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A recent federal cybersecurity advisory is urging health care providers to immediately adopt phishing-resistant multi-factor authentication (MFA) for all administrative access. Providers should put systems in place that verify implementation of new sign-in procedures, implement network segregation controls, and change and remove or deactivate all default credentials.
The advisory was issued by the Cybersecurity and Infrastructure Security Agency (CISA), which conducted a Risk and Vulnerability Assessment (RVA) last year to identify vulnerabilities and areas for improvement. An RVA is a 2-week penetration test of an entire organization, with 1 week spent on external testing and 1 week spent assessing the internal network. As part of the RVA, the CISA assessment team conducted web application, phishing, penetration, database, and wireless assessments. The team assessed a large organization deploying on-premises software.
During the 1-week external assessment, the team did not identify any significant or exploitable conditions in externally available systems. The assessment team was unable to gain initial access to the assessed organization through phishing. During internal penetration testing, however, the team exploited misconfigurations, weak passwords, and other issues through multiple attack paths to compromise the organization’s domain.
In coordination with the assessed organizations, CISA is releasing a new Cybersecurity Advisory (CSA) detailing the RVA team’s activities and key findings to provide network defenders and software manufacturers with recommendations to improve organizations’ and customers’ cyber posture.
“The threat is greater than ever,” said Tamer Baker, a specialist in cybersecurity and the Healthcare Chief Technology Officer at Zscaler, which has its headquarters in San Jose, California. More than 100 million people and 500 hospitals in the United States alone have been impacted by breaches just in 2023, he said.
IT security equals patient security, Baker said. The average financial impact of a health care breach is now $11 million, which far exceeds the spending required to get proper security, according to Baker. “The advisory is long overdue; however, it is still not enough,” he said. “What’s needed is going to be more along the lines of what the state of New York has been leading the charge with. They are not only going to be putting in more regulations and requirements with some enforcement, but are also providing funding to help health systems achieve these goals.”
Impact on Patient Care
Cyberattacks adversely impact patient care in a serious way, and have been associated with extended hospital stays and increased mortality. “According to a national study conducted by Ponemon Institute, these cyberattacks have led to 56% longer hospital lengths of stay and 53% increase in mortality rate,” said Baker, who assists health care organizations, state and local governments, and educational institutions in their digital transformation efforts. Cyberattacks in just the last 12 months have caused thousands of patients to be transferred or diverted to other facilities. The attacks were associated with delays in procedures and tests, increased complications and poor outcomes.
From a user credential perspective, MFA is a good first step, but not enough, according to Baker. Bad actors have found several ways to get through MFA using vectors like MFA-bombing as an example. This is a social engineering cyberattack strategy whereby attackers repeatedly push second-factor authentication requests to the target victim's email, phone, or registered devices. “We need to stop users from ever reaching phishing sites to begin with,” he said. “A big step will be to have security in place which blocks phishing attempts no matter if the user is on-network or off-network (working from anywhere).”
CISA encourages health care providers who are deploying on-premises software, as well as software manufacturers, to apply the recommendations in the mitigations section of the CSA in the new advisory. It is hoped that these recommendations can harden networks against malicious activity and reduce the likelihood of domain compromise.
Offline Security Systems
“A way to stop attacks directly on applications and infrastructure is to just remove them from the internet,” Baker said. “Hide these applications and infrastructure behind a security cloud so the bad actors can’t even find them on the internet. This same security cloud can connect your users to the applications securely.”
In addition to applying the newly listed mitigations, CISA recommends exercising, testing, and validating an organization’s security program against the threat behaviors mapped out in the advisory.
Frank Nydam, the CEO of Tausight, health care’s first AI-powered data security company, said health care providers remain a prime target of cybercriminals, and there is no sign of this trend abating. In the first 6-months of 2023 alone, he said, 325 covered entities reported data breaches to the US Department of Health and Human Services Office for Civil Rights (OCR). This represents an 86% increase from the same period in 2022. “Not only have cyberattacks become more frequent, but they have also become more costly, both from a financial perspective and a patient outcome perspective,” Nydam said.
Mostly Basic Cyber Hygiene
Many health care providers may think they need multiple layers of advanced tools, but Nydam said most of the time all about the fundamentals: “Basic cyber hygiene and understanding where your data are. That’s critical and often overlooked.” These strategies include regular patch updates for vulnerabilities, basic device encryption, monitoring business associates for their access to your data, and following strict access management practices like MFA. Common mistakes include failing to put a cyber response playbook in place,” Nydam said.
Other common oversights include not encrypting and patching machines, and not having proper data recovery systems in place. The most important items on a to-do list can be summarized simply. “Start cleaning up your house,” he said. This includes a data assessment to understand where your sensitive data lives, Nydam said. “House-cleaning steps like this can significantly reduce the attack surface, so that when a cyberattack does occur, it impacts far fewer patients.”
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Clinically significant prostate cancer is found in a “non-negligible” number of men who have screening PSA levels of 1.8 or higher but less than 3.0 ng/mL, according to recent study findings. It remains unclear, however, if a delay in the diagnosis of these cancers until PSA levels rise to 3.0 ng/mL would lower the likelihood of cure.
The findings are from the population-based Göteborg-2 screening study. Among 17,974 participants, 6006 men with a median age of 55.9 years were included in the current analysis. Of these, 82% had a PSA level less than 1.8 ng/mL, 11% had a PSA level of 1.8 or higher but less than 3 ng/mL (low-PSA group; median PSA 2.1 ng/mL), and 6.3% had a PSA level of 3 or higher but less than 10 ng/mL (high-PSA group; median PSA 3.9 ng/mL). Another 0.5% had a PSA level of 10 ng/mL or higher. Patients in the low-PSA group were recommended to undergo magnetic resonance imaging (MRI). Men with positive MRI findings had 4 targeted biopsies from each MRI-visible lesion.
Prostate cancer was found in 64 patients (41%) with positive MRI findings in the low-PSA group, the investigators reported in European Urology. Of these, 33 (21%) had Gleason 6 tumors (insignificant cancer) and 31 (20%) had Gleason 7 or higher tumors (significant cancer). In the high-PSA group, prostate cancer was detected in 61 patients (56%), including 26 (24%) with Gleason 6 tumors and 35 (32%) with Gleason 7 or higher tumors.
“These results are in-line with previous knowledge of prostate cancer incidence at low PSA levels” said study corresponding author Fredrik Möller, MD, of Skövde Hospital in Skövde, Sweden.
He added, “Our study indicates that MRI could be used as a selection tool to reduce prostate cancer overdiagnosis at lower PSA values, but would lead to a large increase in MRI [use]. We hope our future planned study comparing PSA cutoff of 3 ng/mL to a PSA cutoff of 1.8 ng/mL will show robust evidence regarding the benefits and harms of a lower PSA cutoff as an indication for MRI.”
Due to the limited sensitivity and specificity of PSA screening, it has been proposed that MRI be part of first-line screening for prostate cancer. However, the high costs, limited availability, and large inter-reader variability are significant barriers.
The main strength of the current study is its large, population-based design with a relatively high participation rate. “The results should therefore be generalizable to a screening situation,” Dr Möller said. “The main limitations are the relatively young age group and results that are based on a single screening round and lack follow-up so far.”
Despite the strengths of the study, an important question remains as to whether the lead time in diagnosing these cancers (PSA 1.8 or higher versus PSA 3-10 ng/mL) has a major impact on outcomes, said Aly-Khan Lalani, MD, an assistant professor in the department of oncology at McMaster University in Hamilton, Ontario, Canada, who was not involved with the study.
“The larger point is that population-based screening, with rational guidance of when to leverage adjunctive tests and thereby risk stratify patients, will help ensure the most patients who warrant treatment are caught early,” Dr Lalani said. “By balancing this concept and also limiting overdiagnosis or excessive invasive testing, we can seek to provide survival benefits for our patients.”
Michael Whalen, MD, an associate professor of urology and chief of urologic oncology at George Washington University in Washington DC, noted that the number of positive MRI findings in the low-PSA group (25%) was surprisingly quite similar to the rate of positivity in the high PSA (3-10 ng/mL) group (31%). “However, significant cancer detection rates in the low-PSA group were about half of that in the high PSA group,” Dr Whalen said.
He pointed out that 37,887 men were invited to participate in the study, but only 17,806 opted to do so and 6006 were included in the current analysis. “Compared to other screening trials, this number is actually very low. The European Randomized Study of Screening for Prostate Cancer (ERSPC) trial included about 182,000 men, and the Prostate, Lung, Colorectal, and Ovarian (PLCO) trial in the United States included about 76,000 men. “Thus, the generalizability of the findings may be limited,” Dr Whalen said.
The study had a high biopsy compliance rate, so disease detection rates should be accurate, Dr Whalen said. Also, there was pathologic consensus from 3 different experienced uropathologists. “Although racial demographics were unpublished, it is likely predominately a Caucasian population,” he said. “How the lower PSA threshold of 1.8 ng/mL applies to a population with a higher proportion of African American men is unclear. Also, the influence of family history on acceptable PSA threshold was not explored.”
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It is well known that chronic kidney disease (CKD) has an impact on many body systems. Perhaps underappreciated is the link between the kidney and the thyroid. Increasing understanding of the relationship between the kidney and thyroid offers a largely unexplored opportunity to improve management of patients with CKD, in whom thyroid problems are frequently under-recognized.
An estimated 20 million Americans have some type of thyroid disease. Disconcertingly, it is also estimated that 60% of those with a thyroid condition are unaware of it.1 With regard to CKD, subclinical hypothyroidism has been found to increase from 7% to 17% in people whose glomerular filtration rate (GFR) drops to 60 mL/min/1.73 m2 from 90 mL/min/1.73 m2 or higher.2 Recent research indicates that subclinical hypothyroidism can be considered an independent predictor of CKD in the general population, even when adjusting for other common risk factors such as age, hypertension, and obestiy.3
What is this relationship between the kidney and the thyroid? The effects of poor thyroid function on the kidney are widespread, including reduced renin-angiotensin-aldosterone system (RAAS) activity, reduced GFR, and decreased heart rate and cardiac output that leads to diminished renal blood flow and ischemic kidney injury.4 CKD is thought to negatively impact thyroid function through multiple pathways. One such pathway is reduced expression of 1 5’-deiodinase that leads to decreased conversion of T4 to T3. Indeed, the most common finding is not an elevated TSH, but low T3.2 However, TSH is the most common and typically only laboratory measure used to assess thyroid function, which can result in underdiagnosis of thyroid disease. This is significant because it is estimated that GFR is reversibly reduced by about 40% in more than half of adults with hypothyroidism.4
Providers can improve CKD care by:
- Regularly screening for thyroid issues by ordering a full thyroid panel. Because TSH is not a reliable marker of thyroid issues in patients with CKD, a full thyroid panel including TSH, free T3, Free T4 and TPO antibodies would be more informative. It is important to recheck thyroid function as GFR changes as well.2
- Considering patient symptoms. Subclinical hypothyroidism is common in those with CKD, which may mean laboratory values look normal but patients present with common hypothyroidism symptoms like cold intolerance, fatigue, brain fog, hair loss, joint and muscle pain, increased cholesterol and triglycerides, unintentional weight gain or difficulty sleeping.5 These symptoms can be common in CKD due to anemia or other common coexisting conditions, so testing is important to properly identify the root cause.
- Ensuring adequate micronutrients and amino acids. T4 to T3 conversion and thyroid function require several micronutrients, such as zinc, iodine, selenium, choline, iron, folate, and essential amino acids. This is an important consideration if the patient is on a T4-only thyroid medication or on a low-protein or plant-based diet.6 A dietitian can play an important role in assessing nutrient need, guiding diet changes and recommending appropriate supplements.
- Managing stress. Cortisol can inhibit conversion of T4 to T3 and actually increase conversion of T4 to reverse T3.7 While stress management support is not a typical responsibility of nephrology providers, providing tools or referrals to support patients is appropriate. Measures that can reduce stress include meditation, counseling, and vagus nerve stimulation.8
Thyroid disease is under-recognized in many individuals. Because thyroid disease can affect kidney health (and vice versa), nephrology providers are uniquely poised to investigate and identify thyroid issues. As with many connected issues in CKD, nephrology providers need not shoulder the responsibility of treating thyroid disease, but refer out to dietitians, endocrinologists, and other appropriate providers to ensure the patient is getting the best care possible. It is not fully understood how much of an impact supporting thyroid health can have for those with CKD, but with a few simple proactive steps providers can begin to see possibilities.
Lindsey Zirker MS, RD, is a renal dietitian and Director of Clinical Services for the Kidney Nutrition Institute in Titusville, Florida. She specializes in autoimmune kidney disease and advanced practice medical nutrition therapy for people with kidney disease.
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“Don’t ever arrive empty-handed,” my older sister advised me about the etiquette of gift-giving after I graduated college. Beyond the more obvious expectations with birthday parties, she recommended that whenever invited to a barbecue or a dinner party, I should bring a small token of my appreciation of the host’s generosity of the invitation. Although to my young brain she made it sound like a rule, she was describing existing norms that guide social behavior. These norms are not necessarily uniform by culture or country, and they have their exceptions, but they serve a useful role in maintaining social cohesiveness. Given this, it is not unusual that gift-giving from patients may sometimes confound both patients and their physicians.
There are ethical considerations that help inform the potential challenges of gift-giving in a professional setting. (In some states and hospital systems, there may be laws that relate to accepting gifts from patients.) First, the relationship between patient and physician is bound by norms of professional behavior in part because it is ethically distinct from other social relationships. Physicians have an ethical and professional obligation to put patient’s interests above their own. This concept of patient primacy animates the entirety of how physicians care for patients and helps to promote care that is guided not by the physician’s personal interests (e.g., financial, moral, etc.) but by what is primarily in the patient’s best interest.
This so called “frame” of the physician-patient relationship helps create boundaries that advance the goals of medical care by promoting the patient’s interests and avoiding patient exploitation. The most recognizable and easily appreciated boundary is the violation that occurs when a physician has a sexual relationship with a current patient. This violation is so problematic that in some states, for some types of physicians, it has legal consequences for licensure. From an ethics perspective, the prohibition on sexual relationships with patients is based on the inherent power differential and potential for exploitation that exists in the physician-patient relationship. Physicians must not exploit the vulnerability of being a patient to serve their own personal interests.
Second, the physician-patient relationship is not simply transactional. Although there is insurance and potentially co-pays for services rendered, the basis for the relationship is fiduciary. Patients trust that their physician will care for them without regard to who they are, what illness they have, or whether they give gifts. Therefore, the physician should be mindful of the patient’s motivation behind the gift-giving to evaluate when it appears to be primarily transactional. Does this patient believe that unless they provide the physician with a gift, the physician will not give them the time, attention, or individualized are they need? In this case, it is the physician’s responsibility to assure the patient of the fiduciary nature of their relationship and remind them that their care is never contingent on the provision of gifts.
Gift-giving is not likely to violate the same boundaries as a sexual relationship, but the ethical considerations in maintaining appropriate boundaries still applies. Furthermore, there are situations when gift-giving from a patient would be completely appropriate. From a patient’s perspective, gift-giving is often an entirely normal part of social interaction when showing appreciation. So how should clinicians approach this problem when confronted with a gift from a patient?
Questions to Consider
First, clinicians should consider the ethics principles previously described and how they apply to a particular situation. Would accepting the gift be in the patient’s best interests? Does accepting the gift promote the physician’s interests far beyond the patients? Would accepting this gift contribute to or give the impression of exploitation? What are the patient’s potential motivations in giving this gift? The answers to these questions in specific scenarios may depend significantly on the context, suggesting that gift-giving would be ethically justifiable in some cases but not in others.
For example, it is unlikely to be ethically problematic for a physician to accept a patient’s gift of baked goods during the holiday season as a token of the patient’s appreciation. Accepting a relatively inexpensive gift is not likely to exploit the patient and can promote the patient’s best interests by showing appreciation for the thoughtfulness of the gesture. In other words, rejecting a modest gift provided when gifts might normally be exchanged is more likely to harm the physician-patient relationship.
Size of the Gift Matters
Alternatively, a patient who wishes to bequeath their physician with a sizable fortune after their death is likely to be ethically (and potentially legally) problematic. The size of the gift is far beyond a customary show of appreciation for the physician’s care and services. Accepting such a gift would overwhelmingly promote the physician’s interest and would raise concerns that it is exploitative. The motivation behind such a gift would be important to more fully understand. When an appreciative patient wishes to support a physician’s clinical care or research with an estate gift, the donation should be negotiated and managed through an institutional development office which minimizes the potential ethical conflict with the individual physician.
The more challenging cases may be somewhere in the middle of these extremes. Perhaps a patient wishes to gift their physician with expensive tickets to a sporting event or the arts. Again, physicians should discuss with the patient the principles above, trying to understand the patient’s motivation, assuring patient primacy, being mindful of potential exploitation, and assessing what the effect will be on the treatment relationship of accepting the gift. Depending on the answers to those questions, declining a gift might be as simple as saying, “I appreciate this lovely and thoughtful gesture. I can’t accept such large gifts from my patients.” Accepting the gift might be as simple as saying, “Thank you for such a special gift,” and then remaining mindful of maintaining professional boundaries going forward.
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