop acting – I should just be me,” he recalled.

“Peaceful,” performed in French with English subtitles, was nominated for Best Film at the 2022 Lumières Awards.

It tells the story of a 39-year-old man (played by French actor Benoît Magimel) diagnosed with stage 4 pancreatic cancer and the journey, along with his mother (played by renowned actress Catherine Deneuve), through diagnosis, denial, and eventual acceptance of his death.

It is also the story of an oncologist, played by Dr. Sara as himself, who takes his patient by the hand, and refuses to sugarcoat the truth, because he believes that it is only by facing the facts that patients can continue to live – and then die – in peace.

“You’ll never hear me say I’ll cure your cancer. I’d be a liar if I did,” he tells his patient in the film.

“Patients put their life in your hands, so if you don’t tell them the truth you are betraying them,” he explained in the interview. “I have refused to see patients whose family did not allow them to come to the consultation to hear the truth. ... Nobody hears the truth and feels great about it the next day, but the truth helps them focus on what they need to deal with. And once they focus, they’re in control ... a big part of what is terrible for patients is that loss of control.”

The approach may sound harsh, but it is conveyed tenderly in the film. “[Your mother] thinks that half-truths will hurt you half as much,” he tells his patient gently, but “the scariest thing is realizing someone is lying to you. ... We have a tough journey ahead, there’s no room for lies. ... For me, truth is nonnegotiable.”  

Dr. Sara is brimming with stories of real-life patients whose lives were enriched and empowered by the clarity they gained in knowing the full truth.

However, not all oncologists agree with his style.

After screenings of the film in other parts of the world, and even in the United States, he has encountered some physicians who strongly disagree with his uncompromising honesty. “You always have somebody who says you know, in America, you will receive the truth but not in our culture – people are not used to it. I hear this all the time,” he said.

“And a long time ago, I decided I’m not going to accept that conversation. Truth works with all patients across all cultures,” Dr. Sara insisted.

“However, as caregivers, we have to be sensitive and present to the kind of culture we are dealing with. The content has to be always 100% honest but we adapt our language to the cultural and emotional state of the patient in order to successfully transmit the message,” he added.

Helping patients digest the news of their diagnosis and prognosis has been Dr. Sara’s recipe for his own survival at work. Now 68 and recently retired as medical director of the chemotherapy infusion suite and executive director of the patient services initiative at Mount Sinai West, he says he emerged from 40 years of practice without burning out by learning to step in time with each patient.

“My recipe for it is tango,” he said. Regular tango performances on his cancer ward were among his many real-life techniques that Ms. Bercot incorporated into the film. “I feel that we have to dance closely with our patients’ emotion,” he explained. “We have to feel our patients’ emotion and work with that. If you don’t move in harmony with your partner, you trip together and both of you will fall,” he told an audience after a screening of his film in New York City.

“I completely try to isolate my mind from anything else in order to be with the patient – this is what presence is about for me – to be right there for them, close to them. To spend that whole moment with them. That’s what will make the consultation really helpful, and will make me feel that I can move to the next page without feeling exhausted from the first one.”

A key scene in the film comes after the patient’s mother is stunned to discover a cheerful tango performance on her son’s ward, and confronts the doctor angrily.

“It’s like I’m abandoning him,” she says tearfully, when the doctor urges her to accept that her son’s chemotherapy is no longer working and let him live what life he has left.

“Give him permission to go,” he urges her. “It would be your greatest gift of love.”

Dr. Sara encourages a similar approach in his staff. He warns them about the “hero syndrome,” in which dying patients are made to feel they need to “hang on” and “fight” for the sake of their caregivers and families.

“The patient never asked to be the hero, but our attitude is telling him that he’s the hero,” he says in the film. “That puts him in an intolerable impasse because he figures that if he gives up, if he dies, he’s betraying his fans. He needs the exact opposite: to be set free. He needs the permission to die. That permission is given by two people: his doctor and his family.”

Of course, not all cancer patients have such a dim prognosis, and Dr. Sara is the first to forge ahead if he feels it’s appropriate. “If, if there is no option for them, I’m going to be aggressive to protect them. But when there is a curable disease, I will go broke to try to treat my patient. I’m willing to give them toxic drugs and hold their hand, get them through the storm if I believe it’s going to cure what they have, and I will coach them to accept being sick.”

He also believes in physical contact with the patient. “If we have some intimacy with the patient, we can at least palpate the kind of person they are,” he said. But his wife Nada pointed out that physical examinations can sometimes make patients nervous. “She told me, if you have a tie, they might have fun looking at it.” Thus began Dr. Sara’s collection of about 30 fun ties decorated with unicorns or jellyfish tailored to various patients’ preferences.

In the film, his patient teases him about this quirk, but Dr. Sara insists it is a small gesture that carries meaning. “One patient told me a story about lovebugs. She would see them in her kitchen when she was feeling well – so lovebugs became a sign of hope for her. I was telling the story to my wife ... so she got me a tie with lovebugs on it, and my patient was so happy when she saw me wearing that.”

In the film – and in real life – Dr. Sara often played guitar at breakfast music sessions with his staff in which he encouraged them to express their feelings about patients’ struggles. “If you cry, don’t be ashamed. Your patient will feel you’re with him,” he said in the film. In the final scenes, wearing a cloud-covered tie, he says goodbye to his patient with tears in his eyes. “They [the tears] are sincere,” he recalled. “Because I really felt I was looking at a dying patient. I really did.”

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

The Diagnosis: Discoid Lupus Erythematosus

The biopsies demonstrated vacuolar interface changes with superficial and deep perivascular and periadnexal inflammation as well as increased background mucin deposition. The clinical morphology and distributions of the plaques limited to the photoexposed areas of the head suggested a diagnosis of discoid lupus erythematosus (DLE). The interface changes on histopathology supported this clinical impression. Our patient was treated with limited application of triamcinolone ointment 0.1% twice daily around the ears and neck, tacrolimus ointment 0.1% twice daily on the face, and hydroxychloroquine, as well as sun protection instructions. Smoking cessation was strongly advised.

Discoid lupus erythematosus is a disorder with chronic, erythematous, scaly, coin-shaped (discoid) plaques and is the most common form of chronic cutaneous lupus erythematosus.¹ Lesions usually present on sun-exposed areas of the face, scalp, neck, ears, lips, or upper torso. They expand slowly with an active peripheral margin and a central scar that can result in induration, pigmentation changes, telangiectases, pruritus, or tenderness. Hair-bearing areas may be involved, causing hair loss due to follicular plugging; irreversible scarring alopecia can result. Facial DLE often spares the nasolabial folds. Ear involvement characteristically includes the conchal bowl and the outer external auditory canal. Discoid lupus erythematosus is considered localized if most of the head and neck region is involved or generalized if lesions also are present below the neck. Risk factors for DLE include genetic and environmental factors such as UV exposure, hormones, or exposure to toxins such as cigarette smoke.¹ The disorder most commonly affects females and has a higher prevalence in patients of African descent than in Asian and White patients. Disease can occur at any age but usually occurs between 20 and 40 years of age.² Discoid lupus erythematosus and other forms of chronic cutaneous lupus can occur independently or in conjunction with systemic lupus erythematosus (SLE), and approximately 15% to 30% of SLE patients develop DLE.¹

Discoid lupus erythematosus is clinically diagnosed by the presentation of plaques in the characteristic distribution with confirmation via skin biopsy.¹ Elman et al³ created a system for DLE classification that was only clinical and did not involve histopathology. Histologically, DLE often includes basement membrane thickening, follicular keratin plugs, mucin deposition, and vacuolar change with an interface, and a perivascular and periadnexal lymphocytic infiltrate.^3,4 Antibodies such as antinuclear antibodies, rheumatoid factor, anti–double-stranded DNA, anti-Smith, and Sjögren syndrome A and B antibodies may be present (albeit with low positive frequency) in cutaneous lupus erythematosus.4 Characteristics of SLE also may be present, helping to confirm the diagnosis. Because there is an association of DLE with SLE, various laboratory tests should be ordered, including complete blood cell count, renal function panel, inflammatory markers, antibodies, and urinalysis for proteinuria.^2,4

Treatment of DLE consists of preventative measures, such as sun protection with vitamin D supplementation, avoidance of drug triggers, and smoking cessation, as well as pharmacotherapy. The importance of wearing sun protective hats and garments with sunscreen use cannot be understated.¹ Smoking cessation should be advised because smoking reduces the efficacy of antimalarial treatment and potentially increases the likelihood of patients requiring a second antimalarial drug. Quinacrine often is noted in both the dermatology and rheumatology literature to be used for escalating cutaneous lupus erythematosus care when hydroxychloroquine is ineffective or not tolerated, but no US manufacturer produces this medication; thus, compounding is required, which may be financially prohibitive, making this recommendation difficult to translate into clinical practice.⁵ Firstline therapy for acute flares is high-potency topical corticosteroids. If lesions are primarily on areas other than the face, a medium-potency topical steroid may be used. Topical calcineurin inhibitors or intralesional corticosteroids may be used if minimal improvement is seen after initial topical corticosteroid therapy. Treatment for widespread disease or disease that is resistant to local treatment is systemic therapy with antimalarial agents, followed by antimetabolites, systemic retinoids, thalidomide, or dapsone.^1,2 The Cutaneous Lupus Erythematosus Disease Area and Severity Index is a valid tool to gauge the degree of disease and to help with disease progression and treatment response by noting the features of the plaques.¹

Patients also should be educated that this disease can last for years, and long-standing DLE plaques infrequently can give rise to squamous cell carcinoma. In addition, isolated DLE can progress to SLE in 5% to 28% of patients.²

The differential diagnosis in our patient included other diseases with violaceous annular lesions and central clearing. Majocchi granuloma usually presents in areas of prior trauma, possibly due to shaving the face in our patient, or in the setting of topical corticosteroid use or immunosuppression. Scaling often is present within lesions, and histology shows fungal elements.⁶ Cutaneous sarcoidosis usually presents on the face, with scarring alopecia when appearing on the scalp; histology shows noncaseating granulomas, and 70% of patients with cutaneous symptoms will have systemic sarcoidosis.⁷ Granuloma annulare most commonly presents on the extremities, and histology shows lymphohistiocytic granulomas in a palisaded or interstitial pattern with connective-tissue degeneration and mucinous deposits.⁸ Annular psoriasis often is scaly and symmetric with parakeratosis, epidermal hyperplasia, dilated dermal capillaries, loss of granular layer, perivascular mononuclear cell infiltrate, and elongation of rete ridges on histology.⁹ Drug-induced lupus erythematosus always should be considered in patients taking triggering drugs such as antihypertensives, lipid-lowering drugs, antifungals, anti–tumor necrosis factor drugs, and proton pump inhibitors—the latter being a drug our patient was taking.¹⁰

The Diagnosis: Discoid Lupus Erythematosus

The biopsies demonstrated vacuolar interface changes with superficial and deep perivascular and periadnexal inflammation as well as increased background mucin deposition. The clinical morphology and distributions of the plaques limited to the photoexposed areas of the head suggested a diagnosis of discoid lupus erythematosus (DLE). The interface changes on histopathology supported this clinical impression. Our patient was treated with limited application of triamcinolone ointment 0.1% twice daily around the ears and neck, tacrolimus ointment 0.1% twice daily on the face, and hydroxychloroquine, as well as sun protection instructions. Smoking cessation was strongly advised.

Discoid lupus erythematosus is a disorder with chronic, erythematous, scaly, coin-shaped (discoid) plaques and is the most common form of chronic cutaneous lupus erythematosus.¹ Lesions usually present on sun-exposed areas of the face, scalp, neck, ears, lips, or upper torso. They expand slowly with an active peripheral margin and a central scar that can result in induration, pigmentation changes, telangiectases, pruritus, or tenderness. Hair-bearing areas may be involved, causing hair loss due to follicular plugging; irreversible scarring alopecia can result. Facial DLE often spares the nasolabial folds. Ear involvement characteristically includes the conchal bowl and the outer external auditory canal. Discoid lupus erythematosus is considered localized if most of the head and neck region is involved or generalized if lesions also are present below the neck. Risk factors for DLE include genetic and environmental factors such as UV exposure, hormones, or exposure to toxins such as cigarette smoke.¹ The disorder most commonly affects females and has a higher prevalence in patients of African descent than in Asian and White patients. Disease can occur at any age but usually occurs between 20 and 40 years of age.² Discoid lupus erythematosus and other forms of chronic cutaneous lupus can occur independently or in conjunction with systemic lupus erythematosus (SLE), and approximately 15% to 30% of SLE patients develop DLE.¹

Discoid lupus erythematosus is clinically diagnosed by the presentation of plaques in the characteristic distribution with confirmation via skin biopsy.¹ Elman et al³ created a system for DLE classification that was only clinical and did not involve histopathology. Histologically, DLE often includes basement membrane thickening, follicular keratin plugs, mucin deposition, and vacuolar change with an interface, and a perivascular and periadnexal lymphocytic infiltrate.^3,4 Antibodies such as antinuclear antibodies, rheumatoid factor, anti–double-stranded DNA, anti-Smith, and Sjögren syndrome A and B antibodies may be present (albeit with low positive frequency) in cutaneous lupus erythematosus.4 Characteristics of SLE also may be present, helping to confirm the diagnosis. Because there is an association of DLE with SLE, various laboratory tests should be ordered, including complete blood cell count, renal function panel, inflammatory markers, antibodies, and urinalysis for proteinuria.^2,4

Treatment of DLE consists of preventative measures, such as sun protection with vitamin D supplementation, avoidance of drug triggers, and smoking cessation, as well as pharmacotherapy. The importance of wearing sun protective hats and garments with sunscreen use cannot be understated.¹ Smoking cessation should be advised because smoking reduces the efficacy of antimalarial treatment and potentially increases the likelihood of patients requiring a second antimalarial drug. Quinacrine often is noted in both the dermatology and rheumatology literature to be used for escalating cutaneous lupus erythematosus care when hydroxychloroquine is ineffective or not tolerated, but no US manufacturer produces this medication; thus, compounding is required, which may be financially prohibitive, making this recommendation difficult to translate into clinical practice.⁵ Firstline therapy for acute flares is high-potency topical corticosteroids. If lesions are primarily on areas other than the face, a medium-potency topical steroid may be used. Topical calcineurin inhibitors or intralesional corticosteroids may be used if minimal improvement is seen after initial topical corticosteroid therapy. Treatment for widespread disease or disease that is resistant to local treatment is systemic therapy with antimalarial agents, followed by antimetabolites, systemic retinoids, thalidomide, or dapsone.^1,2 The Cutaneous Lupus Erythematosus Disease Area and Severity Index is a valid tool to gauge the degree of disease and to help with disease progression and treatment response by noting the features of the plaques.¹

Patients also should be educated that this disease can last for years, and long-standing DLE plaques infrequently can give rise to squamous cell carcinoma. In addition, isolated DLE can progress to SLE in 5% to 28% of patients.²

The differential diagnosis in our patient included other diseases with violaceous annular lesions and central clearing. Majocchi granuloma usually presents in areas of prior trauma, possibly due to shaving the face in our patient, or in the setting of topical corticosteroid use or immunosuppression. Scaling often is present within lesions, and histology shows fungal elements.⁶ Cutaneous sarcoidosis usually presents on the face, with scarring alopecia when appearing on the scalp; histology shows noncaseating granulomas, and 70% of patients with cutaneous symptoms will have systemic sarcoidosis.⁷ Granuloma annulare most commonly presents on the extremities, and histology shows lymphohistiocytic granulomas in a palisaded or interstitial pattern with connective-tissue degeneration and mucinous deposits.⁸ Annular psoriasis often is scaly and symmetric with parakeratosis, epidermal hyperplasia, dilated dermal capillaries, loss of granular layer, perivascular mononuclear cell infiltrate, and elongation of rete ridges on histology.⁹ Drug-induced lupus erythematosus always should be considered in patients taking triggering drugs such as antihypertensives, lipid-lowering drugs, antifungals, anti–tumor necrosis factor drugs, and proton pump inhibitors—the latter being a drug our patient was taking.¹⁰

The Diagnosis: Discoid Lupus Erythematosus

The biopsies demonstrated vacuolar interface changes with superficial and deep perivascular and periadnexal inflammation as well as increased background mucin deposition. The clinical morphology and distributions of the plaques limited to the photoexposed areas of the head suggested a diagnosis of discoid lupus erythematosus (DLE). The interface changes on histopathology supported this clinical impression. Our patient was treated with limited application of triamcinolone ointment 0.1% twice daily around the ears and neck, tacrolimus ointment 0.1% twice daily on the face, and hydroxychloroquine, as well as sun protection instructions. Smoking cessation was strongly advised.

Discoid lupus erythematosus is a disorder with chronic, erythematous, scaly, coin-shaped (discoid) plaques and is the most common form of chronic cutaneous lupus erythematosus.¹ Lesions usually present on sun-exposed areas of the face, scalp, neck, ears, lips, or upper torso. They expand slowly with an active peripheral margin and a central scar that can result in induration, pigmentation changes, telangiectases, pruritus, or tenderness. Hair-bearing areas may be involved, causing hair loss due to follicular plugging; irreversible scarring alopecia can result. Facial DLE often spares the nasolabial folds. Ear involvement characteristically includes the conchal bowl and the outer external auditory canal. Discoid lupus erythematosus is considered localized if most of the head and neck region is involved or generalized if lesions also are present below the neck. Risk factors for DLE include genetic and environmental factors such as UV exposure, hormones, or exposure to toxins such as cigarette smoke.¹ The disorder most commonly affects females and has a higher prevalence in patients of African descent than in Asian and White patients. Disease can occur at any age but usually occurs between 20 and 40 years of age.² Discoid lupus erythematosus and other forms of chronic cutaneous lupus can occur independently or in conjunction with systemic lupus erythematosus (SLE), and approximately 15% to 30% of SLE patients develop DLE.¹

Discoid lupus erythematosus is clinically diagnosed by the presentation of plaques in the characteristic distribution with confirmation via skin biopsy.¹ Elman et al³ created a system for DLE classification that was only clinical and did not involve histopathology. Histologically, DLE often includes basement membrane thickening, follicular keratin plugs, mucin deposition, and vacuolar change with an interface, and a perivascular and periadnexal lymphocytic infiltrate.^3,4 Antibodies such as antinuclear antibodies, rheumatoid factor, anti–double-stranded DNA, anti-Smith, and Sjögren syndrome A and B antibodies may be present (albeit with low positive frequency) in cutaneous lupus erythematosus.4 Characteristics of SLE also may be present, helping to confirm the diagnosis. Because there is an association of DLE with SLE, various laboratory tests should be ordered, including complete blood cell count, renal function panel, inflammatory markers, antibodies, and urinalysis for proteinuria.^2,4

Treatment of DLE consists of preventative measures, such as sun protection with vitamin D supplementation, avoidance of drug triggers, and smoking cessation, as well as pharmacotherapy. The importance of wearing sun protective hats and garments with sunscreen use cannot be understated.¹ Smoking cessation should be advised because smoking reduces the efficacy of antimalarial treatment and potentially increases the likelihood of patients requiring a second antimalarial drug. Quinacrine often is noted in both the dermatology and rheumatology literature to be used for escalating cutaneous lupus erythematosus care when hydroxychloroquine is ineffective or not tolerated, but no US manufacturer produces this medication; thus, compounding is required, which may be financially prohibitive, making this recommendation difficult to translate into clinical practice.⁵ Firstline therapy for acute flares is high-potency topical corticosteroids. If lesions are primarily on areas other than the face, a medium-potency topical steroid may be used. Topical calcineurin inhibitors or intralesional corticosteroids may be used if minimal improvement is seen after initial topical corticosteroid therapy. Treatment for widespread disease or disease that is resistant to local treatment is systemic therapy with antimalarial agents, followed by antimetabolites, systemic retinoids, thalidomide, or dapsone.^1,2 The Cutaneous Lupus Erythematosus Disease Area and Severity Index is a valid tool to gauge the degree of disease and to help with disease progression and treatment response by noting the features of the plaques.¹

Patients also should be educated that this disease can last for years, and long-standing DLE plaques infrequently can give rise to squamous cell carcinoma. In addition, isolated DLE can progress to SLE in 5% to 28% of patients.²

The differential diagnosis in our patient included other diseases with violaceous annular lesions and central clearing. Majocchi granuloma usually presents in areas of prior trauma, possibly due to shaving the face in our patient, or in the setting of topical corticosteroid use or immunosuppression. Scaling often is present within lesions, and histology shows fungal elements.⁶ Cutaneous sarcoidosis usually presents on the face, with scarring alopecia when appearing on the scalp; histology shows noncaseating granulomas, and 70% of patients with cutaneous symptoms will have systemic sarcoidosis.⁷ Granuloma annulare most commonly presents on the extremities, and histology shows lymphohistiocytic granulomas in a palisaded or interstitial pattern with connective-tissue degeneration and mucinous deposits.⁸ Annular psoriasis often is scaly and symmetric with parakeratosis, epidermal hyperplasia, dilated dermal capillaries, loss of granular layer, perivascular mononuclear cell infiltrate, and elongation of rete ridges on histology.⁹ Drug-induced lupus erythematosus always should be considered in patients taking triggering drugs such as antihypertensives, lipid-lowering drugs, antifungals, anti–tumor necrosis factor drugs, and proton pump inhibitors—the latter being a drug our patient was taking.¹⁰

Educating the next generation of health professionals is 1 of 4 congressionally mandated statutory missions of the US Department of Veterans Affairs (VA).¹ Even before the COVID-19 pandemic, the number of veterans accessing VA health care was increasing, and those veterans are older and more medically complex than those who seek care outside the VA.² Almost half of medical residents reported a decline in the quality of their clinical education since the institution of the 2011 duty hours regulations, and in the past decade, more attention has been paid to the need for structured faculty development programs that focus on clinicians’ roles as medical educators.^3-6 Hospitalists in particular shoulder a large portion of inpatient medicine education.⁷ As a result, hospitalists have adapted known frameworks for medical education to their unique clinical setting and developed novel frameworks to meet the needs of their learners.^8,9

Access to technology and social media have shaped the educational experience of young learners who are accustomed to quick answers and the rapidity of change.¹⁰ The clinical teaching landscape changed again with COVID-19, requiring at least temporary abandonment of traditional in-person teaching methods, which upended well-established educational norms.^11,12 In this evolving field, even seasoned preceptors may feel ill-equipped to manage the nuances of modern clinical education and may struggle to recognize which teaching skills are most critical.^13,14 Baseline core teaching competencies for medical educators have been previously described and are separate from clinical competencies; however, to our knowledge, no needs assessment has previously been performed specifically for VA hospitalist clinician educators.¹⁵

Between May and June of 2020, we distributed an online needs assessment to academic VA hospitalists to identify perceived barriers to effective clinical education and preferred strategies to overcome them. We received 71 responses from 140 hospitalists (50% response rate) on the Veterans Health Administration (VHA) academic hospitalist listserv. Of respondents, 59 (83%) reported teaching health professions trainees every year. VA hospitalists reported educating a diverse group of interprofessional learners, including medical residents and students, physician assistant students, nursing students, pharmacy residents and students, and podiatry students.

Only 14 respondents (20%) were aware of faculty development training available to them through their VA facility, while 53 (75%) were aware of similar resources through academic affiliates or other outside sources. More than 95% of respondents (n = 68) reported interest in receiving VA-specific faculty development to improve skills as clinician educators. The most preferred forms of delivery were in-person or virtual real-time workshops. VA hospitalists reported the least confidence in their ability to support struggling learners, balance supervision and autonomy, and develop individualized learning plans (Table 1).

Teaching the Teacher

Teaching the Teacher began at a single VA institution as a series of in-person, discussion-based faculty development workshops. The series met a local need for collaborative professional development in clinical education for hospitalists and specialists who round with health professions learners on the inpatient wards. Both novice and experienced clinicians participated in the series with positive feedback. Based on the results of the national needs assessment, the program has since expanded to other sites with support from the VHA Hospital Medicine Program Office. The project’s overarching goal was to facilitate sharing of best practices across VA sites and create a network of local and national VA educators that participants could continue to access even after course completion.

Teaching the Teacher is structured into 5 facilitated hour-long sessions that can be completed either daily for 1 week or weekly for 1 month at the discretion of each institution. Each session is dedicated to a subject identified on the needs assessment as being highest yield. The hospitalist needs assessment also identified the preference for targeted faculty development that is relevant specifically to VA clinicians. To meet this need, Teaching the Teacher delivers its content through the unique lens of VA medicine. The educational mission of the VA is threaded throughout all presentations, and tips to maximize teaching in the VA’s unique clinical environments are embedded into each hour. Examples include discussions on how to incorporate veteran patients into bedside teaching, handling challenging patient-practitioner interactions as they pertain to patients, and the use of VA resources to find and teach evidence-based medicine.Each session includes a set of learning objectives; within that framework, facilitators allow participants to guide the nuances of content based on their individual and institutional priorities. The pandemic continues to shape much of the course content, as both hospitalists and their trainees grapple with mental health challenges, decreased bedside teaching, and wide variations in baseline trainee competence due to different institutional responses to teaching during a pandemic.^12,16 Content is regularly updated to incorporate new literature and feedback from participants and prioritize active participation. Continuing medical education/continuing educational units credit is available through the VA for course completion.

In the first session on modern learners, participants discuss the current generation of health professions trainees, including how personality characteristics and COVID-19 have impacted their learning experiences, and strategies to improve our ability to teach them successfully (Table 2).

Program Impact

Ten academically affiliated VA hospital medicine sections across 6 states have participated in Teaching the Teacher and several more are scheduled at other sites. Of the 10, 5 completed the course in collaboration with another VA site. Ninety-seven clinicians completed < 1 session synchronously but given the asynchronous option, this number likely underestimates the total audience. Participants included physicians, nurse practitioners, and physician assistants.

Surveys were conducted before and after the program, with 58 participants completing the presurvey, 32 the postsurvey, and 27 completing both. Of the 32 postsurvey respondents, 31 (97%) would recommend the seminar to colleagues. The live, discussion-based format was the most valued aspect of the course structure, with engaging facilitators and course content also ranking highly. Just over half (n = 17) indicated specific behavioral changes they plan to enact after completing the series, such as connecting with and better understanding learners, prioritizing high-quality feedback more deliberately, and bringing medicine to the bedside. The most common critiques of the course were requests for more time for feedback skills.

Discussion

Teaching the Teacher is a VA-specific faculty development seminar for hospitalists. Participants who responded to a survey reported that it met their needs as VA clinician educators. This is the first published needs assessment of academic VA hospitalists in their roles as clinician educators and the first faculty development initiative to address those specific needs using a collaborative, multisite approach. Although this program is a pilot, the positive response it has received has set a precedent for increased development and growth.

Teaching the Teacher presents a novel approach with a condensed curriculum that is more convenient and accessible to VA clinicians than previous programs with similar goals. Hospitalists have busy and variable work schedules, and it can be difficult to find time to participate in a traditional faculty development program. While these programs are becoming more commonplace, they are often longitudinal and require a significant time and/or financial commitment from participants.¹⁸ In contrast, Teaching the Teacher is only 5 hours long, can be viewed either synchronously or asynchronously, and is no cost to participants. In the future, other specialties may similarly value an efficient faculty development curriculum, and participation from clinicians outside of hospital medicine could augment the richness of content.

Teaching the Teacher’s curriculum is not meant to be exhaustive, but rather to spark conversation among colleagues. According to survey respondents, the most lauded aspect of this program was the facilitated, discussion-based structure, wherein participants are presented with common challenges and encouraged to share their experiences and solutions with colleagues. Of particular interest to the program’s mission of greater community building are the VA facilities that chose to complete the seminar with another hospitalist section from a different institution. Within this structure lies an opportunity for seasoned educators to informally mentor junior colleagues both within and across institutions, and foster connections among educators that continue beyond the completion of the series. We envision this program growing into an enduring professional development course that begins at onboarding and is revisited at regular intervals thereafter.

Another compelling aspect of this project is the interprofessional design, bringing physicians, nurse practitioners, and physician assistants together. Health education, like clinical care, is shifting to a team approach.¹⁹ The curriculum addresses topics previously described as high priority for interprofessional faculty development, such as fostering healthy team leadership, motivating learners, and appraising evidence and online resources.²⁰ A pilot project in VA primary care facilities found that deliberate interprofessional education improved collaboration among health care professionals.²¹ Prior to Teaching the Teacher, no similar faculty development program provided interprofessional learning and collaboration for VA hospitalists.

Limitations and Future Directions

There are several limitations to this preliminary study. Participation at each site was voluntary and did not always reach the full potential audience of hospitalist clinician educators. As one participant stated, future directions include doing “more to involve teachers who need to learn [these skills]. The ones who attended [from our institution] were already the best teachers.” In addition, despite the asynchronous option, lack of protected time for faculty development may be a limiting factor in participation. Support from institutional and national leadership would likely improve participation.

Measured endpoints to date consist primarily of participant satisfaction and do not yet capture objective changes in teaching. Data collection is ongoing to assess immediate and longitudinal changes in confidence and behaviors of attendees and how this might affect their health professions learners.

Last, our initial needs assessment only targeted academic hospitalists, and the needs of VA hospitalists in rural areas or at facilities without academic affiliation may be different. More research is needed to understand the diverse faculty that comprises both urban and rural VA sites, what their professional development needs are, and how those needs can be met.

Conclusions

Teaching the Teacher is a faculty development pilot, tailored to meet the needs of VA hospitalist clinician educators, that has been voluntarily adopted at multiple VA sites. The facilitated discussion format allows participants to guide the conversation and personalize content, thereby promoting a culture of discussing challenges and best practices among colleagues that we hope endures beyond the bounds of the curriculum. The program focuses on elevating the specific teaching mission of the VA and could be incorporated into onboarding and regular VA-sponsored faculty development updates. While Teaching the Teacher was originally developed for VA hospitalists, most of the content is applicable to clinicians outside hospital medicine. This project serves as a model for training clinical educators and has opportunities to expand across VA as a customizable didactic platform.

Acknowledgments

We thank Brian Schneider, MD, for his tireless support of this program, as well as all the VA clinicians who have shared their time, talents, and wisdom with us since this program’s inception.

Educating the next generation of health professionals is 1 of 4 congressionally mandated statutory missions of the US Department of Veterans Affairs (VA).¹ Even before the COVID-19 pandemic, the number of veterans accessing VA health care was increasing, and those veterans are older and more medically complex than those who seek care outside the VA.² Almost half of medical residents reported a decline in the quality of their clinical education since the institution of the 2011 duty hours regulations, and in the past decade, more attention has been paid to the need for structured faculty development programs that focus on clinicians’ roles as medical educators.^3-6 Hospitalists in particular shoulder a large portion of inpatient medicine education.⁷ As a result, hospitalists have adapted known frameworks for medical education to their unique clinical setting and developed novel frameworks to meet the needs of their learners.^8,9

Access to technology and social media have shaped the educational experience of young learners who are accustomed to quick answers and the rapidity of change.¹⁰ The clinical teaching landscape changed again with COVID-19, requiring at least temporary abandonment of traditional in-person teaching methods, which upended well-established educational norms.^11,12 In this evolving field, even seasoned preceptors may feel ill-equipped to manage the nuances of modern clinical education and may struggle to recognize which teaching skills are most critical.^13,14 Baseline core teaching competencies for medical educators have been previously described and are separate from clinical competencies; however, to our knowledge, no needs assessment has previously been performed specifically for VA hospitalist clinician educators.¹⁵

Between May and June of 2020, we distributed an online needs assessment to academic VA hospitalists to identify perceived barriers to effective clinical education and preferred strategies to overcome them. We received 71 responses from 140 hospitalists (50% response rate) on the Veterans Health Administration (VHA) academic hospitalist listserv. Of respondents, 59 (83%) reported teaching health professions trainees every year. VA hospitalists reported educating a diverse group of interprofessional learners, including medical residents and students, physician assistant students, nursing students, pharmacy residents and students, and podiatry students.

Only 14 respondents (20%) were aware of faculty development training available to them through their VA facility, while 53 (75%) were aware of similar resources through academic affiliates or other outside sources. More than 95% of respondents (n = 68) reported interest in receiving VA-specific faculty development to improve skills as clinician educators. The most preferred forms of delivery were in-person or virtual real-time workshops. VA hospitalists reported the least confidence in their ability to support struggling learners, balance supervision and autonomy, and develop individualized learning plans (Table 1).

Teaching the Teacher

Teaching the Teacher began at a single VA institution as a series of in-person, discussion-based faculty development workshops. The series met a local need for collaborative professional development in clinical education for hospitalists and specialists who round with health professions learners on the inpatient wards. Both novice and experienced clinicians participated in the series with positive feedback. Based on the results of the national needs assessment, the program has since expanded to other sites with support from the VHA Hospital Medicine Program Office. The project’s overarching goal was to facilitate sharing of best practices across VA sites and create a network of local and national VA educators that participants could continue to access even after course completion.

Teaching the Teacher is structured into 5 facilitated hour-long sessions that can be completed either daily for 1 week or weekly for 1 month at the discretion of each institution. Each session is dedicated to a subject identified on the needs assessment as being highest yield. The hospitalist needs assessment also identified the preference for targeted faculty development that is relevant specifically to VA clinicians. To meet this need, Teaching the Teacher delivers its content through the unique lens of VA medicine. The educational mission of the VA is threaded throughout all presentations, and tips to maximize teaching in the VA’s unique clinical environments are embedded into each hour. Examples include discussions on how to incorporate veteran patients into bedside teaching, handling challenging patient-practitioner interactions as they pertain to patients, and the use of VA resources to find and teach evidence-based medicine.Each session includes a set of learning objectives; within that framework, facilitators allow participants to guide the nuances of content based on their individual and institutional priorities. The pandemic continues to shape much of the course content, as both hospitalists and their trainees grapple with mental health challenges, decreased bedside teaching, and wide variations in baseline trainee competence due to different institutional responses to teaching during a pandemic.^12,16 Content is regularly updated to incorporate new literature and feedback from participants and prioritize active participation. Continuing medical education/continuing educational units credit is available through the VA for course completion.

In the first session on modern learners, participants discuss the current generation of health professions trainees, including how personality characteristics and COVID-19 have impacted their learning experiences, and strategies to improve our ability to teach them successfully (Table 2).

Program Impact

Ten academically affiliated VA hospital medicine sections across 6 states have participated in Teaching the Teacher and several more are scheduled at other sites. Of the 10, 5 completed the course in collaboration with another VA site. Ninety-seven clinicians completed < 1 session synchronously but given the asynchronous option, this number likely underestimates the total audience. Participants included physicians, nurse practitioners, and physician assistants.

Surveys were conducted before and after the program, with 58 participants completing the presurvey, 32 the postsurvey, and 27 completing both. Of the 32 postsurvey respondents, 31 (97%) would recommend the seminar to colleagues. The live, discussion-based format was the most valued aspect of the course structure, with engaging facilitators and course content also ranking highly. Just over half (n = 17) indicated specific behavioral changes they plan to enact after completing the series, such as connecting with and better understanding learners, prioritizing high-quality feedback more deliberately, and bringing medicine to the bedside. The most common critiques of the course were requests for more time for feedback skills.

Discussion

Teaching the Teacher is a VA-specific faculty development seminar for hospitalists. Participants who responded to a survey reported that it met their needs as VA clinician educators. This is the first published needs assessment of academic VA hospitalists in their roles as clinician educators and the first faculty development initiative to address those specific needs using a collaborative, multisite approach. Although this program is a pilot, the positive response it has received has set a precedent for increased development and growth.

Teaching the Teacher presents a novel approach with a condensed curriculum that is more convenient and accessible to VA clinicians than previous programs with similar goals. Hospitalists have busy and variable work schedules, and it can be difficult to find time to participate in a traditional faculty development program. While these programs are becoming more commonplace, they are often longitudinal and require a significant time and/or financial commitment from participants.¹⁸ In contrast, Teaching the Teacher is only 5 hours long, can be viewed either synchronously or asynchronously, and is no cost to participants. In the future, other specialties may similarly value an efficient faculty development curriculum, and participation from clinicians outside of hospital medicine could augment the richness of content.

Teaching the Teacher’s curriculum is not meant to be exhaustive, but rather to spark conversation among colleagues. According to survey respondents, the most lauded aspect of this program was the facilitated, discussion-based structure, wherein participants are presented with common challenges and encouraged to share their experiences and solutions with colleagues. Of particular interest to the program’s mission of greater community building are the VA facilities that chose to complete the seminar with another hospitalist section from a different institution. Within this structure lies an opportunity for seasoned educators to informally mentor junior colleagues both within and across institutions, and foster connections among educators that continue beyond the completion of the series. We envision this program growing into an enduring professional development course that begins at onboarding and is revisited at regular intervals thereafter.

Another compelling aspect of this project is the interprofessional design, bringing physicians, nurse practitioners, and physician assistants together. Health education, like clinical care, is shifting to a team approach.¹⁹ The curriculum addresses topics previously described as high priority for interprofessional faculty development, such as fostering healthy team leadership, motivating learners, and appraising evidence and online resources.²⁰ A pilot project in VA primary care facilities found that deliberate interprofessional education improved collaboration among health care professionals.²¹ Prior to Teaching the Teacher, no similar faculty development program provided interprofessional learning and collaboration for VA hospitalists.

Limitations and Future Directions

There are several limitations to this preliminary study. Participation at each site was voluntary and did not always reach the full potential audience of hospitalist clinician educators. As one participant stated, future directions include doing “more to involve teachers who need to learn [these skills]. The ones who attended [from our institution] were already the best teachers.” In addition, despite the asynchronous option, lack of protected time for faculty development may be a limiting factor in participation. Support from institutional and national leadership would likely improve participation.

Measured endpoints to date consist primarily of participant satisfaction and do not yet capture objective changes in teaching. Data collection is ongoing to assess immediate and longitudinal changes in confidence and behaviors of attendees and how this might affect their health professions learners.

Last, our initial needs assessment only targeted academic hospitalists, and the needs of VA hospitalists in rural areas or at facilities without academic affiliation may be different. More research is needed to understand the diverse faculty that comprises both urban and rural VA sites, what their professional development needs are, and how those needs can be met.

Conclusions

Teaching the Teacher is a faculty development pilot, tailored to meet the needs of VA hospitalist clinician educators, that has been voluntarily adopted at multiple VA sites. The facilitated discussion format allows participants to guide the conversation and personalize content, thereby promoting a culture of discussing challenges and best practices among colleagues that we hope endures beyond the bounds of the curriculum. The program focuses on elevating the specific teaching mission of the VA and could be incorporated into onboarding and regular VA-sponsored faculty development updates. While Teaching the Teacher was originally developed for VA hospitalists, most of the content is applicable to clinicians outside hospital medicine. This project serves as a model for training clinical educators and has opportunities to expand across VA as a customizable didactic platform.

Acknowledgments

We thank Brian Schneider, MD, for his tireless support of this program, as well as all the VA clinicians who have shared their time, talents, and wisdom with us since this program’s inception.

Educating the next generation of health professionals is 1 of 4 congressionally mandated statutory missions of the US Department of Veterans Affairs (VA).¹ Even before the COVID-19 pandemic, the number of veterans accessing VA health care was increasing, and those veterans are older and more medically complex than those who seek care outside the VA.² Almost half of medical residents reported a decline in the quality of their clinical education since the institution of the 2011 duty hours regulations, and in the past decade, more attention has been paid to the need for structured faculty development programs that focus on clinicians’ roles as medical educators.^3-6 Hospitalists in particular shoulder a large portion of inpatient medicine education.⁷ As a result, hospitalists have adapted known frameworks for medical education to their unique clinical setting and developed novel frameworks to meet the needs of their learners.^8,9

Access to technology and social media have shaped the educational experience of young learners who are accustomed to quick answers and the rapidity of change.¹⁰ The clinical teaching landscape changed again with COVID-19, requiring at least temporary abandonment of traditional in-person teaching methods, which upended well-established educational norms.^11,12 In this evolving field, even seasoned preceptors may feel ill-equipped to manage the nuances of modern clinical education and may struggle to recognize which teaching skills are most critical.^13,14 Baseline core teaching competencies for medical educators have been previously described and are separate from clinical competencies; however, to our knowledge, no needs assessment has previously been performed specifically for VA hospitalist clinician educators.¹⁵

Between May and June of 2020, we distributed an online needs assessment to academic VA hospitalists to identify perceived barriers to effective clinical education and preferred strategies to overcome them. We received 71 responses from 140 hospitalists (50% response rate) on the Veterans Health Administration (VHA) academic hospitalist listserv. Of respondents, 59 (83%) reported teaching health professions trainees every year. VA hospitalists reported educating a diverse group of interprofessional learners, including medical residents and students, physician assistant students, nursing students, pharmacy residents and students, and podiatry students.

Only 14 respondents (20%) were aware of faculty development training available to them through their VA facility, while 53 (75%) were aware of similar resources through academic affiliates or other outside sources. More than 95% of respondents (n = 68) reported interest in receiving VA-specific faculty development to improve skills as clinician educators. The most preferred forms of delivery were in-person or virtual real-time workshops. VA hospitalists reported the least confidence in their ability to support struggling learners, balance supervision and autonomy, and develop individualized learning plans (Table 1).

Teaching the Teacher

Teaching the Teacher began at a single VA institution as a series of in-person, discussion-based faculty development workshops. The series met a local need for collaborative professional development in clinical education for hospitalists and specialists who round with health professions learners on the inpatient wards. Both novice and experienced clinicians participated in the series with positive feedback. Based on the results of the national needs assessment, the program has since expanded to other sites with support from the VHA Hospital Medicine Program Office. The project’s overarching goal was to facilitate sharing of best practices across VA sites and create a network of local and national VA educators that participants could continue to access even after course completion.

Teaching the Teacher is structured into 5 facilitated hour-long sessions that can be completed either daily for 1 week or weekly for 1 month at the discretion of each institution. Each session is dedicated to a subject identified on the needs assessment as being highest yield. The hospitalist needs assessment also identified the preference for targeted faculty development that is relevant specifically to VA clinicians. To meet this need, Teaching the Teacher delivers its content through the unique lens of VA medicine. The educational mission of the VA is threaded throughout all presentations, and tips to maximize teaching in the VA’s unique clinical environments are embedded into each hour. Examples include discussions on how to incorporate veteran patients into bedside teaching, handling challenging patient-practitioner interactions as they pertain to patients, and the use of VA resources to find and teach evidence-based medicine.Each session includes a set of learning objectives; within that framework, facilitators allow participants to guide the nuances of content based on their individual and institutional priorities. The pandemic continues to shape much of the course content, as both hospitalists and their trainees grapple with mental health challenges, decreased bedside teaching, and wide variations in baseline trainee competence due to different institutional responses to teaching during a pandemic.^12,16 Content is regularly updated to incorporate new literature and feedback from participants and prioritize active participation. Continuing medical education/continuing educational units credit is available through the VA for course completion.

In the first session on modern learners, participants discuss the current generation of health professions trainees, including how personality characteristics and COVID-19 have impacted their learning experiences, and strategies to improve our ability to teach them successfully (Table 2).

Program Impact

Ten academically affiliated VA hospital medicine sections across 6 states have participated in Teaching the Teacher and several more are scheduled at other sites. Of the 10, 5 completed the course in collaboration with another VA site. Ninety-seven clinicians completed < 1 session synchronously but given the asynchronous option, this number likely underestimates the total audience. Participants included physicians, nurse practitioners, and physician assistants.

Surveys were conducted before and after the program, with 58 participants completing the presurvey, 32 the postsurvey, and 27 completing both. Of the 32 postsurvey respondents, 31 (97%) would recommend the seminar to colleagues. The live, discussion-based format was the most valued aspect of the course structure, with engaging facilitators and course content also ranking highly. Just over half (n = 17) indicated specific behavioral changes they plan to enact after completing the series, such as connecting with and better understanding learners, prioritizing high-quality feedback more deliberately, and bringing medicine to the bedside. The most common critiques of the course were requests for more time for feedback skills.

Discussion

Teaching the Teacher is a VA-specific faculty development seminar for hospitalists. Participants who responded to a survey reported that it met their needs as VA clinician educators. This is the first published needs assessment of academic VA hospitalists in their roles as clinician educators and the first faculty development initiative to address those specific needs using a collaborative, multisite approach. Although this program is a pilot, the positive response it has received has set a precedent for increased development and growth.

Teaching the Teacher presents a novel approach with a condensed curriculum that is more convenient and accessible to VA clinicians than previous programs with similar goals. Hospitalists have busy and variable work schedules, and it can be difficult to find time to participate in a traditional faculty development program. While these programs are becoming more commonplace, they are often longitudinal and require a significant time and/or financial commitment from participants.¹⁸ In contrast, Teaching the Teacher is only 5 hours long, can be viewed either synchronously or asynchronously, and is no cost to participants. In the future, other specialties may similarly value an efficient faculty development curriculum, and participation from clinicians outside of hospital medicine could augment the richness of content.

Teaching the Teacher’s curriculum is not meant to be exhaustive, but rather to spark conversation among colleagues. According to survey respondents, the most lauded aspect of this program was the facilitated, discussion-based structure, wherein participants are presented with common challenges and encouraged to share their experiences and solutions with colleagues. Of particular interest to the program’s mission of greater community building are the VA facilities that chose to complete the seminar with another hospitalist section from a different institution. Within this structure lies an opportunity for seasoned educators to informally mentor junior colleagues both within and across institutions, and foster connections among educators that continue beyond the completion of the series. We envision this program growing into an enduring professional development course that begins at onboarding and is revisited at regular intervals thereafter.

Another compelling aspect of this project is the interprofessional design, bringing physicians, nurse practitioners, and physician assistants together. Health education, like clinical care, is shifting to a team approach.¹⁹ The curriculum addresses topics previously described as high priority for interprofessional faculty development, such as fostering healthy team leadership, motivating learners, and appraising evidence and online resources.²⁰ A pilot project in VA primary care facilities found that deliberate interprofessional education improved collaboration among health care professionals.²¹ Prior to Teaching the Teacher, no similar faculty development program provided interprofessional learning and collaboration for VA hospitalists.

Limitations and Future Directions

There are several limitations to this preliminary study. Participation at each site was voluntary and did not always reach the full potential audience of hospitalist clinician educators. As one participant stated, future directions include doing “more to involve teachers who need to learn [these skills]. The ones who attended [from our institution] were already the best teachers.” In addition, despite the asynchronous option, lack of protected time for faculty development may be a limiting factor in participation. Support from institutional and national leadership would likely improve participation.

Measured endpoints to date consist primarily of participant satisfaction and do not yet capture objective changes in teaching. Data collection is ongoing to assess immediate and longitudinal changes in confidence and behaviors of attendees and how this might affect their health professions learners.

Last, our initial needs assessment only targeted academic hospitalists, and the needs of VA hospitalists in rural areas or at facilities without academic affiliation may be different. More research is needed to understand the diverse faculty that comprises both urban and rural VA sites, what their professional development needs are, and how those needs can be met.

Conclusions

Teaching the Teacher is a faculty development pilot, tailored to meet the needs of VA hospitalist clinician educators, that has been voluntarily adopted at multiple VA sites. The facilitated discussion format allows participants to guide the conversation and personalize content, thereby promoting a culture of discussing challenges and best practices among colleagues that we hope endures beyond the bounds of the curriculum. The program focuses on elevating the specific teaching mission of the VA and could be incorporated into onboarding and regular VA-sponsored faculty development updates. While Teaching the Teacher was originally developed for VA hospitalists, most of the content is applicable to clinicians outside hospital medicine. This project serves as a model for training clinical educators and has opportunities to expand across VA as a customizable didactic platform.

Acknowledgments

We thank Brian Schneider, MD, for his tireless support of this program, as well as all the VA clinicians who have shared their time, talents, and wisdom with us since this program’s inception.

Maternal primary antibody immunodeficiencies (PIDs) are tied to increased risk for psychiatric disorders and suicidality in offspring, new research suggests.

Results from a cohort study of more than 4.2 million individuals showed that offspring of mothers with PIDs had a 17% increased risk for a psychiatric disorder and a 20% increased risk for suicidal behavior, compared with their peers with mothers who did not have PIDs.

The risk was more pronounced in offspring of mothers with both PIDs and autoimmune diseases. These risks remained after strictly controlling for different covariates, such as the parents’ psychiatric history, offspring PIDs, and offspring autoimmune diseases.

The investigators, led by Josef Isung, MD, PhD, Centre for Psychiatry Research, department of clinical neuroscience, Karolinska Institutet, Stockholm, noted that they could not “pinpoint a precise causal mechanism” underlying these findings.

Still, “the results add to the existing literature suggesting that the intrauterine immune environment may have implications for fetal neurodevelopment and that a compromised maternal immune system during pregnancy may be a risk factor for psychiatric disorders and suicidal behavior in their offspring in the long term,” they wrote.

The findings were published online in JAMA Psychiatry.
 

‘Natural experiment’

Maternal immune activation (MIA) is “an overarching term for aberrant and disrupted immune activity in the mother during gestation [and] has long been of interest in relation to adverse health outcomes in the offspring,” Dr. Isung noted.

“In relation to negative psychiatric outcomes, there is an abundance of preclinical evidence that has shown a negative impact on offspring secondary to MIA. And in humans, there are several observational studies supporting this link,” he said in an interview.

Dr. Isung added that PIDs are “rare conditions” known to be associated with repeated infections and high rates of autoimmune diseases, causing substantial disability.

“PIDs represent an interesting ‘natural experiment’ for researchers to understand more about the association between immune system dysfunctions and mental health,” he said.

Dr. Isung’s group previously showed that individuals with PIDs have increased odds of psychiatric disorders and suicidal behavior. The link was more pronounced in women with PIDs – and was even more pronounced in those with both PIDs and autoimmune diseases.

In the current study, “we wanted to see whether offspring of individuals were differentially at risk of psychiatric disorders and suicidal behavior, depending on being offspring of mothers or fathers with PIDs,” Dr. Isung said.

“Our hypothesis was that mothers with PIDs would have an increased risk of having offspring with neuropsychiatric outcomes, and that this risk could be due to MIA,” he added.

The researchers turned to Swedish nationwide health and administrative registers. They analyzed data on all individuals with diagnoses of PIDs identified between 1973 and 2013. Offspring born prior to 2003 were included, and parent-offspring pairs in which both parents had a history of PIDs were excluded.

The final study sample consisted of 4,294,169 offspring (51.4% boys). Of these participants, 7,270 (0.17%) had a parent with PIDs.

The researchers identified lifetime records of 10 psychiatric disorders: obsessive-compulsive disorder, ADHD, autism spectrum disorders, schizophrenia and other psychotic disorders, bipolar disorders, major depressive disorder and other mood disorders, anxiety and stress-related disorders, eating disorders, substance use disorders, and Tourette syndrome and chronic tic disorders.

The investigators included parental birth year, psychopathology, suicide attempts, suicide deaths, and autoimmune diseases as covariates, as well as offsprings’ birth year and gender.
 

Elucidation needed

Results showed that, of the 4,676 offspring of mothers with PID, 17.1% had a psychiatric disorder versus 12.7% of offspring of mothers without PIDs. This translated “into a 17% increased risk for offspring of mothers with PIDs in the fully adjusted model,” the investigators reported.

The risk was even higher for offspring of mothers who had not only PIDs but also one of six of the individual psychiatric disorders, with incident rate ratios ranging from 1.15 to 1.71.

Important piece of the puzzle?

In a comment, Michael Eriksen Benros, MD, PhD, professor of immunopsychiatry, department of immunology and microbiology, health, and medical sciences, University of Copenhagen, said this was a “high-quality study” that used a “rich data source.”

Dr. Benros, who is also head of research (biological and precision psychiatry) at the Copenhagen Research Centre for Mental Health, Copenhagen University Hospital, was not involved with the current study.

He noted that prior studies, including some conducted by his own group, have shown that maternal infections overall did not seem to be “specifically linked to mental disorders in the offspring.”

However, “specific maternal infections or specific brain-reactive antibodies during the pregnancy period have been shown to be associated with neurodevelopmental outcomes among the children,” such as intellectual disability, he said.

Regarding direct clinical implications of the study, “it is important to note that the increased risk of psychiatric disorders and suicidality in the offspring of mothers with PID were small,” Dr. Benros said.

“However, it adds an important part to the scientific puzzle regarding the role of maternal immune activation during pregnancy and the risk of mental disorders,” he added.

The study was funded by the Söderström König Foundation and the Fredrik and Ingrid Thuring Foundation. Neither Dr. Isung nor Dr. Benros reported no relevant financial relationships.

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

Maternal primary antibody immunodeficiencies (PIDs) are tied to increased risk for psychiatric disorders and suicidality in offspring, new research suggests.

Results from a cohort study of more than 4.2 million individuals showed that offspring of mothers with PIDs had a 17% increased risk for a psychiatric disorder and a 20% increased risk for suicidal behavior, compared with their peers with mothers who did not have PIDs.

The risk was more pronounced in offspring of mothers with both PIDs and autoimmune diseases. These risks remained after strictly controlling for different covariates, such as the parents’ psychiatric history, offspring PIDs, and offspring autoimmune diseases.

The investigators, led by Josef Isung, MD, PhD, Centre for Psychiatry Research, department of clinical neuroscience, Karolinska Institutet, Stockholm, noted that they could not “pinpoint a precise causal mechanism” underlying these findings.

Still, “the results add to the existing literature suggesting that the intrauterine immune environment may have implications for fetal neurodevelopment and that a compromised maternal immune system during pregnancy may be a risk factor for psychiatric disorders and suicidal behavior in their offspring in the long term,” they wrote.

The findings were published online in JAMA Psychiatry.
 

‘Natural experiment’

Maternal immune activation (MIA) is “an overarching term for aberrant and disrupted immune activity in the mother during gestation [and] has long been of interest in relation to adverse health outcomes in the offspring,” Dr. Isung noted.

“In relation to negative psychiatric outcomes, there is an abundance of preclinical evidence that has shown a negative impact on offspring secondary to MIA. And in humans, there are several observational studies supporting this link,” he said in an interview.

Dr. Isung added that PIDs are “rare conditions” known to be associated with repeated infections and high rates of autoimmune diseases, causing substantial disability.

“PIDs represent an interesting ‘natural experiment’ for researchers to understand more about the association between immune system dysfunctions and mental health,” he said.

Dr. Isung’s group previously showed that individuals with PIDs have increased odds of psychiatric disorders and suicidal behavior. The link was more pronounced in women with PIDs – and was even more pronounced in those with both PIDs and autoimmune diseases.

In the current study, “we wanted to see whether offspring of individuals were differentially at risk of psychiatric disorders and suicidal behavior, depending on being offspring of mothers or fathers with PIDs,” Dr. Isung said.

“Our hypothesis was that mothers with PIDs would have an increased risk of having offspring with neuropsychiatric outcomes, and that this risk could be due to MIA,” he added.

The researchers turned to Swedish nationwide health and administrative registers. They analyzed data on all individuals with diagnoses of PIDs identified between 1973 and 2013. Offspring born prior to 2003 were included, and parent-offspring pairs in which both parents had a history of PIDs were excluded.

The final study sample consisted of 4,294,169 offspring (51.4% boys). Of these participants, 7,270 (0.17%) had a parent with PIDs.

The researchers identified lifetime records of 10 psychiatric disorders: obsessive-compulsive disorder, ADHD, autism spectrum disorders, schizophrenia and other psychotic disorders, bipolar disorders, major depressive disorder and other mood disorders, anxiety and stress-related disorders, eating disorders, substance use disorders, and Tourette syndrome and chronic tic disorders.

The investigators included parental birth year, psychopathology, suicide attempts, suicide deaths, and autoimmune diseases as covariates, as well as offsprings’ birth year and gender.
 

Elucidation needed

Results showed that, of the 4,676 offspring of mothers with PID, 17.1% had a psychiatric disorder versus 12.7% of offspring of mothers without PIDs. This translated “into a 17% increased risk for offspring of mothers with PIDs in the fully adjusted model,” the investigators reported.

The risk was even higher for offspring of mothers who had not only PIDs but also one of six of the individual psychiatric disorders, with incident rate ratios ranging from 1.15 to 1.71.

Important piece of the puzzle?

In a comment, Michael Eriksen Benros, MD, PhD, professor of immunopsychiatry, department of immunology and microbiology, health, and medical sciences, University of Copenhagen, said this was a “high-quality study” that used a “rich data source.”

Dr. Benros, who is also head of research (biological and precision psychiatry) at the Copenhagen Research Centre for Mental Health, Copenhagen University Hospital, was not involved with the current study.

He noted that prior studies, including some conducted by his own group, have shown that maternal infections overall did not seem to be “specifically linked to mental disorders in the offspring.”

However, “specific maternal infections or specific brain-reactive antibodies during the pregnancy period have been shown to be associated with neurodevelopmental outcomes among the children,” such as intellectual disability, he said.

Regarding direct clinical implications of the study, “it is important to note that the increased risk of psychiatric disorders and suicidality in the offspring of mothers with PID were small,” Dr. Benros said.

“However, it adds an important part to the scientific puzzle regarding the role of maternal immune activation during pregnancy and the risk of mental disorders,” he added.

The study was funded by the Söderström König Foundation and the Fredrik and Ingrid Thuring Foundation. Neither Dr. Isung nor Dr. Benros reported no relevant financial relationships.

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

Maternal primary antibody immunodeficiencies (PIDs) are tied to increased risk for psychiatric disorders and suicidality in offspring, new research suggests.

Results from a cohort study of more than 4.2 million individuals showed that offspring of mothers with PIDs had a 17% increased risk for a psychiatric disorder and a 20% increased risk for suicidal behavior, compared with their peers with mothers who did not have PIDs.

The risk was more pronounced in offspring of mothers with both PIDs and autoimmune diseases. These risks remained after strictly controlling for different covariates, such as the parents’ psychiatric history, offspring PIDs, and offspring autoimmune diseases.

The investigators, led by Josef Isung, MD, PhD, Centre for Psychiatry Research, department of clinical neuroscience, Karolinska Institutet, Stockholm, noted that they could not “pinpoint a precise causal mechanism” underlying these findings.

Still, “the results add to the existing literature suggesting that the intrauterine immune environment may have implications for fetal neurodevelopment and that a compromised maternal immune system during pregnancy may be a risk factor for psychiatric disorders and suicidal behavior in their offspring in the long term,” they wrote.

The findings were published online in JAMA Psychiatry.
 

‘Natural experiment’

Maternal immune activation (MIA) is “an overarching term for aberrant and disrupted immune activity in the mother during gestation [and] has long been of interest in relation to adverse health outcomes in the offspring,” Dr. Isung noted.

“In relation to negative psychiatric outcomes, there is an abundance of preclinical evidence that has shown a negative impact on offspring secondary to MIA. And in humans, there are several observational studies supporting this link,” he said in an interview.

Dr. Isung added that PIDs are “rare conditions” known to be associated with repeated infections and high rates of autoimmune diseases, causing substantial disability.

“PIDs represent an interesting ‘natural experiment’ for researchers to understand more about the association between immune system dysfunctions and mental health,” he said.

Dr. Isung’s group previously showed that individuals with PIDs have increased odds of psychiatric disorders and suicidal behavior. The link was more pronounced in women with PIDs – and was even more pronounced in those with both PIDs and autoimmune diseases.

In the current study, “we wanted to see whether offspring of individuals were differentially at risk of psychiatric disorders and suicidal behavior, depending on being offspring of mothers or fathers with PIDs,” Dr. Isung said.

“Our hypothesis was that mothers with PIDs would have an increased risk of having offspring with neuropsychiatric outcomes, and that this risk could be due to MIA,” he added.

The researchers turned to Swedish nationwide health and administrative registers. They analyzed data on all individuals with diagnoses of PIDs identified between 1973 and 2013. Offspring born prior to 2003 were included, and parent-offspring pairs in which both parents had a history of PIDs were excluded.

The final study sample consisted of 4,294,169 offspring (51.4% boys). Of these participants, 7,270 (0.17%) had a parent with PIDs.

The researchers identified lifetime records of 10 psychiatric disorders: obsessive-compulsive disorder, ADHD, autism spectrum disorders, schizophrenia and other psychotic disorders, bipolar disorders, major depressive disorder and other mood disorders, anxiety and stress-related disorders, eating disorders, substance use disorders, and Tourette syndrome and chronic tic disorders.

The investigators included parental birth year, psychopathology, suicide attempts, suicide deaths, and autoimmune diseases as covariates, as well as offsprings’ birth year and gender.
 

Elucidation needed

Results showed that, of the 4,676 offspring of mothers with PID, 17.1% had a psychiatric disorder versus 12.7% of offspring of mothers without PIDs. This translated “into a 17% increased risk for offspring of mothers with PIDs in the fully adjusted model,” the investigators reported.

The risk was even higher for offspring of mothers who had not only PIDs but also one of six of the individual psychiatric disorders, with incident rate ratios ranging from 1.15 to 1.71.

Important piece of the puzzle?

In a comment, Michael Eriksen Benros, MD, PhD, professor of immunopsychiatry, department of immunology and microbiology, health, and medical sciences, University of Copenhagen, said this was a “high-quality study” that used a “rich data source.”

Dr. Benros, who is also head of research (biological and precision psychiatry) at the Copenhagen Research Centre for Mental Health, Copenhagen University Hospital, was not involved with the current study.

He noted that prior studies, including some conducted by his own group, have shown that maternal infections overall did not seem to be “specifically linked to mental disorders in the offspring.”

However, “specific maternal infections or specific brain-reactive antibodies during the pregnancy period have been shown to be associated with neurodevelopmental outcomes among the children,” such as intellectual disability, he said.

Regarding direct clinical implications of the study, “it is important to note that the increased risk of psychiatric disorders and suicidality in the offspring of mothers with PID were small,” Dr. Benros said.

“However, it adds an important part to the scientific puzzle regarding the role of maternal immune activation during pregnancy and the risk of mental disorders,” he added.

The study was funded by the Söderström König Foundation and the Fredrik and Ingrid Thuring Foundation. Neither Dr. Isung nor Dr. Benros reported no relevant financial relationships.

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