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Internists still low for earnings and net worth, report finds
according to the Medscape Internist Debt and Net Worth Report 2020.
The results are from a larger survey that tracked physicians’ efforts to reduce or eliminate debt, save, invest, purchase property, and prepare for retirement. The annual survey was completed just as the COVID-19 pandemic was taking hold, and the findings provide a baseline against which to view the effects of the pandemic, which turned the lives of many physicians upside down.
Conducted from Oct. 4, 2019, until Feb. 10, 2020, the survey represents 17,461 physicians from 29 areas of medicine, including family practice, internal medicine, pediatrics, and obstetrics and gynecology.
Earnings and net worth
Internists earned on average $251,000 annually, sixth from the bottom of the list and approximately half the amount of the most lucrative specialty, orthopedics. The annual salary increased from $243,000 in 2019.
The average annual salary for internists represents a 2.5% increase, compared with the 1.5% increase for specialists, whose annual income rose from $341,000 in 2019 to $346,000 in 2020.
The low earnings for internists are echoed in the findings for net worth: 58% of internists have a net worth of less than $1 million, 37% have between $1 million and $5 million, and 5% have more than $5 million. For comparison, half of all physicians have a net worth of less than $1 million, 42% have between $1 million and $5 million, and 8% have over $5 million.
About 40% of internists indicated that their net worth was less than $500,000, which is the fourth highest of the 29 medical fields surveyed. About 44% of pediatricians, 46% of family practitioners, and 30% of ob.gyns. also reported their net worth at less than $500,000, so the primary care providers share low net worth compared with their colleagues. About 41% of neurologists reported a net worth of less than $500,000.
Only 5% of internists reported a net worth of more than $5 million. The specialties with the most physicians with net worth exceeding $5 million are orthopedists, at 19%, and plastic surgeons and gastroenterologists, each at 16%.
Gender disparity in net worth appears to be lower among internists than in other fields. Among all physicians, 56% of men and 39% of women reported a net worth in excess of $1 million, but among internists, 46% of men and 36% of women did so. About 64% of the internists who took the survey are men, and 34% are women.
Higher net worth tracks clearly with age group, as expected in light of diminishing debt over time and an accumulation of wealth.
Expenses
The top three expenses that internists face are mortgage on primary residence (60%), car loans (36%), and credit card debt (26%); 12% of respondents reported no debt or expenses. Among all physicians, the breakdown of expenses by category is very similar to that for internists.
Paying off school loans affects 24% of internists, which was in the middle of the 29 physician groups. The percentage ranges from physical medicine and rehabilitation at 34% to rheumatology at 15%.
About 42% of internists have a mortgage of less than $300,000, and 30% have no mortgage at all. Figures are similar for all physicians.
Internists are apparently savers and not spenders. Only 8% reported living above their means; 39% indicated that they live below their means. These figures are similar for all physicians who responded to the survey.
About 60% of internists put more than $1,000 a month into tax-deferred accounts. Most internists also contribute to taxable savings accounts, which might reflect the fact that they had contributed the maximum amount to tax-deferred accounts.
Two-fifths of the internists reported having worked with a financial planner. Of the nearly three fourths of responding internists who share finances with a spouse or partner, a few more than half pool resources.
In the world before COVID-19, 31% of internists reported significant financial losses over the previous year, most because of bad investments or problems relating to their practice. Financial losses since that time obviously have another predominant cause – the direct and ripple effects of the pandemic.
As of July 22, primary care providers reported a 55% decrease in revenue and a 20%-30% decrease in patient volume, according to Travis Singleton, senior vice president of Merritt Hawkins, a physician placement and recruiting company. Some practitioners have closed their physical offices because patient demand has plummeted and nonessential office procedures and exams have been postponed or canceled. The use of telemedicine has soared.
Medscape’s Internist Debt and Net Worth Report 2020, and the larger report from which it was derived, may come to serve as a marker between two very different financial worlds for clinical medicine.
A version of this article originally appeared on Medscape.com.
according to the Medscape Internist Debt and Net Worth Report 2020.
The results are from a larger survey that tracked physicians’ efforts to reduce or eliminate debt, save, invest, purchase property, and prepare for retirement. The annual survey was completed just as the COVID-19 pandemic was taking hold, and the findings provide a baseline against which to view the effects of the pandemic, which turned the lives of many physicians upside down.
Conducted from Oct. 4, 2019, until Feb. 10, 2020, the survey represents 17,461 physicians from 29 areas of medicine, including family practice, internal medicine, pediatrics, and obstetrics and gynecology.
Earnings and net worth
Internists earned on average $251,000 annually, sixth from the bottom of the list and approximately half the amount of the most lucrative specialty, orthopedics. The annual salary increased from $243,000 in 2019.
The average annual salary for internists represents a 2.5% increase, compared with the 1.5% increase for specialists, whose annual income rose from $341,000 in 2019 to $346,000 in 2020.
The low earnings for internists are echoed in the findings for net worth: 58% of internists have a net worth of less than $1 million, 37% have between $1 million and $5 million, and 5% have more than $5 million. For comparison, half of all physicians have a net worth of less than $1 million, 42% have between $1 million and $5 million, and 8% have over $5 million.
About 40% of internists indicated that their net worth was less than $500,000, which is the fourth highest of the 29 medical fields surveyed. About 44% of pediatricians, 46% of family practitioners, and 30% of ob.gyns. also reported their net worth at less than $500,000, so the primary care providers share low net worth compared with their colleagues. About 41% of neurologists reported a net worth of less than $500,000.
Only 5% of internists reported a net worth of more than $5 million. The specialties with the most physicians with net worth exceeding $5 million are orthopedists, at 19%, and plastic surgeons and gastroenterologists, each at 16%.
Gender disparity in net worth appears to be lower among internists than in other fields. Among all physicians, 56% of men and 39% of women reported a net worth in excess of $1 million, but among internists, 46% of men and 36% of women did so. About 64% of the internists who took the survey are men, and 34% are women.
Higher net worth tracks clearly with age group, as expected in light of diminishing debt over time and an accumulation of wealth.
Expenses
The top three expenses that internists face are mortgage on primary residence (60%), car loans (36%), and credit card debt (26%); 12% of respondents reported no debt or expenses. Among all physicians, the breakdown of expenses by category is very similar to that for internists.
Paying off school loans affects 24% of internists, which was in the middle of the 29 physician groups. The percentage ranges from physical medicine and rehabilitation at 34% to rheumatology at 15%.
About 42% of internists have a mortgage of less than $300,000, and 30% have no mortgage at all. Figures are similar for all physicians.
Internists are apparently savers and not spenders. Only 8% reported living above their means; 39% indicated that they live below their means. These figures are similar for all physicians who responded to the survey.
About 60% of internists put more than $1,000 a month into tax-deferred accounts. Most internists also contribute to taxable savings accounts, which might reflect the fact that they had contributed the maximum amount to tax-deferred accounts.
Two-fifths of the internists reported having worked with a financial planner. Of the nearly three fourths of responding internists who share finances with a spouse or partner, a few more than half pool resources.
In the world before COVID-19, 31% of internists reported significant financial losses over the previous year, most because of bad investments or problems relating to their practice. Financial losses since that time obviously have another predominant cause – the direct and ripple effects of the pandemic.
As of July 22, primary care providers reported a 55% decrease in revenue and a 20%-30% decrease in patient volume, according to Travis Singleton, senior vice president of Merritt Hawkins, a physician placement and recruiting company. Some practitioners have closed their physical offices because patient demand has plummeted and nonessential office procedures and exams have been postponed or canceled. The use of telemedicine has soared.
Medscape’s Internist Debt and Net Worth Report 2020, and the larger report from which it was derived, may come to serve as a marker between two very different financial worlds for clinical medicine.
A version of this article originally appeared on Medscape.com.
according to the Medscape Internist Debt and Net Worth Report 2020.
The results are from a larger survey that tracked physicians’ efforts to reduce or eliminate debt, save, invest, purchase property, and prepare for retirement. The annual survey was completed just as the COVID-19 pandemic was taking hold, and the findings provide a baseline against which to view the effects of the pandemic, which turned the lives of many physicians upside down.
Conducted from Oct. 4, 2019, until Feb. 10, 2020, the survey represents 17,461 physicians from 29 areas of medicine, including family practice, internal medicine, pediatrics, and obstetrics and gynecology.
Earnings and net worth
Internists earned on average $251,000 annually, sixth from the bottom of the list and approximately half the amount of the most lucrative specialty, orthopedics. The annual salary increased from $243,000 in 2019.
The average annual salary for internists represents a 2.5% increase, compared with the 1.5% increase for specialists, whose annual income rose from $341,000 in 2019 to $346,000 in 2020.
The low earnings for internists are echoed in the findings for net worth: 58% of internists have a net worth of less than $1 million, 37% have between $1 million and $5 million, and 5% have more than $5 million. For comparison, half of all physicians have a net worth of less than $1 million, 42% have between $1 million and $5 million, and 8% have over $5 million.
About 40% of internists indicated that their net worth was less than $500,000, which is the fourth highest of the 29 medical fields surveyed. About 44% of pediatricians, 46% of family practitioners, and 30% of ob.gyns. also reported their net worth at less than $500,000, so the primary care providers share low net worth compared with their colleagues. About 41% of neurologists reported a net worth of less than $500,000.
Only 5% of internists reported a net worth of more than $5 million. The specialties with the most physicians with net worth exceeding $5 million are orthopedists, at 19%, and plastic surgeons and gastroenterologists, each at 16%.
Gender disparity in net worth appears to be lower among internists than in other fields. Among all physicians, 56% of men and 39% of women reported a net worth in excess of $1 million, but among internists, 46% of men and 36% of women did so. About 64% of the internists who took the survey are men, and 34% are women.
Higher net worth tracks clearly with age group, as expected in light of diminishing debt over time and an accumulation of wealth.
Expenses
The top three expenses that internists face are mortgage on primary residence (60%), car loans (36%), and credit card debt (26%); 12% of respondents reported no debt or expenses. Among all physicians, the breakdown of expenses by category is very similar to that for internists.
Paying off school loans affects 24% of internists, which was in the middle of the 29 physician groups. The percentage ranges from physical medicine and rehabilitation at 34% to rheumatology at 15%.
About 42% of internists have a mortgage of less than $300,000, and 30% have no mortgage at all. Figures are similar for all physicians.
Internists are apparently savers and not spenders. Only 8% reported living above their means; 39% indicated that they live below their means. These figures are similar for all physicians who responded to the survey.
About 60% of internists put more than $1,000 a month into tax-deferred accounts. Most internists also contribute to taxable savings accounts, which might reflect the fact that they had contributed the maximum amount to tax-deferred accounts.
Two-fifths of the internists reported having worked with a financial planner. Of the nearly three fourths of responding internists who share finances with a spouse or partner, a few more than half pool resources.
In the world before COVID-19, 31% of internists reported significant financial losses over the previous year, most because of bad investments or problems relating to their practice. Financial losses since that time obviously have another predominant cause – the direct and ripple effects of the pandemic.
As of July 22, primary care providers reported a 55% decrease in revenue and a 20%-30% decrease in patient volume, according to Travis Singleton, senior vice president of Merritt Hawkins, a physician placement and recruiting company. Some practitioners have closed their physical offices because patient demand has plummeted and nonessential office procedures and exams have been postponed or canceled. The use of telemedicine has soared.
Medscape’s Internist Debt and Net Worth Report 2020, and the larger report from which it was derived, may come to serve as a marker between two very different financial worlds for clinical medicine.
A version of this article originally appeared on Medscape.com.
‘Defending Jacob’ and defending psychiatry
The 2012 crime fiction novel, “Defending Jacob,” by William Landay was dramatized into a miniseries created by Mark Bomback that premiered on April 24, 2020, on Apple TV+ (and for those resisting a subscription, “The Morning Show” and “Defending Jacob” are both worth it). Both the “Defending Jacob” novel and the miniseries have themes that are of interest to psychiatry, especially to child and forensic psychiatrists, and both the literary and TV versions are excellent, albeit disturbing, diversions from the current pandemic.
(Spoiler alert!) The story is set in the affluent town of Newton, Mass., where crime is generally low and homicides extremely infrequent. Protagonist Andy Barber, a 51-year-old Jewish assistant district attorney, is played by a younger Chris Evans in the miniseries. His wife, Laurie Gold Barber, a 51-year-old Jewish former schoolteacher and stay-at-home mom, is played by a younger Michelle Dockery of Downton Abbey fame. In the miniseries, her character is actively working as a teacher and social activist for children. Other differences between the novel and the miniseries will be pointed out when relevant, but the overall narrative is similar. Both stories are cleverly told through Andy Barber speaking in retrospect as he is being questioned in front of a grand jury for a potential indictment.
When 14-year-old Ben Rifkin is found stabbed to death in Cold Spring Park before school one morning, Andy Barber initially takes the case despite his boss’s reservations that there may be a conflict because Andy’s son Jacob is a student in Ben’s class at school. As the title suggests, it soon becomes clear that Jacob may have had something to do with the murder. At that point, Andy is taken off the case and it is given to a junior colleague, Neal Logiudice, who demonstrates both admiration and contempt for his former mentor, perhaps because of underlying jealousy and insecurity. Neal Logiudice becomes the DA questioning Andy Barber.
Prior to Jacob’s formal accusation of murder, the Barbers appear to be fiercely loyal and unable to fully see and understand their son. The difficulty with objectivity and the reasons why family member physicians should never treat family members – and why family member attorneys should never represent loved ones – is abundantly clear in this story. When Andy receives an anonymous tip that Jacob’s childhood best friend, Derek Yoo, posted on Facebook, “Jake, everyone knows you did it. You have a knife. I’ve seen it,’ ” Andy then looks through Jacob’s drawers and finds a folding knife in one of his T-shirts. In the chapter aptly titled “Denial,” Andy, an experienced prosecutor, does not turn the knife over as evidence, but instead disposes of it – believing Jacob that he did not take the knife to school the day his classmate was stabbed.
After Jacob is indicted, Andy Barber confesses to his wife, Laurie, that his estranged father who left when he was 6 is actually in prison convicted of murdering and raping a woman. In the novel, his grandfather and great-grandfather are also convicted felons. Laurie reveals this family history to Jacob’s attorney, and the attorney subsequently refers the family to a forensic psychologist. In the novel, she is a large Jewish woman; in the miniseries she is played by a very thin Poorna Jagannathan (who incidentally has portrayed a therapist in the television series “Sorry for your Loss,” and a doctor in “The Act,” “Better Call Saul,” “NCIS: Los Angeles,” “House of Cards,” “The Game,” “Law and Order: Criminal Intent,” “Rescue Me,” “Jonny Zero,” “An Actor Prepares,” “The Circle,” “Thanks for Sharing,” and “Montclair.”) Although the goal of the defense was a finding of “not guilty,” a psychiatric defense was going to be used as a last resort if necessary.
Laurie had already googled and learned of “the murder gene,” which was further explained by the forensic psychologist as a mutation called:
“MAOA Knockout. It has been argued in court as a trigger for violence before, but the argument was too simplistic, and it was rejected. Our understanding of the gene-environment interplay has improved since then – the science is getting better and very quickly – and we may have better testimony now. The second mutation is located in what’s called the serotonin transporter gene. The official name for the gene is SLC6A4. It’s located on chromosome 17. It encodes a protein that facilitates the activity of the serotonin transporter system, which is what enables the reuptake of serotonin from the synapse back into the neuron.”1
She further explains that there have been many studies on the “nurture” side of the nature/nurture question and that, with new developments in DNA studies, it is now becoming possible to study the “nature” side.
“Defending Jacob” explores the nature/nurture issue, as well as issues with forensic testimony in court and the criminal justice system in general. The issue of repressing feelings and hiding secrets and then having to confront both in a brutal manner is another theme addressed in the story. Andy tried to hide and forget that his father was in prison and the criminal history in his family, but he was forced to face this and his feelings about it when confronted with his own son being accused of murder. Of note, he does not seek help from a therapist despite these life-altering events. (Humongous spoiler alert:) The story that began with a murder of an unrelated child may end with a family murder, one that would be well described and could be understood by psychiatrists using the categories of motives initially described by Phillip Resnick, MD.2
Once again, and unfortunately, as we have pointed out in other media reviews, the portrayal of psychiatric/psychological themes is problematic. Using a psychologist to explain the science of DNA and not a psychiatrist is an interesting choice. Diagnosing a 14-year-old with personality disorders also contributes to misunderstanding and stigma. In addition, no timely attempt is made to refer the accused Jacob for mental health treatment. The stigmatization of psychiatry in the media was addressed by the World Psychiatric Association task force guidance on how to combat stigmatization of psychiatry and psychiatrists,3 including breaking down negative views of psychiatrists and psychiatry in the general public, among medical students, other health professionals, and patients and relatives. The task force made recommendations for national psychiatric societies and for individual practitioners to help reduce stigma of the profession of psychiatry. We would argue that speaking to the media, including fiction authors, to help educate about mental health is an important role for psychiatrists. It would lead to more realistic portrayals in film and books.
Overall, “Defending Jacob” is a compelling story in both the novel and the miniseries. Despite some problems with how it depicts mental health issues, both are engaging and contain thoughtful, extremely well-written themes of interest to many clinical and forensic psychiatrists.
References
1. Landay W. Defending Jacob, a novel. New York: Delacorte Press, 2012.
2. Friedman SH. Family Murder: Pathologies of Love and Hate. Washington: American Psychiatric Association Publishing, 2019.
3. Sartorius N et al. World Psychiatry. 2010 Oct;9(3):131-44.
Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and on the faculty at Weill Cornell Medical Center. Dr. Hatters Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington: American Psychiatric Association Publishing, 2019), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law and was awarded the 2020 Manfred Gutmacher Award by the American Psychiatric Association.
The 2012 crime fiction novel, “Defending Jacob,” by William Landay was dramatized into a miniseries created by Mark Bomback that premiered on April 24, 2020, on Apple TV+ (and for those resisting a subscription, “The Morning Show” and “Defending Jacob” are both worth it). Both the “Defending Jacob” novel and the miniseries have themes that are of interest to psychiatry, especially to child and forensic psychiatrists, and both the literary and TV versions are excellent, albeit disturbing, diversions from the current pandemic.
(Spoiler alert!) The story is set in the affluent town of Newton, Mass., where crime is generally low and homicides extremely infrequent. Protagonist Andy Barber, a 51-year-old Jewish assistant district attorney, is played by a younger Chris Evans in the miniseries. His wife, Laurie Gold Barber, a 51-year-old Jewish former schoolteacher and stay-at-home mom, is played by a younger Michelle Dockery of Downton Abbey fame. In the miniseries, her character is actively working as a teacher and social activist for children. Other differences between the novel and the miniseries will be pointed out when relevant, but the overall narrative is similar. Both stories are cleverly told through Andy Barber speaking in retrospect as he is being questioned in front of a grand jury for a potential indictment.
When 14-year-old Ben Rifkin is found stabbed to death in Cold Spring Park before school one morning, Andy Barber initially takes the case despite his boss’s reservations that there may be a conflict because Andy’s son Jacob is a student in Ben’s class at school. As the title suggests, it soon becomes clear that Jacob may have had something to do with the murder. At that point, Andy is taken off the case and it is given to a junior colleague, Neal Logiudice, who demonstrates both admiration and contempt for his former mentor, perhaps because of underlying jealousy and insecurity. Neal Logiudice becomes the DA questioning Andy Barber.
Prior to Jacob’s formal accusation of murder, the Barbers appear to be fiercely loyal and unable to fully see and understand their son. The difficulty with objectivity and the reasons why family member physicians should never treat family members – and why family member attorneys should never represent loved ones – is abundantly clear in this story. When Andy receives an anonymous tip that Jacob’s childhood best friend, Derek Yoo, posted on Facebook, “Jake, everyone knows you did it. You have a knife. I’ve seen it,’ ” Andy then looks through Jacob’s drawers and finds a folding knife in one of his T-shirts. In the chapter aptly titled “Denial,” Andy, an experienced prosecutor, does not turn the knife over as evidence, but instead disposes of it – believing Jacob that he did not take the knife to school the day his classmate was stabbed.
After Jacob is indicted, Andy Barber confesses to his wife, Laurie, that his estranged father who left when he was 6 is actually in prison convicted of murdering and raping a woman. In the novel, his grandfather and great-grandfather are also convicted felons. Laurie reveals this family history to Jacob’s attorney, and the attorney subsequently refers the family to a forensic psychologist. In the novel, she is a large Jewish woman; in the miniseries she is played by a very thin Poorna Jagannathan (who incidentally has portrayed a therapist in the television series “Sorry for your Loss,” and a doctor in “The Act,” “Better Call Saul,” “NCIS: Los Angeles,” “House of Cards,” “The Game,” “Law and Order: Criminal Intent,” “Rescue Me,” “Jonny Zero,” “An Actor Prepares,” “The Circle,” “Thanks for Sharing,” and “Montclair.”) Although the goal of the defense was a finding of “not guilty,” a psychiatric defense was going to be used as a last resort if necessary.
Laurie had already googled and learned of “the murder gene,” which was further explained by the forensic psychologist as a mutation called:
“MAOA Knockout. It has been argued in court as a trigger for violence before, but the argument was too simplistic, and it was rejected. Our understanding of the gene-environment interplay has improved since then – the science is getting better and very quickly – and we may have better testimony now. The second mutation is located in what’s called the serotonin transporter gene. The official name for the gene is SLC6A4. It’s located on chromosome 17. It encodes a protein that facilitates the activity of the serotonin transporter system, which is what enables the reuptake of serotonin from the synapse back into the neuron.”1
She further explains that there have been many studies on the “nurture” side of the nature/nurture question and that, with new developments in DNA studies, it is now becoming possible to study the “nature” side.
“Defending Jacob” explores the nature/nurture issue, as well as issues with forensic testimony in court and the criminal justice system in general. The issue of repressing feelings and hiding secrets and then having to confront both in a brutal manner is another theme addressed in the story. Andy tried to hide and forget that his father was in prison and the criminal history in his family, but he was forced to face this and his feelings about it when confronted with his own son being accused of murder. Of note, he does not seek help from a therapist despite these life-altering events. (Humongous spoiler alert:) The story that began with a murder of an unrelated child may end with a family murder, one that would be well described and could be understood by psychiatrists using the categories of motives initially described by Phillip Resnick, MD.2
Once again, and unfortunately, as we have pointed out in other media reviews, the portrayal of psychiatric/psychological themes is problematic. Using a psychologist to explain the science of DNA and not a psychiatrist is an interesting choice. Diagnosing a 14-year-old with personality disorders also contributes to misunderstanding and stigma. In addition, no timely attempt is made to refer the accused Jacob for mental health treatment. The stigmatization of psychiatry in the media was addressed by the World Psychiatric Association task force guidance on how to combat stigmatization of psychiatry and psychiatrists,3 including breaking down negative views of psychiatrists and psychiatry in the general public, among medical students, other health professionals, and patients and relatives. The task force made recommendations for national psychiatric societies and for individual practitioners to help reduce stigma of the profession of psychiatry. We would argue that speaking to the media, including fiction authors, to help educate about mental health is an important role for psychiatrists. It would lead to more realistic portrayals in film and books.
Overall, “Defending Jacob” is a compelling story in both the novel and the miniseries. Despite some problems with how it depicts mental health issues, both are engaging and contain thoughtful, extremely well-written themes of interest to many clinical and forensic psychiatrists.
References
1. Landay W. Defending Jacob, a novel. New York: Delacorte Press, 2012.
2. Friedman SH. Family Murder: Pathologies of Love and Hate. Washington: American Psychiatric Association Publishing, 2019.
3. Sartorius N et al. World Psychiatry. 2010 Oct;9(3):131-44.
Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and on the faculty at Weill Cornell Medical Center. Dr. Hatters Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington: American Psychiatric Association Publishing, 2019), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law and was awarded the 2020 Manfred Gutmacher Award by the American Psychiatric Association.
The 2012 crime fiction novel, “Defending Jacob,” by William Landay was dramatized into a miniseries created by Mark Bomback that premiered on April 24, 2020, on Apple TV+ (and for those resisting a subscription, “The Morning Show” and “Defending Jacob” are both worth it). Both the “Defending Jacob” novel and the miniseries have themes that are of interest to psychiatry, especially to child and forensic psychiatrists, and both the literary and TV versions are excellent, albeit disturbing, diversions from the current pandemic.
(Spoiler alert!) The story is set in the affluent town of Newton, Mass., where crime is generally low and homicides extremely infrequent. Protagonist Andy Barber, a 51-year-old Jewish assistant district attorney, is played by a younger Chris Evans in the miniseries. His wife, Laurie Gold Barber, a 51-year-old Jewish former schoolteacher and stay-at-home mom, is played by a younger Michelle Dockery of Downton Abbey fame. In the miniseries, her character is actively working as a teacher and social activist for children. Other differences between the novel and the miniseries will be pointed out when relevant, but the overall narrative is similar. Both stories are cleverly told through Andy Barber speaking in retrospect as he is being questioned in front of a grand jury for a potential indictment.
When 14-year-old Ben Rifkin is found stabbed to death in Cold Spring Park before school one morning, Andy Barber initially takes the case despite his boss’s reservations that there may be a conflict because Andy’s son Jacob is a student in Ben’s class at school. As the title suggests, it soon becomes clear that Jacob may have had something to do with the murder. At that point, Andy is taken off the case and it is given to a junior colleague, Neal Logiudice, who demonstrates both admiration and contempt for his former mentor, perhaps because of underlying jealousy and insecurity. Neal Logiudice becomes the DA questioning Andy Barber.
Prior to Jacob’s formal accusation of murder, the Barbers appear to be fiercely loyal and unable to fully see and understand their son. The difficulty with objectivity and the reasons why family member physicians should never treat family members – and why family member attorneys should never represent loved ones – is abundantly clear in this story. When Andy receives an anonymous tip that Jacob’s childhood best friend, Derek Yoo, posted on Facebook, “Jake, everyone knows you did it. You have a knife. I’ve seen it,’ ” Andy then looks through Jacob’s drawers and finds a folding knife in one of his T-shirts. In the chapter aptly titled “Denial,” Andy, an experienced prosecutor, does not turn the knife over as evidence, but instead disposes of it – believing Jacob that he did not take the knife to school the day his classmate was stabbed.
After Jacob is indicted, Andy Barber confesses to his wife, Laurie, that his estranged father who left when he was 6 is actually in prison convicted of murdering and raping a woman. In the novel, his grandfather and great-grandfather are also convicted felons. Laurie reveals this family history to Jacob’s attorney, and the attorney subsequently refers the family to a forensic psychologist. In the novel, she is a large Jewish woman; in the miniseries she is played by a very thin Poorna Jagannathan (who incidentally has portrayed a therapist in the television series “Sorry for your Loss,” and a doctor in “The Act,” “Better Call Saul,” “NCIS: Los Angeles,” “House of Cards,” “The Game,” “Law and Order: Criminal Intent,” “Rescue Me,” “Jonny Zero,” “An Actor Prepares,” “The Circle,” “Thanks for Sharing,” and “Montclair.”) Although the goal of the defense was a finding of “not guilty,” a psychiatric defense was going to be used as a last resort if necessary.
Laurie had already googled and learned of “the murder gene,” which was further explained by the forensic psychologist as a mutation called:
“MAOA Knockout. It has been argued in court as a trigger for violence before, but the argument was too simplistic, and it was rejected. Our understanding of the gene-environment interplay has improved since then – the science is getting better and very quickly – and we may have better testimony now. The second mutation is located in what’s called the serotonin transporter gene. The official name for the gene is SLC6A4. It’s located on chromosome 17. It encodes a protein that facilitates the activity of the serotonin transporter system, which is what enables the reuptake of serotonin from the synapse back into the neuron.”1
She further explains that there have been many studies on the “nurture” side of the nature/nurture question and that, with new developments in DNA studies, it is now becoming possible to study the “nature” side.
“Defending Jacob” explores the nature/nurture issue, as well as issues with forensic testimony in court and the criminal justice system in general. The issue of repressing feelings and hiding secrets and then having to confront both in a brutal manner is another theme addressed in the story. Andy tried to hide and forget that his father was in prison and the criminal history in his family, but he was forced to face this and his feelings about it when confronted with his own son being accused of murder. Of note, he does not seek help from a therapist despite these life-altering events. (Humongous spoiler alert:) The story that began with a murder of an unrelated child may end with a family murder, one that would be well described and could be understood by psychiatrists using the categories of motives initially described by Phillip Resnick, MD.2
Once again, and unfortunately, as we have pointed out in other media reviews, the portrayal of psychiatric/psychological themes is problematic. Using a psychologist to explain the science of DNA and not a psychiatrist is an interesting choice. Diagnosing a 14-year-old with personality disorders also contributes to misunderstanding and stigma. In addition, no timely attempt is made to refer the accused Jacob for mental health treatment. The stigmatization of psychiatry in the media was addressed by the World Psychiatric Association task force guidance on how to combat stigmatization of psychiatry and psychiatrists,3 including breaking down negative views of psychiatrists and psychiatry in the general public, among medical students, other health professionals, and patients and relatives. The task force made recommendations for national psychiatric societies and for individual practitioners to help reduce stigma of the profession of psychiatry. We would argue that speaking to the media, including fiction authors, to help educate about mental health is an important role for psychiatrists. It would lead to more realistic portrayals in film and books.
Overall, “Defending Jacob” is a compelling story in both the novel and the miniseries. Despite some problems with how it depicts mental health issues, both are engaging and contain thoughtful, extremely well-written themes of interest to many clinical and forensic psychiatrists.
References
1. Landay W. Defending Jacob, a novel. New York: Delacorte Press, 2012.
2. Friedman SH. Family Murder: Pathologies of Love and Hate. Washington: American Psychiatric Association Publishing, 2019.
3. Sartorius N et al. World Psychiatry. 2010 Oct;9(3):131-44.
Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and on the faculty at Weill Cornell Medical Center. Dr. Hatters Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington: American Psychiatric Association Publishing, 2019), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law and was awarded the 2020 Manfred Gutmacher Award by the American Psychiatric Association.
Novel drug may lower agitation, aggression in multiple psychiatric disorders
The novel lysine-specific demethylase 1 inhibitor vafidemstat (ORY-2001, Oryzon Genomics) is effective for treating agitation and aggression across a number of psychiatric disorders, new research suggests.
The REIMAGINE trial included 30 patients with autism spectrum disorder (ASD), ADHD, or borderline personality disorder (BPD). Results showed significant improvements after 8 weeks in general functioning and agitation-aggression scores for all three disorders.
The study “supports vafidemstat as an emerging therapeutic option to treat aggression-agitation, as well as the nonaggression features of psychiatric diseases with high unmet medical need,” lead researcher Roger Bullock, MD, Oryzon Genomics, Corneliá De Llobregat, Spain, told Medscape Medical News.
Bullock added.
However, another expert urged prudence when interpreting the findings.
“The study results must be viewed with caution, given the inherent limitations of an open-label trial, small sample size, and weak rationale for the sample selection,” said Nathan Kolla, MD, PhD, a psychiatrist at the University of Toronto, Canada, who was not involved with the research.
The findings were presented at the European Psychiatric Association (EPA) 2020 Congress, which was held online this year because of the COVID-19 pandemic.
Little evidence available
“Epigenetic mechanisms have been proposed in many psychiatric conditions, but so far, little clinical evidence is available,” Bullock said during his presentation.
In preclinical models, vafidemstat has been associated with a reduction in aggressive behavior “and the normal response to stress of immediate early genes in the prefrontal cortex” via the modification of gene transcription, noted Bullock.
“This new approach makes it a good candidate to look at aggression in multiple psychiatric and CNS conditions,” he added.
REIMAGINE was a phase 2a open-label trial that included 30 patients (53% women; mean age, 33.5 years; 87% White) with psychiatric disorders who had significant or persistent agitation or aggression that was disruptive of the patients› daily life.
Among the participants, 12 had BPD, 11 had ADHD, and seven had ASD. All were treated with vafidemstat 1.2 mg for 8 weeks.
In all, 23 patients completed all 8 weeks of treatment, including nine patients with BPD, eight with ADHD, and six with ASD.
Results showed that the study drug was well tolerated, with no serious adverse events reported and no patients withdrawing because of safety-related events.
The most common adverse events were headache (20%) and insomnia (10%), which resolved without intervention or treatment modification.
Significantly improved scores
Across the whole cohort, the drug was associated with significant reductions in scores over baseline on the Clinical Global Impression–Severity (CGI-S) and CGI-Improvement (CGI-I) scales. There were also significant improvements for Neuropsychiatric Inventory (NPI) total scores and agitation-aggression scores (P < .001 for comparisons).
Similar results were observed with respect to individual diagnoses, albeit at varying degrees of significance for each scale.
Patients with BPD experienced significant reductions in scores on the Borderline Personality Disorder Checklist (BPDCL) (P < .01). Patients with ADHD experienced reductions on the ADHD Rating Scale (P < .05).
Patients with BPD also experienced reductions in suicidal ideation, as measured with the Columbia Suicide Severity Rating Scale (P < .01). That is “the only cohort where this trait is relevant,” the researchers note.
In addition, significant correlations were shown between NPI total scores and scores on the BPDCL after treatment with vafidemstat (P = .015), as well as between NPI agitation-aggression scores and both CGI-I (P = .008) and CGI-S scores (P = .0001).
“This convergence of signals in scales of different nature and scope support the pharmacological role of vafidemstat in controlling aggression-agitation in different psychiatric conditions,” the investigators note.
Bullock added that further randomized placebo-controlled clinical trials “to confirm vafidemstat’s potential to treat aggression-agitation in psychiatric disorders are now planned.”
First up will be PORTICO, which is planned to start over the coming months in Spain and will include patients with BPD.
Several limitations
Commenting on the study for Medscape Medical News, Kolla, who is also a researcher at the Center for Addiction and Mental Health, noted that REIMAGINE was originally designed to test vafidemstat for the treatment of agitation and aggression in patients with Alzheimer’s disease (AD).
“It seems peculiar that the study investigators would choose to examine three additional psychiatric disorders that bear little resemblance to AD in terms of phenomenology. Additionally, the etiological underpinnings of the three disorders likely differ markedly from AD,” said Kolla, who was not involved with the research.
In addition, the “very small” sample size in each group makes it difficult to interpret the investigators’ conclusions, he noted.
There are also “many more sophisticated scales” to assess agitation and aggression than what were used in the study, he added.
Kolla also questioned the notion that a drug such as vafidemstat satisfies an unmet clinical need for the treatment of aggression and agitation.
Trials that “purport to reduce aggression in these populations often provide some level of global improvement in functioning that may appear as if they directly treat agitation or aggression,” he said. “However, no drug has ever been developed that directly reduces aggression and agitation.”
That means that, for now, there is insufficient evidence to “conclude that vafidemstat overcomes the unmet medical need of treating aggression/agitation,” he said.
For Kolla, the concept of a psychiatric drug that works by effecting epigenetic changes to the genome is also questionable, although such mechanisms may “play a role in the salubrious effects of certain mood stabilizers or antipsychotics for which better-defined mechanisms of action have been established.”
The study was funded by Oryzon Genomics. Bullock and the other investigators are employees of Oryzon Genomics.
This article first appeared on Medscape.com.
The novel lysine-specific demethylase 1 inhibitor vafidemstat (ORY-2001, Oryzon Genomics) is effective for treating agitation and aggression across a number of psychiatric disorders, new research suggests.
The REIMAGINE trial included 30 patients with autism spectrum disorder (ASD), ADHD, or borderline personality disorder (BPD). Results showed significant improvements after 8 weeks in general functioning and agitation-aggression scores for all three disorders.
The study “supports vafidemstat as an emerging therapeutic option to treat aggression-agitation, as well as the nonaggression features of psychiatric diseases with high unmet medical need,” lead researcher Roger Bullock, MD, Oryzon Genomics, Corneliá De Llobregat, Spain, told Medscape Medical News.
Bullock added.
However, another expert urged prudence when interpreting the findings.
“The study results must be viewed with caution, given the inherent limitations of an open-label trial, small sample size, and weak rationale for the sample selection,” said Nathan Kolla, MD, PhD, a psychiatrist at the University of Toronto, Canada, who was not involved with the research.
The findings were presented at the European Psychiatric Association (EPA) 2020 Congress, which was held online this year because of the COVID-19 pandemic.
Little evidence available
“Epigenetic mechanisms have been proposed in many psychiatric conditions, but so far, little clinical evidence is available,” Bullock said during his presentation.
In preclinical models, vafidemstat has been associated with a reduction in aggressive behavior “and the normal response to stress of immediate early genes in the prefrontal cortex” via the modification of gene transcription, noted Bullock.
“This new approach makes it a good candidate to look at aggression in multiple psychiatric and CNS conditions,” he added.
REIMAGINE was a phase 2a open-label trial that included 30 patients (53% women; mean age, 33.5 years; 87% White) with psychiatric disorders who had significant or persistent agitation or aggression that was disruptive of the patients› daily life.
Among the participants, 12 had BPD, 11 had ADHD, and seven had ASD. All were treated with vafidemstat 1.2 mg for 8 weeks.
In all, 23 patients completed all 8 weeks of treatment, including nine patients with BPD, eight with ADHD, and six with ASD.
Results showed that the study drug was well tolerated, with no serious adverse events reported and no patients withdrawing because of safety-related events.
The most common adverse events were headache (20%) and insomnia (10%), which resolved without intervention or treatment modification.
Significantly improved scores
Across the whole cohort, the drug was associated with significant reductions in scores over baseline on the Clinical Global Impression–Severity (CGI-S) and CGI-Improvement (CGI-I) scales. There were also significant improvements for Neuropsychiatric Inventory (NPI) total scores and agitation-aggression scores (P < .001 for comparisons).
Similar results were observed with respect to individual diagnoses, albeit at varying degrees of significance for each scale.
Patients with BPD experienced significant reductions in scores on the Borderline Personality Disorder Checklist (BPDCL) (P < .01). Patients with ADHD experienced reductions on the ADHD Rating Scale (P < .05).
Patients with BPD also experienced reductions in suicidal ideation, as measured with the Columbia Suicide Severity Rating Scale (P < .01). That is “the only cohort where this trait is relevant,” the researchers note.
In addition, significant correlations were shown between NPI total scores and scores on the BPDCL after treatment with vafidemstat (P = .015), as well as between NPI agitation-aggression scores and both CGI-I (P = .008) and CGI-S scores (P = .0001).
“This convergence of signals in scales of different nature and scope support the pharmacological role of vafidemstat in controlling aggression-agitation in different psychiatric conditions,” the investigators note.
Bullock added that further randomized placebo-controlled clinical trials “to confirm vafidemstat’s potential to treat aggression-agitation in psychiatric disorders are now planned.”
First up will be PORTICO, which is planned to start over the coming months in Spain and will include patients with BPD.
Several limitations
Commenting on the study for Medscape Medical News, Kolla, who is also a researcher at the Center for Addiction and Mental Health, noted that REIMAGINE was originally designed to test vafidemstat for the treatment of agitation and aggression in patients with Alzheimer’s disease (AD).
“It seems peculiar that the study investigators would choose to examine three additional psychiatric disorders that bear little resemblance to AD in terms of phenomenology. Additionally, the etiological underpinnings of the three disorders likely differ markedly from AD,” said Kolla, who was not involved with the research.
In addition, the “very small” sample size in each group makes it difficult to interpret the investigators’ conclusions, he noted.
There are also “many more sophisticated scales” to assess agitation and aggression than what were used in the study, he added.
Kolla also questioned the notion that a drug such as vafidemstat satisfies an unmet clinical need for the treatment of aggression and agitation.
Trials that “purport to reduce aggression in these populations often provide some level of global improvement in functioning that may appear as if they directly treat agitation or aggression,” he said. “However, no drug has ever been developed that directly reduces aggression and agitation.”
That means that, for now, there is insufficient evidence to “conclude that vafidemstat overcomes the unmet medical need of treating aggression/agitation,” he said.
For Kolla, the concept of a psychiatric drug that works by effecting epigenetic changes to the genome is also questionable, although such mechanisms may “play a role in the salubrious effects of certain mood stabilizers or antipsychotics for which better-defined mechanisms of action have been established.”
The study was funded by Oryzon Genomics. Bullock and the other investigators are employees of Oryzon Genomics.
This article first appeared on Medscape.com.
The novel lysine-specific demethylase 1 inhibitor vafidemstat (ORY-2001, Oryzon Genomics) is effective for treating agitation and aggression across a number of psychiatric disorders, new research suggests.
The REIMAGINE trial included 30 patients with autism spectrum disorder (ASD), ADHD, or borderline personality disorder (BPD). Results showed significant improvements after 8 weeks in general functioning and agitation-aggression scores for all three disorders.
The study “supports vafidemstat as an emerging therapeutic option to treat aggression-agitation, as well as the nonaggression features of psychiatric diseases with high unmet medical need,” lead researcher Roger Bullock, MD, Oryzon Genomics, Corneliá De Llobregat, Spain, told Medscape Medical News.
Bullock added.
However, another expert urged prudence when interpreting the findings.
“The study results must be viewed with caution, given the inherent limitations of an open-label trial, small sample size, and weak rationale for the sample selection,” said Nathan Kolla, MD, PhD, a psychiatrist at the University of Toronto, Canada, who was not involved with the research.
The findings were presented at the European Psychiatric Association (EPA) 2020 Congress, which was held online this year because of the COVID-19 pandemic.
Little evidence available
“Epigenetic mechanisms have been proposed in many psychiatric conditions, but so far, little clinical evidence is available,” Bullock said during his presentation.
In preclinical models, vafidemstat has been associated with a reduction in aggressive behavior “and the normal response to stress of immediate early genes in the prefrontal cortex” via the modification of gene transcription, noted Bullock.
“This new approach makes it a good candidate to look at aggression in multiple psychiatric and CNS conditions,” he added.
REIMAGINE was a phase 2a open-label trial that included 30 patients (53% women; mean age, 33.5 years; 87% White) with psychiatric disorders who had significant or persistent agitation or aggression that was disruptive of the patients› daily life.
Among the participants, 12 had BPD, 11 had ADHD, and seven had ASD. All were treated with vafidemstat 1.2 mg for 8 weeks.
In all, 23 patients completed all 8 weeks of treatment, including nine patients with BPD, eight with ADHD, and six with ASD.
Results showed that the study drug was well tolerated, with no serious adverse events reported and no patients withdrawing because of safety-related events.
The most common adverse events were headache (20%) and insomnia (10%), which resolved without intervention or treatment modification.
Significantly improved scores
Across the whole cohort, the drug was associated with significant reductions in scores over baseline on the Clinical Global Impression–Severity (CGI-S) and CGI-Improvement (CGI-I) scales. There were also significant improvements for Neuropsychiatric Inventory (NPI) total scores and agitation-aggression scores (P < .001 for comparisons).
Similar results were observed with respect to individual diagnoses, albeit at varying degrees of significance for each scale.
Patients with BPD experienced significant reductions in scores on the Borderline Personality Disorder Checklist (BPDCL) (P < .01). Patients with ADHD experienced reductions on the ADHD Rating Scale (P < .05).
Patients with BPD also experienced reductions in suicidal ideation, as measured with the Columbia Suicide Severity Rating Scale (P < .01). That is “the only cohort where this trait is relevant,” the researchers note.
In addition, significant correlations were shown between NPI total scores and scores on the BPDCL after treatment with vafidemstat (P = .015), as well as between NPI agitation-aggression scores and both CGI-I (P = .008) and CGI-S scores (P = .0001).
“This convergence of signals in scales of different nature and scope support the pharmacological role of vafidemstat in controlling aggression-agitation in different psychiatric conditions,” the investigators note.
Bullock added that further randomized placebo-controlled clinical trials “to confirm vafidemstat’s potential to treat aggression-agitation in psychiatric disorders are now planned.”
First up will be PORTICO, which is planned to start over the coming months in Spain and will include patients with BPD.
Several limitations
Commenting on the study for Medscape Medical News, Kolla, who is also a researcher at the Center for Addiction and Mental Health, noted that REIMAGINE was originally designed to test vafidemstat for the treatment of agitation and aggression in patients with Alzheimer’s disease (AD).
“It seems peculiar that the study investigators would choose to examine three additional psychiatric disorders that bear little resemblance to AD in terms of phenomenology. Additionally, the etiological underpinnings of the three disorders likely differ markedly from AD,” said Kolla, who was not involved with the research.
In addition, the “very small” sample size in each group makes it difficult to interpret the investigators’ conclusions, he noted.
There are also “many more sophisticated scales” to assess agitation and aggression than what were used in the study, he added.
Kolla also questioned the notion that a drug such as vafidemstat satisfies an unmet clinical need for the treatment of aggression and agitation.
Trials that “purport to reduce aggression in these populations often provide some level of global improvement in functioning that may appear as if they directly treat agitation or aggression,” he said. “However, no drug has ever been developed that directly reduces aggression and agitation.”
That means that, for now, there is insufficient evidence to “conclude that vafidemstat overcomes the unmet medical need of treating aggression/agitation,” he said.
For Kolla, the concept of a psychiatric drug that works by effecting epigenetic changes to the genome is also questionable, although such mechanisms may “play a role in the salubrious effects of certain mood stabilizers or antipsychotics for which better-defined mechanisms of action have been established.”
The study was funded by Oryzon Genomics. Bullock and the other investigators are employees of Oryzon Genomics.
This article first appeared on Medscape.com.
Survey: U.S. oncologists have high net worth, live within their means
The average annual income for oncologists surveyed was $377,000, which was 5% higher than the $359,000 reported for 2018. This put oncologists in eleventh place among 29 specialties.
However, this information was obtained prior to February 11, 2020, before the COVID-19 pandemic took hold in the United States, and the financial situation has changed for many physicians.
For example, primary care physicians have reported a 55% decrease in revenue along with a 20% to 30% reduction in patient volume. The decline has even led some to shutter their physical offices, according to the larger survey of all physicians, the Medscape Physician Debt and Net Worth Report 2020. This full survey included 17, 461 physicians and represented 30 specialties.
Physicians in specialty practices may be facing even greater reductions. “Specialists are currently having more troubles than PCPs because they’re largely dependent on elective cases, which can’t be directly addressed by telemedicine,” commented Joel Greenwald, MD, CEO of Greenwald Wealth Management, St. Louis Park, Minnesota, in the survey.
Community oncology clinics and practices have reported a substantial decline in office visits and new patients because of the COVID-19 pandemic. Even before the pandemic, clinics had been closing in recent years as a result of being acquired, merging, or because of financial struggles, although that trend has been plateauing, according to the latest report from the Community Oncology Alliance.
Oncologists’ net worth
With regard to net worth, 42% of the oncologists surveyed reported having assets totaling from $1 million to $5 million, which is about the same for physicians in general. Only 15% reported a net worth of $5 million or higher; a quarter reported a net worth of less than $500,000.
Wealth is more evenly divided when it comes to gender in comparison with other specialties. For all physicians, 56% of men and 39% of women reported a net worth of more than $1 million. For oncologists, that ratio is 59% of men and 54% of women.
Not surprisingly, net worth also increased by age. Only about a quarter (27%) of oncologists younger than age 45 reported a net worth of $1 million to $5 million, compared to 48% aged 45-54 and 56% of physicians aged 55-64. This makes sense, inasmuch as earnings generally increase over time and early-career debt is paid down. However, net worth does appear to decline somewhat after the age of 65, presumably because of a decrease in income on retirement.
Debts and expenses
For debts and expenses that are currently being paid off, mortgage on a primary residence (59%) topped the list. More than half of oncologists reported living in a home that is 3,000 sq ft or larger, and nearly half (49%) have a mortgage of $300,000 or higher. About a third of the oncologists surveyed have no mortgage or one that has been paid off.
Car loan payments (35%) and college education/medical school loans (25%) were the second and third most common sources of debt. As compared with other specialties, oncologists land right in the middle of those still paying off school loans. Only 15% reported that they had no debts or expenses to be paid off.
Savings and living within one’s means
The average American has four credit cards. About half of oncologists surveyed reported having four or fewer, although about a fifth (22%) have seven or more. But the vast majority reported living within their means (49%) or below their means (46%). Only 6% reported living above their means.
Surveyed oncologists also reported putting money aside in a tax-deferred retirement account or college savings account. Almost half (48%) are putting aside more than $2000 every month, and 28% save from $1000 to $2000. A small percentage (8%) reported not doing this on a regular basis.
A smaller percentage (40%) responded that they put more than $2000 a month into a taxable retirement or college savings account; 18% reported not doing this on a regular basis. More than two thirds also reported either having a written budget or a mental one for their personal expenses.
In 2019, most oncologists (77%) did not experience a financial loss. For those who did, bad investments on the stock market (14%) were the main cause. A smaller number reported real estate losses, problems with their practice, or job loss.
Nearly half (49%) reported that they currently work with a financial planner or have done so in the past.
This article first appeared on Medscape.com.
The average annual income for oncologists surveyed was $377,000, which was 5% higher than the $359,000 reported for 2018. This put oncologists in eleventh place among 29 specialties.
However, this information was obtained prior to February 11, 2020, before the COVID-19 pandemic took hold in the United States, and the financial situation has changed for many physicians.
For example, primary care physicians have reported a 55% decrease in revenue along with a 20% to 30% reduction in patient volume. The decline has even led some to shutter their physical offices, according to the larger survey of all physicians, the Medscape Physician Debt and Net Worth Report 2020. This full survey included 17, 461 physicians and represented 30 specialties.
Physicians in specialty practices may be facing even greater reductions. “Specialists are currently having more troubles than PCPs because they’re largely dependent on elective cases, which can’t be directly addressed by telemedicine,” commented Joel Greenwald, MD, CEO of Greenwald Wealth Management, St. Louis Park, Minnesota, in the survey.
Community oncology clinics and practices have reported a substantial decline in office visits and new patients because of the COVID-19 pandemic. Even before the pandemic, clinics had been closing in recent years as a result of being acquired, merging, or because of financial struggles, although that trend has been plateauing, according to the latest report from the Community Oncology Alliance.
Oncologists’ net worth
With regard to net worth, 42% of the oncologists surveyed reported having assets totaling from $1 million to $5 million, which is about the same for physicians in general. Only 15% reported a net worth of $5 million or higher; a quarter reported a net worth of less than $500,000.
Wealth is more evenly divided when it comes to gender in comparison with other specialties. For all physicians, 56% of men and 39% of women reported a net worth of more than $1 million. For oncologists, that ratio is 59% of men and 54% of women.
Not surprisingly, net worth also increased by age. Only about a quarter (27%) of oncologists younger than age 45 reported a net worth of $1 million to $5 million, compared to 48% aged 45-54 and 56% of physicians aged 55-64. This makes sense, inasmuch as earnings generally increase over time and early-career debt is paid down. However, net worth does appear to decline somewhat after the age of 65, presumably because of a decrease in income on retirement.
Debts and expenses
For debts and expenses that are currently being paid off, mortgage on a primary residence (59%) topped the list. More than half of oncologists reported living in a home that is 3,000 sq ft or larger, and nearly half (49%) have a mortgage of $300,000 or higher. About a third of the oncologists surveyed have no mortgage or one that has been paid off.
Car loan payments (35%) and college education/medical school loans (25%) were the second and third most common sources of debt. As compared with other specialties, oncologists land right in the middle of those still paying off school loans. Only 15% reported that they had no debts or expenses to be paid off.
Savings and living within one’s means
The average American has four credit cards. About half of oncologists surveyed reported having four or fewer, although about a fifth (22%) have seven or more. But the vast majority reported living within their means (49%) or below their means (46%). Only 6% reported living above their means.
Surveyed oncologists also reported putting money aside in a tax-deferred retirement account or college savings account. Almost half (48%) are putting aside more than $2000 every month, and 28% save from $1000 to $2000. A small percentage (8%) reported not doing this on a regular basis.
A smaller percentage (40%) responded that they put more than $2000 a month into a taxable retirement or college savings account; 18% reported not doing this on a regular basis. More than two thirds also reported either having a written budget or a mental one for their personal expenses.
In 2019, most oncologists (77%) did not experience a financial loss. For those who did, bad investments on the stock market (14%) were the main cause. A smaller number reported real estate losses, problems with their practice, or job loss.
Nearly half (49%) reported that they currently work with a financial planner or have done so in the past.
This article first appeared on Medscape.com.
The average annual income for oncologists surveyed was $377,000, which was 5% higher than the $359,000 reported for 2018. This put oncologists in eleventh place among 29 specialties.
However, this information was obtained prior to February 11, 2020, before the COVID-19 pandemic took hold in the United States, and the financial situation has changed for many physicians.
For example, primary care physicians have reported a 55% decrease in revenue along with a 20% to 30% reduction in patient volume. The decline has even led some to shutter their physical offices, according to the larger survey of all physicians, the Medscape Physician Debt and Net Worth Report 2020. This full survey included 17, 461 physicians and represented 30 specialties.
Physicians in specialty practices may be facing even greater reductions. “Specialists are currently having more troubles than PCPs because they’re largely dependent on elective cases, which can’t be directly addressed by telemedicine,” commented Joel Greenwald, MD, CEO of Greenwald Wealth Management, St. Louis Park, Minnesota, in the survey.
Community oncology clinics and practices have reported a substantial decline in office visits and new patients because of the COVID-19 pandemic. Even before the pandemic, clinics had been closing in recent years as a result of being acquired, merging, or because of financial struggles, although that trend has been plateauing, according to the latest report from the Community Oncology Alliance.
Oncologists’ net worth
With regard to net worth, 42% of the oncologists surveyed reported having assets totaling from $1 million to $5 million, which is about the same for physicians in general. Only 15% reported a net worth of $5 million or higher; a quarter reported a net worth of less than $500,000.
Wealth is more evenly divided when it comes to gender in comparison with other specialties. For all physicians, 56% of men and 39% of women reported a net worth of more than $1 million. For oncologists, that ratio is 59% of men and 54% of women.
Not surprisingly, net worth also increased by age. Only about a quarter (27%) of oncologists younger than age 45 reported a net worth of $1 million to $5 million, compared to 48% aged 45-54 and 56% of physicians aged 55-64. This makes sense, inasmuch as earnings generally increase over time and early-career debt is paid down. However, net worth does appear to decline somewhat after the age of 65, presumably because of a decrease in income on retirement.
Debts and expenses
For debts and expenses that are currently being paid off, mortgage on a primary residence (59%) topped the list. More than half of oncologists reported living in a home that is 3,000 sq ft or larger, and nearly half (49%) have a mortgage of $300,000 or higher. About a third of the oncologists surveyed have no mortgage or one that has been paid off.
Car loan payments (35%) and college education/medical school loans (25%) were the second and third most common sources of debt. As compared with other specialties, oncologists land right in the middle of those still paying off school loans. Only 15% reported that they had no debts or expenses to be paid off.
Savings and living within one’s means
The average American has four credit cards. About half of oncologists surveyed reported having four or fewer, although about a fifth (22%) have seven or more. But the vast majority reported living within their means (49%) or below their means (46%). Only 6% reported living above their means.
Surveyed oncologists also reported putting money aside in a tax-deferred retirement account or college savings account. Almost half (48%) are putting aside more than $2000 every month, and 28% save from $1000 to $2000. A small percentage (8%) reported not doing this on a regular basis.
A smaller percentage (40%) responded that they put more than $2000 a month into a taxable retirement or college savings account; 18% reported not doing this on a regular basis. More than two thirds also reported either having a written budget or a mental one for their personal expenses.
In 2019, most oncologists (77%) did not experience a financial loss. For those who did, bad investments on the stock market (14%) were the main cause. A smaller number reported real estate losses, problems with their practice, or job loss.
Nearly half (49%) reported that they currently work with a financial planner or have done so in the past.
This article first appeared on Medscape.com.
New CDC guidance for health care personnel exposed to HCV
The new guidance was developed in part as a result of an increase in the incidence of acute HCV infection in the United States, which increases the risk for occupational exposure among HCP. “[I]n certain health care settings, HCP might be exposed to source patients with early HCV infection before those patients develop serologic evidence of infection or symptoms indicative of viral hepatitis,” wrote the authors of the report, published online July 24 in the CDC’s Morbidity and Mortality Weekly Report.
The guidelines, which no longer recommend waiting for spontaneous resolution upon initial diagnosis, include recommendations and algorithms for baseline and follow-up testing, appropriate test type, and recommendations for clinical management. The recommendations were developed on the basis of a current literature review, expert opinion from subject matter experts, and recent guidance from the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America.
Baseline testing ASAP
Baseline testing of the source patient and the HCP should be performed as soon as possible, preferably within 48 hours of exposure. The source patient should be tested for HCV RNA using a nucleic acid test. Alternatively, screening anti-HCV serology can be performed in patients at low risk for HCV and a nucleic acid test performed if serology is positive.
Baseline testing for the HCP should include anti-HCV testing and, if positive, HCV RNA testing is recommended. HCPs who test positive for HCV RNA at baseline are considered to have a preexisting HCV infection and should be referred for treatment.
Follow-up testing
For HCPs with exposure to blood or body fluids from a patient who is anti-HCV positive but HCV RNA negative, follow-up testing is not required.
If the source patient is HCV RNA positive, or if status of the source patient is unknown, the authors recommend that exposed HCPs have HCV RNA follow-up testing at 3-6 weeks post exposure, in addition to baseline testing. A final anti-HCV test is recommended at 4-6 months post exposure as there can be potential periods of aviremia during acute HCV infection.
Exposed HCPs who develop signs of illness indicative of HCV infection at any time should be tested for HCV RNA.
HCPs with positive HCV RNA test results should be referred for care and curative antiviral therapy.
Postexposure prophylaxis is not recommended
Recent data have shown that the risk for HCV infection from percutaneous exposure is 0.2% and from mucocutaneous exposure is 0%. On the basis of this information, the CDC guidelines no longer recommend routine postexposure prophylaxis for HCPs with occupational exposure to HCV. Rather, curative antiviral regimens should be reserved for instances of documented HCV transmission.
The authors disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
The new guidance was developed in part as a result of an increase in the incidence of acute HCV infection in the United States, which increases the risk for occupational exposure among HCP. “[I]n certain health care settings, HCP might be exposed to source patients with early HCV infection before those patients develop serologic evidence of infection or symptoms indicative of viral hepatitis,” wrote the authors of the report, published online July 24 in the CDC’s Morbidity and Mortality Weekly Report.
The guidelines, which no longer recommend waiting for spontaneous resolution upon initial diagnosis, include recommendations and algorithms for baseline and follow-up testing, appropriate test type, and recommendations for clinical management. The recommendations were developed on the basis of a current literature review, expert opinion from subject matter experts, and recent guidance from the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America.
Baseline testing ASAP
Baseline testing of the source patient and the HCP should be performed as soon as possible, preferably within 48 hours of exposure. The source patient should be tested for HCV RNA using a nucleic acid test. Alternatively, screening anti-HCV serology can be performed in patients at low risk for HCV and a nucleic acid test performed if serology is positive.
Baseline testing for the HCP should include anti-HCV testing and, if positive, HCV RNA testing is recommended. HCPs who test positive for HCV RNA at baseline are considered to have a preexisting HCV infection and should be referred for treatment.
Follow-up testing
For HCPs with exposure to blood or body fluids from a patient who is anti-HCV positive but HCV RNA negative, follow-up testing is not required.
If the source patient is HCV RNA positive, or if status of the source patient is unknown, the authors recommend that exposed HCPs have HCV RNA follow-up testing at 3-6 weeks post exposure, in addition to baseline testing. A final anti-HCV test is recommended at 4-6 months post exposure as there can be potential periods of aviremia during acute HCV infection.
Exposed HCPs who develop signs of illness indicative of HCV infection at any time should be tested for HCV RNA.
HCPs with positive HCV RNA test results should be referred for care and curative antiviral therapy.
Postexposure prophylaxis is not recommended
Recent data have shown that the risk for HCV infection from percutaneous exposure is 0.2% and from mucocutaneous exposure is 0%. On the basis of this information, the CDC guidelines no longer recommend routine postexposure prophylaxis for HCPs with occupational exposure to HCV. Rather, curative antiviral regimens should be reserved for instances of documented HCV transmission.
The authors disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
The new guidance was developed in part as a result of an increase in the incidence of acute HCV infection in the United States, which increases the risk for occupational exposure among HCP. “[I]n certain health care settings, HCP might be exposed to source patients with early HCV infection before those patients develop serologic evidence of infection or symptoms indicative of viral hepatitis,” wrote the authors of the report, published online July 24 in the CDC’s Morbidity and Mortality Weekly Report.
The guidelines, which no longer recommend waiting for spontaneous resolution upon initial diagnosis, include recommendations and algorithms for baseline and follow-up testing, appropriate test type, and recommendations for clinical management. The recommendations were developed on the basis of a current literature review, expert opinion from subject matter experts, and recent guidance from the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America.
Baseline testing ASAP
Baseline testing of the source patient and the HCP should be performed as soon as possible, preferably within 48 hours of exposure. The source patient should be tested for HCV RNA using a nucleic acid test. Alternatively, screening anti-HCV serology can be performed in patients at low risk for HCV and a nucleic acid test performed if serology is positive.
Baseline testing for the HCP should include anti-HCV testing and, if positive, HCV RNA testing is recommended. HCPs who test positive for HCV RNA at baseline are considered to have a preexisting HCV infection and should be referred for treatment.
Follow-up testing
For HCPs with exposure to blood or body fluids from a patient who is anti-HCV positive but HCV RNA negative, follow-up testing is not required.
If the source patient is HCV RNA positive, or if status of the source patient is unknown, the authors recommend that exposed HCPs have HCV RNA follow-up testing at 3-6 weeks post exposure, in addition to baseline testing. A final anti-HCV test is recommended at 4-6 months post exposure as there can be potential periods of aviremia during acute HCV infection.
Exposed HCPs who develop signs of illness indicative of HCV infection at any time should be tested for HCV RNA.
HCPs with positive HCV RNA test results should be referred for care and curative antiviral therapy.
Postexposure prophylaxis is not recommended
Recent data have shown that the risk for HCV infection from percutaneous exposure is 0.2% and from mucocutaneous exposure is 0%. On the basis of this information, the CDC guidelines no longer recommend routine postexposure prophylaxis for HCPs with occupational exposure to HCV. Rather, curative antiviral regimens should be reserved for instances of documented HCV transmission.
The authors disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
Lenalidomide may be an answer for refractory cutaneous lupus
Cutaneous lupus erythematosus (CLE) is present in 25% of patients with systemic lupus at the time of diagnosis, but it can also occur in up to 85% of cases at some point in their disease course, Eveline Y. Wu, MD, said during the virtual annual meeting of the Society for Pediatric Dermatology.
“CLE can also occur without any systemic disease,” said Dr. Wu, associate professor of pediatrics at the University of North Carolina at Chapel Hill. “It’s been shown that the risk of developing systemic lupus differs according to the type of skin involvement, meaning that cutaneous lupus can be classified into acute, subacute, chronic, and intermittent forms.”
Malar rash is the prototypical acute cutaneous lesion and is associated with active systemic lupus erythematosus (SLE) and anti–double stranded DNA antibody positivity, while discoid lupus erythematosus is the most common chronic lesion. “A small percentage of patients with discoid lupus can develop systemic lupus, particularly when the lesions are more disseminated,” said Dr. Wu, who specializes in pediatric rheumatology as well as allergy and immunology.
In the American College of Rheumatology’s 1997 classification system, mucocutaneous manifestations constitute 4 out of the 11 criteria that clinicians use to make a diagnosis of SLE: malar rash, discoid-lupus rash, photosensitivity, and oral or nasal mucocutaneous ulcerations. Dr. Wu recommends performing an oral exam on suspect cases, “because the oral ulcers that we see in systemic lupus tend to be painless, so oftentimes patients don’t realize they have them.”
Five other organ-specific manifestations of SLE include nonerosive arthritis, nephritis, encephalopathy, pleuritis or pericarditis, and cytopenia. The two other criteria are positive immunoserology and a positive antinuclear antibody test. “If you have any individuals present with one of these [mucocutaneous manifestations criteria], you want to think about getting a CBC to look for cytopenia or a urinalysis to look for evidence of nephritis, and potentially some additional blood studies, depending on your level of suspicion for systemic lupus,” Dr. Wu said.
Other rarer CLE manifestations include lupus pernio or chilblains, lupus panniculitis, livedo reticularis, bullous LE, urticarial vasculitis, neutrophilic dermatoses, and alopecia.
Common treatments for cutaneous manifestations associated pediatric SLE include hydroxychloroquine, low dose corticosteroids, topical steroids, methotrexate, and leflunomide. Other options for increasing severity of systemic disease include lenalidomide/thalidomide, azathioprine, calcineurin inhibitors, belimumab (Benlysta), high-dose corticosteroids, mycophenolate mofetil (CellCept), rituximab (Rituxan), and cyclophosphamide. Cutaneous manifestations of pediatric SLE can often be refractory to treatments.
In 2017, Dr. Wu and associates published a retrospective chart review of 10 adolescents who received lenalidomide for refractory CLE. One of the subjects was a 21-year-old male with a significant malar rash despite being on hydroxychloroquine, azathioprine, and prednisone 40 mg daily. “One month after being on lenalidomide he had a pretty impressive response,” Dr. Wu said. “It’s not quite clear how lenalidomide works in cutaneous lupus. Currently it’s only approved for use in myelodysplastic syndromes, multiple myeloma, as well as certain lymphomas. It’s thought to modulate different parts of the immune system, which collectively result in the cytotoxicity against tumor cells.”
Lenalidomide is supplied in capsule sizes ranging from 2.5 mg to 25 mg and is given once daily. “For a smaller child, I would think about starting 5 mg once a day,” Dr. Wu said. “For an adult-sized adolescent, you could start at 10 mg once a day and then titrate up based on response. Side effects that you need to worry about are cytopenia and GI symptoms. The venous and arterial thromboembolism risk has been seen in patients with multiple myeloma, and it is unclear if this risk is applicable to all indications.” Use of the medication requires enrollment into a safety monitoring program.
She reported having no financial disclosures.
Cutaneous lupus erythematosus (CLE) is present in 25% of patients with systemic lupus at the time of diagnosis, but it can also occur in up to 85% of cases at some point in their disease course, Eveline Y. Wu, MD, said during the virtual annual meeting of the Society for Pediatric Dermatology.
“CLE can also occur without any systemic disease,” said Dr. Wu, associate professor of pediatrics at the University of North Carolina at Chapel Hill. “It’s been shown that the risk of developing systemic lupus differs according to the type of skin involvement, meaning that cutaneous lupus can be classified into acute, subacute, chronic, and intermittent forms.”
Malar rash is the prototypical acute cutaneous lesion and is associated with active systemic lupus erythematosus (SLE) and anti–double stranded DNA antibody positivity, while discoid lupus erythematosus is the most common chronic lesion. “A small percentage of patients with discoid lupus can develop systemic lupus, particularly when the lesions are more disseminated,” said Dr. Wu, who specializes in pediatric rheumatology as well as allergy and immunology.
In the American College of Rheumatology’s 1997 classification system, mucocutaneous manifestations constitute 4 out of the 11 criteria that clinicians use to make a diagnosis of SLE: malar rash, discoid-lupus rash, photosensitivity, and oral or nasal mucocutaneous ulcerations. Dr. Wu recommends performing an oral exam on suspect cases, “because the oral ulcers that we see in systemic lupus tend to be painless, so oftentimes patients don’t realize they have them.”
Five other organ-specific manifestations of SLE include nonerosive arthritis, nephritis, encephalopathy, pleuritis or pericarditis, and cytopenia. The two other criteria are positive immunoserology and a positive antinuclear antibody test. “If you have any individuals present with one of these [mucocutaneous manifestations criteria], you want to think about getting a CBC to look for cytopenia or a urinalysis to look for evidence of nephritis, and potentially some additional blood studies, depending on your level of suspicion for systemic lupus,” Dr. Wu said.
Other rarer CLE manifestations include lupus pernio or chilblains, lupus panniculitis, livedo reticularis, bullous LE, urticarial vasculitis, neutrophilic dermatoses, and alopecia.
Common treatments for cutaneous manifestations associated pediatric SLE include hydroxychloroquine, low dose corticosteroids, topical steroids, methotrexate, and leflunomide. Other options for increasing severity of systemic disease include lenalidomide/thalidomide, azathioprine, calcineurin inhibitors, belimumab (Benlysta), high-dose corticosteroids, mycophenolate mofetil (CellCept), rituximab (Rituxan), and cyclophosphamide. Cutaneous manifestations of pediatric SLE can often be refractory to treatments.
In 2017, Dr. Wu and associates published a retrospective chart review of 10 adolescents who received lenalidomide for refractory CLE. One of the subjects was a 21-year-old male with a significant malar rash despite being on hydroxychloroquine, azathioprine, and prednisone 40 mg daily. “One month after being on lenalidomide he had a pretty impressive response,” Dr. Wu said. “It’s not quite clear how lenalidomide works in cutaneous lupus. Currently it’s only approved for use in myelodysplastic syndromes, multiple myeloma, as well as certain lymphomas. It’s thought to modulate different parts of the immune system, which collectively result in the cytotoxicity against tumor cells.”
Lenalidomide is supplied in capsule sizes ranging from 2.5 mg to 25 mg and is given once daily. “For a smaller child, I would think about starting 5 mg once a day,” Dr. Wu said. “For an adult-sized adolescent, you could start at 10 mg once a day and then titrate up based on response. Side effects that you need to worry about are cytopenia and GI symptoms. The venous and arterial thromboembolism risk has been seen in patients with multiple myeloma, and it is unclear if this risk is applicable to all indications.” Use of the medication requires enrollment into a safety monitoring program.
She reported having no financial disclosures.
Cutaneous lupus erythematosus (CLE) is present in 25% of patients with systemic lupus at the time of diagnosis, but it can also occur in up to 85% of cases at some point in their disease course, Eveline Y. Wu, MD, said during the virtual annual meeting of the Society for Pediatric Dermatology.
“CLE can also occur without any systemic disease,” said Dr. Wu, associate professor of pediatrics at the University of North Carolina at Chapel Hill. “It’s been shown that the risk of developing systemic lupus differs according to the type of skin involvement, meaning that cutaneous lupus can be classified into acute, subacute, chronic, and intermittent forms.”
Malar rash is the prototypical acute cutaneous lesion and is associated with active systemic lupus erythematosus (SLE) and anti–double stranded DNA antibody positivity, while discoid lupus erythematosus is the most common chronic lesion. “A small percentage of patients with discoid lupus can develop systemic lupus, particularly when the lesions are more disseminated,” said Dr. Wu, who specializes in pediatric rheumatology as well as allergy and immunology.
In the American College of Rheumatology’s 1997 classification system, mucocutaneous manifestations constitute 4 out of the 11 criteria that clinicians use to make a diagnosis of SLE: malar rash, discoid-lupus rash, photosensitivity, and oral or nasal mucocutaneous ulcerations. Dr. Wu recommends performing an oral exam on suspect cases, “because the oral ulcers that we see in systemic lupus tend to be painless, so oftentimes patients don’t realize they have them.”
Five other organ-specific manifestations of SLE include nonerosive arthritis, nephritis, encephalopathy, pleuritis or pericarditis, and cytopenia. The two other criteria are positive immunoserology and a positive antinuclear antibody test. “If you have any individuals present with one of these [mucocutaneous manifestations criteria], you want to think about getting a CBC to look for cytopenia or a urinalysis to look for evidence of nephritis, and potentially some additional blood studies, depending on your level of suspicion for systemic lupus,” Dr. Wu said.
Other rarer CLE manifestations include lupus pernio or chilblains, lupus panniculitis, livedo reticularis, bullous LE, urticarial vasculitis, neutrophilic dermatoses, and alopecia.
Common treatments for cutaneous manifestations associated pediatric SLE include hydroxychloroquine, low dose corticosteroids, topical steroids, methotrexate, and leflunomide. Other options for increasing severity of systemic disease include lenalidomide/thalidomide, azathioprine, calcineurin inhibitors, belimumab (Benlysta), high-dose corticosteroids, mycophenolate mofetil (CellCept), rituximab (Rituxan), and cyclophosphamide. Cutaneous manifestations of pediatric SLE can often be refractory to treatments.
In 2017, Dr. Wu and associates published a retrospective chart review of 10 adolescents who received lenalidomide for refractory CLE. One of the subjects was a 21-year-old male with a significant malar rash despite being on hydroxychloroquine, azathioprine, and prednisone 40 mg daily. “One month after being on lenalidomide he had a pretty impressive response,” Dr. Wu said. “It’s not quite clear how lenalidomide works in cutaneous lupus. Currently it’s only approved for use in myelodysplastic syndromes, multiple myeloma, as well as certain lymphomas. It’s thought to modulate different parts of the immune system, which collectively result in the cytotoxicity against tumor cells.”
Lenalidomide is supplied in capsule sizes ranging from 2.5 mg to 25 mg and is given once daily. “For a smaller child, I would think about starting 5 mg once a day,” Dr. Wu said. “For an adult-sized adolescent, you could start at 10 mg once a day and then titrate up based on response. Side effects that you need to worry about are cytopenia and GI symptoms. The venous and arterial thromboembolism risk has been seen in patients with multiple myeloma, and it is unclear if this risk is applicable to all indications.” Use of the medication requires enrollment into a safety monitoring program.
She reported having no financial disclosures.
FROM SPD 2020
Marked improvements seen for women in dermatology since the 1970s
Wilma F. Bergfeld, MD, one of only five women in her medical school class of 1964 and the third female in her dermatology residency program, had recently been appointed as a junior clinical dermatologist and head of dermatopathology at the Cleveland Clinic when she was told by a superior that she would not be promoted or invited to serve on any committee or decision-making group.
“I was told I should go home at night and take care of my husband and two children,” she recalled of that moment in the 1970s. The comment made her feel “outraged,” and it drove her, calmly and steadily, to work harder and to “challenge the system.”
Dr. Bergfeld not only was elected to the Cleveland Clinic’s board of governors and board of trustees and served as president of the Clinic’s staff in 1990, she also became the first woman president of the American Academy of Dermatology (1992) and led numerous other dermatologic organizations. Much earlier on, in 1973, to help fulfill her vision of “women helping women,” she had also founded the Women’s Dermatologic Society (WDS). Three years earlier, in 1970, 6.9% of the approximately 4,000 dermatologists in the United States were women, according to the American Medical Association.
Today, when she goes to work as the long-time director of the Clinic’s dermatopathology fellowship and professor of dermatology and pathology at the Cleveland Clinic Educational Foundation, she sees a transformed staff and, more broadly, a national physician workforce in which women made up almost 50% of active dermatologists in 2017 and almost 60% of dermatology residents in 2018, according to data from the American Association of Medical Colleges.
It’s a different and better world, she and other women dermatologists said, but one in which women must continue to mentor other women and continue to challenge the system. Achieving work-life balance, fairer compensation, and a greater proportion of women in the higher ranks of academia are all on their work list.
Women’s impact on the specialty
Dr. Bergfeld and Molly Hinshaw, MD, the current president of the WDS, said they believe women are drawn to dermatology for its visual nature, the growth in diagnostic tests and therapies, and the opportunity to diagnose early and prevent progression of disease in patients of all ages. “It’s a small but mighty specialty,” said Dr. Hinshaw, associate professor of dermatology and section chief of dermatopathology at the University of Wisconsin–Madison.
It’s also a versatile specialty with a variety of subspecialties and niches to pursue – and women have been stepping in to fill unmet needs, Dr. Hinshaw said. “Women dermatologists are directing vulvar specialty clinics across the country, for example. There aren’t that many, but they’re filling an important niche. We have one at [our university] and it is packed.”
Women have also been drawn to the in-demand subspecialty of pediatric dermatology, she noted. They now make up more than two-thirds of all pediatric dermatologists, and many in practice have trained the old-fashioned way, completing two residencies. “That’s [involved] self-selection into an additional year of years training and a commitment to caring for special populations that, quite honestly, takes more time,” said Dr. Hinshaw, who, as part of her dermatology practice, runs a nail clinic at UW Health in Madison.
Amy S. Paller, MD, who chairs the department of dermatology at Northwestern University, Chicago, where she is professor of dermatology and pediatrics and directs the Skin Biology & Diseases Resource-Based Center, is one of these women. She took a long and determined journey into the subspecialty, encountering bias and discouragement while actively seeking out mentors who helped her advance.
While in medical school at Stanford (Calif.) University in the late 1970s in a class “very progressively” made up of about one-third women, Dr. Paller met Alvin Jacobs, MD, who, in 1975, had founded the Society for Pediatric Dermatology. “There wasn’t much pediatric dermatology in the world at the time, and it was Al who helped [me realize] that it combined my love of genetic research with my [desire] to work with children,” she recalled.
Per Dr. Jacob’s advice, she went to Northwestern to train in both pediatrics and dermatology under Nancy Esterly, MD, who “is considered by many to be the mother of pediatric dermatology.” And knowing that she wanted to do research, Dr. Paller also worked with Ruth Freinkel, MD, who “was the strongest bench researcher” at Northwestern. (Dr. Freinkel had been one of the first female dermatology residents at Harvard and was the first full-time faculty member in dermatology at Northwestern).
After completing postdoctoral research at the University of North Carolina at Chapel Hill, Dr. Paller returned to Chicago and assumed Dr. Esterly’s position as chief of dermatology at the Children’s National Hospital of Chicago. It was there that “someone in a leadership position questioned me about how I could possibly be a scientist, a strong clinician, and a good mother to my three children – and suggested that I drop research,” Dr. Paller recalled.
“I think this person was trying to be helpful to me, but I was shocked,” she said. Just as Dr. Bergfeld had done, Dr. Paller channeled her frustration into new pursuits.
“It made me go home and think, how could I strengthen myself? What else could I do?” she said. “Soon after, with a highly supportive husband, I did a ‘pseudosabbatical,’ basically spending every ounce of spare time I had working with one of the premier female scientists in the country, Elaine Fuchs, and learning molecular biology” in her lab at the University of Chicago.
“I think we’ve all had discrimination along the way. Sometimes there’s implicit bias and sometimes there’s overt bias,” said Dr. Paller, who in 2004 led the society which her mentor Dr. Jacobs had founded several decades earlier. “I just jumped right in, and that’s enabled me to find good role models.”
Across dermatology broadly, the often holistic nature of the specialty – of the ability to peer into the body and its internal health – is another quality that women have been drawn to and advanced, Dr. Hinshaw said. “One of the reasons why I chose dermatology is because it’s a window to total patient health. Patients often see their dermatologists as physicians who help them identify next steps in their health care, who can help them address issues related to their overall health and well-being, including their mental health.”
In a WDS membership survey conducted in 2018, most respondents reported that they frequently or occasionally detect and diagnose systemic/internal diseases and conditions in their female patients, and that they consult and collaborate with different kinds of physicians (Int J Womens Dermatol. 2018 Nov 15;4[4]:189-92).
And in a March 2019 “Dialogues in Dermatology” podcast episode on the history and advancement of women in dermatology produced by the American Academy of Dermatology, Pearl Grimes, MD, a clinical professor of dermatology of the University of California, Los Angeles, and then-president of the WDS, described why “total women’s health” had become an additional focus for the society.
“We’re already gatekeepers” in many respects, Dr. Grimes said. “In addition to my addressing specific skin issues, my patients query me on hormone issues, on nutrition, on stress-related issues….and on [what other physicians they should see].”
Phoebe Rich, MD, who owns a small all-woman practice and a research center in Portland, Oregon, said that, in general, many women also communicate and practice in a way that facilitates holistic care. “These qualities aren’t exclusive to women, but women are very caring. We take time and are interested in [patients’] lives in general, not just their disease.”
Disparities in academia
Dermatology departments in academic medicine have burgeoned in size in the past 50 years, and women are well represented overall. In 2018, women comprised 51.2% of dermatology department faculty – up from 10.8% in 1970 – a current proportion that ranks fifth among specialties for the proportion of female faculty, according to a cross-sectional study of faculty diversity trends using data from the AAMC faculty roster (JAMA Dermatol. 2020 Jan 8;156[3]:280-7).
The AAMC data show the share of women dermatology faculty declining at each subsequent rank, however – a finding that suggests that women are not promoted as quickly or to the same levels of leadership as men, the report’s authors noted. (Dermatology isn’t alone: The AAMC issued a call to action on gender equity in medicine this year, citing this inverse association.)
Another recently published study of gender trends in academic dermatology – this one looking at a smaller sample of data from 15 institutions – similarly found that women dermatologists made up a majority of faculty (53.6%) and were well represented as assistant professors (60.7%) but underrepresented as full professors (17%).
This study differed from the larger AAMC study, however, in that it controlled for “achievement indicators” – career duration, publications per year, and National Institutes of Health research funding – and found that gender alone was not associated with higher rank. Instead, promotions were correlated most significantly with NIH research funding and also with career duration and publications per year.
“If research achievement is to be used as a benchmark for academic promotion, increased efforts are needed to support the research activities of women,” the authors wrote, adding that recognition should be given to other factors as well.
Dr. Paller and Dr. Hinshaw both described the situation as complex and multifaceted. Some research on promotion in academia in general – but not all – has suggested that women do need to publish more than men in order to be promoted. But “the promotion process also has within it the ability to use judgment [about] the impact and merits of work,” said Dr. Hinshaw. “Not all publications [and levels of authorship] may be considered equal, for instance.”
Dr. Hinshaw said she is also concerned by data showing that women still perform the majority of household duties, “even in households in which both partners work outside the home equivalently.” As long as this is the case, women may be “inherently disadvantaged” in their ability to have adequate research time and to advance.
From where she sits, Dr. Paller sees several factors at play: “The pipeline, achievement during the pipeline, and decision-making about advancement” on the part of women themselves. Having served on search committees for top leadership in specialties in which women are well represented, she said, “I’ve seen fewer women who’ve come forward and been interested in rising into a chair or a dean position.”
And “having talked to so many women,” Dr. Paller added, “I think there’s a phenomenon where it’s harder for women to accept positions [that require] a significant change.”
Women “are nurturers, which makes them extremely good [leaders] and chairs, but it also makes it harder to make life changes that affect the people they love,” she said, noting that becoming a department chair or a dean often involves moving. “I also think that women in general are happier and committed to what they’re [currently] doing.”
Dr. Paller is optimistic that, with the support of department chairs and continued attention to role modeling and mentoring, the portrait of women in academic dermatology will continue to improve. Currently, 34 chairs of dermatology departments are female, she noted. “That number was 11 less 15 years ago.”
In the meantime, researchers are increasingly documenting trends in women’s editorships of journals as well as leadership and speaking opportunities at professional conferences.
The authors of one study published this year, for instance, reviewed the editorial boards of dermatology journals and found that women occupied 18% of editor in chief roles, 36% of deputy editor positions, and 22% of overall editorial board roles (Int J Womens Dermatol. 2019 Sep 12;6[1]:20-4). Other research shows women comprising 43% of all authorships across 23 dermatologic journals from 2008 to May 2017, 50.2% of first authorships, and 33.1% of last authorships (BMJ Open. 2018 Apr 13;8[4]:e020089).
Both in academic medicine and in practice, a gender pay gap still affects women physicians across the board. Medscape’s 2020 dermatologist compensation report shows male dermatologists earning about 12% more than their female peers (average, $435,000 vs. $387,000, respectively), while the average number of hours per week spent seeing patients is similar (36.2 vs. 35.6 hours, respectively).
And in its 2020 statement on gender equity, the AAMC said that women in academic medicine are offered less in starting salary, negotiated pay, and other forms of compensation than men “despite equal effort, rank, training, and experience.”
It’s complicated to tease apart all the factors that may be involved – but important to keep challenging the system, said Dr. Bergfeld, who was a long-time board adviser for Dermatology News. “I was underpaid,” she noted, and “this was only rectified in the last 10 years.”
Work-life balance
In the AAD podcast on women in dermatology, Dr. Grimes said that achieving a healthy and balanced work life remains one of the greatest challenges for women dermatologists – and it may be even greater than in the past given the growing numbers of group practices. “When women enter the realm of group practice, they have less flexibility in controlling their time and their own schedules.”
If Anna Hare, MD, is any indication, younger dermatologists may buck this trend. The daughter of Dr. Rich in Portland, Dr. Hare joined her mother’s dermatology practice and research center knowing that she’d have “the respect and flexibility for deciding how I want to practice.”
Younger dermatologists, she said, place “more of an emphasis on work-life balance and quality of life.”
Fortunately, said Dr. Bergfeld, women have advanced enough in the ranks of dermatology that, in networking, in mentorship, and in workplace settings, attention can be paid more fully to discussions about work-life management – “how to manage your life when you’re working with family and kids and parents.”
In the 1970s, at the Cleveland Clinic, “there were only five women on staff and we were fighting for [basic] rights,” she said. “We wanted equality – we were [perceived as] little worker bees….We needed to climb as the men did to positions of leadership and address the problems of women.”
In pursuing their goals and making further progress, women dermatologists today should be “steady and calm,” she advised. Formally acquiring leadership skills and communication skills is a timeless need. And when there are biases or conflicts, “you cannot have righteous indignation, you cannot have revenge. You have to calm yourself and move forward.”
Wilma F. Bergfeld, MD, one of only five women in her medical school class of 1964 and the third female in her dermatology residency program, had recently been appointed as a junior clinical dermatologist and head of dermatopathology at the Cleveland Clinic when she was told by a superior that she would not be promoted or invited to serve on any committee or decision-making group.
“I was told I should go home at night and take care of my husband and two children,” she recalled of that moment in the 1970s. The comment made her feel “outraged,” and it drove her, calmly and steadily, to work harder and to “challenge the system.”
Dr. Bergfeld not only was elected to the Cleveland Clinic’s board of governors and board of trustees and served as president of the Clinic’s staff in 1990, she also became the first woman president of the American Academy of Dermatology (1992) and led numerous other dermatologic organizations. Much earlier on, in 1973, to help fulfill her vision of “women helping women,” she had also founded the Women’s Dermatologic Society (WDS). Three years earlier, in 1970, 6.9% of the approximately 4,000 dermatologists in the United States were women, according to the American Medical Association.
Today, when she goes to work as the long-time director of the Clinic’s dermatopathology fellowship and professor of dermatology and pathology at the Cleveland Clinic Educational Foundation, she sees a transformed staff and, more broadly, a national physician workforce in which women made up almost 50% of active dermatologists in 2017 and almost 60% of dermatology residents in 2018, according to data from the American Association of Medical Colleges.
It’s a different and better world, she and other women dermatologists said, but one in which women must continue to mentor other women and continue to challenge the system. Achieving work-life balance, fairer compensation, and a greater proportion of women in the higher ranks of academia are all on their work list.
Women’s impact on the specialty
Dr. Bergfeld and Molly Hinshaw, MD, the current president of the WDS, said they believe women are drawn to dermatology for its visual nature, the growth in diagnostic tests and therapies, and the opportunity to diagnose early and prevent progression of disease in patients of all ages. “It’s a small but mighty specialty,” said Dr. Hinshaw, associate professor of dermatology and section chief of dermatopathology at the University of Wisconsin–Madison.
It’s also a versatile specialty with a variety of subspecialties and niches to pursue – and women have been stepping in to fill unmet needs, Dr. Hinshaw said. “Women dermatologists are directing vulvar specialty clinics across the country, for example. There aren’t that many, but they’re filling an important niche. We have one at [our university] and it is packed.”
Women have also been drawn to the in-demand subspecialty of pediatric dermatology, she noted. They now make up more than two-thirds of all pediatric dermatologists, and many in practice have trained the old-fashioned way, completing two residencies. “That’s [involved] self-selection into an additional year of years training and a commitment to caring for special populations that, quite honestly, takes more time,” said Dr. Hinshaw, who, as part of her dermatology practice, runs a nail clinic at UW Health in Madison.
Amy S. Paller, MD, who chairs the department of dermatology at Northwestern University, Chicago, where she is professor of dermatology and pediatrics and directs the Skin Biology & Diseases Resource-Based Center, is one of these women. She took a long and determined journey into the subspecialty, encountering bias and discouragement while actively seeking out mentors who helped her advance.
While in medical school at Stanford (Calif.) University in the late 1970s in a class “very progressively” made up of about one-third women, Dr. Paller met Alvin Jacobs, MD, who, in 1975, had founded the Society for Pediatric Dermatology. “There wasn’t much pediatric dermatology in the world at the time, and it was Al who helped [me realize] that it combined my love of genetic research with my [desire] to work with children,” she recalled.
Per Dr. Jacob’s advice, she went to Northwestern to train in both pediatrics and dermatology under Nancy Esterly, MD, who “is considered by many to be the mother of pediatric dermatology.” And knowing that she wanted to do research, Dr. Paller also worked with Ruth Freinkel, MD, who “was the strongest bench researcher” at Northwestern. (Dr. Freinkel had been one of the first female dermatology residents at Harvard and was the first full-time faculty member in dermatology at Northwestern).
After completing postdoctoral research at the University of North Carolina at Chapel Hill, Dr. Paller returned to Chicago and assumed Dr. Esterly’s position as chief of dermatology at the Children’s National Hospital of Chicago. It was there that “someone in a leadership position questioned me about how I could possibly be a scientist, a strong clinician, and a good mother to my three children – and suggested that I drop research,” Dr. Paller recalled.
“I think this person was trying to be helpful to me, but I was shocked,” she said. Just as Dr. Bergfeld had done, Dr. Paller channeled her frustration into new pursuits.
“It made me go home and think, how could I strengthen myself? What else could I do?” she said. “Soon after, with a highly supportive husband, I did a ‘pseudosabbatical,’ basically spending every ounce of spare time I had working with one of the premier female scientists in the country, Elaine Fuchs, and learning molecular biology” in her lab at the University of Chicago.
“I think we’ve all had discrimination along the way. Sometimes there’s implicit bias and sometimes there’s overt bias,” said Dr. Paller, who in 2004 led the society which her mentor Dr. Jacobs had founded several decades earlier. “I just jumped right in, and that’s enabled me to find good role models.”
Across dermatology broadly, the often holistic nature of the specialty – of the ability to peer into the body and its internal health – is another quality that women have been drawn to and advanced, Dr. Hinshaw said. “One of the reasons why I chose dermatology is because it’s a window to total patient health. Patients often see their dermatologists as physicians who help them identify next steps in their health care, who can help them address issues related to their overall health and well-being, including their mental health.”
In a WDS membership survey conducted in 2018, most respondents reported that they frequently or occasionally detect and diagnose systemic/internal diseases and conditions in their female patients, and that they consult and collaborate with different kinds of physicians (Int J Womens Dermatol. 2018 Nov 15;4[4]:189-92).
And in a March 2019 “Dialogues in Dermatology” podcast episode on the history and advancement of women in dermatology produced by the American Academy of Dermatology, Pearl Grimes, MD, a clinical professor of dermatology of the University of California, Los Angeles, and then-president of the WDS, described why “total women’s health” had become an additional focus for the society.
“We’re already gatekeepers” in many respects, Dr. Grimes said. “In addition to my addressing specific skin issues, my patients query me on hormone issues, on nutrition, on stress-related issues….and on [what other physicians they should see].”
Phoebe Rich, MD, who owns a small all-woman practice and a research center in Portland, Oregon, said that, in general, many women also communicate and practice in a way that facilitates holistic care. “These qualities aren’t exclusive to women, but women are very caring. We take time and are interested in [patients’] lives in general, not just their disease.”
Disparities in academia
Dermatology departments in academic medicine have burgeoned in size in the past 50 years, and women are well represented overall. In 2018, women comprised 51.2% of dermatology department faculty – up from 10.8% in 1970 – a current proportion that ranks fifth among specialties for the proportion of female faculty, according to a cross-sectional study of faculty diversity trends using data from the AAMC faculty roster (JAMA Dermatol. 2020 Jan 8;156[3]:280-7).
The AAMC data show the share of women dermatology faculty declining at each subsequent rank, however – a finding that suggests that women are not promoted as quickly or to the same levels of leadership as men, the report’s authors noted. (Dermatology isn’t alone: The AAMC issued a call to action on gender equity in medicine this year, citing this inverse association.)
Another recently published study of gender trends in academic dermatology – this one looking at a smaller sample of data from 15 institutions – similarly found that women dermatologists made up a majority of faculty (53.6%) and were well represented as assistant professors (60.7%) but underrepresented as full professors (17%).
This study differed from the larger AAMC study, however, in that it controlled for “achievement indicators” – career duration, publications per year, and National Institutes of Health research funding – and found that gender alone was not associated with higher rank. Instead, promotions were correlated most significantly with NIH research funding and also with career duration and publications per year.
“If research achievement is to be used as a benchmark for academic promotion, increased efforts are needed to support the research activities of women,” the authors wrote, adding that recognition should be given to other factors as well.
Dr. Paller and Dr. Hinshaw both described the situation as complex and multifaceted. Some research on promotion in academia in general – but not all – has suggested that women do need to publish more than men in order to be promoted. But “the promotion process also has within it the ability to use judgment [about] the impact and merits of work,” said Dr. Hinshaw. “Not all publications [and levels of authorship] may be considered equal, for instance.”
Dr. Hinshaw said she is also concerned by data showing that women still perform the majority of household duties, “even in households in which both partners work outside the home equivalently.” As long as this is the case, women may be “inherently disadvantaged” in their ability to have adequate research time and to advance.
From where she sits, Dr. Paller sees several factors at play: “The pipeline, achievement during the pipeline, and decision-making about advancement” on the part of women themselves. Having served on search committees for top leadership in specialties in which women are well represented, she said, “I’ve seen fewer women who’ve come forward and been interested in rising into a chair or a dean position.”
And “having talked to so many women,” Dr. Paller added, “I think there’s a phenomenon where it’s harder for women to accept positions [that require] a significant change.”
Women “are nurturers, which makes them extremely good [leaders] and chairs, but it also makes it harder to make life changes that affect the people they love,” she said, noting that becoming a department chair or a dean often involves moving. “I also think that women in general are happier and committed to what they’re [currently] doing.”
Dr. Paller is optimistic that, with the support of department chairs and continued attention to role modeling and mentoring, the portrait of women in academic dermatology will continue to improve. Currently, 34 chairs of dermatology departments are female, she noted. “That number was 11 less 15 years ago.”
In the meantime, researchers are increasingly documenting trends in women’s editorships of journals as well as leadership and speaking opportunities at professional conferences.
The authors of one study published this year, for instance, reviewed the editorial boards of dermatology journals and found that women occupied 18% of editor in chief roles, 36% of deputy editor positions, and 22% of overall editorial board roles (Int J Womens Dermatol. 2019 Sep 12;6[1]:20-4). Other research shows women comprising 43% of all authorships across 23 dermatologic journals from 2008 to May 2017, 50.2% of first authorships, and 33.1% of last authorships (BMJ Open. 2018 Apr 13;8[4]:e020089).
Both in academic medicine and in practice, a gender pay gap still affects women physicians across the board. Medscape’s 2020 dermatologist compensation report shows male dermatologists earning about 12% more than their female peers (average, $435,000 vs. $387,000, respectively), while the average number of hours per week spent seeing patients is similar (36.2 vs. 35.6 hours, respectively).
And in its 2020 statement on gender equity, the AAMC said that women in academic medicine are offered less in starting salary, negotiated pay, and other forms of compensation than men “despite equal effort, rank, training, and experience.”
It’s complicated to tease apart all the factors that may be involved – but important to keep challenging the system, said Dr. Bergfeld, who was a long-time board adviser for Dermatology News. “I was underpaid,” she noted, and “this was only rectified in the last 10 years.”
Work-life balance
In the AAD podcast on women in dermatology, Dr. Grimes said that achieving a healthy and balanced work life remains one of the greatest challenges for women dermatologists – and it may be even greater than in the past given the growing numbers of group practices. “When women enter the realm of group practice, they have less flexibility in controlling their time and their own schedules.”
If Anna Hare, MD, is any indication, younger dermatologists may buck this trend. The daughter of Dr. Rich in Portland, Dr. Hare joined her mother’s dermatology practice and research center knowing that she’d have “the respect and flexibility for deciding how I want to practice.”
Younger dermatologists, she said, place “more of an emphasis on work-life balance and quality of life.”
Fortunately, said Dr. Bergfeld, women have advanced enough in the ranks of dermatology that, in networking, in mentorship, and in workplace settings, attention can be paid more fully to discussions about work-life management – “how to manage your life when you’re working with family and kids and parents.”
In the 1970s, at the Cleveland Clinic, “there were only five women on staff and we were fighting for [basic] rights,” she said. “We wanted equality – we were [perceived as] little worker bees….We needed to climb as the men did to positions of leadership and address the problems of women.”
In pursuing their goals and making further progress, women dermatologists today should be “steady and calm,” she advised. Formally acquiring leadership skills and communication skills is a timeless need. And when there are biases or conflicts, “you cannot have righteous indignation, you cannot have revenge. You have to calm yourself and move forward.”
Wilma F. Bergfeld, MD, one of only five women in her medical school class of 1964 and the third female in her dermatology residency program, had recently been appointed as a junior clinical dermatologist and head of dermatopathology at the Cleveland Clinic when she was told by a superior that she would not be promoted or invited to serve on any committee or decision-making group.
“I was told I should go home at night and take care of my husband and two children,” she recalled of that moment in the 1970s. The comment made her feel “outraged,” and it drove her, calmly and steadily, to work harder and to “challenge the system.”
Dr. Bergfeld not only was elected to the Cleveland Clinic’s board of governors and board of trustees and served as president of the Clinic’s staff in 1990, she also became the first woman president of the American Academy of Dermatology (1992) and led numerous other dermatologic organizations. Much earlier on, in 1973, to help fulfill her vision of “women helping women,” she had also founded the Women’s Dermatologic Society (WDS). Three years earlier, in 1970, 6.9% of the approximately 4,000 dermatologists in the United States were women, according to the American Medical Association.
Today, when she goes to work as the long-time director of the Clinic’s dermatopathology fellowship and professor of dermatology and pathology at the Cleveland Clinic Educational Foundation, she sees a transformed staff and, more broadly, a national physician workforce in which women made up almost 50% of active dermatologists in 2017 and almost 60% of dermatology residents in 2018, according to data from the American Association of Medical Colleges.
It’s a different and better world, she and other women dermatologists said, but one in which women must continue to mentor other women and continue to challenge the system. Achieving work-life balance, fairer compensation, and a greater proportion of women in the higher ranks of academia are all on their work list.
Women’s impact on the specialty
Dr. Bergfeld and Molly Hinshaw, MD, the current president of the WDS, said they believe women are drawn to dermatology for its visual nature, the growth in diagnostic tests and therapies, and the opportunity to diagnose early and prevent progression of disease in patients of all ages. “It’s a small but mighty specialty,” said Dr. Hinshaw, associate professor of dermatology and section chief of dermatopathology at the University of Wisconsin–Madison.
It’s also a versatile specialty with a variety of subspecialties and niches to pursue – and women have been stepping in to fill unmet needs, Dr. Hinshaw said. “Women dermatologists are directing vulvar specialty clinics across the country, for example. There aren’t that many, but they’re filling an important niche. We have one at [our university] and it is packed.”
Women have also been drawn to the in-demand subspecialty of pediatric dermatology, she noted. They now make up more than two-thirds of all pediatric dermatologists, and many in practice have trained the old-fashioned way, completing two residencies. “That’s [involved] self-selection into an additional year of years training and a commitment to caring for special populations that, quite honestly, takes more time,” said Dr. Hinshaw, who, as part of her dermatology practice, runs a nail clinic at UW Health in Madison.
Amy S. Paller, MD, who chairs the department of dermatology at Northwestern University, Chicago, where she is professor of dermatology and pediatrics and directs the Skin Biology & Diseases Resource-Based Center, is one of these women. She took a long and determined journey into the subspecialty, encountering bias and discouragement while actively seeking out mentors who helped her advance.
While in medical school at Stanford (Calif.) University in the late 1970s in a class “very progressively” made up of about one-third women, Dr. Paller met Alvin Jacobs, MD, who, in 1975, had founded the Society for Pediatric Dermatology. “There wasn’t much pediatric dermatology in the world at the time, and it was Al who helped [me realize] that it combined my love of genetic research with my [desire] to work with children,” she recalled.
Per Dr. Jacob’s advice, she went to Northwestern to train in both pediatrics and dermatology under Nancy Esterly, MD, who “is considered by many to be the mother of pediatric dermatology.” And knowing that she wanted to do research, Dr. Paller also worked with Ruth Freinkel, MD, who “was the strongest bench researcher” at Northwestern. (Dr. Freinkel had been one of the first female dermatology residents at Harvard and was the first full-time faculty member in dermatology at Northwestern).
After completing postdoctoral research at the University of North Carolina at Chapel Hill, Dr. Paller returned to Chicago and assumed Dr. Esterly’s position as chief of dermatology at the Children’s National Hospital of Chicago. It was there that “someone in a leadership position questioned me about how I could possibly be a scientist, a strong clinician, and a good mother to my three children – and suggested that I drop research,” Dr. Paller recalled.
“I think this person was trying to be helpful to me, but I was shocked,” she said. Just as Dr. Bergfeld had done, Dr. Paller channeled her frustration into new pursuits.
“It made me go home and think, how could I strengthen myself? What else could I do?” she said. “Soon after, with a highly supportive husband, I did a ‘pseudosabbatical,’ basically spending every ounce of spare time I had working with one of the premier female scientists in the country, Elaine Fuchs, and learning molecular biology” in her lab at the University of Chicago.
“I think we’ve all had discrimination along the way. Sometimes there’s implicit bias and sometimes there’s overt bias,” said Dr. Paller, who in 2004 led the society which her mentor Dr. Jacobs had founded several decades earlier. “I just jumped right in, and that’s enabled me to find good role models.”
Across dermatology broadly, the often holistic nature of the specialty – of the ability to peer into the body and its internal health – is another quality that women have been drawn to and advanced, Dr. Hinshaw said. “One of the reasons why I chose dermatology is because it’s a window to total patient health. Patients often see their dermatologists as physicians who help them identify next steps in their health care, who can help them address issues related to their overall health and well-being, including their mental health.”
In a WDS membership survey conducted in 2018, most respondents reported that they frequently or occasionally detect and diagnose systemic/internal diseases and conditions in their female patients, and that they consult and collaborate with different kinds of physicians (Int J Womens Dermatol. 2018 Nov 15;4[4]:189-92).
And in a March 2019 “Dialogues in Dermatology” podcast episode on the history and advancement of women in dermatology produced by the American Academy of Dermatology, Pearl Grimes, MD, a clinical professor of dermatology of the University of California, Los Angeles, and then-president of the WDS, described why “total women’s health” had become an additional focus for the society.
“We’re already gatekeepers” in many respects, Dr. Grimes said. “In addition to my addressing specific skin issues, my patients query me on hormone issues, on nutrition, on stress-related issues….and on [what other physicians they should see].”
Phoebe Rich, MD, who owns a small all-woman practice and a research center in Portland, Oregon, said that, in general, many women also communicate and practice in a way that facilitates holistic care. “These qualities aren’t exclusive to women, but women are very caring. We take time and are interested in [patients’] lives in general, not just their disease.”
Disparities in academia
Dermatology departments in academic medicine have burgeoned in size in the past 50 years, and women are well represented overall. In 2018, women comprised 51.2% of dermatology department faculty – up from 10.8% in 1970 – a current proportion that ranks fifth among specialties for the proportion of female faculty, according to a cross-sectional study of faculty diversity trends using data from the AAMC faculty roster (JAMA Dermatol. 2020 Jan 8;156[3]:280-7).
The AAMC data show the share of women dermatology faculty declining at each subsequent rank, however – a finding that suggests that women are not promoted as quickly or to the same levels of leadership as men, the report’s authors noted. (Dermatology isn’t alone: The AAMC issued a call to action on gender equity in medicine this year, citing this inverse association.)
Another recently published study of gender trends in academic dermatology – this one looking at a smaller sample of data from 15 institutions – similarly found that women dermatologists made up a majority of faculty (53.6%) and were well represented as assistant professors (60.7%) but underrepresented as full professors (17%).
This study differed from the larger AAMC study, however, in that it controlled for “achievement indicators” – career duration, publications per year, and National Institutes of Health research funding – and found that gender alone was not associated with higher rank. Instead, promotions were correlated most significantly with NIH research funding and also with career duration and publications per year.
“If research achievement is to be used as a benchmark for academic promotion, increased efforts are needed to support the research activities of women,” the authors wrote, adding that recognition should be given to other factors as well.
Dr. Paller and Dr. Hinshaw both described the situation as complex and multifaceted. Some research on promotion in academia in general – but not all – has suggested that women do need to publish more than men in order to be promoted. But “the promotion process also has within it the ability to use judgment [about] the impact and merits of work,” said Dr. Hinshaw. “Not all publications [and levels of authorship] may be considered equal, for instance.”
Dr. Hinshaw said she is also concerned by data showing that women still perform the majority of household duties, “even in households in which both partners work outside the home equivalently.” As long as this is the case, women may be “inherently disadvantaged” in their ability to have adequate research time and to advance.
From where she sits, Dr. Paller sees several factors at play: “The pipeline, achievement during the pipeline, and decision-making about advancement” on the part of women themselves. Having served on search committees for top leadership in specialties in which women are well represented, she said, “I’ve seen fewer women who’ve come forward and been interested in rising into a chair or a dean position.”
And “having talked to so many women,” Dr. Paller added, “I think there’s a phenomenon where it’s harder for women to accept positions [that require] a significant change.”
Women “are nurturers, which makes them extremely good [leaders] and chairs, but it also makes it harder to make life changes that affect the people they love,” she said, noting that becoming a department chair or a dean often involves moving. “I also think that women in general are happier and committed to what they’re [currently] doing.”
Dr. Paller is optimistic that, with the support of department chairs and continued attention to role modeling and mentoring, the portrait of women in academic dermatology will continue to improve. Currently, 34 chairs of dermatology departments are female, she noted. “That number was 11 less 15 years ago.”
In the meantime, researchers are increasingly documenting trends in women’s editorships of journals as well as leadership and speaking opportunities at professional conferences.
The authors of one study published this year, for instance, reviewed the editorial boards of dermatology journals and found that women occupied 18% of editor in chief roles, 36% of deputy editor positions, and 22% of overall editorial board roles (Int J Womens Dermatol. 2019 Sep 12;6[1]:20-4). Other research shows women comprising 43% of all authorships across 23 dermatologic journals from 2008 to May 2017, 50.2% of first authorships, and 33.1% of last authorships (BMJ Open. 2018 Apr 13;8[4]:e020089).
Both in academic medicine and in practice, a gender pay gap still affects women physicians across the board. Medscape’s 2020 dermatologist compensation report shows male dermatologists earning about 12% more than their female peers (average, $435,000 vs. $387,000, respectively), while the average number of hours per week spent seeing patients is similar (36.2 vs. 35.6 hours, respectively).
And in its 2020 statement on gender equity, the AAMC said that women in academic medicine are offered less in starting salary, negotiated pay, and other forms of compensation than men “despite equal effort, rank, training, and experience.”
It’s complicated to tease apart all the factors that may be involved – but important to keep challenging the system, said Dr. Bergfeld, who was a long-time board adviser for Dermatology News. “I was underpaid,” she noted, and “this was only rectified in the last 10 years.”
Work-life balance
In the AAD podcast on women in dermatology, Dr. Grimes said that achieving a healthy and balanced work life remains one of the greatest challenges for women dermatologists – and it may be even greater than in the past given the growing numbers of group practices. “When women enter the realm of group practice, they have less flexibility in controlling their time and their own schedules.”
If Anna Hare, MD, is any indication, younger dermatologists may buck this trend. The daughter of Dr. Rich in Portland, Dr. Hare joined her mother’s dermatology practice and research center knowing that she’d have “the respect and flexibility for deciding how I want to practice.”
Younger dermatologists, she said, place “more of an emphasis on work-life balance and quality of life.”
Fortunately, said Dr. Bergfeld, women have advanced enough in the ranks of dermatology that, in networking, in mentorship, and in workplace settings, attention can be paid more fully to discussions about work-life management – “how to manage your life when you’re working with family and kids and parents.”
In the 1970s, at the Cleveland Clinic, “there were only five women on staff and we were fighting for [basic] rights,” she said. “We wanted equality – we were [perceived as] little worker bees….We needed to climb as the men did to positions of leadership and address the problems of women.”
In pursuing their goals and making further progress, women dermatologists today should be “steady and calm,” she advised. Formally acquiring leadership skills and communication skills is a timeless need. And when there are biases or conflicts, “you cannot have righteous indignation, you cannot have revenge. You have to calm yourself and move forward.”
Rapid drop of antibodies seen in those with mild COVID-19
The research was conducted by F. Javier Ibarrondo, PhD, and colleagues and was published online on July 21 in a letter to the editor of the New England Journal of Medicine. Ibarrondo is associate researcher at the University of California, Los Angeles. (The original letter incorrectly calculated the half-life at 73 days.)
Coauthor Otto Yang, MD, professor of medicine in the division of infectious diseases at UCLA, told Medscape Medical News that the rapidity in the antibody drop at 5 weeks “is striking compared to other infections.”
The phenomenon has been suspected and has been observed before but had not been quantified.
“Our paper is the first to put firm numbers on the dropping of antibodies after early infection,” he said.
The researchers evaluated 34 people (average age, 43 years) who had recovered from mild COVID-19 and had referred themselves to UCLA for observational research.
Previous report also found a quick fade
As Medscape Medical News reported, a previous study from China that was published in Nature Medicine also found that the antibodies fade quickly.
Interpreting the meaning of the current research comes with a few caveats, Dr. Yang said.
“One is that we don’t know for sure that antibodies are what protect people from getting infected,” he said. Although it’s a reasonable assumption, he said, that’s not always the case.
Another caveat is that even if antibodies do protect, the tests being used to measure them – including the test that was used in this study – may not measure them the right way, and it is not yet known how many antibodies are needed for protection, he explained.
The UCLA researchers used an enzyme-linked immunosorbent assay to detect anti–SARS-CoV-2 spike receptor–binding domain immunoglobulin G concentrations.
“No reason for anybody to be getting an antibody test medically”
The study provides further proof that “[t]here’s no reason for anybody to be getting an antibody test medically right now,” Dr. Yang said.
Additionally, “FDA-approved tests are not approved for quantitative measures, only qualitative,” he continued. He noted that the findings may have implications with respect to herd immunity.
“Herd immunity depends on a lot of people having immunity to the infection all at the same time. If infection is followed by only brief protection from infection, the natural infection is not going to reach herd immunity,” he explained.
Buddy Creech, MD, MPH, associate professor of pediatrics and director of the Vanderbilt Vaccine Research Program in Nashville, Tenn., pointed out that antibodies “are just part of the story.”
“When we make an immune response to any germ,” he said, “we not only make an immune response for the time being but for the future. The next time we’re exposed, we can call into action B cells and T cells who have been there and done that.”
So even though the antibodies fade over time, other arms of the immune system are being trained for future action, he said.
Herd immunity does not require that populations have a huge level of antibodies that remains forever, he explained.
“It requires that in general, we’re not going to get infected as easily, and we’re not going to have disease as easily, and we’re not going to transmit the virus for as long,” he said.
Dr. Creech said he and others researching COVID-19 find that studies that show that antibodies fade quickly provide more proof “that this coronavirus is going to be here to stay unless we can take care of it through very effective treatments to take it from potentially fatal disease to one that is nothing more than a cold” or until a vaccine is developed.
He noted there are four other coronaviruses in widespread circulation every year that “amount to about 25% of the common cold.”
This study may help narrow the window as to when convalescent plasma – plasma that is taken from people who have recovered from COVID-19 and that is used to help people who are acutely ill with the disease – will be most effective, Dr. Creech explained. He said the results suggest that it is important that plasma be collected within the first couple of months after recovery so as to capture the most antibodies.
This study is important as another snapshot “so we understand the differences between severe and mild disease, so we can study it over time, so we have all the tools we need as we start these pivotal vaccine studies to make sure we’re making the right immune response for the right duration of time so we can put an end to this pandemic,” Dr. Creech concluded.
The study was supported by grants from the AIDS Healthcare Foundation, the Doris Duke Charitable Foundation, the National Institutes of Health, the James B. Pendleton Charitable Trust, and the McCarthy Family Foundation. A coauthor reports receiving grants from Gilead outside the submitted work. Dr. Creech has disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
The research was conducted by F. Javier Ibarrondo, PhD, and colleagues and was published online on July 21 in a letter to the editor of the New England Journal of Medicine. Ibarrondo is associate researcher at the University of California, Los Angeles. (The original letter incorrectly calculated the half-life at 73 days.)
Coauthor Otto Yang, MD, professor of medicine in the division of infectious diseases at UCLA, told Medscape Medical News that the rapidity in the antibody drop at 5 weeks “is striking compared to other infections.”
The phenomenon has been suspected and has been observed before but had not been quantified.
“Our paper is the first to put firm numbers on the dropping of antibodies after early infection,” he said.
The researchers evaluated 34 people (average age, 43 years) who had recovered from mild COVID-19 and had referred themselves to UCLA for observational research.
Previous report also found a quick fade
As Medscape Medical News reported, a previous study from China that was published in Nature Medicine also found that the antibodies fade quickly.
Interpreting the meaning of the current research comes with a few caveats, Dr. Yang said.
“One is that we don’t know for sure that antibodies are what protect people from getting infected,” he said. Although it’s a reasonable assumption, he said, that’s not always the case.
Another caveat is that even if antibodies do protect, the tests being used to measure them – including the test that was used in this study – may not measure them the right way, and it is not yet known how many antibodies are needed for protection, he explained.
The UCLA researchers used an enzyme-linked immunosorbent assay to detect anti–SARS-CoV-2 spike receptor–binding domain immunoglobulin G concentrations.
“No reason for anybody to be getting an antibody test medically”
The study provides further proof that “[t]here’s no reason for anybody to be getting an antibody test medically right now,” Dr. Yang said.
Additionally, “FDA-approved tests are not approved for quantitative measures, only qualitative,” he continued. He noted that the findings may have implications with respect to herd immunity.
“Herd immunity depends on a lot of people having immunity to the infection all at the same time. If infection is followed by only brief protection from infection, the natural infection is not going to reach herd immunity,” he explained.
Buddy Creech, MD, MPH, associate professor of pediatrics and director of the Vanderbilt Vaccine Research Program in Nashville, Tenn., pointed out that antibodies “are just part of the story.”
“When we make an immune response to any germ,” he said, “we not only make an immune response for the time being but for the future. The next time we’re exposed, we can call into action B cells and T cells who have been there and done that.”
So even though the antibodies fade over time, other arms of the immune system are being trained for future action, he said.
Herd immunity does not require that populations have a huge level of antibodies that remains forever, he explained.
“It requires that in general, we’re not going to get infected as easily, and we’re not going to have disease as easily, and we’re not going to transmit the virus for as long,” he said.
Dr. Creech said he and others researching COVID-19 find that studies that show that antibodies fade quickly provide more proof “that this coronavirus is going to be here to stay unless we can take care of it through very effective treatments to take it from potentially fatal disease to one that is nothing more than a cold” or until a vaccine is developed.
He noted there are four other coronaviruses in widespread circulation every year that “amount to about 25% of the common cold.”
This study may help narrow the window as to when convalescent plasma – plasma that is taken from people who have recovered from COVID-19 and that is used to help people who are acutely ill with the disease – will be most effective, Dr. Creech explained. He said the results suggest that it is important that plasma be collected within the first couple of months after recovery so as to capture the most antibodies.
This study is important as another snapshot “so we understand the differences between severe and mild disease, so we can study it over time, so we have all the tools we need as we start these pivotal vaccine studies to make sure we’re making the right immune response for the right duration of time so we can put an end to this pandemic,” Dr. Creech concluded.
The study was supported by grants from the AIDS Healthcare Foundation, the Doris Duke Charitable Foundation, the National Institutes of Health, the James B. Pendleton Charitable Trust, and the McCarthy Family Foundation. A coauthor reports receiving grants from Gilead outside the submitted work. Dr. Creech has disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
The research was conducted by F. Javier Ibarrondo, PhD, and colleagues and was published online on July 21 in a letter to the editor of the New England Journal of Medicine. Ibarrondo is associate researcher at the University of California, Los Angeles. (The original letter incorrectly calculated the half-life at 73 days.)
Coauthor Otto Yang, MD, professor of medicine in the division of infectious diseases at UCLA, told Medscape Medical News that the rapidity in the antibody drop at 5 weeks “is striking compared to other infections.”
The phenomenon has been suspected and has been observed before but had not been quantified.
“Our paper is the first to put firm numbers on the dropping of antibodies after early infection,” he said.
The researchers evaluated 34 people (average age, 43 years) who had recovered from mild COVID-19 and had referred themselves to UCLA for observational research.
Previous report also found a quick fade
As Medscape Medical News reported, a previous study from China that was published in Nature Medicine also found that the antibodies fade quickly.
Interpreting the meaning of the current research comes with a few caveats, Dr. Yang said.
“One is that we don’t know for sure that antibodies are what protect people from getting infected,” he said. Although it’s a reasonable assumption, he said, that’s not always the case.
Another caveat is that even if antibodies do protect, the tests being used to measure them – including the test that was used in this study – may not measure them the right way, and it is not yet known how many antibodies are needed for protection, he explained.
The UCLA researchers used an enzyme-linked immunosorbent assay to detect anti–SARS-CoV-2 spike receptor–binding domain immunoglobulin G concentrations.
“No reason for anybody to be getting an antibody test medically”
The study provides further proof that “[t]here’s no reason for anybody to be getting an antibody test medically right now,” Dr. Yang said.
Additionally, “FDA-approved tests are not approved for quantitative measures, only qualitative,” he continued. He noted that the findings may have implications with respect to herd immunity.
“Herd immunity depends on a lot of people having immunity to the infection all at the same time. If infection is followed by only brief protection from infection, the natural infection is not going to reach herd immunity,” he explained.
Buddy Creech, MD, MPH, associate professor of pediatrics and director of the Vanderbilt Vaccine Research Program in Nashville, Tenn., pointed out that antibodies “are just part of the story.”
“When we make an immune response to any germ,” he said, “we not only make an immune response for the time being but for the future. The next time we’re exposed, we can call into action B cells and T cells who have been there and done that.”
So even though the antibodies fade over time, other arms of the immune system are being trained for future action, he said.
Herd immunity does not require that populations have a huge level of antibodies that remains forever, he explained.
“It requires that in general, we’re not going to get infected as easily, and we’re not going to have disease as easily, and we’re not going to transmit the virus for as long,” he said.
Dr. Creech said he and others researching COVID-19 find that studies that show that antibodies fade quickly provide more proof “that this coronavirus is going to be here to stay unless we can take care of it through very effective treatments to take it from potentially fatal disease to one that is nothing more than a cold” or until a vaccine is developed.
He noted there are four other coronaviruses in widespread circulation every year that “amount to about 25% of the common cold.”
This study may help narrow the window as to when convalescent plasma – plasma that is taken from people who have recovered from COVID-19 and that is used to help people who are acutely ill with the disease – will be most effective, Dr. Creech explained. He said the results suggest that it is important that plasma be collected within the first couple of months after recovery so as to capture the most antibodies.
This study is important as another snapshot “so we understand the differences between severe and mild disease, so we can study it over time, so we have all the tools we need as we start these pivotal vaccine studies to make sure we’re making the right immune response for the right duration of time so we can put an end to this pandemic,” Dr. Creech concluded.
The study was supported by grants from the AIDS Healthcare Foundation, the Doris Duke Charitable Foundation, the National Institutes of Health, the James B. Pendleton Charitable Trust, and the McCarthy Family Foundation. A coauthor reports receiving grants from Gilead outside the submitted work. Dr. Creech has disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
Is the presence of enanthem a clue for COVID-19?
Larger studies should explore and confirm this association, the study’s authors and other experts suggested.
Dermatologists are already aware of the connection between enanthem and viral etiology. “As seen with other viral infections, we wondered if COVID-19 could produce enanthem in addition to skin rash exanthem,” one of the study author’s, Juan Jiménez-Cauhe, MD, a dermatologist with Hospital Universitario Ramon y Cajal, Madrid, said in an interview. He and his colleagues summarized their findings in a research letter in JAMA Dermatology.
They examined the oral cavity of 21 COVID-19 patients at a tertiary care hospital who also had a skin rash from March 30 to April 8. They classified enanthems into four categories: petechial, macular, macular with petechiae, or erythematovesicular. Six of the patients presented with oral lesions, all of them located in the palate; in one patient, the enanthem was macular, it was petechial in two patients and was macular with petechiae in three patients. The six patients ranged between the ages of 40 and 69 years; four were women.
Petechial or vesicular patterns are often associated with viral infections. In this particular study, the investigators did not observe vesicular lesions.
On average, mucocutaneous lesions appeared about 12 days after the onset of COVID-19 symptoms. “Interestingly, this latency was shorter in patients with petechial enanthem, compared with those with a macular lesion with petechiae appearance,” the authors wrote.
This shorter time might suggest an association for SARS-CoV-2, said Dr. Jiménez-Cauhe. Strong cough may have also caused petechial lesions on the palate, but it’s unlikely, as they appeared close in time to COVID-19 symptoms. It’s also unlikely that any drugs caused the lesions, as drug rashes can take 2-3 weeks to appear.
This fits in line with other evidence of broader skin manifestations appearing at the same time or after COVID-19, Esther Freeman, MD, said in an interview. Dr. Freeman, director of global health dermatology at Massachusetts General Hospital, Boston, is the principal investigator of the COVID-19 Dermatology Registry, a collaboration of the American Academy of Dermatology and International League of Dermatological Societies.
The study’s small cohort made it difficult to establish a solid association between the oral lesions and SARS-CoV-2. “However, the presence of enanthem in a patient with a skin rash is a useful finding that suggests a viral etiology rather than a drug reaction. This is particularly useful in COVID-19 patients, who were receiving many drugs as part of the treatment,” Dr. Jimenez-Cauhe said. Future studies should assess whether the presence of enanthem and exanthem lead physicians to consider SARS-CoV-2 as possible agents, ruling out infection with a blood or nasopharyngeal test.
This study adds to the growing body of knowledge on cutaneous and mucocutaneous findings associated with SARS-CoV-2 infection, Jules Lipoff, MD, of the department of dermatology, University of Pennsylvania, Philadelphia, said in an interview. “One challenge in evaluating these findings is that these findings are nonspecific, and medication reactions can often cause similar rashes, such as morbilliform eruptions that can be associated with both viruses and medications.”
Enanthems, as the study authors noted, are more specific to viral infections and are less commonly associated with medication reactions. “So, even though this is a small case series with significant limitations, it does add more evidence that COVID-19 is directly responsible for findings in the skin and mucous membranes,” said Dr. Lipoff.
Dr. Freeman noted that the study may also encourage clinicians to look in a patient’s mouth when assessing for SARS-CoV-2. Additional research should examine these data in a larger population.
Several studies by Dr. Freeman, Dr. Lipoff, and others strongly suggest that SARS-CoV-2 has a spectrum of associated dermatologic manifestations. One evaluated perniolike skin lesions (J Am Acad Dermatol. 2020 Aug; 83[2]:486-92). The other was a case series from the COVID-19 registry that examined 716 cases of new-onset dermatologic symptoms in patients from 31 countries with confirmed/suspected SARS-CoV-2 (J Am Acad Dermatol. 2020 Jul 2;S0190-9622[20]32126-5.).
The authors of the report had no disclosures.
SOURCE: Jimenez-Cauhe J et al. JAMA Dermatol. 2020 Jul 15. doi: 10.1001/jamadermatol.2020.2550.
Larger studies should explore and confirm this association, the study’s authors and other experts suggested.
Dermatologists are already aware of the connection between enanthem and viral etiology. “As seen with other viral infections, we wondered if COVID-19 could produce enanthem in addition to skin rash exanthem,” one of the study author’s, Juan Jiménez-Cauhe, MD, a dermatologist with Hospital Universitario Ramon y Cajal, Madrid, said in an interview. He and his colleagues summarized their findings in a research letter in JAMA Dermatology.
They examined the oral cavity of 21 COVID-19 patients at a tertiary care hospital who also had a skin rash from March 30 to April 8. They classified enanthems into four categories: petechial, macular, macular with petechiae, or erythematovesicular. Six of the patients presented with oral lesions, all of them located in the palate; in one patient, the enanthem was macular, it was petechial in two patients and was macular with petechiae in three patients. The six patients ranged between the ages of 40 and 69 years; four were women.
Petechial or vesicular patterns are often associated with viral infections. In this particular study, the investigators did not observe vesicular lesions.
On average, mucocutaneous lesions appeared about 12 days after the onset of COVID-19 symptoms. “Interestingly, this latency was shorter in patients with petechial enanthem, compared with those with a macular lesion with petechiae appearance,” the authors wrote.
This shorter time might suggest an association for SARS-CoV-2, said Dr. Jiménez-Cauhe. Strong cough may have also caused petechial lesions on the palate, but it’s unlikely, as they appeared close in time to COVID-19 symptoms. It’s also unlikely that any drugs caused the lesions, as drug rashes can take 2-3 weeks to appear.
This fits in line with other evidence of broader skin manifestations appearing at the same time or after COVID-19, Esther Freeman, MD, said in an interview. Dr. Freeman, director of global health dermatology at Massachusetts General Hospital, Boston, is the principal investigator of the COVID-19 Dermatology Registry, a collaboration of the American Academy of Dermatology and International League of Dermatological Societies.
The study’s small cohort made it difficult to establish a solid association between the oral lesions and SARS-CoV-2. “However, the presence of enanthem in a patient with a skin rash is a useful finding that suggests a viral etiology rather than a drug reaction. This is particularly useful in COVID-19 patients, who were receiving many drugs as part of the treatment,” Dr. Jimenez-Cauhe said. Future studies should assess whether the presence of enanthem and exanthem lead physicians to consider SARS-CoV-2 as possible agents, ruling out infection with a blood or nasopharyngeal test.
This study adds to the growing body of knowledge on cutaneous and mucocutaneous findings associated with SARS-CoV-2 infection, Jules Lipoff, MD, of the department of dermatology, University of Pennsylvania, Philadelphia, said in an interview. “One challenge in evaluating these findings is that these findings are nonspecific, and medication reactions can often cause similar rashes, such as morbilliform eruptions that can be associated with both viruses and medications.”
Enanthems, as the study authors noted, are more specific to viral infections and are less commonly associated with medication reactions. “So, even though this is a small case series with significant limitations, it does add more evidence that COVID-19 is directly responsible for findings in the skin and mucous membranes,” said Dr. Lipoff.
Dr. Freeman noted that the study may also encourage clinicians to look in a patient’s mouth when assessing for SARS-CoV-2. Additional research should examine these data in a larger population.
Several studies by Dr. Freeman, Dr. Lipoff, and others strongly suggest that SARS-CoV-2 has a spectrum of associated dermatologic manifestations. One evaluated perniolike skin lesions (J Am Acad Dermatol. 2020 Aug; 83[2]:486-92). The other was a case series from the COVID-19 registry that examined 716 cases of new-onset dermatologic symptoms in patients from 31 countries with confirmed/suspected SARS-CoV-2 (J Am Acad Dermatol. 2020 Jul 2;S0190-9622[20]32126-5.).
The authors of the report had no disclosures.
SOURCE: Jimenez-Cauhe J et al. JAMA Dermatol. 2020 Jul 15. doi: 10.1001/jamadermatol.2020.2550.
Larger studies should explore and confirm this association, the study’s authors and other experts suggested.
Dermatologists are already aware of the connection between enanthem and viral etiology. “As seen with other viral infections, we wondered if COVID-19 could produce enanthem in addition to skin rash exanthem,” one of the study author’s, Juan Jiménez-Cauhe, MD, a dermatologist with Hospital Universitario Ramon y Cajal, Madrid, said in an interview. He and his colleagues summarized their findings in a research letter in JAMA Dermatology.
They examined the oral cavity of 21 COVID-19 patients at a tertiary care hospital who also had a skin rash from March 30 to April 8. They classified enanthems into four categories: petechial, macular, macular with petechiae, or erythematovesicular. Six of the patients presented with oral lesions, all of them located in the palate; in one patient, the enanthem was macular, it was petechial in two patients and was macular with petechiae in three patients. The six patients ranged between the ages of 40 and 69 years; four were women.
Petechial or vesicular patterns are often associated with viral infections. In this particular study, the investigators did not observe vesicular lesions.
On average, mucocutaneous lesions appeared about 12 days after the onset of COVID-19 symptoms. “Interestingly, this latency was shorter in patients with petechial enanthem, compared with those with a macular lesion with petechiae appearance,” the authors wrote.
This shorter time might suggest an association for SARS-CoV-2, said Dr. Jiménez-Cauhe. Strong cough may have also caused petechial lesions on the palate, but it’s unlikely, as they appeared close in time to COVID-19 symptoms. It’s also unlikely that any drugs caused the lesions, as drug rashes can take 2-3 weeks to appear.
This fits in line with other evidence of broader skin manifestations appearing at the same time or after COVID-19, Esther Freeman, MD, said in an interview. Dr. Freeman, director of global health dermatology at Massachusetts General Hospital, Boston, is the principal investigator of the COVID-19 Dermatology Registry, a collaboration of the American Academy of Dermatology and International League of Dermatological Societies.
The study’s small cohort made it difficult to establish a solid association between the oral lesions and SARS-CoV-2. “However, the presence of enanthem in a patient with a skin rash is a useful finding that suggests a viral etiology rather than a drug reaction. This is particularly useful in COVID-19 patients, who were receiving many drugs as part of the treatment,” Dr. Jimenez-Cauhe said. Future studies should assess whether the presence of enanthem and exanthem lead physicians to consider SARS-CoV-2 as possible agents, ruling out infection with a blood or nasopharyngeal test.
This study adds to the growing body of knowledge on cutaneous and mucocutaneous findings associated with SARS-CoV-2 infection, Jules Lipoff, MD, of the department of dermatology, University of Pennsylvania, Philadelphia, said in an interview. “One challenge in evaluating these findings is that these findings are nonspecific, and medication reactions can often cause similar rashes, such as morbilliform eruptions that can be associated with both viruses and medications.”
Enanthems, as the study authors noted, are more specific to viral infections and are less commonly associated with medication reactions. “So, even though this is a small case series with significant limitations, it does add more evidence that COVID-19 is directly responsible for findings in the skin and mucous membranes,” said Dr. Lipoff.
Dr. Freeman noted that the study may also encourage clinicians to look in a patient’s mouth when assessing for SARS-CoV-2. Additional research should examine these data in a larger population.
Several studies by Dr. Freeman, Dr. Lipoff, and others strongly suggest that SARS-CoV-2 has a spectrum of associated dermatologic manifestations. One evaluated perniolike skin lesions (J Am Acad Dermatol. 2020 Aug; 83[2]:486-92). The other was a case series from the COVID-19 registry that examined 716 cases of new-onset dermatologic symptoms in patients from 31 countries with confirmed/suspected SARS-CoV-2 (J Am Acad Dermatol. 2020 Jul 2;S0190-9622[20]32126-5.).
The authors of the report had no disclosures.
SOURCE: Jimenez-Cauhe J et al. JAMA Dermatol. 2020 Jul 15. doi: 10.1001/jamadermatol.2020.2550.
FROM JAMA DERMATOLOGY
New developments in pustular psoriasis
It has various dermatologic and rheumatologic manifestations and sometimes overlaps with plaque psoriasis. Pustular palmoplantar psoriasis (PPP) affects the palmar and plantar areas of the skin, while generalized pustular psoriasis (GPP) can affect large areas of skin and tends to be more severe, even life threatening. PPP can accompany psoriatic arthritis or can be a side effect of tumor necrosis factor (TNF) inhibitor therapy, or a non–drug-induced component of rheumatologic syndromes, according to Kristina Callis Duffin, MD, an associate professor and chair of dermatology at the University of Utah, Salt Lake City.
“Each phenotype could be considered an orphan disease, and the response to therapy is often unpredictable,” Dr. Duffin said during a session on pustular psoriasis at the virtual annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis.
But there is some positive news. A study in 2011 of several people with GPP opened the door to better understanding the pathophysiology of pustular psoriasis. Researchers identified a causal autosomal mutation in the IL36RN gene, which encodes an antagonist to the interleukin-36 receptor (Am J Hum Genet. 2011 Sep 9;89[3]:432-7). “As a result of this paper and others, drug development in this space has recently accelerated,” Dr. Duffin said.
In fact, she added,“it’s my opinion that pustular psoriasis is now where plaque psoriasis was 20 years ago, when accelerated drug development was driving a better understanding of the pathogenesis of psoriatic disease and its comorbidities, and also driving outcome measure development.”
In another presentation at the meeting, Hervé Bachelez, MD, PhD, professor of dermatology and immunologist at the University of Paris and Saint-Louis Hospital, Paris, discussed recent advances in drug development for pustular psoriasis. He noted other recent findings of genetic variants related to the disease, including AP1S3, CARD14, and SERPINA3.
For GPP, he said, the current algorithm for management is based on weak evidence for treatments like acitretin, cyclosporine, methotrexate, and infliximab. The story is similar for other biologics, with evidence in the form of case series; open-label studies; controlled, prospective studies; or retrospective analyses. Most of the evidence has been amassed for TNF inhibitors. A retrospective study of all TNF inhibitors suggested they may be effective as induction and maintenance therapy, he noted.
Among IL-17A inhibitors, a prospective study of 12 patients in Japan found secukinumab showed efficacy against GPP, as did studies of ixekizumab and brodalumab. A small phase 3 study in Japan demonstrated efficacy for the IL-23 inhibitor guselkumab in patients with erythrodermic psoriasis and GPP (J Dermatol. 2018 May;45[5]:529-39).
The limited data are a reflection in part of the difficulty in studying GPP, since its flares tend to be more self-remitting than with psoriasis vulgaris or PPP.
There are two monoclonal antibodies against the IL-36 receptor currently being developed. A proof-of-concept study of one of them, spesolimab, showed promise against GPP, with five of seven patients reaching “clear” or “almost clear” scores on the Generalized Pustular Psoriasis Physician Global Assessment within a week after infusion and in all seven by the fourth week (N Engl J Med. 2019 Mar 7;380[10]:981-3).
With respect to PPP, the strongest evidence for conventional therapies comes from two randomized, controlled trials of cyclosporine, with response rates of 48% and 89%, compared with 19% and 21%, respectively, in the placebo groups, although the primary endpoint was poorly designed, according to Dr. Bachelez. Retinoids like etretinate and acitretin, combined with psoralen and UVA, also have some supporting evidence regarding efficacy.
Among biologics, secukinumab did not fare well in a phase 3 study of patients with PPP. A subset of patients may benefit from it, but there are no biomarkers available to identify them, Dr. Bachelez said. A phase 2 study of guselkumab in Japan told a similar story, with only weak signs of efficacy. While there are many more ongoing clinical trials evaluating treatments for PPP, which is encouraging, PPP seems to be more challenging at this stage to tackle than GPP, Dr. Bachelez added. “The genetically inherited IL-36 antagonist abnormalities are clearly driving the advances regarding the pathogenesis of the disease, mainly for GPP rather than PPP.”
Part of the efforts to develop therapies for pustular psoriasis relies on the development of new outcome measures, or adaptation of existing ones. “We have a need to adapt or develop new investigator-reported measures, we need to adapt or develop new patient-reported outcomes,” Dr. Duffin said.
Many existing measures use inconsistent language and anchoring definitions, and some may be proprietary, she added. “The language varies by sponsor and is sometimes tweaked or modified by the agencies. Often synonyms are being used … it raises questions, does it change the validity of the instrument?”
Dr. Duffin called for the research community to use the pause in clinical research during the COVID-19 pandemic to reassess the research agenda, develop consensus on performing and training for GPP and PPP assessments, develop patient-reported outcomes, and strengthen connections to industry.
Dr. Duffin and Dr. Bachelez have consulted, served on the advisory board, been a speaker for, and/or received research support from a wide range of pharmaceutical companies, including those that manufacture and develop psoriasis treatments.
It has various dermatologic and rheumatologic manifestations and sometimes overlaps with plaque psoriasis. Pustular palmoplantar psoriasis (PPP) affects the palmar and plantar areas of the skin, while generalized pustular psoriasis (GPP) can affect large areas of skin and tends to be more severe, even life threatening. PPP can accompany psoriatic arthritis or can be a side effect of tumor necrosis factor (TNF) inhibitor therapy, or a non–drug-induced component of rheumatologic syndromes, according to Kristina Callis Duffin, MD, an associate professor and chair of dermatology at the University of Utah, Salt Lake City.
“Each phenotype could be considered an orphan disease, and the response to therapy is often unpredictable,” Dr. Duffin said during a session on pustular psoriasis at the virtual annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis.
But there is some positive news. A study in 2011 of several people with GPP opened the door to better understanding the pathophysiology of pustular psoriasis. Researchers identified a causal autosomal mutation in the IL36RN gene, which encodes an antagonist to the interleukin-36 receptor (Am J Hum Genet. 2011 Sep 9;89[3]:432-7). “As a result of this paper and others, drug development in this space has recently accelerated,” Dr. Duffin said.
In fact, she added,“it’s my opinion that pustular psoriasis is now where plaque psoriasis was 20 years ago, when accelerated drug development was driving a better understanding of the pathogenesis of psoriatic disease and its comorbidities, and also driving outcome measure development.”
In another presentation at the meeting, Hervé Bachelez, MD, PhD, professor of dermatology and immunologist at the University of Paris and Saint-Louis Hospital, Paris, discussed recent advances in drug development for pustular psoriasis. He noted other recent findings of genetic variants related to the disease, including AP1S3, CARD14, and SERPINA3.
For GPP, he said, the current algorithm for management is based on weak evidence for treatments like acitretin, cyclosporine, methotrexate, and infliximab. The story is similar for other biologics, with evidence in the form of case series; open-label studies; controlled, prospective studies; or retrospective analyses. Most of the evidence has been amassed for TNF inhibitors. A retrospective study of all TNF inhibitors suggested they may be effective as induction and maintenance therapy, he noted.
Among IL-17A inhibitors, a prospective study of 12 patients in Japan found secukinumab showed efficacy against GPP, as did studies of ixekizumab and brodalumab. A small phase 3 study in Japan demonstrated efficacy for the IL-23 inhibitor guselkumab in patients with erythrodermic psoriasis and GPP (J Dermatol. 2018 May;45[5]:529-39).
The limited data are a reflection in part of the difficulty in studying GPP, since its flares tend to be more self-remitting than with psoriasis vulgaris or PPP.
There are two monoclonal antibodies against the IL-36 receptor currently being developed. A proof-of-concept study of one of them, spesolimab, showed promise against GPP, with five of seven patients reaching “clear” or “almost clear” scores on the Generalized Pustular Psoriasis Physician Global Assessment within a week after infusion and in all seven by the fourth week (N Engl J Med. 2019 Mar 7;380[10]:981-3).
With respect to PPP, the strongest evidence for conventional therapies comes from two randomized, controlled trials of cyclosporine, with response rates of 48% and 89%, compared with 19% and 21%, respectively, in the placebo groups, although the primary endpoint was poorly designed, according to Dr. Bachelez. Retinoids like etretinate and acitretin, combined with psoralen and UVA, also have some supporting evidence regarding efficacy.
Among biologics, secukinumab did not fare well in a phase 3 study of patients with PPP. A subset of patients may benefit from it, but there are no biomarkers available to identify them, Dr. Bachelez said. A phase 2 study of guselkumab in Japan told a similar story, with only weak signs of efficacy. While there are many more ongoing clinical trials evaluating treatments for PPP, which is encouraging, PPP seems to be more challenging at this stage to tackle than GPP, Dr. Bachelez added. “The genetically inherited IL-36 antagonist abnormalities are clearly driving the advances regarding the pathogenesis of the disease, mainly for GPP rather than PPP.”
Part of the efforts to develop therapies for pustular psoriasis relies on the development of new outcome measures, or adaptation of existing ones. “We have a need to adapt or develop new investigator-reported measures, we need to adapt or develop new patient-reported outcomes,” Dr. Duffin said.
Many existing measures use inconsistent language and anchoring definitions, and some may be proprietary, she added. “The language varies by sponsor and is sometimes tweaked or modified by the agencies. Often synonyms are being used … it raises questions, does it change the validity of the instrument?”
Dr. Duffin called for the research community to use the pause in clinical research during the COVID-19 pandemic to reassess the research agenda, develop consensus on performing and training for GPP and PPP assessments, develop patient-reported outcomes, and strengthen connections to industry.
Dr. Duffin and Dr. Bachelez have consulted, served on the advisory board, been a speaker for, and/or received research support from a wide range of pharmaceutical companies, including those that manufacture and develop psoriasis treatments.
It has various dermatologic and rheumatologic manifestations and sometimes overlaps with plaque psoriasis. Pustular palmoplantar psoriasis (PPP) affects the palmar and plantar areas of the skin, while generalized pustular psoriasis (GPP) can affect large areas of skin and tends to be more severe, even life threatening. PPP can accompany psoriatic arthritis or can be a side effect of tumor necrosis factor (TNF) inhibitor therapy, or a non–drug-induced component of rheumatologic syndromes, according to Kristina Callis Duffin, MD, an associate professor and chair of dermatology at the University of Utah, Salt Lake City.
“Each phenotype could be considered an orphan disease, and the response to therapy is often unpredictable,” Dr. Duffin said during a session on pustular psoriasis at the virtual annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis.
But there is some positive news. A study in 2011 of several people with GPP opened the door to better understanding the pathophysiology of pustular psoriasis. Researchers identified a causal autosomal mutation in the IL36RN gene, which encodes an antagonist to the interleukin-36 receptor (Am J Hum Genet. 2011 Sep 9;89[3]:432-7). “As a result of this paper and others, drug development in this space has recently accelerated,” Dr. Duffin said.
In fact, she added,“it’s my opinion that pustular psoriasis is now where plaque psoriasis was 20 years ago, when accelerated drug development was driving a better understanding of the pathogenesis of psoriatic disease and its comorbidities, and also driving outcome measure development.”
In another presentation at the meeting, Hervé Bachelez, MD, PhD, professor of dermatology and immunologist at the University of Paris and Saint-Louis Hospital, Paris, discussed recent advances in drug development for pustular psoriasis. He noted other recent findings of genetic variants related to the disease, including AP1S3, CARD14, and SERPINA3.
For GPP, he said, the current algorithm for management is based on weak evidence for treatments like acitretin, cyclosporine, methotrexate, and infliximab. The story is similar for other biologics, with evidence in the form of case series; open-label studies; controlled, prospective studies; or retrospective analyses. Most of the evidence has been amassed for TNF inhibitors. A retrospective study of all TNF inhibitors suggested they may be effective as induction and maintenance therapy, he noted.
Among IL-17A inhibitors, a prospective study of 12 patients in Japan found secukinumab showed efficacy against GPP, as did studies of ixekizumab and brodalumab. A small phase 3 study in Japan demonstrated efficacy for the IL-23 inhibitor guselkumab in patients with erythrodermic psoriasis and GPP (J Dermatol. 2018 May;45[5]:529-39).
The limited data are a reflection in part of the difficulty in studying GPP, since its flares tend to be more self-remitting than with psoriasis vulgaris or PPP.
There are two monoclonal antibodies against the IL-36 receptor currently being developed. A proof-of-concept study of one of them, spesolimab, showed promise against GPP, with five of seven patients reaching “clear” or “almost clear” scores on the Generalized Pustular Psoriasis Physician Global Assessment within a week after infusion and in all seven by the fourth week (N Engl J Med. 2019 Mar 7;380[10]:981-3).
With respect to PPP, the strongest evidence for conventional therapies comes from two randomized, controlled trials of cyclosporine, with response rates of 48% and 89%, compared with 19% and 21%, respectively, in the placebo groups, although the primary endpoint was poorly designed, according to Dr. Bachelez. Retinoids like etretinate and acitretin, combined with psoralen and UVA, also have some supporting evidence regarding efficacy.
Among biologics, secukinumab did not fare well in a phase 3 study of patients with PPP. A subset of patients may benefit from it, but there are no biomarkers available to identify them, Dr. Bachelez said. A phase 2 study of guselkumab in Japan told a similar story, with only weak signs of efficacy. While there are many more ongoing clinical trials evaluating treatments for PPP, which is encouraging, PPP seems to be more challenging at this stage to tackle than GPP, Dr. Bachelez added. “The genetically inherited IL-36 antagonist abnormalities are clearly driving the advances regarding the pathogenesis of the disease, mainly for GPP rather than PPP.”
Part of the efforts to develop therapies for pustular psoriasis relies on the development of new outcome measures, or adaptation of existing ones. “We have a need to adapt or develop new investigator-reported measures, we need to adapt or develop new patient-reported outcomes,” Dr. Duffin said.
Many existing measures use inconsistent language and anchoring definitions, and some may be proprietary, she added. “The language varies by sponsor and is sometimes tweaked or modified by the agencies. Often synonyms are being used … it raises questions, does it change the validity of the instrument?”
Dr. Duffin called for the research community to use the pause in clinical research during the COVID-19 pandemic to reassess the research agenda, develop consensus on performing and training for GPP and PPP assessments, develop patient-reported outcomes, and strengthen connections to industry.
Dr. Duffin and Dr. Bachelez have consulted, served on the advisory board, been a speaker for, and/or received research support from a wide range of pharmaceutical companies, including those that manufacture and develop psoriasis treatments.
FROM THE GRAPPA 2020 VIRTUAL ANNUAL MEETING