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Medscape
7 hours ago
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- Medscape
Medscape Readers Offer Their Opinion on UTI Management
I recently presented a clinical scenario of a 34-year-old woman who called the clinic after hours, reporting symptoms consistent with a urinary tract infection (UTI). The only in-person clinical care available at the time was the emergency department, and urgent care wouldn't open until the following morning. Given this history, I asked Medscape readers what they would do next. Thank you for the excellent participation and comments that you provided. It was wonderful to hear different perspectives. According to our reader poll, the most popular management option for this patient was a recommendation to visit the urgent care center on Saturday morning. This would be the most reasonable approach if there was some doubt as to the diagnosis of UTI. As I described in the previous article (and as one reader commented), there is a possibility that this patient might have a sexually transmitted infection, not a UTI. However, a brief screen for symptoms and sexual history could be performed over the phone and, if negative, would make the diagnosis of UTI much more likely. If clinical questioning indicates that the patient might be experiencing menopause, genitourinary syndrome of menopause (GSM) becomes a consideration. Among women, postmenopausal dysuria can have multiple etiologies, but clinicians should strongly consider GSM as a potential diagnosis. GSM is a term that describes the genital, sexual, and urinary symptoms that affect over 80% of postmenopausal women. These symptoms can include vaginal dryness and burning, dyspareunia, and dysuria. So, how can physicians differentiate GSM from UTI? I focus on the anatomical location of discomfort. Is it around the urethra and vagina or deeper in the suprapubic area? UTI is more likely to be associated with urinary urgency and frequency, but if GSM is accompanied by detrusor instability — another very common condition — the lines between diagnoses can continue to blur. Finally, a pelvic examination with evidence of vaginal atrophy would suggest GSM. In my professional opinion, GSM is not a consideration in our 34-year-old patient. Instead, I agree with the 27% of respondents who wanted to treat her empirically with nitrofurantoin. Nitrofurantoin is well-tolerated and one of the three preferred antibiotics for uncomplicated UTIs among women, according to the 2010 guidelines from the Infectious Diseases Society of America. The other first-line antibiotics for uncomplicated UTI were trimethoprim-sulfamethoxazole and fosfomycin. Of these three recommended antibiotics, nitrofurantoin and fosfomycin are associated with the lowest rates of antimicrobial resistance, and nitrofurantoin is generally more readily available in pharmacies than is fosfomycin. Fluoroquinolones are less preferred for the treatment of UTI because of higher rates of antimicrobial resistance. In a study of 3779 adults with UTI presenting to US emergency departments between 2018 and 2020, 22.1% of Escherichia coli isolates were resistant to fluoroquinolones. As one reader astutely noted, fluoroquinolones can also promote myalgia, tendonitis, and tendon rupture. As for beta-lactams, inferiority to fluoroquinolones for clinical cure rates of UTI and concerns regarding the promotion of extended-spectrum beta-lactamase resistance of gram-negative bacteria limit their use in the treatment of UTI. A new antibiotic, gepotidacin, was approved in March 2025 for the management of uncomplicated UTI among female patients aged 12 years or older. Investigators compared gepotidacin vs nitrofurantoin among 3136 women with UTI in two randomized controlled trials. The treatment course of both gepotidacin and nitrofurantoin was 5 days. The investigators found that gepotidacin was noninferior to nitrofurantoin in the outcome of treatment success (defined by symptomatic plus microbiologic success) in one of the trials, and superior to nitrofurantoin in the other trial. Of note, treatment success for resistant phenotypes of E coli generally favored gepotidacin. Diarrhea occurred in 14% and 18% of women treated with gepotidacin in the two studies, respectively, whereas 4% of women treated with nitrofurantoin developed nausea. Although UTI is one of the most common bacterial infections worldwide, it does not receive the attention from researchers and clinicians that it should. So, it is exciting to have a new class of antibiotic to offer women with UTI, and treatment guidelines are currently being updated to incorporate data regarding emerging treatments for UTI. The future is bright! As always, thank you for your contributions to this series.
Medscape
2 days ago
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- Medscape
Your Patient's Smartwatch Could Be a Legal Time Bomb
A few years ago, a patient in her 30s saw Nicholas Dragolea, MBBS, a general practitioner when her Apple Watch showed an irregular heart rhythm. She had no family history of heart disease or any related symptoms, such as breathlessness, palpitations, lightheadedness, heart racing, or chest pain, Dragolea said. He ordered a Holter monitor and confirmed that the patient had paroxysmal atrial fibrillation. He started her on weight control treatment and anticoagulants. 'It's important because if you don't diagnose and treat it [PAF] early, it increases the risk of stroke, and the patient can become more symptomatic later on,' he told Medscape Medical News. As patients buy and use more wearable devices, doctors are increasingly being presented with data from their patients asking for medical opinions. It's an extension of Dr Google, when patients come to their physicians after having read about a medical condition online. How doctors react (or not) to their patient's wearable data and their legal liability in doing so has implications for both doctor and patient. About Medscape Data Medscape continually surveys physicians and other medical professionals about key practice challenges and current issues, creating high-impact analyses. For example, a Physicians and Malpractice Report 2024 found that Two out of three physicians worry about malpractice exposure occasionally. 53% of doctors say improving communication between physicians and patients can discourage lawsuits. 6 in 10 doctors have been named in a malpractice suit. Growing Use of Wearables A December 2024 survey from The Ohio State University Wexner Medical Center, Columbus, Ohio, found that about two thirds of Americans regularly use wearable devices to monitor their heart, including smartwatches, portable blood pressure machines, fitness apps, and wearable movement/fitness trackers. The study found that only one quarter of these users, however, currently share their data with their physician. For physicians without protocols for handling the data, this may be a relief. A 2024 ZS Future of Health Report showed that 71% of US physicians surveyed were overwhelmed by the amount of data available to them, a potential barrier to adopting connected health systems. The same percentage said they don't know what to do with the onslaught of that data. How to Assess Patients' Wearables Data When a patient shares concerning wearables data, the physician should prioritize the history and examination, said Dragolea, also following any national guidelines. Sharing guidelines can help calm a patient's nerves as well, if the doctor does conduct follow-up testing. Dragolea would ask patients about their family history, symptoms, how they felt when the wearables data were recorded, what the patient's concern is, and any expectations they have in handling it. 'Nowadays, they will likely have done research about what it means,' he said. He doesn't recommend overinvestigating an issue that's less concerning. But if doing nothing will make the patient anxious, that's not good either — because they'll likely just make an appointment with another doctor. It's also important to assess the data source. Someone with a wearable that showed low oxygen readings may just need education that the devices can give erroneous readings if moved the wrong way or if the patient was sweaty when the reading occurred. Dragolea sometimes explains to patients that the devices are mostly for wellness and are not approved medical devices. 'The data is not always accurate, and it is not always data we can act on to instruct us in any particular problem or diagnosis,' Dragolea said. Some devices have FDA medical clearance, and others do not. Dragolea takes heart data from an Apple Watch more seriously than devices without this regulatory approval, he said. If a doctor has not heard of the patient's device, they can quickly search online to see if it has FDA clearance or if there are clinical studies citing methodology backing up the outcomes, said Bethany Corbin, a healthcare innovation attorney at Corbin Legal. 'It can take 1 or 2 minutes to type in the device name plus 'clinical trial' to see if it's vetted from a clinical perspective,' she said. If it's not, that doesn't mean it's inaccurate, but doctors should take the readings with a different grain of salt, she added. William Haas, MD, who specializes in wellness and integrative medicine, uses wearable data more frequently than many practices. 'From the lens of the average practitioner, a lot has to do with the alerts alongside the symptoms,' he said. 'Then I decide if I need to pursue proper medical testing to evaluate it further.' When talking to patients about wearables, Haas tells them, 'They're not diagnostics, but they're excellent early warning signs.' If a device shows low oxygen saturation at night, it could be sleep apnea. He then asks the patient if their partner says they snore or if the partner notices the patient having periods during sleep when they're not breathing. He asks if they wake up tired in the morning. For cardiac issues, 'we try to match up data like an elevated heart rate, lightheadedness, and dizziness — targeted symptoms to match up to data points.' Haas gives less credence to devices' proprietary health indices. 'They may come up with a recovery index based on heart rate variability, but I'd be more apt to look at actual heart rate variation,' he said. In addition to smartwatches and rings, there are wearables like glucose and blood pressure monitors. And there's overlap with patient-submitted data, which can also be instructive. Corbin shared the story of a woman who brought her phone-based period tracking app data to her provider. The data showed cycle irregularity including breakthrough bleeding. The provider performed a physical exam and said the patient was fine, suggesting stress as a cause. The woman went to a different provider who followed the patient for a few months, ordering a Pap smear, which was positive for cervical cancer. Proactive Tracking A lot of doctors are hesitant to recommend wearable technologies, as they haven't vetted them and don't know what's most accurate, said Corbin. 'Patients and consumers know more about devices than doctors do,' she added. There can be practice liability if it's not set up to collect and track wearables data in the electronic health record, if they're not consistently monitoring incoming data, and there's no feedback loop. 'I don't see doctors embracing digital health tools,' she said. 'There's more liability in not monitoring versus not using them.' Haas does incorporate wearables in his practice, which focuses on wellness. 'In my practice I almost never make a recommendation to my patients that I don't use myself,' he said, as he wants to know how the device works and what potentially can be tracked. He also uses a platform [Headsuphealth] to aggregate smart data, lab testing, and self-reported questionnaires. It shares trends over time for individual patients and groups of patients. 'It gives me more context on how to interpret some smart device data to match up to lab testing and to look for correlations.' Legal Liability Haas noted that 'you're not legally required to act on every bit of data,' but there are legal risks if a doctor ignores a patient's symptoms alongside wearable alerts without proper documentation. It's an issue worth following, as more patients will report wearables data to doctors in the future, said Dragolea. 'I believe the numbers will increase as more people get wearables, rings, watches, and earrings as well.' This will require a lot more conversations with patients about the data quality and maybe more help from regulators on what to do in these cases, he said.
Medscape
2 days ago
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- Medscape
‘This Doesn't Look Good': Such Words Can Worsen Patient Pain
Negative expectations are more persistent and more potent than placebo effects, according to a recent study led by Ulrike Bingel, MD, PhD, professor of clinical neuroscience and director of Interdisciplinary Centre for Pain Medicine at University Hospital Essen, Germany. Bingel and her research team found that negative expectations intensify pain more significantly and with greater lasting impact than positive expectations help relieve it. In the study, Bingel and colleagues tested 104 healthy volunteers who were exposed to short-term heat pain. On average, participants rated their pain 11 points higher when primed with negative expectations compared with a control condition. In an interview with Medscape's German edition , Bingel — also spokesperson of the Collaborative Research Center "Treatment Expectation" — explains how clinicians can better communicate with patients to improve outcomes and avoid common pitfalls. Her team has also developed practical communication resources for healthcare providers and patients. Your study shows that negative expectations influence pain perception more strongly and persistently than positive beliefs. Was that the outcome you anticipated? Yes, that was in fact our hypothesis. A smaller prior study had already suggested that nocebo effects — that is, effects driven by negative expectations — are easier to trigger than placebo effects. In an earlier study, we also showed that memories of negative events form more readily and endure longer than positive ones. So, the findings align with each other and support what could be described as an evolutionary 'better safe than sorry' strategy. How should physicians ideally inform patients about a treatment? There are many ways to approach this, depending on the patient's individual needs and preferences. But what's crucial is that patients understand what the treatment is for and what outcomes they can expect. What benefit does it offer me? What's the intended goal? While this may sound straightforward, many patients only know the number of pills to take and when — perhaps their shape or color — but very few understand what the medications are meant to achieve or how they work. Unfortunately, package inserts don't help much with that either. So, the first step is always to explain the treatment objective clearly, why it is the best choice for that patient, and when they can expect it to start working. From there, many communication strategies can be personalized. The key is to help patients begin treatment with clarity and as little anxiety as possible. Should patients be told that negative expectations are more powerful than positive ones? I'm not aware of any studies that specifically address that question. However, we do know that simply educating patients about the nocebo effect can help reduce both the incidence and severity of adverse effects. You recommend avoiding unintentionally negative phrasing. Can you give a few classic examples? The list is practically endless. Just think about what might sound unsettling to you. Phrases like, 'Whew, that doesn't look good,' or 'I really don't know what else to try,' or 'There's nothing we can do,' are all problematic. Even something like, 'You're a high-risk patient,' said ahead of a necessary surgery, can be discouraging. A more reassuring alternative would be, 'We'll take every measure to support you through this operation, even with your preexisting conditions.' I believe communication missteps begin when we lose sight — even briefly — of how powerful our words can be. That's easy to do in the stress of daily clinical practice. But precisely in those moments, it's our responsibility to stay composed, create a secure conversational space, and communicate in a way patients can receive with trust and minimal anxiety. Regarding shared decision-making, patients increasingly want to be involved in treatment decisions. How do you view this in light of your findings? Should patients, for example, be discouraged from reading the package insert too closely? We know that shared decision-making is helpful, even from a placebo and nocebo perspective. That's particularly true when there aren't too many competing treatment options. An overload of choices can be confusing or even distressing. But when the clinical guidelines support options A, B, or C equally, involving patients in the choice is beneficial. The option they trust more will have a psychological edge. Where that trust comes from differs for each person. Maybe the drug's mechanism of action feels more intuitive to them. Maybe they know someone who did well on it. Or maybe they overheard something positive during morning rounds. That doesn't really matter. What matters is that, in my view, patient preferences should always be considered — within the boundaries of evidence-based, guideline-compliant care. To what extent are your findings transferable to clinical settings? Are further studies planned? I'm convinced that the effects we observed in healthy volunteers likely underestimate what happens in clinical practice. Many medical scenarios — whether evaluating acute symptoms, delivering a new and possibly serious diagnosis like cancer, or managing chronic illnesses with limited treatment options — are inherently anxiety-provoking and often accompanied by fear and negative expectations. We know from research that all of this fuels nocebo effects. There's already a substantial body of evidence showing that a significant proportion of adverse effects seen in routine clinical care are driven by nocebo responses. The next step in research isn't to confirm this effect again, but to test targeted therapeutic strategies aimed at minimizing or even preventing nocebo effects in day-to-day care. Doing so could make treatments more effective and better tolerated and help ensure that patients don't avoid essential medications due to fear.
Medscape
3 days ago
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- Medscape
Dire Warnings, Rosy Future: Medicare at 60
The creation of Medicare in 1965 was hailed as a watershed for the social safety net, offering millions of older Americans financial security and freedom from worry about their medical expenses. But critics of the legislation cast dire warnings about what the law would do to the nation's physicians, the doctor-patient relationship, and even the country's way of life. Who was right? To mark the 60th anniversary of Medicare, Medscape asked leaders in healthcare, American history, and public policy to reflect on the words of the program's earliest champions and critics. Comments have been edited for length and clarity. Democratic presidential nominee John F. Kennedy, August 14, 1960. Then-Senator John F. Kennedy , spoke in support of a national insurance program for the elderly at an event on August 14, 1960: "Three out of every five of these [people over age 65] — more than 9.5 million people — must struggle to survive on an income of under $1000 a year. …This poverty and hardship turn into heartbreak and despair when illness threatens. Medicines and drugs are more expensive than ever before — hospital rates have more than doubled — doctor bills have skyrocketed. …Those over 65 suffer from chronic diseases at almost twice the rate of our younger population — they spend more than twice as many days restricted to bed — and they must visit a doctor twice as often." Commentary Keith Wailoo, PhD, Henry Putnam University professor of history and public affairs at Princeton University and past president of the American Association for the History of Medicine: "An important backdrop behind JFK's comment is reflecting 10 years prior on the failure of President Harry Truman's national health insurance proposals. The frustrations and the stories he's telling were evident after World War II. Keith Wailoo, PhD "He's describing a landscape where — in the course of the war — private insurance became more attached to employment, wage freezes meant that companies couldn't raise wages, unions lobbied and employers argued that benefits could be increased, and as a result of a momentous Supreme Court ruling, health insurance became increasingly a byproduct of employment. Healthcare costs were rising, and insurance was becoming a passage point to getting hospital care. "The face of the poor and medical needy were the elderly by 1960. They were not working, and because of advancing life expectancy, there was more infirmity and yet they were locked out of the system. "So we've recreated the world, and with that we have also changed people's expectations about what they can hope for." Ronald Reagan and the American Medical Association, 1961 audio recording on LP. In 1961, Ronald Reagan released a speech against a proposed bill that would cover hospital costs for the elderly. The effort was later revealed to be part of a campaign by the American Medical Association (AMA) to quash efforts to create a national health insurance program. Reagan said: "[The bill] was simply an excuse to bring about what they wanted all the time, socialized medicine. … First, you decide that the doctor can have so many patients, they're equally divided among the various doctors by the government. But then the doctors aren't equally divided geographically. So a doctor decides he wants to practice in one town, and the government has to say to him, 'You can't live in that town. They already have enough doctors,' and from here, it's only a short step to dictating where he will go." Commentary Reid B. Blackwelder, MD, associate dean for graduate medical and continuing education, DIO, Quillen College of Medicine, East Tennessee State University, and past president of the American Academy of Family Physicians: "Reagan's warning that nationalized health insurance would lead to government direction for where physicians practice has not happened. Physicians have the freedom to accept insurance or not and to practice anywhere they want. Sadly, our country is facing increasing healthcare deserts for various reasons. Reid B. Blackwelder, MD "We already had a serious and growing access problem for patients. Now, patients in rural areas especially are losing even more access to primary care physicians and specialists as rural hospitals shut down and physicians like obstetricians stop practicing outside of urban areas. "Ironically, Medicare is perhaps the most lenient health insurance in terms of providing that freedom of choice Reagan described for patients. Because Medicare is popular and widely accepted by patients and physicians, patients can readily choose the physician they want, including subspecialists. On the other hand, for-profit insurance has created significant limits on which physicians a patient may select based on acceptance of that insurance and cost. It can be difficult for a patient to see the physician of their choice." Dr Edward Annis ( left ), holding an anatomical model of a human heart, speaks with TV host Johnny Carson ( right ) on the The Tonight Show , December 11, 1963. Edward Annis, MD , chairman of the AMA 's speakers' bureau — and later president of the association — appeared in a televised May 21, 1962, address about the proposed King-Anderson bill, an early iteration of what would become the legislation that created Medicare. Annis said: 'It wastefully covers millions who do not need it, it heartlessly ignores millions who do need coverage. It is not true insurance. It will create an enormous and unpredictable burden on every working taxpayer. It offers sharply limited benefits. And it will serve as a forerunner of a different system of medicine for all Americans.' Commentary Jonathan Oberlander, PhD, professor of social medicine at the University of North Carolina at Chapel Hill, and editor of the Journal of Health Politics, Policy and Law: "The AMA's overheated rhetoric against Medicare did not age well. Doctors would later face challenges to their clinical autonomy, as Annis had feared, but that intrusion came from private managed care insurers trying to control skyrocketing costs, not Medicare. "Yet the AMA was right about one thing. Although they didn't admit it during the 1960s, Medicare's architects saw the program as the first step to universal health insurance, and after covering the elderly, they hoped to next turn to children and eventually cover everyone via government insurance. Medicare for All was the aspiration. "That did not happen, and although Medicare expanded eligibility in 1972 to cover persons with permanent disabilities and end-stage renal disease — six decades after the program's enactment — its primary beneficiaries are still older Americans, an outcome that would have stunned its creators. "After Medicare's enactment in 1965, the AMA's opposition to the program faded, much to Annis' consternation. Forty years later, he still expressed regret that the association did not take a more 'militant' stand highlighting the program's problems." Dr Edward Annis (right) with Dr Arthur Fleming. Annis continued: "This King-Anderson Bill is a cruel hoax and illusion. … It will come between the patient and his doctor." Commentary Reid B. Blackwelder, MD, associate dean for graduate medical and continuing education, DIO, Quillen College of Medicine, East Tennessee State University, and past president of the American Academy of Family Physicians "The special and powerful relationship between patients and physicians is a real thing. Medicare did not damage it. Other insurance coverage did not damage it. Having any insurance coverage is one of the foundations of getting to good health outcomes. The other is having a source of comprehensive care. Patients need both. "The very real threat to the physician-patient relationship that is accelerating today is from legislative intrusions into the patient room. When laws are passed that make even just exploring options with patients around things like reproductive health a criminal offense, government has overstepped. "When laws are enacted that require a physician to call their lawyer rather than a specialty consult before providing life-saving care, we have entered a new and dangerous era of governmental oversight. Recent laws have done more damage to the sanctity of the physician-patient relationship that Medicare actually helped improve." Rep. Durward Gorham Hall, 1969 Representative Durward Gorham Hall, MD (R, Missouri), made these remarks below during debates on Medicare in the House of Representatives: "This conflict is testing whether art and science of medicine will be permitted to grow and flourish in freedom and competitively, or whether progress in medicine will be stunted and shriveled by an excess of Government control." Commentary Jonathan B. Jaffery, MD, MS, MMM, chief healthcare officer at the Association of American Medical Colleges: "By supporting the training of physicians, Medicare helps create the physician workforce for future generations of Americans, crucial for the care of an aging population. And through iterative developments over the last 60 years, such as Coverage with Evidence Development or the Center for Medicare and Medicaid Innovations, the Medicare program — coupled with federal investments in biomedical research — has been able to support innovations in both medical technologies and models of care delivery that continue to improve the lives and well-beings of millions. Jonathan B. Jaffery, MD "The reality is, prior to 1965, many elderly Americans with healthcare needs were forced to rely on financial support from their families or spend all their life's savings, hope for charity care, or forego care altogether. And of course, the cost of care has only skyrocketed, so that in 2025 even very high-net worth individuals would struggle to cover the costs of a lengthy hospitalization or extended illness, let alone the price tag of many new life-saving medications." Hall continued: "The result will inescapably be third-party intrusion in the practice of hospitalization and medicine. His diagnostic and therapeutic decisions would be subject to disapproval by those controlling the expenditure of tax money." Commentary G. William Hoagland, senior vice president, Bipartisan Policy Center, former executive at Cigna, and former US Senate staffer "Representative Hall was prescient in his observation about the future of healthcare resulting from the creation of Medicare. The 60-year history of the Medicare program, particularly since the enactment of the Tax Equity and Fiscal Responsibility Act in 1982, the Medicare Modernization Act in 2003, and the Patient Protection and Affordable Care Act in 2010, has resulted in the 'corporatization' of healthcare. G. William Hoagland "Today, Medicare Advantage, dominated by 'third-party' corporate insurance companies, has transferred the physician's independent decisions to actuaries and corporate financial decision makers. The result has also been horizontal consolidation of what were locally controlled entities to nationally or regionally controlled corporations along with vertical consolidation of payers and care delivery entities. "The impact of these changes, along with dramatic scientific advances in diagnosis with advanced treatment protocols, precipitating higher healthcare utilization, has not been to reduce costs but to in fact increase healthcare costs." President Lyndon Johnson ( left ) flips through the pages of the Medicare bill so former President Harry Truman ( right) can see it. Following passage of the Social Security Amendments of 1965 out of the Senate by a vote of 68-21, President Lyndon B. Johnson said: "It will help pay for care in hospitals. If hospitalization is unnecessary, it will help pay for care in nursing homes or in the home. And wherever illness is treated — in home or hospital — it will also help meet the fees of doctors and the costs of drugs." Commentary Bruce Leff, MD, professor of medicine and director of the Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine in Baltimore: "Johnson's statement regarding care at home was appropriate for the mid-1960s. To this day, skilled home healthcare remains the most used home-based service by Medicare beneficiaries. "Since Medicare was enacted, a bevy of evidence-based home care delivery models have been developed and proven. These home-based models span the care continuum including home and community-based services, home-based primary care, transitional care, and home-based palliative care. Bruce Leff, MD "Unfortunately, Medicare payment policies incentivized the centralization of care in facilities and a facility-centric culture of care delivery. Care delivery hasn't kept pace with the needs of an aging population with a high prevalence of homebound older Americans or with the advances that enable even hospital care to be delivered to patients in their preferred setting, their homes. "The hospital of the future will comprise of emergency departments, operating rooms, and intensive care units. Most other care can and will be provided in the home setting. We have all the pieces to develop this future home-based care vision. Achieving this vision will require a culture shift with associated payment and regulatory enhancements, ongoing attention to improvements in technology, logistics, and data management." An elderly woman shows her gratitude to President Lyndon B. Johnson for his signing of the Medicare healthcare bill in April 1965. Johnson continued: "Older citizens will no longer have to fear that illness will wipe out their savings, eat up their income, and destroy lifelong hope of dignity and independence. For every family with older members, it will mean relief from the often-crushing responsibilities of care." Commentary Gretchen Jacobson, PhD, vice president, Medicare program, Commonwealth Fund: Gretchen Jacobson, PhD "One third of Medicare beneficiaries said in 2023 that it was difficult to afford healthcare costs. More than 1 in 5 beneficiaries reported in 2023 delaying or skipping needed healthcare because of the cost. Similarly, some Medicare beneficiaries trade off paying for other necessities to pay for needed healthcare. The lack of a limit on out-of-pocket spending on hospital and physician services for traditional Medicare has, for most traditional Medicare enrollees, necessitated purchasing supplemental insurance coverage. Yet, the limited availability of this supplemental coverage has resulted in more beneficiaries enrolling in Medicare Advantage and high underinsurance rates among those in traditional Medicare without supplemental coverage. "Medicare beneficiaries who do not have a family caregiver and cannot afford to pay out-of-pocket for a formal caregiver are typically forced to deplete their financial resources to qualify for Medicaid coverage, the largest payer for long-term care in the US."
Medscape
4 days ago
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- Medscape
Helping Your Patients Manage COPD in the Workplace
Your patients with chronic obstructive pulmonary disease (COPD) may need help not just coping with their condition but also managing it in their workplace. The symptoms of COPD, a lung and airway condition that causes shortness of breath, fatigue, and persistent cough, may interfere with some job responsibilities, according to several pulmonologists Medscape Medical News consulted as well as studies published in the past few years about COPD in the workplace. The Mayo Clinic reported that symptoms for most patients with COPD begin when they are at least 40 years, so well into their working years. Patients with COPD must continuously monitor if their condition affects their job performance and how potential workplace exposures to toxic chemicals or dust, and hazards such as stairs, worsen their breathing issues, the pulmonologists told Medscape Medical News . Several recent studies evaluated how workplace exposures to gases, vapors, dust, and fumes raised employees' risks of developing COPD, worsened their symptoms, or increased their chances of complications from the chronic disease. To combat such outcomes, pulmonologists share ways they teach their patients about navigating their workplace environment, recognizing hazards, understanding workplace protections, and seeking help. Weighing Work Options Whether a COPD patient can keep up with the job requirements depends on the person and their worksite experience, said David Mannino, MD, a pulmonologist and chief medical officer for the COPD Foundation, and chair of the Department of Occupational Medicine and Environmental Health at the University of Kentucky, Lexington, Kentucky. 'Some jobs are more physically demanding than others,' he said. 'Every patient has a unique situation and there's never a one-size-fits-all approach. It's very individualized.' Mannino said he's had patients who worked in coal mines or warehouses, and had to navigate those dusty and dirty environments, which can be difficult for patients with COPD. David Mannino, MD If they can't function reasonably well or keep up with the demands of the job, they may need to ask their employer for special accommodations such as switching to a different position or changing worksites, said Mannino, who sees patients several times. 'Some of my patients are on oxygen and that's fine if you're at a desk job. You can wear oxygen and that's not a problem.' In other settings, it might be more difficult or impossible, he said. 'If you have a patient who is a woodworker and he is self-employed and he uses respiratory protection, that he can do reasonably well. I've had some older patients who work at the university in desk jobs and so they can continue to work with no real changes in their responsibilities or schedules.' Some people with COPD may choose to retrain for careers where there aren't as many physical demands, he said. Mannino treated an older patient who was a plumber and could no longer keep up with some of the physical aspects of his job, so he was able to retire. Environmental Triggers Cleveland Clinic Pulmonologist Maeve MacMurdo, MD, said she spends time with patients with COPD evaluating their job, their challenges in the workplace with the disease, and potential triggers. 'So often people find that common triggers are things like strong perfumes or chemical cleaners,' she said. Incense and candles might also trigger COPD for some. Weather also plays a major role in the lives of patients with COPD. 'The humidity definitely impacts a lot of patients, so the air quality is one thing I tell them, when you wake up in the morning, look at the humidity for the day,' said Rohan Mankikar, MD, a pulmonologist with NYU Langone Health, New York City. 'The sweet spot for my COPD patients is like between 40%-70%, so if the humidity is above 70%, they might feel it more.' Maeve MacMurdo, MD On cold days, humidity < 20% might also affect patients with COPD, he said. 'But even days that it rains, snows, [they are] exposed to environmental changes such as wildfire smoke, I have patients that come in with COPD flares or exacerbations.' Patients should also check the allergen, pollen counts, and the air quality index for the day, Mankikar said. 'This is just something simple they can do before driving to work because sometimes you drive with the windows down and you might be inhaling pollen. The job site could be construction and there's exposure to dust,' he said. Potential workplace hazards are myriad, he said. From copy machines that accumulate dust to beauticians who get exposed to different chemicals and smells, it all could possibly trigger an episode. Mankikar said some of his patients wear a mask when they can. Patients should note what triggers their COPD and if it improves in different environments, Mankikar said. They should survey their work area to ensure it's safe for them. For instance, the air quality or humidity in the room. If it's a confined space with poor ventilation or an old building with mold that might require mold remediation. One of the most important triggers to address is smoking, which is the primary cause of COPD, he said. 'That's the biggest allergen for them and they might not realize it because they're saying: 'Well I'm used to this and did this [most of] my life.' But it weakens the immune system when you're actively smoking and creates more mucus production, which then acts like a glue for dust and pollen exposure.' Workplace Protections The Americans with Disabilities Act (ADA) protects employees with substantial breathing difficulty and requires employers to provide 'reasonable accommodations' or adjustments to the employee's role. Though the ADA doesn't list specific medical conditions such as COPD, it considers breathing a physical impairment that substantially limits or restricts a major life activity covered under the act. Major life activities include respiratory functions along with performing manual tasks, working, learning, reading, thinking, and communicating. To be protected, an employee must have a record of or be regarded as having a substantial impairment. If an employee's COPD stops or limits their ability to work effectively, they can apply for disability benefits through the Social Security Administration (SSA). COPD is listed among the respiratory disorders covered under the SSA's list of covered impairments. Monthly SSA disability benefits can be used to pay for food, clothing, housing, medical bills, medications, childcare, and training if an employee wants to return to work. To qualify, the government requires medical evidence to document the severity of the respiratory disorder such as with pulmonary function tests, including spirometry, which measures ventilation of the lungs, or pulse oximetry, which measures oxygen saturation of peripheral blood hemoglobin. What Help Patients May Need In addition to portable oxygen, patients may have to request access to therapeutic options to help them perform their job functions, Mannino said. Those might include access to medications that can be used at work, such as handheld inhalers or nebulizers. If a patient becomes short of breath when they climb stairs and that's a job requirement, they may have to ask their employer to modify their duties or look for another position within the company, resign or retire, he said. It's up to the employer to decide whether the request for accommodation is reasonable, Mannino said. If you're a welder and you need to be on oxygen, that's not really safe because it can create a fire hazard, he said. 'I think employers want to typically work with their employees…and that it's possible to make the workplace better for that person who has COPD.' If the company has an occupational health specialist in their human resources department, they may be able to assess the employee's needs and offer suggestions, said Francesca Polverino, MD, PhD, a pulmonologist and medical spokesperson for the American Lung Association. For some employees, access to a wheelchair may help them navigate the distances they might have to traverse at work, especially if they are carrying oxygen, said Polverino, who is also a professor of medicine at the Baylor College of Medicine. Francesca Polverino, MD, PhD Patients with COPD also would benefit from further education of their coworkers and supervisors about the disease because there's often a stigma associated with it, Polverino said. Compared with asthma, which tends to be inherited or unintentionally acquired, COPD is often caused by a preventable addiction — smoking. It's also not considered as alarming as other chronic diseases because COPD worsens slowly over a longer period, she said. For these reasons, workers with COPD may be reticent to ask for help, she added. MacMurdo said 'reasonable accommodation' from an employer might include a private office, an air purifier, working from home or having a flexible schedule. She agreed that not all work adaptations will be possible, but employees can brainstorm solutions with their doctors. Patients should keep a log of what they are doing and when they experience symptoms to help doctors identify triggers and come up with workarounds they can suggest to their employers, MacMurdo said. Ideally, patients should discuss with their doctors what they recommend and decide what's practical for the particular job to control COPD symptoms, she said. How to Ask for Help Mankikar said he's written letters for patients to take to their employer asking if it's possible for them not to be exposed to certain chemicals or dust that might exacerbate their COPD. 'For example, if the patient is a teacher and has COPD and they're doing construction [nearby], then I might have them try to teach a different class that's away from the construction site, so they're not in the hallways inhaling the dust.' Patients often request a doctor's note to leave early from work for pulmonary rehabilitation, Mankikar said. 'Unfortunately, those facilities are only open Monday through Friday from 9 to 5…so that's an example of writing a letter to make that accommodation happen to strengthen their lungs.' Employers tend to be very responsive to his notes, he said. 'The moment they know that some of these dust exposures can increase their [employee's] risk of COPD they want to make accommodation for them because they don't want the employee to miss work due to the illness.' Employers know that if their employees are exposed to chemicals or allergens, there's also a financial burden they might face, Mankikar said. If the employer is willing to work with the patient, they might move them to an administrative role instead of a direct occupational one. He cited a patient who worked for a landscaping company and managed other landscapers. The exposure to allergens raised his risk for COPD flareups, so his employer agreed to move him to an area that's well-ventilated and on days when the pollen count was high, he was able to work at a different site. These resources also may help patients navigate COPD in the workplace: How to Manage COPD's Impact on Your Job Early Warning Signs of Work-Related COPD | American Lung Association Lung Health on the Job | NHLBI, NIH
