Opinion

Two themes have emerged recently in my psychotherapy practice, and in the mirror: relief and exhaustion. Some peace in the public discourse, or at least a pause in the ominous discord, has had the effect of a lightening, an unburdening. Some release from a contracted sense of tension around the specifics of violence and a broader sense of civil fracture has been palpable like a big, deep breath, exhaled. No sensible person would mistake this for being out of the metaphoric woods. A virus menaces and mutates, economic woes follow, and lots of us don’t get along. But, yes, there is some relief, some good change.

But even good change, even a downshift into relief, can pose some challenges to look for and overcome.

Consider for a moment the notion that every change represents a loss, a metaphoric “death” of the prior state of things. This is true of big, painful losses, like the death of a loved one, and small ones, like finding an empty cookie jar. It’s also true in changes we associate with benefit or relief: a refund check, a job promotion, a resolving migraine, or the breaking out of some civility.

In changes of all sorts, the world outside of one’s mind has shifted – at odds, momentarily, with our inner, now obsolete understanding of that changed world. The inside of the head does not match the outside. How we make that adjustment, so “inside = outside,” is a clinically familiar process: it’s grieving, with a sequence famously elaborated upon by Elisabeth Kübler-Ross, MD,¹ and others.

We all likely know the steps: shock/denial, anger, “bargaining,” depression, and acceptance. A quick review: Our initial anxious/threat reaction leads to grievous judgment, to rationalizing “woulda/coulda/shoulda’s,” then to truly landing in the disappointment of a loss or change, and the accepting of a new steady state. Inside proceeds to match outside.

So, what then of relief? How do we process “good” change? I think we still must move from “in ≠ out” to “in = out,” navigating some pitfalls along the way.

Initial threat often remains; apprehension of the “new” still can generate energy, and even a sense of threat, regardless of a kiss or a shove. Our brainstems run roughshod over this first phase.

Step two is about judgment. We can move past the threat to, “How do I feel about it?” Here’s where grievous feeling gets swapped out for something more peak-positive – joy, or relief if the change represents an ending of a state of suffering, tension, or uncertainty.

The “bargaining” step still happens, but often around a kind of testing regimen: Is this too good to be true? Is it really different? We run scenarios.

The thud of disappointment also gets a makeover. It’s a settling into the beneficial change and its associations: gratitude, a sense of energy shifting.

The bookend “OK” seems anodyne here – why would anyone not accept relief, some good change?² But it can nevertheless represent a challenge for many. The receding tension of the last year could open into a burst of energy, but I’m finding that exhaustion is just as or more common. That’s not illness, but a weary exhaling from the longest of held breaths.

One other twist: What happens when one of those steps is an individual obstacle, trigger, or hard-to-hold state? Especially for those with deep experience in disappointment or even trauma, buying into acceptance of a new normal can feel like a fool’s game. This is an especially complex spot for individuals who won’t quite allow for joyful acceptance to break out, lest it reveals itself as a humiliating trick or a too-brief respite from the “usual.”

Mindfulness practices, such as meditation, are helpful in managing this process. Committed time and optimal conditions to witness and adapt to the various inner states that ebb and flow generate a clear therapeutic benefit. Incorporating meditation training into my work with psychotherapy patients also becomes a kind of diagnostic force multiplier. Patients improve their identification of somatic manifestations, emotional reactions, and cycling ruminations of thought. What generates distraction and loss of mindful attention becomes better recognized. Contemplative work in between sessions becomes more productive.

What else do I advise?³ Patience, and some compassion for ourselves in this unusual time. Grief, and relief, are complex but truly human processes that generate not just one state of experience, but a cascade of them. While that cascade can hurt, it’s actually normal, not illness. But it can be exhausting.
 

Dr. Sazima is a Northern California psychiatrist, educator, and author. He is senior behavioral faculty at the Stanford-O’Connor Family Medicine Residency Program in San José, Calif. His latest book is “Practical Mindfulness: A Physician’s No-Nonsense Guide to Meditation for Beginners,” Miami: Mango Publishing, 2021. Dr. Sazima disclosed no relevant financial relationships.

References

1. Kübler-Ross E. “On Death And Dying,” New York: Simon & Schuster, 1969.

2. Selye H. “Stress Without Distress,” New York: Lippincott, Williams & Wilkins, 1974.

3. Sazima G. “Practical Mindfulness: A Physician’s No-Nonsense Guide to Meditation for Beginners,” Miami: Mango Publishing, 2021.

Two themes have emerged recently in my psychotherapy practice, and in the mirror: relief and exhaustion. Some peace in the public discourse, or at least a pause in the ominous discord, has had the effect of a lightening, an unburdening. Some release from a contracted sense of tension around the specifics of violence and a broader sense of civil fracture has been palpable like a big, deep breath, exhaled. No sensible person would mistake this for being out of the metaphoric woods. A virus menaces and mutates, economic woes follow, and lots of us don’t get along. But, yes, there is some relief, some good change.

But even good change, even a downshift into relief, can pose some challenges to look for and overcome.

Consider for a moment the notion that every change represents a loss, a metaphoric “death” of the prior state of things. This is true of big, painful losses, like the death of a loved one, and small ones, like finding an empty cookie jar. It’s also true in changes we associate with benefit or relief: a refund check, a job promotion, a resolving migraine, or the breaking out of some civility.

In changes of all sorts, the world outside of one’s mind has shifted – at odds, momentarily, with our inner, now obsolete understanding of that changed world. The inside of the head does not match the outside. How we make that adjustment, so “inside = outside,” is a clinically familiar process: it’s grieving, with a sequence famously elaborated upon by Elisabeth Kübler-Ross, MD,¹ and others.

We all likely know the steps: shock/denial, anger, “bargaining,” depression, and acceptance. A quick review: Our initial anxious/threat reaction leads to grievous judgment, to rationalizing “woulda/coulda/shoulda’s,” then to truly landing in the disappointment of a loss or change, and the accepting of a new steady state. Inside proceeds to match outside.

So, what then of relief? How do we process “good” change? I think we still must move from “in ≠ out” to “in = out,” navigating some pitfalls along the way.

Initial threat often remains; apprehension of the “new” still can generate energy, and even a sense of threat, regardless of a kiss or a shove. Our brainstems run roughshod over this first phase.

Step two is about judgment. We can move past the threat to, “How do I feel about it?” Here’s where grievous feeling gets swapped out for something more peak-positive – joy, or relief if the change represents an ending of a state of suffering, tension, or uncertainty.

The “bargaining” step still happens, but often around a kind of testing regimen: Is this too good to be true? Is it really different? We run scenarios.

The thud of disappointment also gets a makeover. It’s a settling into the beneficial change and its associations: gratitude, a sense of energy shifting.

The bookend “OK” seems anodyne here – why would anyone not accept relief, some good change?² But it can nevertheless represent a challenge for many. The receding tension of the last year could open into a burst of energy, but I’m finding that exhaustion is just as or more common. That’s not illness, but a weary exhaling from the longest of held breaths.

One other twist: What happens when one of those steps is an individual obstacle, trigger, or hard-to-hold state? Especially for those with deep experience in disappointment or even trauma, buying into acceptance of a new normal can feel like a fool’s game. This is an especially complex spot for individuals who won’t quite allow for joyful acceptance to break out, lest it reveals itself as a humiliating trick or a too-brief respite from the “usual.”

Mindfulness practices, such as meditation, are helpful in managing this process. Committed time and optimal conditions to witness and adapt to the various inner states that ebb and flow generate a clear therapeutic benefit. Incorporating meditation training into my work with psychotherapy patients also becomes a kind of diagnostic force multiplier. Patients improve their identification of somatic manifestations, emotional reactions, and cycling ruminations of thought. What generates distraction and loss of mindful attention becomes better recognized. Contemplative work in between sessions becomes more productive.

What else do I advise?³ Patience, and some compassion for ourselves in this unusual time. Grief, and relief, are complex but truly human processes that generate not just one state of experience, but a cascade of them. While that cascade can hurt, it’s actually normal, not illness. But it can be exhausting.
 

Dr. Sazima is a Northern California psychiatrist, educator, and author. He is senior behavioral faculty at the Stanford-O’Connor Family Medicine Residency Program in San José, Calif. His latest book is “Practical Mindfulness: A Physician’s No-Nonsense Guide to Meditation for Beginners,” Miami: Mango Publishing, 2021. Dr. Sazima disclosed no relevant financial relationships.

References

1. Kübler-Ross E. “On Death And Dying,” New York: Simon & Schuster, 1969.

2. Selye H. “Stress Without Distress,” New York: Lippincott, Williams & Wilkins, 1974.

3. Sazima G. “Practical Mindfulness: A Physician’s No-Nonsense Guide to Meditation for Beginners,” Miami: Mango Publishing, 2021.

Two themes have emerged recently in my psychotherapy practice, and in the mirror: relief and exhaustion. Some peace in the public discourse, or at least a pause in the ominous discord, has had the effect of a lightening, an unburdening. Some release from a contracted sense of tension around the specifics of violence and a broader sense of civil fracture has been palpable like a big, deep breath, exhaled. No sensible person would mistake this for being out of the metaphoric woods. A virus menaces and mutates, economic woes follow, and lots of us don’t get along. But, yes, there is some relief, some good change.

But even good change, even a downshift into relief, can pose some challenges to look for and overcome.

Consider for a moment the notion that every change represents a loss, a metaphoric “death” of the prior state of things. This is true of big, painful losses, like the death of a loved one, and small ones, like finding an empty cookie jar. It’s also true in changes we associate with benefit or relief: a refund check, a job promotion, a resolving migraine, or the breaking out of some civility.

In changes of all sorts, the world outside of one’s mind has shifted – at odds, momentarily, with our inner, now obsolete understanding of that changed world. The inside of the head does not match the outside. How we make that adjustment, so “inside = outside,” is a clinically familiar process: it’s grieving, with a sequence famously elaborated upon by Elisabeth Kübler-Ross, MD,¹ and others.

We all likely know the steps: shock/denial, anger, “bargaining,” depression, and acceptance. A quick review: Our initial anxious/threat reaction leads to grievous judgment, to rationalizing “woulda/coulda/shoulda’s,” then to truly landing in the disappointment of a loss or change, and the accepting of a new steady state. Inside proceeds to match outside.

So, what then of relief? How do we process “good” change? I think we still must move from “in ≠ out” to “in = out,” navigating some pitfalls along the way.

Initial threat often remains; apprehension of the “new” still can generate energy, and even a sense of threat, regardless of a kiss or a shove. Our brainstems run roughshod over this first phase.

Step two is about judgment. We can move past the threat to, “How do I feel about it?” Here’s where grievous feeling gets swapped out for something more peak-positive – joy, or relief if the change represents an ending of a state of suffering, tension, or uncertainty.

The “bargaining” step still happens, but often around a kind of testing regimen: Is this too good to be true? Is it really different? We run scenarios.

The thud of disappointment also gets a makeover. It’s a settling into the beneficial change and its associations: gratitude, a sense of energy shifting.

The bookend “OK” seems anodyne here – why would anyone not accept relief, some good change?² But it can nevertheless represent a challenge for many. The receding tension of the last year could open into a burst of energy, but I’m finding that exhaustion is just as or more common. That’s not illness, but a weary exhaling from the longest of held breaths.

One other twist: What happens when one of those steps is an individual obstacle, trigger, or hard-to-hold state? Especially for those with deep experience in disappointment or even trauma, buying into acceptance of a new normal can feel like a fool’s game. This is an especially complex spot for individuals who won’t quite allow for joyful acceptance to break out, lest it reveals itself as a humiliating trick or a too-brief respite from the “usual.”

Mindfulness practices, such as meditation, are helpful in managing this process. Committed time and optimal conditions to witness and adapt to the various inner states that ebb and flow generate a clear therapeutic benefit. Incorporating meditation training into my work with psychotherapy patients also becomes a kind of diagnostic force multiplier. Patients improve their identification of somatic manifestations, emotional reactions, and cycling ruminations of thought. What generates distraction and loss of mindful attention becomes better recognized. Contemplative work in between sessions becomes more productive.

What else do I advise?³ Patience, and some compassion for ourselves in this unusual time. Grief, and relief, are complex but truly human processes that generate not just one state of experience, but a cascade of them. While that cascade can hurt, it’s actually normal, not illness. But it can be exhausting.
 

Dr. Sazima is a Northern California psychiatrist, educator, and author. He is senior behavioral faculty at the Stanford-O’Connor Family Medicine Residency Program in San José, Calif. His latest book is “Practical Mindfulness: A Physician’s No-Nonsense Guide to Meditation for Beginners,” Miami: Mango Publishing, 2021. Dr. Sazima disclosed no relevant financial relationships.

References

1. Kübler-Ross E. “On Death And Dying,” New York: Simon & Schuster, 1969.

2. Selye H. “Stress Without Distress,” New York: Lippincott, Williams & Wilkins, 1974.

3. Sazima G. “Practical Mindfulness: A Physician’s No-Nonsense Guide to Meditation for Beginners,” Miami: Mango Publishing, 2021.

The weeks leading up to our Annual Conference always trigger certain rituals for me.

Deciding which sessions to attend feels like planning an intellectual feast mixed with an exercise in compromise, as I realize there is just no way to attend every session that I want to. Scheduling all my plans to connect over dinner and drinks with current and former colleagues is a logistical challenge I undertake with anticipation and some stress, especially when I’m the one tasked with making restaurant reservations. Thinking about how to pay for it all means digging out the rules around my CME faculty allowance, after first figuring out if I still even have a CME allowance, of course.

In the years that I am presenting, there are the last-minute emails with my co-presenters to arrange a time to run through our slides together on site. The prospect of seeing cherished colleagues and friends from SHM mixes with the fact that I know I will miss my wife and young son while I am away. Overall though, I am filled with a tremendous sense of excitement, a feeling that I enjoy in a sustained way for weeks before the meeting.

My excitement for SHM Converge is just as strong, but different in some great and important ways. The availability of on-demand content means I won’t have to choose one session over another this year – I can have my cake and eat it, too. Without the need to travel, expenses will be considerably less, and I won’t need to be away from my family.

But what I am most thrilled about when I think about SHM Converge is the content. A year of planning by our outstanding SHM staff, leadership, and Annual Conference Committee has produced a lineup of world-class speakers. Our virtual platform will offer a rich interactive and networking experience. Perennial favorite sessions, such as the Great Debate, Rapid Fire, and Update sessions will provide attendees the chance to update their core clinical knowledge across the breadth of hospital medicine.

Many aspects of health equity will be explored. Over 15 sessions and four special-interest forums covering topics such as racial and gender inequities, implicit bias, vulnerable populations, and ethics will help attendees not only understand the issues but also will show them how they can take action to make a difference.

Clinical and operational aspects of COVID-19 will also be covered at SHM Converge as speakers share the tremendous innovation, triumphs, and challenges that have taken place over the past year. Wellness and resilience are, of course, as relevant as ever, and sessions on balancing parenthood and work, learning from personal failures, and how to handle uncertainty and be resilient are among the topics that will be covered.

The essence of what we will do at SHM Converge in May is captured in our new meeting logo, an animation of nodes connecting with each other through lines that travel short and long, and intersect along the way. It’s a great representation of the togetherness, community, and mutual support that is at the core of who we are as SHM – now, more than ever. Thank you for joining us!

Dr. Steinberg is chief patient safety officer at Mount Sinai Downtown, and associate dean for quality/patient safety in GME, Mount Sinai Health System, New York. He is professor of medicine and medical education at the Icahn School of Medicine at Mount Sinai, and course director of SHM Converge.

The weeks leading up to our Annual Conference always trigger certain rituals for me.

Deciding which sessions to attend feels like planning an intellectual feast mixed with an exercise in compromise, as I realize there is just no way to attend every session that I want to. Scheduling all my plans to connect over dinner and drinks with current and former colleagues is a logistical challenge I undertake with anticipation and some stress, especially when I’m the one tasked with making restaurant reservations. Thinking about how to pay for it all means digging out the rules around my CME faculty allowance, after first figuring out if I still even have a CME allowance, of course.

In the years that I am presenting, there are the last-minute emails with my co-presenters to arrange a time to run through our slides together on site. The prospect of seeing cherished colleagues and friends from SHM mixes with the fact that I know I will miss my wife and young son while I am away. Overall though, I am filled with a tremendous sense of excitement, a feeling that I enjoy in a sustained way for weeks before the meeting.

My excitement for SHM Converge is just as strong, but different in some great and important ways. The availability of on-demand content means I won’t have to choose one session over another this year – I can have my cake and eat it, too. Without the need to travel, expenses will be considerably less, and I won’t need to be away from my family.

But what I am most thrilled about when I think about SHM Converge is the content. A year of planning by our outstanding SHM staff, leadership, and Annual Conference Committee has produced a lineup of world-class speakers. Our virtual platform will offer a rich interactive and networking experience. Perennial favorite sessions, such as the Great Debate, Rapid Fire, and Update sessions will provide attendees the chance to update their core clinical knowledge across the breadth of hospital medicine.

Many aspects of health equity will be explored. Over 15 sessions and four special-interest forums covering topics such as racial and gender inequities, implicit bias, vulnerable populations, and ethics will help attendees not only understand the issues but also will show them how they can take action to make a difference.

Clinical and operational aspects of COVID-19 will also be covered at SHM Converge as speakers share the tremendous innovation, triumphs, and challenges that have taken place over the past year. Wellness and resilience are, of course, as relevant as ever, and sessions on balancing parenthood and work, learning from personal failures, and how to handle uncertainty and be resilient are among the topics that will be covered.

The essence of what we will do at SHM Converge in May is captured in our new meeting logo, an animation of nodes connecting with each other through lines that travel short and long, and intersect along the way. It’s a great representation of the togetherness, community, and mutual support that is at the core of who we are as SHM – now, more than ever. Thank you for joining us!

Dr. Steinberg is chief patient safety officer at Mount Sinai Downtown, and associate dean for quality/patient safety in GME, Mount Sinai Health System, New York. He is professor of medicine and medical education at the Icahn School of Medicine at Mount Sinai, and course director of SHM Converge.

The weeks leading up to our Annual Conference always trigger certain rituals for me.

Deciding which sessions to attend feels like planning an intellectual feast mixed with an exercise in compromise, as I realize there is just no way to attend every session that I want to. Scheduling all my plans to connect over dinner and drinks with current and former colleagues is a logistical challenge I undertake with anticipation and some stress, especially when I’m the one tasked with making restaurant reservations. Thinking about how to pay for it all means digging out the rules around my CME faculty allowance, after first figuring out if I still even have a CME allowance, of course.

In the years that I am presenting, there are the last-minute emails with my co-presenters to arrange a time to run through our slides together on site. The prospect of seeing cherished colleagues and friends from SHM mixes with the fact that I know I will miss my wife and young son while I am away. Overall though, I am filled with a tremendous sense of excitement, a feeling that I enjoy in a sustained way for weeks before the meeting.

My excitement for SHM Converge is just as strong, but different in some great and important ways. The availability of on-demand content means I won’t have to choose one session over another this year – I can have my cake and eat it, too. Without the need to travel, expenses will be considerably less, and I won’t need to be away from my family.

But what I am most thrilled about when I think about SHM Converge is the content. A year of planning by our outstanding SHM staff, leadership, and Annual Conference Committee has produced a lineup of world-class speakers. Our virtual platform will offer a rich interactive and networking experience. Perennial favorite sessions, such as the Great Debate, Rapid Fire, and Update sessions will provide attendees the chance to update their core clinical knowledge across the breadth of hospital medicine.

Many aspects of health equity will be explored. Over 15 sessions and four special-interest forums covering topics such as racial and gender inequities, implicit bias, vulnerable populations, and ethics will help attendees not only understand the issues but also will show them how they can take action to make a difference.

Clinical and operational aspects of COVID-19 will also be covered at SHM Converge as speakers share the tremendous innovation, triumphs, and challenges that have taken place over the past year. Wellness and resilience are, of course, as relevant as ever, and sessions on balancing parenthood and work, learning from personal failures, and how to handle uncertainty and be resilient are among the topics that will be covered.

The essence of what we will do at SHM Converge in May is captured in our new meeting logo, an animation of nodes connecting with each other through lines that travel short and long, and intersect along the way. It’s a great representation of the togetherness, community, and mutual support that is at the core of who we are as SHM – now, more than ever. Thank you for joining us!

Dr. Steinberg is chief patient safety officer at Mount Sinai Downtown, and associate dean for quality/patient safety in GME, Mount Sinai Health System, New York. He is professor of medicine and medical education at the Icahn School of Medicine at Mount Sinai, and course director of SHM Converge.

I am hopeful that we are beginning to see a sustained decline in COVID-19 cases and hospitalizations. Although, total COVID-19 cases and deaths continue to rise (more than 460,000 deaths in the United States), vaccinations and treatment options have reduced the prevalence of severe disease, hospitalizations, and mortality rates. Worries about variants continue, but we now will enter a prolonged phase before we finally subdue COVID-19 and fully open our economies.

Health systems and practices are looking ahead and beginning to focus on how practice will look after COVID-19. From a business standpoint, we are seeing an accelerating consolidation of community practices. We anticipate the first resale of a private equity (PE)–acquired GI practice: Gastro Health was the first practice to join with a PE firm in 2016. Published rumors suggest a sale of the (now larger, multistate) practice at 15-times-plus EBITDA (earnings before interest, taxes, depreciation, and amortization) could begin as early as this quarter. It would not be a surprise to see 40% of independent gastroenterologists employed in a PE-backed model within a few years. Health systems and payers (especially United Health Group) continue to scoop up practices as well.

Clinical care has been changed forever. I expect fully 30% of visits will remain virtual, and innovative health systems will capitalize on that fact to right-size their brick-and-mortar facilities. Start-up companies will virtualize care and develop new models that allow board-certified gastroenterologist to focus on care they only can provide, resulting in substantial cost savings and (hopefully) similar or better outcomes. Remote patient monitoring (both reactive and predictive) is now firmly entrenched in our care armamentarium.

As you will see in this issue, we must create more effective interventions for NAFLD. Obesity will play an increasingly important role in the development of digestive and liver disease, so gastroenterologists must develop better tools and processes to combat root causes.

Begin thinking about DDW. While it again will be a virtual meeting, the content will be rich. Virtual meetings open up additional possibilities to gain new knowledge, although those personal connections over cocktails will be sorely missed.

John I. Allen, MD, MBA, AGAF
Editor in Chief

I am hopeful that we are beginning to see a sustained decline in COVID-19 cases and hospitalizations. Although, total COVID-19 cases and deaths continue to rise (more than 460,000 deaths in the United States), vaccinations and treatment options have reduced the prevalence of severe disease, hospitalizations, and mortality rates. Worries about variants continue, but we now will enter a prolonged phase before we finally subdue COVID-19 and fully open our economies.

Health systems and practices are looking ahead and beginning to focus on how practice will look after COVID-19. From a business standpoint, we are seeing an accelerating consolidation of community practices. We anticipate the first resale of a private equity (PE)–acquired GI practice: Gastro Health was the first practice to join with a PE firm in 2016. Published rumors suggest a sale of the (now larger, multistate) practice at 15-times-plus EBITDA (earnings before interest, taxes, depreciation, and amortization) could begin as early as this quarter. It would not be a surprise to see 40% of independent gastroenterologists employed in a PE-backed model within a few years. Health systems and payers (especially United Health Group) continue to scoop up practices as well.

Clinical care has been changed forever. I expect fully 30% of visits will remain virtual, and innovative health systems will capitalize on that fact to right-size their brick-and-mortar facilities. Start-up companies will virtualize care and develop new models that allow board-certified gastroenterologist to focus on care they only can provide, resulting in substantial cost savings and (hopefully) similar or better outcomes. Remote patient monitoring (both reactive and predictive) is now firmly entrenched in our care armamentarium.

As you will see in this issue, we must create more effective interventions for NAFLD. Obesity will play an increasingly important role in the development of digestive and liver disease, so gastroenterologists must develop better tools and processes to combat root causes.

Begin thinking about DDW. While it again will be a virtual meeting, the content will be rich. Virtual meetings open up additional possibilities to gain new knowledge, although those personal connections over cocktails will be sorely missed.

John I. Allen, MD, MBA, AGAF
Editor in Chief

I am hopeful that we are beginning to see a sustained decline in COVID-19 cases and hospitalizations. Although, total COVID-19 cases and deaths continue to rise (more than 460,000 deaths in the United States), vaccinations and treatment options have reduced the prevalence of severe disease, hospitalizations, and mortality rates. Worries about variants continue, but we now will enter a prolonged phase before we finally subdue COVID-19 and fully open our economies.

Health systems and practices are looking ahead and beginning to focus on how practice will look after COVID-19. From a business standpoint, we are seeing an accelerating consolidation of community practices. We anticipate the first resale of a private equity (PE)–acquired GI practice: Gastro Health was the first practice to join with a PE firm in 2016. Published rumors suggest a sale of the (now larger, multistate) practice at 15-times-plus EBITDA (earnings before interest, taxes, depreciation, and amortization) could begin as early as this quarter. It would not be a surprise to see 40% of independent gastroenterologists employed in a PE-backed model within a few years. Health systems and payers (especially United Health Group) continue to scoop up practices as well.

Clinical care has been changed forever. I expect fully 30% of visits will remain virtual, and innovative health systems will capitalize on that fact to right-size their brick-and-mortar facilities. Start-up companies will virtualize care and develop new models that allow board-certified gastroenterologist to focus on care they only can provide, resulting in substantial cost savings and (hopefully) similar or better outcomes. Remote patient monitoring (both reactive and predictive) is now firmly entrenched in our care armamentarium.

As you will see in this issue, we must create more effective interventions for NAFLD. Obesity will play an increasingly important role in the development of digestive and liver disease, so gastroenterologists must develop better tools and processes to combat root causes.

Begin thinking about DDW. While it again will be a virtual meeting, the content will be rich. Virtual meetings open up additional possibilities to gain new knowledge, although those personal connections over cocktails will be sorely missed.

John I. Allen, MD, MBA, AGAF
Editor in Chief

I got an interesting fax recently.

It started with how tough things have been for small practices during the pandemic (like I need reminding) and suggests it has solutions for my practice to stay afloat.

I’m used to all kinds of these approaches, and was going to toss the fax, but decided to read on out of curiosity. I assumed it was an advertisement for a loan company, or to sell vitamins out of my office.

This one, surprisingly, suggested I buy gadgets that would allow me to “balance uneven skin tones,” “shrink pores,” “eliminate freckles and stretch marks,” and do “laser vaginal resurfacing”

Are you kidding me?

First of all, I try very hard to stay in my lane. I’m a neurologist, hopefully a competent one, and have no desire to go beyond that. Imagine how bad this would look in a legal case: I’d be pretty hard pressed to convince a malpractice lawyer and jury that “eliminating stretch marks” and “laser vaginal resurfacing” are within the scope and training of your average neurologist.

Second, I don’t see this sort of thing as reflecting well on me. Patients come here to be treated for Parkinson’s disease, strokes, and epilepsy. If I tried to change the appointment’s topic to “those issues are minor, let’s talk about your stretch marks” I’m pretty sure they’d be looking for a new neurologist. And, when it got back to the physician who referred them, so would she.

Third, my patients are tightening their belts like everyone else in this pandemic-associated economic downturn. Suddenly trying to sell them on a pricey cash-pay procedure, let alone one that’s pretty far out of my field, isn’t going to fly. Like my own family they’re watching every penny right now and shrinking pores is at the bottom of their financial priorities. If they really want that done I’d to happy to refer them to a dermatologist.

Not surprisingly, I tossed the fax. Caring for my patients is challenging enough when I stick to what I do best. Trying to push procedures I have no business doing, solely to pry extra money out of them, isn’t just outside my field, It’s flat-out wrong.

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

I got an interesting fax recently.

It started with how tough things have been for small practices during the pandemic (like I need reminding) and suggests it has solutions for my practice to stay afloat.

I’m used to all kinds of these approaches, and was going to toss the fax, but decided to read on out of curiosity. I assumed it was an advertisement for a loan company, or to sell vitamins out of my office.

This one, surprisingly, suggested I buy gadgets that would allow me to “balance uneven skin tones,” “shrink pores,” “eliminate freckles and stretch marks,” and do “laser vaginal resurfacing”

Are you kidding me?

First of all, I try very hard to stay in my lane. I’m a neurologist, hopefully a competent one, and have no desire to go beyond that. Imagine how bad this would look in a legal case: I’d be pretty hard pressed to convince a malpractice lawyer and jury that “eliminating stretch marks” and “laser vaginal resurfacing” are within the scope and training of your average neurologist.

Second, I don’t see this sort of thing as reflecting well on me. Patients come here to be treated for Parkinson’s disease, strokes, and epilepsy. If I tried to change the appointment’s topic to “those issues are minor, let’s talk about your stretch marks” I’m pretty sure they’d be looking for a new neurologist. And, when it got back to the physician who referred them, so would she.

Third, my patients are tightening their belts like everyone else in this pandemic-associated economic downturn. Suddenly trying to sell them on a pricey cash-pay procedure, let alone one that’s pretty far out of my field, isn’t going to fly. Like my own family they’re watching every penny right now and shrinking pores is at the bottom of their financial priorities. If they really want that done I’d to happy to refer them to a dermatologist.

Not surprisingly, I tossed the fax. Caring for my patients is challenging enough when I stick to what I do best. Trying to push procedures I have no business doing, solely to pry extra money out of them, isn’t just outside my field, It’s flat-out wrong.

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

I got an interesting fax recently.

It started with how tough things have been for small practices during the pandemic (like I need reminding) and suggests it has solutions for my practice to stay afloat.

I’m used to all kinds of these approaches, and was going to toss the fax, but decided to read on out of curiosity. I assumed it was an advertisement for a loan company, or to sell vitamins out of my office.

This one, surprisingly, suggested I buy gadgets that would allow me to “balance uneven skin tones,” “shrink pores,” “eliminate freckles and stretch marks,” and do “laser vaginal resurfacing”

Are you kidding me?

First of all, I try very hard to stay in my lane. I’m a neurologist, hopefully a competent one, and have no desire to go beyond that. Imagine how bad this would look in a legal case: I’d be pretty hard pressed to convince a malpractice lawyer and jury that “eliminating stretch marks” and “laser vaginal resurfacing” are within the scope and training of your average neurologist.

Second, I don’t see this sort of thing as reflecting well on me. Patients come here to be treated for Parkinson’s disease, strokes, and epilepsy. If I tried to change the appointment’s topic to “those issues are minor, let’s talk about your stretch marks” I’m pretty sure they’d be looking for a new neurologist. And, when it got back to the physician who referred them, so would she.

Third, my patients are tightening their belts like everyone else in this pandemic-associated economic downturn. Suddenly trying to sell them on a pricey cash-pay procedure, let alone one that’s pretty far out of my field, isn’t going to fly. Like my own family they’re watching every penny right now and shrinking pores is at the bottom of their financial priorities. If they really want that done I’d to happy to refer them to a dermatologist.

Not surprisingly, I tossed the fax. Caring for my patients is challenging enough when I stick to what I do best. Trying to push procedures I have no business doing, solely to pry extra money out of them, isn’t just outside my field, It’s flat-out wrong.

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

Approximately half of all patients with locally advanced or metastatic urothelial cancer (la/mUC) are ineligible to receive cisplatin-based chemotherapy. They face poor outlooks and extremely limited treatment options.

A new study indicates that enfortumab vedotin (EV) can cause major, prolonged responses in most patients in that unfortunate setting.
 

EV is an antibody-drug conjugate directed against nectin-4, an immunoglobulin-like cell adhesion molecule that is highly expressed in UC, obviating the need for testing prior to treatment. It is internalized in malignant cells, with release of the active moiety (monomethyl auristatin E; MMAE). MMAE causes microtubule disruption, with resultant cell-cycle arrest and apoptosis.

EV received accelerated approval from the Food and Drug Administration in December 2019 after publication of the results from cohort 1 of the open-label, single-arm, phase 2 EV-201 study.

Arjun V. Balar, MD, of the Perlmutter Cancer Center at New York University Langone Health, presented results from cohort 2 of EV-201 – the cisplatin-ineligible cohort – at the 2021 Genitourinary Cancer Symposium (Abstract 394).
 

EV in patients ineligible for platinum-based therapy

Patients in cohort 2 of EV-201 had received immune checkpoint inhibitor therapy for la/mUC. They received EV in the FDA-approved dose for cohort 1: 1.25 mg/kg EV on days 1, 8, and 15 of a 28-day cycle.

Patients experienced disease progression during or following their most recent treatment. Patients with more than two neuropathies, active central nervous system metastases, and uncontrolled diabetes mellitus were excluded.

“Platinum ineligible” was defined as a creatinine clearance between 30-59 cm³/min, Eastern Cooperative Oncology Group performance status (ECOG PS) 2, or hearing loss of grade 2 or greater.

The primary endpoint for cohort 2 was confirmed overall response rate (ORR) per RECIST 1.1 by blinded independent central review. Secondary endpoints were duration of response, progression-free survival, overall survival, and safety.

There were 91 patients enrolled. Two patients never received EV treatment because of deterioration after registration. The median treatment duration among the remaining 89 patients was 6.0 months (range, 0.3-24.6).

Impressive results in poor-risk patients

The patients in EV-201 cohort 2 were elderly (median age, 75 years; range, 49-90) with comorbidities. The primary reasons for platinum-ineligibility were creatinine clearance less than 60 mL/min (66%), grade 2 or greater hearing loss (15%), and ECOG PS 2 (7%); 12% of patients met more than one criterion for platinum ineligibility.

The primary tumor site was in the upper urinary tract in 43% of patients, and 79% had visceral metastases, including 24% with liver involvement.

The confirmed ORR was 52% (95% confidence interval, 40.8-62.4), with 20% complete responses. There were responses in all subgroups, including patients with primary tumor sites in the upper tract (ORR, 61%), those with liver metastasis (ORR, 48%), and patients who had not responded to immune checkpoint inhibitors (ORR, 48%).

A total of 88% of patients had some decrease in measurable tumor diameters, generally within a few weeks of treatment initiation (median time to response, 1.8 months). The rapid response to treatment was especially important to patients having cancer-associated pain.

The median progression-free and overall survival durations were 5.8 months (95% CI, 5.0-8.3) and 14.7 months (95% CI, 10.5-18.2), respectively. The median response duration was 10.9 months (95% CI, 5.78-NR). More than 25% of responses extended beyond 12 months.

About 82% of patients in cohort 2 discontinued treatment, most commonly because of disease progression (51%). The second most common reason was the development of treatment-related adverse events (TRAE; 24%).
 

 

Drilling down on treatment-related adverse events

As might be expected for cisplatin-ineligible patients, adverse events were higher for patients in cohort 2 than for cohort 1 and led to treatment discontinuation in 16% of patients overall.

TRAEs over grade 3 occurred in 55% of patients. TRAEs of special interest included rash (61% overall; 17% ≥ grade 3), peripheral neuropathy (54% overall; 8% ≥ grade 3), and hyperglycemia (10% overall; 6% ≥ grade 3). Dose reductions, interruptions, and physical therapy were helpful.

Twenty percent of patients with TRAE hyperglycemia had hyperglycemia at baseline, and 30% of TRAEs were in patients with high body mass index (BMI).

There were four treatment-related deaths, all in patients 75 years or older with multiple comorbidities. Three of the four deaths occurred within 30 days of first EV dose in patients with BMI of 30 or greater (acute kidney injury, metabolic acidosis, and multiple organ dysfunction syndrome). The remaining death occurred more than 30 days after the last dose (pneumonitis).
 

Context and caution

The authors concluded that EV produced durable responses in platinum-ineligible patients with la/mUC, including 20% complete responses. Safety was felt to be as expected, given the known toxicities of the agent and the compromised medical condition of the patients studied.

The study discussant, Arlene O. Siefker-Radtke, MD, of the University of Texas MD Anderson Cancer Center, Houston, agreed that EV fills an unmet need, showing impressive responses in patients with visceral, liver, and bone metastases. She agreed that EV should be investigated across the spectrum of urothelial cancer.

Dr. Siefker-Radtke reminded attendees that the FDA package insert for EV described a 48% increase in the area under the concentration-time curve concentration of the MMAE active moiety in patients with mild hepatic impairment and that EV use should be avoided entirely in patients with moderate to severe liver disease.

She speculated whether augmented toxicity in patients with a high BMI could be attributable to clinically occult impaired hepatic function from fatty liver infiltration.

She indicated that clinicians should monitor closely patients with higher BMI and grade 3-4 hyperglycemia or elevated hemoglobin A1c levels and advised holding EV in patients who develop:

• Glucose levels above 250 mg/dL
• Peeling skin or bullous skin lesions. These lesions can be heralded by a diffuse erythematous or papillary rash in the preceding weeks.
• Grade 3 diarrhea or mucosal membrane toxicity of other types.

Notwithstanding concerns about toxicity and the need for monitoring, EV merits continued study in combination with other agents and in additional settings in the clinical spectrum of urothelial cancer. It is an important new option for oncologists caring for patients with urothelial cancer.

The EV-201 study was funded by Seagen. Dr. Balar and Dr. Siefker-Radtke disclosed relationships with Seagen and many other companies.

Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers, as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.

Approximately half of all patients with locally advanced or metastatic urothelial cancer (la/mUC) are ineligible to receive cisplatin-based chemotherapy. They face poor outlooks and extremely limited treatment options.

A new study indicates that enfortumab vedotin (EV) can cause major, prolonged responses in most patients in that unfortunate setting.
 

EV is an antibody-drug conjugate directed against nectin-4, an immunoglobulin-like cell adhesion molecule that is highly expressed in UC, obviating the need for testing prior to treatment. It is internalized in malignant cells, with release of the active moiety (monomethyl auristatin E; MMAE). MMAE causes microtubule disruption, with resultant cell-cycle arrest and apoptosis.

EV received accelerated approval from the Food and Drug Administration in December 2019 after publication of the results from cohort 1 of the open-label, single-arm, phase 2 EV-201 study.

Arjun V. Balar, MD, of the Perlmutter Cancer Center at New York University Langone Health, presented results from cohort 2 of EV-201 – the cisplatin-ineligible cohort – at the 2021 Genitourinary Cancer Symposium (Abstract 394).
 

EV in patients ineligible for platinum-based therapy

Patients in cohort 2 of EV-201 had received immune checkpoint inhibitor therapy for la/mUC. They received EV in the FDA-approved dose for cohort 1: 1.25 mg/kg EV on days 1, 8, and 15 of a 28-day cycle.

Patients experienced disease progression during or following their most recent treatment. Patients with more than two neuropathies, active central nervous system metastases, and uncontrolled diabetes mellitus were excluded.

“Platinum ineligible” was defined as a creatinine clearance between 30-59 cm³/min, Eastern Cooperative Oncology Group performance status (ECOG PS) 2, or hearing loss of grade 2 or greater.

The primary endpoint for cohort 2 was confirmed overall response rate (ORR) per RECIST 1.1 by blinded independent central review. Secondary endpoints were duration of response, progression-free survival, overall survival, and safety.

There were 91 patients enrolled. Two patients never received EV treatment because of deterioration after registration. The median treatment duration among the remaining 89 patients was 6.0 months (range, 0.3-24.6).

Impressive results in poor-risk patients

The patients in EV-201 cohort 2 were elderly (median age, 75 years; range, 49-90) with comorbidities. The primary reasons for platinum-ineligibility were creatinine clearance less than 60 mL/min (66%), grade 2 or greater hearing loss (15%), and ECOG PS 2 (7%); 12% of patients met more than one criterion for platinum ineligibility.

The primary tumor site was in the upper urinary tract in 43% of patients, and 79% had visceral metastases, including 24% with liver involvement.

The confirmed ORR was 52% (95% confidence interval, 40.8-62.4), with 20% complete responses. There were responses in all subgroups, including patients with primary tumor sites in the upper tract (ORR, 61%), those with liver metastasis (ORR, 48%), and patients who had not responded to immune checkpoint inhibitors (ORR, 48%).

A total of 88% of patients had some decrease in measurable tumor diameters, generally within a few weeks of treatment initiation (median time to response, 1.8 months). The rapid response to treatment was especially important to patients having cancer-associated pain.

The median progression-free and overall survival durations were 5.8 months (95% CI, 5.0-8.3) and 14.7 months (95% CI, 10.5-18.2), respectively. The median response duration was 10.9 months (95% CI, 5.78-NR). More than 25% of responses extended beyond 12 months.

About 82% of patients in cohort 2 discontinued treatment, most commonly because of disease progression (51%). The second most common reason was the development of treatment-related adverse events (TRAE; 24%).
 

 

Drilling down on treatment-related adverse events

As might be expected for cisplatin-ineligible patients, adverse events were higher for patients in cohort 2 than for cohort 1 and led to treatment discontinuation in 16% of patients overall.

TRAEs over grade 3 occurred in 55% of patients. TRAEs of special interest included rash (61% overall; 17% ≥ grade 3), peripheral neuropathy (54% overall; 8% ≥ grade 3), and hyperglycemia (10% overall; 6% ≥ grade 3). Dose reductions, interruptions, and physical therapy were helpful.

Twenty percent of patients with TRAE hyperglycemia had hyperglycemia at baseline, and 30% of TRAEs were in patients with high body mass index (BMI).

There were four treatment-related deaths, all in patients 75 years or older with multiple comorbidities. Three of the four deaths occurred within 30 days of first EV dose in patients with BMI of 30 or greater (acute kidney injury, metabolic acidosis, and multiple organ dysfunction syndrome). The remaining death occurred more than 30 days after the last dose (pneumonitis).
 

Context and caution

The authors concluded that EV produced durable responses in platinum-ineligible patients with la/mUC, including 20% complete responses. Safety was felt to be as expected, given the known toxicities of the agent and the compromised medical condition of the patients studied.

The study discussant, Arlene O. Siefker-Radtke, MD, of the University of Texas MD Anderson Cancer Center, Houston, agreed that EV fills an unmet need, showing impressive responses in patients with visceral, liver, and bone metastases. She agreed that EV should be investigated across the spectrum of urothelial cancer.

Dr. Siefker-Radtke reminded attendees that the FDA package insert for EV described a 48% increase in the area under the concentration-time curve concentration of the MMAE active moiety in patients with mild hepatic impairment and that EV use should be avoided entirely in patients with moderate to severe liver disease.

She speculated whether augmented toxicity in patients with a high BMI could be attributable to clinically occult impaired hepatic function from fatty liver infiltration.

She indicated that clinicians should monitor closely patients with higher BMI and grade 3-4 hyperglycemia or elevated hemoglobin A1c levels and advised holding EV in patients who develop:

• Glucose levels above 250 mg/dL
• Peeling skin or bullous skin lesions. These lesions can be heralded by a diffuse erythematous or papillary rash in the preceding weeks.
• Grade 3 diarrhea or mucosal membrane toxicity of other types.

Notwithstanding concerns about toxicity and the need for monitoring, EV merits continued study in combination with other agents and in additional settings in the clinical spectrum of urothelial cancer. It is an important new option for oncologists caring for patients with urothelial cancer.

The EV-201 study was funded by Seagen. Dr. Balar and Dr. Siefker-Radtke disclosed relationships with Seagen and many other companies.

Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers, as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.

Approximately half of all patients with locally advanced or metastatic urothelial cancer (la/mUC) are ineligible to receive cisplatin-based chemotherapy. They face poor outlooks and extremely limited treatment options.

A new study indicates that enfortumab vedotin (EV) can cause major, prolonged responses in most patients in that unfortunate setting.
 

EV is an antibody-drug conjugate directed against nectin-4, an immunoglobulin-like cell adhesion molecule that is highly expressed in UC, obviating the need for testing prior to treatment. It is internalized in malignant cells, with release of the active moiety (monomethyl auristatin E; MMAE). MMAE causes microtubule disruption, with resultant cell-cycle arrest and apoptosis.

EV received accelerated approval from the Food and Drug Administration in December 2019 after publication of the results from cohort 1 of the open-label, single-arm, phase 2 EV-201 study.

Arjun V. Balar, MD, of the Perlmutter Cancer Center at New York University Langone Health, presented results from cohort 2 of EV-201 – the cisplatin-ineligible cohort – at the 2021 Genitourinary Cancer Symposium (Abstract 394).
 

EV in patients ineligible for platinum-based therapy

Patients in cohort 2 of EV-201 had received immune checkpoint inhibitor therapy for la/mUC. They received EV in the FDA-approved dose for cohort 1: 1.25 mg/kg EV on days 1, 8, and 15 of a 28-day cycle.

Patients experienced disease progression during or following their most recent treatment. Patients with more than two neuropathies, active central nervous system metastases, and uncontrolled diabetes mellitus were excluded.

“Platinum ineligible” was defined as a creatinine clearance between 30-59 cm³/min, Eastern Cooperative Oncology Group performance status (ECOG PS) 2, or hearing loss of grade 2 or greater.

The primary endpoint for cohort 2 was confirmed overall response rate (ORR) per RECIST 1.1 by blinded independent central review. Secondary endpoints were duration of response, progression-free survival, overall survival, and safety.

There were 91 patients enrolled. Two patients never received EV treatment because of deterioration after registration. The median treatment duration among the remaining 89 patients was 6.0 months (range, 0.3-24.6).

Impressive results in poor-risk patients

The patients in EV-201 cohort 2 were elderly (median age, 75 years; range, 49-90) with comorbidities. The primary reasons for platinum-ineligibility were creatinine clearance less than 60 mL/min (66%), grade 2 or greater hearing loss (15%), and ECOG PS 2 (7%); 12% of patients met more than one criterion for platinum ineligibility.

The primary tumor site was in the upper urinary tract in 43% of patients, and 79% had visceral metastases, including 24% with liver involvement.

The confirmed ORR was 52% (95% confidence interval, 40.8-62.4), with 20% complete responses. There were responses in all subgroups, including patients with primary tumor sites in the upper tract (ORR, 61%), those with liver metastasis (ORR, 48%), and patients who had not responded to immune checkpoint inhibitors (ORR, 48%).

A total of 88% of patients had some decrease in measurable tumor diameters, generally within a few weeks of treatment initiation (median time to response, 1.8 months). The rapid response to treatment was especially important to patients having cancer-associated pain.

The median progression-free and overall survival durations were 5.8 months (95% CI, 5.0-8.3) and 14.7 months (95% CI, 10.5-18.2), respectively. The median response duration was 10.9 months (95% CI, 5.78-NR). More than 25% of responses extended beyond 12 months.

About 82% of patients in cohort 2 discontinued treatment, most commonly because of disease progression (51%). The second most common reason was the development of treatment-related adverse events (TRAE; 24%).
 

 

Drilling down on treatment-related adverse events

As might be expected for cisplatin-ineligible patients, adverse events were higher for patients in cohort 2 than for cohort 1 and led to treatment discontinuation in 16% of patients overall.

TRAEs over grade 3 occurred in 55% of patients. TRAEs of special interest included rash (61% overall; 17% ≥ grade 3), peripheral neuropathy (54% overall; 8% ≥ grade 3), and hyperglycemia (10% overall; 6% ≥ grade 3). Dose reductions, interruptions, and physical therapy were helpful.

Twenty percent of patients with TRAE hyperglycemia had hyperglycemia at baseline, and 30% of TRAEs were in patients with high body mass index (BMI).

There were four treatment-related deaths, all in patients 75 years or older with multiple comorbidities. Three of the four deaths occurred within 30 days of first EV dose in patients with BMI of 30 or greater (acute kidney injury, metabolic acidosis, and multiple organ dysfunction syndrome). The remaining death occurred more than 30 days after the last dose (pneumonitis).
 

Context and caution

The authors concluded that EV produced durable responses in platinum-ineligible patients with la/mUC, including 20% complete responses. Safety was felt to be as expected, given the known toxicities of the agent and the compromised medical condition of the patients studied.

The study discussant, Arlene O. Siefker-Radtke, MD, of the University of Texas MD Anderson Cancer Center, Houston, agreed that EV fills an unmet need, showing impressive responses in patients with visceral, liver, and bone metastases. She agreed that EV should be investigated across the spectrum of urothelial cancer.

Dr. Siefker-Radtke reminded attendees that the FDA package insert for EV described a 48% increase in the area under the concentration-time curve concentration of the MMAE active moiety in patients with mild hepatic impairment and that EV use should be avoided entirely in patients with moderate to severe liver disease.

She speculated whether augmented toxicity in patients with a high BMI could be attributable to clinically occult impaired hepatic function from fatty liver infiltration.

She indicated that clinicians should monitor closely patients with higher BMI and grade 3-4 hyperglycemia or elevated hemoglobin A1c levels and advised holding EV in patients who develop:

• Glucose levels above 250 mg/dL
• Peeling skin or bullous skin lesions. These lesions can be heralded by a diffuse erythematous or papillary rash in the preceding weeks.
• Grade 3 diarrhea or mucosal membrane toxicity of other types.

Notwithstanding concerns about toxicity and the need for monitoring, EV merits continued study in combination with other agents and in additional settings in the clinical spectrum of urothelial cancer. It is an important new option for oncologists caring for patients with urothelial cancer.

The EV-201 study was funded by Seagen. Dr. Balar and Dr. Siefker-Radtke disclosed relationships with Seagen and many other companies.

Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers, as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.

This past year, the referrals to my private practice have taken a noticeable shift and caused me to pause.

HRAUN/Getty Images

More calls have come from nurses, many who work directly with COVID-19 patients, understandably seeking mental health treatment, or support. Especially in this time, nurses are facing trauma and stress that is unimaginable to many, myself included. Despite the collective efforts we have made as a society to recognize their work, I do not think we have given enough consideration to the enormous sacrifice nurses are currently undertaking to save our collective psyche.

As physicians and mental health providers, we have a glimpse into the complexities and stressors of medical treatment. In our line of work, we support patients with trauma on a regular basis. We feel deeply connected to patients, some of whom we have treated until the end of their lives. Despite that, I am not sure that I, or anyone, can truly comprehend what nurses face in today’s climate of care.

There is no denying that doctors are of value to our system, but our service has limits; nurses and doctors operate as two sides to a shared coin. As doctors, we diagnose and prescribe, while nurses explain and dispense. As doctors, we talk to patients, while nurses comfort them. Imagine spending an entire year working in a hospital diligently wiping endotracheal tubes that are responsible for maintaining someone’s life. Imagine spending an entire year laboring through the heavy task of lifting patients to prone them in a position that may save their lives. Imagine spending an entire year holding the hands of comatose patients in hopes of maintaining a sense of humanity.

And this only begins to describe the tasks bestowed upon nurses. While doctors answer pagers or complete insurance authorization forms, nurses empathize and reassure scared and isolated patients. Imagine spending an entire year updating crying family members who cannot see their loved ones. Imagine spending an entire year explaining and pleading to the outside world that wearing a mask and washing hands would reduce the suffering that takes place inside the hospital walls.

Despite the uncertainties, pressures, and demands, nurses have continued, and will continue, to show up for their patients, shift by shift. It takes a tragic number of deaths for the nurses I see in my practice to share that they have lost count. These numbers reflect people they held to feed, carried to prevent ulcers, wiped for decency, caressed for compassion, probed with IVs and tubes, monitored for signs of life, and warmed with blankets. If love were in any job description, it would fall under that of a nurse.

And we can’t ignore the fact that all the lives lost by COVID-19 had family. Family members who, without ever stepping foot in the hospital, needed a place to be heard, a place to receive explanation, and a place for reassurance. This invaluable place is cultivated by nurses. Through Zoom and phone calls, nurses share messages of hope, love, and fear between patients and family. Through Zoom and phone calls, nurses orchestrate visits and last goodbyes.

There is no denying that we have all been affected by this shared human experience. But the pause we owe our nurses feels long overdue, and of great importance. Nurses need a space to be heard, to be comforted, to be recognized. They come to our practices, trying to contain the world’s angst, while also navigating for themselves what it means to go through what they are going through. They hope that by coming to see us, they will find the strength to go back another day, another week, another month. Sometimes, they come to talk about everything but the job, in hopes that by talking about more mundane problems, they will feel “normal” and reconnected.

I hope that our empathy, congruence, and unconditional positive regard will allow them to feel heard.¹ I hope that our warmth, concern, and hopefulness provide a welcoming place to voice sadness, anger, and fears.² I hope that our processing of traumatic memory, our challenge to avoid inaccurate self-blaming beliefs, and our encouragement to create more thought-out conclusions will allow them to understand what is happening more accurately.³

Yet, I worry. I worry that society hasn’t been particularly successful with helping prior generations of heroes. From war veterans, to Sept. 11, 2001, firefighters, it seems that we have repeated mistakes. The suffering that lingers from these types of experiences can’t be healed or erased by standing ovations at baseball stadiums, free health care, or money. My experience with veterans in particular has taught me that for many who are suffering, it feels like society has broken its very fabric by being bystanders to the pain.

But suffering and tragedy are an inevitable part of the human experience that we share. What we can keep sight of is this: As physicians, we work with nurses. We are witnessing firsthand the impossible sacrifice they are taking and the limits of resilience. Let us not be too busy to stop and give recognition where and when it is due. Let us listen and learn from our past, and present, heroes. And let us never forget to extend our own hand to those who make a living extending theirs.
 

Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com.

References

1. Rogers CR. J Consult Psychol. 1957;21(2):95-103.

2. Mallo CJ, Mintz DL. Psychodyn Psychiatry. 2013 Mar;41(1):13-37.

3. Resick PA et al. Cognitive Processing Therapy for PTSD: A Comprehensive Manual. Guilford Publications, 2016.

This past year, the referrals to my private practice have taken a noticeable shift and caused me to pause.

HRAUN/Getty Images

More calls have come from nurses, many who work directly with COVID-19 patients, understandably seeking mental health treatment, or support. Especially in this time, nurses are facing trauma and stress that is unimaginable to many, myself included. Despite the collective efforts we have made as a society to recognize their work, I do not think we have given enough consideration to the enormous sacrifice nurses are currently undertaking to save our collective psyche.

As physicians and mental health providers, we have a glimpse into the complexities and stressors of medical treatment. In our line of work, we support patients with trauma on a regular basis. We feel deeply connected to patients, some of whom we have treated until the end of their lives. Despite that, I am not sure that I, or anyone, can truly comprehend what nurses face in today’s climate of care.

There is no denying that doctors are of value to our system, but our service has limits; nurses and doctors operate as two sides to a shared coin. As doctors, we diagnose and prescribe, while nurses explain and dispense. As doctors, we talk to patients, while nurses comfort them. Imagine spending an entire year working in a hospital diligently wiping endotracheal tubes that are responsible for maintaining someone’s life. Imagine spending an entire year laboring through the heavy task of lifting patients to prone them in a position that may save their lives. Imagine spending an entire year holding the hands of comatose patients in hopes of maintaining a sense of humanity.

And this only begins to describe the tasks bestowed upon nurses. While doctors answer pagers or complete insurance authorization forms, nurses empathize and reassure scared and isolated patients. Imagine spending an entire year updating crying family members who cannot see their loved ones. Imagine spending an entire year explaining and pleading to the outside world that wearing a mask and washing hands would reduce the suffering that takes place inside the hospital walls.

Despite the uncertainties, pressures, and demands, nurses have continued, and will continue, to show up for their patients, shift by shift. It takes a tragic number of deaths for the nurses I see in my practice to share that they have lost count. These numbers reflect people they held to feed, carried to prevent ulcers, wiped for decency, caressed for compassion, probed with IVs and tubes, monitored for signs of life, and warmed with blankets. If love were in any job description, it would fall under that of a nurse.

And we can’t ignore the fact that all the lives lost by COVID-19 had family. Family members who, without ever stepping foot in the hospital, needed a place to be heard, a place to receive explanation, and a place for reassurance. This invaluable place is cultivated by nurses. Through Zoom and phone calls, nurses share messages of hope, love, and fear between patients and family. Through Zoom and phone calls, nurses orchestrate visits and last goodbyes.

There is no denying that we have all been affected by this shared human experience. But the pause we owe our nurses feels long overdue, and of great importance. Nurses need a space to be heard, to be comforted, to be recognized. They come to our practices, trying to contain the world’s angst, while also navigating for themselves what it means to go through what they are going through. They hope that by coming to see us, they will find the strength to go back another day, another week, another month. Sometimes, they come to talk about everything but the job, in hopes that by talking about more mundane problems, they will feel “normal” and reconnected.

I hope that our empathy, congruence, and unconditional positive regard will allow them to feel heard.¹ I hope that our warmth, concern, and hopefulness provide a welcoming place to voice sadness, anger, and fears.² I hope that our processing of traumatic memory, our challenge to avoid inaccurate self-blaming beliefs, and our encouragement to create more thought-out conclusions will allow them to understand what is happening more accurately.³

Yet, I worry. I worry that society hasn’t been particularly successful with helping prior generations of heroes. From war veterans, to Sept. 11, 2001, firefighters, it seems that we have repeated mistakes. The suffering that lingers from these types of experiences can’t be healed or erased by standing ovations at baseball stadiums, free health care, or money. My experience with veterans in particular has taught me that for many who are suffering, it feels like society has broken its very fabric by being bystanders to the pain.

But suffering and tragedy are an inevitable part of the human experience that we share. What we can keep sight of is this: As physicians, we work with nurses. We are witnessing firsthand the impossible sacrifice they are taking and the limits of resilience. Let us not be too busy to stop and give recognition where and when it is due. Let us listen and learn from our past, and present, heroes. And let us never forget to extend our own hand to those who make a living extending theirs.
 

Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com.

References

1. Rogers CR. J Consult Psychol. 1957;21(2):95-103.

2. Mallo CJ, Mintz DL. Psychodyn Psychiatry. 2013 Mar;41(1):13-37.

3. Resick PA et al. Cognitive Processing Therapy for PTSD: A Comprehensive Manual. Guilford Publications, 2016.

This past year, the referrals to my private practice have taken a noticeable shift and caused me to pause.

HRAUN/Getty Images

More calls have come from nurses, many who work directly with COVID-19 patients, understandably seeking mental health treatment, or support. Especially in this time, nurses are facing trauma and stress that is unimaginable to many, myself included. Despite the collective efforts we have made as a society to recognize their work, I do not think we have given enough consideration to the enormous sacrifice nurses are currently undertaking to save our collective psyche.

As physicians and mental health providers, we have a glimpse into the complexities and stressors of medical treatment. In our line of work, we support patients with trauma on a regular basis. We feel deeply connected to patients, some of whom we have treated until the end of their lives. Despite that, I am not sure that I, or anyone, can truly comprehend what nurses face in today’s climate of care.

There is no denying that doctors are of value to our system, but our service has limits; nurses and doctors operate as two sides to a shared coin. As doctors, we diagnose and prescribe, while nurses explain and dispense. As doctors, we talk to patients, while nurses comfort them. Imagine spending an entire year working in a hospital diligently wiping endotracheal tubes that are responsible for maintaining someone’s life. Imagine spending an entire year laboring through the heavy task of lifting patients to prone them in a position that may save their lives. Imagine spending an entire year holding the hands of comatose patients in hopes of maintaining a sense of humanity.

And this only begins to describe the tasks bestowed upon nurses. While doctors answer pagers or complete insurance authorization forms, nurses empathize and reassure scared and isolated patients. Imagine spending an entire year updating crying family members who cannot see their loved ones. Imagine spending an entire year explaining and pleading to the outside world that wearing a mask and washing hands would reduce the suffering that takes place inside the hospital walls.

Despite the uncertainties, pressures, and demands, nurses have continued, and will continue, to show up for their patients, shift by shift. It takes a tragic number of deaths for the nurses I see in my practice to share that they have lost count. These numbers reflect people they held to feed, carried to prevent ulcers, wiped for decency, caressed for compassion, probed with IVs and tubes, monitored for signs of life, and warmed with blankets. If love were in any job description, it would fall under that of a nurse.

And we can’t ignore the fact that all the lives lost by COVID-19 had family. Family members who, without ever stepping foot in the hospital, needed a place to be heard, a place to receive explanation, and a place for reassurance. This invaluable place is cultivated by nurses. Through Zoom and phone calls, nurses share messages of hope, love, and fear between patients and family. Through Zoom and phone calls, nurses orchestrate visits and last goodbyes.

There is no denying that we have all been affected by this shared human experience. But the pause we owe our nurses feels long overdue, and of great importance. Nurses need a space to be heard, to be comforted, to be recognized. They come to our practices, trying to contain the world’s angst, while also navigating for themselves what it means to go through what they are going through. They hope that by coming to see us, they will find the strength to go back another day, another week, another month. Sometimes, they come to talk about everything but the job, in hopes that by talking about more mundane problems, they will feel “normal” and reconnected.

I hope that our empathy, congruence, and unconditional positive regard will allow them to feel heard.¹ I hope that our warmth, concern, and hopefulness provide a welcoming place to voice sadness, anger, and fears.² I hope that our processing of traumatic memory, our challenge to avoid inaccurate self-blaming beliefs, and our encouragement to create more thought-out conclusions will allow them to understand what is happening more accurately.³

Yet, I worry. I worry that society hasn’t been particularly successful with helping prior generations of heroes. From war veterans, to Sept. 11, 2001, firefighters, it seems that we have repeated mistakes. The suffering that lingers from these types of experiences can’t be healed or erased by standing ovations at baseball stadiums, free health care, or money. My experience with veterans in particular has taught me that for many who are suffering, it feels like society has broken its very fabric by being bystanders to the pain.

But suffering and tragedy are an inevitable part of the human experience that we share. What we can keep sight of is this: As physicians, we work with nurses. We are witnessing firsthand the impossible sacrifice they are taking and the limits of resilience. Let us not be too busy to stop and give recognition where and when it is due. Let us listen and learn from our past, and present, heroes. And let us never forget to extend our own hand to those who make a living extending theirs.
 

Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com.

References

1. Rogers CR. J Consult Psychol. 1957;21(2):95-103.

2. Mallo CJ, Mintz DL. Psychodyn Psychiatry. 2013 Mar;41(1):13-37.

3. Resick PA et al. Cognitive Processing Therapy for PTSD: A Comprehensive Manual. Guilford Publications, 2016.

I think there are multiple factors explaining why the percentage of family physicians treating children declined again. Not the least of these is that pediatricians have a very limited scope of practice and need to market and attract patients, which they do quite a bit. There are even pediatric urgent care centers popping up all over the place now, some likely funded by venture capital just as other urgent care centers have been funded.

The loss of pediatric inpatient volume because of the effectiveness of vaccines that prevent many bacterial and viral illnesses means that fewer pediatric graduates are spending time in the hospital.

Family doctors used to retain their pediatric patients by delivering babies, seeing them in the newborn nursery, and beginning their relationship with the kids there. FPs are delivering fewer babies and the subsequent reduction in new kids in their practices has been a factor in this as well.

Finally, in multispecialty practices, pediatricians are employed there. Families immediately assume that their kids should be going to the pediatricians, not the family doctors. We need to keep talking up the fact that we take care of whole families to retain our pediatric practices.

Neil S. Calman, MD, is president and chief executive officer of the Institute for Family Health and is professor and chair of the Alfred and Gail Engelberg department of family medicine and community health at the Icahn School of Medicine at Mount Sinai and the Mount Sinai Health System, both in New York. Dr. Calman also serves on the editorial advisory board of Family Practice News.

I think there are multiple factors explaining why the percentage of family physicians treating children declined again. Not the least of these is that pediatricians have a very limited scope of practice and need to market and attract patients, which they do quite a bit. There are even pediatric urgent care centers popping up all over the place now, some likely funded by venture capital just as other urgent care centers have been funded.

The loss of pediatric inpatient volume because of the effectiveness of vaccines that prevent many bacterial and viral illnesses means that fewer pediatric graduates are spending time in the hospital.

Family doctors used to retain their pediatric patients by delivering babies, seeing them in the newborn nursery, and beginning their relationship with the kids there. FPs are delivering fewer babies and the subsequent reduction in new kids in their practices has been a factor in this as well.

Finally, in multispecialty practices, pediatricians are employed there. Families immediately assume that their kids should be going to the pediatricians, not the family doctors. We need to keep talking up the fact that we take care of whole families to retain our pediatric practices.

Neil S. Calman, MD, is president and chief executive officer of the Institute for Family Health and is professor and chair of the Alfred and Gail Engelberg department of family medicine and community health at the Icahn School of Medicine at Mount Sinai and the Mount Sinai Health System, both in New York. Dr. Calman also serves on the editorial advisory board of Family Practice News.

I think there are multiple factors explaining why the percentage of family physicians treating children declined again. Not the least of these is that pediatricians have a very limited scope of practice and need to market and attract patients, which they do quite a bit. There are even pediatric urgent care centers popping up all over the place now, some likely funded by venture capital just as other urgent care centers have been funded.

The loss of pediatric inpatient volume because of the effectiveness of vaccines that prevent many bacterial and viral illnesses means that fewer pediatric graduates are spending time in the hospital.

Family doctors used to retain their pediatric patients by delivering babies, seeing them in the newborn nursery, and beginning their relationship with the kids there. FPs are delivering fewer babies and the subsequent reduction in new kids in their practices has been a factor in this as well.

Finally, in multispecialty practices, pediatricians are employed there. Families immediately assume that their kids should be going to the pediatricians, not the family doctors. We need to keep talking up the fact that we take care of whole families to retain our pediatric practices.

Neil S. Calman, MD, is president and chief executive officer of the Institute for Family Health and is professor and chair of the Alfred and Gail Engelberg department of family medicine and community health at the Icahn School of Medicine at Mount Sinai and the Mount Sinai Health System, both in New York. Dr. Calman also serves on the editorial advisory board of Family Practice News.

After 15 years of limping and a gradual downhill slide in mobility, recreational walking had become uncomfortable enough that I’ve decided to shed my proudly worn cloak of denial and seek help. Even I could see that the x-ray made a total knee replacement the only option for some return to near normalcy. Scheduling a total knee replacement became a no-brainer.

My decision to accept the risks to reap the benefits of surgery is small potatoes compared with the decisions that the parents of a child born with a deformed lower extremity must face. In the Family Partnerships section of the February 2021 issue of Pediatrics you will find a heart-wrenching story of a family who embarked on what turned out to be painful and frustrating journey to lengthen their daughter’s congenitally deficient leg. In their own words, the mother and daughter describe how neither of them were prepared for the pain and life-altering complications the daughter has endured. Influenced by the optimism exuded by surgeons, the family gave little thought to the magnitude of the decision they were being asked to make. One has to wonder in retrospect if a well-timed amputation and prosthesis might have been a better decision. However, the thought of removing an extremity, even one that isn’t fully functional, is not one that most of us like to consider.

Over the last several decades I have read stories about people – usually athletes – born with short or deformed lower extremities who have faced the decision of amputation. I recall one college-age young man who despite his deformity and with the help of a prosthesis was a competitive multisport athlete. However, it became clear that his deformed foot was preventing him from accessing the most advanced prosthetic technology. Although he was highly motivated, he described his struggle with the decision to part with a portion of his body that despite its appearance and dysfunction had been with him since birth. On the other hand, I have read stories of young people who had become so frustrated by their deformity that they were more than eager to undergo amputation despite the concerns of their parents.

Early in my career I encountered a 3-year-old with phocomelia whose family was visiting from out of town and had come to our clinic because his older sibling was sick. The youngster, as I recall, had only one complete extremity, an arm. Like most 3-year-olds, he was driven to explore at breakneck speed. I will never forget watching him streak back and forth the length of our linoleum covered hallway like a crab skittering along the beach. His mother described how she and his well-meaning physicians were struggling unsuccessfully to get him to accept prostheses. Later I learned that his resistance is shared by many of the survivors of the thalidomide disaster who felt that the most frustrating period in their lives came when, again well-meaning, caregivers had tried to make them look and function more normally by fitting them with prostheses.

These anecdotal observations make clear a philosophy that we should have already internalized. In most clinic decisions the patient, pretty much regardless of age, should be a full participant in the process. And, to do this the patient and his or her family must be as informed as possible. Managing the aftermath of a traumatic amputation presents it own special set of challenges, but when it comes to elective amputation or prosthetic application for a congenital deficiency it is dangerous for us to insert our personal bias into the decision making.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

After 15 years of limping and a gradual downhill slide in mobility, recreational walking had become uncomfortable enough that I’ve decided to shed my proudly worn cloak of denial and seek help. Even I could see that the x-ray made a total knee replacement the only option for some return to near normalcy. Scheduling a total knee replacement became a no-brainer.

My decision to accept the risks to reap the benefits of surgery is small potatoes compared with the decisions that the parents of a child born with a deformed lower extremity must face. In the Family Partnerships section of the February 2021 issue of Pediatrics you will find a heart-wrenching story of a family who embarked on what turned out to be painful and frustrating journey to lengthen their daughter’s congenitally deficient leg. In their own words, the mother and daughter describe how neither of them were prepared for the pain and life-altering complications the daughter has endured. Influenced by the optimism exuded by surgeons, the family gave little thought to the magnitude of the decision they were being asked to make. One has to wonder in retrospect if a well-timed amputation and prosthesis might have been a better decision. However, the thought of removing an extremity, even one that isn’t fully functional, is not one that most of us like to consider.

Over the last several decades I have read stories about people – usually athletes – born with short or deformed lower extremities who have faced the decision of amputation. I recall one college-age young man who despite his deformity and with the help of a prosthesis was a competitive multisport athlete. However, it became clear that his deformed foot was preventing him from accessing the most advanced prosthetic technology. Although he was highly motivated, he described his struggle with the decision to part with a portion of his body that despite its appearance and dysfunction had been with him since birth. On the other hand, I have read stories of young people who had become so frustrated by their deformity that they were more than eager to undergo amputation despite the concerns of their parents.

Early in my career I encountered a 3-year-old with phocomelia whose family was visiting from out of town and had come to our clinic because his older sibling was sick. The youngster, as I recall, had only one complete extremity, an arm. Like most 3-year-olds, he was driven to explore at breakneck speed. I will never forget watching him streak back and forth the length of our linoleum covered hallway like a crab skittering along the beach. His mother described how she and his well-meaning physicians were struggling unsuccessfully to get him to accept prostheses. Later I learned that his resistance is shared by many of the survivors of the thalidomide disaster who felt that the most frustrating period in their lives came when, again well-meaning, caregivers had tried to make them look and function more normally by fitting them with prostheses.

These anecdotal observations make clear a philosophy that we should have already internalized. In most clinic decisions the patient, pretty much regardless of age, should be a full participant in the process. And, to do this the patient and his or her family must be as informed as possible. Managing the aftermath of a traumatic amputation presents it own special set of challenges, but when it comes to elective amputation or prosthetic application for a congenital deficiency it is dangerous for us to insert our personal bias into the decision making.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

After 15 years of limping and a gradual downhill slide in mobility, recreational walking had become uncomfortable enough that I’ve decided to shed my proudly worn cloak of denial and seek help. Even I could see that the x-ray made a total knee replacement the only option for some return to near normalcy. Scheduling a total knee replacement became a no-brainer.

My decision to accept the risks to reap the benefits of surgery is small potatoes compared with the decisions that the parents of a child born with a deformed lower extremity must face. In the Family Partnerships section of the February 2021 issue of Pediatrics you will find a heart-wrenching story of a family who embarked on what turned out to be painful and frustrating journey to lengthen their daughter’s congenitally deficient leg. In their own words, the mother and daughter describe how neither of them were prepared for the pain and life-altering complications the daughter has endured. Influenced by the optimism exuded by surgeons, the family gave little thought to the magnitude of the decision they were being asked to make. One has to wonder in retrospect if a well-timed amputation and prosthesis might have been a better decision. However, the thought of removing an extremity, even one that isn’t fully functional, is not one that most of us like to consider.

Over the last several decades I have read stories about people – usually athletes – born with short or deformed lower extremities who have faced the decision of amputation. I recall one college-age young man who despite his deformity and with the help of a prosthesis was a competitive multisport athlete. However, it became clear that his deformed foot was preventing him from accessing the most advanced prosthetic technology. Although he was highly motivated, he described his struggle with the decision to part with a portion of his body that despite its appearance and dysfunction had been with him since birth. On the other hand, I have read stories of young people who had become so frustrated by their deformity that they were more than eager to undergo amputation despite the concerns of their parents.

Early in my career I encountered a 3-year-old with phocomelia whose family was visiting from out of town and had come to our clinic because his older sibling was sick. The youngster, as I recall, had only one complete extremity, an arm. Like most 3-year-olds, he was driven to explore at breakneck speed. I will never forget watching him streak back and forth the length of our linoleum covered hallway like a crab skittering along the beach. His mother described how she and his well-meaning physicians were struggling unsuccessfully to get him to accept prostheses. Later I learned that his resistance is shared by many of the survivors of the thalidomide disaster who felt that the most frustrating period in their lives came when, again well-meaning, caregivers had tried to make them look and function more normally by fitting them with prostheses.

These anecdotal observations make clear a philosophy that we should have already internalized. In most clinic decisions the patient, pretty much regardless of age, should be a full participant in the process. And, to do this the patient and his or her family must be as informed as possible. Managing the aftermath of a traumatic amputation presents it own special set of challenges, but when it comes to elective amputation or prosthetic application for a congenital deficiency it is dangerous for us to insert our personal bias into the decision making.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

In a time when this country is struggling to find topics on which we can achieve broad consensus, the question of whether in-class learning is important stands as an outlier. Parents, teachers, students, and pediatricians all agree that having children learn in a social, face-to-face environment is critical to their education and mental health. Because school has become a de facto daycare source for many families, employers have joined in the chorus supporting a return to in-class education.

Of course, beyond that basic point of agreement the myriad of questions relating to when and how that return to the educational norm can be achieved we divide into groups with almost as many answers as there are questions. Part of the problem stems from the national leadership vacuum that fed the confusion. In this void the topic of school reopening has become politicized.

On Jan. 5, 2021, the American Academy of Pediatrics released an updated interim COVID-19 Guidance for Safe Schools at services.aap.org. It is a thorough and well thought out document that should function as a roadmap for communities and pediatricians who serve as official and unofficial advisers to their local school departments. At the very outset it reminds us that “school transmission mirrors but does not drive community transmission.”

Unfortunately, timing is everything and while the document’s salient points received some media attention it was mostly buried by the tsunami of press coverage in the wake of the storming of the Capitol the next day and the postinauguration reshuffling of the federal government. Even if it had been released on one of those seldom seen quiet news days, I fear the document’s message encouraging the return to in-class learning would have still not received the attention it deserved.

The lack of a high-visibility celebrity spokesperson and a system of short-tenure presidencies puts the AAP at a disadvantage when it comes to getting its message across to a national audience. The advocacy role filters down to those of us in our own communities who must convince school boards that not only is in-class learning critical but there are safe ways to do it.

In some communities the timing of return to in-class learning may pit pediatricians against teachers. Usually, these two groups share an enthusiastic advocacy for children. However, facing what has up to this point been a poorly defined health risk, teachers are understandably resistant to return to the classroom although they acknowledge its importance.

Armed with the AAP’s guidance document, pediatricians should encourage school boards and state and local health departments to look closely at the epidemiologic evidence and consider creative ways to prioritize teachers for what currently are limited and erratic vaccine supplies. Strategies might include offering vaccines to teachers based strictly on their age and/or health status. However, teachers and in-class education are so critical to the educational process and the national economy that an open offer to all teachers makes more sense.

While some states have already prioritized teachers for vaccines, the AAP must continue to speak loudly that in-class education is critical and urge all states to do what is necessary to make teachers feel safe to return to the classroom.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

In a time when this country is struggling to find topics on which we can achieve broad consensus, the question of whether in-class learning is important stands as an outlier. Parents, teachers, students, and pediatricians all agree that having children learn in a social, face-to-face environment is critical to their education and mental health. Because school has become a de facto daycare source for many families, employers have joined in the chorus supporting a return to in-class education.

Of course, beyond that basic point of agreement the myriad of questions relating to when and how that return to the educational norm can be achieved we divide into groups with almost as many answers as there are questions. Part of the problem stems from the national leadership vacuum that fed the confusion. In this void the topic of school reopening has become politicized.

On Jan. 5, 2021, the American Academy of Pediatrics released an updated interim COVID-19 Guidance for Safe Schools at services.aap.org. It is a thorough and well thought out document that should function as a roadmap for communities and pediatricians who serve as official and unofficial advisers to their local school departments. At the very outset it reminds us that “school transmission mirrors but does not drive community transmission.”

Unfortunately, timing is everything and while the document’s salient points received some media attention it was mostly buried by the tsunami of press coverage in the wake of the storming of the Capitol the next day and the postinauguration reshuffling of the federal government. Even if it had been released on one of those seldom seen quiet news days, I fear the document’s message encouraging the return to in-class learning would have still not received the attention it deserved.

The lack of a high-visibility celebrity spokesperson and a system of short-tenure presidencies puts the AAP at a disadvantage when it comes to getting its message across to a national audience. The advocacy role filters down to those of us in our own communities who must convince school boards that not only is in-class learning critical but there are safe ways to do it.

In some communities the timing of return to in-class learning may pit pediatricians against teachers. Usually, these two groups share an enthusiastic advocacy for children. However, facing what has up to this point been a poorly defined health risk, teachers are understandably resistant to return to the classroom although they acknowledge its importance.

Armed with the AAP’s guidance document, pediatricians should encourage school boards and state and local health departments to look closely at the epidemiologic evidence and consider creative ways to prioritize teachers for what currently are limited and erratic vaccine supplies. Strategies might include offering vaccines to teachers based strictly on their age and/or health status. However, teachers and in-class education are so critical to the educational process and the national economy that an open offer to all teachers makes more sense.

While some states have already prioritized teachers for vaccines, the AAP must continue to speak loudly that in-class education is critical and urge all states to do what is necessary to make teachers feel safe to return to the classroom.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

In a time when this country is struggling to find topics on which we can achieve broad consensus, the question of whether in-class learning is important stands as an outlier. Parents, teachers, students, and pediatricians all agree that having children learn in a social, face-to-face environment is critical to their education and mental health. Because school has become a de facto daycare source for many families, employers have joined in the chorus supporting a return to in-class education.

Of course, beyond that basic point of agreement the myriad of questions relating to when and how that return to the educational norm can be achieved we divide into groups with almost as many answers as there are questions. Part of the problem stems from the national leadership vacuum that fed the confusion. In this void the topic of school reopening has become politicized.

On Jan. 5, 2021, the American Academy of Pediatrics released an updated interim COVID-19 Guidance for Safe Schools at services.aap.org. It is a thorough and well thought out document that should function as a roadmap for communities and pediatricians who serve as official and unofficial advisers to their local school departments. At the very outset it reminds us that “school transmission mirrors but does not drive community transmission.”

Unfortunately, timing is everything and while the document’s salient points received some media attention it was mostly buried by the tsunami of press coverage in the wake of the storming of the Capitol the next day and the postinauguration reshuffling of the federal government. Even if it had been released on one of those seldom seen quiet news days, I fear the document’s message encouraging the return to in-class learning would have still not received the attention it deserved.

The lack of a high-visibility celebrity spokesperson and a system of short-tenure presidencies puts the AAP at a disadvantage when it comes to getting its message across to a national audience. The advocacy role filters down to those of us in our own communities who must convince school boards that not only is in-class learning critical but there are safe ways to do it.

In some communities the timing of return to in-class learning may pit pediatricians against teachers. Usually, these two groups share an enthusiastic advocacy for children. However, facing what has up to this point been a poorly defined health risk, teachers are understandably resistant to return to the classroom although they acknowledge its importance.

Armed with the AAP’s guidance document, pediatricians should encourage school boards and state and local health departments to look closely at the epidemiologic evidence and consider creative ways to prioritize teachers for what currently are limited and erratic vaccine supplies. Strategies might include offering vaccines to teachers based strictly on their age and/or health status. However, teachers and in-class education are so critical to the educational process and the national economy that an open offer to all teachers makes more sense.

While some states have already prioritized teachers for vaccines, the AAP must continue to speak loudly that in-class education is critical and urge all states to do what is necessary to make teachers feel safe to return to the classroom.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

The COVID-19 pandemic, multiple national displays of racial and social injustice, and recent political strife have left many feeling uncertain, anxious, sad, angry, grief-stricken, and struggling to cope. Coping may be especially difficult for our clients already grappling with mental health concerns, and many are looking to mental health professionals to restore a sense of well-being.

Marija Jovovic/Getty Images

As professionals, we may be unsure about the best approach; after all, we haven’t experienced anything like this before! We’re facing many unknowns and unanswered questions, but one thing we do know is that we’re dealing with constant change. And, in fact, the only certainty is continued change and uncertainty. The truth of uncertainty can be challenging to contend with, especially when so much, including our country’s future, is in question. In times like this, there is likely no perfect treatment, but mindfulness can serve as a powerful intervention for coping with uncertainty and change, and for managing a range of difficult reactions.

 

The ‘what’ of mindfulness: Awareness, being in the now, and nonattachment

It’s crucial that we understand what mindfulness really is. It’s become something of a buzzword in American society, complete with misconceptions. Mindfulness has roots in many faith traditions, but as it’s practiced in the Western world, it usually has roots in Hinduism and Buddhism.

Mindfulness roughly means “awareness”; this is an approximate translation of the Pali (an ancient Indian language) word “Sati.” Mindfulness is moment-to-moment awareness and acceptance of our present experiences, thoughts, and feelings, without judgment or attachment. Attachment relates to the continually changing nature of all thoughts, feelings, and situations. Because everything is continuously changing, we needn’t become attached; attachment can keep us from being in the now. Acceptance means facing the now, which is essential when we feel tempted to avoid or deny painful feelings or situations. Acceptance doesn’t mean that we’ve resigned to being in pain forever; it merely means that we’re willing to see things as they actually are right now. This honest assessment of the present can prepare us for next steps.

Being in touch with the now helps us reconnect with ourselves, promote clarity about our situation and choices, and increases our awareness of our thoughts and feelings, moment to moment. It can also help us realize when we’ve fallen into unhelpful or catastrophic thinking, the risk of which is high during intense stress and uncertainty like what we’re facing now. Mindfulness helps us catch ourselves so we have the opportunity to make different choices, and feel better.
 

The how of mindfulness: Symptom management and changes in the brain

Research on mindfulness suggests that it can improve coping with anxiety,¹ regulate mood,² improve depression,³ reduce rumination,⁴ and mitigate trauma symptom severity.

Because mindfulness can effectively address psychiatric concerns, mindfulness-based clinical interventions such as mindfulness-based stress reduction and mindfulness-based cognitive therapy have been developed. These may reduce anxiety,⁵ depression, and posttraumatic stress disorder.⁶ Mindfulness can have a powerful impact on the brain; it’s been shown to improve the functioning of the regions associated with emotional regulation⁷ and change the regions related to awareness and fear.⁸ So, whether mindfulness is practiced in our clients’ everyday lives or used as the basis of therapeutic programs, it can promote well-being.
 

 

The how of mindfulness: In everyday life and treatment

How can we help our clients enjoy mindfulness’ benefits? I suggest that we start with ourselves. We’ll be more effective at guiding our clients in using mindfulness if we have our own experience.

And, mindfulness may help us to be more attentive to and effective in treatment. There is research demonstrating that treatment providers can benefit from mindfulness practices,⁹ and that clinicians who practice mindfulness report higher levels of empathy toward their clients.¹⁰ Because mindfulness is about attention and nonjudgmental and nonattached observation, it can be incorporated into many aspects of everyday life. Many options are available; we might encourage our clients to begin their day with a mindful pause, simply breathing and observing thoughts, feelings, sensations, or anything else that comes up. If they find themselves fixated on negative thinking or feelings, nonjudgmentally recognizing these experiences as temporary can help to prevent immersion and overwhelm. We can also encourage mindful pauses throughout the day, perhaps during tasks such as housekeeping, working, talking with others, exercising, and even eating.

It can be beneficial to practice mindfulness before, during, and after situations that our clients know may bring on increased stress, anxiety, negative mood, and other undesirable experiences, such as watching the news or using some forms of social media. For clients who want more structure or guidance, several mobile apps are available, such as InsightTimer, Ten Percent Happier, or for Black clients, Liberate, which may be especially helpful for the impacts of racial injustice. Apps may also help clients who want to establish a formal mindfulness meditation practice, which may decrease anxiety and depression in some clinical populations.¹¹ And, of course, with training, we can incorporate mindfulness into treatment. We may encourage clients to start our treatment or therapy sessions with a mindful pause to help them attain calm and focus, and depending on their concerns and needs, during times at which they feel particularly strong emotions. Clients may consider taking a Mindfulness-Based Stress Reduction course if something more intensive is needed, or clinicians may consider becoming trained in mindfulness-based cognitive therapy. Because recognition is increasing that mindfulness can address many clinical concerns, and because we’re contending with unprecedented challenges, mindfulness training for clinicians has become widely available.


 

Calm, clarity, and choices

None of us as individuals can eliminate the strife our country is living through, and none of us as clinicians can completely prevent or alleviate our clients’ pain. But by employing mindfulness, we can help clients cope with change and uncertainty, gain greater awareness of themselves and their experiences, feel calmer, attain more clarity to make better choices, and ultimately, feel better.

References

1. Bernstein A et al. J Cogn Psychother. 2011;25(2):99-113.

2. Remmers C et al. Mindfulness. 2016;7(4):829-37.

3. Rodrigues MF et al. Trends Psychiatry Psychother. Jul-Sep 2017;39(3):207-15.

4. Chambers R et al. Cogn Ther Res. 2008;32(3):303-22.

5. Montero-Marin et al. Psychol Med. 2019 Oct;49(13)2118-33.

6. Khusid MA, Vythilingam M. Mil Med. 2016 Sep;181(9):961-8.

7. Kral TRA et al. Neuroimage. 2018 Nov 1;181:301-13.

8. Desbordes G et al. Front Hum Neurosci. 2012 Nov 1. doi: 10.33891/fnhum.2012.00292.

9. Escuriex BF, Labbé EE. Mindfulness. 2011;2(4):242-53.

10. Aiken GA. Dissertation Abstracts Int Sec B: Sci Eng. 2006;67(4-B),2212.

11. Goyal M et al. JAMA Intern Med. 2014 Mar;174:357-68.

Dr. Collins is a Brooklyn-based licensed counseling psychologist, educator, and speaker. She is experienced in addressing a wide range of mental health concerns within youth, adult, and family populations. Her work has a strong social justice emphasis, and she is particularly skilled at working with clients of color. She has been a mindfulness practitioner for 10 years and is passionate about sharing the practice with others. Dr. Collins has no conflicts of interest.

The COVID-19 pandemic, multiple national displays of racial and social injustice, and recent political strife have left many feeling uncertain, anxious, sad, angry, grief-stricken, and struggling to cope. Coping may be especially difficult for our clients already grappling with mental health concerns, and many are looking to mental health professionals to restore a sense of well-being.

Marija Jovovic/Getty Images

As professionals, we may be unsure about the best approach; after all, we haven’t experienced anything like this before! We’re facing many unknowns and unanswered questions, but one thing we do know is that we’re dealing with constant change. And, in fact, the only certainty is continued change and uncertainty. The truth of uncertainty can be challenging to contend with, especially when so much, including our country’s future, is in question. In times like this, there is likely no perfect treatment, but mindfulness can serve as a powerful intervention for coping with uncertainty and change, and for managing a range of difficult reactions.

 

The ‘what’ of mindfulness: Awareness, being in the now, and nonattachment

It’s crucial that we understand what mindfulness really is. It’s become something of a buzzword in American society, complete with misconceptions. Mindfulness has roots in many faith traditions, but as it’s practiced in the Western world, it usually has roots in Hinduism and Buddhism.

Mindfulness roughly means “awareness”; this is an approximate translation of the Pali (an ancient Indian language) word “Sati.” Mindfulness is moment-to-moment awareness and acceptance of our present experiences, thoughts, and feelings, without judgment or attachment. Attachment relates to the continually changing nature of all thoughts, feelings, and situations. Because everything is continuously changing, we needn’t become attached; attachment can keep us from being in the now. Acceptance means facing the now, which is essential when we feel tempted to avoid or deny painful feelings or situations. Acceptance doesn’t mean that we’ve resigned to being in pain forever; it merely means that we’re willing to see things as they actually are right now. This honest assessment of the present can prepare us for next steps.

Being in touch with the now helps us reconnect with ourselves, promote clarity about our situation and choices, and increases our awareness of our thoughts and feelings, moment to moment. It can also help us realize when we’ve fallen into unhelpful or catastrophic thinking, the risk of which is high during intense stress and uncertainty like what we’re facing now. Mindfulness helps us catch ourselves so we have the opportunity to make different choices, and feel better.
 

The how of mindfulness: Symptom management and changes in the brain

Research on mindfulness suggests that it can improve coping with anxiety,¹ regulate mood,² improve depression,³ reduce rumination,⁴ and mitigate trauma symptom severity.

Because mindfulness can effectively address psychiatric concerns, mindfulness-based clinical interventions such as mindfulness-based stress reduction and mindfulness-based cognitive therapy have been developed. These may reduce anxiety,⁵ depression, and posttraumatic stress disorder.⁶ Mindfulness can have a powerful impact on the brain; it’s been shown to improve the functioning of the regions associated with emotional regulation⁷ and change the regions related to awareness and fear.⁸ So, whether mindfulness is practiced in our clients’ everyday lives or used as the basis of therapeutic programs, it can promote well-being.
 

 

The how of mindfulness: In everyday life and treatment

How can we help our clients enjoy mindfulness’ benefits? I suggest that we start with ourselves. We’ll be more effective at guiding our clients in using mindfulness if we have our own experience.

And, mindfulness may help us to be more attentive to and effective in treatment. There is research demonstrating that treatment providers can benefit from mindfulness practices,⁹ and that clinicians who practice mindfulness report higher levels of empathy toward their clients.¹⁰ Because mindfulness is about attention and nonjudgmental and nonattached observation, it can be incorporated into many aspects of everyday life. Many options are available; we might encourage our clients to begin their day with a mindful pause, simply breathing and observing thoughts, feelings, sensations, or anything else that comes up. If they find themselves fixated on negative thinking or feelings, nonjudgmentally recognizing these experiences as temporary can help to prevent immersion and overwhelm. We can also encourage mindful pauses throughout the day, perhaps during tasks such as housekeeping, working, talking with others, exercising, and even eating.

It can be beneficial to practice mindfulness before, during, and after situations that our clients know may bring on increased stress, anxiety, negative mood, and other undesirable experiences, such as watching the news or using some forms of social media. For clients who want more structure or guidance, several mobile apps are available, such as InsightTimer, Ten Percent Happier, or for Black clients, Liberate, which may be especially helpful for the impacts of racial injustice. Apps may also help clients who want to establish a formal mindfulness meditation practice, which may decrease anxiety and depression in some clinical populations.¹¹ And, of course, with training, we can incorporate mindfulness into treatment. We may encourage clients to start our treatment or therapy sessions with a mindful pause to help them attain calm and focus, and depending on their concerns and needs, during times at which they feel particularly strong emotions. Clients may consider taking a Mindfulness-Based Stress Reduction course if something more intensive is needed, or clinicians may consider becoming trained in mindfulness-based cognitive therapy. Because recognition is increasing that mindfulness can address many clinical concerns, and because we’re contending with unprecedented challenges, mindfulness training for clinicians has become widely available.


 

Calm, clarity, and choices

None of us as individuals can eliminate the strife our country is living through, and none of us as clinicians can completely prevent or alleviate our clients’ pain. But by employing mindfulness, we can help clients cope with change and uncertainty, gain greater awareness of themselves and their experiences, feel calmer, attain more clarity to make better choices, and ultimately, feel better.

References

1. Bernstein A et al. J Cogn Psychother. 2011;25(2):99-113.

2. Remmers C et al. Mindfulness. 2016;7(4):829-37.

3. Rodrigues MF et al. Trends Psychiatry Psychother. Jul-Sep 2017;39(3):207-15.

4. Chambers R et al. Cogn Ther Res. 2008;32(3):303-22.

5. Montero-Marin et al. Psychol Med. 2019 Oct;49(13)2118-33.

6. Khusid MA, Vythilingam M. Mil Med. 2016 Sep;181(9):961-8.

7. Kral TRA et al. Neuroimage. 2018 Nov 1;181:301-13.

8. Desbordes G et al. Front Hum Neurosci. 2012 Nov 1. doi: 10.33891/fnhum.2012.00292.

9. Escuriex BF, Labbé EE. Mindfulness. 2011;2(4):242-53.

10. Aiken GA. Dissertation Abstracts Int Sec B: Sci Eng. 2006;67(4-B),2212.

11. Goyal M et al. JAMA Intern Med. 2014 Mar;174:357-68.

Dr. Collins is a Brooklyn-based licensed counseling psychologist, educator, and speaker. She is experienced in addressing a wide range of mental health concerns within youth, adult, and family populations. Her work has a strong social justice emphasis, and she is particularly skilled at working with clients of color. She has been a mindfulness practitioner for 10 years and is passionate about sharing the practice with others. Dr. Collins has no conflicts of interest.

The COVID-19 pandemic, multiple national displays of racial and social injustice, and recent political strife have left many feeling uncertain, anxious, sad, angry, grief-stricken, and struggling to cope. Coping may be especially difficult for our clients already grappling with mental health concerns, and many are looking to mental health professionals to restore a sense of well-being.

Marija Jovovic/Getty Images

As professionals, we may be unsure about the best approach; after all, we haven’t experienced anything like this before! We’re facing many unknowns and unanswered questions, but one thing we do know is that we’re dealing with constant change. And, in fact, the only certainty is continued change and uncertainty. The truth of uncertainty can be challenging to contend with, especially when so much, including our country’s future, is in question. In times like this, there is likely no perfect treatment, but mindfulness can serve as a powerful intervention for coping with uncertainty and change, and for managing a range of difficult reactions.

 

The ‘what’ of mindfulness: Awareness, being in the now, and nonattachment

It’s crucial that we understand what mindfulness really is. It’s become something of a buzzword in American society, complete with misconceptions. Mindfulness has roots in many faith traditions, but as it’s practiced in the Western world, it usually has roots in Hinduism and Buddhism.

Mindfulness roughly means “awareness”; this is an approximate translation of the Pali (an ancient Indian language) word “Sati.” Mindfulness is moment-to-moment awareness and acceptance of our present experiences, thoughts, and feelings, without judgment or attachment. Attachment relates to the continually changing nature of all thoughts, feelings, and situations. Because everything is continuously changing, we needn’t become attached; attachment can keep us from being in the now. Acceptance means facing the now, which is essential when we feel tempted to avoid or deny painful feelings or situations. Acceptance doesn’t mean that we’ve resigned to being in pain forever; it merely means that we’re willing to see things as they actually are right now. This honest assessment of the present can prepare us for next steps.

Being in touch with the now helps us reconnect with ourselves, promote clarity about our situation and choices, and increases our awareness of our thoughts and feelings, moment to moment. It can also help us realize when we’ve fallen into unhelpful or catastrophic thinking, the risk of which is high during intense stress and uncertainty like what we’re facing now. Mindfulness helps us catch ourselves so we have the opportunity to make different choices, and feel better.
 

The how of mindfulness: Symptom management and changes in the brain

Research on mindfulness suggests that it can improve coping with anxiety,¹ regulate mood,² improve depression,³ reduce rumination,⁴ and mitigate trauma symptom severity.

Because mindfulness can effectively address psychiatric concerns, mindfulness-based clinical interventions such as mindfulness-based stress reduction and mindfulness-based cognitive therapy have been developed. These may reduce anxiety,⁵ depression, and posttraumatic stress disorder.⁶ Mindfulness can have a powerful impact on the brain; it’s been shown to improve the functioning of the regions associated with emotional regulation⁷ and change the regions related to awareness and fear.⁸ So, whether mindfulness is practiced in our clients’ everyday lives or used as the basis of therapeutic programs, it can promote well-being.
 

 

The how of mindfulness: In everyday life and treatment

How can we help our clients enjoy mindfulness’ benefits? I suggest that we start with ourselves. We’ll be more effective at guiding our clients in using mindfulness if we have our own experience.

And, mindfulness may help us to be more attentive to and effective in treatment. There is research demonstrating that treatment providers can benefit from mindfulness practices,⁹ and that clinicians who practice mindfulness report higher levels of empathy toward their clients.¹⁰ Because mindfulness is about attention and nonjudgmental and nonattached observation, it can be incorporated into many aspects of everyday life. Many options are available; we might encourage our clients to begin their day with a mindful pause, simply breathing and observing thoughts, feelings, sensations, or anything else that comes up. If they find themselves fixated on negative thinking or feelings, nonjudgmentally recognizing these experiences as temporary can help to prevent immersion and overwhelm. We can also encourage mindful pauses throughout the day, perhaps during tasks such as housekeeping, working, talking with others, exercising, and even eating.

It can be beneficial to practice mindfulness before, during, and after situations that our clients know may bring on increased stress, anxiety, negative mood, and other undesirable experiences, such as watching the news or using some forms of social media. For clients who want more structure or guidance, several mobile apps are available, such as InsightTimer, Ten Percent Happier, or for Black clients, Liberate, which may be especially helpful for the impacts of racial injustice. Apps may also help clients who want to establish a formal mindfulness meditation practice, which may decrease anxiety and depression in some clinical populations.¹¹ And, of course, with training, we can incorporate mindfulness into treatment. We may encourage clients to start our treatment or therapy sessions with a mindful pause to help them attain calm and focus, and depending on their concerns and needs, during times at which they feel particularly strong emotions. Clients may consider taking a Mindfulness-Based Stress Reduction course if something more intensive is needed, or clinicians may consider becoming trained in mindfulness-based cognitive therapy. Because recognition is increasing that mindfulness can address many clinical concerns, and because we’re contending with unprecedented challenges, mindfulness training for clinicians has become widely available.


 

Calm, clarity, and choices

None of us as individuals can eliminate the strife our country is living through, and none of us as clinicians can completely prevent or alleviate our clients’ pain. But by employing mindfulness, we can help clients cope with change and uncertainty, gain greater awareness of themselves and their experiences, feel calmer, attain more clarity to make better choices, and ultimately, feel better.

References

1. Bernstein A et al. J Cogn Psychother. 2011;25(2):99-113.

2. Remmers C et al. Mindfulness. 2016;7(4):829-37.

3. Rodrigues MF et al. Trends Psychiatry Psychother. Jul-Sep 2017;39(3):207-15.

4. Chambers R et al. Cogn Ther Res. 2008;32(3):303-22.

5. Montero-Marin et al. Psychol Med. 2019 Oct;49(13)2118-33.

6. Khusid MA, Vythilingam M. Mil Med. 2016 Sep;181(9):961-8.

7. Kral TRA et al. Neuroimage. 2018 Nov 1;181:301-13.

8. Desbordes G et al. Front Hum Neurosci. 2012 Nov 1. doi: 10.33891/fnhum.2012.00292.

9. Escuriex BF, Labbé EE. Mindfulness. 2011;2(4):242-53.

10. Aiken GA. Dissertation Abstracts Int Sec B: Sci Eng. 2006;67(4-B),2212.

11. Goyal M et al. JAMA Intern Med. 2014 Mar;174:357-68.

Dr. Collins is a Brooklyn-based licensed counseling psychologist, educator, and speaker. She is experienced in addressing a wide range of mental health concerns within youth, adult, and family populations. Her work has a strong social justice emphasis, and she is particularly skilled at working with clients of color. She has been a mindfulness practitioner for 10 years and is passionate about sharing the practice with others. Dr. Collins has no conflicts of interest.