Opinion

The dopamine receptors of the brain get their fair share amid the didactics we receive in residency. From discussions of antipsychotics and schizophrenia to stimulants and ADHD, dopamine plays a key role. Depending on the program and interest of faculty, methamphetamine may get its own lecture or be mixed in with other stimulants of abuse. During that discussion, a comment might be made in passing on the impact of methamphetamine on sexual desire and activity.

Experiences in the emergency department caring for patients who are intoxicated from methamphetamine then effectively make up for any gaps in trainees’ knowledge base. From patients engaging in self-pleasing pursuits in the emergency room to unfiltered reports of sexual exploits and desires, the impact of methamphetamine on sexual behavior quickly becomes apparent. Those experiences are later reinforced when residents are exposed to more long-term rehabilitation programs and have more in-depth conversations with patients about the sex-culture surrounding methamphetamine.

It is common to hear that, under the influence of methamphetamine, any available body will become an acceptable sexual partner – at times resulting in significant regrets, dangerous sexual activity, and complicated questions surrounding consent. Some early studies have found up to 72% increase in risky sexual behavior in methamphetamine users.¹ This is particularly problematic as society has recently taken on the difficult and important work to re-examine the role and nature of consent in sexual activities. This falls within the larger #MeToo movement and has led to advocating for harsher sentencing of sexual offenders.

Yet simultaneously, society has also reconsidered its approach to apportioning blame on drug users.² This shift to a more compassionate stance has resulted in a desire to treat and care for a disorder, rather than punish and condemn a poor choice. As forensic psychiatrists, we have noted this significant change. Where substance use disorders were once considered a risk factor for recidivism, they are now considered a disability that not only warrants treatment but can also diminish the share of blame one may be responsible for.

The convergence of those two societal movements often plays out in the courtroom, and in our experience when faced with those two opposing viewpoints, triers of fact (judges and juries) often favor punishing sexual offense over empathizing with an addictive disorder. While certainly not implying methamphetamine use condones sexual offense, we do posit the particular relationship between methamphetamine use and sexual activity should be explained to those entrusted with deciding guilt.

Examples of such problems are extremely common. A routine case involves IK,³ a 48-year-old male without significant history of legal problems, arrested for indecent exposure. His history of mental illness is closely intertwined with a history of substance use, leading to many psychiatric hospitalizations for methamphetamine-induced psychosis. After many hospitalizations he was placed in an assertive community treatment (ACT) team.

One day, IK is approached by an industrious drug dealer who frequents multiple board-and-cares in search for customers interested in relapsing. IK uses methamphetamine and within hours finds himself having walked miles away, naked, in the middle of an RV park. He subsequently describes the experience of unrelenting sexual desire, accompanied by ideas of reference involving billboards encouraging him to demonstrate his sexual prowess, as well as auditory hallucinations of women cheering him on. This leads to him pleasing himself publicly and his subsequent arrest.

Interviewing IK, 3 months later, he is embarrassed and apologetic. He is cognizant of the inappropriate nature of the incident and the foolishness of his actions. However, when asked whether he considers himself a sexual offender, he protests that he would never act in such a manner if not under the influence of methamphetamine. He points to his lack of significant sexual urges when sober, his lack of prior sexual offense, his lack of sexually violent offense, and his lack of unusual sexual interests.

It is unclear to us how society will or should adjudicate on such a case. It is not under the purview of forensic psychiatry to become a trier of fact. However, psychiatry should have a better working framework of how to discuss and conceptualize such situations, especially considering the dire consequences for those involved.

While any criminal conviction already has the potential to destroy a person’s life, sexual crimes bring particularly serious consequences. Entry into the national sex offender registry, in addition to carrying an unshakable stigma, comes with additional degrees of lost freedom. These individuals are prohibited from living or working in areas that have children in proximity, subjecting them to the outskirts of society and greatly restricting any chance of economic escape from poverty. Parks, libraries, and shopping malls can become off limits. Privacy for these individuals is nonexistent; from websites they visit to where they travel physically can be monitored. Even where they live and a detailed physical description are often easily accessible by members of their community.

When should it be permissible to consider sex offender status for someone on the grounds of a mental illness? A patient with obsessive-compulsive disorder might have sadistic obsessions and compulsions to commit violent sexual acts, which, along with being repugnant to society, are entirely ego-dystonic to the suffering patient. Psychosis is often characterized as involving a loss of insight and impaired reality testing. If society accepts insanity as grounds to mitigate sentencing, then why not permit it for grounds to wave the designation of sex offender to those with certain disorders, including substance use disorder? Wherever we come down on this issue, it is a sad fact that in practically no other medical field can a person be sentenced for having a disease.

Should IK have to register as a sex offender? Regardless of the circumstances, he did publicly masturbate. Society has determined that public sexual displays are a crime worth carrying the pariah status of sex offender – why should an exception be made for methamphetamine use? On the other hand, it is difficult to claim that IK’s behavior was entirely of his own free will. Most triers of fact will have never experienced that amount of dopamine reward. They can’t attest to the remaining free will after experiencing more pleasurable salience and positive reinforcement than ever naturally possible.

How we deal with the behavioral consequences, and other sequelae, of methamphetamine use is a growing problem. Access to and use of methamphetamine is no longer reserved for soldiers patrolling the jungles of Vietnam. Once thought to be a scourge of the West Coast, methamphetamine is now widely available throughout the United States.⁴ The use of methamphetamine is likely to continue to expand as society keeps pursuing the decriminalizing of drug use. Psychiatrists practicing in areas heavily affected by methamphetamine see firsthand the burden it places on community resources in the form of increased psychosis, emergency room utilization, medical resource strain, and encounters with police.⁵

The presence of mental illness is tied to a small but statistically significant risk of violence. However, substance use is a well-established risk factor for violence.⁶ What is often missed is that many sexual offenders have not committed a violent offense. However, like IK, they have been charged with indecent exposure or other nonviolent sexual offenses, such as prostitution and solicitation. Those nonviolent offenses are driven by poor judgment and impulsivity, the trademarks of substance use. The answer cannot be to incarcerate, and eventually add to the sex offender registry, the growing number of these individuals.

Yet, as psychiatrists, we seem at a loss for how to treat these patients. The prescription of allowing them to spend a night in the ED with a complementary sandwich garnished with olanzapine often feels like enabling. Substance use treatment programs are too limited, and the wait list is rarely shorter than the time it takes our patient to purchase their next hit.

There are no effective pharmacologic treatments for methamphetamine use disorder.⁷ The recommendations of cognitive-behavioral therapy, family and group therapy, contingency management, and a 12-step program may be sufficient for the most motivated and well-supported patients but are inadequate for the vast majority.⁸ As much as we want to laud the merits of community psychiatry and the ACT [assertive community treatment] model of care, it is hard to carry that banner while confronted with the reality these patients face on a day-to-day basis during any shift in the emergency room. Eventually the countless encounters with homeless, helplessly meth-addicted patients ending in discharge back to the streets begins to tarnish the bright rhetoric surrounding community care, which starts to sound more and more like abandonment of patients to suffer in futility.⁹

It is not up to forensic psychiatrists, or even psychiatry as a whole, to fix the myriad of inadequacies surrounding how society handles those suffering from methamphetamine addiction. However, it is essential for psychiatry to study and educate society on the interaction of methamphetamine use and sexual behavior. There has been some exploration into other risk factors for paraphilic behavior while under the influence of substances, but there is a dearth of information on this topic. Establishing a nomenclature called “substance-induced paraphilia” might be a way to bring clarity to such instances in both a forensic and general psychiatric setting.

Dr. Compton is a psychiatry resident at University of California, San Diego. His background includes medical education, mental health advocacy, work with underserved populations, and brain cancer research. Dr. Compton has no conflicts of interest. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. He has no conflicts of interest.

References

1. Psychol Addict Behav. 2016;30(2)147-57.

2. Monitor Psychol. 2019;50(6).

3. IK’s case has been modified in certain ways to maintain confidentiality.

4. J Psychoactive Drugs. 2000;(2):137-41.

5. Acad Emerg Med. 2020 Nov;27(11):1116-25.

6. Swanson JW. Mental disorder, substance abuse, and community violence: An epidemiological approach, in: Monahan J and Steadman HJ, eds. “Violence and Mental Disorder: Developments in Risk Assessment” (Chicago: University of Chicago Press, 1994, pp. 101-36).

7. Addiction. 2004 Jun;99(6)708-17.

8. Am Fam Physician. 2007 Oct 15;76(8):1169-74.

9. Perspect Biol Med. 2021;64(1)70-81.

The dopamine receptors of the brain get their fair share amid the didactics we receive in residency. From discussions of antipsychotics and schizophrenia to stimulants and ADHD, dopamine plays a key role. Depending on the program and interest of faculty, methamphetamine may get its own lecture or be mixed in with other stimulants of abuse. During that discussion, a comment might be made in passing on the impact of methamphetamine on sexual desire and activity.

Experiences in the emergency department caring for patients who are intoxicated from methamphetamine then effectively make up for any gaps in trainees’ knowledge base. From patients engaging in self-pleasing pursuits in the emergency room to unfiltered reports of sexual exploits and desires, the impact of methamphetamine on sexual behavior quickly becomes apparent. Those experiences are later reinforced when residents are exposed to more long-term rehabilitation programs and have more in-depth conversations with patients about the sex-culture surrounding methamphetamine.

It is common to hear that, under the influence of methamphetamine, any available body will become an acceptable sexual partner – at times resulting in significant regrets, dangerous sexual activity, and complicated questions surrounding consent. Some early studies have found up to 72% increase in risky sexual behavior in methamphetamine users.¹ This is particularly problematic as society has recently taken on the difficult and important work to re-examine the role and nature of consent in sexual activities. This falls within the larger #MeToo movement and has led to advocating for harsher sentencing of sexual offenders.

Yet simultaneously, society has also reconsidered its approach to apportioning blame on drug users.² This shift to a more compassionate stance has resulted in a desire to treat and care for a disorder, rather than punish and condemn a poor choice. As forensic psychiatrists, we have noted this significant change. Where substance use disorders were once considered a risk factor for recidivism, they are now considered a disability that not only warrants treatment but can also diminish the share of blame one may be responsible for.

The convergence of those two societal movements often plays out in the courtroom, and in our experience when faced with those two opposing viewpoints, triers of fact (judges and juries) often favor punishing sexual offense over empathizing with an addictive disorder. While certainly not implying methamphetamine use condones sexual offense, we do posit the particular relationship between methamphetamine use and sexual activity should be explained to those entrusted with deciding guilt.

Examples of such problems are extremely common. A routine case involves IK,³ a 48-year-old male without significant history of legal problems, arrested for indecent exposure. His history of mental illness is closely intertwined with a history of substance use, leading to many psychiatric hospitalizations for methamphetamine-induced psychosis. After many hospitalizations he was placed in an assertive community treatment (ACT) team.

One day, IK is approached by an industrious drug dealer who frequents multiple board-and-cares in search for customers interested in relapsing. IK uses methamphetamine and within hours finds himself having walked miles away, naked, in the middle of an RV park. He subsequently describes the experience of unrelenting sexual desire, accompanied by ideas of reference involving billboards encouraging him to demonstrate his sexual prowess, as well as auditory hallucinations of women cheering him on. This leads to him pleasing himself publicly and his subsequent arrest.

Interviewing IK, 3 months later, he is embarrassed and apologetic. He is cognizant of the inappropriate nature of the incident and the foolishness of his actions. However, when asked whether he considers himself a sexual offender, he protests that he would never act in such a manner if not under the influence of methamphetamine. He points to his lack of significant sexual urges when sober, his lack of prior sexual offense, his lack of sexually violent offense, and his lack of unusual sexual interests.

It is unclear to us how society will or should adjudicate on such a case. It is not under the purview of forensic psychiatry to become a trier of fact. However, psychiatry should have a better working framework of how to discuss and conceptualize such situations, especially considering the dire consequences for those involved.

While any criminal conviction already has the potential to destroy a person’s life, sexual crimes bring particularly serious consequences. Entry into the national sex offender registry, in addition to carrying an unshakable stigma, comes with additional degrees of lost freedom. These individuals are prohibited from living or working in areas that have children in proximity, subjecting them to the outskirts of society and greatly restricting any chance of economic escape from poverty. Parks, libraries, and shopping malls can become off limits. Privacy for these individuals is nonexistent; from websites they visit to where they travel physically can be monitored. Even where they live and a detailed physical description are often easily accessible by members of their community.

When should it be permissible to consider sex offender status for someone on the grounds of a mental illness? A patient with obsessive-compulsive disorder might have sadistic obsessions and compulsions to commit violent sexual acts, which, along with being repugnant to society, are entirely ego-dystonic to the suffering patient. Psychosis is often characterized as involving a loss of insight and impaired reality testing. If society accepts insanity as grounds to mitigate sentencing, then why not permit it for grounds to wave the designation of sex offender to those with certain disorders, including substance use disorder? Wherever we come down on this issue, it is a sad fact that in practically no other medical field can a person be sentenced for having a disease.

Should IK have to register as a sex offender? Regardless of the circumstances, he did publicly masturbate. Society has determined that public sexual displays are a crime worth carrying the pariah status of sex offender – why should an exception be made for methamphetamine use? On the other hand, it is difficult to claim that IK’s behavior was entirely of his own free will. Most triers of fact will have never experienced that amount of dopamine reward. They can’t attest to the remaining free will after experiencing more pleasurable salience and positive reinforcement than ever naturally possible.

How we deal with the behavioral consequences, and other sequelae, of methamphetamine use is a growing problem. Access to and use of methamphetamine is no longer reserved for soldiers patrolling the jungles of Vietnam. Once thought to be a scourge of the West Coast, methamphetamine is now widely available throughout the United States.⁴ The use of methamphetamine is likely to continue to expand as society keeps pursuing the decriminalizing of drug use. Psychiatrists practicing in areas heavily affected by methamphetamine see firsthand the burden it places on community resources in the form of increased psychosis, emergency room utilization, medical resource strain, and encounters with police.⁵

The presence of mental illness is tied to a small but statistically significant risk of violence. However, substance use is a well-established risk factor for violence.⁶ What is often missed is that many sexual offenders have not committed a violent offense. However, like IK, they have been charged with indecent exposure or other nonviolent sexual offenses, such as prostitution and solicitation. Those nonviolent offenses are driven by poor judgment and impulsivity, the trademarks of substance use. The answer cannot be to incarcerate, and eventually add to the sex offender registry, the growing number of these individuals.

Yet, as psychiatrists, we seem at a loss for how to treat these patients. The prescription of allowing them to spend a night in the ED with a complementary sandwich garnished with olanzapine often feels like enabling. Substance use treatment programs are too limited, and the wait list is rarely shorter than the time it takes our patient to purchase their next hit.

There are no effective pharmacologic treatments for methamphetamine use disorder.⁷ The recommendations of cognitive-behavioral therapy, family and group therapy, contingency management, and a 12-step program may be sufficient for the most motivated and well-supported patients but are inadequate for the vast majority.⁸ As much as we want to laud the merits of community psychiatry and the ACT [assertive community treatment] model of care, it is hard to carry that banner while confronted with the reality these patients face on a day-to-day basis during any shift in the emergency room. Eventually the countless encounters with homeless, helplessly meth-addicted patients ending in discharge back to the streets begins to tarnish the bright rhetoric surrounding community care, which starts to sound more and more like abandonment of patients to suffer in futility.⁹

It is not up to forensic psychiatrists, or even psychiatry as a whole, to fix the myriad of inadequacies surrounding how society handles those suffering from methamphetamine addiction. However, it is essential for psychiatry to study and educate society on the interaction of methamphetamine use and sexual behavior. There has been some exploration into other risk factors for paraphilic behavior while under the influence of substances, but there is a dearth of information on this topic. Establishing a nomenclature called “substance-induced paraphilia” might be a way to bring clarity to such instances in both a forensic and general psychiatric setting.

Dr. Compton is a psychiatry resident at University of California, San Diego. His background includes medical education, mental health advocacy, work with underserved populations, and brain cancer research. Dr. Compton has no conflicts of interest. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. He has no conflicts of interest.

References

1. Psychol Addict Behav. 2016;30(2)147-57.

2. Monitor Psychol. 2019;50(6).

3. IK’s case has been modified in certain ways to maintain confidentiality.

4. J Psychoactive Drugs. 2000;(2):137-41.

5. Acad Emerg Med. 2020 Nov;27(11):1116-25.

6. Swanson JW. Mental disorder, substance abuse, and community violence: An epidemiological approach, in: Monahan J and Steadman HJ, eds. “Violence and Mental Disorder: Developments in Risk Assessment” (Chicago: University of Chicago Press, 1994, pp. 101-36).

7. Addiction. 2004 Jun;99(6)708-17.

8. Am Fam Physician. 2007 Oct 15;76(8):1169-74.

9. Perspect Biol Med. 2021;64(1)70-81.

The dopamine receptors of the brain get their fair share amid the didactics we receive in residency. From discussions of antipsychotics and schizophrenia to stimulants and ADHD, dopamine plays a key role. Depending on the program and interest of faculty, methamphetamine may get its own lecture or be mixed in with other stimulants of abuse. During that discussion, a comment might be made in passing on the impact of methamphetamine on sexual desire and activity.

Experiences in the emergency department caring for patients who are intoxicated from methamphetamine then effectively make up for any gaps in trainees’ knowledge base. From patients engaging in self-pleasing pursuits in the emergency room to unfiltered reports of sexual exploits and desires, the impact of methamphetamine on sexual behavior quickly becomes apparent. Those experiences are later reinforced when residents are exposed to more long-term rehabilitation programs and have more in-depth conversations with patients about the sex-culture surrounding methamphetamine.

It is common to hear that, under the influence of methamphetamine, any available body will become an acceptable sexual partner – at times resulting in significant regrets, dangerous sexual activity, and complicated questions surrounding consent. Some early studies have found up to 72% increase in risky sexual behavior in methamphetamine users.¹ This is particularly problematic as society has recently taken on the difficult and important work to re-examine the role and nature of consent in sexual activities. This falls within the larger #MeToo movement and has led to advocating for harsher sentencing of sexual offenders.

Yet simultaneously, society has also reconsidered its approach to apportioning blame on drug users.² This shift to a more compassionate stance has resulted in a desire to treat and care for a disorder, rather than punish and condemn a poor choice. As forensic psychiatrists, we have noted this significant change. Where substance use disorders were once considered a risk factor for recidivism, they are now considered a disability that not only warrants treatment but can also diminish the share of blame one may be responsible for.

The convergence of those two societal movements often plays out in the courtroom, and in our experience when faced with those two opposing viewpoints, triers of fact (judges and juries) often favor punishing sexual offense over empathizing with an addictive disorder. While certainly not implying methamphetamine use condones sexual offense, we do posit the particular relationship between methamphetamine use and sexual activity should be explained to those entrusted with deciding guilt.

Examples of such problems are extremely common. A routine case involves IK,³ a 48-year-old male without significant history of legal problems, arrested for indecent exposure. His history of mental illness is closely intertwined with a history of substance use, leading to many psychiatric hospitalizations for methamphetamine-induced psychosis. After many hospitalizations he was placed in an assertive community treatment (ACT) team.

One day, IK is approached by an industrious drug dealer who frequents multiple board-and-cares in search for customers interested in relapsing. IK uses methamphetamine and within hours finds himself having walked miles away, naked, in the middle of an RV park. He subsequently describes the experience of unrelenting sexual desire, accompanied by ideas of reference involving billboards encouraging him to demonstrate his sexual prowess, as well as auditory hallucinations of women cheering him on. This leads to him pleasing himself publicly and his subsequent arrest.

Interviewing IK, 3 months later, he is embarrassed and apologetic. He is cognizant of the inappropriate nature of the incident and the foolishness of his actions. However, when asked whether he considers himself a sexual offender, he protests that he would never act in such a manner if not under the influence of methamphetamine. He points to his lack of significant sexual urges when sober, his lack of prior sexual offense, his lack of sexually violent offense, and his lack of unusual sexual interests.

It is unclear to us how society will or should adjudicate on such a case. It is not under the purview of forensic psychiatry to become a trier of fact. However, psychiatry should have a better working framework of how to discuss and conceptualize such situations, especially considering the dire consequences for those involved.

While any criminal conviction already has the potential to destroy a person’s life, sexual crimes bring particularly serious consequences. Entry into the national sex offender registry, in addition to carrying an unshakable stigma, comes with additional degrees of lost freedom. These individuals are prohibited from living or working in areas that have children in proximity, subjecting them to the outskirts of society and greatly restricting any chance of economic escape from poverty. Parks, libraries, and shopping malls can become off limits. Privacy for these individuals is nonexistent; from websites they visit to where they travel physically can be monitored. Even where they live and a detailed physical description are often easily accessible by members of their community.

When should it be permissible to consider sex offender status for someone on the grounds of a mental illness? A patient with obsessive-compulsive disorder might have sadistic obsessions and compulsions to commit violent sexual acts, which, along with being repugnant to society, are entirely ego-dystonic to the suffering patient. Psychosis is often characterized as involving a loss of insight and impaired reality testing. If society accepts insanity as grounds to mitigate sentencing, then why not permit it for grounds to wave the designation of sex offender to those with certain disorders, including substance use disorder? Wherever we come down on this issue, it is a sad fact that in practically no other medical field can a person be sentenced for having a disease.

Should IK have to register as a sex offender? Regardless of the circumstances, he did publicly masturbate. Society has determined that public sexual displays are a crime worth carrying the pariah status of sex offender – why should an exception be made for methamphetamine use? On the other hand, it is difficult to claim that IK’s behavior was entirely of his own free will. Most triers of fact will have never experienced that amount of dopamine reward. They can’t attest to the remaining free will after experiencing more pleasurable salience and positive reinforcement than ever naturally possible.

How we deal with the behavioral consequences, and other sequelae, of methamphetamine use is a growing problem. Access to and use of methamphetamine is no longer reserved for soldiers patrolling the jungles of Vietnam. Once thought to be a scourge of the West Coast, methamphetamine is now widely available throughout the United States.⁴ The use of methamphetamine is likely to continue to expand as society keeps pursuing the decriminalizing of drug use. Psychiatrists practicing in areas heavily affected by methamphetamine see firsthand the burden it places on community resources in the form of increased psychosis, emergency room utilization, medical resource strain, and encounters with police.⁵

The presence of mental illness is tied to a small but statistically significant risk of violence. However, substance use is a well-established risk factor for violence.⁶ What is often missed is that many sexual offenders have not committed a violent offense. However, like IK, they have been charged with indecent exposure or other nonviolent sexual offenses, such as prostitution and solicitation. Those nonviolent offenses are driven by poor judgment and impulsivity, the trademarks of substance use. The answer cannot be to incarcerate, and eventually add to the sex offender registry, the growing number of these individuals.

Yet, as psychiatrists, we seem at a loss for how to treat these patients. The prescription of allowing them to spend a night in the ED with a complementary sandwich garnished with olanzapine often feels like enabling. Substance use treatment programs are too limited, and the wait list is rarely shorter than the time it takes our patient to purchase their next hit.

There are no effective pharmacologic treatments for methamphetamine use disorder.⁷ The recommendations of cognitive-behavioral therapy, family and group therapy, contingency management, and a 12-step program may be sufficient for the most motivated and well-supported patients but are inadequate for the vast majority.⁸ As much as we want to laud the merits of community psychiatry and the ACT [assertive community treatment] model of care, it is hard to carry that banner while confronted with the reality these patients face on a day-to-day basis during any shift in the emergency room. Eventually the countless encounters with homeless, helplessly meth-addicted patients ending in discharge back to the streets begins to tarnish the bright rhetoric surrounding community care, which starts to sound more and more like abandonment of patients to suffer in futility.⁹

It is not up to forensic psychiatrists, or even psychiatry as a whole, to fix the myriad of inadequacies surrounding how society handles those suffering from methamphetamine addiction. However, it is essential for psychiatry to study and educate society on the interaction of methamphetamine use and sexual behavior. There has been some exploration into other risk factors for paraphilic behavior while under the influence of substances, but there is a dearth of information on this topic. Establishing a nomenclature called “substance-induced paraphilia” might be a way to bring clarity to such instances in both a forensic and general psychiatric setting.

Dr. Compton is a psychiatry resident at University of California, San Diego. His background includes medical education, mental health advocacy, work with underserved populations, and brain cancer research. Dr. Compton has no conflicts of interest. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. He has no conflicts of interest.

References

1. Psychol Addict Behav. 2016;30(2)147-57.

2. Monitor Psychol. 2019;50(6).

3. IK’s case has been modified in certain ways to maintain confidentiality.

4. J Psychoactive Drugs. 2000;(2):137-41.

5. Acad Emerg Med. 2020 Nov;27(11):1116-25.

6. Swanson JW. Mental disorder, substance abuse, and community violence: An epidemiological approach, in: Monahan J and Steadman HJ, eds. “Violence and Mental Disorder: Developments in Risk Assessment” (Chicago: University of Chicago Press, 1994, pp. 101-36).

7. Addiction. 2004 Jun;99(6)708-17.

8. Am Fam Physician. 2007 Oct 15;76(8):1169-74.

9. Perspect Biol Med. 2021;64(1)70-81.

For those of us who see adolescent patients on a regular basis, it seems that they use new vocabulary almost every day. While you may not need to know what “lit” means, you probably do need to understand terms used to describe your patients’ identities. At times it feels like we, as providers, have to be on TikTok to keep up with our patients, and while this may be an amusing way to educate ourselves, a judicious Google search can be much more helpful. The interesting part about LGBTQ+ terminology is that it stems from the community and thus is frequently updated to reflect our evolving understanding of gender, sexuality, and identity. That being said, it can make it difficult for those who are not plugged in to the community to keep up to date. While we have learned in medicine to use accurate terminology and appropriate three-letter acronyms (or “TLAs” as one of my residents referenced them when I was a medical student) to describe medical conditions, the LGBTQ+ community has its own set of terms and acronyms. These new words may seem daunting, but they are often based in Latin roots or prefixes such as a-, demi-, poly-, and pan-, which may be familiar to those of us who use plenty of other Latin-based terms in medicine and our everyday lives. By paying attention to how people define and use terminology, we can better recognize their true identities and become better providers.

The first, and perhaps most important, piece of advice is to maintain cultural humility. Know when to admit you don’t recognize a term and politely ask the definition. For example, the first time I heard the term “demiboy” I said “I’m not familiar with that word. Can you explain what it means to you?” Phrasing the question as such is also helpful in that it gives the individuals a chance to really define their identity. In addition, some words may be used differently by various individuals and by asking what the word means to them, you can have a better understanding of how they are using the terminology. In this particular instance, the patient felt more masculine, but not 100%, partway between agender (meaning having no gender identity) and being “all male.” By embracing cultural humility, we place the patients in the role of expert on their own identity and orientation. According to Maria Ruud, DNP, of the University of Minnesota, Minneapolis, cultural humility is the “ongoing self-reflection and education …[seeking] to gain an awareness of their own assumptions and biases that may contribute to health disparities.”¹

Dr. Lawlis is an assistant professor of pediatrics at the University of Oklahoma Health Sciences Center, Oklahoma City, and an adolescent medicine specialist at OU Children’s. She has no relevant financial disclosures. Email her at [email protected].

References

1. Ruud M. Nursing for women’s health. 2018;22(3):255-63.

2. Killermann S. It’s Pronounced Metrosexual. 2020.

3. Killermann S. Defining LGBTQ+: A guide to gender and sexuality terminology. 2019, Feb 25.

4. The Joint Commission. Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide. Oak Brook, Ill. 2011.

5. LGBT health disparities. American Psychiatric Association Public Interest Government Relations Office. 2013 May.

6. Lawlis S et al. Health services for LGBTQ+ patients. Psychiatr Ann. 2019;49(10):426-35.

7. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.

8. Center of Excellence for Transgender Health, department of family and community medicine, UCSF. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. 2016 Jun 17.

For those of us who see adolescent patients on a regular basis, it seems that they use new vocabulary almost every day. While you may not need to know what “lit” means, you probably do need to understand terms used to describe your patients’ identities. At times it feels like we, as providers, have to be on TikTok to keep up with our patients, and while this may be an amusing way to educate ourselves, a judicious Google search can be much more helpful. The interesting part about LGBTQ+ terminology is that it stems from the community and thus is frequently updated to reflect our evolving understanding of gender, sexuality, and identity. That being said, it can make it difficult for those who are not plugged in to the community to keep up to date. While we have learned in medicine to use accurate terminology and appropriate three-letter acronyms (or “TLAs” as one of my residents referenced them when I was a medical student) to describe medical conditions, the LGBTQ+ community has its own set of terms and acronyms. These new words may seem daunting, but they are often based in Latin roots or prefixes such as a-, demi-, poly-, and pan-, which may be familiar to those of us who use plenty of other Latin-based terms in medicine and our everyday lives. By paying attention to how people define and use terminology, we can better recognize their true identities and become better providers.

The first, and perhaps most important, piece of advice is to maintain cultural humility. Know when to admit you don’t recognize a term and politely ask the definition. For example, the first time I heard the term “demiboy” I said “I’m not familiar with that word. Can you explain what it means to you?” Phrasing the question as such is also helpful in that it gives the individuals a chance to really define their identity. In addition, some words may be used differently by various individuals and by asking what the word means to them, you can have a better understanding of how they are using the terminology. In this particular instance, the patient felt more masculine, but not 100%, partway between agender (meaning having no gender identity) and being “all male.” By embracing cultural humility, we place the patients in the role of expert on their own identity and orientation. According to Maria Ruud, DNP, of the University of Minnesota, Minneapolis, cultural humility is the “ongoing self-reflection and education …[seeking] to gain an awareness of their own assumptions and biases that may contribute to health disparities.”¹

Dr. Lawlis is an assistant professor of pediatrics at the University of Oklahoma Health Sciences Center, Oklahoma City, and an adolescent medicine specialist at OU Children’s. She has no relevant financial disclosures. Email her at [email protected].

References

1. Ruud M. Nursing for women’s health. 2018;22(3):255-63.

2. Killermann S. It’s Pronounced Metrosexual. 2020.

3. Killermann S. Defining LGBTQ+: A guide to gender and sexuality terminology. 2019, Feb 25.

4. The Joint Commission. Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide. Oak Brook, Ill. 2011.

5. LGBT health disparities. American Psychiatric Association Public Interest Government Relations Office. 2013 May.

6. Lawlis S et al. Health services for LGBTQ+ patients. Psychiatr Ann. 2019;49(10):426-35.

7. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.

8. Center of Excellence for Transgender Health, department of family and community medicine, UCSF. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. 2016 Jun 17.

For those of us who see adolescent patients on a regular basis, it seems that they use new vocabulary almost every day. While you may not need to know what “lit” means, you probably do need to understand terms used to describe your patients’ identities. At times it feels like we, as providers, have to be on TikTok to keep up with our patients, and while this may be an amusing way to educate ourselves, a judicious Google search can be much more helpful. The interesting part about LGBTQ+ terminology is that it stems from the community and thus is frequently updated to reflect our evolving understanding of gender, sexuality, and identity. That being said, it can make it difficult for those who are not plugged in to the community to keep up to date. While we have learned in medicine to use accurate terminology and appropriate three-letter acronyms (or “TLAs” as one of my residents referenced them when I was a medical student) to describe medical conditions, the LGBTQ+ community has its own set of terms and acronyms. These new words may seem daunting, but they are often based in Latin roots or prefixes such as a-, demi-, poly-, and pan-, which may be familiar to those of us who use plenty of other Latin-based terms in medicine and our everyday lives. By paying attention to how people define and use terminology, we can better recognize their true identities and become better providers.

The first, and perhaps most important, piece of advice is to maintain cultural humility. Know when to admit you don’t recognize a term and politely ask the definition. For example, the first time I heard the term “demiboy” I said “I’m not familiar with that word. Can you explain what it means to you?” Phrasing the question as such is also helpful in that it gives the individuals a chance to really define their identity. In addition, some words may be used differently by various individuals and by asking what the word means to them, you can have a better understanding of how they are using the terminology. In this particular instance, the patient felt more masculine, but not 100%, partway between agender (meaning having no gender identity) and being “all male.” By embracing cultural humility, we place the patients in the role of expert on their own identity and orientation. According to Maria Ruud, DNP, of the University of Minnesota, Minneapolis, cultural humility is the “ongoing self-reflection and education …[seeking] to gain an awareness of their own assumptions and biases that may contribute to health disparities.”¹

Dr. Lawlis is an assistant professor of pediatrics at the University of Oklahoma Health Sciences Center, Oklahoma City, and an adolescent medicine specialist at OU Children’s. She has no relevant financial disclosures. Email her at [email protected].

References

1. Ruud M. Nursing for women’s health. 2018;22(3):255-63.

2. Killermann S. It’s Pronounced Metrosexual. 2020.

3. Killermann S. Defining LGBTQ+: A guide to gender and sexuality terminology. 2019, Feb 25.

4. The Joint Commission. Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide. Oak Brook, Ill. 2011.

5. LGBT health disparities. American Psychiatric Association Public Interest Government Relations Office. 2013 May.

6. Lawlis S et al. Health services for LGBTQ+ patients. Psychiatr Ann. 2019;49(10):426-35.

7. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.

8. Center of Excellence for Transgender Health, department of family and community medicine, UCSF. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. 2016 Jun 17.

This transcript has been edited for clarity. The transcript and an accompanying video first appeared on Medscape.com.

Justin L. Berk, MD, MPH, MBA: Welcome back to The Cribsiders, our video recap of our pediatric medicine podcast. We interview leading experts in the field to bring clinical pearls and practice-changing knowledge, and answer lingering questions about core topics in pediatric medicine. Chris, what is our topic today?

Christopher J. Chiu, MD: I was really happy to be able to talk about our recent episode with Dr. Carissa Baker-Smith, a pediatric cardiologist and director of the Nemours preventive cardiology program. She helped us review the pediatric screening guidelines for blood pressure, including initial workup and treatment.

Dr. Berk: This was a really great episode that a lot of people found really helpful. What were some of the key takeaway pearls that you think listeners would be interested in?

Dr. Chiu: We talked about when and how we should be checking blood pressures in children. Blood pressure should be checked at every well-child visit starting at age 3. But if they have other risk factors like kidney disease or a condition such as coarctation of the aorta, then blood pressure should be checked at every visit.

Dr. Berk: One thing she spoke about was how blood pressures should be measured. How should we be checking blood pressures in the clinic?

Dr. Chiu: Clinic blood pressures are usually checked with oscillometric devices. They can differ by manufacturer, but basically they find a mean arterial pressure and then each device has a method of calculating systolic and diastolic pressures. Now after that, if the child’s blood pressure is maybe abnormal, you want to double-check a manual blood pressure using Korotkoff sounds to confirm the blood pressure.

She reminded us that blood pressure should be measured with the child sitting with their back supported, feet flat on the floor, and arm at the level of the heart. Make sure you use the right size cuff. The bladder of the cuff should be 40% of the width of the arm, and about 80%-100% of the arm circumference. She recommends sizing up if you have to.

Dr. Berk: Accuracy of blood pressure management was a really important point, especially for diagnosis at this stage. Can you walk us through what we learned about diagnosis of hypertension?

Dr. Chiu: The definitions of hypertension come from the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Up until the age of 13, they define prehypertension as systolic and diastolic blood pressures between the 90th and 95th percentile, or if the blood pressure exceeds 120/80 mm Hg. Hypertension is defined when blood pressure reaches the 95th percentile. Now age 13 is when it gets a little hazy. Many changes in the guidelines happen at age 13, when hypertension starts being defined by adult guidelines. The 2017 adult hypertension guidelines define stage 1 hypertension as 130/89 to 139/89, and stage 2 hypertension as greater than 140/90.

Dr. Berk: How about workup of hypertension? The work of pediatric hypertension is always a little bit complex. What are some of the pearls you took away?

Dr. Chui: She talked about tailoring the workup to the child. So when we’re doing our workup, obviously physical exam should be the first thing we do. You have to assess and compare pulses, which is one of the most important parts of the initial evaluation. Obviously, looking at coarctation of the aorta, but also looking for things like a cushingoid appearance. If the child is less than 6 years of age, she recommends a referral to nephrology for more comprehensive renovascular workup, which probably will include renal ultrasound, urinalysis, metabolic panel, and thyroid studies.

We have to be cognizant of secondary causes of hypertension, such as endocrine tumors, hyperthyroidism, aortic disease, or even medication-induced hypertension. She told us that in the majority of these cases, especially with our obese older children, primary hypertension or essential hypertension is the most likely cause.

Dr. Berk: That was my big takeaway. If they’re really young, they need a big workup, but otherwise it is likely primary hypertension. What did we learn about treatment?

Dr. Chui: Just as we tailor our assessment to the child, we also have to tailor treatment. We know that lifestyle modification is usually the first line of treatment, especially for primary hypertension, and Dr. Baker-Smith tells us that we really need to perform counseling that meets the patient where they are. So if they like dancing to the newest TikTok trends or music videos, maybe we can encourage them to move more that way. Using our motivational interviewing skills is really key here.

If you want to start medication, Dr. Baker-Smith uses things like low-dose ACE inhibitors or calcium channel blockers, but obviously it’ll be tailored to the patient and any underlying conditions.

Dr. Berk: That’s great – a lot of wonderful pearls on the diagnosis and management of pediatric hypertension. Thank you for joining us for another video recap of The Cribsiders pediatric podcast. You can download the full podcast, Off the Cuff: Managing Pediatric Hypertension in Your Primary Care Clinic, on any podcast player, or check out our website at www.theCribsiders.com.

Christopher J. Chiu, MD, is assistant professor, department of internal medicine, division of general internal medicine, Ohio State University, Columbus; lead physician, general internal medicine, OSU Outpatient Care East; department of internal medicine, division of general internal medicine, Ohio State University Wexner Medical Center. Dr. Chiu has disclosed no relevant financial relationships. Justin L. Berk, MD, MPH, MBA, is assistant professor, department of medicine; assistant professor, department of pediatrics, Brown University, Providence, R.I.

This transcript has been edited for clarity. The transcript and an accompanying video first appeared on Medscape.com.

Justin L. Berk, MD, MPH, MBA: Welcome back to The Cribsiders, our video recap of our pediatric medicine podcast. We interview leading experts in the field to bring clinical pearls and practice-changing knowledge, and answer lingering questions about core topics in pediatric medicine. Chris, what is our topic today?

Christopher J. Chiu, MD: I was really happy to be able to talk about our recent episode with Dr. Carissa Baker-Smith, a pediatric cardiologist and director of the Nemours preventive cardiology program. She helped us review the pediatric screening guidelines for blood pressure, including initial workup and treatment.

Dr. Berk: This was a really great episode that a lot of people found really helpful. What were some of the key takeaway pearls that you think listeners would be interested in?

Dr. Chiu: We talked about when and how we should be checking blood pressures in children. Blood pressure should be checked at every well-child visit starting at age 3. But if they have other risk factors like kidney disease or a condition such as coarctation of the aorta, then blood pressure should be checked at every visit.

Dr. Berk: One thing she spoke about was how blood pressures should be measured. How should we be checking blood pressures in the clinic?

Dr. Chiu: Clinic blood pressures are usually checked with oscillometric devices. They can differ by manufacturer, but basically they find a mean arterial pressure and then each device has a method of calculating systolic and diastolic pressures. Now after that, if the child’s blood pressure is maybe abnormal, you want to double-check a manual blood pressure using Korotkoff sounds to confirm the blood pressure.

She reminded us that blood pressure should be measured with the child sitting with their back supported, feet flat on the floor, and arm at the level of the heart. Make sure you use the right size cuff. The bladder of the cuff should be 40% of the width of the arm, and about 80%-100% of the arm circumference. She recommends sizing up if you have to.

Dr. Berk: Accuracy of blood pressure management was a really important point, especially for diagnosis at this stage. Can you walk us through what we learned about diagnosis of hypertension?

Dr. Chiu: The definitions of hypertension come from the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Up until the age of 13, they define prehypertension as systolic and diastolic blood pressures between the 90th and 95th percentile, or if the blood pressure exceeds 120/80 mm Hg. Hypertension is defined when blood pressure reaches the 95th percentile. Now age 13 is when it gets a little hazy. Many changes in the guidelines happen at age 13, when hypertension starts being defined by adult guidelines. The 2017 adult hypertension guidelines define stage 1 hypertension as 130/89 to 139/89, and stage 2 hypertension as greater than 140/90.

Dr. Berk: How about workup of hypertension? The work of pediatric hypertension is always a little bit complex. What are some of the pearls you took away?

Dr. Chui: She talked about tailoring the workup to the child. So when we’re doing our workup, obviously physical exam should be the first thing we do. You have to assess and compare pulses, which is one of the most important parts of the initial evaluation. Obviously, looking at coarctation of the aorta, but also looking for things like a cushingoid appearance. If the child is less than 6 years of age, she recommends a referral to nephrology for more comprehensive renovascular workup, which probably will include renal ultrasound, urinalysis, metabolic panel, and thyroid studies.

We have to be cognizant of secondary causes of hypertension, such as endocrine tumors, hyperthyroidism, aortic disease, or even medication-induced hypertension. She told us that in the majority of these cases, especially with our obese older children, primary hypertension or essential hypertension is the most likely cause.

Dr. Berk: That was my big takeaway. If they’re really young, they need a big workup, but otherwise it is likely primary hypertension. What did we learn about treatment?

Dr. Chui: Just as we tailor our assessment to the child, we also have to tailor treatment. We know that lifestyle modification is usually the first line of treatment, especially for primary hypertension, and Dr. Baker-Smith tells us that we really need to perform counseling that meets the patient where they are. So if they like dancing to the newest TikTok trends or music videos, maybe we can encourage them to move more that way. Using our motivational interviewing skills is really key here.

If you want to start medication, Dr. Baker-Smith uses things like low-dose ACE inhibitors or calcium channel blockers, but obviously it’ll be tailored to the patient and any underlying conditions.

Dr. Berk: That’s great – a lot of wonderful pearls on the diagnosis and management of pediatric hypertension. Thank you for joining us for another video recap of The Cribsiders pediatric podcast. You can download the full podcast, Off the Cuff: Managing Pediatric Hypertension in Your Primary Care Clinic, on any podcast player, or check out our website at www.theCribsiders.com.

Christopher J. Chiu, MD, is assistant professor, department of internal medicine, division of general internal medicine, Ohio State University, Columbus; lead physician, general internal medicine, OSU Outpatient Care East; department of internal medicine, division of general internal medicine, Ohio State University Wexner Medical Center. Dr. Chiu has disclosed no relevant financial relationships. Justin L. Berk, MD, MPH, MBA, is assistant professor, department of medicine; assistant professor, department of pediatrics, Brown University, Providence, R.I.

This transcript has been edited for clarity. The transcript and an accompanying video first appeared on Medscape.com.

Justin L. Berk, MD, MPH, MBA: Welcome back to The Cribsiders, our video recap of our pediatric medicine podcast. We interview leading experts in the field to bring clinical pearls and practice-changing knowledge, and answer lingering questions about core topics in pediatric medicine. Chris, what is our topic today?

Christopher J. Chiu, MD: I was really happy to be able to talk about our recent episode with Dr. Carissa Baker-Smith, a pediatric cardiologist and director of the Nemours preventive cardiology program. She helped us review the pediatric screening guidelines for blood pressure, including initial workup and treatment.

Dr. Berk: This was a really great episode that a lot of people found really helpful. What were some of the key takeaway pearls that you think listeners would be interested in?

Dr. Chiu: We talked about when and how we should be checking blood pressures in children. Blood pressure should be checked at every well-child visit starting at age 3. But if they have other risk factors like kidney disease or a condition such as coarctation of the aorta, then blood pressure should be checked at every visit.

Dr. Berk: One thing she spoke about was how blood pressures should be measured. How should we be checking blood pressures in the clinic?

Dr. Chiu: Clinic blood pressures are usually checked with oscillometric devices. They can differ by manufacturer, but basically they find a mean arterial pressure and then each device has a method of calculating systolic and diastolic pressures. Now after that, if the child’s blood pressure is maybe abnormal, you want to double-check a manual blood pressure using Korotkoff sounds to confirm the blood pressure.

She reminded us that blood pressure should be measured with the child sitting with their back supported, feet flat on the floor, and arm at the level of the heart. Make sure you use the right size cuff. The bladder of the cuff should be 40% of the width of the arm, and about 80%-100% of the arm circumference. She recommends sizing up if you have to.

Dr. Berk: Accuracy of blood pressure management was a really important point, especially for diagnosis at this stage. Can you walk us through what we learned about diagnosis of hypertension?

Dr. Chiu: The definitions of hypertension come from the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Up until the age of 13, they define prehypertension as systolic and diastolic blood pressures between the 90th and 95th percentile, or if the blood pressure exceeds 120/80 mm Hg. Hypertension is defined when blood pressure reaches the 95th percentile. Now age 13 is when it gets a little hazy. Many changes in the guidelines happen at age 13, when hypertension starts being defined by adult guidelines. The 2017 adult hypertension guidelines define stage 1 hypertension as 130/89 to 139/89, and stage 2 hypertension as greater than 140/90.

Dr. Berk: How about workup of hypertension? The work of pediatric hypertension is always a little bit complex. What are some of the pearls you took away?

Dr. Chui: She talked about tailoring the workup to the child. So when we’re doing our workup, obviously physical exam should be the first thing we do. You have to assess and compare pulses, which is one of the most important parts of the initial evaluation. Obviously, looking at coarctation of the aorta, but also looking for things like a cushingoid appearance. If the child is less than 6 years of age, she recommends a referral to nephrology for more comprehensive renovascular workup, which probably will include renal ultrasound, urinalysis, metabolic panel, and thyroid studies.

We have to be cognizant of secondary causes of hypertension, such as endocrine tumors, hyperthyroidism, aortic disease, or even medication-induced hypertension. She told us that in the majority of these cases, especially with our obese older children, primary hypertension or essential hypertension is the most likely cause.

Dr. Berk: That was my big takeaway. If they’re really young, they need a big workup, but otherwise it is likely primary hypertension. What did we learn about treatment?

Dr. Chui: Just as we tailor our assessment to the child, we also have to tailor treatment. We know that lifestyle modification is usually the first line of treatment, especially for primary hypertension, and Dr. Baker-Smith tells us that we really need to perform counseling that meets the patient where they are. So if they like dancing to the newest TikTok trends or music videos, maybe we can encourage them to move more that way. Using our motivational interviewing skills is really key here.

If you want to start medication, Dr. Baker-Smith uses things like low-dose ACE inhibitors or calcium channel blockers, but obviously it’ll be tailored to the patient and any underlying conditions.

Dr. Berk: That’s great – a lot of wonderful pearls on the diagnosis and management of pediatric hypertension. Thank you for joining us for another video recap of The Cribsiders pediatric podcast. You can download the full podcast, Off the Cuff: Managing Pediatric Hypertension in Your Primary Care Clinic, on any podcast player, or check out our website at www.theCribsiders.com.

Christopher J. Chiu, MD, is assistant professor, department of internal medicine, division of general internal medicine, Ohio State University, Columbus; lead physician, general internal medicine, OSU Outpatient Care East; department of internal medicine, division of general internal medicine, Ohio State University Wexner Medical Center. Dr. Chiu has disclosed no relevant financial relationships. Justin L. Berk, MD, MPH, MBA, is assistant professor, department of medicine; assistant professor, department of pediatrics, Brown University, Providence, R.I.

I would like to start the new year off by returning to the past – when the physical exam was emphasized and utilized in decision making. I think a big reason that its use has diminished in recent years is due to the physical exam not having been emphasized in training.

For those seeking to increase their comfort with conducting the physical exam, below are several methods I have found helpful to use in practice.
 

Examining the pharynx

We were usually taught to ask the patient to say ahhh, with or without a nasty tongue depressor.

When I was on my pediatrics rotation, I was taught to ask the patients to roar like a lion, which always gave a nice look at their posterior pharynx. The kids also really liked doing this, but it might seem a little strange to ask adults to do this.

A technique I have found that works well with adults is to ask them to yawn. I have found that this get me a great look at the pharynx for about half of my patients.
 

Auscultatory percussion for pleural effusions

Guarino and colleagues described a technique that is easily mastered and very effective for determining the presence of pleural effusions.¹ It involves placing the stethoscope 3 cm below the last rib in the mid clavicular line and tapping from the apex down to the last rib.

For patients without effusion, a sharp change to a loud percussion note will occur at the last rib.

If the patient has an effusion, the loud percussion note will start at the top of the effusion.

This method was remarkably successful at finding pleural effusions. In the study, Dr. Guarino found a sensitivity of 96% and a specificity of 100%.
 

Physical exam for anemia

Look at the nails and see if they look pale. How can we do this?

The first step is to know what your own hematocrit is. You can then compare the color of your nail to that of the patient.

If you have a normal hematocrit and the patient’s nail bed color is lighter than yours, the patient likely has anemia. If you do this frequently, you will get good at estimating hematocrit. This is especially important if you do not have labs readily available.

Another way to assess for anemia is to look at the color tint of the lower conjunctiva. The best way to look for this is to look at whether there is a generous amount of visible capillaries in the lower conjunctiva. Patients without anemia have a darker red color because of these vessels, whereas patients with anemia are a lighter pink.

Strobach and colleagues² looked at both nail bed rubor and color tint of the lower conjunctiva and found that both reliably predicted presence and degree of anemia.

Determining if clubbing is present

Most physicians are aware of Shamroth sign, and use it to evaluate for clubbing. Shamroth sign is the loss of the diamond that is created by placing the back surfaces of opposite terminal phalanges together.

I have found that it’s easier to diagnose mild clubbing by looking at the finger in profile. If the ratio of the distal phalangeal depth compared to the depth across the distal interphalangeal joint is greater than 1:1, then clubbing is present.³

Pearls

1. Have the patient try yawning to better see the pharynx without using a tongue blade.

2. Try the technique of auscultatory percussion to be more accurate at picking up pleural effusions.

3. Know your hematocrit, so you can better use color shade to assess for anemia.

4. Try looking at fingers in profile to pick up clubbing.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as 3rd-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].

References

1. Guarino JR and Guarino JC. Auscultatory percussion: A simple method to detect pleural effusion. J Gen Intern Med. 1994 Feb;9(2):71-4.

2. Strobach RS et al. The value of the physical examination in the diagnosis of anemia. Correlation of the physical findings and the hemoglobin concentration. Arch Intern Med. 1988 Apr;148(4):831-2.

3. Spicknall KE et al. Clubbing: an update on diagnosis, differential diagnosis, pathophysiology, and clinical relevance. J Am Acad Dermatol. 2005 Jun;52(6):1020-8.

I would like to start the new year off by returning to the past – when the physical exam was emphasized and utilized in decision making. I think a big reason that its use has diminished in recent years is due to the physical exam not having been emphasized in training.

For those seeking to increase their comfort with conducting the physical exam, below are several methods I have found helpful to use in practice.
 

Examining the pharynx

We were usually taught to ask the patient to say ahhh, with or without a nasty tongue depressor.

When I was on my pediatrics rotation, I was taught to ask the patients to roar like a lion, which always gave a nice look at their posterior pharynx. The kids also really liked doing this, but it might seem a little strange to ask adults to do this.

A technique I have found that works well with adults is to ask them to yawn. I have found that this get me a great look at the pharynx for about half of my patients.
 

Auscultatory percussion for pleural effusions

Guarino and colleagues described a technique that is easily mastered and very effective for determining the presence of pleural effusions.¹ It involves placing the stethoscope 3 cm below the last rib in the mid clavicular line and tapping from the apex down to the last rib.

For patients without effusion, a sharp change to a loud percussion note will occur at the last rib.

If the patient has an effusion, the loud percussion note will start at the top of the effusion.

This method was remarkably successful at finding pleural effusions. In the study, Dr. Guarino found a sensitivity of 96% and a specificity of 100%.
 

Physical exam for anemia

Look at the nails and see if they look pale. How can we do this?

The first step is to know what your own hematocrit is. You can then compare the color of your nail to that of the patient.

If you have a normal hematocrit and the patient’s nail bed color is lighter than yours, the patient likely has anemia. If you do this frequently, you will get good at estimating hematocrit. This is especially important if you do not have labs readily available.

Another way to assess for anemia is to look at the color tint of the lower conjunctiva. The best way to look for this is to look at whether there is a generous amount of visible capillaries in the lower conjunctiva. Patients without anemia have a darker red color because of these vessels, whereas patients with anemia are a lighter pink.

Strobach and colleagues² looked at both nail bed rubor and color tint of the lower conjunctiva and found that both reliably predicted presence and degree of anemia.

Determining if clubbing is present

Most physicians are aware of Shamroth sign, and use it to evaluate for clubbing. Shamroth sign is the loss of the diamond that is created by placing the back surfaces of opposite terminal phalanges together.

I have found that it’s easier to diagnose mild clubbing by looking at the finger in profile. If the ratio of the distal phalangeal depth compared to the depth across the distal interphalangeal joint is greater than 1:1, then clubbing is present.³

Pearls

1. Have the patient try yawning to better see the pharynx without using a tongue blade.

2. Try the technique of auscultatory percussion to be more accurate at picking up pleural effusions.

3. Know your hematocrit, so you can better use color shade to assess for anemia.

4. Try looking at fingers in profile to pick up clubbing.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as 3rd-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].

References

1. Guarino JR and Guarino JC. Auscultatory percussion: A simple method to detect pleural effusion. J Gen Intern Med. 1994 Feb;9(2):71-4.

2. Strobach RS et al. The value of the physical examination in the diagnosis of anemia. Correlation of the physical findings and the hemoglobin concentration. Arch Intern Med. 1988 Apr;148(4):831-2.

3. Spicknall KE et al. Clubbing: an update on diagnosis, differential diagnosis, pathophysiology, and clinical relevance. J Am Acad Dermatol. 2005 Jun;52(6):1020-8.

I would like to start the new year off by returning to the past – when the physical exam was emphasized and utilized in decision making. I think a big reason that its use has diminished in recent years is due to the physical exam not having been emphasized in training.

For those seeking to increase their comfort with conducting the physical exam, below are several methods I have found helpful to use in practice.
 

Examining the pharynx

We were usually taught to ask the patient to say ahhh, with or without a nasty tongue depressor.

When I was on my pediatrics rotation, I was taught to ask the patients to roar like a lion, which always gave a nice look at their posterior pharynx. The kids also really liked doing this, but it might seem a little strange to ask adults to do this.

A technique I have found that works well with adults is to ask them to yawn. I have found that this get me a great look at the pharynx for about half of my patients.
 

Auscultatory percussion for pleural effusions

Guarino and colleagues described a technique that is easily mastered and very effective for determining the presence of pleural effusions.¹ It involves placing the stethoscope 3 cm below the last rib in the mid clavicular line and tapping from the apex down to the last rib.

For patients without effusion, a sharp change to a loud percussion note will occur at the last rib.

If the patient has an effusion, the loud percussion note will start at the top of the effusion.

This method was remarkably successful at finding pleural effusions. In the study, Dr. Guarino found a sensitivity of 96% and a specificity of 100%.
 

Physical exam for anemia

Look at the nails and see if they look pale. How can we do this?

The first step is to know what your own hematocrit is. You can then compare the color of your nail to that of the patient.

If you have a normal hematocrit and the patient’s nail bed color is lighter than yours, the patient likely has anemia. If you do this frequently, you will get good at estimating hematocrit. This is especially important if you do not have labs readily available.

Another way to assess for anemia is to look at the color tint of the lower conjunctiva. The best way to look for this is to look at whether there is a generous amount of visible capillaries in the lower conjunctiva. Patients without anemia have a darker red color because of these vessels, whereas patients with anemia are a lighter pink.

Strobach and colleagues² looked at both nail bed rubor and color tint of the lower conjunctiva and found that both reliably predicted presence and degree of anemia.

Determining if clubbing is present

Most physicians are aware of Shamroth sign, and use it to evaluate for clubbing. Shamroth sign is the loss of the diamond that is created by placing the back surfaces of opposite terminal phalanges together.

I have found that it’s easier to diagnose mild clubbing by looking at the finger in profile. If the ratio of the distal phalangeal depth compared to the depth across the distal interphalangeal joint is greater than 1:1, then clubbing is present.³

Pearls

1. Have the patient try yawning to better see the pharynx without using a tongue blade.

2. Try the technique of auscultatory percussion to be more accurate at picking up pleural effusions.

3. Know your hematocrit, so you can better use color shade to assess for anemia.

4. Try looking at fingers in profile to pick up clubbing.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as 3rd-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].

References

1. Guarino JR and Guarino JC. Auscultatory percussion: A simple method to detect pleural effusion. J Gen Intern Med. 1994 Feb;9(2):71-4.

2. Strobach RS et al. The value of the physical examination in the diagnosis of anemia. Correlation of the physical findings and the hemoglobin concentration. Arch Intern Med. 1988 Apr;148(4):831-2.

3. Spicknall KE et al. Clubbing: an update on diagnosis, differential diagnosis, pathophysiology, and clinical relevance. J Am Acad Dermatol. 2005 Jun;52(6):1020-8.

I am a psychiatrist, which means I am a mental health professional, which means I work with people with mental illness. Sometimes people with mental health conditions who suffer from mental illness need to take a day off work – also called a mental health day – because they are too symptomatic to work, and sometimes people who don’t have a mental illness need to take a day off work, also called a mental health day, because they are feeling stressed.

Sometimes professional athletes don’t do things they agreed to do in their contracts because they realize that doing these things is very upsetting and will be detrimental to their mental health, or maybe they have a mental illness and doing these things will worsen their mental health condition, which is, in fact, a mental illness. Other times people with mental health conditions need to have pets travel with them because this mitigates the symptoms of their mental illness or perhaps it’s just good for their mental health. And finally, some people suffer from mental illnesses, or sometimes from learning problems, which are severe enough that a person with these conditions has a disability and needs special accommodations to function optimally in educational or occupational settings, or needs public financial support because their difficulties disable them to the point that they can’t work at all.

Is your head spinning yet? The point I am trying to make is that, as a profession, we have done an abysmal job of defining what we do, who we serve, and differentiating the fact that what someone with a psychiatric disorder needs to do to function or to alleviate emotional suffering may be entirely different from the things that everyone needs to do, regardless of whether they have a psychiatric disorder, to feel their emotional best.

The National Alliance on Mental Illness tells us that one in five Americans are suffering from a mental illness, while the Epidemiologic Catchment Area Program revealed that half of people will meet criteria for a mental illness at some point in their lives. We hear about “the mentally ill” constantly in the news – often in relation to mass shooters or homelessness – yet even psychiatrists might be pressed to define who exactly the “mentally ill” are. And how many of us could not somehow, at some time, find ourselves in 1 of the 157 disorders that DSM-5 lists – down from 365 disorders in the DSM-IV-TR?

Differentiating mental health from mental illness is just the beginning of our semantic confusion. As psychiatrists we treat major depression, and yet the illness “depression,” a syndromic constellation of symptoms, includes the key symptom of sadness. People often say they are “depressed” when they mean they are sad or demoralized, and yet, if their sadness persists in the absence of other symptoms, they may well want, or feel they “should” have medications, even in the absence of a disorder. And maybe those medications help them feel better, so that the presence or absence of a verified illness doesn’t really matter. But if the medications cause adverse reactions, then psychiatry might have done a better job by that person’s sadness. Melancholia, or perhaps any designation than “depression,” with its multiple meanings, might better serve our patients and our profession. This is only one example, as the number of people who tell me they have obsessive-compulsive disorder – or more often announce, “I’m OCD!” because they are well organized in a productive way is remarkable. And while I have treated only a few people who meet the criteria for narcissistic personality disorder, from general conversation it would seem that they are at every dinner table and by every water cooler.

Does it matter? A diagnostic lexicon can be so helpful when it guides treatment, provides a heterogeneous group of patients for research studies, and allows for an understanding of the etiology, course, and prognosis of a given condition. When someone is so depressed that they can’t get out of bed, or is so disorganized that they can’t perform their job and might cause a disturbance in their workplace, it is good to instruct them to take time off work and send them back well with a doctor’s note. But this is different from the person who doesn’t want to face a difficult situation, who simply doesn’t like their job or their boss, or who wants their pet declared an emotional support animal to avoid the fee the airlines charge to bring an animal on board if one does not have a psychiatric diagnosis. Sometimes these lines are blurry – if someone does not want to do something because it makes them anxious, does it matter how deep the pit in their stomach is, or if they are having full-blown panic attacks? When do we agree that their distress is reason to allow them to avoid responsibilities without repercussions versus a violation of their obligations and an infringement on others?

Diagnoses offer solace to some patients: There is a name for their suffering, available treatment, and often others with the same condition to look to for guidance and community. For others, a psychiatric diagnosis is a source of shame, a label they see as damaging to their character and sometimes to their careers – including in medicine – where we have been particularly unsympathetic to those who announce a psychiatric history.

In some cultures, the label itself decreases someone’s attractiveness as a potential marriage partner. We would all like to see the stigma of mental illness vanish, but we have a long way to go.

Psychiatric diagnoses move over time and with our politics and culture. This is good; we don’t hold on to what we learn to be untrue. But they may well add to issues of inequity. Those who can afford to pay for expensive educational assessments can request educational accommodations, including untimed standardized tests. This advantage may not be available to those without the resources to pay for these evaluations, and one might wonder why all comers can’t take untimed tests so as not to favor the privileged. Psychiatry has long been accused of diagnosing people of color with poor prognosis illnesses and women with conditions that imply emotional weakness.

While our diagnoses have clinical utility, it is unfortunate that they have come to be about reimbursement. A diagnosis needs to be assigned for insurers to pay for care, and so we create diagnostic categories to allow for treatment. Is this reasonable? Do we need to say that someone who is suffering after the death of a loved one has a mental illness in order to allow them to seek relief from their suffering? It leads us to believe that all suffering is about pathology, that we should expect pain-free emotional lives. Perhaps we need a diagnostic category of psychic pain, not otherwise specified, to allow for treatment for those who simply ache.

Mental illness is about interventions to alleviate the suffering of those with disorders. Mental health is about interventions that may benefit everyone, whether they suffer from a mental illness or not. Sleep, nutrition, exercise, sunlight, nature, entertainment and escape, yoga, meditation, vacations in beautiful places with loving people – these are things that potentially help us all whether we do or do not have an illness. With so much confusion about what it is we do, and about who “should” get help, who can get help, who might want help, and where they should go to seek help, perhaps it would be better if our lingo were more precise.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). The has a private practice and is assistant professor of psychiatry ad behavioral sciences at Johns Hopkins University, both in Baltimore. She has no disclosures.

I am a psychiatrist, which means I am a mental health professional, which means I work with people with mental illness. Sometimes people with mental health conditions who suffer from mental illness need to take a day off work – also called a mental health day – because they are too symptomatic to work, and sometimes people who don’t have a mental illness need to take a day off work, also called a mental health day, because they are feeling stressed.

Sometimes professional athletes don’t do things they agreed to do in their contracts because they realize that doing these things is very upsetting and will be detrimental to their mental health, or maybe they have a mental illness and doing these things will worsen their mental health condition, which is, in fact, a mental illness. Other times people with mental health conditions need to have pets travel with them because this mitigates the symptoms of their mental illness or perhaps it’s just good for their mental health. And finally, some people suffer from mental illnesses, or sometimes from learning problems, which are severe enough that a person with these conditions has a disability and needs special accommodations to function optimally in educational or occupational settings, or needs public financial support because their difficulties disable them to the point that they can’t work at all.

Is your head spinning yet? The point I am trying to make is that, as a profession, we have done an abysmal job of defining what we do, who we serve, and differentiating the fact that what someone with a psychiatric disorder needs to do to function or to alleviate emotional suffering may be entirely different from the things that everyone needs to do, regardless of whether they have a psychiatric disorder, to feel their emotional best.

The National Alliance on Mental Illness tells us that one in five Americans are suffering from a mental illness, while the Epidemiologic Catchment Area Program revealed that half of people will meet criteria for a mental illness at some point in their lives. We hear about “the mentally ill” constantly in the news – often in relation to mass shooters or homelessness – yet even psychiatrists might be pressed to define who exactly the “mentally ill” are. And how many of us could not somehow, at some time, find ourselves in 1 of the 157 disorders that DSM-5 lists – down from 365 disorders in the DSM-IV-TR?

Differentiating mental health from mental illness is just the beginning of our semantic confusion. As psychiatrists we treat major depression, and yet the illness “depression,” a syndromic constellation of symptoms, includes the key symptom of sadness. People often say they are “depressed” when they mean they are sad or demoralized, and yet, if their sadness persists in the absence of other symptoms, they may well want, or feel they “should” have medications, even in the absence of a disorder. And maybe those medications help them feel better, so that the presence or absence of a verified illness doesn’t really matter. But if the medications cause adverse reactions, then psychiatry might have done a better job by that person’s sadness. Melancholia, or perhaps any designation than “depression,” with its multiple meanings, might better serve our patients and our profession. This is only one example, as the number of people who tell me they have obsessive-compulsive disorder – or more often announce, “I’m OCD!” because they are well organized in a productive way is remarkable. And while I have treated only a few people who meet the criteria for narcissistic personality disorder, from general conversation it would seem that they are at every dinner table and by every water cooler.

Does it matter? A diagnostic lexicon can be so helpful when it guides treatment, provides a heterogeneous group of patients for research studies, and allows for an understanding of the etiology, course, and prognosis of a given condition. When someone is so depressed that they can’t get out of bed, or is so disorganized that they can’t perform their job and might cause a disturbance in their workplace, it is good to instruct them to take time off work and send them back well with a doctor’s note. But this is different from the person who doesn’t want to face a difficult situation, who simply doesn’t like their job or their boss, or who wants their pet declared an emotional support animal to avoid the fee the airlines charge to bring an animal on board if one does not have a psychiatric diagnosis. Sometimes these lines are blurry – if someone does not want to do something because it makes them anxious, does it matter how deep the pit in their stomach is, or if they are having full-blown panic attacks? When do we agree that their distress is reason to allow them to avoid responsibilities without repercussions versus a violation of their obligations and an infringement on others?

Diagnoses offer solace to some patients: There is a name for their suffering, available treatment, and often others with the same condition to look to for guidance and community. For others, a psychiatric diagnosis is a source of shame, a label they see as damaging to their character and sometimes to their careers – including in medicine – where we have been particularly unsympathetic to those who announce a psychiatric history.

In some cultures, the label itself decreases someone’s attractiveness as a potential marriage partner. We would all like to see the stigma of mental illness vanish, but we have a long way to go.

Psychiatric diagnoses move over time and with our politics and culture. This is good; we don’t hold on to what we learn to be untrue. But they may well add to issues of inequity. Those who can afford to pay for expensive educational assessments can request educational accommodations, including untimed standardized tests. This advantage may not be available to those without the resources to pay for these evaluations, and one might wonder why all comers can’t take untimed tests so as not to favor the privileged. Psychiatry has long been accused of diagnosing people of color with poor prognosis illnesses and women with conditions that imply emotional weakness.

While our diagnoses have clinical utility, it is unfortunate that they have come to be about reimbursement. A diagnosis needs to be assigned for insurers to pay for care, and so we create diagnostic categories to allow for treatment. Is this reasonable? Do we need to say that someone who is suffering after the death of a loved one has a mental illness in order to allow them to seek relief from their suffering? It leads us to believe that all suffering is about pathology, that we should expect pain-free emotional lives. Perhaps we need a diagnostic category of psychic pain, not otherwise specified, to allow for treatment for those who simply ache.

Mental illness is about interventions to alleviate the suffering of those with disorders. Mental health is about interventions that may benefit everyone, whether they suffer from a mental illness or not. Sleep, nutrition, exercise, sunlight, nature, entertainment and escape, yoga, meditation, vacations in beautiful places with loving people – these are things that potentially help us all whether we do or do not have an illness. With so much confusion about what it is we do, and about who “should” get help, who can get help, who might want help, and where they should go to seek help, perhaps it would be better if our lingo were more precise.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). The has a private practice and is assistant professor of psychiatry ad behavioral sciences at Johns Hopkins University, both in Baltimore. She has no disclosures.

I am a psychiatrist, which means I am a mental health professional, which means I work with people with mental illness. Sometimes people with mental health conditions who suffer from mental illness need to take a day off work – also called a mental health day – because they are too symptomatic to work, and sometimes people who don’t have a mental illness need to take a day off work, also called a mental health day, because they are feeling stressed.

Sometimes professional athletes don’t do things they agreed to do in their contracts because they realize that doing these things is very upsetting and will be detrimental to their mental health, or maybe they have a mental illness and doing these things will worsen their mental health condition, which is, in fact, a mental illness. Other times people with mental health conditions need to have pets travel with them because this mitigates the symptoms of their mental illness or perhaps it’s just good for their mental health. And finally, some people suffer from mental illnesses, or sometimes from learning problems, which are severe enough that a person with these conditions has a disability and needs special accommodations to function optimally in educational or occupational settings, or needs public financial support because their difficulties disable them to the point that they can’t work at all.

Is your head spinning yet? The point I am trying to make is that, as a profession, we have done an abysmal job of defining what we do, who we serve, and differentiating the fact that what someone with a psychiatric disorder needs to do to function or to alleviate emotional suffering may be entirely different from the things that everyone needs to do, regardless of whether they have a psychiatric disorder, to feel their emotional best.

The National Alliance on Mental Illness tells us that one in five Americans are suffering from a mental illness, while the Epidemiologic Catchment Area Program revealed that half of people will meet criteria for a mental illness at some point in their lives. We hear about “the mentally ill” constantly in the news – often in relation to mass shooters or homelessness – yet even psychiatrists might be pressed to define who exactly the “mentally ill” are. And how many of us could not somehow, at some time, find ourselves in 1 of the 157 disorders that DSM-5 lists – down from 365 disorders in the DSM-IV-TR?

Differentiating mental health from mental illness is just the beginning of our semantic confusion. As psychiatrists we treat major depression, and yet the illness “depression,” a syndromic constellation of symptoms, includes the key symptom of sadness. People often say they are “depressed” when they mean they are sad or demoralized, and yet, if their sadness persists in the absence of other symptoms, they may well want, or feel they “should” have medications, even in the absence of a disorder. And maybe those medications help them feel better, so that the presence or absence of a verified illness doesn’t really matter. But if the medications cause adverse reactions, then psychiatry might have done a better job by that person’s sadness. Melancholia, or perhaps any designation than “depression,” with its multiple meanings, might better serve our patients and our profession. This is only one example, as the number of people who tell me they have obsessive-compulsive disorder – or more often announce, “I’m OCD!” because they are well organized in a productive way is remarkable. And while I have treated only a few people who meet the criteria for narcissistic personality disorder, from general conversation it would seem that they are at every dinner table and by every water cooler.

Does it matter? A diagnostic lexicon can be so helpful when it guides treatment, provides a heterogeneous group of patients for research studies, and allows for an understanding of the etiology, course, and prognosis of a given condition. When someone is so depressed that they can’t get out of bed, or is so disorganized that they can’t perform their job and might cause a disturbance in their workplace, it is good to instruct them to take time off work and send them back well with a doctor’s note. But this is different from the person who doesn’t want to face a difficult situation, who simply doesn’t like their job or their boss, or who wants their pet declared an emotional support animal to avoid the fee the airlines charge to bring an animal on board if one does not have a psychiatric diagnosis. Sometimes these lines are blurry – if someone does not want to do something because it makes them anxious, does it matter how deep the pit in their stomach is, or if they are having full-blown panic attacks? When do we agree that their distress is reason to allow them to avoid responsibilities without repercussions versus a violation of their obligations and an infringement on others?

Diagnoses offer solace to some patients: There is a name for their suffering, available treatment, and often others with the same condition to look to for guidance and community. For others, a psychiatric diagnosis is a source of shame, a label they see as damaging to their character and sometimes to their careers – including in medicine – where we have been particularly unsympathetic to those who announce a psychiatric history.

In some cultures, the label itself decreases someone’s attractiveness as a potential marriage partner. We would all like to see the stigma of mental illness vanish, but we have a long way to go.

Psychiatric diagnoses move over time and with our politics and culture. This is good; we don’t hold on to what we learn to be untrue. But they may well add to issues of inequity. Those who can afford to pay for expensive educational assessments can request educational accommodations, including untimed standardized tests. This advantage may not be available to those without the resources to pay for these evaluations, and one might wonder why all comers can’t take untimed tests so as not to favor the privileged. Psychiatry has long been accused of diagnosing people of color with poor prognosis illnesses and women with conditions that imply emotional weakness.

While our diagnoses have clinical utility, it is unfortunate that they have come to be about reimbursement. A diagnosis needs to be assigned for insurers to pay for care, and so we create diagnostic categories to allow for treatment. Is this reasonable? Do we need to say that someone who is suffering after the death of a loved one has a mental illness in order to allow them to seek relief from their suffering? It leads us to believe that all suffering is about pathology, that we should expect pain-free emotional lives. Perhaps we need a diagnostic category of psychic pain, not otherwise specified, to allow for treatment for those who simply ache.

Mental illness is about interventions to alleviate the suffering of those with disorders. Mental health is about interventions that may benefit everyone, whether they suffer from a mental illness or not. Sleep, nutrition, exercise, sunlight, nature, entertainment and escape, yoga, meditation, vacations in beautiful places with loving people – these are things that potentially help us all whether we do or do not have an illness. With so much confusion about what it is we do, and about who “should” get help, who can get help, who might want help, and where they should go to seek help, perhaps it would be better if our lingo were more precise.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). The has a private practice and is assistant professor of psychiatry ad behavioral sciences at Johns Hopkins University, both in Baltimore. She has no disclosures.

As a physician first and a mental health clinician second, I hope to provide factual medical information on the Omicron variant to my patients, family members, and friends. I also try to remain curious instead of angry about why some choose not to vaccinate.

The most effective way to encourage people to obtain a vaccination is to use communication free of judgment and criticism, which allows a safe space for the unvaccinated to express their motivations and fears behind their current choice of not vaccinating and explore possible barriers to an alternative option that could lead to vaccination.

As an adult psychiatrist, ADHD specialist, and amateur COVID-19 expert, I’d like to offer 10 reasons why Omicron – which ironically means “small” in Latin, can still cause big destruction. Please share these 10 reasons with your patients.

• If you are not vaccinated, this virus will find you within the next few weeks and likely lead to severe symptoms.
• Long-haul symptoms from COVID-19 infection are still possible even for people who contract a milder case of the Omicron variant.
• The monoclonal antibody and antiviral treatments recently approved by the Food and Drug Administration for pre-exposure prevention of COVID-19 are limited. For many reasons, now is not the best time to play Russian roulette and intentionally get infected with a “mild” variant.
• There are not enough testing sites or over-the-counter rapid COVID tests available to keep up with the demand, and the latter are cost prohibitive for many people.
• Emergency care during the next few weeks for unforeseen non–COVID-related illnesses, such as a sudden heart attack or stroke, may be affected by the shortage of medical providers because of illness, quarantine, and burnout.
• There will be fewer first responders, including EMTs, police officers, and firefighters, because of COVID quarantines from illness and exposure.
• Although most Americans oppose temporary shutdowns, de facto shutdowns might be necessary because of the absence of healthy, COVID-negative individuals to maintain a functional society.
• Omicron math is deceiving, since the risk of hospitalization with Omicron appears to be far lower than with the Delta variant. However, the higher volume of infections with Omicron will offset the lower severity leading to comparable numbers of hospitalizations.
• Omicron has made it difficult for some schools to reopen after the holiday break, and reopening might become even more difficult as the surge progresses. Many schools already were in desperate need of substitute teachers, bus drivers, and additional staff necessary for COVID safety precautions before the emergence of the Omicron variant.
• And, for a less altruistic reason, as if the nine reasons above weren’t enough – if infections continue, especially among the unvaccinated – where the virus mutates the most – this can lead to a trifecta variant that not only evades the immune system and is highly infectious but causes severe disease in both the unvaccinated as well as the vaccinated.

Because of its extremely high transmissibility, the Omicron variant – layered atop Delta – presents great risk to us as a society. We must do all we can as clinicians to educate our patients so that they can protect themselves and their families.

Dr. Abraham is a psychiatrist in private practice in Philadelphia. She has no disclosures.

As a physician first and a mental health clinician second, I hope to provide factual medical information on the Omicron variant to my patients, family members, and friends. I also try to remain curious instead of angry about why some choose not to vaccinate.

The most effective way to encourage people to obtain a vaccination is to use communication free of judgment and criticism, which allows a safe space for the unvaccinated to express their motivations and fears behind their current choice of not vaccinating and explore possible barriers to an alternative option that could lead to vaccination.

As an adult psychiatrist, ADHD specialist, and amateur COVID-19 expert, I’d like to offer 10 reasons why Omicron – which ironically means “small” in Latin, can still cause big destruction. Please share these 10 reasons with your patients.

• If you are not vaccinated, this virus will find you within the next few weeks and likely lead to severe symptoms.
• Long-haul symptoms from COVID-19 infection are still possible even for people who contract a milder case of the Omicron variant.
• The monoclonal antibody and antiviral treatments recently approved by the Food and Drug Administration for pre-exposure prevention of COVID-19 are limited. For many reasons, now is not the best time to play Russian roulette and intentionally get infected with a “mild” variant.
• There are not enough testing sites or over-the-counter rapid COVID tests available to keep up with the demand, and the latter are cost prohibitive for many people.
• Emergency care during the next few weeks for unforeseen non–COVID-related illnesses, such as a sudden heart attack or stroke, may be affected by the shortage of medical providers because of illness, quarantine, and burnout.
• There will be fewer first responders, including EMTs, police officers, and firefighters, because of COVID quarantines from illness and exposure.
• Although most Americans oppose temporary shutdowns, de facto shutdowns might be necessary because of the absence of healthy, COVID-negative individuals to maintain a functional society.
• Omicron math is deceiving, since the risk of hospitalization with Omicron appears to be far lower than with the Delta variant. However, the higher volume of infections with Omicron will offset the lower severity leading to comparable numbers of hospitalizations.
• Omicron has made it difficult for some schools to reopen after the holiday break, and reopening might become even more difficult as the surge progresses. Many schools already were in desperate need of substitute teachers, bus drivers, and additional staff necessary for COVID safety precautions before the emergence of the Omicron variant.
• And, for a less altruistic reason, as if the nine reasons above weren’t enough – if infections continue, especially among the unvaccinated – where the virus mutates the most – this can lead to a trifecta variant that not only evades the immune system and is highly infectious but causes severe disease in both the unvaccinated as well as the vaccinated.

Because of its extremely high transmissibility, the Omicron variant – layered atop Delta – presents great risk to us as a society. We must do all we can as clinicians to educate our patients so that they can protect themselves and their families.

Dr. Abraham is a psychiatrist in private practice in Philadelphia. She has no disclosures.

As a physician first and a mental health clinician second, I hope to provide factual medical information on the Omicron variant to my patients, family members, and friends. I also try to remain curious instead of angry about why some choose not to vaccinate.

The most effective way to encourage people to obtain a vaccination is to use communication free of judgment and criticism, which allows a safe space for the unvaccinated to express their motivations and fears behind their current choice of not vaccinating and explore possible barriers to an alternative option that could lead to vaccination.

As an adult psychiatrist, ADHD specialist, and amateur COVID-19 expert, I’d like to offer 10 reasons why Omicron – which ironically means “small” in Latin, can still cause big destruction. Please share these 10 reasons with your patients.

• If you are not vaccinated, this virus will find you within the next few weeks and likely lead to severe symptoms.
• Long-haul symptoms from COVID-19 infection are still possible even for people who contract a milder case of the Omicron variant.
• The monoclonal antibody and antiviral treatments recently approved by the Food and Drug Administration for pre-exposure prevention of COVID-19 are limited. For many reasons, now is not the best time to play Russian roulette and intentionally get infected with a “mild” variant.
• There are not enough testing sites or over-the-counter rapid COVID tests available to keep up with the demand, and the latter are cost prohibitive for many people.
• Emergency care during the next few weeks for unforeseen non–COVID-related illnesses, such as a sudden heart attack or stroke, may be affected by the shortage of medical providers because of illness, quarantine, and burnout.
• There will be fewer first responders, including EMTs, police officers, and firefighters, because of COVID quarantines from illness and exposure.
• Although most Americans oppose temporary shutdowns, de facto shutdowns might be necessary because of the absence of healthy, COVID-negative individuals to maintain a functional society.
• Omicron math is deceiving, since the risk of hospitalization with Omicron appears to be far lower than with the Delta variant. However, the higher volume of infections with Omicron will offset the lower severity leading to comparable numbers of hospitalizations.
• Omicron has made it difficult for some schools to reopen after the holiday break, and reopening might become even more difficult as the surge progresses. Many schools already were in desperate need of substitute teachers, bus drivers, and additional staff necessary for COVID safety precautions before the emergence of the Omicron variant.
• And, for a less altruistic reason, as if the nine reasons above weren’t enough – if infections continue, especially among the unvaccinated – where the virus mutates the most – this can lead to a trifecta variant that not only evades the immune system and is highly infectious but causes severe disease in both the unvaccinated as well as the vaccinated.

Because of its extremely high transmissibility, the Omicron variant – layered atop Delta – presents great risk to us as a society. We must do all we can as clinicians to educate our patients so that they can protect themselves and their families.

Dr. Abraham is a psychiatrist in private practice in Philadelphia. She has no disclosures.

The nation’s Surgeon General, Vice Admiral Vivek H. Murthy, MD, MBA, recently released an advisory report on the current state of youth mental health and recommendations to improve well-being. This action follows a number of emergency declarations that have been made by professional organizations such as the American Academy of Child and Adolescent Psychiatry (AACAP), the American Academy of Pediatrics (AAP), and other health care groups to raise awareness about the alarming increase of depression, suicide, anxiety, and other mental health problems in youth.

These reports can be helpful in focusing attention and resources for important public health problems. Many still reference the 1999 report from former Surgeon General David Satcher, MD, PhD, which offered a number of eye-opening statistics regarding the prevalence of mental health conditions and the amount of disability associated with them.

Sadly, the present report indicates that many of these indices have grown worse in the past 20 years. For example, the advisory notes that, even before COVID-19, fully half of female high school students reported persistent feelings of sadness or hopelessness (up 40% from 2009). The report then goes on to cite a number of studies documenting even further rises in youth mental health problems associated with the pandemic.

Most of the advisory, however, is devoted to actions that can be taken by different groups, including young people themselves, parents, educators, the government, and even social media and video game companies, to support mental health and well-being. Multiple online resources are provided at the end of each of these sections.

One of the segments is aimed at health care organizations and professionals. While first making a fairly sweeping statement that “our health care system today is not set up optimally to support the mental health and well-being of children and youth,” this part then outlines five broad recommendations that might help improve the fit. These include the following.

• Increase prevention efforts, such as coordination to enrichment programs and referrals for economic and legal supports for families in need.
• Screen routinely for mental health conditions and link those who screen in with appropriate care.
• Identify mental health needs in parents and caregivers such as depression and substance use that can have negative effects on children.
• Increase partnerships between health care groups and community organizations.
• Build multidisciplinary teams that are culturally appropriate and maximally engage children and caretakers in the decision-making process.

The current report is downloadable for free (see reference below) and it is certainly worthwhile for pediatricians to take a look. Dr. Murthy writes, regarding the current state of mental health, that “it would be a tragedy if we beat back one public health crisis only to allow another to grow in its place.”

The report also outlines specific areas where additional research is needed, such as data on racial and sexual minorities and research on innovative and scalable therapies. In addition to the online resources that are provided, the report is backed by over 250 references.

Since its release, the report has generally been well received, and, indeed, there is much to support. The well-known Child Mind Institute in New York tweeted that “this document is a wake-up call for the country and a long-overdue statement of leadership from the federal government.”

Many of the recommendations are admittedly somewhat commons sense, but there are some that are much less so. For example, one recommendation to youth themselves is to serve others – something that may first come across as counterintuitive but can indeed help children and adolescents develop a sense of purpose and self-worth. The call for pediatric health care professionals to screen parents in addition to the patients themselves will likely result in some debate as well. The recommendation to reduce access to lethal means, including the specific naming of firearms, is also a welcome addition. This report also rightly puts a spotlight on the role of societal factors such as racism and poverty in the development of mental health problems and in getting access to quality treatment.

Also worth noting is how much of the advisory examined the role of media in both the problem and the solution. While recognizing that technology, smartphones, and social media are here to stay, a number of suggestions were given to parents, media organizations, journalists, and entertainment companies to reduce the negative impacts these mediums can have. Explicitly recognized in the report is that “there can be tension between what’s best for the technology company and what’s best for the individual user or society.” Also acknowledged was that the link between media of various types and mental health is complex and inconsistent with there being a strong need for additional work in this area when it comes to academic research as well as product development within these companies themselves.

Yet while there is much to like about the advisory, there remain some areas that seem lacking. For example, the text about what causes mental health conditions gets a little dualistic in mentioning biological and environmental factors without much appreciation that these are hardly independent domains. Perhaps more substantially, there was surprisingly little airtime devoted to an enormous issue that underlies so many other challenges related to mental health care – namely an inadequate workforce that gets smaller by the minute. The topic was treated much too superficially with lots of vague calls to “expand” the workforce that lacked substance or detail.

Overall, however, the new Surgeon General’s Advisory is a welcome document that offers updated knowledge of our current challenges and provides practical responses that truly could make a difference. Now all we have to do is put these recommendations into action.

Dr. Rettew is a child and adolescent psychiatrist and medical director of Lane County Behavioral Health in Eugene, Ore. His latest book is “Parenting Made Complicated: What Science Really Knows About the Greatest Debates of Early Childhood.” You can follow him on Twitter and Facebook @PediPsych.

Reference

“Protecting Youth Mental Health – The U.S. Surgeon General’s Advisory,” U.S. Department of Health & Human Services (2021).

The nation’s Surgeon General, Vice Admiral Vivek H. Murthy, MD, MBA, recently released an advisory report on the current state of youth mental health and recommendations to improve well-being. This action follows a number of emergency declarations that have been made by professional organizations such as the American Academy of Child and Adolescent Psychiatry (AACAP), the American Academy of Pediatrics (AAP), and other health care groups to raise awareness about the alarming increase of depression, suicide, anxiety, and other mental health problems in youth.

These reports can be helpful in focusing attention and resources for important public health problems. Many still reference the 1999 report from former Surgeon General David Satcher, MD, PhD, which offered a number of eye-opening statistics regarding the prevalence of mental health conditions and the amount of disability associated with them.

Sadly, the present report indicates that many of these indices have grown worse in the past 20 years. For example, the advisory notes that, even before COVID-19, fully half of female high school students reported persistent feelings of sadness or hopelessness (up 40% from 2009). The report then goes on to cite a number of studies documenting even further rises in youth mental health problems associated with the pandemic.

Most of the advisory, however, is devoted to actions that can be taken by different groups, including young people themselves, parents, educators, the government, and even social media and video game companies, to support mental health and well-being. Multiple online resources are provided at the end of each of these sections.

One of the segments is aimed at health care organizations and professionals. While first making a fairly sweeping statement that “our health care system today is not set up optimally to support the mental health and well-being of children and youth,” this part then outlines five broad recommendations that might help improve the fit. These include the following.

• Increase prevention efforts, such as coordination to enrichment programs and referrals for economic and legal supports for families in need.
• Screen routinely for mental health conditions and link those who screen in with appropriate care.
• Identify mental health needs in parents and caregivers such as depression and substance use that can have negative effects on children.
• Increase partnerships between health care groups and community organizations.
• Build multidisciplinary teams that are culturally appropriate and maximally engage children and caretakers in the decision-making process.

The current report is downloadable for free (see reference below) and it is certainly worthwhile for pediatricians to take a look. Dr. Murthy writes, regarding the current state of mental health, that “it would be a tragedy if we beat back one public health crisis only to allow another to grow in its place.”

The report also outlines specific areas where additional research is needed, such as data on racial and sexual minorities and research on innovative and scalable therapies. In addition to the online resources that are provided, the report is backed by over 250 references.

Since its release, the report has generally been well received, and, indeed, there is much to support. The well-known Child Mind Institute in New York tweeted that “this document is a wake-up call for the country and a long-overdue statement of leadership from the federal government.”

Many of the recommendations are admittedly somewhat commons sense, but there are some that are much less so. For example, one recommendation to youth themselves is to serve others – something that may first come across as counterintuitive but can indeed help children and adolescents develop a sense of purpose and self-worth. The call for pediatric health care professionals to screen parents in addition to the patients themselves will likely result in some debate as well. The recommendation to reduce access to lethal means, including the specific naming of firearms, is also a welcome addition. This report also rightly puts a spotlight on the role of societal factors such as racism and poverty in the development of mental health problems and in getting access to quality treatment.

Also worth noting is how much of the advisory examined the role of media in both the problem and the solution. While recognizing that technology, smartphones, and social media are here to stay, a number of suggestions were given to parents, media organizations, journalists, and entertainment companies to reduce the negative impacts these mediums can have. Explicitly recognized in the report is that “there can be tension between what’s best for the technology company and what’s best for the individual user or society.” Also acknowledged was that the link between media of various types and mental health is complex and inconsistent with there being a strong need for additional work in this area when it comes to academic research as well as product development within these companies themselves.

Yet while there is much to like about the advisory, there remain some areas that seem lacking. For example, the text about what causes mental health conditions gets a little dualistic in mentioning biological and environmental factors without much appreciation that these are hardly independent domains. Perhaps more substantially, there was surprisingly little airtime devoted to an enormous issue that underlies so many other challenges related to mental health care – namely an inadequate workforce that gets smaller by the minute. The topic was treated much too superficially with lots of vague calls to “expand” the workforce that lacked substance or detail.

Overall, however, the new Surgeon General’s Advisory is a welcome document that offers updated knowledge of our current challenges and provides practical responses that truly could make a difference. Now all we have to do is put these recommendations into action.

Dr. Rettew is a child and adolescent psychiatrist and medical director of Lane County Behavioral Health in Eugene, Ore. His latest book is “Parenting Made Complicated: What Science Really Knows About the Greatest Debates of Early Childhood.” You can follow him on Twitter and Facebook @PediPsych.

Reference

“Protecting Youth Mental Health – The U.S. Surgeon General’s Advisory,” U.S. Department of Health & Human Services (2021).

The nation’s Surgeon General, Vice Admiral Vivek H. Murthy, MD, MBA, recently released an advisory report on the current state of youth mental health and recommendations to improve well-being. This action follows a number of emergency declarations that have been made by professional organizations such as the American Academy of Child and Adolescent Psychiatry (AACAP), the American Academy of Pediatrics (AAP), and other health care groups to raise awareness about the alarming increase of depression, suicide, anxiety, and other mental health problems in youth.

These reports can be helpful in focusing attention and resources for important public health problems. Many still reference the 1999 report from former Surgeon General David Satcher, MD, PhD, which offered a number of eye-opening statistics regarding the prevalence of mental health conditions and the amount of disability associated with them.

Sadly, the present report indicates that many of these indices have grown worse in the past 20 years. For example, the advisory notes that, even before COVID-19, fully half of female high school students reported persistent feelings of sadness or hopelessness (up 40% from 2009). The report then goes on to cite a number of studies documenting even further rises in youth mental health problems associated with the pandemic.

Most of the advisory, however, is devoted to actions that can be taken by different groups, including young people themselves, parents, educators, the government, and even social media and video game companies, to support mental health and well-being. Multiple online resources are provided at the end of each of these sections.

One of the segments is aimed at health care organizations and professionals. While first making a fairly sweeping statement that “our health care system today is not set up optimally to support the mental health and well-being of children and youth,” this part then outlines five broad recommendations that might help improve the fit. These include the following.

• Increase prevention efforts, such as coordination to enrichment programs and referrals for economic and legal supports for families in need.
• Screen routinely for mental health conditions and link those who screen in with appropriate care.
• Identify mental health needs in parents and caregivers such as depression and substance use that can have negative effects on children.
• Increase partnerships between health care groups and community organizations.
• Build multidisciplinary teams that are culturally appropriate and maximally engage children and caretakers in the decision-making process.

The current report is downloadable for free (see reference below) and it is certainly worthwhile for pediatricians to take a look. Dr. Murthy writes, regarding the current state of mental health, that “it would be a tragedy if we beat back one public health crisis only to allow another to grow in its place.”

The report also outlines specific areas where additional research is needed, such as data on racial and sexual minorities and research on innovative and scalable therapies. In addition to the online resources that are provided, the report is backed by over 250 references.

Since its release, the report has generally been well received, and, indeed, there is much to support. The well-known Child Mind Institute in New York tweeted that “this document is a wake-up call for the country and a long-overdue statement of leadership from the federal government.”

Many of the recommendations are admittedly somewhat commons sense, but there are some that are much less so. For example, one recommendation to youth themselves is to serve others – something that may first come across as counterintuitive but can indeed help children and adolescents develop a sense of purpose and self-worth. The call for pediatric health care professionals to screen parents in addition to the patients themselves will likely result in some debate as well. The recommendation to reduce access to lethal means, including the specific naming of firearms, is also a welcome addition. This report also rightly puts a spotlight on the role of societal factors such as racism and poverty in the development of mental health problems and in getting access to quality treatment.

Also worth noting is how much of the advisory examined the role of media in both the problem and the solution. While recognizing that technology, smartphones, and social media are here to stay, a number of suggestions were given to parents, media organizations, journalists, and entertainment companies to reduce the negative impacts these mediums can have. Explicitly recognized in the report is that “there can be tension between what’s best for the technology company and what’s best for the individual user or society.” Also acknowledged was that the link between media of various types and mental health is complex and inconsistent with there being a strong need for additional work in this area when it comes to academic research as well as product development within these companies themselves.

Yet while there is much to like about the advisory, there remain some areas that seem lacking. For example, the text about what causes mental health conditions gets a little dualistic in mentioning biological and environmental factors without much appreciation that these are hardly independent domains. Perhaps more substantially, there was surprisingly little airtime devoted to an enormous issue that underlies so many other challenges related to mental health care – namely an inadequate workforce that gets smaller by the minute. The topic was treated much too superficially with lots of vague calls to “expand” the workforce that lacked substance or detail.

Overall, however, the new Surgeon General’s Advisory is a welcome document that offers updated knowledge of our current challenges and provides practical responses that truly could make a difference. Now all we have to do is put these recommendations into action.

Dr. Rettew is a child and adolescent psychiatrist and medical director of Lane County Behavioral Health in Eugene, Ore. His latest book is “Parenting Made Complicated: What Science Really Knows About the Greatest Debates of Early Childhood.” You can follow him on Twitter and Facebook @PediPsych.

Reference

“Protecting Youth Mental Health – The U.S. Surgeon General’s Advisory,” U.S. Department of Health & Human Services (2021).

“I am capable and ready to begin.”

Sounds trite, doesn’t it? What slush pile did that come from?

Actually, it was the closing sentence of the 1988 “personal statement” I wrote for my medical school applications. (I applied to something like 25 schools, maybe more.) Come to think of it, I suspect my father came up with that line.

Have you read your personal statement since you became an attending? It’s like a letter from an alternate universe, where you weren’t a doctor, weren’t sure you’d ever be one, and were trying very hard to sound confident in the face of an uncertain future.

Mine began in a melodramatic way, emphasizing what I’d seen as an emergency department volunteer. When I wrote it I thought I’d be an ED doc, and never imagined that years later I’d be doing something entirely different – and loving it.

Having the opportunity to go back and talk to our younger selves is a common trope in movies, but in real life reading something like this is as close as it gets. But it’s still neat. It brings back not who you are, but who you were. Reminds you why you wanted to be a doctor, when you were younger, probably more naive, and felt medicine was a calling, not a job.

Do you still feel that way, after years of paperwork, insurance games, a mortgage, a family, defensive medicine, your own health changes, and all the other things life and the often-jaded medical field bring?

I hope the answer is still yes.

On my first day at Creighton Medical School, our dean – the late William L. Pancoe, PhD – gave us a “go get ‘em!” speech. His main theme was that we should “wear sneakers and hit the ground running” on day 1, because otherwise we’d never catch up. But he also told us to remember and hold on to the feeling we had when we got our first medical school acceptance letter. That feeling of relief, joy, the realization that we’d been given a chance to make our dream come true. He told us that feeling might be all that would get us through the long nights of studying, the occasional failures, the self-doubts, and all the other things in the 4 years to come.

Dean Pancoe, you were absolutely right. Today I’m older than you were when you gave us that speech. My only additions would be:

1. Don’t just hold onto that feeling for medical school, but for life.

2. Always keep one copy of your personal statement (even if in your picture you were wearing hideous 1980s-style glasses, like mine). Keep it in your work desk, not in the bottom of a filing cabinet or scrapbook. Read it at least once a year. It’ll take maybe 2 minutes. You have that much time to spare.

Because it’s not just the young who can learn from the wisdom of the old. The older can learn, and be reminded of, many good things from the young. Even if that younger person is you.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“I am capable and ready to begin.”

Sounds trite, doesn’t it? What slush pile did that come from?

Actually, it was the closing sentence of the 1988 “personal statement” I wrote for my medical school applications. (I applied to something like 25 schools, maybe more.) Come to think of it, I suspect my father came up with that line.

Have you read your personal statement since you became an attending? It’s like a letter from an alternate universe, where you weren’t a doctor, weren’t sure you’d ever be one, and were trying very hard to sound confident in the face of an uncertain future.

Mine began in a melodramatic way, emphasizing what I’d seen as an emergency department volunteer. When I wrote it I thought I’d be an ED doc, and never imagined that years later I’d be doing something entirely different – and loving it.

Having the opportunity to go back and talk to our younger selves is a common trope in movies, but in real life reading something like this is as close as it gets. But it’s still neat. It brings back not who you are, but who you were. Reminds you why you wanted to be a doctor, when you were younger, probably more naive, and felt medicine was a calling, not a job.

Do you still feel that way, after years of paperwork, insurance games, a mortgage, a family, defensive medicine, your own health changes, and all the other things life and the often-jaded medical field bring?

I hope the answer is still yes.

On my first day at Creighton Medical School, our dean – the late William L. Pancoe, PhD – gave us a “go get ‘em!” speech. His main theme was that we should “wear sneakers and hit the ground running” on day 1, because otherwise we’d never catch up. But he also told us to remember and hold on to the feeling we had when we got our first medical school acceptance letter. That feeling of relief, joy, the realization that we’d been given a chance to make our dream come true. He told us that feeling might be all that would get us through the long nights of studying, the occasional failures, the self-doubts, and all the other things in the 4 years to come.

Dean Pancoe, you were absolutely right. Today I’m older than you were when you gave us that speech. My only additions would be:

1. Don’t just hold onto that feeling for medical school, but for life.

2. Always keep one copy of your personal statement (even if in your picture you were wearing hideous 1980s-style glasses, like mine). Keep it in your work desk, not in the bottom of a filing cabinet or scrapbook. Read it at least once a year. It’ll take maybe 2 minutes. You have that much time to spare.

Because it’s not just the young who can learn from the wisdom of the old. The older can learn, and be reminded of, many good things from the young. Even if that younger person is you.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“I am capable and ready to begin.”

Sounds trite, doesn’t it? What slush pile did that come from?

Actually, it was the closing sentence of the 1988 “personal statement” I wrote for my medical school applications. (I applied to something like 25 schools, maybe more.) Come to think of it, I suspect my father came up with that line.

Have you read your personal statement since you became an attending? It’s like a letter from an alternate universe, where you weren’t a doctor, weren’t sure you’d ever be one, and were trying very hard to sound confident in the face of an uncertain future.

Mine began in a melodramatic way, emphasizing what I’d seen as an emergency department volunteer. When I wrote it I thought I’d be an ED doc, and never imagined that years later I’d be doing something entirely different – and loving it.

Having the opportunity to go back and talk to our younger selves is a common trope in movies, but in real life reading something like this is as close as it gets. But it’s still neat. It brings back not who you are, but who you were. Reminds you why you wanted to be a doctor, when you were younger, probably more naive, and felt medicine was a calling, not a job.

Do you still feel that way, after years of paperwork, insurance games, a mortgage, a family, defensive medicine, your own health changes, and all the other things life and the often-jaded medical field bring?

I hope the answer is still yes.

On my first day at Creighton Medical School, our dean – the late William L. Pancoe, PhD – gave us a “go get ‘em!” speech. His main theme was that we should “wear sneakers and hit the ground running” on day 1, because otherwise we’d never catch up. But he also told us to remember and hold on to the feeling we had when we got our first medical school acceptance letter. That feeling of relief, joy, the realization that we’d been given a chance to make our dream come true. He told us that feeling might be all that would get us through the long nights of studying, the occasional failures, the self-doubts, and all the other things in the 4 years to come.

Dean Pancoe, you were absolutely right. Today I’m older than you were when you gave us that speech. My only additions would be:

1. Don’t just hold onto that feeling for medical school, but for life.

2. Always keep one copy of your personal statement (even if in your picture you were wearing hideous 1980s-style glasses, like mine). Keep it in your work desk, not in the bottom of a filing cabinet or scrapbook. Read it at least once a year. It’ll take maybe 2 minutes. You have that much time to spare.

Because it’s not just the young who can learn from the wisdom of the old. The older can learn, and be reminded of, many good things from the young. Even if that younger person is you.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The Centers for Disease Control and Prevention’s decision to shorten the length of isolation time for asymptomatic Americans with COVID-19, regardless of their vaccination status, to 5 days from 10 days is confusing. I hope the agency reconsiders this decision.

After all, one of the CDC’s key messages during this pandemic has been that even people with asymptomatic COVID who have been vaccinated and boosted can transmit the disease. So it seems to me that the Dec. 27, 2021, recommendation about shortening the isolation time for COVID-19–positive people, like the agency’s earlier guidance encouraging people who are vaccinated to stop wearing masks while in indoor settings, runs contrary to good public health principles.

As an expert in human behavior, I am worried about the impact of these confusing messages on the psyche of people in general, as well as on our patients.
 

Mental health impact

Soon after the United States went on lockdown in March 2020, I wrote about the likelihood of a pandemic of PTSD, anxiety, and depression that would occur in the wake of rising COVID-19 rates. Well, it happened.

Many people have felt a sense of existential despair, depression, and anxiety. As we head into year No. 3 of disruption of our daily lives – and face the loss of more than 825,000 Americans to COVID – we continue to navigate this uncertainty. And now we must deal with Omicron, a variant that is so highly transmissible that it is apparently able to, in some cases, evade two-dose regimens of mRNA vaccines, boosters, and immunity from past infections, according to a report from Imperial College London. Yet, we are being told by some that Omicron might be less severe, compared with other variants. I worry that this assessment is misleading. In that same report, the Imperial College said it “found no evidence” that Omicron is less virulent than Delta, based on the risk of hospitalization and symptom status.

Meanwhile, animal studies suggest that the Omicron variant might lead to less lung damage than previous variants. A preprint article that is being considered for publication by a Nature Portfolio journal suggests that hamsters and mice infected with the Omicron variant do not have as much lung damage as those infected with other variants. More data need to come in for us to get a true understanding of Omicron’s virulence and transmissibility. We should keep an eye on Israel, which is launching a clinical trial of a second booster, or fourth mRNA shot.

As clinicians, we should give our patients and other people with whom we come in contact a sense of hope. In addition to urging people to get boosters, let’s tell them to err on the side of safety when it comes to this pandemic. That means encouraging them to remain isolated for longer than 5 days – until they test negative for COVID. It also means encouraging patients to wear high-quality face masks while inside public spaces – even in the absence of mandates. I have found it heartbreaking to watch televised broadcasts of sporting events held at some stadiums across the country where masks are not being worn. This absence of face coverings is counterintuitive at a time when some Broadway shows are closing. Even the great Radio City Rockettes shut down their holiday shows early in December 2021 because of COVID.

And, as I’ve argued before, we must not give up on unvaccinated people. I have had success in changing the minds of a few patients and some acquaintances with gentle, respectful prodding and vaccine education.

I would also like to see public health principles implemented in our schools and colleges. To protect the health of our children and young adults, we must continue to be nimble – which means school districts should implement layered prevention strategies, as the CDC recommends. This includes not only encouraging eligible staff members and students to get vaccinated, but requiring face masks inside school facilities, maintaining a physical distance of at least 3 feet, “screening testing, ventilation, handwashing, and staying home when sick.”

Furthermore, in deciding whether schools should remain open or be closed after positive COVID cases are discovered, officials should look at the vaccine demographics of that particular school. For example, if 15% of students are vaccinated in one school and 70% are vaccinated in another, the judgment would be different. Of course, it’s clearly best for schools to remain open, but perhaps closing them temporarily – perhaps for a week or 10 days – should be on the table if infection rates reach a certain level.

Now that we know more and have the benefit of getting more than 200 million Americans fully vaccinated, we can be far more selective about closings and openings. An important part of our strategy must be to communicate honestly with the public about which measures are best for safety. As a key tenet of cognitive-behavioral therapy tells us, “all-or-nothing” thinking is not productive. That should also be the case with our approach to managing COVID-19.

We don’t know the future of the pandemic. Yes, it will end, and possibly COVID will become endemic – like the flu. However, in the meantime, in addition to promoting vaccinations and boosters, we must rigorously encourage our patients to follow public health standards of masking, social distancing, and closing down businesses – and schools – temporarily.

This pandemic has taken a horrendous mental health toll on all of us – especially our patients and frontline health care workers. I’ve spoken with numerous people who were anxious, depressed, and showed signs of PTSD in early 2020; after they got vaccinated, COVID spread diminished, and as public health protocols began to lift, so did their spirits. Clearly for some, the benefit of psychiatric/psychological care centering on the pandemic has proven invaluable. In some ways, the pandemic has brought to the surface the importance of mental health care and removed some of the stigma from mental illness. And that’s a good thing.

Dr. London is a practicing psychiatrist who has been a newspaper columnist for 35 years, specializing in writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He is author of “Find Freedom Fast” (New York: Kettlehole Publishing, 2019). He has no conflicts of interest.
 

The Centers for Disease Control and Prevention’s decision to shorten the length of isolation time for asymptomatic Americans with COVID-19, regardless of their vaccination status, to 5 days from 10 days is confusing. I hope the agency reconsiders this decision.

After all, one of the CDC’s key messages during this pandemic has been that even people with asymptomatic COVID who have been vaccinated and boosted can transmit the disease. So it seems to me that the Dec. 27, 2021, recommendation about shortening the isolation time for COVID-19–positive people, like the agency’s earlier guidance encouraging people who are vaccinated to stop wearing masks while in indoor settings, runs contrary to good public health principles.

As an expert in human behavior, I am worried about the impact of these confusing messages on the psyche of people in general, as well as on our patients.
 

Mental health impact

Soon after the United States went on lockdown in March 2020, I wrote about the likelihood of a pandemic of PTSD, anxiety, and depression that would occur in the wake of rising COVID-19 rates. Well, it happened.

Many people have felt a sense of existential despair, depression, and anxiety. As we head into year No. 3 of disruption of our daily lives – and face the loss of more than 825,000 Americans to COVID – we continue to navigate this uncertainty. And now we must deal with Omicron, a variant that is so highly transmissible that it is apparently able to, in some cases, evade two-dose regimens of mRNA vaccines, boosters, and immunity from past infections, according to a report from Imperial College London. Yet, we are being told by some that Omicron might be less severe, compared with other variants. I worry that this assessment is misleading. In that same report, the Imperial College said it “found no evidence” that Omicron is less virulent than Delta, based on the risk of hospitalization and symptom status.

Meanwhile, animal studies suggest that the Omicron variant might lead to less lung damage than previous variants. A preprint article that is being considered for publication by a Nature Portfolio journal suggests that hamsters and mice infected with the Omicron variant do not have as much lung damage as those infected with other variants. More data need to come in for us to get a true understanding of Omicron’s virulence and transmissibility. We should keep an eye on Israel, which is launching a clinical trial of a second booster, or fourth mRNA shot.

As clinicians, we should give our patients and other people with whom we come in contact a sense of hope. In addition to urging people to get boosters, let’s tell them to err on the side of safety when it comes to this pandemic. That means encouraging them to remain isolated for longer than 5 days – until they test negative for COVID. It also means encouraging patients to wear high-quality face masks while inside public spaces – even in the absence of mandates. I have found it heartbreaking to watch televised broadcasts of sporting events held at some stadiums across the country where masks are not being worn. This absence of face coverings is counterintuitive at a time when some Broadway shows are closing. Even the great Radio City Rockettes shut down their holiday shows early in December 2021 because of COVID.

And, as I’ve argued before, we must not give up on unvaccinated people. I have had success in changing the minds of a few patients and some acquaintances with gentle, respectful prodding and vaccine education.

I would also like to see public health principles implemented in our schools and colleges. To protect the health of our children and young adults, we must continue to be nimble – which means school districts should implement layered prevention strategies, as the CDC recommends. This includes not only encouraging eligible staff members and students to get vaccinated, but requiring face masks inside school facilities, maintaining a physical distance of at least 3 feet, “screening testing, ventilation, handwashing, and staying home when sick.”

Furthermore, in deciding whether schools should remain open or be closed after positive COVID cases are discovered, officials should look at the vaccine demographics of that particular school. For example, if 15% of students are vaccinated in one school and 70% are vaccinated in another, the judgment would be different. Of course, it’s clearly best for schools to remain open, but perhaps closing them temporarily – perhaps for a week or 10 days – should be on the table if infection rates reach a certain level.

Now that we know more and have the benefit of getting more than 200 million Americans fully vaccinated, we can be far more selective about closings and openings. An important part of our strategy must be to communicate honestly with the public about which measures are best for safety. As a key tenet of cognitive-behavioral therapy tells us, “all-or-nothing” thinking is not productive. That should also be the case with our approach to managing COVID-19.

We don’t know the future of the pandemic. Yes, it will end, and possibly COVID will become endemic – like the flu. However, in the meantime, in addition to promoting vaccinations and boosters, we must rigorously encourage our patients to follow public health standards of masking, social distancing, and closing down businesses – and schools – temporarily.

This pandemic has taken a horrendous mental health toll on all of us – especially our patients and frontline health care workers. I’ve spoken with numerous people who were anxious, depressed, and showed signs of PTSD in early 2020; after they got vaccinated, COVID spread diminished, and as public health protocols began to lift, so did their spirits. Clearly for some, the benefit of psychiatric/psychological care centering on the pandemic has proven invaluable. In some ways, the pandemic has brought to the surface the importance of mental health care and removed some of the stigma from mental illness. And that’s a good thing.

Dr. London is a practicing psychiatrist who has been a newspaper columnist for 35 years, specializing in writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He is author of “Find Freedom Fast” (New York: Kettlehole Publishing, 2019). He has no conflicts of interest.
 

The Centers for Disease Control and Prevention’s decision to shorten the length of isolation time for asymptomatic Americans with COVID-19, regardless of their vaccination status, to 5 days from 10 days is confusing. I hope the agency reconsiders this decision.

After all, one of the CDC’s key messages during this pandemic has been that even people with asymptomatic COVID who have been vaccinated and boosted can transmit the disease. So it seems to me that the Dec. 27, 2021, recommendation about shortening the isolation time for COVID-19–positive people, like the agency’s earlier guidance encouraging people who are vaccinated to stop wearing masks while in indoor settings, runs contrary to good public health principles.

As an expert in human behavior, I am worried about the impact of these confusing messages on the psyche of people in general, as well as on our patients.
 

Mental health impact

Soon after the United States went on lockdown in March 2020, I wrote about the likelihood of a pandemic of PTSD, anxiety, and depression that would occur in the wake of rising COVID-19 rates. Well, it happened.

Many people have felt a sense of existential despair, depression, and anxiety. As we head into year No. 3 of disruption of our daily lives – and face the loss of more than 825,000 Americans to COVID – we continue to navigate this uncertainty. And now we must deal with Omicron, a variant that is so highly transmissible that it is apparently able to, in some cases, evade two-dose regimens of mRNA vaccines, boosters, and immunity from past infections, according to a report from Imperial College London. Yet, we are being told by some that Omicron might be less severe, compared with other variants. I worry that this assessment is misleading. In that same report, the Imperial College said it “found no evidence” that Omicron is less virulent than Delta, based on the risk of hospitalization and symptom status.

Meanwhile, animal studies suggest that the Omicron variant might lead to less lung damage than previous variants. A preprint article that is being considered for publication by a Nature Portfolio journal suggests that hamsters and mice infected with the Omicron variant do not have as much lung damage as those infected with other variants. More data need to come in for us to get a true understanding of Omicron’s virulence and transmissibility. We should keep an eye on Israel, which is launching a clinical trial of a second booster, or fourth mRNA shot.

As clinicians, we should give our patients and other people with whom we come in contact a sense of hope. In addition to urging people to get boosters, let’s tell them to err on the side of safety when it comes to this pandemic. That means encouraging them to remain isolated for longer than 5 days – until they test negative for COVID. It also means encouraging patients to wear high-quality face masks while inside public spaces – even in the absence of mandates. I have found it heartbreaking to watch televised broadcasts of sporting events held at some stadiums across the country where masks are not being worn. This absence of face coverings is counterintuitive at a time when some Broadway shows are closing. Even the great Radio City Rockettes shut down their holiday shows early in December 2021 because of COVID.

And, as I’ve argued before, we must not give up on unvaccinated people. I have had success in changing the minds of a few patients and some acquaintances with gentle, respectful prodding and vaccine education.

I would also like to see public health principles implemented in our schools and colleges. To protect the health of our children and young adults, we must continue to be nimble – which means school districts should implement layered prevention strategies, as the CDC recommends. This includes not only encouraging eligible staff members and students to get vaccinated, but requiring face masks inside school facilities, maintaining a physical distance of at least 3 feet, “screening testing, ventilation, handwashing, and staying home when sick.”

Furthermore, in deciding whether schools should remain open or be closed after positive COVID cases are discovered, officials should look at the vaccine demographics of that particular school. For example, if 15% of students are vaccinated in one school and 70% are vaccinated in another, the judgment would be different. Of course, it’s clearly best for schools to remain open, but perhaps closing them temporarily – perhaps for a week or 10 days – should be on the table if infection rates reach a certain level.

Now that we know more and have the benefit of getting more than 200 million Americans fully vaccinated, we can be far more selective about closings and openings. An important part of our strategy must be to communicate honestly with the public about which measures are best for safety. As a key tenet of cognitive-behavioral therapy tells us, “all-or-nothing” thinking is not productive. That should also be the case with our approach to managing COVID-19.

We don’t know the future of the pandemic. Yes, it will end, and possibly COVID will become endemic – like the flu. However, in the meantime, in addition to promoting vaccinations and boosters, we must rigorously encourage our patients to follow public health standards of masking, social distancing, and closing down businesses – and schools – temporarily.

This pandemic has taken a horrendous mental health toll on all of us – especially our patients and frontline health care workers. I’ve spoken with numerous people who were anxious, depressed, and showed signs of PTSD in early 2020; after they got vaccinated, COVID spread diminished, and as public health protocols began to lift, so did their spirits. Clearly for some, the benefit of psychiatric/psychological care centering on the pandemic has proven invaluable. In some ways, the pandemic has brought to the surface the importance of mental health care and removed some of the stigma from mental illness. And that’s a good thing.

Dr. London is a practicing psychiatrist who has been a newspaper columnist for 35 years, specializing in writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He is author of “Find Freedom Fast” (New York: Kettlehole Publishing, 2019). He has no conflicts of interest.
 

As a health care provider, I have always been interested in topics that concern incarcerated citizens, whether the discussion is related to the pursuit of aggressive care or jurisprudence in general. Additionally, I have followed the issue of capital punishment for most of my career, wondering if our democracy would continue this form of punishment for violent crimes.

In the early 2000s, public opinion moved away from capital punishment. The days of executing violent criminals such as Ted Bundy (who was killed in the electric chair in 1989) seemed to be in the rearview mirror. The ability of prison systems to obtain drugs for execution had become arduous, and Americans appeared disinterested in continuing with the process. Slowly, states began opting out of executions. Currently, 27 U.S. states offer the death penalty as an option at prosecution.
 

Botched executions

So far in 2021, 11 prisoners have been put to death by the federal government as well as five states, using either a one-drug or three-drug intravenous protocol. Of those prisoners, one was female.

The length of time from sentencing to date of execution varied from a low of 9 years to a high of 29 years, according to the Death Penalty Information Center. Of the executions performed this year, one was considered “botched.” The victim convulsed and vomited for several minutes before his ultimate demise. In fact, in the history of using the death penalty, from 1890 to 2010, approximately 3% of total executions (276 prisoners) were botched. They involved failed electric shocks, convulsions, labored breathing, and in one particularly horrific incident, a victim who was shot in the hip and abdomen by a firing squad and took several minutes to die.

One of the more difficult tasks for conducting an execution is intravenous access, with acquisition of an intravenous site proving to be a common issue. Another concern involves intravenous efficacy, or failure of the site to remain patent until death is achieved. That is why a few states that still practice capital punishment have returned to an electric chair option for execution (the method is chosen by the prisoner).
 

Majority favor capital punishment

But why do most Americans believe we need the death penalty? According to a 2021 poll by the Pew Research Center, 60% of U.S. citizens favor the use of capital punishment for those convicted of murder, including 27% who strongly favor its use. About 4 in 10 oppose the punishment, but only 15% are strongly opposed. The belief of those who favor retaining execution is that use of the death penalty deters violent crime.

Surprisingly, the American South has both the highest murder rate in the country and the highest percentage of executions. This geographic area encompasses 81% of the nation’s executions. A 2012 National Research Council poll determined that studies claiming the death penalty deters violent crime are “fundamentally flawed.” States that have abolished the death penalty do not show an increase in murder rates; in fact, the opposite is true, the organization concluded.

Since 1990, states without death penalty punishment have had consistently lower murder rates than those that retain capital punishment.
 

Where does that leave us?

Place my attitude in the column labeled “undecided.” I would love to believe capital punishment is a deterrent to violent crime, yet statistics do not prove the hypothesis to be true. We live in one of the more violent times in history, with mass shootings becoming commonplace. Large-scale retail theft has also been on the rise, especially in recent weeks.

The idea of severe punishment for heinous crime appeals to me, yet in 2001 Timothy McVeigh was executed after eating ice cream and gazing at the moon. His treatment before execution and the length of time he served were in opposition to other inmates sentenced to death. This, despite being punished for killing 168 people (including 19 children) in the Oklahoma City bombings.

I know we cannot be complacent. Violent crime needs to be reduced, and Americans need to feel safe. The process for achieving that goal? You tell me.
 

Nurses in prisons

About 1% of employed nurses (i.e., close to 21,000) in the United States work in prisons. This figure does not include the many LPNs and unlicensed assistive personnel who are also working in the field and may underrepresent actual numbers.

Correctional nurses have their own scope and standards of practice. They demonstrate superb assessment skills and organization.

If you can hire a correctional nurse, or even aspire to be one, do not hesitate. Patients will thank you.

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

As a health care provider, I have always been interested in topics that concern incarcerated citizens, whether the discussion is related to the pursuit of aggressive care or jurisprudence in general. Additionally, I have followed the issue of capital punishment for most of my career, wondering if our democracy would continue this form of punishment for violent crimes.

In the early 2000s, public opinion moved away from capital punishment. The days of executing violent criminals such as Ted Bundy (who was killed in the electric chair in 1989) seemed to be in the rearview mirror. The ability of prison systems to obtain drugs for execution had become arduous, and Americans appeared disinterested in continuing with the process. Slowly, states began opting out of executions. Currently, 27 U.S. states offer the death penalty as an option at prosecution.
 

Botched executions

So far in 2021, 11 prisoners have been put to death by the federal government as well as five states, using either a one-drug or three-drug intravenous protocol. Of those prisoners, one was female.

The length of time from sentencing to date of execution varied from a low of 9 years to a high of 29 years, according to the Death Penalty Information Center. Of the executions performed this year, one was considered “botched.” The victim convulsed and vomited for several minutes before his ultimate demise. In fact, in the history of using the death penalty, from 1890 to 2010, approximately 3% of total executions (276 prisoners) were botched. They involved failed electric shocks, convulsions, labored breathing, and in one particularly horrific incident, a victim who was shot in the hip and abdomen by a firing squad and took several minutes to die.

One of the more difficult tasks for conducting an execution is intravenous access, with acquisition of an intravenous site proving to be a common issue. Another concern involves intravenous efficacy, or failure of the site to remain patent until death is achieved. That is why a few states that still practice capital punishment have returned to an electric chair option for execution (the method is chosen by the prisoner).
 

Majority favor capital punishment

But why do most Americans believe we need the death penalty? According to a 2021 poll by the Pew Research Center, 60% of U.S. citizens favor the use of capital punishment for those convicted of murder, including 27% who strongly favor its use. About 4 in 10 oppose the punishment, but only 15% are strongly opposed. The belief of those who favor retaining execution is that use of the death penalty deters violent crime.

Surprisingly, the American South has both the highest murder rate in the country and the highest percentage of executions. This geographic area encompasses 81% of the nation’s executions. A 2012 National Research Council poll determined that studies claiming the death penalty deters violent crime are “fundamentally flawed.” States that have abolished the death penalty do not show an increase in murder rates; in fact, the opposite is true, the organization concluded.

Since 1990, states without death penalty punishment have had consistently lower murder rates than those that retain capital punishment.
 

Where does that leave us?

Place my attitude in the column labeled “undecided.” I would love to believe capital punishment is a deterrent to violent crime, yet statistics do not prove the hypothesis to be true. We live in one of the more violent times in history, with mass shootings becoming commonplace. Large-scale retail theft has also been on the rise, especially in recent weeks.

The idea of severe punishment for heinous crime appeals to me, yet in 2001 Timothy McVeigh was executed after eating ice cream and gazing at the moon. His treatment before execution and the length of time he served were in opposition to other inmates sentenced to death. This, despite being punished for killing 168 people (including 19 children) in the Oklahoma City bombings.

I know we cannot be complacent. Violent crime needs to be reduced, and Americans need to feel safe. The process for achieving that goal? You tell me.
 

Nurses in prisons

About 1% of employed nurses (i.e., close to 21,000) in the United States work in prisons. This figure does not include the many LPNs and unlicensed assistive personnel who are also working in the field and may underrepresent actual numbers.

Correctional nurses have their own scope and standards of practice. They demonstrate superb assessment skills and organization.

If you can hire a correctional nurse, or even aspire to be one, do not hesitate. Patients will thank you.

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

As a health care provider, I have always been interested in topics that concern incarcerated citizens, whether the discussion is related to the pursuit of aggressive care or jurisprudence in general. Additionally, I have followed the issue of capital punishment for most of my career, wondering if our democracy would continue this form of punishment for violent crimes.

In the early 2000s, public opinion moved away from capital punishment. The days of executing violent criminals such as Ted Bundy (who was killed in the electric chair in 1989) seemed to be in the rearview mirror. The ability of prison systems to obtain drugs for execution had become arduous, and Americans appeared disinterested in continuing with the process. Slowly, states began opting out of executions. Currently, 27 U.S. states offer the death penalty as an option at prosecution.
 

Botched executions

So far in 2021, 11 prisoners have been put to death by the federal government as well as five states, using either a one-drug or three-drug intravenous protocol. Of those prisoners, one was female.

The length of time from sentencing to date of execution varied from a low of 9 years to a high of 29 years, according to the Death Penalty Information Center. Of the executions performed this year, one was considered “botched.” The victim convulsed and vomited for several minutes before his ultimate demise. In fact, in the history of using the death penalty, from 1890 to 2010, approximately 3% of total executions (276 prisoners) were botched. They involved failed electric shocks, convulsions, labored breathing, and in one particularly horrific incident, a victim who was shot in the hip and abdomen by a firing squad and took several minutes to die.

One of the more difficult tasks for conducting an execution is intravenous access, with acquisition of an intravenous site proving to be a common issue. Another concern involves intravenous efficacy, or failure of the site to remain patent until death is achieved. That is why a few states that still practice capital punishment have returned to an electric chair option for execution (the method is chosen by the prisoner).
 

Majority favor capital punishment

But why do most Americans believe we need the death penalty? According to a 2021 poll by the Pew Research Center, 60% of U.S. citizens favor the use of capital punishment for those convicted of murder, including 27% who strongly favor its use. About 4 in 10 oppose the punishment, but only 15% are strongly opposed. The belief of those who favor retaining execution is that use of the death penalty deters violent crime.

Surprisingly, the American South has both the highest murder rate in the country and the highest percentage of executions. This geographic area encompasses 81% of the nation’s executions. A 2012 National Research Council poll determined that studies claiming the death penalty deters violent crime are “fundamentally flawed.” States that have abolished the death penalty do not show an increase in murder rates; in fact, the opposite is true, the organization concluded.

Since 1990, states without death penalty punishment have had consistently lower murder rates than those that retain capital punishment.
 

Where does that leave us?

Place my attitude in the column labeled “undecided.” I would love to believe capital punishment is a deterrent to violent crime, yet statistics do not prove the hypothesis to be true. We live in one of the more violent times in history, with mass shootings becoming commonplace. Large-scale retail theft has also been on the rise, especially in recent weeks.

The idea of severe punishment for heinous crime appeals to me, yet in 2001 Timothy McVeigh was executed after eating ice cream and gazing at the moon. His treatment before execution and the length of time he served were in opposition to other inmates sentenced to death. This, despite being punished for killing 168 people (including 19 children) in the Oklahoma City bombings.

I know we cannot be complacent. Violent crime needs to be reduced, and Americans need to feel safe. The process for achieving that goal? You tell me.
 

Nurses in prisons

About 1% of employed nurses (i.e., close to 21,000) in the United States work in prisons. This figure does not include the many LPNs and unlicensed assistive personnel who are also working in the field and may underrepresent actual numbers.

Correctional nurses have their own scope and standards of practice. They demonstrate superb assessment skills and organization.

If you can hire a correctional nurse, or even aspire to be one, do not hesitate. Patients will thank you.

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