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My experience as a family medicine resident in 2021
I did not get a medical school graduation; I was one of the many thousands of newly graduated students who simply left their 4th-year rotation sites one chilly day in March 2020 and just never went back. My medical school education didn’t end with me walking triumphantly across the stage – a first-generation college student finally achieving the greatest dream in her life. Instead, it ended with a Zoom “graduation” and a cross-country move from Georgia to Pennsylvania amidst the greatest pandemic in recent memory. To say my impostor syndrome was bad would be an understatement.
Residency in the COVID-19-era
The joy and the draw to family medicine for me has always been the broad scope of conditions that we see and treat. From day 1, however, much of my residency has been devoted to one very small subset of patients – those with COVID-19. At one point, our hospital was so strained that our family medicine program had to run a second inpatient service alongside our usual five-resident service team just to provide care to everybody. Patients were in the hallways. The ER was packed to the gills. We were sleepless, terrified, unvaccinated, and desperate to help our patients survive a disease that was incompletely understood, with very few tools in our toolbox to combat it.
I distinctly remember sitting in the workroom with a coresident of mine, our faces seemingly permanently lined from wearing N95s all shift, and saying to him, “I worry I will be a bad family medicine physician. I worry I haven’t seen enough, other than COVID.” It was midway through my intern year; the days were short, so I was driving to and from the hospital in chilly darkness. My patients, like many around the country, were doing poorly. Vaccines seemed like a promise too good to be true. Worst of all: Those of us who were interns, who had no triumphant podium moment to end our medical school education, were suffering with an intense sense of impostor syndrome which was strengthened by every “there is nothing else we can offer your loved one at this time,” conversation we had. My apprehension about not having seen a wider breadth of medicine during my training is a sentiment still widely shared by COVID-era residents.
Luckily, my coresident was supportive.
“We’re going to be great family medicine physicians,” he said. “We’re learning the hard stuff – the bread and butter of FM – up-front. You’ll see.”
In some ways, I think he was right. Clinical skills, empathy, humility, and forging strong relationships are at the center of every family medicine physician’s heart; my generation has had to learn these skills early and under pressure. Sometimes, there are no answers. Sometimes, the best thing a family doctor can do for a patient is to hear them, understand them, and hold their hand.
‘We watched Cinderella together’
Shortly after that conversation with my coresident, I had a particular case which moved me. This gentleman with intellectual disability and COVID had been declining steadily since his admission to the hospital. He was isolated from everybody he knew and loved, but it did not dampen his spirits. He was cheerful to every person who entered his room, clad in their shrouds of PPE, which more often than not felt more like mourning garb than protective wear. I remember very little about this patient’s clinical picture – the COVID, the superimposed pneumonia, the repeated intubations. What I do remember is he loved the Disney classic, Cinderella. I knew this because I developed a very close relationship with his family during the course of his hospitalization. Amidst the torrential onslaught of patients, I made sure to call families every day – not because I wanted to, but because my mentors and attendings and coresidents had all drilled into me from day 1 that we are family medicine, and a large part of our role is to advocate for our patients, and to communicate with their loved ones. So I called. I learned a lot about him; his likes, his dislikes, his close bond with his siblings, and of course his lifelong love for Cinderella. On the last week of my ICU rotation, my patient passed peacefully. His nurse and I were bedside. We held his hand. We told him his family loved him. We watched Cinderella together on an iPad encased in protective plastic.
My next rotation was an outpatient one and it looked more like the “bread and butter” of family medicine. But as I whisked in and out of patient rooms, attending to patients with diabetes, with depression, with pain, I could not stop thinking about my hospitalized patients who my coresidents had assumed care of. Each exam room I entered, I rather morbidly thought “this patient could be next on our hospital service.” Without realizing it, I made more of an effort to get to know each patient holistically. I learned who they were as people. I found myself writing small, medically low-yield details in the chart: “Margaret loves to sing in her church choir;” “Katherine is a self-published author.”
I learned from my attendings. As I sat at the precepting table with them, observing their conversations about patients, their collective decades of experience were apparent.
“I’ve been seeing this patient every few weeks since I was a resident,” said one of my attendings.
“I don’t even see my parents that often,” I thought.
The depth of her relationship with, understanding of, and compassion for this patient struck me deeply. This was why I went into family medicine. My attending knew her patients; they were not faceless unknowns in a hospital gown to her. She would have known to play Cinderella for them in the end.
This is a unique time for trainees. We have been challenged, terrified, overwhelmed, and heartbroken. But at no point have we been isolated. We’ve had the generations of doctors before us to lead the way, to teach us the “hard stuff.” We’ve had senior residents to lean on, who have taken us aside and told us, “I can do the goals-of-care talk today, you need a break.” While the plague seems to have passed over our hospital for now, it has left behind a class of family medicine residents who are proud to carry on our specialty’s long tradition of compassionate, empathetic, lifelong care. “We care for all life stages, from cradle to grave,” says every family medicine physician.
My class, for better or for worse, has cared more often for patients in the twilight of their lives, and while it has been hard, I believe it has made us all better doctors. Now, when I hold a newborn in my arms for a well-child check, I am exceptionally grateful – for the opportunities I have been given, for new beginnings amidst so much sadness, and for the great privilege of being a family medicine physician.
Dr. Persampiere is a 2nd-year resident in the family medicine residency program at Abington (Pa.) Jefferson Health. You can contact her directly at [email protected] or via [email protected].
I did not get a medical school graduation; I was one of the many thousands of newly graduated students who simply left their 4th-year rotation sites one chilly day in March 2020 and just never went back. My medical school education didn’t end with me walking triumphantly across the stage – a first-generation college student finally achieving the greatest dream in her life. Instead, it ended with a Zoom “graduation” and a cross-country move from Georgia to Pennsylvania amidst the greatest pandemic in recent memory. To say my impostor syndrome was bad would be an understatement.
Residency in the COVID-19-era
The joy and the draw to family medicine for me has always been the broad scope of conditions that we see and treat. From day 1, however, much of my residency has been devoted to one very small subset of patients – those with COVID-19. At one point, our hospital was so strained that our family medicine program had to run a second inpatient service alongside our usual five-resident service team just to provide care to everybody. Patients were in the hallways. The ER was packed to the gills. We were sleepless, terrified, unvaccinated, and desperate to help our patients survive a disease that was incompletely understood, with very few tools in our toolbox to combat it.
I distinctly remember sitting in the workroom with a coresident of mine, our faces seemingly permanently lined from wearing N95s all shift, and saying to him, “I worry I will be a bad family medicine physician. I worry I haven’t seen enough, other than COVID.” It was midway through my intern year; the days were short, so I was driving to and from the hospital in chilly darkness. My patients, like many around the country, were doing poorly. Vaccines seemed like a promise too good to be true. Worst of all: Those of us who were interns, who had no triumphant podium moment to end our medical school education, were suffering with an intense sense of impostor syndrome which was strengthened by every “there is nothing else we can offer your loved one at this time,” conversation we had. My apprehension about not having seen a wider breadth of medicine during my training is a sentiment still widely shared by COVID-era residents.
Luckily, my coresident was supportive.
“We’re going to be great family medicine physicians,” he said. “We’re learning the hard stuff – the bread and butter of FM – up-front. You’ll see.”
In some ways, I think he was right. Clinical skills, empathy, humility, and forging strong relationships are at the center of every family medicine physician’s heart; my generation has had to learn these skills early and under pressure. Sometimes, there are no answers. Sometimes, the best thing a family doctor can do for a patient is to hear them, understand them, and hold their hand.
‘We watched Cinderella together’
Shortly after that conversation with my coresident, I had a particular case which moved me. This gentleman with intellectual disability and COVID had been declining steadily since his admission to the hospital. He was isolated from everybody he knew and loved, but it did not dampen his spirits. He was cheerful to every person who entered his room, clad in their shrouds of PPE, which more often than not felt more like mourning garb than protective wear. I remember very little about this patient’s clinical picture – the COVID, the superimposed pneumonia, the repeated intubations. What I do remember is he loved the Disney classic, Cinderella. I knew this because I developed a very close relationship with his family during the course of his hospitalization. Amidst the torrential onslaught of patients, I made sure to call families every day – not because I wanted to, but because my mentors and attendings and coresidents had all drilled into me from day 1 that we are family medicine, and a large part of our role is to advocate for our patients, and to communicate with their loved ones. So I called. I learned a lot about him; his likes, his dislikes, his close bond with his siblings, and of course his lifelong love for Cinderella. On the last week of my ICU rotation, my patient passed peacefully. His nurse and I were bedside. We held his hand. We told him his family loved him. We watched Cinderella together on an iPad encased in protective plastic.
My next rotation was an outpatient one and it looked more like the “bread and butter” of family medicine. But as I whisked in and out of patient rooms, attending to patients with diabetes, with depression, with pain, I could not stop thinking about my hospitalized patients who my coresidents had assumed care of. Each exam room I entered, I rather morbidly thought “this patient could be next on our hospital service.” Without realizing it, I made more of an effort to get to know each patient holistically. I learned who they were as people. I found myself writing small, medically low-yield details in the chart: “Margaret loves to sing in her church choir;” “Katherine is a self-published author.”
I learned from my attendings. As I sat at the precepting table with them, observing their conversations about patients, their collective decades of experience were apparent.
“I’ve been seeing this patient every few weeks since I was a resident,” said one of my attendings.
“I don’t even see my parents that often,” I thought.
The depth of her relationship with, understanding of, and compassion for this patient struck me deeply. This was why I went into family medicine. My attending knew her patients; they were not faceless unknowns in a hospital gown to her. She would have known to play Cinderella for them in the end.
This is a unique time for trainees. We have been challenged, terrified, overwhelmed, and heartbroken. But at no point have we been isolated. We’ve had the generations of doctors before us to lead the way, to teach us the “hard stuff.” We’ve had senior residents to lean on, who have taken us aside and told us, “I can do the goals-of-care talk today, you need a break.” While the plague seems to have passed over our hospital for now, it has left behind a class of family medicine residents who are proud to carry on our specialty’s long tradition of compassionate, empathetic, lifelong care. “We care for all life stages, from cradle to grave,” says every family medicine physician.
My class, for better or for worse, has cared more often for patients in the twilight of their lives, and while it has been hard, I believe it has made us all better doctors. Now, when I hold a newborn in my arms for a well-child check, I am exceptionally grateful – for the opportunities I have been given, for new beginnings amidst so much sadness, and for the great privilege of being a family medicine physician.
Dr. Persampiere is a 2nd-year resident in the family medicine residency program at Abington (Pa.) Jefferson Health. You can contact her directly at [email protected] or via [email protected].
I did not get a medical school graduation; I was one of the many thousands of newly graduated students who simply left their 4th-year rotation sites one chilly day in March 2020 and just never went back. My medical school education didn’t end with me walking triumphantly across the stage – a first-generation college student finally achieving the greatest dream in her life. Instead, it ended with a Zoom “graduation” and a cross-country move from Georgia to Pennsylvania amidst the greatest pandemic in recent memory. To say my impostor syndrome was bad would be an understatement.
Residency in the COVID-19-era
The joy and the draw to family medicine for me has always been the broad scope of conditions that we see and treat. From day 1, however, much of my residency has been devoted to one very small subset of patients – those with COVID-19. At one point, our hospital was so strained that our family medicine program had to run a second inpatient service alongside our usual five-resident service team just to provide care to everybody. Patients were in the hallways. The ER was packed to the gills. We were sleepless, terrified, unvaccinated, and desperate to help our patients survive a disease that was incompletely understood, with very few tools in our toolbox to combat it.
I distinctly remember sitting in the workroom with a coresident of mine, our faces seemingly permanently lined from wearing N95s all shift, and saying to him, “I worry I will be a bad family medicine physician. I worry I haven’t seen enough, other than COVID.” It was midway through my intern year; the days were short, so I was driving to and from the hospital in chilly darkness. My patients, like many around the country, were doing poorly. Vaccines seemed like a promise too good to be true. Worst of all: Those of us who were interns, who had no triumphant podium moment to end our medical school education, were suffering with an intense sense of impostor syndrome which was strengthened by every “there is nothing else we can offer your loved one at this time,” conversation we had. My apprehension about not having seen a wider breadth of medicine during my training is a sentiment still widely shared by COVID-era residents.
Luckily, my coresident was supportive.
“We’re going to be great family medicine physicians,” he said. “We’re learning the hard stuff – the bread and butter of FM – up-front. You’ll see.”
In some ways, I think he was right. Clinical skills, empathy, humility, and forging strong relationships are at the center of every family medicine physician’s heart; my generation has had to learn these skills early and under pressure. Sometimes, there are no answers. Sometimes, the best thing a family doctor can do for a patient is to hear them, understand them, and hold their hand.
‘We watched Cinderella together’
Shortly after that conversation with my coresident, I had a particular case which moved me. This gentleman with intellectual disability and COVID had been declining steadily since his admission to the hospital. He was isolated from everybody he knew and loved, but it did not dampen his spirits. He was cheerful to every person who entered his room, clad in their shrouds of PPE, which more often than not felt more like mourning garb than protective wear. I remember very little about this patient’s clinical picture – the COVID, the superimposed pneumonia, the repeated intubations. What I do remember is he loved the Disney classic, Cinderella. I knew this because I developed a very close relationship with his family during the course of his hospitalization. Amidst the torrential onslaught of patients, I made sure to call families every day – not because I wanted to, but because my mentors and attendings and coresidents had all drilled into me from day 1 that we are family medicine, and a large part of our role is to advocate for our patients, and to communicate with their loved ones. So I called. I learned a lot about him; his likes, his dislikes, his close bond with his siblings, and of course his lifelong love for Cinderella. On the last week of my ICU rotation, my patient passed peacefully. His nurse and I were bedside. We held his hand. We told him his family loved him. We watched Cinderella together on an iPad encased in protective plastic.
My next rotation was an outpatient one and it looked more like the “bread and butter” of family medicine. But as I whisked in and out of patient rooms, attending to patients with diabetes, with depression, with pain, I could not stop thinking about my hospitalized patients who my coresidents had assumed care of. Each exam room I entered, I rather morbidly thought “this patient could be next on our hospital service.” Without realizing it, I made more of an effort to get to know each patient holistically. I learned who they were as people. I found myself writing small, medically low-yield details in the chart: “Margaret loves to sing in her church choir;” “Katherine is a self-published author.”
I learned from my attendings. As I sat at the precepting table with them, observing their conversations about patients, their collective decades of experience were apparent.
“I’ve been seeing this patient every few weeks since I was a resident,” said one of my attendings.
“I don’t even see my parents that often,” I thought.
The depth of her relationship with, understanding of, and compassion for this patient struck me deeply. This was why I went into family medicine. My attending knew her patients; they were not faceless unknowns in a hospital gown to her. She would have known to play Cinderella for them in the end.
This is a unique time for trainees. We have been challenged, terrified, overwhelmed, and heartbroken. But at no point have we been isolated. We’ve had the generations of doctors before us to lead the way, to teach us the “hard stuff.” We’ve had senior residents to lean on, who have taken us aside and told us, “I can do the goals-of-care talk today, you need a break.” While the plague seems to have passed over our hospital for now, it has left behind a class of family medicine residents who are proud to carry on our specialty’s long tradition of compassionate, empathetic, lifelong care. “We care for all life stages, from cradle to grave,” says every family medicine physician.
My class, for better or for worse, has cared more often for patients in the twilight of their lives, and while it has been hard, I believe it has made us all better doctors. Now, when I hold a newborn in my arms for a well-child check, I am exceptionally grateful – for the opportunities I have been given, for new beginnings amidst so much sadness, and for the great privilege of being a family medicine physician.
Dr. Persampiere is a 2nd-year resident in the family medicine residency program at Abington (Pa.) Jefferson Health. You can contact her directly at [email protected] or via [email protected].
The male biological clock – How to tell the time
For decades, we have recognized the age-related natural decline in female fecundity (the ability to reproduce) after the age of 30 (Maturitas 1988;[Suppl]1:15-22). Advanced maternal age (AMA) has also been demonstrated to increase miscarriage and pregnancies with chromosomal abnormalities, presumably from the increased rate of oocyte aneuploidy. There has been a sixfold increase in the rate of first birth in women aged 35-39 years (NCHS Data Brief 2014;152:1-8). Consequently, over the last decade, women, often before they reach AMA, have turned to elective oocyte cryopreservation for fertility preservation.
Ovarian aging
Ovarian aging occurs through the decline in quality and quantity of oocytes. The former is a reflection of the woman’s chronologic age. Markers of female ovarian aging have been utilized, for the past 3 decades, most commonly by basal follicle stimulating hormone. Currently, to assess the quantity of ovarian follicles, antimüllerian hormone (AMH) and transvaginal ultrasound for ovarian antral follicle count (AFC) are the most accurate indicators (J Clin Endocrinol Metab 2004:89:2977-81). While ovarian age testing, particularly AMH, has been widely used to assess a woman’s “fertility potential,” it does not reflect her natural fecundity. In a prospective cohort study, AMH levels (ng/mL) divided into < 0.7, 0.7-8.4, and > 8.4, did not affect natural conception in women aged 30-44 who were divided into the categories of <35, 35-37, or 38-44 years (JAMA 2017;318:1367-76). Although AMH does reduce success with IVF, its main value is the inverse correlation when prescribing gonadotropin dosage for controlled ovarian stimulation.
Despite the familiarity with ovarian aging effects on fertility, the male biological clock remains less studied and understood. Over the last 4 decades, paternal age has increased an average of 3.5 years presumably due to delayed child rearing from professional or personal reasons, improved contraception as well as increased divorce, remarriage, and life expectancy (Hum Reprod. 2017;32:2110-6). Nevertheless, we have little data to definitively counsel men on the effects of advanced paternal age (APA) and no consensus on an actual defined age of designation. This month’s article will summarize the current literature on male age and its impact on fertility.
Testicular aging
Men older than 45 years require approximately five times longer to achieve a pregnancy as men less than 25 after adjustment for female age (Fertil Steril. 2003;79:1520-7). The most likely parameter to assess male fertility, other than pregnancy rates, would be the sperm. Sperm counts, beginning at age 41, may decline but concentrations have been shown to increase in older men apparently because of declining semen volume (Ageing Res Rev. 2015;19:22-33). Sperm motility, but not morphology, also declines while genetic alterations of sperm increase with age. The issue of chromosomal abnormalities in sperm from men of advanced age appears to be similar to that in the oocytes of women with AMA. Consequently, both sexes may contribute to embryo aneuploidy resulting in declining fertility and increasing miscarriage.
For all ages, studies have suggested that elevated male body mass index as well as alcohol consumption and cigarette smoking, including e-cigarettes, can lead to impaired sperm production (Hum Reprod Update 2013;19:221-31).
Fertility treatment outcomes
A mainstay of fertility treatment, particularly in men with mild to moderate impairments in semen parameters, is ovulation induction with intrauterine insemination. Male age has been shown to be a significant indicator for pregnancy rates, including those with normal semen parameters (J Obstet Gynaecol. 2011;31:420-3). Men above age 45 contributed to lower pregnancy rates and higher miscarriages during IUI treatment cycles (Reprod BioMed Online 2008;17:392-7).
During IVF cycles, the sperm of men with APA often undergo ICSI (intracytoplasmic sperm injection) due to higher fertilization rates compared with standard insemination. However, APA sperm appear to have lower fertilization rates and decreased embryo development to the blastocyst stage during cycles using donor oocytes, although pregnancy outcomes are inconsistent (Trans Androl Urol. 2019;8[Suppl 1]:S22-S30; Fertil Steril. 2008;90:97-103).
Perinatal and children’s health
The offspring from APA men appear to have higher rates of stillbirth, low birth weight, and preterm birth, as well as birth defects. Men older than 40-45 years have twice the risk of an autistic child and three times the risk of schizophrenia in their offspring (Transl Psychiatry 2017;7:e1019; Am J Psychiatry 2002;159:1528-33).
Conclusions
Most of the literature supports negative effects on sperm and reproduction from men with APA. The challenge in deciphering the true role of APA on fertility is that the partner is often of AMA. A consideration to avoid this effect would be sperm cryopreservation at a younger age, similar to the common trend among women. Preimplantation genetic testing of embryos from men with APA is also a potential option to reduce miscarriage and avoid a chromosomally abnormal pregnancy. Ethicists have pondered the impact of APA on parenthood and the detrimental effect of early paternal death on the child. Nevertheless, the effect of APA in reproduction is a vital area to study with the same fervor as AMA (Fertil Steril 2009;92:1772-5).
Dr. Trolice is director of Fertility CARE – The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando. He has no conflicts. Email him at [email protected].
For decades, we have recognized the age-related natural decline in female fecundity (the ability to reproduce) after the age of 30 (Maturitas 1988;[Suppl]1:15-22). Advanced maternal age (AMA) has also been demonstrated to increase miscarriage and pregnancies with chromosomal abnormalities, presumably from the increased rate of oocyte aneuploidy. There has been a sixfold increase in the rate of first birth in women aged 35-39 years (NCHS Data Brief 2014;152:1-8). Consequently, over the last decade, women, often before they reach AMA, have turned to elective oocyte cryopreservation for fertility preservation.
Ovarian aging
Ovarian aging occurs through the decline in quality and quantity of oocytes. The former is a reflection of the woman’s chronologic age. Markers of female ovarian aging have been utilized, for the past 3 decades, most commonly by basal follicle stimulating hormone. Currently, to assess the quantity of ovarian follicles, antimüllerian hormone (AMH) and transvaginal ultrasound for ovarian antral follicle count (AFC) are the most accurate indicators (J Clin Endocrinol Metab 2004:89:2977-81). While ovarian age testing, particularly AMH, has been widely used to assess a woman’s “fertility potential,” it does not reflect her natural fecundity. In a prospective cohort study, AMH levels (ng/mL) divided into < 0.7, 0.7-8.4, and > 8.4, did not affect natural conception in women aged 30-44 who were divided into the categories of <35, 35-37, or 38-44 years (JAMA 2017;318:1367-76). Although AMH does reduce success with IVF, its main value is the inverse correlation when prescribing gonadotropin dosage for controlled ovarian stimulation.
Despite the familiarity with ovarian aging effects on fertility, the male biological clock remains less studied and understood. Over the last 4 decades, paternal age has increased an average of 3.5 years presumably due to delayed child rearing from professional or personal reasons, improved contraception as well as increased divorce, remarriage, and life expectancy (Hum Reprod. 2017;32:2110-6). Nevertheless, we have little data to definitively counsel men on the effects of advanced paternal age (APA) and no consensus on an actual defined age of designation. This month’s article will summarize the current literature on male age and its impact on fertility.
Testicular aging
Men older than 45 years require approximately five times longer to achieve a pregnancy as men less than 25 after adjustment for female age (Fertil Steril. 2003;79:1520-7). The most likely parameter to assess male fertility, other than pregnancy rates, would be the sperm. Sperm counts, beginning at age 41, may decline but concentrations have been shown to increase in older men apparently because of declining semen volume (Ageing Res Rev. 2015;19:22-33). Sperm motility, but not morphology, also declines while genetic alterations of sperm increase with age. The issue of chromosomal abnormalities in sperm from men of advanced age appears to be similar to that in the oocytes of women with AMA. Consequently, both sexes may contribute to embryo aneuploidy resulting in declining fertility and increasing miscarriage.
For all ages, studies have suggested that elevated male body mass index as well as alcohol consumption and cigarette smoking, including e-cigarettes, can lead to impaired sperm production (Hum Reprod Update 2013;19:221-31).
Fertility treatment outcomes
A mainstay of fertility treatment, particularly in men with mild to moderate impairments in semen parameters, is ovulation induction with intrauterine insemination. Male age has been shown to be a significant indicator for pregnancy rates, including those with normal semen parameters (J Obstet Gynaecol. 2011;31:420-3). Men above age 45 contributed to lower pregnancy rates and higher miscarriages during IUI treatment cycles (Reprod BioMed Online 2008;17:392-7).
During IVF cycles, the sperm of men with APA often undergo ICSI (intracytoplasmic sperm injection) due to higher fertilization rates compared with standard insemination. However, APA sperm appear to have lower fertilization rates and decreased embryo development to the blastocyst stage during cycles using donor oocytes, although pregnancy outcomes are inconsistent (Trans Androl Urol. 2019;8[Suppl 1]:S22-S30; Fertil Steril. 2008;90:97-103).
Perinatal and children’s health
The offspring from APA men appear to have higher rates of stillbirth, low birth weight, and preterm birth, as well as birth defects. Men older than 40-45 years have twice the risk of an autistic child and three times the risk of schizophrenia in their offspring (Transl Psychiatry 2017;7:e1019; Am J Psychiatry 2002;159:1528-33).
Conclusions
Most of the literature supports negative effects on sperm and reproduction from men with APA. The challenge in deciphering the true role of APA on fertility is that the partner is often of AMA. A consideration to avoid this effect would be sperm cryopreservation at a younger age, similar to the common trend among women. Preimplantation genetic testing of embryos from men with APA is also a potential option to reduce miscarriage and avoid a chromosomally abnormal pregnancy. Ethicists have pondered the impact of APA on parenthood and the detrimental effect of early paternal death on the child. Nevertheless, the effect of APA in reproduction is a vital area to study with the same fervor as AMA (Fertil Steril 2009;92:1772-5).
Dr. Trolice is director of Fertility CARE – The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando. He has no conflicts. Email him at [email protected].
For decades, we have recognized the age-related natural decline in female fecundity (the ability to reproduce) after the age of 30 (Maturitas 1988;[Suppl]1:15-22). Advanced maternal age (AMA) has also been demonstrated to increase miscarriage and pregnancies with chromosomal abnormalities, presumably from the increased rate of oocyte aneuploidy. There has been a sixfold increase in the rate of first birth in women aged 35-39 years (NCHS Data Brief 2014;152:1-8). Consequently, over the last decade, women, often before they reach AMA, have turned to elective oocyte cryopreservation for fertility preservation.
Ovarian aging
Ovarian aging occurs through the decline in quality and quantity of oocytes. The former is a reflection of the woman’s chronologic age. Markers of female ovarian aging have been utilized, for the past 3 decades, most commonly by basal follicle stimulating hormone. Currently, to assess the quantity of ovarian follicles, antimüllerian hormone (AMH) and transvaginal ultrasound for ovarian antral follicle count (AFC) are the most accurate indicators (J Clin Endocrinol Metab 2004:89:2977-81). While ovarian age testing, particularly AMH, has been widely used to assess a woman’s “fertility potential,” it does not reflect her natural fecundity. In a prospective cohort study, AMH levels (ng/mL) divided into < 0.7, 0.7-8.4, and > 8.4, did not affect natural conception in women aged 30-44 who were divided into the categories of <35, 35-37, or 38-44 years (JAMA 2017;318:1367-76). Although AMH does reduce success with IVF, its main value is the inverse correlation when prescribing gonadotropin dosage for controlled ovarian stimulation.
Despite the familiarity with ovarian aging effects on fertility, the male biological clock remains less studied and understood. Over the last 4 decades, paternal age has increased an average of 3.5 years presumably due to delayed child rearing from professional or personal reasons, improved contraception as well as increased divorce, remarriage, and life expectancy (Hum Reprod. 2017;32:2110-6). Nevertheless, we have little data to definitively counsel men on the effects of advanced paternal age (APA) and no consensus on an actual defined age of designation. This month’s article will summarize the current literature on male age and its impact on fertility.
Testicular aging
Men older than 45 years require approximately five times longer to achieve a pregnancy as men less than 25 after adjustment for female age (Fertil Steril. 2003;79:1520-7). The most likely parameter to assess male fertility, other than pregnancy rates, would be the sperm. Sperm counts, beginning at age 41, may decline but concentrations have been shown to increase in older men apparently because of declining semen volume (Ageing Res Rev. 2015;19:22-33). Sperm motility, but not morphology, also declines while genetic alterations of sperm increase with age. The issue of chromosomal abnormalities in sperm from men of advanced age appears to be similar to that in the oocytes of women with AMA. Consequently, both sexes may contribute to embryo aneuploidy resulting in declining fertility and increasing miscarriage.
For all ages, studies have suggested that elevated male body mass index as well as alcohol consumption and cigarette smoking, including e-cigarettes, can lead to impaired sperm production (Hum Reprod Update 2013;19:221-31).
Fertility treatment outcomes
A mainstay of fertility treatment, particularly in men with mild to moderate impairments in semen parameters, is ovulation induction with intrauterine insemination. Male age has been shown to be a significant indicator for pregnancy rates, including those with normal semen parameters (J Obstet Gynaecol. 2011;31:420-3). Men above age 45 contributed to lower pregnancy rates and higher miscarriages during IUI treatment cycles (Reprod BioMed Online 2008;17:392-7).
During IVF cycles, the sperm of men with APA often undergo ICSI (intracytoplasmic sperm injection) due to higher fertilization rates compared with standard insemination. However, APA sperm appear to have lower fertilization rates and decreased embryo development to the blastocyst stage during cycles using donor oocytes, although pregnancy outcomes are inconsistent (Trans Androl Urol. 2019;8[Suppl 1]:S22-S30; Fertil Steril. 2008;90:97-103).
Perinatal and children’s health
The offspring from APA men appear to have higher rates of stillbirth, low birth weight, and preterm birth, as well as birth defects. Men older than 40-45 years have twice the risk of an autistic child and three times the risk of schizophrenia in their offspring (Transl Psychiatry 2017;7:e1019; Am J Psychiatry 2002;159:1528-33).
Conclusions
Most of the literature supports negative effects on sperm and reproduction from men with APA. The challenge in deciphering the true role of APA on fertility is that the partner is often of AMA. A consideration to avoid this effect would be sperm cryopreservation at a younger age, similar to the common trend among women. Preimplantation genetic testing of embryos from men with APA is also a potential option to reduce miscarriage and avoid a chromosomally abnormal pregnancy. Ethicists have pondered the impact of APA on parenthood and the detrimental effect of early paternal death on the child. Nevertheless, the effect of APA in reproduction is a vital area to study with the same fervor as AMA (Fertil Steril 2009;92:1772-5).
Dr. Trolice is director of Fertility CARE – The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando. He has no conflicts. Email him at [email protected].
But I am the therapist!
Dr. Smith’s patient, Anna, was struggling. Her mother, with whom she lived, had died, her boyfriend had broken up with her, her teenagers were being difficult, and her anxiety about catching COVID left her isolated and lonely.
She was working in psychotherapy and a number of medications had been tried, but when Anna suggested that her children might be better off without her, Dr. Smith referred her to an inpatient unit at a local hospital for admission. He faxed over the clinical and demographic information that the hospital wanted, and he never heard a word from the inpatient unit until Anna texted him that she had been discharged. She noted that the hospitalization had been helpful.
“I have an appointment next week with a therapist,” Anna texted.
Dr. Smith was puzzled and he conveyed that in his response to her.
“They told me that you are the psychiatrist and I should see you once a month and that I need a therapist to see weekly.”
Dr. Smith remained puzzled. At times he had seen Anna weekly, and he always saw her for 50-minute (or longer) sessions, but he realized that the person in charge of discharge had decided that psychiatrists are not psychotherapists. As a psychiatrist who sees patients for psychotherapy, Dr. Smith was not in Anna’s health insurance plan, and perhaps the hospital discharged people to see in-network clinicians. Or perhaps they thought that if he were a better psychiatrist, his patient would not need an inpatient admission. All he could do was surmise, but clearly ; they had changed Anna’s treatment without the courtesy of a phone call.
“This happens to me all the time,” said Sally Waddington, MD, a psychiatrist in private practice in Laurel, Md. “Hospitals will tell my patients that psychiatrists are for medications and they need a separate therapist. It really undermines the treatment.”
Ramin Mojtabai, MD, PhD, MPH, is a psychiatrist at Johns Hopkins Hospital in Baltimore. He has done research on trends in psychotherapy among psychiatrists and in 2008 published a study which showed that only 10.8% of psychiatrists see all of their patients for psychotherapy. The same data, however, revealed that 59.4% – or a majority – of psychiatrists see at least some of their patients for psychotherapy.
“Unfortunately, our profession has been defined by the insurance industry for decades,” Dr. Mojtabai said in an interview, “so, I am not surprised that the patient was told to see a ‘proper’ psychotherapist.”
George Dawson, MD, spent 22 years as a psychiatrist on an inpatient unit in Minnesota. On his blog, “Real Psychiatry,” Dr. Dawson has a lengthy post dated Oct. 3, 2021, titled “The problem with inpatient units.” Dr. Dawson writes, “There is a lack of collaboration with outpatient staff: Good inpatient care proceeds from the assumption that the main focus of treatment is with the primary psychiatrist or treatment team. ... The only acceptable reasons are that the patient does not have outpatient care, the patient refuses to consent to the communication, or the outpatient physician or their proxy cannot be contacted with a good faith effort. Being on both ends of that call – a good faith effort to me means leaving a cell phone number with the message to ‘call me at any time.’ I have found that effort is required in an era of overproduction and no set times in the outpatient clinic for necessary phone calls.”
In an interview, Dr. Dawson commented on the predicament of Dr. Smith and Anna. “The inpatient staff seem to have a grandiose idea of where the care should be centered and that is with the outpatient doctor making the referral. Any plan not involving the referring doctor is not likely to be successful.”
Dr. Waddington talked about how she handles the situation when an inpatient unit refers her patients to a separate psychotherapist. “Usually, I discuss it with my patient. Sometimes they want a change and so I continue to see them for medications. Most of the time, they keep seeing me for therapy.” She went on to note, “I recently had a patient who was in the hospital and was referred to a trauma specialist for therapy. The referral was probably appropriate in her case; I just wish they had discussed this with me first.”
Dr. Smith calls himself “a dinosaur” – he likes treating patients with a combination of medications and psychotherapy and he does not enjoy seeing patients for brief visits for medication management. He was, however, concerned that Anna had been stretching out the time between sessions because of financial concerns, so he suggested she could meet with the therapist and see if she thought this might be helpful to her. If it was, he recommended she find a psychiatrist in her insurance network to prescribe her medications, with the hope that this would be a reasonable alternative to their current conundrum.
“I believe that many patients are best served by having their care come from a single psychiatrist and not treatment split between clinicians; however, I recognize that this is not always financially the best option. Anna might benefit from not having the financial stress of care from a psychiatrist where she is not reimbursed as well – if at all – by insurance. Still, I am annoyed; it feels like the inpatient team decided to write a new job description for me and to dictate through my patient how it is I should be practicing. And after they implied that I was not the best therapist for her, they hijacked her and sent her to someone who may well have much less experience than I do.”
In the clinical care of any patient, communication between the inpatient team and the outpatient physician is essential, and all too often, this doesn’t happen.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2018). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore.
Dr. Smith’s patient, Anna, was struggling. Her mother, with whom she lived, had died, her boyfriend had broken up with her, her teenagers were being difficult, and her anxiety about catching COVID left her isolated and lonely.
She was working in psychotherapy and a number of medications had been tried, but when Anna suggested that her children might be better off without her, Dr. Smith referred her to an inpatient unit at a local hospital for admission. He faxed over the clinical and demographic information that the hospital wanted, and he never heard a word from the inpatient unit until Anna texted him that she had been discharged. She noted that the hospitalization had been helpful.
“I have an appointment next week with a therapist,” Anna texted.
Dr. Smith was puzzled and he conveyed that in his response to her.
“They told me that you are the psychiatrist and I should see you once a month and that I need a therapist to see weekly.”
Dr. Smith remained puzzled. At times he had seen Anna weekly, and he always saw her for 50-minute (or longer) sessions, but he realized that the person in charge of discharge had decided that psychiatrists are not psychotherapists. As a psychiatrist who sees patients for psychotherapy, Dr. Smith was not in Anna’s health insurance plan, and perhaps the hospital discharged people to see in-network clinicians. Or perhaps they thought that if he were a better psychiatrist, his patient would not need an inpatient admission. All he could do was surmise, but clearly ; they had changed Anna’s treatment without the courtesy of a phone call.
“This happens to me all the time,” said Sally Waddington, MD, a psychiatrist in private practice in Laurel, Md. “Hospitals will tell my patients that psychiatrists are for medications and they need a separate therapist. It really undermines the treatment.”
Ramin Mojtabai, MD, PhD, MPH, is a psychiatrist at Johns Hopkins Hospital in Baltimore. He has done research on trends in psychotherapy among psychiatrists and in 2008 published a study which showed that only 10.8% of psychiatrists see all of their patients for psychotherapy. The same data, however, revealed that 59.4% – or a majority – of psychiatrists see at least some of their patients for psychotherapy.
“Unfortunately, our profession has been defined by the insurance industry for decades,” Dr. Mojtabai said in an interview, “so, I am not surprised that the patient was told to see a ‘proper’ psychotherapist.”
George Dawson, MD, spent 22 years as a psychiatrist on an inpatient unit in Minnesota. On his blog, “Real Psychiatry,” Dr. Dawson has a lengthy post dated Oct. 3, 2021, titled “The problem with inpatient units.” Dr. Dawson writes, “There is a lack of collaboration with outpatient staff: Good inpatient care proceeds from the assumption that the main focus of treatment is with the primary psychiatrist or treatment team. ... The only acceptable reasons are that the patient does not have outpatient care, the patient refuses to consent to the communication, or the outpatient physician or their proxy cannot be contacted with a good faith effort. Being on both ends of that call – a good faith effort to me means leaving a cell phone number with the message to ‘call me at any time.’ I have found that effort is required in an era of overproduction and no set times in the outpatient clinic for necessary phone calls.”
In an interview, Dr. Dawson commented on the predicament of Dr. Smith and Anna. “The inpatient staff seem to have a grandiose idea of where the care should be centered and that is with the outpatient doctor making the referral. Any plan not involving the referring doctor is not likely to be successful.”
Dr. Waddington talked about how she handles the situation when an inpatient unit refers her patients to a separate psychotherapist. “Usually, I discuss it with my patient. Sometimes they want a change and so I continue to see them for medications. Most of the time, they keep seeing me for therapy.” She went on to note, “I recently had a patient who was in the hospital and was referred to a trauma specialist for therapy. The referral was probably appropriate in her case; I just wish they had discussed this with me first.”
Dr. Smith calls himself “a dinosaur” – he likes treating patients with a combination of medications and psychotherapy and he does not enjoy seeing patients for brief visits for medication management. He was, however, concerned that Anna had been stretching out the time between sessions because of financial concerns, so he suggested she could meet with the therapist and see if she thought this might be helpful to her. If it was, he recommended she find a psychiatrist in her insurance network to prescribe her medications, with the hope that this would be a reasonable alternative to their current conundrum.
“I believe that many patients are best served by having their care come from a single psychiatrist and not treatment split between clinicians; however, I recognize that this is not always financially the best option. Anna might benefit from not having the financial stress of care from a psychiatrist where she is not reimbursed as well – if at all – by insurance. Still, I am annoyed; it feels like the inpatient team decided to write a new job description for me and to dictate through my patient how it is I should be practicing. And after they implied that I was not the best therapist for her, they hijacked her and sent her to someone who may well have much less experience than I do.”
In the clinical care of any patient, communication between the inpatient team and the outpatient physician is essential, and all too often, this doesn’t happen.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2018). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore.
Dr. Smith’s patient, Anna, was struggling. Her mother, with whom she lived, had died, her boyfriend had broken up with her, her teenagers were being difficult, and her anxiety about catching COVID left her isolated and lonely.
She was working in psychotherapy and a number of medications had been tried, but when Anna suggested that her children might be better off without her, Dr. Smith referred her to an inpatient unit at a local hospital for admission. He faxed over the clinical and demographic information that the hospital wanted, and he never heard a word from the inpatient unit until Anna texted him that she had been discharged. She noted that the hospitalization had been helpful.
“I have an appointment next week with a therapist,” Anna texted.
Dr. Smith was puzzled and he conveyed that in his response to her.
“They told me that you are the psychiatrist and I should see you once a month and that I need a therapist to see weekly.”
Dr. Smith remained puzzled. At times he had seen Anna weekly, and he always saw her for 50-minute (or longer) sessions, but he realized that the person in charge of discharge had decided that psychiatrists are not psychotherapists. As a psychiatrist who sees patients for psychotherapy, Dr. Smith was not in Anna’s health insurance plan, and perhaps the hospital discharged people to see in-network clinicians. Or perhaps they thought that if he were a better psychiatrist, his patient would not need an inpatient admission. All he could do was surmise, but clearly ; they had changed Anna’s treatment without the courtesy of a phone call.
“This happens to me all the time,” said Sally Waddington, MD, a psychiatrist in private practice in Laurel, Md. “Hospitals will tell my patients that psychiatrists are for medications and they need a separate therapist. It really undermines the treatment.”
Ramin Mojtabai, MD, PhD, MPH, is a psychiatrist at Johns Hopkins Hospital in Baltimore. He has done research on trends in psychotherapy among psychiatrists and in 2008 published a study which showed that only 10.8% of psychiatrists see all of their patients for psychotherapy. The same data, however, revealed that 59.4% – or a majority – of psychiatrists see at least some of their patients for psychotherapy.
“Unfortunately, our profession has been defined by the insurance industry for decades,” Dr. Mojtabai said in an interview, “so, I am not surprised that the patient was told to see a ‘proper’ psychotherapist.”
George Dawson, MD, spent 22 years as a psychiatrist on an inpatient unit in Minnesota. On his blog, “Real Psychiatry,” Dr. Dawson has a lengthy post dated Oct. 3, 2021, titled “The problem with inpatient units.” Dr. Dawson writes, “There is a lack of collaboration with outpatient staff: Good inpatient care proceeds from the assumption that the main focus of treatment is with the primary psychiatrist or treatment team. ... The only acceptable reasons are that the patient does not have outpatient care, the patient refuses to consent to the communication, or the outpatient physician or their proxy cannot be contacted with a good faith effort. Being on both ends of that call – a good faith effort to me means leaving a cell phone number with the message to ‘call me at any time.’ I have found that effort is required in an era of overproduction and no set times in the outpatient clinic for necessary phone calls.”
In an interview, Dr. Dawson commented on the predicament of Dr. Smith and Anna. “The inpatient staff seem to have a grandiose idea of where the care should be centered and that is with the outpatient doctor making the referral. Any plan not involving the referring doctor is not likely to be successful.”
Dr. Waddington talked about how she handles the situation when an inpatient unit refers her patients to a separate psychotherapist. “Usually, I discuss it with my patient. Sometimes they want a change and so I continue to see them for medications. Most of the time, they keep seeing me for therapy.” She went on to note, “I recently had a patient who was in the hospital and was referred to a trauma specialist for therapy. The referral was probably appropriate in her case; I just wish they had discussed this with me first.”
Dr. Smith calls himself “a dinosaur” – he likes treating patients with a combination of medications and psychotherapy and he does not enjoy seeing patients for brief visits for medication management. He was, however, concerned that Anna had been stretching out the time between sessions because of financial concerns, so he suggested she could meet with the therapist and see if she thought this might be helpful to her. If it was, he recommended she find a psychiatrist in her insurance network to prescribe her medications, with the hope that this would be a reasonable alternative to their current conundrum.
“I believe that many patients are best served by having their care come from a single psychiatrist and not treatment split between clinicians; however, I recognize that this is not always financially the best option. Anna might benefit from not having the financial stress of care from a psychiatrist where she is not reimbursed as well – if at all – by insurance. Still, I am annoyed; it feels like the inpatient team decided to write a new job description for me and to dictate through my patient how it is I should be practicing. And after they implied that I was not the best therapist for her, they hijacked her and sent her to someone who may well have much less experience than I do.”
In the clinical care of any patient, communication between the inpatient team and the outpatient physician is essential, and all too often, this doesn’t happen.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2018). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore.
To meme or not to meme: The likability and ‘virability’ of memes
As the famous saying goes, “laughter is the best medicine.”
So it’s no surprise that humor is a great way to connect with different people and across various groups.
Memes are usually conveyed as images and texts that communicate ideas or thoughts. A meme, or “imitated thing” (translation from the Greek mimeme), was reappropriated from Richard Dawkins in his book The Selfish Gene;
I am a big fan of memes. In fact, I can confidently say that one-third of my camera roll is dedicated to saved memes from Facebook, Instagram, and friends. Shameless to say, I’m also part of a few online groups dedicated to memes. They are relatable, as well as quick and fun ways to make light of an otherwise dull or upsetting situation.
Memes are contagious. From the moment they are created, they can be shared from one person to another, be edited or changed to adapt to the current situation, and become viral. They can be used to augment a conversation or replace the need for text communication entirely – in a sense, they are an entire language in and of themselves. They are constantly undergoing selection, repacking, and filtration. As a result, the most popular, successful, and, usually, relatable meme comes out on top, whereas the others fall behind and become “extinct.”
Memes generally adopt a form of word- or image-play that resonates well with people. The type of content varies from general lighthearted harmless animal humor to wry political and/or social commentary. They can be nearly universal or target specific groups (for example, students).
The popularity of memes depends on two factors: likability and “viralability.” Likability refers to how stimulating or engaging the content is, whereas “viralability” refers to the ability of the content to create a similar effect of user engagement across multiple people. Both factors are dynamic and can be quantified on the basis of the number of likes, shares, and/or comments.
In a content analysis of 1,000 memes on Facebook, researchers found that affiliative and aggressive humor styles were the most prevalent. Affiliative humor refers to a style of banter or joke that portrays others in a positive light, whereas aggressive humor achieves the opposite (that is, portrays others in a negative light). Interestingly, the type of humor that achieved the average most likes and shares was self-defeating humor (that is, disparaging one’s own situation in a negative perspective).
Self-defeating memes are suggested to have higher meme fitness. Meme fitness refers to the replicability of a meme. In this context, self-defeating memes have a unique ability to resonate with peoples’ thoughts and feelings in a sarcastic way and create laughter in contexts of general hardships (for example, failed relationships, academic hardships, or general life weaknesses). In a way, I’ve found that self-defeating memes offer a branch of support; to know that I am not going through certain problems alone, and that others can understand these difficulties, is comforting.
Memes can target emotional pain, neutralize the threat, and turn discomfort into a discourse of playfulness and warmth. Especially during times of great uncertainty, a bit of banter and wry humor may be just what we need to make light of difficult situations.
Leanna M.W. Lui, HBSc, completed an HBSc global health specialist degree at the University of Toronto, where she is now an MSc student.
A version of this article first appeared on Medscape.com.
As the famous saying goes, “laughter is the best medicine.”
So it’s no surprise that humor is a great way to connect with different people and across various groups.
Memes are usually conveyed as images and texts that communicate ideas or thoughts. A meme, or “imitated thing” (translation from the Greek mimeme), was reappropriated from Richard Dawkins in his book The Selfish Gene;
I am a big fan of memes. In fact, I can confidently say that one-third of my camera roll is dedicated to saved memes from Facebook, Instagram, and friends. Shameless to say, I’m also part of a few online groups dedicated to memes. They are relatable, as well as quick and fun ways to make light of an otherwise dull or upsetting situation.
Memes are contagious. From the moment they are created, they can be shared from one person to another, be edited or changed to adapt to the current situation, and become viral. They can be used to augment a conversation or replace the need for text communication entirely – in a sense, they are an entire language in and of themselves. They are constantly undergoing selection, repacking, and filtration. As a result, the most popular, successful, and, usually, relatable meme comes out on top, whereas the others fall behind and become “extinct.”
Memes generally adopt a form of word- or image-play that resonates well with people. The type of content varies from general lighthearted harmless animal humor to wry political and/or social commentary. They can be nearly universal or target specific groups (for example, students).
The popularity of memes depends on two factors: likability and “viralability.” Likability refers to how stimulating or engaging the content is, whereas “viralability” refers to the ability of the content to create a similar effect of user engagement across multiple people. Both factors are dynamic and can be quantified on the basis of the number of likes, shares, and/or comments.
In a content analysis of 1,000 memes on Facebook, researchers found that affiliative and aggressive humor styles were the most prevalent. Affiliative humor refers to a style of banter or joke that portrays others in a positive light, whereas aggressive humor achieves the opposite (that is, portrays others in a negative light). Interestingly, the type of humor that achieved the average most likes and shares was self-defeating humor (that is, disparaging one’s own situation in a negative perspective).
Self-defeating memes are suggested to have higher meme fitness. Meme fitness refers to the replicability of a meme. In this context, self-defeating memes have a unique ability to resonate with peoples’ thoughts and feelings in a sarcastic way and create laughter in contexts of general hardships (for example, failed relationships, academic hardships, or general life weaknesses). In a way, I’ve found that self-defeating memes offer a branch of support; to know that I am not going through certain problems alone, and that others can understand these difficulties, is comforting.
Memes can target emotional pain, neutralize the threat, and turn discomfort into a discourse of playfulness and warmth. Especially during times of great uncertainty, a bit of banter and wry humor may be just what we need to make light of difficult situations.
Leanna M.W. Lui, HBSc, completed an HBSc global health specialist degree at the University of Toronto, where she is now an MSc student.
A version of this article first appeared on Medscape.com.
As the famous saying goes, “laughter is the best medicine.”
So it’s no surprise that humor is a great way to connect with different people and across various groups.
Memes are usually conveyed as images and texts that communicate ideas or thoughts. A meme, or “imitated thing” (translation from the Greek mimeme), was reappropriated from Richard Dawkins in his book The Selfish Gene;
I am a big fan of memes. In fact, I can confidently say that one-third of my camera roll is dedicated to saved memes from Facebook, Instagram, and friends. Shameless to say, I’m also part of a few online groups dedicated to memes. They are relatable, as well as quick and fun ways to make light of an otherwise dull or upsetting situation.
Memes are contagious. From the moment they are created, they can be shared from one person to another, be edited or changed to adapt to the current situation, and become viral. They can be used to augment a conversation or replace the need for text communication entirely – in a sense, they are an entire language in and of themselves. They are constantly undergoing selection, repacking, and filtration. As a result, the most popular, successful, and, usually, relatable meme comes out on top, whereas the others fall behind and become “extinct.”
Memes generally adopt a form of word- or image-play that resonates well with people. The type of content varies from general lighthearted harmless animal humor to wry political and/or social commentary. They can be nearly universal or target specific groups (for example, students).
The popularity of memes depends on two factors: likability and “viralability.” Likability refers to how stimulating or engaging the content is, whereas “viralability” refers to the ability of the content to create a similar effect of user engagement across multiple people. Both factors are dynamic and can be quantified on the basis of the number of likes, shares, and/or comments.
In a content analysis of 1,000 memes on Facebook, researchers found that affiliative and aggressive humor styles were the most prevalent. Affiliative humor refers to a style of banter or joke that portrays others in a positive light, whereas aggressive humor achieves the opposite (that is, portrays others in a negative light). Interestingly, the type of humor that achieved the average most likes and shares was self-defeating humor (that is, disparaging one’s own situation in a negative perspective).
Self-defeating memes are suggested to have higher meme fitness. Meme fitness refers to the replicability of a meme. In this context, self-defeating memes have a unique ability to resonate with peoples’ thoughts and feelings in a sarcastic way and create laughter in contexts of general hardships (for example, failed relationships, academic hardships, or general life weaknesses). In a way, I’ve found that self-defeating memes offer a branch of support; to know that I am not going through certain problems alone, and that others can understand these difficulties, is comforting.
Memes can target emotional pain, neutralize the threat, and turn discomfort into a discourse of playfulness and warmth. Especially during times of great uncertainty, a bit of banter and wry humor may be just what we need to make light of difficult situations.
Leanna M.W. Lui, HBSc, completed an HBSc global health specialist degree at the University of Toronto, where she is now an MSc student.
A version of this article first appeared on Medscape.com.
Guidelines for dementia and age-related cognitive changes
It is estimated that by the year 2060, 13.9 million Americans over the age of 65 will be diagnosed with dementia. Few good treatments are currently available.
Earlier this year, the American Psychological Association (APA) Task Force issued clinical guidelines “for the Evaluation of Dementia and Age-Related Cognitive Change.” While these 16 guidelines are aimed at psychologists, primary care doctors are often the first ones to evaluate a patient who may have dementia. As a family physician, I find having these guidelines especially helpful.
Neuropsychiatric testing and defining severity and type
This new guidance places emphasis on neuropsychiatric testing and defining the severity and type of dementia present.
Over the past 2 decades, diagnoses of mild neurocognitive disorders have increased, and this, in part, is due to diagnosing these problems earlier and with greater precision. It is also important to know that biomarkers are being increasingly researched, and it is imperative that we stay current with this research.
Cognitive decline may also occur with the coexistence of other mental health disorders, such as depression, so it is important that we screen for these as well. This is often difficult given the behavioral changes that can arise in dementia, but, as primary care doctors, we must differentiate these to treat our patients appropriately.
Informed consent
Informed consent can become an issue with patients with dementia. It must be assessed whether the patient has the capacity to make an informed decision and can competently communicate that decision.
The diagnosis of dementia alone does not preclude a patient from giving informed consent. A patient’s mental capacity must be determined, and if they are not capable of making an informed decision, the person legally responsible for giving informed consent on behalf of the patient must be identified.
Patients with dementia often have other medical comorbidities and take several medications. It is imperative to keep accurate medical records and medication lists. Sometimes, patients with dementia cannot provide this information. If that is the case, every attempt should be made to obtain records from every possible source.
Cultural competence
The guidelines also stress that there may be cultural differences when applying neuropsychiatric tests. It is our duty to maintain cultural competence and understand these differences. We all need to work to ensure we control our biases, and it is suggested that we review relevant evidence-based literature.
While ageism is common in our society, it shouldn’t be in our practices. For these reasons, outreach in at-risk populations is very important.
Pertinent data
The guidelines also suggest obtaining all possible information in our evaluation, especially when the patient is unable to give it to us.
Often, as primary care physicians, we refer these patients to other providers, and we should be providing all pertinent data to those we are referring these patients to. If all information is not available at the time of evaluation, follow-up visits should be scheduled.
If possible, family members should be present at the time of visit. They often provide valuable information regarding the extent and progression of the decline. Also, they know how the patient is functioning in the home setting and how much assistance they need with activities of daily living.
Caretaker support
Another important factor to consider is caretaker burnout. Caretakers are often under a lot of stress and have high rates of depression. It is important to provide them with education and support, as well as resources that may be available to them. For some, accepting the diagnosis that their loved one has dementia may be a struggle.
As doctors treating dementia patients, we need to know the resources that are available to assist dementia patients and their families. There are many local organizations that can help.
Also, research into dementia is ongoing and we need to stay current. The diagnosis of dementia should be made as early as possible using appropriate screening tools. The sooner the diagnosis is made, the quicker interventions can be started and the family members, as well as the patient, can come to accept the diagnosis.
As the population ages, we can expect the demands of dementia to rise as well. Primary care doctors are in a unique position to diagnose dementia once it starts to appear.
Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. You can contact her at [email protected].
It is estimated that by the year 2060, 13.9 million Americans over the age of 65 will be diagnosed with dementia. Few good treatments are currently available.
Earlier this year, the American Psychological Association (APA) Task Force issued clinical guidelines “for the Evaluation of Dementia and Age-Related Cognitive Change.” While these 16 guidelines are aimed at psychologists, primary care doctors are often the first ones to evaluate a patient who may have dementia. As a family physician, I find having these guidelines especially helpful.
Neuropsychiatric testing and defining severity and type
This new guidance places emphasis on neuropsychiatric testing and defining the severity and type of dementia present.
Over the past 2 decades, diagnoses of mild neurocognitive disorders have increased, and this, in part, is due to diagnosing these problems earlier and with greater precision. It is also important to know that biomarkers are being increasingly researched, and it is imperative that we stay current with this research.
Cognitive decline may also occur with the coexistence of other mental health disorders, such as depression, so it is important that we screen for these as well. This is often difficult given the behavioral changes that can arise in dementia, but, as primary care doctors, we must differentiate these to treat our patients appropriately.
Informed consent
Informed consent can become an issue with patients with dementia. It must be assessed whether the patient has the capacity to make an informed decision and can competently communicate that decision.
The diagnosis of dementia alone does not preclude a patient from giving informed consent. A patient’s mental capacity must be determined, and if they are not capable of making an informed decision, the person legally responsible for giving informed consent on behalf of the patient must be identified.
Patients with dementia often have other medical comorbidities and take several medications. It is imperative to keep accurate medical records and medication lists. Sometimes, patients with dementia cannot provide this information. If that is the case, every attempt should be made to obtain records from every possible source.
Cultural competence
The guidelines also stress that there may be cultural differences when applying neuropsychiatric tests. It is our duty to maintain cultural competence and understand these differences. We all need to work to ensure we control our biases, and it is suggested that we review relevant evidence-based literature.
While ageism is common in our society, it shouldn’t be in our practices. For these reasons, outreach in at-risk populations is very important.
Pertinent data
The guidelines also suggest obtaining all possible information in our evaluation, especially when the patient is unable to give it to us.
Often, as primary care physicians, we refer these patients to other providers, and we should be providing all pertinent data to those we are referring these patients to. If all information is not available at the time of evaluation, follow-up visits should be scheduled.
If possible, family members should be present at the time of visit. They often provide valuable information regarding the extent and progression of the decline. Also, they know how the patient is functioning in the home setting and how much assistance they need with activities of daily living.
Caretaker support
Another important factor to consider is caretaker burnout. Caretakers are often under a lot of stress and have high rates of depression. It is important to provide them with education and support, as well as resources that may be available to them. For some, accepting the diagnosis that their loved one has dementia may be a struggle.
As doctors treating dementia patients, we need to know the resources that are available to assist dementia patients and their families. There are many local organizations that can help.
Also, research into dementia is ongoing and we need to stay current. The diagnosis of dementia should be made as early as possible using appropriate screening tools. The sooner the diagnosis is made, the quicker interventions can be started and the family members, as well as the patient, can come to accept the diagnosis.
As the population ages, we can expect the demands of dementia to rise as well. Primary care doctors are in a unique position to diagnose dementia once it starts to appear.
Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. You can contact her at [email protected].
It is estimated that by the year 2060, 13.9 million Americans over the age of 65 will be diagnosed with dementia. Few good treatments are currently available.
Earlier this year, the American Psychological Association (APA) Task Force issued clinical guidelines “for the Evaluation of Dementia and Age-Related Cognitive Change.” While these 16 guidelines are aimed at psychologists, primary care doctors are often the first ones to evaluate a patient who may have dementia. As a family physician, I find having these guidelines especially helpful.
Neuropsychiatric testing and defining severity and type
This new guidance places emphasis on neuropsychiatric testing and defining the severity and type of dementia present.
Over the past 2 decades, diagnoses of mild neurocognitive disorders have increased, and this, in part, is due to diagnosing these problems earlier and with greater precision. It is also important to know that biomarkers are being increasingly researched, and it is imperative that we stay current with this research.
Cognitive decline may also occur with the coexistence of other mental health disorders, such as depression, so it is important that we screen for these as well. This is often difficult given the behavioral changes that can arise in dementia, but, as primary care doctors, we must differentiate these to treat our patients appropriately.
Informed consent
Informed consent can become an issue with patients with dementia. It must be assessed whether the patient has the capacity to make an informed decision and can competently communicate that decision.
The diagnosis of dementia alone does not preclude a patient from giving informed consent. A patient’s mental capacity must be determined, and if they are not capable of making an informed decision, the person legally responsible for giving informed consent on behalf of the patient must be identified.
Patients with dementia often have other medical comorbidities and take several medications. It is imperative to keep accurate medical records and medication lists. Sometimes, patients with dementia cannot provide this information. If that is the case, every attempt should be made to obtain records from every possible source.
Cultural competence
The guidelines also stress that there may be cultural differences when applying neuropsychiatric tests. It is our duty to maintain cultural competence and understand these differences. We all need to work to ensure we control our biases, and it is suggested that we review relevant evidence-based literature.
While ageism is common in our society, it shouldn’t be in our practices. For these reasons, outreach in at-risk populations is very important.
Pertinent data
The guidelines also suggest obtaining all possible information in our evaluation, especially when the patient is unable to give it to us.
Often, as primary care physicians, we refer these patients to other providers, and we should be providing all pertinent data to those we are referring these patients to. If all information is not available at the time of evaluation, follow-up visits should be scheduled.
If possible, family members should be present at the time of visit. They often provide valuable information regarding the extent and progression of the decline. Also, they know how the patient is functioning in the home setting and how much assistance they need with activities of daily living.
Caretaker support
Another important factor to consider is caretaker burnout. Caretakers are often under a lot of stress and have high rates of depression. It is important to provide them with education and support, as well as resources that may be available to them. For some, accepting the diagnosis that their loved one has dementia may be a struggle.
As doctors treating dementia patients, we need to know the resources that are available to assist dementia patients and their families. There are many local organizations that can help.
Also, research into dementia is ongoing and we need to stay current. The diagnosis of dementia should be made as early as possible using appropriate screening tools. The sooner the diagnosis is made, the quicker interventions can be started and the family members, as well as the patient, can come to accept the diagnosis.
As the population ages, we can expect the demands of dementia to rise as well. Primary care doctors are in a unique position to diagnose dementia once it starts to appear.
Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. You can contact her at [email protected].
A 70-year-old man presents with firm papules on his hand and fingers
, although women are more often affected than men. GA most commonly appears in the first 3 decades of life. Although the etiology is not known, GA may represent a delayed hypersensitivity reaction. A link between GA and diabetes mellitus, autoimmune thyroiditis, dyslipidemia, and rarely, malignancy may exist.
GA is most commonly localized, presenting as an asymptomatic, erythematous, annular plaque with a firm border and central clearing localized to the wrists, ankles, and dorsal hands or feet. This form is the type most often seen in children. Generalized GA is far less common and presents later in life as multiple asymptomatic or pruritic papules and plaques on the trunk and extremities. Less common variants include subcutaneous GA, patch GA, atypical GA, and perforating GA. Perforating GA occurs on the dorsal hands and presents as (umbilicated) papules, and seems consistent with this patient’s clinical presentation. Histologically, transepidermal elimination of collagen is typically seen in perforating GA.1
Histology in this patient’s biopsy revealed a granulomatous dermatitis consistent with granuloma annulare. A palisaded arrangement of histiocytic cells surrounding altered collagen with increased dermal mucin was seen. There was associated perivascular mononuclear inflammatory infiltrates. The overlying epidermis was unremarkable.
Granuloma annulare often spontaneously resolves without sequelae. In some cases, atrophy may result. Lesions may also recur. Localized GA is often treated with high-potency topical corticosteroids or intralesional corticosteroids. For generalized GA, topical or intralesional corticosteroids may be used for select lesions. Topical calcineurin inhibitors, light therapy, cryotherapy, imiquimod, hydroxychloroquine, isotretinoin, and dapsone have also been reported in the literature as possible treatments.
This case and photo were provided by Dr. Berke, of Three Rivers Dermatology, Pittsburgh, and Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
References
1 Alves J, Barreiros H, Bartolo E. Healthcare (Basel). 2014 Sep 4;2(3):338-45.
2. Bolognia J et al. Dermatology (St. Louis: Mosby/Elsevier, 2008).
3. “Andrews’ Diseases of the Skin,” 13th ed. James W et al. Philadelphia: Saunders Elsevier, 2006.
, although women are more often affected than men. GA most commonly appears in the first 3 decades of life. Although the etiology is not known, GA may represent a delayed hypersensitivity reaction. A link between GA and diabetes mellitus, autoimmune thyroiditis, dyslipidemia, and rarely, malignancy may exist.
GA is most commonly localized, presenting as an asymptomatic, erythematous, annular plaque with a firm border and central clearing localized to the wrists, ankles, and dorsal hands or feet. This form is the type most often seen in children. Generalized GA is far less common and presents later in life as multiple asymptomatic or pruritic papules and plaques on the trunk and extremities. Less common variants include subcutaneous GA, patch GA, atypical GA, and perforating GA. Perforating GA occurs on the dorsal hands and presents as (umbilicated) papules, and seems consistent with this patient’s clinical presentation. Histologically, transepidermal elimination of collagen is typically seen in perforating GA.1
Histology in this patient’s biopsy revealed a granulomatous dermatitis consistent with granuloma annulare. A palisaded arrangement of histiocytic cells surrounding altered collagen with increased dermal mucin was seen. There was associated perivascular mononuclear inflammatory infiltrates. The overlying epidermis was unremarkable.
Granuloma annulare often spontaneously resolves without sequelae. In some cases, atrophy may result. Lesions may also recur. Localized GA is often treated with high-potency topical corticosteroids or intralesional corticosteroids. For generalized GA, topical or intralesional corticosteroids may be used for select lesions. Topical calcineurin inhibitors, light therapy, cryotherapy, imiquimod, hydroxychloroquine, isotretinoin, and dapsone have also been reported in the literature as possible treatments.
This case and photo were provided by Dr. Berke, of Three Rivers Dermatology, Pittsburgh, and Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
References
1 Alves J, Barreiros H, Bartolo E. Healthcare (Basel). 2014 Sep 4;2(3):338-45.
2. Bolognia J et al. Dermatology (St. Louis: Mosby/Elsevier, 2008).
3. “Andrews’ Diseases of the Skin,” 13th ed. James W et al. Philadelphia: Saunders Elsevier, 2006.
, although women are more often affected than men. GA most commonly appears in the first 3 decades of life. Although the etiology is not known, GA may represent a delayed hypersensitivity reaction. A link between GA and diabetes mellitus, autoimmune thyroiditis, dyslipidemia, and rarely, malignancy may exist.
GA is most commonly localized, presenting as an asymptomatic, erythematous, annular plaque with a firm border and central clearing localized to the wrists, ankles, and dorsal hands or feet. This form is the type most often seen in children. Generalized GA is far less common and presents later in life as multiple asymptomatic or pruritic papules and plaques on the trunk and extremities. Less common variants include subcutaneous GA, patch GA, atypical GA, and perforating GA. Perforating GA occurs on the dorsal hands and presents as (umbilicated) papules, and seems consistent with this patient’s clinical presentation. Histologically, transepidermal elimination of collagen is typically seen in perforating GA.1
Histology in this patient’s biopsy revealed a granulomatous dermatitis consistent with granuloma annulare. A palisaded arrangement of histiocytic cells surrounding altered collagen with increased dermal mucin was seen. There was associated perivascular mononuclear inflammatory infiltrates. The overlying epidermis was unremarkable.
Granuloma annulare often spontaneously resolves without sequelae. In some cases, atrophy may result. Lesions may also recur. Localized GA is often treated with high-potency topical corticosteroids or intralesional corticosteroids. For generalized GA, topical or intralesional corticosteroids may be used for select lesions. Topical calcineurin inhibitors, light therapy, cryotherapy, imiquimod, hydroxychloroquine, isotretinoin, and dapsone have also been reported in the literature as possible treatments.
This case and photo were provided by Dr. Berke, of Three Rivers Dermatology, Pittsburgh, and Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
References
1 Alves J, Barreiros H, Bartolo E. Healthcare (Basel). 2014 Sep 4;2(3):338-45.
2. Bolognia J et al. Dermatology (St. Louis: Mosby/Elsevier, 2008).
3. “Andrews’ Diseases of the Skin,” 13th ed. James W et al. Philadelphia: Saunders Elsevier, 2006.
Teen boy’s knee lesion has changed
A biopsy of the lesion was performed which showed an increased number of eccrine glands and blood vessels within the dermis. Some areas showed an increase in adipocytes and smooth muscle bundles. The changes were consistent with eccrine angiomatous hamartoma (EAH).
The boy was referred to vascular laser therapy for treatment of the lesion.
EAH is a rare benign vascular growth characterized by an increased number of mature eccrine glands and blood vessels in the dermis and subcutis. The lesions are mostly present on the extremities, but cases of diffuse congenital lesions and lesions on the face and trunk have also been described. The lesions can be seen at birth or during the first years of life in about half of the cases, and the others tend to occur later in puberty and rarely in adulthood.1
Clinically, EAH lesions present as red, yellow to brown papules and plaques. Different dermoscopic patterns have been described which include the popcorn pattern that presents as yellow, confluent nodules with popcornlike shapes over a background of erythema, and linear arborizing vessels. The spitzoid pattern are brown globules on a background of erythema and pseudoreticular pigmentation around the globules. The verrucous hemangiomalike pattern has a bluish-white hue, reddish-blue or bluish lacunae, as seen in our patient.2-4
Most of the lesions are asymptomatic, but in some patients, they can be associated with pain, hyperhidrosis, and sometimes bleeding. Hyperhidrosis has been reported early in the presentation or during puberty or pregnancy. Our patient had started on amphetamines when hyperhidrosis occurred. Hyperhidrosis is a knowns side effect of this type of medication and may have had a role in the increased sweating noted on the hamartoma.
EAH can clinically look like verrucous hemangiomas, angiokeratomas, and vascular malformations, and histopathology may be needed to differentiate between them. Eccrine nevi and EAH can be similar. Hyperhidrosis is an early and predominant component of eccrine nevi, compared with one-third of EAH.
The exact etiology of this lesion is not known. It is thought to be caused by an abnormal differentiation of the epithelium, adnexal structure, and the mesenchyme during organogenesis.3 No other associated conditions have been described with EAH.
EAH are benign lesions that rarely require treatment. If the lesions are symptomatic or because of cosmetic reasons, they can be removed surgically. There are some reports of successful treatment with pulse dual-wavelength sequential 595- and 1064-nm lasers.5 Botulinum toxin has also been used in cases of symptomatic hyperhidrosis.
Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. She has no conflicts. Email her at [email protected].
References
1. Smith SD et al. Pediatr Dermatol. 2019 Nov;36(6):909-12.
2. Patterson AT et al. Am J Dermatopathol. 2016;38:413-7.
3. Garcıa-Garcıa SC et al. JAAD Case Rep. 2018;4(2):165-7.
4. Awatef Kelati et al. JAAD Case Rep. 2018;4(8)835-6.
5. Felgueiras J et al. Dermatol Surg. 2015 Mar;41(3):428-30.
A biopsy of the lesion was performed which showed an increased number of eccrine glands and blood vessels within the dermis. Some areas showed an increase in adipocytes and smooth muscle bundles. The changes were consistent with eccrine angiomatous hamartoma (EAH).
The boy was referred to vascular laser therapy for treatment of the lesion.
EAH is a rare benign vascular growth characterized by an increased number of mature eccrine glands and blood vessels in the dermis and subcutis. The lesions are mostly present on the extremities, but cases of diffuse congenital lesions and lesions on the face and trunk have also been described. The lesions can be seen at birth or during the first years of life in about half of the cases, and the others tend to occur later in puberty and rarely in adulthood.1
Clinically, EAH lesions present as red, yellow to brown papules and plaques. Different dermoscopic patterns have been described which include the popcorn pattern that presents as yellow, confluent nodules with popcornlike shapes over a background of erythema, and linear arborizing vessels. The spitzoid pattern are brown globules on a background of erythema and pseudoreticular pigmentation around the globules. The verrucous hemangiomalike pattern has a bluish-white hue, reddish-blue or bluish lacunae, as seen in our patient.2-4
Most of the lesions are asymptomatic, but in some patients, they can be associated with pain, hyperhidrosis, and sometimes bleeding. Hyperhidrosis has been reported early in the presentation or during puberty or pregnancy. Our patient had started on amphetamines when hyperhidrosis occurred. Hyperhidrosis is a knowns side effect of this type of medication and may have had a role in the increased sweating noted on the hamartoma.
EAH can clinically look like verrucous hemangiomas, angiokeratomas, and vascular malformations, and histopathology may be needed to differentiate between them. Eccrine nevi and EAH can be similar. Hyperhidrosis is an early and predominant component of eccrine nevi, compared with one-third of EAH.
The exact etiology of this lesion is not known. It is thought to be caused by an abnormal differentiation of the epithelium, adnexal structure, and the mesenchyme during organogenesis.3 No other associated conditions have been described with EAH.
EAH are benign lesions that rarely require treatment. If the lesions are symptomatic or because of cosmetic reasons, they can be removed surgically. There are some reports of successful treatment with pulse dual-wavelength sequential 595- and 1064-nm lasers.5 Botulinum toxin has also been used in cases of symptomatic hyperhidrosis.
Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. She has no conflicts. Email her at [email protected].
References
1. Smith SD et al. Pediatr Dermatol. 2019 Nov;36(6):909-12.
2. Patterson AT et al. Am J Dermatopathol. 2016;38:413-7.
3. Garcıa-Garcıa SC et al. JAAD Case Rep. 2018;4(2):165-7.
4. Awatef Kelati et al. JAAD Case Rep. 2018;4(8)835-6.
5. Felgueiras J et al. Dermatol Surg. 2015 Mar;41(3):428-30.
A biopsy of the lesion was performed which showed an increased number of eccrine glands and blood vessels within the dermis. Some areas showed an increase in adipocytes and smooth muscle bundles. The changes were consistent with eccrine angiomatous hamartoma (EAH).
The boy was referred to vascular laser therapy for treatment of the lesion.
EAH is a rare benign vascular growth characterized by an increased number of mature eccrine glands and blood vessels in the dermis and subcutis. The lesions are mostly present on the extremities, but cases of diffuse congenital lesions and lesions on the face and trunk have also been described. The lesions can be seen at birth or during the first years of life in about half of the cases, and the others tend to occur later in puberty and rarely in adulthood.1
Clinically, EAH lesions present as red, yellow to brown papules and plaques. Different dermoscopic patterns have been described which include the popcorn pattern that presents as yellow, confluent nodules with popcornlike shapes over a background of erythema, and linear arborizing vessels. The spitzoid pattern are brown globules on a background of erythema and pseudoreticular pigmentation around the globules. The verrucous hemangiomalike pattern has a bluish-white hue, reddish-blue or bluish lacunae, as seen in our patient.2-4
Most of the lesions are asymptomatic, but in some patients, they can be associated with pain, hyperhidrosis, and sometimes bleeding. Hyperhidrosis has been reported early in the presentation or during puberty or pregnancy. Our patient had started on amphetamines when hyperhidrosis occurred. Hyperhidrosis is a knowns side effect of this type of medication and may have had a role in the increased sweating noted on the hamartoma.
EAH can clinically look like verrucous hemangiomas, angiokeratomas, and vascular malformations, and histopathology may be needed to differentiate between them. Eccrine nevi and EAH can be similar. Hyperhidrosis is an early and predominant component of eccrine nevi, compared with one-third of EAH.
The exact etiology of this lesion is not known. It is thought to be caused by an abnormal differentiation of the epithelium, adnexal structure, and the mesenchyme during organogenesis.3 No other associated conditions have been described with EAH.
EAH are benign lesions that rarely require treatment. If the lesions are symptomatic or because of cosmetic reasons, they can be removed surgically. There are some reports of successful treatment with pulse dual-wavelength sequential 595- and 1064-nm lasers.5 Botulinum toxin has also been used in cases of symptomatic hyperhidrosis.
Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. She has no conflicts. Email her at [email protected].
References
1. Smith SD et al. Pediatr Dermatol. 2019 Nov;36(6):909-12.
2. Patterson AT et al. Am J Dermatopathol. 2016;38:413-7.
3. Garcıa-Garcıa SC et al. JAAD Case Rep. 2018;4(2):165-7.
4. Awatef Kelati et al. JAAD Case Rep. 2018;4(8)835-6.
5. Felgueiras J et al. Dermatol Surg. 2015 Mar;41(3):428-30.
A 14-year-old male was referred to our pediatric dermatology clinic for evaluation of a lesion on the left knee that appeared at 1 year of age. The lesion has been growing with him and was not symptomatic until 6 months prior to the consultation, when it started bleeding and feeling wet.
He has a history of attention-deficit/hyperactivity disorder managed with dextroamphetamine-amphetamine. The changes noted on the knee lesion seem to occur at the same time that his ADHD medication was started.
On physical exam he had a violaceous circular plaque on the left knee.
On dermoscopy the lesion showed multiple dilated red and violaceous lacunae and whitish blue hue.
Sleep apnea has many faces
Fortunately her problem stemmed from sleep apnea, and resolved with continuous positive airway pressure (CPAP) therapy.
Wallace and Bucks performed a meta analysis of 42 studies of memory in patients with sleep apnea and found sleep apnea patients were impaired when compared to healthy controls on verbal episodic memory (immediate recall, delayed recall, learning, and recognition) and visuospatial episodic memory (immediate and delayed recall).1 A meta-analysis by Olaithe and associates found an improvement in executive function in patients with sleep apnea who were treated with CPAP.2 I think this is worth considering especially in your patients who have subjective memory disturbances and do not appear to have a mild cognitive impairment or dementia.
About 15 years ago I saw a 74-year-old man for nocturia. He had seen two urologists and had a transurethral resection of the prostate (TURP) without any real change in his nocturia. I trialed him on all sorts of medications, and he seemed to improve temporarily a little on trazodone (went from seven episodes a night to four).
Eventually, after several years, I sent him for a sleep study. He had severe sleep apnea (Apnea Hypopnea Index, 65; O2 saturations as low as 60%). With treatment, his nocturia resolved. He went from seven episodes to two each night.
Zhou and colleagues performed a meta-analysis of 13 studies looking at the association of sleep apnea with nocturia.3 They found that men with sleep apnea have a high incidence of nocturia.
Miyazato and colleagues looked at the effect of CPAP treatment on nighttime urine production in patients with obstructive sleep apnea.4 In this small study of 40 patients, mean nighttime voiding episodes decreased from 2.1 to 1.2 (P < .01).
I have seen several patients with night sweats who ended up having sleep apnea. These patients have had a resolution of their night sweats with sleep apnea treatment.
Arnardottir and colleagues found that obstructive sleep apnea was associated with frequent nocturnal sweating.5 They found that 31% of men and 33% of women with OSA had nocturnal sweating, compared with about 10% of the general population.
When the OSA patients were treated with positive airway pressure, the prevalence of nocturnal sweating decreased to 11.5%, which is similar to general population numbers. Given how common both sleep apnea and night sweats are, this is an important consideration as you evaluate night sweats.
I have seen many patients who have had atrial fibrillation and sleep apnea. Shapira-Daniels and colleagues did a prospective study of 188 patients with atrial fibrillation without a history of sleep apnea who were referred for ablation.6 All patients had home sleep studies, and testing was consistent with sleep apnea in 82% of patients.
Kanagala and associates found that patients with untreated sleep apnea had a greater chance of recurrent atrial fibrillation after cardioversion.7 Recurrence of atrial fibrillation at 12 months was 82% in untreated OSA patients, higher than the 42% recurrence in the treated OSA group (P = .013) and the 53% recurrence in control patients.
I think sleep apnea evaluation should be strongly considered in patients with atrial fibrillation and should be done before referral for ablations.
Pearl: Consider sleep apnea as a possible cause of or contributing factor to the common primary care problems of cognitive concerns, nocturia, night sweats, and atrial fibrillation.
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. Wallace A and Bucks RS. Memory and obstructive sleep apnea: a meta-analysis. Sleep. 2013;36(2):203. Epub 2013 Feb 1.
2. Olaithe M and Bucks RS. Executive dysfunction in OSA before and after treatment: a meta-analysis. Sleep. 2013;36(9):1297. Epub 2013 Sep 1.
3. Zhou J et al. Association between obstructive sleep apnea syndrome and nocturia: a meta-analysis. Sleep Breath. 2020 Dec;24(4):1293-8.
4. Miyauchi Y et al. Effect of the continuous positive airway pressure on the nocturnal urine volume or night-time frequency in patients with obstructive sleep apnea syndrome. Urology 2015;85:333.
5. Arnardottir ES et al. Nocturnal sweating–a common symptom of obstructive sleep apnoea: the Icelandic sleep apnoea cohort. BMJ Open. 2013 May 14;3(5):e002795. BMJ Open 2013;3:e002795
6. Shapira-Daniels A et al. Prevalence of undiagnosed sleep apnea in patients with atrial fibrillation and its impact on therapy. JACC Clin Electrophysiol. 2020;6(12):1499. Epub 2020 Aug 12.
7. Kanagala R et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation. 2003;107(20):2589. Epub 2003 May 12.
Fortunately her problem stemmed from sleep apnea, and resolved with continuous positive airway pressure (CPAP) therapy.
Wallace and Bucks performed a meta analysis of 42 studies of memory in patients with sleep apnea and found sleep apnea patients were impaired when compared to healthy controls on verbal episodic memory (immediate recall, delayed recall, learning, and recognition) and visuospatial episodic memory (immediate and delayed recall).1 A meta-analysis by Olaithe and associates found an improvement in executive function in patients with sleep apnea who were treated with CPAP.2 I think this is worth considering especially in your patients who have subjective memory disturbances and do not appear to have a mild cognitive impairment or dementia.
About 15 years ago I saw a 74-year-old man for nocturia. He had seen two urologists and had a transurethral resection of the prostate (TURP) without any real change in his nocturia. I trialed him on all sorts of medications, and he seemed to improve temporarily a little on trazodone (went from seven episodes a night to four).
Eventually, after several years, I sent him for a sleep study. He had severe sleep apnea (Apnea Hypopnea Index, 65; O2 saturations as low as 60%). With treatment, his nocturia resolved. He went from seven episodes to two each night.
Zhou and colleagues performed a meta-analysis of 13 studies looking at the association of sleep apnea with nocturia.3 They found that men with sleep apnea have a high incidence of nocturia.
Miyazato and colleagues looked at the effect of CPAP treatment on nighttime urine production in patients with obstructive sleep apnea.4 In this small study of 40 patients, mean nighttime voiding episodes decreased from 2.1 to 1.2 (P < .01).
I have seen several patients with night sweats who ended up having sleep apnea. These patients have had a resolution of their night sweats with sleep apnea treatment.
Arnardottir and colleagues found that obstructive sleep apnea was associated with frequent nocturnal sweating.5 They found that 31% of men and 33% of women with OSA had nocturnal sweating, compared with about 10% of the general population.
When the OSA patients were treated with positive airway pressure, the prevalence of nocturnal sweating decreased to 11.5%, which is similar to general population numbers. Given how common both sleep apnea and night sweats are, this is an important consideration as you evaluate night sweats.
I have seen many patients who have had atrial fibrillation and sleep apnea. Shapira-Daniels and colleagues did a prospective study of 188 patients with atrial fibrillation without a history of sleep apnea who were referred for ablation.6 All patients had home sleep studies, and testing was consistent with sleep apnea in 82% of patients.
Kanagala and associates found that patients with untreated sleep apnea had a greater chance of recurrent atrial fibrillation after cardioversion.7 Recurrence of atrial fibrillation at 12 months was 82% in untreated OSA patients, higher than the 42% recurrence in the treated OSA group (P = .013) and the 53% recurrence in control patients.
I think sleep apnea evaluation should be strongly considered in patients with atrial fibrillation and should be done before referral for ablations.
Pearl: Consider sleep apnea as a possible cause of or contributing factor to the common primary care problems of cognitive concerns, nocturia, night sweats, and atrial fibrillation.
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. Wallace A and Bucks RS. Memory and obstructive sleep apnea: a meta-analysis. Sleep. 2013;36(2):203. Epub 2013 Feb 1.
2. Olaithe M and Bucks RS. Executive dysfunction in OSA before and after treatment: a meta-analysis. Sleep. 2013;36(9):1297. Epub 2013 Sep 1.
3. Zhou J et al. Association between obstructive sleep apnea syndrome and nocturia: a meta-analysis. Sleep Breath. 2020 Dec;24(4):1293-8.
4. Miyauchi Y et al. Effect of the continuous positive airway pressure on the nocturnal urine volume or night-time frequency in patients with obstructive sleep apnea syndrome. Urology 2015;85:333.
5. Arnardottir ES et al. Nocturnal sweating–a common symptom of obstructive sleep apnoea: the Icelandic sleep apnoea cohort. BMJ Open. 2013 May 14;3(5):e002795. BMJ Open 2013;3:e002795
6. Shapira-Daniels A et al. Prevalence of undiagnosed sleep apnea in patients with atrial fibrillation and its impact on therapy. JACC Clin Electrophysiol. 2020;6(12):1499. Epub 2020 Aug 12.
7. Kanagala R et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation. 2003;107(20):2589. Epub 2003 May 12.
Fortunately her problem stemmed from sleep apnea, and resolved with continuous positive airway pressure (CPAP) therapy.
Wallace and Bucks performed a meta analysis of 42 studies of memory in patients with sleep apnea and found sleep apnea patients were impaired when compared to healthy controls on verbal episodic memory (immediate recall, delayed recall, learning, and recognition) and visuospatial episodic memory (immediate and delayed recall).1 A meta-analysis by Olaithe and associates found an improvement in executive function in patients with sleep apnea who were treated with CPAP.2 I think this is worth considering especially in your patients who have subjective memory disturbances and do not appear to have a mild cognitive impairment or dementia.
About 15 years ago I saw a 74-year-old man for nocturia. He had seen two urologists and had a transurethral resection of the prostate (TURP) without any real change in his nocturia. I trialed him on all sorts of medications, and he seemed to improve temporarily a little on trazodone (went from seven episodes a night to four).
Eventually, after several years, I sent him for a sleep study. He had severe sleep apnea (Apnea Hypopnea Index, 65; O2 saturations as low as 60%). With treatment, his nocturia resolved. He went from seven episodes to two each night.
Zhou and colleagues performed a meta-analysis of 13 studies looking at the association of sleep apnea with nocturia.3 They found that men with sleep apnea have a high incidence of nocturia.
Miyazato and colleagues looked at the effect of CPAP treatment on nighttime urine production in patients with obstructive sleep apnea.4 In this small study of 40 patients, mean nighttime voiding episodes decreased from 2.1 to 1.2 (P < .01).
I have seen several patients with night sweats who ended up having sleep apnea. These patients have had a resolution of their night sweats with sleep apnea treatment.
Arnardottir and colleagues found that obstructive sleep apnea was associated with frequent nocturnal sweating.5 They found that 31% of men and 33% of women with OSA had nocturnal sweating, compared with about 10% of the general population.
When the OSA patients were treated with positive airway pressure, the prevalence of nocturnal sweating decreased to 11.5%, which is similar to general population numbers. Given how common both sleep apnea and night sweats are, this is an important consideration as you evaluate night sweats.
I have seen many patients who have had atrial fibrillation and sleep apnea. Shapira-Daniels and colleagues did a prospective study of 188 patients with atrial fibrillation without a history of sleep apnea who were referred for ablation.6 All patients had home sleep studies, and testing was consistent with sleep apnea in 82% of patients.
Kanagala and associates found that patients with untreated sleep apnea had a greater chance of recurrent atrial fibrillation after cardioversion.7 Recurrence of atrial fibrillation at 12 months was 82% in untreated OSA patients, higher than the 42% recurrence in the treated OSA group (P = .013) and the 53% recurrence in control patients.
I think sleep apnea evaluation should be strongly considered in patients with atrial fibrillation and should be done before referral for ablations.
Pearl: Consider sleep apnea as a possible cause of or contributing factor to the common primary care problems of cognitive concerns, nocturia, night sweats, and atrial fibrillation.
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. Wallace A and Bucks RS. Memory and obstructive sleep apnea: a meta-analysis. Sleep. 2013;36(2):203. Epub 2013 Feb 1.
2. Olaithe M and Bucks RS. Executive dysfunction in OSA before and after treatment: a meta-analysis. Sleep. 2013;36(9):1297. Epub 2013 Sep 1.
3. Zhou J et al. Association between obstructive sleep apnea syndrome and nocturia: a meta-analysis. Sleep Breath. 2020 Dec;24(4):1293-8.
4. Miyauchi Y et al. Effect of the continuous positive airway pressure on the nocturnal urine volume or night-time frequency in patients with obstructive sleep apnea syndrome. Urology 2015;85:333.
5. Arnardottir ES et al. Nocturnal sweating–a common symptom of obstructive sleep apnoea: the Icelandic sleep apnoea cohort. BMJ Open. 2013 May 14;3(5):e002795. BMJ Open 2013;3:e002795
6. Shapira-Daniels A et al. Prevalence of undiagnosed sleep apnea in patients with atrial fibrillation and its impact on therapy. JACC Clin Electrophysiol. 2020;6(12):1499. Epub 2020 Aug 12.
7. Kanagala R et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation. 2003;107(20):2589. Epub 2003 May 12.
What I will and won’t miss
Someday I plan to retire.
Hopefully it’s not coming up anytime soon, but I’m sure it’s sooner than I realize. I’ve been in practice for 23 years, so I’m well past the halfway point of an average medical career.
I will miss a lot. There will be many things I won’t miss, but the job has far more good than bad, even today.
I’ve spent a lot of time at this huge desk, which my dad bought for his solo law practice in 1967. Although I won’t miss the lack of sleep, I will miss the silence of getting to the office before first light, making tea, and getting started for the day. It’s a peaceful daily start in a less-then-predictable job.
I’ll miss my patients. Not all of them, but most. The majority are decent people, and it’s an honor to be able to help them. Doing that has been the driving force that started me on this path a long time ago and still keeps me moving forward.
In some respects I’ll feel bad about retiring and leaving them. Some have been with me since residency. It will bother me that they’ll have to start over with a new neurologist. Hopefully that person will give them care as good, if not better, than I have.
I’ll really miss my staff. I’ve been lucky. They’re awesome, and have stayed with me for this crazy ride. My MA has been here since 1999, my secretary since 2004. At work they’re my family. Away from work they’re a part of my family. The three of us have survived my hospital call, good economic times, bad economic times, moving the office, my MA moving to the boondocks, the antics and events of our kids, and, as of now, a pandemic. They make the day fun. I’ll feel bad that they’ll need to change jobs if they’re still working then.
What I won’t miss are more concrete things – the endless forms, time spent on the phone and online to get medications and tests approved, the difficult (personality wise) patients who think being nasty and mean is going to get them better care, and having to practice CYA defensive medicine.
It’s good to look back after 23 years, and still have, overall, no regrets about choosing this ride.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Someday I plan to retire.
Hopefully it’s not coming up anytime soon, but I’m sure it’s sooner than I realize. I’ve been in practice for 23 years, so I’m well past the halfway point of an average medical career.
I will miss a lot. There will be many things I won’t miss, but the job has far more good than bad, even today.
I’ve spent a lot of time at this huge desk, which my dad bought for his solo law practice in 1967. Although I won’t miss the lack of sleep, I will miss the silence of getting to the office before first light, making tea, and getting started for the day. It’s a peaceful daily start in a less-then-predictable job.
I’ll miss my patients. Not all of them, but most. The majority are decent people, and it’s an honor to be able to help them. Doing that has been the driving force that started me on this path a long time ago and still keeps me moving forward.
In some respects I’ll feel bad about retiring and leaving them. Some have been with me since residency. It will bother me that they’ll have to start over with a new neurologist. Hopefully that person will give them care as good, if not better, than I have.
I’ll really miss my staff. I’ve been lucky. They’re awesome, and have stayed with me for this crazy ride. My MA has been here since 1999, my secretary since 2004. At work they’re my family. Away from work they’re a part of my family. The three of us have survived my hospital call, good economic times, bad economic times, moving the office, my MA moving to the boondocks, the antics and events of our kids, and, as of now, a pandemic. They make the day fun. I’ll feel bad that they’ll need to change jobs if they’re still working then.
What I won’t miss are more concrete things – the endless forms, time spent on the phone and online to get medications and tests approved, the difficult (personality wise) patients who think being nasty and mean is going to get them better care, and having to practice CYA defensive medicine.
It’s good to look back after 23 years, and still have, overall, no regrets about choosing this ride.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Someday I plan to retire.
Hopefully it’s not coming up anytime soon, but I’m sure it’s sooner than I realize. I’ve been in practice for 23 years, so I’m well past the halfway point of an average medical career.
I will miss a lot. There will be many things I won’t miss, but the job has far more good than bad, even today.
I’ve spent a lot of time at this huge desk, which my dad bought for his solo law practice in 1967. Although I won’t miss the lack of sleep, I will miss the silence of getting to the office before first light, making tea, and getting started for the day. It’s a peaceful daily start in a less-then-predictable job.
I’ll miss my patients. Not all of them, but most. The majority are decent people, and it’s an honor to be able to help them. Doing that has been the driving force that started me on this path a long time ago and still keeps me moving forward.
In some respects I’ll feel bad about retiring and leaving them. Some have been with me since residency. It will bother me that they’ll have to start over with a new neurologist. Hopefully that person will give them care as good, if not better, than I have.
I’ll really miss my staff. I’ve been lucky. They’re awesome, and have stayed with me for this crazy ride. My MA has been here since 1999, my secretary since 2004. At work they’re my family. Away from work they’re a part of my family. The three of us have survived my hospital call, good economic times, bad economic times, moving the office, my MA moving to the boondocks, the antics and events of our kids, and, as of now, a pandemic. They make the day fun. I’ll feel bad that they’ll need to change jobs if they’re still working then.
What I won’t miss are more concrete things – the endless forms, time spent on the phone and online to get medications and tests approved, the difficult (personality wise) patients who think being nasty and mean is going to get them better care, and having to practice CYA defensive medicine.
It’s good to look back after 23 years, and still have, overall, no regrets about choosing this ride.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
An integrated response to Surfside: Lessons learned
The catastrophic collapse of the Surfside, Fla., Champlain Towers South left ambiguous loss, trauma, grief, and other psychiatric and psychological sequelae in its wake.
Now that a few months have passed since the tragedy, which took the lives of 98 residents, it is helpful to examine the psychiatric and psychological support efforts that emerged.
We can think of those support efforts as operating on two tracks: one was pursued by mental health professionals representing numerous organizations; the other was pursued by local, regional, and international first responders – specifically, by Israeli Defense Force (IDF) members who came to our community at the request of Surfside families.
Those efforts were guided by existing frameworks for crisis response designed to provide containment amid the naturally disorganizing effects of the trauma and ambiguous loss. In retrospect, it was clear that the mechanisms by which those frameworks coalesced and functioned were more implicit and organically synchronous than explicitly coordinated and agreed upon. key themes emerged and revealed intrinsic links between the first-responder/search and rescue and psychological strategies.
In this article, we discuss relevant themes and parallels between the psychological intervention/strategies and the first-responder disaster response and the practical utility of implementing an integrated strategy. Our hope is that a better understanding of these strategies will help future therapists and responders who respond to crises.
Setting the frame
The importance of setting a psychotherapeutic frame is indisputable regardless of theoretical orientation or therapeutic modality. Predictable, consistent conditions under which therapy takes place support a patient’s capacity to tolerate the ambiguous and unpredictable aspects of the process. Those “rules of engagement” provide a structure where subjective experiences can be formulated, organized, understood, and integrated. Twice-daily briefs held in a centralized location (dubbed the Surfside “family center”) paralleled this frame and served that same containing function by offering structure, order, and predictability amid the palpable chaos of ambiguous loss and traumatic grief. Those briefs provided key information on the status of the operation and described the rescue strategy. These were led by the Miami-Dade assistant fire chief and IDF colonel (E.E.), who presented a unified front and consistent presence.
It is essential that briefings such as these be coordinated (and unified) with clear expectations about ground rules, much like what is involved in therapeutic informed consent. In this context, rules included permissions related to documentation of meetings, information sharing, and rules of communication with the media in an effort to protect the vulnerable.
The centralized meeting location served as an important center of gravity and unified place of waiting and information receipt. It provided a dedicated space to meet with humanitarian aid organizations and government officials, and symbolized continuity, consistency, ease of information transmission, and a place where practical needs could be addressed. Meals, toiletries, and other supplies were provided to simplify and maintain daily routines. Those are otherwise unremarkable practices that seemed impossible to manage amid a crisis, yet can be inherently grounding and emotionally organizing when facing deep psychological fragmentation.
Meeting in person allowed the IDF to offer operational visuals to allow those affected to feel less helpless and cultivate a sense of purpose by being part of the strategy/mission. Their strategy included “population intelligence,” which was aimed at both information gathering to practically facilitate the rescue/recovery process (for example, locating victims, property, and recreating a visual of how the building fell), and inspiring people to participate. This engagement helped many transition from a place of denial/repression to acknowledging loss/grief, and from a passive to active part of the effort, in a way that was safe and realistic – as opposed to going to the site and aiding themselves, as some had requested.
Naturally, a central location made it possible to offer immediate psychological assistance and support. Clinicians responding to crisis should be carefully selected in light of the immense suffering, emotional vulnerability, and heightened reactivity of those affected. People were overwhelmed by deep sorrow, fear, anger, and uncertainty, vacillating between hope and despair, and mobilized by a desire to help. Those providing support need to be interpersonally skilled and able to regulate their own emotions. They must be able to formulate – in real time – an understanding of what is needed, and implement a strategic plan. Like first responders, it is also key for providers to be easily accessible and identifiable in uniform so that people in the grip of a survival response can easily identify and elicit support.
The power of strategy
The Israeli delegation and mental health approaches were aligned with respect to cultivating a team identity and keeping the team spirit elevated. The delegation’s approach was to deemphasize rank during the mission in that everyone was responsible for anything that was needed and no task was below anyone’s rank. The same was true for the mental health support response: Early interventions were focused on addressing practical needs – providing blankets, water, chargers, food, and a calming presence to counter the initial chaos. No task was too small, regardless of title or role. As more structure and order ensued, it was possible to offer more traditional crisis-related interventions aimed at grounding those affected.
Both teams worked to ensure 24-hour coverage, which was crucial given the need for consistency and continuity. Our commitment was to support the victims’ families and survivors by fully embracing the chaos and the situational demands, offering attunement and support, and satisfying both basic and higher-level needs. We divided and conquered work, observed signals of need, offered immediate support where necessary, and coordinated longer-term care plans when possible. The importance of ongoing self-care, consultation, and debriefing while doing this work cannot be overstated. Time to address basic needs and the impact of vicarious trauma as a team must be built in.
Importance of flexibility
This tragedy came with unique complexities and sensitivities that needed to be identified expediently and addressed with a concrete, comprehensive plan. This was true for both the rescue and psychological support efforts, and flexibility was key. There was nothing traditional about our work from a therapeutic perspective – we found quiet corners and empty offices, went for walks, met in lobbies, and checked in by phone. The interventions were brief.
Roles shifted often between aiding in addressing practical needs, advocating for victims and connecting them to appropriate resources, supporting the police in making death notifications, providing support and space for processing during and after briefings, and more.
Similarly, the rescue team constantly reevaluated their strategy because of what they discovered as they dismantled the collapsed building, in addition to managing external impacting factors (heat, rain, lightning, and the threat of the remaining structure falling).
Language matters
The iteration of commitment to the families/victims/mission and to work speedily and efficiently was important for both rescuers and therapists. It was key during the briefings for the chief and colonel (E.E.) to share information in a manner that was professional, discreet, honest and explicit. Their willingness and ability to be vulnerable and to share their personal feelings as active rescuers humanized them. Their approach was matter of fact, yet warm, loving, and containing, all of which conveyed dignity and respect.
Word choice mattered, and the IDF’s intentional choice to refer to recovered victims as “souls,” rather than “bodies,” conveyed their sensitivity to the intensity of anguish, depth of loss, and gravity of the situation. From a psychological perspective, the transition between “rescue” efforts signifying the potential saving of lives to “recovery” of bodies or remains was significant and demarcated a dramatic shift. The weeks-long efforts, once painfully slow, then felt too abrupt to process.
One extraordinary moment was the chief’s response to the families’ discomfort at the news of the switch from rescue to recovery. The families were anxious about losing the structure that the briefings provided and were apprehensive about the handoff from fire to the police department. With great compassion and attunement, he assured them that he would stay with them, and they together, as a family, would decide when to conclude the in-person briefings. The colonel (E.E.), too, provided assurance that neither procedure nor the urgency of the recovery would change. It was both heart-warming and containing that information related to the operation was shared in a clear manner, and that the thought process and rationale behind major decisions (e.g., demolishing the remaining building, decision to pause operations, switch from rescue to recovery) was shared. It was useful for the clinicians to be aware of this rationale in helping individuals metabolize the information and process the associated trauma and grief.
Unification is key
Surfside has left an indelible impact on us. We saw and experienced unity in many respects – clinicians from various backgrounds collaborating, families bonding and caring for one another, community support and solidarity, and the cooperation and coordination of the search and rescue teams. The diverse groups providing support came to feel like a family, and the importance of inter- and intrateam integration cannot be overstated. We were transformed both by our professional collaborations and authentic connections with those affected, and will forever cherish the experience, one another, the families, and the souls lost.
Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of The Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures. Col. Edri is the Israeli Defense Forces District Commander of the Home Front Command Haifa District. He served as the deputy commander for the Israeli Defense Forces Search and Rescue Delegation, which was brought in to provide international aid to the local and domestic forces responding to the Surfside, Fla., building collapse. Col. Edri has no disclosures. Dr. Davidtz is a licensed psychologist and associate professor in the College of Psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she is director of internship training for the Psychology Services Center and director of psychological services for the emotionally distressed, a specialty clinic that serves people with serious mental illness and personality disorders. She also maintains a part-time private practice specializing in the treatment of complex posttraumatic conditions and personality disorders. Dr. Davidtz has no disclosures.
The catastrophic collapse of the Surfside, Fla., Champlain Towers South left ambiguous loss, trauma, grief, and other psychiatric and psychological sequelae in its wake.
Now that a few months have passed since the tragedy, which took the lives of 98 residents, it is helpful to examine the psychiatric and psychological support efforts that emerged.
We can think of those support efforts as operating on two tracks: one was pursued by mental health professionals representing numerous organizations; the other was pursued by local, regional, and international first responders – specifically, by Israeli Defense Force (IDF) members who came to our community at the request of Surfside families.
Those efforts were guided by existing frameworks for crisis response designed to provide containment amid the naturally disorganizing effects of the trauma and ambiguous loss. In retrospect, it was clear that the mechanisms by which those frameworks coalesced and functioned were more implicit and organically synchronous than explicitly coordinated and agreed upon. key themes emerged and revealed intrinsic links between the first-responder/search and rescue and psychological strategies.
In this article, we discuss relevant themes and parallels between the psychological intervention/strategies and the first-responder disaster response and the practical utility of implementing an integrated strategy. Our hope is that a better understanding of these strategies will help future therapists and responders who respond to crises.
Setting the frame
The importance of setting a psychotherapeutic frame is indisputable regardless of theoretical orientation or therapeutic modality. Predictable, consistent conditions under which therapy takes place support a patient’s capacity to tolerate the ambiguous and unpredictable aspects of the process. Those “rules of engagement” provide a structure where subjective experiences can be formulated, organized, understood, and integrated. Twice-daily briefs held in a centralized location (dubbed the Surfside “family center”) paralleled this frame and served that same containing function by offering structure, order, and predictability amid the palpable chaos of ambiguous loss and traumatic grief. Those briefs provided key information on the status of the operation and described the rescue strategy. These were led by the Miami-Dade assistant fire chief and IDF colonel (E.E.), who presented a unified front and consistent presence.
It is essential that briefings such as these be coordinated (and unified) with clear expectations about ground rules, much like what is involved in therapeutic informed consent. In this context, rules included permissions related to documentation of meetings, information sharing, and rules of communication with the media in an effort to protect the vulnerable.
The centralized meeting location served as an important center of gravity and unified place of waiting and information receipt. It provided a dedicated space to meet with humanitarian aid organizations and government officials, and symbolized continuity, consistency, ease of information transmission, and a place where practical needs could be addressed. Meals, toiletries, and other supplies were provided to simplify and maintain daily routines. Those are otherwise unremarkable practices that seemed impossible to manage amid a crisis, yet can be inherently grounding and emotionally organizing when facing deep psychological fragmentation.
Meeting in person allowed the IDF to offer operational visuals to allow those affected to feel less helpless and cultivate a sense of purpose by being part of the strategy/mission. Their strategy included “population intelligence,” which was aimed at both information gathering to practically facilitate the rescue/recovery process (for example, locating victims, property, and recreating a visual of how the building fell), and inspiring people to participate. This engagement helped many transition from a place of denial/repression to acknowledging loss/grief, and from a passive to active part of the effort, in a way that was safe and realistic – as opposed to going to the site and aiding themselves, as some had requested.
Naturally, a central location made it possible to offer immediate psychological assistance and support. Clinicians responding to crisis should be carefully selected in light of the immense suffering, emotional vulnerability, and heightened reactivity of those affected. People were overwhelmed by deep sorrow, fear, anger, and uncertainty, vacillating between hope and despair, and mobilized by a desire to help. Those providing support need to be interpersonally skilled and able to regulate their own emotions. They must be able to formulate – in real time – an understanding of what is needed, and implement a strategic plan. Like first responders, it is also key for providers to be easily accessible and identifiable in uniform so that people in the grip of a survival response can easily identify and elicit support.
The power of strategy
The Israeli delegation and mental health approaches were aligned with respect to cultivating a team identity and keeping the team spirit elevated. The delegation’s approach was to deemphasize rank during the mission in that everyone was responsible for anything that was needed and no task was below anyone’s rank. The same was true for the mental health support response: Early interventions were focused on addressing practical needs – providing blankets, water, chargers, food, and a calming presence to counter the initial chaos. No task was too small, regardless of title or role. As more structure and order ensued, it was possible to offer more traditional crisis-related interventions aimed at grounding those affected.
Both teams worked to ensure 24-hour coverage, which was crucial given the need for consistency and continuity. Our commitment was to support the victims’ families and survivors by fully embracing the chaos and the situational demands, offering attunement and support, and satisfying both basic and higher-level needs. We divided and conquered work, observed signals of need, offered immediate support where necessary, and coordinated longer-term care plans when possible. The importance of ongoing self-care, consultation, and debriefing while doing this work cannot be overstated. Time to address basic needs and the impact of vicarious trauma as a team must be built in.
Importance of flexibility
This tragedy came with unique complexities and sensitivities that needed to be identified expediently and addressed with a concrete, comprehensive plan. This was true for both the rescue and psychological support efforts, and flexibility was key. There was nothing traditional about our work from a therapeutic perspective – we found quiet corners and empty offices, went for walks, met in lobbies, and checked in by phone. The interventions were brief.
Roles shifted often between aiding in addressing practical needs, advocating for victims and connecting them to appropriate resources, supporting the police in making death notifications, providing support and space for processing during and after briefings, and more.
Similarly, the rescue team constantly reevaluated their strategy because of what they discovered as they dismantled the collapsed building, in addition to managing external impacting factors (heat, rain, lightning, and the threat of the remaining structure falling).
Language matters
The iteration of commitment to the families/victims/mission and to work speedily and efficiently was important for both rescuers and therapists. It was key during the briefings for the chief and colonel (E.E.) to share information in a manner that was professional, discreet, honest and explicit. Their willingness and ability to be vulnerable and to share their personal feelings as active rescuers humanized them. Their approach was matter of fact, yet warm, loving, and containing, all of which conveyed dignity and respect.
Word choice mattered, and the IDF’s intentional choice to refer to recovered victims as “souls,” rather than “bodies,” conveyed their sensitivity to the intensity of anguish, depth of loss, and gravity of the situation. From a psychological perspective, the transition between “rescue” efforts signifying the potential saving of lives to “recovery” of bodies or remains was significant and demarcated a dramatic shift. The weeks-long efforts, once painfully slow, then felt too abrupt to process.
One extraordinary moment was the chief’s response to the families’ discomfort at the news of the switch from rescue to recovery. The families were anxious about losing the structure that the briefings provided and were apprehensive about the handoff from fire to the police department. With great compassion and attunement, he assured them that he would stay with them, and they together, as a family, would decide when to conclude the in-person briefings. The colonel (E.E.), too, provided assurance that neither procedure nor the urgency of the recovery would change. It was both heart-warming and containing that information related to the operation was shared in a clear manner, and that the thought process and rationale behind major decisions (e.g., demolishing the remaining building, decision to pause operations, switch from rescue to recovery) was shared. It was useful for the clinicians to be aware of this rationale in helping individuals metabolize the information and process the associated trauma and grief.
Unification is key
Surfside has left an indelible impact on us. We saw and experienced unity in many respects – clinicians from various backgrounds collaborating, families bonding and caring for one another, community support and solidarity, and the cooperation and coordination of the search and rescue teams. The diverse groups providing support came to feel like a family, and the importance of inter- and intrateam integration cannot be overstated. We were transformed both by our professional collaborations and authentic connections with those affected, and will forever cherish the experience, one another, the families, and the souls lost.
Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of The Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures. Col. Edri is the Israeli Defense Forces District Commander of the Home Front Command Haifa District. He served as the deputy commander for the Israeli Defense Forces Search and Rescue Delegation, which was brought in to provide international aid to the local and domestic forces responding to the Surfside, Fla., building collapse. Col. Edri has no disclosures. Dr. Davidtz is a licensed psychologist and associate professor in the College of Psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she is director of internship training for the Psychology Services Center and director of psychological services for the emotionally distressed, a specialty clinic that serves people with serious mental illness and personality disorders. She also maintains a part-time private practice specializing in the treatment of complex posttraumatic conditions and personality disorders. Dr. Davidtz has no disclosures.
The catastrophic collapse of the Surfside, Fla., Champlain Towers South left ambiguous loss, trauma, grief, and other psychiatric and psychological sequelae in its wake.
Now that a few months have passed since the tragedy, which took the lives of 98 residents, it is helpful to examine the psychiatric and psychological support efforts that emerged.
We can think of those support efforts as operating on two tracks: one was pursued by mental health professionals representing numerous organizations; the other was pursued by local, regional, and international first responders – specifically, by Israeli Defense Force (IDF) members who came to our community at the request of Surfside families.
Those efforts were guided by existing frameworks for crisis response designed to provide containment amid the naturally disorganizing effects of the trauma and ambiguous loss. In retrospect, it was clear that the mechanisms by which those frameworks coalesced and functioned were more implicit and organically synchronous than explicitly coordinated and agreed upon. key themes emerged and revealed intrinsic links between the first-responder/search and rescue and psychological strategies.
In this article, we discuss relevant themes and parallels between the psychological intervention/strategies and the first-responder disaster response and the practical utility of implementing an integrated strategy. Our hope is that a better understanding of these strategies will help future therapists and responders who respond to crises.
Setting the frame
The importance of setting a psychotherapeutic frame is indisputable regardless of theoretical orientation or therapeutic modality. Predictable, consistent conditions under which therapy takes place support a patient’s capacity to tolerate the ambiguous and unpredictable aspects of the process. Those “rules of engagement” provide a structure where subjective experiences can be formulated, organized, understood, and integrated. Twice-daily briefs held in a centralized location (dubbed the Surfside “family center”) paralleled this frame and served that same containing function by offering structure, order, and predictability amid the palpable chaos of ambiguous loss and traumatic grief. Those briefs provided key information on the status of the operation and described the rescue strategy. These were led by the Miami-Dade assistant fire chief and IDF colonel (E.E.), who presented a unified front and consistent presence.
It is essential that briefings such as these be coordinated (and unified) with clear expectations about ground rules, much like what is involved in therapeutic informed consent. In this context, rules included permissions related to documentation of meetings, information sharing, and rules of communication with the media in an effort to protect the vulnerable.
The centralized meeting location served as an important center of gravity and unified place of waiting and information receipt. It provided a dedicated space to meet with humanitarian aid organizations and government officials, and symbolized continuity, consistency, ease of information transmission, and a place where practical needs could be addressed. Meals, toiletries, and other supplies were provided to simplify and maintain daily routines. Those are otherwise unremarkable practices that seemed impossible to manage amid a crisis, yet can be inherently grounding and emotionally organizing when facing deep psychological fragmentation.
Meeting in person allowed the IDF to offer operational visuals to allow those affected to feel less helpless and cultivate a sense of purpose by being part of the strategy/mission. Their strategy included “population intelligence,” which was aimed at both information gathering to practically facilitate the rescue/recovery process (for example, locating victims, property, and recreating a visual of how the building fell), and inspiring people to participate. This engagement helped many transition from a place of denial/repression to acknowledging loss/grief, and from a passive to active part of the effort, in a way that was safe and realistic – as opposed to going to the site and aiding themselves, as some had requested.
Naturally, a central location made it possible to offer immediate psychological assistance and support. Clinicians responding to crisis should be carefully selected in light of the immense suffering, emotional vulnerability, and heightened reactivity of those affected. People were overwhelmed by deep sorrow, fear, anger, and uncertainty, vacillating between hope and despair, and mobilized by a desire to help. Those providing support need to be interpersonally skilled and able to regulate their own emotions. They must be able to formulate – in real time – an understanding of what is needed, and implement a strategic plan. Like first responders, it is also key for providers to be easily accessible and identifiable in uniform so that people in the grip of a survival response can easily identify and elicit support.
The power of strategy
The Israeli delegation and mental health approaches were aligned with respect to cultivating a team identity and keeping the team spirit elevated. The delegation’s approach was to deemphasize rank during the mission in that everyone was responsible for anything that was needed and no task was below anyone’s rank. The same was true for the mental health support response: Early interventions were focused on addressing practical needs – providing blankets, water, chargers, food, and a calming presence to counter the initial chaos. No task was too small, regardless of title or role. As more structure and order ensued, it was possible to offer more traditional crisis-related interventions aimed at grounding those affected.
Both teams worked to ensure 24-hour coverage, which was crucial given the need for consistency and continuity. Our commitment was to support the victims’ families and survivors by fully embracing the chaos and the situational demands, offering attunement and support, and satisfying both basic and higher-level needs. We divided and conquered work, observed signals of need, offered immediate support where necessary, and coordinated longer-term care plans when possible. The importance of ongoing self-care, consultation, and debriefing while doing this work cannot be overstated. Time to address basic needs and the impact of vicarious trauma as a team must be built in.
Importance of flexibility
This tragedy came with unique complexities and sensitivities that needed to be identified expediently and addressed with a concrete, comprehensive plan. This was true for both the rescue and psychological support efforts, and flexibility was key. There was nothing traditional about our work from a therapeutic perspective – we found quiet corners and empty offices, went for walks, met in lobbies, and checked in by phone. The interventions were brief.
Roles shifted often between aiding in addressing practical needs, advocating for victims and connecting them to appropriate resources, supporting the police in making death notifications, providing support and space for processing during and after briefings, and more.
Similarly, the rescue team constantly reevaluated their strategy because of what they discovered as they dismantled the collapsed building, in addition to managing external impacting factors (heat, rain, lightning, and the threat of the remaining structure falling).
Language matters
The iteration of commitment to the families/victims/mission and to work speedily and efficiently was important for both rescuers and therapists. It was key during the briefings for the chief and colonel (E.E.) to share information in a manner that was professional, discreet, honest and explicit. Their willingness and ability to be vulnerable and to share their personal feelings as active rescuers humanized them. Their approach was matter of fact, yet warm, loving, and containing, all of which conveyed dignity and respect.
Word choice mattered, and the IDF’s intentional choice to refer to recovered victims as “souls,” rather than “bodies,” conveyed their sensitivity to the intensity of anguish, depth of loss, and gravity of the situation. From a psychological perspective, the transition between “rescue” efforts signifying the potential saving of lives to “recovery” of bodies or remains was significant and demarcated a dramatic shift. The weeks-long efforts, once painfully slow, then felt too abrupt to process.
One extraordinary moment was the chief’s response to the families’ discomfort at the news of the switch from rescue to recovery. The families were anxious about losing the structure that the briefings provided and were apprehensive about the handoff from fire to the police department. With great compassion and attunement, he assured them that he would stay with them, and they together, as a family, would decide when to conclude the in-person briefings. The colonel (E.E.), too, provided assurance that neither procedure nor the urgency of the recovery would change. It was both heart-warming and containing that information related to the operation was shared in a clear manner, and that the thought process and rationale behind major decisions (e.g., demolishing the remaining building, decision to pause operations, switch from rescue to recovery) was shared. It was useful for the clinicians to be aware of this rationale in helping individuals metabolize the information and process the associated trauma and grief.
Unification is key
Surfside has left an indelible impact on us. We saw and experienced unity in many respects – clinicians from various backgrounds collaborating, families bonding and caring for one another, community support and solidarity, and the cooperation and coordination of the search and rescue teams. The diverse groups providing support came to feel like a family, and the importance of inter- and intrateam integration cannot be overstated. We were transformed both by our professional collaborations and authentic connections with those affected, and will forever cherish the experience, one another, the families, and the souls lost.
Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of The Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures. Col. Edri is the Israeli Defense Forces District Commander of the Home Front Command Haifa District. He served as the deputy commander for the Israeli Defense Forces Search and Rescue Delegation, which was brought in to provide international aid to the local and domestic forces responding to the Surfside, Fla., building collapse. Col. Edri has no disclosures. Dr. Davidtz is a licensed psychologist and associate professor in the College of Psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she is director of internship training for the Psychology Services Center and director of psychological services for the emotionally distressed, a specialty clinic that serves people with serious mental illness and personality disorders. She also maintains a part-time private practice specializing in the treatment of complex posttraumatic conditions and personality disorders. Dr. Davidtz has no disclosures.