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The Kidney Disease: Improving Global Outcomes (KDIGO) organization has released a new 2024 clinical practice guideline document on evaluating and managing nondialysis-dependent chronic kidney disease (CKD).

The guideline – a much anticipated update from 2012 – contains mostly new recommendations based on a systematic review of moderate- to high-quality studies conducted up to July 2023. It is designed to assist health care providers with decision-making with respect to the evaluation and management of CKD, defined as abnormalities of kidney structure or function persisting for more than 3 months (excluding dialysis and kidney transplantation).

Key highlights include guidance updates on the measurements of estimated glomerular filtration rate (eGFR) and albuminuria, use of CKD risk prediction equations, and personalized treatment recommendations for kidney and cardiovascular risk reductions tailored to individual patient needs and preferences. Managing blood pressure, diabetes, lipids, CKD-MBD, and anemia (to be updated in 2024) has been addressed in detail in other KDIGO guidelines.

It remains important to determine the cause of each patient’s CKD, whether congenital or genetic, a consequence of systemic diseases, or primary using serum and urine tests, imaging, biopsy, and/or genetic testing.

“Recent advancements in GFR evaluation, risk prediction, and the arrival of novel treatments are poised to enhance CKD prognosis and management,” work group co-chair Adeera Levin, MD, stated in a KDIGO news release. “We also hope the guideline’s emphasis on multidisciplinary teamwork, patient engagement, and a holistic, evidence-based approach to care will help catalyze positive change, resulting in more coordinated CKD care management worldwide.”

Gauging Glomerular Filtration Rate

The guideline provides actionable recommendations based on graded evidence as well as consensus-based practice points on established CKD, staged preferably using the race-free eGFRcr-cys equation and albumin-to-creatinine ratio. If a more accurate assessment of GFR is needed for clinical decision-making, clinicians may measure GFR using plasma or urinary clearance of exogenous filtration markers.

In patients with CKD G3-G5, the guideline recommends using an externally validated risk equation to estimate the absolute risk of kidney failure. Patients believed to have immunoglobulin A nephropathy (IgAN) or autosomal dominant polycystic kidney disease (ADPKD) may want to use disease-specific, externally validated prediction equations, according to a practice point. Risk prediction tools for cardiovascular disease or mortality need to include eGFR and albuminuria or be specific to the CKD population.

Delaying CKD Progression

A practice point encourages clinicians to form a comprehensive and tailored treatment strategy to reduce patients’ risks of progression of CKD and its associated complications. Clinicians should prevent and treat clinical symptoms and signs, such as blood pressure; maintain physical function; and monitor and treat laboratory abnormalities such as anemia, CKD-MBD, potassium disorders, and acidosis, as appropriate.

Activity: According to the guideline, adults with CKD should undertake moderate-intensity physical activity for at least 150 minutes per week, if tolerable.

Diet: The guideline suggests maintaining a dietary protein intake of 0.8 g/kg body weight/d in adults with CKD G3-G5 (evidence level 2C). A practice point suggests avoiding high protein intake exceeding 1.3 g/kg body weight/d. Plant-based, Mediterranean style diets appear prudent, and working with a renal dietitian and receiving appropriate medical nutrition therapy can be beneficial. The guideline also suggests limiting sodium intake to less than 2 g of sodium per day. Special considerations are given for children and older adults.

Blood pressure: With respect to blood pressure control in adults, the guideline recommends that high blood pressure and CKD be treated to a target systolic blood pressure (SBP) of less than 120 mm Hg, when tolerated, using standardized office BP measurement. In children, 24-hour mean arterial pressure by ambulatory blood pressure monitoring should be lowered to the 50th percentile or less for age, sex, and height.

The guideline recommends starting renin-angiotensin-system inhibitors (RASi) (eg, angiotensin-converting enzyme inhibitor [ACEi] or angiotensin II receptor blocker [ARB]) for patients with severely increased albuminuria (G1-G4, A3) without diabetes and suggests this step for patients with moderately increased albuminuria (G1-G4, A2) without diabetes. It also recommends RASi for patients with moderately-to-severely increased albuminuria (G1-G4, A2, and A3) who have diabetes. Avoid any combination of ACEi, ARB, and direct renin inhibitor therapy in the CKD population.

At RASi initiation or dose change, practice points suggest checking within 2-4 weeks for changes in blood pressure, serum creatinine, and serum potassium. Clinicians should continue ACEi or ARB therapy unless serum creatinine rises by more than 30% within 4 weeks. Consider reducing the dose or discontinuing ACEi or ARB if there is symptomatic hypotension or uncontrolled hyperkalemia despite medical treatment, or to reduce uremic symptoms while treating kidney failure.

The guideline suggests a nonsteroidal mineralocorticoid receptor antagonist with proven kidney or cardiovascular benefit for adults with type 2 diabetes, an eGFR exceeding 25 mL/min/1.73m2, normal serum potassium concentration, and albuminuria exceeding 30 mg/g despite maximum tolerated dose of RASi.

Glycemic control: The guideline recommends treating patients with type 2 diabetes, CKD, and an eGFR of at least 20 mL/min/1.73m2 with a sodium-glucose cotransporter-2 inhibitors (SGLT2i). This advice also applies to patients with CKD alone (without diabetes) who have heart failure or a urine ACR of 200 mg/g or more. SGLT2i is also suggested for adults with an eGFR of 20 to 45 mL/min/1.73m2 with urine ACR less than 200 mg/g.

In adults with type 2 diabetes and CKD who have not achieved individualized glycemic targets despite use of metformin and SGLT2i, or who are unable to use those medications, the guideline recommends a long-acting glucagon-like peptide-1 receptor agonist (GLP-1 RA).

Hyperuricemia: The guideline recommends patients with CKD and symptomatic hyperuricemia should be offered uric acid-lowering intervention. Practice points suggest xanthine oxidase inhibitors rather than uricosuric agents. For acute gout, low-dose colchicine or intra-articular/oral glucocorticoids are preferable to nonsteroidal anti-inflammatory drugs (NSAIDs). Patients without symptoms should not receive uric acid-lowering drugs.

Preventing and Managing Cardiovascular Disease

Lipid management: Statins are recommended for adults aged 50 years and older with stage 1-5 CKD (not on dialysis or receiving a transplant). A statin/ezetimibe combination should only be considered for patients with stage 3-5 CKD. Younger adults with coronary disease (myocardial infarction or coronary revascularization), diabetes mellitus, prior ischemic stroke, or an estimated 10-year incidence of coronary death or nonfatal myocardial infarction exceeding 10% should also consider a statin.

Antiplatelet therapy: The guideline recommends oral low-dose aspirin for secondary prevention of recurrent ischemic cardiovascular disease events.

Coronary artery disease: In stable, stress-test confirmed ischemic heart disease, clinicians may first attempt intensive medical therapy. Unstable or acute conditions may warrant an invasive strategy.

Atrial fibrillation: The guideline recommends non-vitamin K antagonist oral anticoagulants rather than vitamin K antagonists such as warfarin for thromboprophylaxis in atrial fibrillation in people with CKD G1-G4.

Imaging: The guideline suggests following advice from radiology societies. Patients with CKD, acute kidney injury (AKI), diabetes, reduced intravascular volume, or concomitant nephrotoxic drugs have increased risk for contrast-associated AKI.

Medication Management and Drug Stewardship

The guideline offers myriad practice points for safe medication use including limiting over-the-counter medicines and herbal and dietary supplements, considering the nephrotoxic effects of medications, reviewing teratogenicity in case of pregnancy, and monitoring eGFR to balance effectiveness and potential adverse effects.

Dose adjustments by eGFR are frequently required for medications cleared by the kidneys. While creatinine-based eGFR is appropriate for drug dosing in most cases, using equations that combine both creatinine and cystatin C, or measured GFR may be indicated when drugs have a narrow therapeutic or toxic range. Use eGFR nonindexed for body surface area in people with extremes of body weight. Adapt drug dosing when the volume of distribution is not in steady state.

Medications discontinued due to illness or prior to elective surgery or acute management of adverse effects should have a plan for restart.

Periodic medication review and pharmacist involvement is necessary.

"
Recent advancements in GFR, risk prediction, and the arrival of novel treatments are poised to enhance CKD prognosis and management.

Optimal Models of Care

The guideline offers a series of practice points to optimize care. Referral to specialist kidney care services is warranted when the cause of CKD is uncertain and in cases of  hereditary kidney disease or recurrent extensive nephrolithiasis. It is also warranted when the 5-year risk for kidney replacement therapy exceeds 5%, eGFR drops by 20%-30%, or eGFR falls below 30 mL/min/1.73m2. Significant albuminuria and microscopic hematuria also require further evaluation and management.

Referral of children and adolescents to specialist kidney care services is indicated when urine ACR is 30 mg/g or PCR is 200 mg/g or more or there is persistent hematuria, a sustained decrease in eGFR, hypertension, kidney outflow obstruction, kidney and urinary tract anomalies, suspected CKD, or recurrent urinary tract infection. Transition from pediatric to adult care should begin at age 11 to 14 years using checklists to assess readiness and guide preparation. Kidney transplantation is recommended, either preemptively or when kidney failure occurs.

Timely referral to specialist kidney care is paramount to avoid poor outcomes, such as hospitalization.

Symptoms: A practice point suggests screening people with CKD G4-G5, age older than 65 years, poor growth, or symptoms such as involuntary weight loss, frailty, or poor appetite twice annually for malnutrition using a validated assessment tool. The guideline also offers lifestyle and pharmacologic options for managing other symptoms such as pain, poor sleep, and uremic pruritus.

Multidisciplinary care: Clinicians should ensure access to dietary counseling, medication management, education, and counseling about kidney replacement modalities, transplant options, dialysis access surgery, and ethical, psychological, and social care for people with CKD.

Dialysis Initiation

According to practice points, dialysis is indicated when symptoms or signs attributable to kidney failure are present, such as neurologic signs of uremia, pericarditis, anorexia, medically resistant acid-based or electrolyte abnormalities, intractable pruritus, serositis, and acid-base or electrolyte abnormalities or the patient has inability to control volume status or blood pressure. This often occurs when GFR is 5 to 10 mL/min/1.73 m2.

Consider planning for preemptive kidney transplantation and/or dialysis access in adults when the GFR is less than 15 to 20 mL/min/1.73m2 or risk of KRT exceeds 40% over 2 years. Pediatric patients have special considerations and should ideally seek transplantation.

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A new clinical practice guideline on salvage therapy for prostate cancer has been released by the American Urological Association (AUA), the American Society for Radiation Oncology (ASTRO), and the Society of Urologic Oncology (SUO).

“With a focus on evidence-based approaches and a commitment to patient-centered care, this guideline will make a real difference for patients dealing with recurrence of their prostate cancer following initial treatment,” guideline panel chair Todd Morgan, MD, stated in an AUA news release. This guideline was based on research published up to July 2023 and expert consensus. The full guideline contains 30 recommendations and is now available at auanet.org/STPCGuideline.

In The Journal of Urology, the guideline panel presented a 3-part series focusing on key aspects of the guideline including treatment decision-making and delivery at the time of suspected biochemical recurrence (BCR) after definitive radical prostatectomy (RP), radiation therapy (RT), and focal therapy, including for local and regional recurrence and oligometastasis. Here’s a synopsis of some key points:

When to Consider Salvage RT

Clinicians and patients should consider salvage RT when the PSA is 0.5 ng/mL or less for greater effectiveness. For high-risk patients, RT can be considered at a PSA less than 0.2 ng/mL. High-risk features include Grade Group 4-5, stage pT3b-4, positive surgical margins, node-positive disease, short PSA doubling time (PSADT), early PSA recurrence including persistent detectable PSA after RP, and higher post-surgery PSA. Genomic classifier risk and PET imaging findings also may considered. Clinicians may obtain ultrasensitive PSA after RP for patients with high-risk features, but they should confirm a rising trend in PSA before commencing therapy.

Clinicians may obtain a PSMA PET scan instead of conventional imaging or after negative results to identify clinical recurrence. Pelvic MRI may be used with PET/CT for evaluation of local recurrence. Next generation molecular PET imaging should be used when planning RT. Radiation to the salvage prostate bed and diseased pelvic nodes should be in the plan, even if PET/CT imaging is negative.

Clinicians should inform patients that salvage RT after RP poses inherent risks to urinary control and erectile and bowel function.

Nonmetastatic BCR After Surgery

For patients with high-risk features such as node-positive disease, offer androgen deprivation therapy (ADT) at a minimum of 4-6 months and up to 18-24 months with salvage RT. Use expanded radiation fields that include the regional lymph nodes. Do not add docetaxel. Patients without high-risk features can undergo RT alone. Intensified androgen receptor suppression (eg, abiraterone acetate, enzalutamide, apalutamide, and darolutamide) should be used for patients without nodal disease only within a clinical trial setting.

Clinicians should discuss ADT and RT side effects with patients and their influence on medical comorbidities. Applying RT to regional lymph nodes may increase the risk of side effects.

Nonmetastatic Recurrence After RT, Focal Ablation

For BCR after primary RT or ablative therapy, clinicians should perform a prostate biopsy to evaluate patients for local recurrence amenable to local salvage therapy. If clinical recurrence is confirmed, clinicians should offer patients the choice of RP, cryoablation, high intensity focused ultrasound (HIFU), or reirradiation during shared decision-making. For BCR after focal ablation, clinicians should offer whole gland treatment by RP or RT.

Regional Recurrence

In patients with pelvic nodal recurrence following primary RP, clinicians should offer ADT plus salvage RT to the prostate bed and pelvic lymph nodes. For pelvic nodal recurrence following primary RT, clinicians should offer salvage pelvic nodal RT plus ADT. Salvage pelvic lymphadenectomy is possible but has uncertain benefit in this setting.

For regional or metastatic oligorecurrence following primary RP or RT, clinicians may perform metastasis-directed therapy using stereotactic ablative radiation therapy after weighing the risk of toxicity against the potential benefits.

For patients with nonregional disease on PET/CT (but no visible disease on conventional imaging), clinicians may omit salvage RT to the prostate bed and discuss the uncertain role of systemic therapy.

Future Considerations

Studies investigating the ability of prostate-specific membrane antigen PSMA PET/CT to optimize patient selection and guide radiation planning for locoregional recurrences will be completed soon. Efforts are underway to optimize use of systemic therapies, particular suppression of androgen receptor activation, for example, using genomic classifiers. Studies are underway looking at the use of intensified androgen suppression during salvage RT.

“Continuous and deliberate efforts for multidisciplinary care in prostate cancer will be required to optimize and improve the oncologic and functional outcomes of patients treated with salvage therapies in the future,” the panel wrote.

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First-line immuno-oncology (IO)-based regimens and intensive focal therapies are associated with significantly prolonged overall survival (OS) among patients with brain metastases from renal cell carcinoma (RCC), new findings suggest.

In a real-world study, median OS was 32.7 months for patients who received first-line IO-based combination regimens compared with 20.6 months for those who received tyrosine kinase inhibitor (TKI) monotherapy, Kosuke Takemura, MD, of the Tom Baker Cancer Centre at the University of Calgary in Alberta, Canada, and colleagues reported in European Urology. Patients who received intensive focal therapies with stereotactic radiotherapy or neurosurgery have significantly longer OS compared with those who receive whole-brain radiotherapy alone or no focal therapy (31.4 vs 16.5 months).

On multivariable analysis, IO-based regimens were significantly associated with a 51% reduced risk for death compared with TKI regimens. Stereotactic radiotherapy or neurosurgery was significantly associated with a 52% lower risk for death compared with whole-brain radiotherapy alone or no focal therapy.

IMDC favorable- or intermediate-risk disease was significantly associated with a 60% lower risk for death compared with poor-risk disease.

The findings are from an analysis of data from the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC). Of 4799 patients with metastatic RCC, 389 (8.1%) had brain metastases at initiation of systemic therapy. The goal of the study was to define the clinical effectiveness of modern multi-modal cancer treatment for patients with brain metastases from RCC. The investigators did not probe the causal pathways between treatments and outcomes. 

The study included patients who received first-line IO-based combination therapy (nivolumab/ipilimumab, pembrolizumab/axitinib, avelumab/axitinib, nivolumab/cabozantinib, pembrolizumab/lenvatinib, or atezolizumab/bevacizumab) or TKI monotherapy (sunitinib or pazopanib) and had data available on brain metastases before initiation of systemic therapy. Of the 389 patients, 99 (25%) received IO-based regimens.

The patients with brain metastases were more likely to be younger (63 vs 65 years) and to have lung metastases (80% vs 67%), spleen metastases (2.0% vs 0.8%), and multiple sites of metastases (96% vs 80%). The group with brain metastases had a shorter median OS compared with patients without brain metastases (22.8 vs 34.7 months).

The study was limited by its retrospective design and absence of data on PD-L1 expression or intracranial/ extracranial disease status.

“This is a very important study and highlights that this patient population should be considered as the focus of future innovative clinical trials, and there definitely should not be an exclusion simply because they are not anticipated to have a favorable outcome,” said genitourinary surgical oncologist Philippe E. Spiess, MD, assistant chief of surgical services and high-volume kidney cancer surgeon at the Moffitt Cancer Center in Tampa, Florida. “Up until this point, these patients were never eligible for clinical trial participation, as it was thought they would do poorly, but now with promising outcomes with new treatment combinations along with site-directed brain radiation, our clinical approach to these patients needs to adapt to one offering more hope and personalization.”

In addition, the morbidity and mortality of these therapeutic modalities are improving, he said, “and now our focus should be in knowing which of these systemic therapies when used in combinations along with radiation [therapies] can offer a curative potential to a subset of patients.”

Scott S Tykodi, MD, PhD, Director of Kidney Cancer Research at the University of Washington’s Fred Hutchinson Cancer Center in Seattle, said the real-world data used in the study are informative because the outcomes are likely closer to what is seen in the clinic versus clinical trial results, which usually exclude patients with comorbidities and unfavorable disease presentations like brain metastases.

"The trends observed in the IMDC data are consistent with our expectations that front-line IO-based regimens are better than TKI monotherapy, and an oligometastatic pattern of brain metastases amenable to surgery or stereotactic radiation is a better prognosis than widespread disease managed by whole brain radiation or no localized therapy at all," Dr Tykodi said. “While this study reinforces our usual treatment patterns, it also confirms the survival penalty associated with brain involvement by the metastatic disease burden.”

Marc A. Bjurlin, DO, MSc, Director of Clinical Trials at the Lineberger Comprehensive Cancer Center at the University of North Carolina, Chapel Hill, North Carolina, said the new study provides a context in which clinicians can better counsel patients with RCC brain metastases in terms of expected OS by taking into account both focal therapy options and systemic therapy.

The IMDC database enabled investigators to capture a broad selection of clinically important and informative variables in a cohort of patients with a relatively long follow-up, Dr Bjurlin said. He pointed out, however, that there is a selection bias in that only patients who were suitable for stereotactic radiotherapy or neurosurgery were selected for those interventions, whereas those who were unable to receive these treatments due to such issues as the presence of more or larger tumors might have been steered toward whole brain radiotherapy.

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National Women in Medicine Day, celebrated earlier this month, “acknowledges the vital roles that female physicians play in patient care, medical research and leadership within the health care field,” according to the American Medical Association (AMA).1

Established on February 3, 2018, (on the birthday of Dr Elizabeth Blackwell, who became the first US woman to earn a medical degree in 1849), the Women in Medicine Day observance “underscores the importance of fostering gender diversity and equitable opportunities in the medical profession, ensuring that the legacy of pioneering women physicians endures,” states the AMA website.1

Despite the vital role played by women in today’s health care system, female physicians still face many challenges. These challenges were highlighted at the fifth annual Women in Medicine Summit, a continuing medical education conference hosted late last year by Women in Medicine (WIM), a Chicago-based nonprofit organization. Since then, WIM has also worked with Sheryl Sandberg, author of the best-selling book Lean In: Women, Work and the Will to Lead and the creator of the nonprofit organization Lean In, to create professional networking and mentoring groups for female physicians.

To mark Women in Medicine Day as well as International Women’s Day on March 8, this report offers highlights of the latest Women in Medicine Summit along with details of WIM’s newly created Lean In Circles and other initiatives aimed at empowering and advancing women in medicine.

"
Female physicians encounter gender bias from both other medical professionals and patients, which often manifests as an overall lack of respect for their expertise and accomplishments.

Addressing Systemic Challenges

The first Women in Medicine Summit was organized in 2019 by Shikha Jain, MD, an associate professor of medicine in the Division of Hematology and Oncology at the University of Illinois in Chicago. Dr Jain subsequently founded the Women in Medicine organization. After hearing many of her female colleagues tell stories about the challenges and barriers they had faced early in their careers — challenges that she herself had also faced — Dr Jain determined that many of these problems were systemic and needed to be identified and addressed as such. She noted that many of these pressures are even greater for female physicians with intersectional identities, such as women of color.

As Dr Jain explained, “We wanted women to have a space to come together and talk about challenges. We wanted to provide tools, education, and opportunities for people to work towards changing the systems within their own institutions and organizations while also pursuing professional development and personal growth.”

Systemic challenges that still affect women in medicine include:

Gender Bias

Female physicians encounter gender bias from both other medical professionals and patients, which often manifests as an overall lack of respect for their expertise and accomplishments. Gender bias is often expressed unconsciously. For example, women in medicine are less likely to be called by their professional titles than are men. This under-use of titles and differential use of formality can influence perceived competence and authority.2 Various forms of gender bias can also indirectly contribute to the experience of imposter syndrome among women and even to physician burnout.3

Sexual Harassment

Awareness of sexual harassment as a problem in the medical field has grown over the past several years, yet incidents still occur. Dr Jain pointed out that the current systems do a poor job of holding harassers accountable; women who report harassment are often the ones who end up penalized. Trainees and young career professionals may especially be afraid to report harassment, fearing possible career retaliation, and offenders with the highest status are often the most protected.4

Balancing Career and Family

Another ongoing challenge for women is balancing their career responsibilities with their personal obligations, such as caring for children and aging parents. Institutions and workplaces differ in terms of the support and flexibility allotted to women during pregnancy and breastfeeding. Even beyond that, women often end up taking on more household and family responsibilities compared to their male counterparts.

Dr Jain pointed out that after a woman has a child, people sometimes make certain assumptions – such as thinking that motherhood will ultimately limit the woman’s career growth and options. These assumptions often affect the advice and opportunities offered — or not offered — to women who are both physicians and mothers. It should not be assumed that women with children can’t or shouldn’t take on demanding career roles, Dr Jain stressed; women should have the opportunity to make their own choices about how to best manage their professional and personal lives.

Compensation and Career Paths

Relatedly, salary gaps persist for women in every medical specialty. It’s not clear to what extent this is mediated by the different financial effects of parenthood on women compared with men, but the effect seems to persist even after accounting for factors such as maternity leave and part-time hours.5 Some evidence suggests that, on average, female physicians more often provide preventive care, perform more psychosocial counseling and patient-centered communication, adhere more closely to clinical guidelines, and provide care with better overall patient outcomes.6 Yet female physicians are sometimes not compensated for many of the activities that improve both patients’ experience and overall outcomes, like responding to patient online questions, spending more time on documentation, or helping with diversity, equity, and inclusion (DEI) initiatives.7

Women are now graduating from medical school at slightly greater numbers than men, although some specialty areas are still somewhat male dominated, such as orthopedics or neurosurgery. However, at the highest levels of medicine, women are significantly underrepresented compared with men — for example, as deans, department chairs, or full professors in academic medicine.8 This disparity may be partly because promotions are determined more by factors such as grants obtained and less by other factors that are also important to women, such as mentorship, volunteering, and advocacy work.

Sponsorship Is Key

One of the reasons Dr Jain wanted to found the Women in Medicine Summit and WIM nonprofit was to provide more opportunities for mentorship and sponsorship. Mentorship is key for providing guidance on specific career development steps, said Dr Jain, but sponsorship is also critical and is often absent for many women. Sponsorship goes one step further than mentorship: a sponsor actively advocates for the person being supported. For example, a sponsor may recommend someone for an opportunity in a hospital, and then mentor the person to succeed in that role, or nominate someone for an award or a position at a national organization.9,10

New Power to Create Change

Female physicians can best tackle these and other challenges by working collaboratively, said 2023 WIM Summit Keynote Speaker Megan Ranney, MD, MPH, an emergency physician, dean of the Yale School of Public Health, and an advocate for innovative approaches in public health. Collaborative efforts can improve an individual’s sense of empowerment and control, which in turn protects against burnout and promotes resilience, she noted. “We can’t control so many things, like viruses that emerge, or actions of the CEO at our hospital, but we can control the coalitions we make,” Dr Ranney said.

By working collectively, physicians and other advocates can achieve what otherwise would not be possible. This is part of the concept of “New Power,” an understanding of power that defines it as being open, participatory, and peer-driven — where power is shared with many, rather than hoarded by a limited few, and channeled for good.11 The “New Power” concept was detailed in the 2018 book New Power: How Power Works in Our Hyperconnected World — and How to Make It Work for You, by Jeremy Heimans and Henry Timms.

“Old Power” models are often authoritarian, competitive, exclusive, formal, and rooted in longstanding institutions, Dr Ranney explained. In contrast, “New Power” is more informally governed as well as more inclusive, collaborative, and transparent, and sometimes more temporary in nature, depending on the specific situation. Dr Ranney noted that this “New Power” approach is very consistent with the way many women intuitively come together and collaborate to solve problems.11

Although using “New Power” models can be very effective, “Old Power” and “New Power” systems exist on a continuum, and it’s critical to be realistic about working with existing structures. “As women in medicine, we are inherently living in an “Old Power” world, and we still need to follow “Old Power” structures,” Dr Ranney stressed.

To illustrate how “New Power” models can scaffold onto “Old Power” structures, Dr Ranney talked about her involvement with the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM). In 1996, a congressional spending bill rider prohibited use of Centers and Disease Control and Prevention (CDC) funds for advocating or promoting gun control. In the 20 years that followed, research on firearm prevention ground almost to a halt. In contrast to other public health problems — such as car crashes or HIV deaths — which had improved with the aid of public health research and investment, the rate of firearm deaths was not improving. Dr Ranney said she was urged to stay away from this topic, as it would pose a problem for her career.

Determined to not let the issue drop, Dr Ranney instead connected with others who began talking about the topic publicly via social media and professional publications. When the National Rifle Association (NRA) sent a tweet criticizing “anti-gun” doctors for not “staying in their lane,” it set off an avalanche of tweets, in which many people both inside and outside the medical community shared their personal stories of gun violence.12,13 Eventually this work led to attention from “Old Power,” leading to over 75 million dollars over 3 years in monetary appropriations from the federal government, with additional donations from philanthropic organizations.

After AFFIRM achieved its initial aim of getting funding from the federal government, group leaders decided to merge with an “Old Power” organization, the Aspen Institute, in order to most effectively use resources. This example illustrates the fluidity of “New Power” movements and the potential need for such movements to scaffold onto existing “Old Power” structures as part of the change-making process.

“We want to organize and empower and work with inclusive communities, but for us to create true impact, we often need to work with universities or politicians or hospitals or the supply chain or other ‘Old Power’ institutions,” Dr Ranney explained.

Other Women in Medicine Initiatives

In addition to its annual summit, the Women in Medicine organization offers other leadership development and education opportunities for both women and male allies, a research lab to promote investigation into relevant topics, as well as a speakers’ bureau of that connects women in medicine with speaking opportunities.  

The 2023 Summit also was the launch point for WIM “Lean In Circles,” formed through a partnership with Sheryl Sandberg’s Lean In organization. Through these Lean In Circles, small groups meet virtually or in-person on a regular basis to share skills, expertise, and inspiration. A number of circles are now meeting on an ongoing basis, and opportunities are still available to found new circles (with the help of training and support from WIM) and to join existing circles.

The Lean In Circles offer a way for women in different fields or areas to collaborate, said Dr Jain. Different circles may have the goal of bringing together specific types of professionals, people from a particular locale, or individuals with certain common interests. This format “creates great opportunities for women to learn from each other, grow their networks, and potentially even help [one another] with professional advancement,” said Dr Jain.

WIM has also launched an auxiliary council, providing women across the country with more opportunities to take on leadership positions and plan events in their respective communities. Later this year, WIM is also launching an online social networking platform for female physicians. As Dr Jain explained, “We wanted to create a safe space for women physicians to have a social and professional network along with educational content.”

The sixth annual Women in Medicine Summit will take place September 13 to 14, 2024, in Chicago.

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