Opinion

A shot of relief. A shot of hope. Those are the words used to describe COVID-19 vaccines on a television commercial running in prime time in Kentucky.

“We all can’t get the vaccine at once,” the announcer says solemnly, “but we’ll all get a turn.”

For some of us, that turn came quickly. In December, the Advisory Committee on Immunization Practices recommended that health care personnel (HCP) and long-term care facility residents be the first to be immunized with COVID-19 vaccines (see table).

On Dec. 14, 2020, Sandra Lindsay, a nurse and director of patient care services in the intensive care unit at Long Island Jewish Medical Center, was the first person in the United States to receive a COVID-19 vaccine outside a clinical trial.

In subsequent days, social media sites were quickly flooded with photos of HCP rolling up their sleeves or flashing their immunization cards. There was jubilation ... and perhaps a little bit of jealousy. There were tears of joy and some tears of frustration.

There are more than 21 million HCP in the United States and to date, there have not been enough vaccines nor adequate infrastructure to immunize all of them. According to the Centers for Disease Control and Prevention Data Tracker, as of Jan. 7, 2021, 21,419,800 doses of vaccine had been distributed to states to immunize everyone identified in phase 1a, but only 5,919,418 people had received a first dose. Limited supply has necessitated prioritization of subgroups of HCP; those in the front of the line have varied by state, and even by hospital or health care systems within states. Both the American Academy of Pediatrics and the American Academy of Family Physicians have noted that primary care providers not employed by a hospital may have more difficulty accessing vaccine.

The mismatch between supply and demand has created an intense focus on improving supply and distribution. Soon though, we’re going to shift our attention to how we increase demand. We don’t have good data on those who being are offered COVID-19 vaccine and declining, but several studies that predate the Emergency Use Authorization for the Pfizer-BioNTech and Moderna vaccines suggest significant COVID-19 vaccine hesitancy among adults in the United States.

One large, longitudinal Internet-based study of U.S. adults found that the proportion who reported they were “somewhat or very likely” to receive COVID-19 vaccine declined from 74% in early April to 56% in early December.

In the Understanding America Study, self-reported likelihood of being vaccinated with COVID-19 vaccine was lower among Black compared to White respondents (38% vs. 59%; aRR, 0.7 [95% confidence interval, 0.6-0.8]), and lower among women compared to men (51% vs. 62%; aRR, 0.9 [95% CI, 0.8-0.9]). Those 65 years of age and older were more likely to report a willingness to be vaccinated than were those 18-49 years of age, as were those with at least a bachelor’s degree compared to those with a high school education or less.

A study conducted by the Pew Research Center in November – before any COVID-19 vaccines were available – found that only 60% of American adults said they would “definitely or probably get a vaccine for coronavirus” if one were available. That was an increase from 51% in September, but and overall decrease of 72% in May. Of the remaining 40%, just over half said they did not intend to get vaccinated and were “pretty certain” that more information would not change their minds.

Concern about acquiring a serious case of COVID-19 and trust in the vaccine development process were associated with an intent to receive vaccine, as was a personal history of receiving a flu shot annually. Willingness to be vaccinated varied by age, race, and family income, with Black respondents, women, and those with a lower family incomes less likely to accept a vaccine.

To date, few data are available about HCP and willingness to receive COVID-19 vaccine. A preprint posted at medrxiv.org reports on a cross-sectional study of more than 3,400 HCP surveyed between Oct. 7 and Nov. 9, 2020. In that study, only 36% of respondents voiced a willingness to be immunized as soon as vaccine is available. Vaccine acceptance increased with increasing age, income level, and education. As in other studies, self-reported willingness to accept vaccine was lower in women and Black individuals. While vaccine acceptance was higher in direct medical care providers than others, it was still only 49%.

So here’s the paradox: Even as limited supplies of vaccine are available and many are frustrated about lack of access, we need to promote the value of immunization to those who are hesitant. Pediatricians are trusted sources of vaccine information and we are in a good position to educate our colleagues, our staff, the parents of our patients and the community at-large.

A useful resource for those ready to take that step it is the CDC’s COVID-19 Vaccination Communication Toolkit. While this collection is designed to build vaccine confidence and promote immunization among health care providers, many of the strategies will be easily adapted for use with patients.

It’s not clear when we might have a COVID 19 vaccine for most children. The Pfizer-BioNTech vaccine emergency use authorization includes those as young as 16 years of age, and 16- and 17-year-olds with high risk medical conditions are included in phase 1c of vaccine allocation. Pfizer is currently enrolling children as young as 12 years of age in clinical trials, and Moderna and Janssen are poised to do the same. It is conceivable but far from certain that we could have a vaccine for children late this year. Are parents going to be ready to vaccinate their children?

Limited data about parental acceptance of vaccine for their children mirrors what was seen in the Understanding America Study and the Pew Research Study. In December 2020, the National Parents Union surveyed 1,008 parents of public school students enrolled in kindergarten through 12th grade. Sixty percent of parents said they would allow their children to receive a COVID-19 vaccine, while 25% would not and 15% were unsure. This suggests that now is the time to begin building vaccine confidence with parents. One conversation starter might be, “I am going to be vaccinated as soon as the vaccine is available.” Ideally, many of you will soon be able to say what I do: “I am excited to tell you that I have been immunized with the COVID-19 vaccine. I did this to protect myself, my family, and our community. I’m hopeful that vaccine will soon be available for all of us.”
 

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at [email protected].

A shot of relief. A shot of hope. Those are the words used to describe COVID-19 vaccines on a television commercial running in prime time in Kentucky.

“We all can’t get the vaccine at once,” the announcer says solemnly, “but we’ll all get a turn.”

For some of us, that turn came quickly. In December, the Advisory Committee on Immunization Practices recommended that health care personnel (HCP) and long-term care facility residents be the first to be immunized with COVID-19 vaccines (see table).

On Dec. 14, 2020, Sandra Lindsay, a nurse and director of patient care services in the intensive care unit at Long Island Jewish Medical Center, was the first person in the United States to receive a COVID-19 vaccine outside a clinical trial.

In subsequent days, social media sites were quickly flooded with photos of HCP rolling up their sleeves or flashing their immunization cards. There was jubilation ... and perhaps a little bit of jealousy. There were tears of joy and some tears of frustration.

There are more than 21 million HCP in the United States and to date, there have not been enough vaccines nor adequate infrastructure to immunize all of them. According to the Centers for Disease Control and Prevention Data Tracker, as of Jan. 7, 2021, 21,419,800 doses of vaccine had been distributed to states to immunize everyone identified in phase 1a, but only 5,919,418 people had received a first dose. Limited supply has necessitated prioritization of subgroups of HCP; those in the front of the line have varied by state, and even by hospital or health care systems within states. Both the American Academy of Pediatrics and the American Academy of Family Physicians have noted that primary care providers not employed by a hospital may have more difficulty accessing vaccine.

The mismatch between supply and demand has created an intense focus on improving supply and distribution. Soon though, we’re going to shift our attention to how we increase demand. We don’t have good data on those who being are offered COVID-19 vaccine and declining, but several studies that predate the Emergency Use Authorization for the Pfizer-BioNTech and Moderna vaccines suggest significant COVID-19 vaccine hesitancy among adults in the United States.

One large, longitudinal Internet-based study of U.S. adults found that the proportion who reported they were “somewhat or very likely” to receive COVID-19 vaccine declined from 74% in early April to 56% in early December.

In the Understanding America Study, self-reported likelihood of being vaccinated with COVID-19 vaccine was lower among Black compared to White respondents (38% vs. 59%; aRR, 0.7 [95% confidence interval, 0.6-0.8]), and lower among women compared to men (51% vs. 62%; aRR, 0.9 [95% CI, 0.8-0.9]). Those 65 years of age and older were more likely to report a willingness to be vaccinated than were those 18-49 years of age, as were those with at least a bachelor’s degree compared to those with a high school education or less.

A study conducted by the Pew Research Center in November – before any COVID-19 vaccines were available – found that only 60% of American adults said they would “definitely or probably get a vaccine for coronavirus” if one were available. That was an increase from 51% in September, but and overall decrease of 72% in May. Of the remaining 40%, just over half said they did not intend to get vaccinated and were “pretty certain” that more information would not change their minds.

Concern about acquiring a serious case of COVID-19 and trust in the vaccine development process were associated with an intent to receive vaccine, as was a personal history of receiving a flu shot annually. Willingness to be vaccinated varied by age, race, and family income, with Black respondents, women, and those with a lower family incomes less likely to accept a vaccine.

To date, few data are available about HCP and willingness to receive COVID-19 vaccine. A preprint posted at medrxiv.org reports on a cross-sectional study of more than 3,400 HCP surveyed between Oct. 7 and Nov. 9, 2020. In that study, only 36% of respondents voiced a willingness to be immunized as soon as vaccine is available. Vaccine acceptance increased with increasing age, income level, and education. As in other studies, self-reported willingness to accept vaccine was lower in women and Black individuals. While vaccine acceptance was higher in direct medical care providers than others, it was still only 49%.

So here’s the paradox: Even as limited supplies of vaccine are available and many are frustrated about lack of access, we need to promote the value of immunization to those who are hesitant. Pediatricians are trusted sources of vaccine information and we are in a good position to educate our colleagues, our staff, the parents of our patients and the community at-large.

A useful resource for those ready to take that step it is the CDC’s COVID-19 Vaccination Communication Toolkit. While this collection is designed to build vaccine confidence and promote immunization among health care providers, many of the strategies will be easily adapted for use with patients.

It’s not clear when we might have a COVID 19 vaccine for most children. The Pfizer-BioNTech vaccine emergency use authorization includes those as young as 16 years of age, and 16- and 17-year-olds with high risk medical conditions are included in phase 1c of vaccine allocation. Pfizer is currently enrolling children as young as 12 years of age in clinical trials, and Moderna and Janssen are poised to do the same. It is conceivable but far from certain that we could have a vaccine for children late this year. Are parents going to be ready to vaccinate their children?

Limited data about parental acceptance of vaccine for their children mirrors what was seen in the Understanding America Study and the Pew Research Study. In December 2020, the National Parents Union surveyed 1,008 parents of public school students enrolled in kindergarten through 12th grade. Sixty percent of parents said they would allow their children to receive a COVID-19 vaccine, while 25% would not and 15% were unsure. This suggests that now is the time to begin building vaccine confidence with parents. One conversation starter might be, “I am going to be vaccinated as soon as the vaccine is available.” Ideally, many of you will soon be able to say what I do: “I am excited to tell you that I have been immunized with the COVID-19 vaccine. I did this to protect myself, my family, and our community. I’m hopeful that vaccine will soon be available for all of us.”
 

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at [email protected].

A shot of relief. A shot of hope. Those are the words used to describe COVID-19 vaccines on a television commercial running in prime time in Kentucky.

“We all can’t get the vaccine at once,” the announcer says solemnly, “but we’ll all get a turn.”

For some of us, that turn came quickly. In December, the Advisory Committee on Immunization Practices recommended that health care personnel (HCP) and long-term care facility residents be the first to be immunized with COVID-19 vaccines (see table).

On Dec. 14, 2020, Sandra Lindsay, a nurse and director of patient care services in the intensive care unit at Long Island Jewish Medical Center, was the first person in the United States to receive a COVID-19 vaccine outside a clinical trial.

In subsequent days, social media sites were quickly flooded with photos of HCP rolling up their sleeves or flashing their immunization cards. There was jubilation ... and perhaps a little bit of jealousy. There were tears of joy and some tears of frustration.

There are more than 21 million HCP in the United States and to date, there have not been enough vaccines nor adequate infrastructure to immunize all of them. According to the Centers for Disease Control and Prevention Data Tracker, as of Jan. 7, 2021, 21,419,800 doses of vaccine had been distributed to states to immunize everyone identified in phase 1a, but only 5,919,418 people had received a first dose. Limited supply has necessitated prioritization of subgroups of HCP; those in the front of the line have varied by state, and even by hospital or health care systems within states. Both the American Academy of Pediatrics and the American Academy of Family Physicians have noted that primary care providers not employed by a hospital may have more difficulty accessing vaccine.

The mismatch between supply and demand has created an intense focus on improving supply and distribution. Soon though, we’re going to shift our attention to how we increase demand. We don’t have good data on those who being are offered COVID-19 vaccine and declining, but several studies that predate the Emergency Use Authorization for the Pfizer-BioNTech and Moderna vaccines suggest significant COVID-19 vaccine hesitancy among adults in the United States.

One large, longitudinal Internet-based study of U.S. adults found that the proportion who reported they were “somewhat or very likely” to receive COVID-19 vaccine declined from 74% in early April to 56% in early December.

In the Understanding America Study, self-reported likelihood of being vaccinated with COVID-19 vaccine was lower among Black compared to White respondents (38% vs. 59%; aRR, 0.7 [95% confidence interval, 0.6-0.8]), and lower among women compared to men (51% vs. 62%; aRR, 0.9 [95% CI, 0.8-0.9]). Those 65 years of age and older were more likely to report a willingness to be vaccinated than were those 18-49 years of age, as were those with at least a bachelor’s degree compared to those with a high school education or less.

A study conducted by the Pew Research Center in November – before any COVID-19 vaccines were available – found that only 60% of American adults said they would “definitely or probably get a vaccine for coronavirus” if one were available. That was an increase from 51% in September, but and overall decrease of 72% in May. Of the remaining 40%, just over half said they did not intend to get vaccinated and were “pretty certain” that more information would not change their minds.

Concern about acquiring a serious case of COVID-19 and trust in the vaccine development process were associated with an intent to receive vaccine, as was a personal history of receiving a flu shot annually. Willingness to be vaccinated varied by age, race, and family income, with Black respondents, women, and those with a lower family incomes less likely to accept a vaccine.

To date, few data are available about HCP and willingness to receive COVID-19 vaccine. A preprint posted at medrxiv.org reports on a cross-sectional study of more than 3,400 HCP surveyed between Oct. 7 and Nov. 9, 2020. In that study, only 36% of respondents voiced a willingness to be immunized as soon as vaccine is available. Vaccine acceptance increased with increasing age, income level, and education. As in other studies, self-reported willingness to accept vaccine was lower in women and Black individuals. While vaccine acceptance was higher in direct medical care providers than others, it was still only 49%.

So here’s the paradox: Even as limited supplies of vaccine are available and many are frustrated about lack of access, we need to promote the value of immunization to those who are hesitant. Pediatricians are trusted sources of vaccine information and we are in a good position to educate our colleagues, our staff, the parents of our patients and the community at-large.

A useful resource for those ready to take that step it is the CDC’s COVID-19 Vaccination Communication Toolkit. While this collection is designed to build vaccine confidence and promote immunization among health care providers, many of the strategies will be easily adapted for use with patients.

It’s not clear when we might have a COVID 19 vaccine for most children. The Pfizer-BioNTech vaccine emergency use authorization includes those as young as 16 years of age, and 16- and 17-year-olds with high risk medical conditions are included in phase 1c of vaccine allocation. Pfizer is currently enrolling children as young as 12 years of age in clinical trials, and Moderna and Janssen are poised to do the same. It is conceivable but far from certain that we could have a vaccine for children late this year. Are parents going to be ready to vaccinate their children?

Limited data about parental acceptance of vaccine for their children mirrors what was seen in the Understanding America Study and the Pew Research Study. In December 2020, the National Parents Union surveyed 1,008 parents of public school students enrolled in kindergarten through 12th grade. Sixty percent of parents said they would allow their children to receive a COVID-19 vaccine, while 25% would not and 15% were unsure. This suggests that now is the time to begin building vaccine confidence with parents. One conversation starter might be, “I am going to be vaccinated as soon as the vaccine is available.” Ideally, many of you will soon be able to say what I do: “I am excited to tell you that I have been immunized with the COVID-19 vaccine. I did this to protect myself, my family, and our community. I’m hopeful that vaccine will soon be available for all of us.”
 

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at [email protected].

Joe and Esi were in the therapist’s office wanting help with their relationship. The therapist had just asked the BIG question: How does race impact your lives?”

Esi began with her story about her ethics class, a story that was at sufficient distance from her life. Depending on her husband’s response, she would move in closer. His somewhat patronizing response made her feel both angry and that he lacked any real understanding.

“Me and a mulatto girl were in ethics class,” said Esi, who grew in Kenya. We had a White professor. He seemed to think I had no education. If you are a woman of color, you are automatically thought to have no education and that you don’t know what you are talking about. He tried to shut me up. When I persisted, I know he thought from the tone of my voice that I was an angry Black woman, even although I am not Black and I am not angry! In this country, if you have any color to your skin, you are called Black and relegated to a certain place: The bottom. I was excited about what he was teaching us, but when everyone looked at me with a certain gaze, like something bad was going to happen, all those White people, just looking, I tightened up inside and sat back down.”

Esi looked down at her folded hands. Her husband, who was White, reached over and reassuringly patted her hands.

“Yes, Esi, they are wrong. They shouldn’t have treated you that way. White people can be insensitive.”

Then, she continued, “Joe, you do the same to me!”

“What do you mean, Esi?” responded Joe, with an innocent and anxious look scanning back and forth between her and the White male therapist.

“Well, Joe, do you really want to hear how I felt last week after we came back from that party at your sister’s house?”

“Yes, Esi.”

“But do you really? Are you sure you want to hear this?”

“Yes, Esi.”

“Remember when we went over, me and the kids sat with the other people of color and you sat with your sister and her side of the family?

“Yes, I remember. What is wrong with that?”

“Well, me and my colored friends got loud and excited, and you shot me a look, like ‘pipe down over there.’ THEN, after we got home, the next day, your sister called you and said that you had better control your wife; she is too loud. Do you remember all that?

“Yes, well you do get loud – especially when you are around your people.”

“So why is it I have to fit in with your relatives and not the other way round? Why do I have to conform to the whiteness in your sister’s world, not the other way round?”

“Well, we were in her house.”

“So if they came to our house and were too quiet, how would you feel if I called them up and said they needed to participate with more enthusiasm?”

“Esi, that’s not fair, and you know it isn’t.”

Esi stops and looks at the therapist.

“So I check myself. It is the same all over, White people imposing their values and beliefs on me, on us. I am not an angry Black woman. I am just frustrated. People, White people, always want an explanation for what they think is my loss of control. You can see when their demeanor changes, they pull back, sit up, back away, fidget, and won’t look you in the eye. All these little tics that show that they are trying to get out of the situation.”

Esi took a breath and saw that her husband and the therapist were listening.

“These signs are ingrained in your brain ... these signs ... I saw it when I first came here to this country. The first time I had a good dose of it ... was in that ethics class in college. You can’t use words that you are accustomed to, ’cause they mean something else here, something bad.”

“Oh, Esi, I am so sorry,” said Joe, looking concerned.

“You may be sorry but you are not willing to stand up for me against your sister and her White values. You want me to conform.”

“What do you want me to do?”

“I want you to call your sister out.”

“But she may not ever speak to me again!”

“OK, don’t then,” and Esi looked down at her hands. She was finished talking. Joe looked at the therapist, waiting for something.

The therapist resisted intervening on the issue. “Keep talking this through,” he instructed them.

Joe could see that Esi had done talking and that it was his move.

“Do you really want me to call my sister out, even if it means that she will not talk to me again?”

“Yes.”

“I don’t know if I can do that.”

The therapist now intervened: “What does that mean to you, Esi, that he doesn’t know if he can do that.”

“It means he doesn’t really love me or value me or even value our mulatto children. What do think our daughter is learning?”

“That’s not true, Esi.”

The therapist, Dr. Swarthmore, watched Esi, who has very a dark, blue-black skin tone, with a flawless complexion and a shapely body. She wears her hair cropped and she looks like that Black model, what’s her name. Joe was short, a little plump with ultra White skin and freckles on his nose. He had been brought up in the Midwest and had had little exposure to Africans before his internship abroad in Kenya. Dr. S. thought he had probably not really thought much about Esi’s dilemma.

Dr. Swarthmore encouraged Esi to talk about her immigration experience.

“Esi, can you talk more about what it is like to be an immigrant from Africa?”

“Well, I just have to check myself so that I can fit in with this White culture. If you want to see how I feel about it, you will have to see an angry Black woman and I have learned not to give you that satisfaction. You will just dismiss me. Please Dr. Swarthmore, can we move on?”

Dr. Swarthmore was caught between his desire to accept her wish to move on and his wish to have her express herself fully. He realized that it was not his desire that mattered; that the couple had to work this out between them if they were going to move forward. So he punted it back to them.

“Esi and Joe, you are both caught in an important dilemma. Esi, you want more respect from your husband and his family. Joe, you do not want to upset your family by confronting them. Is that right? You are both dammed if you do and dammed if you don’t.”

“I agree,” Joe and Esi both said, nodding.

“Do you want to work on this issue?”

They both agreed with equal enthusiasm.

“Ok, can you spend the next 10 minutes to work on this?”

They agreed.

“Ok, let’s start. What skills do you have that can help you resolve this important issue?”

Dr. Swarthmore framed the issue as one to be solved by the couple. The couple discussed that they are usually good at communication and solving problems. This problem is about whether or not Joe is more aligned with his White family than with Esi and their children.

Dr. Swarthmore encouraged them to think about this more deeply and over time; that this is such an important issue that it requires time and deep conversation.

“How do you think you can educate yourselves about the issues at hand?”

Esi suggested several books to Joe, and he agreed to read one of them.
 

Esi’s reading list

1. “Why I’m No Longer Talking to White People About Race” by Reni Eddo-Lodge (London: Bloomsbury, 2018).

2. “Americanah” by Chimamanda Ngozi Adichie (New York: Alfred A. Knopf, 2013).

3. “How to be an Antiracist” by Ibram X. Kendi (New York: Random House, 2019).
 

Joe suggests that Esi think about what it might mean if his sister and their children were no longer part of their lives. She agrees to do this.

Dr. Swarthmore asks if they can each do their homework before they come back. They agree and thought they could manage that and the book for 2 weeks out.

Dr. Swarthmore decides that he will read one of the books Esi suggested, as he does not know much about racism and White privilege and he wants to learn more. Dr. Swarthmore demonstrates his desire to become more racially sensitive. The following steps can be taken by therapists who want to become more racially sensitive, according to TA Laszloffy and KV Hardy (Fam Process. 2000 Spring;39[1]:35-50):
 

1. Read and watch movies that address the experience of other cultural groups.

2. Go to and participate in cross-cultural events.

3. Engage in a racial self-exploration process. The following questions can begin the racial identity exploration process:

• How do I define myself racially?
• When did I first become aware of race/skin color in general, and mine in particular?
• What messages did I learn about race/skin color based on that first experience?
• What direct and indirect messages did I receive about race/skin color?
• How did the messages that I received about race/skin color affect how I thought and felt about myself racially?
• What benefits did I gain because of my race/skin color?
• What did I lose because of my race/skin?
• Have I ever dated cross-racially? Why or why not?
• How many friends of a different race do I have?

4. Internal commitment. This means committing to addressing racism in therapeutic encounters.
 

Lessons learned for psychiatrists

1. Therapeutic space is allocated to discuss the issue.

2. The time is strictly limited to 10 minutes, so the couple won’t feel that their emotions will overwhelm them.

3. The space is to focus on the strengths that they can bring to resolving the issue.

4. Give patients the impression that they can solve this and that it is an important issue.

5. Do not put yourself in the patients’ argument; take neither side.
 

Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest. Dr. Heru wrote the article in collaboration with Lynette Ramsingh Barros, artist and social commentator.

Joe and Esi were in the therapist’s office wanting help with their relationship. The therapist had just asked the BIG question: How does race impact your lives?”

Esi began with her story about her ethics class, a story that was at sufficient distance from her life. Depending on her husband’s response, she would move in closer. His somewhat patronizing response made her feel both angry and that he lacked any real understanding.

“Me and a mulatto girl were in ethics class,” said Esi, who grew in Kenya. We had a White professor. He seemed to think I had no education. If you are a woman of color, you are automatically thought to have no education and that you don’t know what you are talking about. He tried to shut me up. When I persisted, I know he thought from the tone of my voice that I was an angry Black woman, even although I am not Black and I am not angry! In this country, if you have any color to your skin, you are called Black and relegated to a certain place: The bottom. I was excited about what he was teaching us, but when everyone looked at me with a certain gaze, like something bad was going to happen, all those White people, just looking, I tightened up inside and sat back down.”

Esi looked down at her folded hands. Her husband, who was White, reached over and reassuringly patted her hands.

“Yes, Esi, they are wrong. They shouldn’t have treated you that way. White people can be insensitive.”

Then, she continued, “Joe, you do the same to me!”

“What do you mean, Esi?” responded Joe, with an innocent and anxious look scanning back and forth between her and the White male therapist.

“Well, Joe, do you really want to hear how I felt last week after we came back from that party at your sister’s house?”

“Yes, Esi.”

“But do you really? Are you sure you want to hear this?”

“Yes, Esi.”

“Remember when we went over, me and the kids sat with the other people of color and you sat with your sister and her side of the family?

“Yes, I remember. What is wrong with that?”

“Well, me and my colored friends got loud and excited, and you shot me a look, like ‘pipe down over there.’ THEN, after we got home, the next day, your sister called you and said that you had better control your wife; she is too loud. Do you remember all that?

“Yes, well you do get loud – especially when you are around your people.”

“So why is it I have to fit in with your relatives and not the other way round? Why do I have to conform to the whiteness in your sister’s world, not the other way round?”

“Well, we were in her house.”

“So if they came to our house and were too quiet, how would you feel if I called them up and said they needed to participate with more enthusiasm?”

“Esi, that’s not fair, and you know it isn’t.”

Esi stops and looks at the therapist.

“So I check myself. It is the same all over, White people imposing their values and beliefs on me, on us. I am not an angry Black woman. I am just frustrated. People, White people, always want an explanation for what they think is my loss of control. You can see when their demeanor changes, they pull back, sit up, back away, fidget, and won’t look you in the eye. All these little tics that show that they are trying to get out of the situation.”

Esi took a breath and saw that her husband and the therapist were listening.

“These signs are ingrained in your brain ... these signs ... I saw it when I first came here to this country. The first time I had a good dose of it ... was in that ethics class in college. You can’t use words that you are accustomed to, ’cause they mean something else here, something bad.”

“Oh, Esi, I am so sorry,” said Joe, looking concerned.

“You may be sorry but you are not willing to stand up for me against your sister and her White values. You want me to conform.”

“What do you want me to do?”

“I want you to call your sister out.”

“But she may not ever speak to me again!”

“OK, don’t then,” and Esi looked down at her hands. She was finished talking. Joe looked at the therapist, waiting for something.

The therapist resisted intervening on the issue. “Keep talking this through,” he instructed them.

Joe could see that Esi had done talking and that it was his move.

“Do you really want me to call my sister out, even if it means that she will not talk to me again?”

“Yes.”

“I don’t know if I can do that.”

The therapist now intervened: “What does that mean to you, Esi, that he doesn’t know if he can do that.”

“It means he doesn’t really love me or value me or even value our mulatto children. What do think our daughter is learning?”

“That’s not true, Esi.”

The therapist, Dr. Swarthmore, watched Esi, who has very a dark, blue-black skin tone, with a flawless complexion and a shapely body. She wears her hair cropped and she looks like that Black model, what’s her name. Joe was short, a little plump with ultra White skin and freckles on his nose. He had been brought up in the Midwest and had had little exposure to Africans before his internship abroad in Kenya. Dr. S. thought he had probably not really thought much about Esi’s dilemma.

Dr. Swarthmore encouraged Esi to talk about her immigration experience.

“Esi, can you talk more about what it is like to be an immigrant from Africa?”

“Well, I just have to check myself so that I can fit in with this White culture. If you want to see how I feel about it, you will have to see an angry Black woman and I have learned not to give you that satisfaction. You will just dismiss me. Please Dr. Swarthmore, can we move on?”

Dr. Swarthmore was caught between his desire to accept her wish to move on and his wish to have her express herself fully. He realized that it was not his desire that mattered; that the couple had to work this out between them if they were going to move forward. So he punted it back to them.

“Esi and Joe, you are both caught in an important dilemma. Esi, you want more respect from your husband and his family. Joe, you do not want to upset your family by confronting them. Is that right? You are both dammed if you do and dammed if you don’t.”

“I agree,” Joe and Esi both said, nodding.

“Do you want to work on this issue?”

They both agreed with equal enthusiasm.

“Ok, can you spend the next 10 minutes to work on this?”

They agreed.

“Ok, let’s start. What skills do you have that can help you resolve this important issue?”

Dr. Swarthmore framed the issue as one to be solved by the couple. The couple discussed that they are usually good at communication and solving problems. This problem is about whether or not Joe is more aligned with his White family than with Esi and their children.

Dr. Swarthmore encouraged them to think about this more deeply and over time; that this is such an important issue that it requires time and deep conversation.

“How do you think you can educate yourselves about the issues at hand?”

Esi suggested several books to Joe, and he agreed to read one of them.
 

Esi’s reading list

1. “Why I’m No Longer Talking to White People About Race” by Reni Eddo-Lodge (London: Bloomsbury, 2018).

2. “Americanah” by Chimamanda Ngozi Adichie (New York: Alfred A. Knopf, 2013).

3. “How to be an Antiracist” by Ibram X. Kendi (New York: Random House, 2019).
 

Joe suggests that Esi think about what it might mean if his sister and their children were no longer part of their lives. She agrees to do this.

Dr. Swarthmore asks if they can each do their homework before they come back. They agree and thought they could manage that and the book for 2 weeks out.

Dr. Swarthmore decides that he will read one of the books Esi suggested, as he does not know much about racism and White privilege and he wants to learn more. Dr. Swarthmore demonstrates his desire to become more racially sensitive. The following steps can be taken by therapists who want to become more racially sensitive, according to TA Laszloffy and KV Hardy (Fam Process. 2000 Spring;39[1]:35-50):
 

1. Read and watch movies that address the experience of other cultural groups.

2. Go to and participate in cross-cultural events.

3. Engage in a racial self-exploration process. The following questions can begin the racial identity exploration process:

• How do I define myself racially?
• When did I first become aware of race/skin color in general, and mine in particular?
• What messages did I learn about race/skin color based on that first experience?
• What direct and indirect messages did I receive about race/skin color?
• How did the messages that I received about race/skin color affect how I thought and felt about myself racially?
• What benefits did I gain because of my race/skin color?
• What did I lose because of my race/skin?
• Have I ever dated cross-racially? Why or why not?
• How many friends of a different race do I have?

4. Internal commitment. This means committing to addressing racism in therapeutic encounters.
 

Lessons learned for psychiatrists

1. Therapeutic space is allocated to discuss the issue.

2. The time is strictly limited to 10 minutes, so the couple won’t feel that their emotions will overwhelm them.

3. The space is to focus on the strengths that they can bring to resolving the issue.

4. Give patients the impression that they can solve this and that it is an important issue.

5. Do not put yourself in the patients’ argument; take neither side.
 

Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest. Dr. Heru wrote the article in collaboration with Lynette Ramsingh Barros, artist and social commentator.

Joe and Esi were in the therapist’s office wanting help with their relationship. The therapist had just asked the BIG question: How does race impact your lives?”

Esi began with her story about her ethics class, a story that was at sufficient distance from her life. Depending on her husband’s response, she would move in closer. His somewhat patronizing response made her feel both angry and that he lacked any real understanding.

“Me and a mulatto girl were in ethics class,” said Esi, who grew in Kenya. We had a White professor. He seemed to think I had no education. If you are a woman of color, you are automatically thought to have no education and that you don’t know what you are talking about. He tried to shut me up. When I persisted, I know he thought from the tone of my voice that I was an angry Black woman, even although I am not Black and I am not angry! In this country, if you have any color to your skin, you are called Black and relegated to a certain place: The bottom. I was excited about what he was teaching us, but when everyone looked at me with a certain gaze, like something bad was going to happen, all those White people, just looking, I tightened up inside and sat back down.”

Esi looked down at her folded hands. Her husband, who was White, reached over and reassuringly patted her hands.

“Yes, Esi, they are wrong. They shouldn’t have treated you that way. White people can be insensitive.”

Then, she continued, “Joe, you do the same to me!”

“What do you mean, Esi?” responded Joe, with an innocent and anxious look scanning back and forth between her and the White male therapist.

“Well, Joe, do you really want to hear how I felt last week after we came back from that party at your sister’s house?”

“Yes, Esi.”

“But do you really? Are you sure you want to hear this?”

“Yes, Esi.”

“Remember when we went over, me and the kids sat with the other people of color and you sat with your sister and her side of the family?

“Yes, I remember. What is wrong with that?”

“Well, me and my colored friends got loud and excited, and you shot me a look, like ‘pipe down over there.’ THEN, after we got home, the next day, your sister called you and said that you had better control your wife; she is too loud. Do you remember all that?

“Yes, well you do get loud – especially when you are around your people.”

“So why is it I have to fit in with your relatives and not the other way round? Why do I have to conform to the whiteness in your sister’s world, not the other way round?”

“Well, we were in her house.”

“So if they came to our house and were too quiet, how would you feel if I called them up and said they needed to participate with more enthusiasm?”

“Esi, that’s not fair, and you know it isn’t.”

Esi stops and looks at the therapist.

“So I check myself. It is the same all over, White people imposing their values and beliefs on me, on us. I am not an angry Black woman. I am just frustrated. People, White people, always want an explanation for what they think is my loss of control. You can see when their demeanor changes, they pull back, sit up, back away, fidget, and won’t look you in the eye. All these little tics that show that they are trying to get out of the situation.”

Esi took a breath and saw that her husband and the therapist were listening.

“These signs are ingrained in your brain ... these signs ... I saw it when I first came here to this country. The first time I had a good dose of it ... was in that ethics class in college. You can’t use words that you are accustomed to, ’cause they mean something else here, something bad.”

“Oh, Esi, I am so sorry,” said Joe, looking concerned.

“You may be sorry but you are not willing to stand up for me against your sister and her White values. You want me to conform.”

“What do you want me to do?”

“I want you to call your sister out.”

“But she may not ever speak to me again!”

“OK, don’t then,” and Esi looked down at her hands. She was finished talking. Joe looked at the therapist, waiting for something.

The therapist resisted intervening on the issue. “Keep talking this through,” he instructed them.

Joe could see that Esi had done talking and that it was his move.

“Do you really want me to call my sister out, even if it means that she will not talk to me again?”

“Yes.”

“I don’t know if I can do that.”

The therapist now intervened: “What does that mean to you, Esi, that he doesn’t know if he can do that.”

“It means he doesn’t really love me or value me or even value our mulatto children. What do think our daughter is learning?”

“That’s not true, Esi.”

The therapist, Dr. Swarthmore, watched Esi, who has very a dark, blue-black skin tone, with a flawless complexion and a shapely body. She wears her hair cropped and she looks like that Black model, what’s her name. Joe was short, a little plump with ultra White skin and freckles on his nose. He had been brought up in the Midwest and had had little exposure to Africans before his internship abroad in Kenya. Dr. S. thought he had probably not really thought much about Esi’s dilemma.

Dr. Swarthmore encouraged Esi to talk about her immigration experience.

“Esi, can you talk more about what it is like to be an immigrant from Africa?”

“Well, I just have to check myself so that I can fit in with this White culture. If you want to see how I feel about it, you will have to see an angry Black woman and I have learned not to give you that satisfaction. You will just dismiss me. Please Dr. Swarthmore, can we move on?”

Dr. Swarthmore was caught between his desire to accept her wish to move on and his wish to have her express herself fully. He realized that it was not his desire that mattered; that the couple had to work this out between them if they were going to move forward. So he punted it back to them.

“Esi and Joe, you are both caught in an important dilemma. Esi, you want more respect from your husband and his family. Joe, you do not want to upset your family by confronting them. Is that right? You are both dammed if you do and dammed if you don’t.”

“I agree,” Joe and Esi both said, nodding.

“Do you want to work on this issue?”

They both agreed with equal enthusiasm.

“Ok, can you spend the next 10 minutes to work on this?”

They agreed.

“Ok, let’s start. What skills do you have that can help you resolve this important issue?”

Dr. Swarthmore framed the issue as one to be solved by the couple. The couple discussed that they are usually good at communication and solving problems. This problem is about whether or not Joe is more aligned with his White family than with Esi and their children.

Dr. Swarthmore encouraged them to think about this more deeply and over time; that this is such an important issue that it requires time and deep conversation.

“How do you think you can educate yourselves about the issues at hand?”

Esi suggested several books to Joe, and he agreed to read one of them.
 

Esi’s reading list

1. “Why I’m No Longer Talking to White People About Race” by Reni Eddo-Lodge (London: Bloomsbury, 2018).

2. “Americanah” by Chimamanda Ngozi Adichie (New York: Alfred A. Knopf, 2013).

3. “How to be an Antiracist” by Ibram X. Kendi (New York: Random House, 2019).
 

Joe suggests that Esi think about what it might mean if his sister and their children were no longer part of their lives. She agrees to do this.

Dr. Swarthmore asks if they can each do their homework before they come back. They agree and thought they could manage that and the book for 2 weeks out.

Dr. Swarthmore decides that he will read one of the books Esi suggested, as he does not know much about racism and White privilege and he wants to learn more. Dr. Swarthmore demonstrates his desire to become more racially sensitive. The following steps can be taken by therapists who want to become more racially sensitive, according to TA Laszloffy and KV Hardy (Fam Process. 2000 Spring;39[1]:35-50):
 

1. Read and watch movies that address the experience of other cultural groups.

2. Go to and participate in cross-cultural events.

3. Engage in a racial self-exploration process. The following questions can begin the racial identity exploration process:

• How do I define myself racially?
• When did I first become aware of race/skin color in general, and mine in particular?
• What messages did I learn about race/skin color based on that first experience?
• What direct and indirect messages did I receive about race/skin color?
• How did the messages that I received about race/skin color affect how I thought and felt about myself racially?
• What benefits did I gain because of my race/skin color?
• What did I lose because of my race/skin?
• Have I ever dated cross-racially? Why or why not?
• How many friends of a different race do I have?

4. Internal commitment. This means committing to addressing racism in therapeutic encounters.
 

Lessons learned for psychiatrists

1. Therapeutic space is allocated to discuss the issue.

2. The time is strictly limited to 10 minutes, so the couple won’t feel that their emotions will overwhelm them.

3. The space is to focus on the strengths that they can bring to resolving the issue.

4. Give patients the impression that they can solve this and that it is an important issue.

5. Do not put yourself in the patients’ argument; take neither side.
 

Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest. Dr. Heru wrote the article in collaboration with Lynette Ramsingh Barros, artist and social commentator.

Jean Hanff Korelitz’s ironic psychological thriller, “You Should Have Known,” (New York: Grand Central Publishing, 2014) was transformed into an HBO miniseries called “The Undoing,” written and produced by David E. Kelley and directed by Susanne Bier, which premiered on Oct. 25, 2020.

The television drama differed from the novel in fundamental ways, but both have themes related to the therapeutic process. In the novel, a New York City–based couples therapist, Grace Reinhart Sachs, had recently written a book called “You Should Have Known,” about women who married their spouses disregarding their gut instinct that their partner was not fundamentally right for them, or might potentially cheat on them, or whose stories contained contradictions. In the miniseries, Grace (played by Nicole Kidman), is a therapist but there is no mention of her having written a book. Grace in both the novel and the miniseries is married to a pediatric oncologist, Jonathan (his ethnicity and surname were changed in the miniseries from a Jewish New Yorker in the novel to a British Dr. Jonathan Fraser in the series, played by Hugh Grant).

[Spoiler alert]: Prepandemic New York City’s Upper East Side is scandalized when a murdered mother is found by her young son the day after a lavish fund-raising auction party for a private school. Grace and Jonathan’s son, Henry, attends this school as well, and Grace had served on the auction committee with the murdered mother. When two detectives question Grace in the course of their investigation, she assumes that they are questioning her as they would any parent in the school. However, when she tries to reach her husband about the news and the investigation, she cannot. She thought he was at a medical conference in Cleveland, but she realizes that she does not know exactly what conference and exactly where. After many failed attempts at calling and texting, she hears a familiar alert sound coming from his nightstand drawer where she retrieves the cell phone that had been deliberately placed.

In the novel, Jonathan never reappears from “Cleveland,” and although it takes Grace a while to understand that her husband is not who she thought he was, she eventually does. In the miniseries, Jonathan appears in their lake house and a trial ensues with Jonathan adamantly proclaiming his innocence despite all evidence to the contrary.

Undoing in psychoanalysis is a defense mechanism initially described by Freud. The Oxford Reference defines undoing as “an emotional conflict associated with an action is dealt with by negating the action or attempting ‘magically’ to cause it not to have occurred by substituting an approximately opposite action.” It is not that the consequences of the action are attempted to be negated (as in making amends or showing remorse), but the action itself. In this way, the miniseries is aptly named since both main characters, Grace and Jonathan, use this defense mechanism. Grace has difficulty acknowledging that her husband could be capable of any wrongdoing, even as she is faced with fact after fact that contradicts this premise – and counsels others about their relationship choices. Similarly, Jonathan’s choice of profession is likely an attempt to undo his 4-year-old sister’s death that occurred on his watch when he was 14. However, even treating children’s cancer cannot undo the many indiscretions he has apparently committed in his adult life.

In the portrayal of a doctor with narcissistic, and possibly psychopathic, traits, “The Undoing” joins multiple recent podcasts that document real-life bad doctors, including Wondery’s “The Shrink Next Door,” “Dr. Death” (seasons 1 and 2), and “Do No Harm.” While most physicians go into medicine to heal and improve peoples’ lives, others, such as the character of Dr. Jonathan Fraser, appear to become physicians for ulterior and sinister motivations. Jonathan’s difficulty with empathy was present when he was a child as a character trait – rather than being attributable to any childhood traumatic event, as Grace had let herself believe.

In a Dec. 11, 2020, New York Times op-ed, Richard A. Friedman, MD, a psychiatrist affiliated with New York Presbyterian-Cornell University, discussed three “dangerous doctors” during the pandemic who are potentially harming the nation. Scott Atlas, MD, a radiologist on leave from Stanford (Calif.) University, advised President Trump on the coronavirus despite having no training in public health or infectious disease. Before resigning, he questioned the use of face masks, contradicting scientific proof of their prevention of disease. Another doctor, a cardiologist in Washington, also publicly disputed scientific evidence of the efficacy of face masks and social distancing, and a third physician promoted hydroxychloroquine as a treatment for coronavirus despite scientific evidence that it has been ineffective and possibly even harmful to patients with the virus.

Both the novel “You Should Have Known” and the series “The Undoing” will be of interest to psychiatrists, especially therapists and forensic psychiatrists, because of the themes portrayed, such as defense mechanisms, therapeutic process, and a homicide investigation – as well as the common human experience of being an expert in something in one’s professional life, yet occasionally falling short of recognizing the same phenomena in one’s personal life.
 

Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and is on the faculty at Weill-Cornell Medical Center. She has no conflicts of interest. Dr. Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington: American Psychiatric Publishing, 2019), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law, and which was awarded the 2020 Manfred Gutmacher Award by the American Psychiatric Association. She has no conflicts of interest.

Jean Hanff Korelitz’s ironic psychological thriller, “You Should Have Known,” (New York: Grand Central Publishing, 2014) was transformed into an HBO miniseries called “The Undoing,” written and produced by David E. Kelley and directed by Susanne Bier, which premiered on Oct. 25, 2020.

The television drama differed from the novel in fundamental ways, but both have themes related to the therapeutic process. In the novel, a New York City–based couples therapist, Grace Reinhart Sachs, had recently written a book called “You Should Have Known,” about women who married their spouses disregarding their gut instinct that their partner was not fundamentally right for them, or might potentially cheat on them, or whose stories contained contradictions. In the miniseries, Grace (played by Nicole Kidman), is a therapist but there is no mention of her having written a book. Grace in both the novel and the miniseries is married to a pediatric oncologist, Jonathan (his ethnicity and surname were changed in the miniseries from a Jewish New Yorker in the novel to a British Dr. Jonathan Fraser in the series, played by Hugh Grant).

[Spoiler alert]: Prepandemic New York City’s Upper East Side is scandalized when a murdered mother is found by her young son the day after a lavish fund-raising auction party for a private school. Grace and Jonathan’s son, Henry, attends this school as well, and Grace had served on the auction committee with the murdered mother. When two detectives question Grace in the course of their investigation, she assumes that they are questioning her as they would any parent in the school. However, when she tries to reach her husband about the news and the investigation, she cannot. She thought he was at a medical conference in Cleveland, but she realizes that she does not know exactly what conference and exactly where. After many failed attempts at calling and texting, she hears a familiar alert sound coming from his nightstand drawer where she retrieves the cell phone that had been deliberately placed.

In the novel, Jonathan never reappears from “Cleveland,” and although it takes Grace a while to understand that her husband is not who she thought he was, she eventually does. In the miniseries, Jonathan appears in their lake house and a trial ensues with Jonathan adamantly proclaiming his innocence despite all evidence to the contrary.

Undoing in psychoanalysis is a defense mechanism initially described by Freud. The Oxford Reference defines undoing as “an emotional conflict associated with an action is dealt with by negating the action or attempting ‘magically’ to cause it not to have occurred by substituting an approximately opposite action.” It is not that the consequences of the action are attempted to be negated (as in making amends or showing remorse), but the action itself. In this way, the miniseries is aptly named since both main characters, Grace and Jonathan, use this defense mechanism. Grace has difficulty acknowledging that her husband could be capable of any wrongdoing, even as she is faced with fact after fact that contradicts this premise – and counsels others about their relationship choices. Similarly, Jonathan’s choice of profession is likely an attempt to undo his 4-year-old sister’s death that occurred on his watch when he was 14. However, even treating children’s cancer cannot undo the many indiscretions he has apparently committed in his adult life.

In the portrayal of a doctor with narcissistic, and possibly psychopathic, traits, “The Undoing” joins multiple recent podcasts that document real-life bad doctors, including Wondery’s “The Shrink Next Door,” “Dr. Death” (seasons 1 and 2), and “Do No Harm.” While most physicians go into medicine to heal and improve peoples’ lives, others, such as the character of Dr. Jonathan Fraser, appear to become physicians for ulterior and sinister motivations. Jonathan’s difficulty with empathy was present when he was a child as a character trait – rather than being attributable to any childhood traumatic event, as Grace had let herself believe.

In a Dec. 11, 2020, New York Times op-ed, Richard A. Friedman, MD, a psychiatrist affiliated with New York Presbyterian-Cornell University, discussed three “dangerous doctors” during the pandemic who are potentially harming the nation. Scott Atlas, MD, a radiologist on leave from Stanford (Calif.) University, advised President Trump on the coronavirus despite having no training in public health or infectious disease. Before resigning, he questioned the use of face masks, contradicting scientific proof of their prevention of disease. Another doctor, a cardiologist in Washington, also publicly disputed scientific evidence of the efficacy of face masks and social distancing, and a third physician promoted hydroxychloroquine as a treatment for coronavirus despite scientific evidence that it has been ineffective and possibly even harmful to patients with the virus.

Both the novel “You Should Have Known” and the series “The Undoing” will be of interest to psychiatrists, especially therapists and forensic psychiatrists, because of the themes portrayed, such as defense mechanisms, therapeutic process, and a homicide investigation – as well as the common human experience of being an expert in something in one’s professional life, yet occasionally falling short of recognizing the same phenomena in one’s personal life.
 

Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and is on the faculty at Weill-Cornell Medical Center. She has no conflicts of interest. Dr. Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington: American Psychiatric Publishing, 2019), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law, and which was awarded the 2020 Manfred Gutmacher Award by the American Psychiatric Association. She has no conflicts of interest.

Jean Hanff Korelitz’s ironic psychological thriller, “You Should Have Known,” (New York: Grand Central Publishing, 2014) was transformed into an HBO miniseries called “The Undoing,” written and produced by David E. Kelley and directed by Susanne Bier, which premiered on Oct. 25, 2020.

The television drama differed from the novel in fundamental ways, but both have themes related to the therapeutic process. In the novel, a New York City–based couples therapist, Grace Reinhart Sachs, had recently written a book called “You Should Have Known,” about women who married their spouses disregarding their gut instinct that their partner was not fundamentally right for them, or might potentially cheat on them, or whose stories contained contradictions. In the miniseries, Grace (played by Nicole Kidman), is a therapist but there is no mention of her having written a book. Grace in both the novel and the miniseries is married to a pediatric oncologist, Jonathan (his ethnicity and surname were changed in the miniseries from a Jewish New Yorker in the novel to a British Dr. Jonathan Fraser in the series, played by Hugh Grant).

[Spoiler alert]: Prepandemic New York City’s Upper East Side is scandalized when a murdered mother is found by her young son the day after a lavish fund-raising auction party for a private school. Grace and Jonathan’s son, Henry, attends this school as well, and Grace had served on the auction committee with the murdered mother. When two detectives question Grace in the course of their investigation, she assumes that they are questioning her as they would any parent in the school. However, when she tries to reach her husband about the news and the investigation, she cannot. She thought he was at a medical conference in Cleveland, but she realizes that she does not know exactly what conference and exactly where. After many failed attempts at calling and texting, she hears a familiar alert sound coming from his nightstand drawer where she retrieves the cell phone that had been deliberately placed.

In the novel, Jonathan never reappears from “Cleveland,” and although it takes Grace a while to understand that her husband is not who she thought he was, she eventually does. In the miniseries, Jonathan appears in their lake house and a trial ensues with Jonathan adamantly proclaiming his innocence despite all evidence to the contrary.

Undoing in psychoanalysis is a defense mechanism initially described by Freud. The Oxford Reference defines undoing as “an emotional conflict associated with an action is dealt with by negating the action or attempting ‘magically’ to cause it not to have occurred by substituting an approximately opposite action.” It is not that the consequences of the action are attempted to be negated (as in making amends or showing remorse), but the action itself. In this way, the miniseries is aptly named since both main characters, Grace and Jonathan, use this defense mechanism. Grace has difficulty acknowledging that her husband could be capable of any wrongdoing, even as she is faced with fact after fact that contradicts this premise – and counsels others about their relationship choices. Similarly, Jonathan’s choice of profession is likely an attempt to undo his 4-year-old sister’s death that occurred on his watch when he was 14. However, even treating children’s cancer cannot undo the many indiscretions he has apparently committed in his adult life.

In the portrayal of a doctor with narcissistic, and possibly psychopathic, traits, “The Undoing” joins multiple recent podcasts that document real-life bad doctors, including Wondery’s “The Shrink Next Door,” “Dr. Death” (seasons 1 and 2), and “Do No Harm.” While most physicians go into medicine to heal and improve peoples’ lives, others, such as the character of Dr. Jonathan Fraser, appear to become physicians for ulterior and sinister motivations. Jonathan’s difficulty with empathy was present when he was a child as a character trait – rather than being attributable to any childhood traumatic event, as Grace had let herself believe.

In a Dec. 11, 2020, New York Times op-ed, Richard A. Friedman, MD, a psychiatrist affiliated with New York Presbyterian-Cornell University, discussed three “dangerous doctors” during the pandemic who are potentially harming the nation. Scott Atlas, MD, a radiologist on leave from Stanford (Calif.) University, advised President Trump on the coronavirus despite having no training in public health or infectious disease. Before resigning, he questioned the use of face masks, contradicting scientific proof of their prevention of disease. Another doctor, a cardiologist in Washington, also publicly disputed scientific evidence of the efficacy of face masks and social distancing, and a third physician promoted hydroxychloroquine as a treatment for coronavirus despite scientific evidence that it has been ineffective and possibly even harmful to patients with the virus.

Both the novel “You Should Have Known” and the series “The Undoing” will be of interest to psychiatrists, especially therapists and forensic psychiatrists, because of the themes portrayed, such as defense mechanisms, therapeutic process, and a homicide investigation – as well as the common human experience of being an expert in something in one’s professional life, yet occasionally falling short of recognizing the same phenomena in one’s personal life.
 

Dr. Rosenbaum is a clinical and forensic psychiatrist in private practice in New York. She is an assistant clinical professor at New York University Langone Medical Center and is on the faculty at Weill-Cornell Medical Center. She has no conflicts of interest. Dr. Friedman serves as the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University, Cleveland. She is also editor of Family Murder: Pathologies of Love and Hate (Washington: American Psychiatric Publishing, 2019), which was written by the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law, and which was awarded the 2020 Manfred Gutmacher Award by the American Psychiatric Association. She has no conflicts of interest.

Many scientific problems are complex. Finding the solution can require the concerted efforts of a team. Producing a vaccine for COVID-19 involved a multidisciplinary team with a variety of highly specialized expertises, extensive technological resources, and a history of previous scientific discoveries upon whose shoulders today’s scientists can stand.

Many ethical problems are also complex. Finding the ideal, multifaceted answer that addresses all the nuances of a social problem requires brilliant minds, a refined ability for logical analysis and rhetoric, the empowerment of the voices of all stakeholders, and attention to social values such as diversity and justice.

In both endeavors, the typical scientists and ethicists involved tend to presume that if they can determine an ideal solution, it will be rapidly and enthusiastically adopted and implemented for the betterment of society. That is, after all, exactly how those researchers would choose to act. Scientists see moral actions as having two steps. The hard part is deciding what is right. Doing the right thing is the easier task. This delusion is ubiquitous. Many scientists and ethicists recognize the delusion of the existence of a rational society, but proceed anyhow as if one exists.

There is a chorus of voices capable of debunking this delusion. Any priest who hears confessions will testify that the vast majority of harm comes from the failure to do what people already know is right, not from uncertainty, confusion, or ignorance. Psychologists and substance abuse counselors are inundated with people who are stuck doing harmful and self-destructive acts. Internists discuss diet and exercise with their patients, but find the advice is infrequently adopted. Master in business administration programs are devoted to training graduates in methods of motivating people to do what is right.

The response of the scientific establishment to the COVID-19 pandemic was imperfect. There were gaps in knowledge and some early information from China was misleading. The initial CDC test kit production was flawed. The early appeal for the public not to buy masks was strongly driven by a desire to preserve supplies for health care workers. Despite these missteps, the overall advice of scientists was wildly successful and beneficial. The goal was to flatten the curve, and a comparison of the April-June time frame with the November-January period shows markedly fewer COVID-19 cases, hospitalizations, and deaths. Confronted with the pandemic of the century, my assessment is that scientific establishment has performed well.

I am far more negative in my assessment of the institutions that support morality, form the social order, establish justice, and promote the general welfare. For instance, misinformation on social media is rampant, including conspiracy theories and outright denials of the pandemic. Scientific advice has been undercut and impugned. Policy recommendations of esteemed scientific institutions have been ignored. The public’s cooperation has fatigued. Laws on public gatherings, quarantines, and social distancing have been broken. Communitarian ethics and devotion to the common good have been left in a trash heap. The consequences have been hundreds of thousands of lives lost in 2020 and some states are on the brink of much worse.

Medical ethicists have debated in fine detail how to triage ventilators, ration antibody treatments, and prioritize vaccinations. Those policy recommendations have had limited influence. Medical ethics has inadequately addressed the age old problem of morality, which is getting people to behave as they know they ought. Modern medical ethics may have exacerbated the deviancy. Medical ethics for 50 years has emphasized replacing paternalism with autonomy, but it has not adequately promoted communitarian virtues, self-regulation, and personal integrity.

There were many accomplishments and many people to admire in 2020 when compared to historical actions by the health care professionals during crises. Doctors, confronted with the COVID-19 plague, have not abandoned the cities as happened in prior centuries. Patients have not been shunned like lepers, though the total-body protective equipment and the no-visitor policies come very close. Nurses have heroically provided bedside care, though I am haunted by one dissident nurse during a protest carrying a sign saying “Don’t call me a hero. I am being martyred against my will.”

As a scientist, I am prone to the delusion that, if I can build a better mouse trap, people will use it. I’ve lived with that delusion for decades. It carries over into my medical ethics work. Yet I see hospitals in California being overwhelmed by the surge on top of a surge due to unwise and unsafe holiday travel. I can see that optimized solutions aren’t the answer – it is better behavior by the public. I recall when I was a child, my mother would simply command, “Behave yourself.” And never, in any of those recollections, was I in doubt about which correct behavior she meant.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

Many scientific problems are complex. Finding the solution can require the concerted efforts of a team. Producing a vaccine for COVID-19 involved a multidisciplinary team with a variety of highly specialized expertises, extensive technological resources, and a history of previous scientific discoveries upon whose shoulders today’s scientists can stand.

Many ethical problems are also complex. Finding the ideal, multifaceted answer that addresses all the nuances of a social problem requires brilliant minds, a refined ability for logical analysis and rhetoric, the empowerment of the voices of all stakeholders, and attention to social values such as diversity and justice.

In both endeavors, the typical scientists and ethicists involved tend to presume that if they can determine an ideal solution, it will be rapidly and enthusiastically adopted and implemented for the betterment of society. That is, after all, exactly how those researchers would choose to act. Scientists see moral actions as having two steps. The hard part is deciding what is right. Doing the right thing is the easier task. This delusion is ubiquitous. Many scientists and ethicists recognize the delusion of the existence of a rational society, but proceed anyhow as if one exists.

There is a chorus of voices capable of debunking this delusion. Any priest who hears confessions will testify that the vast majority of harm comes from the failure to do what people already know is right, not from uncertainty, confusion, or ignorance. Psychologists and substance abuse counselors are inundated with people who are stuck doing harmful and self-destructive acts. Internists discuss diet and exercise with their patients, but find the advice is infrequently adopted. Master in business administration programs are devoted to training graduates in methods of motivating people to do what is right.

The response of the scientific establishment to the COVID-19 pandemic was imperfect. There were gaps in knowledge and some early information from China was misleading. The initial CDC test kit production was flawed. The early appeal for the public not to buy masks was strongly driven by a desire to preserve supplies for health care workers. Despite these missteps, the overall advice of scientists was wildly successful and beneficial. The goal was to flatten the curve, and a comparison of the April-June time frame with the November-January period shows markedly fewer COVID-19 cases, hospitalizations, and deaths. Confronted with the pandemic of the century, my assessment is that scientific establishment has performed well.

I am far more negative in my assessment of the institutions that support morality, form the social order, establish justice, and promote the general welfare. For instance, misinformation on social media is rampant, including conspiracy theories and outright denials of the pandemic. Scientific advice has been undercut and impugned. Policy recommendations of esteemed scientific institutions have been ignored. The public’s cooperation has fatigued. Laws on public gatherings, quarantines, and social distancing have been broken. Communitarian ethics and devotion to the common good have been left in a trash heap. The consequences have been hundreds of thousands of lives lost in 2020 and some states are on the brink of much worse.

Medical ethicists have debated in fine detail how to triage ventilators, ration antibody treatments, and prioritize vaccinations. Those policy recommendations have had limited influence. Medical ethics has inadequately addressed the age old problem of morality, which is getting people to behave as they know they ought. Modern medical ethics may have exacerbated the deviancy. Medical ethics for 50 years has emphasized replacing paternalism with autonomy, but it has not adequately promoted communitarian virtues, self-regulation, and personal integrity.

There were many accomplishments and many people to admire in 2020 when compared to historical actions by the health care professionals during crises. Doctors, confronted with the COVID-19 plague, have not abandoned the cities as happened in prior centuries. Patients have not been shunned like lepers, though the total-body protective equipment and the no-visitor policies come very close. Nurses have heroically provided bedside care, though I am haunted by one dissident nurse during a protest carrying a sign saying “Don’t call me a hero. I am being martyred against my will.”

As a scientist, I am prone to the delusion that, if I can build a better mouse trap, people will use it. I’ve lived with that delusion for decades. It carries over into my medical ethics work. Yet I see hospitals in California being overwhelmed by the surge on top of a surge due to unwise and unsafe holiday travel. I can see that optimized solutions aren’t the answer – it is better behavior by the public. I recall when I was a child, my mother would simply command, “Behave yourself.” And never, in any of those recollections, was I in doubt about which correct behavior she meant.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

Many scientific problems are complex. Finding the solution can require the concerted efforts of a team. Producing a vaccine for COVID-19 involved a multidisciplinary team with a variety of highly specialized expertises, extensive technological resources, and a history of previous scientific discoveries upon whose shoulders today’s scientists can stand.

Many ethical problems are also complex. Finding the ideal, multifaceted answer that addresses all the nuances of a social problem requires brilliant minds, a refined ability for logical analysis and rhetoric, the empowerment of the voices of all stakeholders, and attention to social values such as diversity and justice.

In both endeavors, the typical scientists and ethicists involved tend to presume that if they can determine an ideal solution, it will be rapidly and enthusiastically adopted and implemented for the betterment of society. That is, after all, exactly how those researchers would choose to act. Scientists see moral actions as having two steps. The hard part is deciding what is right. Doing the right thing is the easier task. This delusion is ubiquitous. Many scientists and ethicists recognize the delusion of the existence of a rational society, but proceed anyhow as if one exists.

There is a chorus of voices capable of debunking this delusion. Any priest who hears confessions will testify that the vast majority of harm comes from the failure to do what people already know is right, not from uncertainty, confusion, or ignorance. Psychologists and substance abuse counselors are inundated with people who are stuck doing harmful and self-destructive acts. Internists discuss diet and exercise with their patients, but find the advice is infrequently adopted. Master in business administration programs are devoted to training graduates in methods of motivating people to do what is right.

The response of the scientific establishment to the COVID-19 pandemic was imperfect. There were gaps in knowledge and some early information from China was misleading. The initial CDC test kit production was flawed. The early appeal for the public not to buy masks was strongly driven by a desire to preserve supplies for health care workers. Despite these missteps, the overall advice of scientists was wildly successful and beneficial. The goal was to flatten the curve, and a comparison of the April-June time frame with the November-January period shows markedly fewer COVID-19 cases, hospitalizations, and deaths. Confronted with the pandemic of the century, my assessment is that scientific establishment has performed well.

I am far more negative in my assessment of the institutions that support morality, form the social order, establish justice, and promote the general welfare. For instance, misinformation on social media is rampant, including conspiracy theories and outright denials of the pandemic. Scientific advice has been undercut and impugned. Policy recommendations of esteemed scientific institutions have been ignored. The public’s cooperation has fatigued. Laws on public gatherings, quarantines, and social distancing have been broken. Communitarian ethics and devotion to the common good have been left in a trash heap. The consequences have been hundreds of thousands of lives lost in 2020 and some states are on the brink of much worse.

Medical ethicists have debated in fine detail how to triage ventilators, ration antibody treatments, and prioritize vaccinations. Those policy recommendations have had limited influence. Medical ethics has inadequately addressed the age old problem of morality, which is getting people to behave as they know they ought. Modern medical ethics may have exacerbated the deviancy. Medical ethics for 50 years has emphasized replacing paternalism with autonomy, but it has not adequately promoted communitarian virtues, self-regulation, and personal integrity.

There were many accomplishments and many people to admire in 2020 when compared to historical actions by the health care professionals during crises. Doctors, confronted with the COVID-19 plague, have not abandoned the cities as happened in prior centuries. Patients have not been shunned like lepers, though the total-body protective equipment and the no-visitor policies come very close. Nurses have heroically provided bedside care, though I am haunted by one dissident nurse during a protest carrying a sign saying “Don’t call me a hero. I am being martyred against my will.”

As a scientist, I am prone to the delusion that, if I can build a better mouse trap, people will use it. I’ve lived with that delusion for decades. It carries over into my medical ethics work. Yet I see hospitals in California being overwhelmed by the surge on top of a surge due to unwise and unsafe holiday travel. I can see that optimized solutions aren’t the answer – it is better behavior by the public. I recall when I was a child, my mother would simply command, “Behave yourself.” And never, in any of those recollections, was I in doubt about which correct behavior she meant.
 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

“My census is too high.”

“I don’t have enough time to talk to patients.”

“These are outside our scope of practice.”

These are statements that I have heard from colleagues over the last fourteen years as a hospitalist. Back in 1996, when Dr. Bob Wachter coined the term ‘hospitalist,’ we were still in our infancy – the scope of what we could do had yet to be fully realized. Our focus was on providing care for hospitalized patients and improving quality of clinical care and patient safety. As health care organizations began to see the potential for our field, the demands on our services grew. We grew to comanage patients with our surgical colleagues, worked on patient satisfaction, facilitated transitions of care, and attempted to reduce readmissions – all of which improved patient care and the bottom line for our organizations.

Somewhere along the way, we were expected to staff high patient volumes to add more value, but this always seemed to come with compromise in another aspect of care or our own well-being. After all, there are only so many hours in the day and a limit on what one individual can accomplish in that time.

One of the reasons I love hospital medicine is the novelty of what we do – we are creative thinkers. We have the capacity to innovate solutions to hospital problems based on our expertise as frontline providers for our patients. Hospitalists of every discipline staff a large majority of inpatients, which makes our collective experience significant to the management of inpatient health care. We are often the ones tasked with executing improvement projects, but how often are we involved in their design? I know that we collectively have an enormous opportunity to improve our health care practice, both for ourselves, our patients, and the institutions we work for. But more than just being a voice of advocacy, we need to understand how to positively influence the health care structures that allow us to deliver quality patient care.

It is no surprise that the inefficiencies we deal with in our hospitals are many – daily workflow interruptions, delays in results, scheduling issues, communication difficulties. These are not unique to any one institution. The pandemic added more to that plate – PPE deficiencies, patient volume triage, and resource management are examples. Hospitals often contract consultants to help solve these problems, and many utilize a variety of frameworks to improve these system processes. The Lean framework is one of these, and it originated in the manufacturing industry to eliminate waste in systems in the pursuit of efficiency.

In my business training and prior hospital medicine leadership roles, I was educated in Lean thinking and methodologies for improving quality and applied its principles to projects for improving workflow. Last year I attended a virtual conference on ‘Lean Innovation during the pandemic’ for New York region hospitals, and it again highlighted how the Lean management methodology can help improve patient care but importantly, our workflow as clinicians. This got me thinking. Why is Lean well accepted in business and manufacturing circles, but less so in health care?

I think the answer is twofold – knowledge and people.

 

What is Lean and how can it help us?

The ‘Toyota Production System’-based philosophy has 14 core principles that help eliminate waste in systems in pursuit of efficiency. These principles are the “Toyota Way.” They center around two pillars: continuous improvement and respect for people. The cornerstone of this management methodology is based on efficient processes, developing employees to add value to the organization and continuous improvement through problem-solving and organizational learning.

Lean is often implemented with Six Sigma methodology. Six Sigma has its origins in Motorola. While Lean cuts waste in our systems to provide value, Six Sigma uses DMAIC (Define, Measure, Analyze, Improve, Control) to reduce variation in our processes. When done in its entirety, Lean Six Sigma methodology adds value by increasing efficiency, reducing cost, and improving our everyday work.

Statistical principles suggest that 80% of consequences comes from 20% of causes. Lean methodology and tools allow us to systematically identify root causes for the problems we face and help narrow it down to the ‘vital few.’ In other words, fixing these would give us the most bang for our buck. As hospitalists, we are able to do this better than most because we work in these hospital processes everyday – we truly know the strengths and weaknesses of our systems.

As a hospitalist, I would love for the process of seeing patients in hospitals to be more efficient, less variable, and be more cost-effective for my institution. By eliminating the time wasted performing unnecessary and redundant tasks in my everyday work, I can reallocate that time to patient care – the very reason I chose a career in medicine.
 

We, the people

There are two common rebuttals I hear for adopting Lean Six Sigma methodology in health care. A frequent misconception is that Lean is all about reducing staff or time with patients. The second is that manufacturing methodologies do not work for a service profession. For instance, an article published on Reuters Events (www.reutersevents.com/supplychain/supply-chain/end-just-time) talks about Lean JIT (Just In Time) inventory as a culprit for creating a supply chain deficit during COVID-19. It is not entirely without merit. However, if done the correct way, Lean is all about involving the frontline worker to create a workflow that would work best for them.

Reducing the waste in our processes and empowering our frontline doctors to be creative in finding solutions naturally leads to cost reduction. The cornerstone of Lean is creating a continuously learning organization and putting your employees at the forefront. I think it is important that Lean principles be utilized within health care – but we cannot push to fix every problem in our systems to perfection at a significant expense to the physician and other health care staff.
 

Why HM can benefit from Lean

There is no hard and fast rule about the way health care should adopt Lean thinking. It is a way of thinking that aims to balance purpose, people, and process – extremes of inventory management may not be necessary to be successful in health care. Lean tools alone would not create results. John Shook, chairman of Lean Global Network, has said that the social side of Lean needs to be in balance with the technical side. In other words, rigidity and efficiency is good, but so is encouraging creativity and flexibility in thinking within the workforce.

In the crisis created by the novel coronavirus, many hospitals in New York state, including my own, turned to Lean to respond quickly and effectively to the challenges. Lean principles helped them problem-solve and develop strategies to both recover from the pandemic surge and adapt to future problems that could occur. Geographic clustering of patients, PPE supply, OR shut down and ramp up, emergency management offices at the peak of the pandemic, telehealth streamlining, and post-COVID-19 care planning are some areas where the application of Lean resulted in successful responses to the challenges that 2020 brought to our work.

As Warren Bennis said, ‘The manager accepts the status quo; the leader challenges it.’ As hospitalists, we can lead the way our hospitals provide care. Lean is not just a way for hospitals to cut costs (although it helps quite a bit there). Its processes and philosophies could enable hospitalists to maximize potential, efficiency, quality of care, and allow for a balanced work environment. When applied in a manner that focuses on continuous improvement (and is cognizant of its limitations), it has the potential to increase the capability of our service lines and streamline our processes and workday for greater efficiency. As a specialty, we stand to benefit by taking the lead role in choosing how best to improve how we work. We should think outside the box. What better time to do this than now?

Dr. Kanikkannan is a practicing hospitalist and assistant professor of medicine at Albany (N.Y) Medical College. She is a former hospitalist medical director and has served on SHM’s national committees, and is a certified Lean Six Sigma black belt and MBA candidate.

“My census is too high.”

“I don’t have enough time to talk to patients.”

“These are outside our scope of practice.”

These are statements that I have heard from colleagues over the last fourteen years as a hospitalist. Back in 1996, when Dr. Bob Wachter coined the term ‘hospitalist,’ we were still in our infancy – the scope of what we could do had yet to be fully realized. Our focus was on providing care for hospitalized patients and improving quality of clinical care and patient safety. As health care organizations began to see the potential for our field, the demands on our services grew. We grew to comanage patients with our surgical colleagues, worked on patient satisfaction, facilitated transitions of care, and attempted to reduce readmissions – all of which improved patient care and the bottom line for our organizations.

Somewhere along the way, we were expected to staff high patient volumes to add more value, but this always seemed to come with compromise in another aspect of care or our own well-being. After all, there are only so many hours in the day and a limit on what one individual can accomplish in that time.

One of the reasons I love hospital medicine is the novelty of what we do – we are creative thinkers. We have the capacity to innovate solutions to hospital problems based on our expertise as frontline providers for our patients. Hospitalists of every discipline staff a large majority of inpatients, which makes our collective experience significant to the management of inpatient health care. We are often the ones tasked with executing improvement projects, but how often are we involved in their design? I know that we collectively have an enormous opportunity to improve our health care practice, both for ourselves, our patients, and the institutions we work for. But more than just being a voice of advocacy, we need to understand how to positively influence the health care structures that allow us to deliver quality patient care.

It is no surprise that the inefficiencies we deal with in our hospitals are many – daily workflow interruptions, delays in results, scheduling issues, communication difficulties. These are not unique to any one institution. The pandemic added more to that plate – PPE deficiencies, patient volume triage, and resource management are examples. Hospitals often contract consultants to help solve these problems, and many utilize a variety of frameworks to improve these system processes. The Lean framework is one of these, and it originated in the manufacturing industry to eliminate waste in systems in the pursuit of efficiency.

In my business training and prior hospital medicine leadership roles, I was educated in Lean thinking and methodologies for improving quality and applied its principles to projects for improving workflow. Last year I attended a virtual conference on ‘Lean Innovation during the pandemic’ for New York region hospitals, and it again highlighted how the Lean management methodology can help improve patient care but importantly, our workflow as clinicians. This got me thinking. Why is Lean well accepted in business and manufacturing circles, but less so in health care?

I think the answer is twofold – knowledge and people.

 

What is Lean and how can it help us?

The ‘Toyota Production System’-based philosophy has 14 core principles that help eliminate waste in systems in pursuit of efficiency. These principles are the “Toyota Way.” They center around two pillars: continuous improvement and respect for people. The cornerstone of this management methodology is based on efficient processes, developing employees to add value to the organization and continuous improvement through problem-solving and organizational learning.

Lean is often implemented with Six Sigma methodology. Six Sigma has its origins in Motorola. While Lean cuts waste in our systems to provide value, Six Sigma uses DMAIC (Define, Measure, Analyze, Improve, Control) to reduce variation in our processes. When done in its entirety, Lean Six Sigma methodology adds value by increasing efficiency, reducing cost, and improving our everyday work.

Statistical principles suggest that 80% of consequences comes from 20% of causes. Lean methodology and tools allow us to systematically identify root causes for the problems we face and help narrow it down to the ‘vital few.’ In other words, fixing these would give us the most bang for our buck. As hospitalists, we are able to do this better than most because we work in these hospital processes everyday – we truly know the strengths and weaknesses of our systems.

As a hospitalist, I would love for the process of seeing patients in hospitals to be more efficient, less variable, and be more cost-effective for my institution. By eliminating the time wasted performing unnecessary and redundant tasks in my everyday work, I can reallocate that time to patient care – the very reason I chose a career in medicine.
 

We, the people

There are two common rebuttals I hear for adopting Lean Six Sigma methodology in health care. A frequent misconception is that Lean is all about reducing staff or time with patients. The second is that manufacturing methodologies do not work for a service profession. For instance, an article published on Reuters Events (www.reutersevents.com/supplychain/supply-chain/end-just-time) talks about Lean JIT (Just In Time) inventory as a culprit for creating a supply chain deficit during COVID-19. It is not entirely without merit. However, if done the correct way, Lean is all about involving the frontline worker to create a workflow that would work best for them.

Reducing the waste in our processes and empowering our frontline doctors to be creative in finding solutions naturally leads to cost reduction. The cornerstone of Lean is creating a continuously learning organization and putting your employees at the forefront. I think it is important that Lean principles be utilized within health care – but we cannot push to fix every problem in our systems to perfection at a significant expense to the physician and other health care staff.
 

Why HM can benefit from Lean

There is no hard and fast rule about the way health care should adopt Lean thinking. It is a way of thinking that aims to balance purpose, people, and process – extremes of inventory management may not be necessary to be successful in health care. Lean tools alone would not create results. John Shook, chairman of Lean Global Network, has said that the social side of Lean needs to be in balance with the technical side. In other words, rigidity and efficiency is good, but so is encouraging creativity and flexibility in thinking within the workforce.

In the crisis created by the novel coronavirus, many hospitals in New York state, including my own, turned to Lean to respond quickly and effectively to the challenges. Lean principles helped them problem-solve and develop strategies to both recover from the pandemic surge and adapt to future problems that could occur. Geographic clustering of patients, PPE supply, OR shut down and ramp up, emergency management offices at the peak of the pandemic, telehealth streamlining, and post-COVID-19 care planning are some areas where the application of Lean resulted in successful responses to the challenges that 2020 brought to our work.

As Warren Bennis said, ‘The manager accepts the status quo; the leader challenges it.’ As hospitalists, we can lead the way our hospitals provide care. Lean is not just a way for hospitals to cut costs (although it helps quite a bit there). Its processes and philosophies could enable hospitalists to maximize potential, efficiency, quality of care, and allow for a balanced work environment. When applied in a manner that focuses on continuous improvement (and is cognizant of its limitations), it has the potential to increase the capability of our service lines and streamline our processes and workday for greater efficiency. As a specialty, we stand to benefit by taking the lead role in choosing how best to improve how we work. We should think outside the box. What better time to do this than now?

Dr. Kanikkannan is a practicing hospitalist and assistant professor of medicine at Albany (N.Y) Medical College. She is a former hospitalist medical director and has served on SHM’s national committees, and is a certified Lean Six Sigma black belt and MBA candidate.

“My census is too high.”

“I don’t have enough time to talk to patients.”

“These are outside our scope of practice.”

These are statements that I have heard from colleagues over the last fourteen years as a hospitalist. Back in 1996, when Dr. Bob Wachter coined the term ‘hospitalist,’ we were still in our infancy – the scope of what we could do had yet to be fully realized. Our focus was on providing care for hospitalized patients and improving quality of clinical care and patient safety. As health care organizations began to see the potential for our field, the demands on our services grew. We grew to comanage patients with our surgical colleagues, worked on patient satisfaction, facilitated transitions of care, and attempted to reduce readmissions – all of which improved patient care and the bottom line for our organizations.

Somewhere along the way, we were expected to staff high patient volumes to add more value, but this always seemed to come with compromise in another aspect of care or our own well-being. After all, there are only so many hours in the day and a limit on what one individual can accomplish in that time.

One of the reasons I love hospital medicine is the novelty of what we do – we are creative thinkers. We have the capacity to innovate solutions to hospital problems based on our expertise as frontline providers for our patients. Hospitalists of every discipline staff a large majority of inpatients, which makes our collective experience significant to the management of inpatient health care. We are often the ones tasked with executing improvement projects, but how often are we involved in their design? I know that we collectively have an enormous opportunity to improve our health care practice, both for ourselves, our patients, and the institutions we work for. But more than just being a voice of advocacy, we need to understand how to positively influence the health care structures that allow us to deliver quality patient care.

It is no surprise that the inefficiencies we deal with in our hospitals are many – daily workflow interruptions, delays in results, scheduling issues, communication difficulties. These are not unique to any one institution. The pandemic added more to that plate – PPE deficiencies, patient volume triage, and resource management are examples. Hospitals often contract consultants to help solve these problems, and many utilize a variety of frameworks to improve these system processes. The Lean framework is one of these, and it originated in the manufacturing industry to eliminate waste in systems in the pursuit of efficiency.

In my business training and prior hospital medicine leadership roles, I was educated in Lean thinking and methodologies for improving quality and applied its principles to projects for improving workflow. Last year I attended a virtual conference on ‘Lean Innovation during the pandemic’ for New York region hospitals, and it again highlighted how the Lean management methodology can help improve patient care but importantly, our workflow as clinicians. This got me thinking. Why is Lean well accepted in business and manufacturing circles, but less so in health care?

I think the answer is twofold – knowledge and people.

 

What is Lean and how can it help us?

The ‘Toyota Production System’-based philosophy has 14 core principles that help eliminate waste in systems in pursuit of efficiency. These principles are the “Toyota Way.” They center around two pillars: continuous improvement and respect for people. The cornerstone of this management methodology is based on efficient processes, developing employees to add value to the organization and continuous improvement through problem-solving and organizational learning.

Lean is often implemented with Six Sigma methodology. Six Sigma has its origins in Motorola. While Lean cuts waste in our systems to provide value, Six Sigma uses DMAIC (Define, Measure, Analyze, Improve, Control) to reduce variation in our processes. When done in its entirety, Lean Six Sigma methodology adds value by increasing efficiency, reducing cost, and improving our everyday work.

Statistical principles suggest that 80% of consequences comes from 20% of causes. Lean methodology and tools allow us to systematically identify root causes for the problems we face and help narrow it down to the ‘vital few.’ In other words, fixing these would give us the most bang for our buck. As hospitalists, we are able to do this better than most because we work in these hospital processes everyday – we truly know the strengths and weaknesses of our systems.

As a hospitalist, I would love for the process of seeing patients in hospitals to be more efficient, less variable, and be more cost-effective for my institution. By eliminating the time wasted performing unnecessary and redundant tasks in my everyday work, I can reallocate that time to patient care – the very reason I chose a career in medicine.
 

We, the people

There are two common rebuttals I hear for adopting Lean Six Sigma methodology in health care. A frequent misconception is that Lean is all about reducing staff or time with patients. The second is that manufacturing methodologies do not work for a service profession. For instance, an article published on Reuters Events (www.reutersevents.com/supplychain/supply-chain/end-just-time) talks about Lean JIT (Just In Time) inventory as a culprit for creating a supply chain deficit during COVID-19. It is not entirely without merit. However, if done the correct way, Lean is all about involving the frontline worker to create a workflow that would work best for them.

Reducing the waste in our processes and empowering our frontline doctors to be creative in finding solutions naturally leads to cost reduction. The cornerstone of Lean is creating a continuously learning organization and putting your employees at the forefront. I think it is important that Lean principles be utilized within health care – but we cannot push to fix every problem in our systems to perfection at a significant expense to the physician and other health care staff.
 

Why HM can benefit from Lean

There is no hard and fast rule about the way health care should adopt Lean thinking. It is a way of thinking that aims to balance purpose, people, and process – extremes of inventory management may not be necessary to be successful in health care. Lean tools alone would not create results. John Shook, chairman of Lean Global Network, has said that the social side of Lean needs to be in balance with the technical side. In other words, rigidity and efficiency is good, but so is encouraging creativity and flexibility in thinking within the workforce.

In the crisis created by the novel coronavirus, many hospitals in New York state, including my own, turned to Lean to respond quickly and effectively to the challenges. Lean principles helped them problem-solve and develop strategies to both recover from the pandemic surge and adapt to future problems that could occur. Geographic clustering of patients, PPE supply, OR shut down and ramp up, emergency management offices at the peak of the pandemic, telehealth streamlining, and post-COVID-19 care planning are some areas where the application of Lean resulted in successful responses to the challenges that 2020 brought to our work.

As Warren Bennis said, ‘The manager accepts the status quo; the leader challenges it.’ As hospitalists, we can lead the way our hospitals provide care. Lean is not just a way for hospitals to cut costs (although it helps quite a bit there). Its processes and philosophies could enable hospitalists to maximize potential, efficiency, quality of care, and allow for a balanced work environment. When applied in a manner that focuses on continuous improvement (and is cognizant of its limitations), it has the potential to increase the capability of our service lines and streamline our processes and workday for greater efficiency. As a specialty, we stand to benefit by taking the lead role in choosing how best to improve how we work. We should think outside the box. What better time to do this than now?

Dr. Kanikkannan is a practicing hospitalist and assistant professor of medicine at Albany (N.Y) Medical College. She is a former hospitalist medical director and has served on SHM’s national committees, and is a certified Lean Six Sigma black belt and MBA candidate.

How many providers does it take to depersonalize a patient? Nine? 1. A psychiatrist for transcranial magnetic stimulation (TMS). 2. A psychiatrist for ketamine. 3. A psychiatrist who specializes in substance use disorder medication. 4. A psychiatrist for the rest of the psychotropic medication. 5. An alternative medicine provider who prescribes supplements. 6. A therapist for depression who uses cognitive-behavioral therapy. 7. A therapist for posttraumatic stress disorder who uses eye movement desensitization and reprocessing. 8. An addiction counselor. 9. An equine therapist.

This doesn’t include other providers and professionals who likely contribute to one’s mental well-being, including yoga instructors and personal trainers. In addition, any one of those psychiatrists may have one or more nurse practitioners who routinely step in to attend to appointments.

In our uncertain and lonely times, the value of human contact and interaction has become exponentially more precious. I long to see my patients in my private practice office. I am now much more aware of their grounding effect on my life, and I suspect I had a similar grounding effect on theirs. Few things provide me more comfort than sitting on my lounge chair with a curious gaze waiting for the patient to start the visit. I often wonder what makes a patient choose to go see a private practice physician. Yet a common reason offered is, “Wait! You do everything? Therapy and meds if I need them? You’ll see me every week?”

While I am realistic about the need and use of split-care, I have never been enamored with the concept. I think that few medical students choose psychiatry with the goal of referring all psychotherapeutic needs and intervention to “allied mental health providers” as my prior managed care organization liked to refer to psychologists, social workers, marriage and family therapists, and other counselors. I remember particularly as a chief resident being bombarded by complaints of therapists complaining about psychiatry residents. All of their patients’ symptoms allegedly required medication adjustment and residents were supposedly dismissing them. In return, residents would complain that the therapists did not address the psychological manifestations of the patient’s ailments. Herein lies my problem with split-care, it encourages psychotherapy to be about medication management, and medication management to be about psychotherapy.

However, this is not an article against split-treatment. Psychiatrists, for a variety of reasons, are not suited to perform psychotherapy in most management care models. The main reason being that psychiatrists’ time is too expensive to justify the expense, and psychiatrists are (for the most part), the only ones able to prescribe medications for which the wait-list is already long enough. This article is about the absurd levels at which we have fragmented care of certain patients. Split-treatment is relevant in that its negative side effects, we are almost all familiar with, exemplify the problem of the fragmentation of modern psychiatry. In many ways this fragmentation of care is similar to polypharmacy – the premise for each psychotropic intervention may be sound, but the end result is often incoherent.

My main concern with the fragmentation of modern psychiatry stems from my belief that the most important facet of our work is our relationship with our patients. It is the duty we owe them, the attention we give them, the unique nature of interactions. Who among the nine providers is responsible for writing a discharge summary? Who is responsible for calling an emergency contact in a critical situation? Who communicates with the new provider when someone is taken off an insurance panel? Who makes the patient feel cared for? I am often confronted by this situation when TMS or ketamine providers say, “I just give the procedure/medication that was ordered by the referring psychiatrist.” This response disturbs me in that I could not imagine myself being so hands off in the care of a patient. There is an implication of projected immunity and lack of responsibility that bothers me.

But my concerns are also practical. From my forensic experience, I am well aware that the larger the number of providers treating a patient, the larger the number of inconsistent diagnoses, the more likely medication reconciliations are not kept up to date or incorrect, and the more likely intervention recommendations are contrary to one another. A disengaged ketamine provider may not realize that the patient was more recently enrolled in a substance use disorder program, a potential contraindication for ketamine, if not well-abreast of the patient’s continued evolution. A disengaged therapist may not realize that a patient appears unmotivated because of an increasing dose of medication rather than poor effort. A substance use disorder psychiatric specialist may be at odds with a substance use disorder counselor who worries about the message of treating psychiatric symptoms with chemical substances if they don’t communicate.

As with polypharmacy, “polydoctoring” has negative effects. While the field of psychiatry’s advancing knowledge may encourage providers to specialize, patients still desire and benefit from an intimate and close relationship with one provider who is warm, concerned, and hopeful. Those traits can theoretically be provided by anyone and there is not something inherently wrong with having more than one provider. However, psychiatry would be wise to recognize this concerning trend, especially at a time when we all feel lonely, disconnected, and depersonalized.
 

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.

How many providers does it take to depersonalize a patient? Nine? 1. A psychiatrist for transcranial magnetic stimulation (TMS). 2. A psychiatrist for ketamine. 3. A psychiatrist who specializes in substance use disorder medication. 4. A psychiatrist for the rest of the psychotropic medication. 5. An alternative medicine provider who prescribes supplements. 6. A therapist for depression who uses cognitive-behavioral therapy. 7. A therapist for posttraumatic stress disorder who uses eye movement desensitization and reprocessing. 8. An addiction counselor. 9. An equine therapist.

This doesn’t include other providers and professionals who likely contribute to one’s mental well-being, including yoga instructors and personal trainers. In addition, any one of those psychiatrists may have one or more nurse practitioners who routinely step in to attend to appointments.

In our uncertain and lonely times, the value of human contact and interaction has become exponentially more precious. I long to see my patients in my private practice office. I am now much more aware of their grounding effect on my life, and I suspect I had a similar grounding effect on theirs. Few things provide me more comfort than sitting on my lounge chair with a curious gaze waiting for the patient to start the visit. I often wonder what makes a patient choose to go see a private practice physician. Yet a common reason offered is, “Wait! You do everything? Therapy and meds if I need them? You’ll see me every week?”

While I am realistic about the need and use of split-care, I have never been enamored with the concept. I think that few medical students choose psychiatry with the goal of referring all psychotherapeutic needs and intervention to “allied mental health providers” as my prior managed care organization liked to refer to psychologists, social workers, marriage and family therapists, and other counselors. I remember particularly as a chief resident being bombarded by complaints of therapists complaining about psychiatry residents. All of their patients’ symptoms allegedly required medication adjustment and residents were supposedly dismissing them. In return, residents would complain that the therapists did not address the psychological manifestations of the patient’s ailments. Herein lies my problem with split-care, it encourages psychotherapy to be about medication management, and medication management to be about psychotherapy.

However, this is not an article against split-treatment. Psychiatrists, for a variety of reasons, are not suited to perform psychotherapy in most management care models. The main reason being that psychiatrists’ time is too expensive to justify the expense, and psychiatrists are (for the most part), the only ones able to prescribe medications for which the wait-list is already long enough. This article is about the absurd levels at which we have fragmented care of certain patients. Split-treatment is relevant in that its negative side effects, we are almost all familiar with, exemplify the problem of the fragmentation of modern psychiatry. In many ways this fragmentation of care is similar to polypharmacy – the premise for each psychotropic intervention may be sound, but the end result is often incoherent.

My main concern with the fragmentation of modern psychiatry stems from my belief that the most important facet of our work is our relationship with our patients. It is the duty we owe them, the attention we give them, the unique nature of interactions. Who among the nine providers is responsible for writing a discharge summary? Who is responsible for calling an emergency contact in a critical situation? Who communicates with the new provider when someone is taken off an insurance panel? Who makes the patient feel cared for? I am often confronted by this situation when TMS or ketamine providers say, “I just give the procedure/medication that was ordered by the referring psychiatrist.” This response disturbs me in that I could not imagine myself being so hands off in the care of a patient. There is an implication of projected immunity and lack of responsibility that bothers me.

But my concerns are also practical. From my forensic experience, I am well aware that the larger the number of providers treating a patient, the larger the number of inconsistent diagnoses, the more likely medication reconciliations are not kept up to date or incorrect, and the more likely intervention recommendations are contrary to one another. A disengaged ketamine provider may not realize that the patient was more recently enrolled in a substance use disorder program, a potential contraindication for ketamine, if not well-abreast of the patient’s continued evolution. A disengaged therapist may not realize that a patient appears unmotivated because of an increasing dose of medication rather than poor effort. A substance use disorder psychiatric specialist may be at odds with a substance use disorder counselor who worries about the message of treating psychiatric symptoms with chemical substances if they don’t communicate.

As with polypharmacy, “polydoctoring” has negative effects. While the field of psychiatry’s advancing knowledge may encourage providers to specialize, patients still desire and benefit from an intimate and close relationship with one provider who is warm, concerned, and hopeful. Those traits can theoretically be provided by anyone and there is not something inherently wrong with having more than one provider. However, psychiatry would be wise to recognize this concerning trend, especially at a time when we all feel lonely, disconnected, and depersonalized.
 

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.

How many providers does it take to depersonalize a patient? Nine? 1. A psychiatrist for transcranial magnetic stimulation (TMS). 2. A psychiatrist for ketamine. 3. A psychiatrist who specializes in substance use disorder medication. 4. A psychiatrist for the rest of the psychotropic medication. 5. An alternative medicine provider who prescribes supplements. 6. A therapist for depression who uses cognitive-behavioral therapy. 7. A therapist for posttraumatic stress disorder who uses eye movement desensitization and reprocessing. 8. An addiction counselor. 9. An equine therapist.

This doesn’t include other providers and professionals who likely contribute to one’s mental well-being, including yoga instructors and personal trainers. In addition, any one of those psychiatrists may have one or more nurse practitioners who routinely step in to attend to appointments.

In our uncertain and lonely times, the value of human contact and interaction has become exponentially more precious. I long to see my patients in my private practice office. I am now much more aware of their grounding effect on my life, and I suspect I had a similar grounding effect on theirs. Few things provide me more comfort than sitting on my lounge chair with a curious gaze waiting for the patient to start the visit. I often wonder what makes a patient choose to go see a private practice physician. Yet a common reason offered is, “Wait! You do everything? Therapy and meds if I need them? You’ll see me every week?”

While I am realistic about the need and use of split-care, I have never been enamored with the concept. I think that few medical students choose psychiatry with the goal of referring all psychotherapeutic needs and intervention to “allied mental health providers” as my prior managed care organization liked to refer to psychologists, social workers, marriage and family therapists, and other counselors. I remember particularly as a chief resident being bombarded by complaints of therapists complaining about psychiatry residents. All of their patients’ symptoms allegedly required medication adjustment and residents were supposedly dismissing them. In return, residents would complain that the therapists did not address the psychological manifestations of the patient’s ailments. Herein lies my problem with split-care, it encourages psychotherapy to be about medication management, and medication management to be about psychotherapy.

However, this is not an article against split-treatment. Psychiatrists, for a variety of reasons, are not suited to perform psychotherapy in most management care models. The main reason being that psychiatrists’ time is too expensive to justify the expense, and psychiatrists are (for the most part), the only ones able to prescribe medications for which the wait-list is already long enough. This article is about the absurd levels at which we have fragmented care of certain patients. Split-treatment is relevant in that its negative side effects, we are almost all familiar with, exemplify the problem of the fragmentation of modern psychiatry. In many ways this fragmentation of care is similar to polypharmacy – the premise for each psychotropic intervention may be sound, but the end result is often incoherent.

My main concern with the fragmentation of modern psychiatry stems from my belief that the most important facet of our work is our relationship with our patients. It is the duty we owe them, the attention we give them, the unique nature of interactions. Who among the nine providers is responsible for writing a discharge summary? Who is responsible for calling an emergency contact in a critical situation? Who communicates with the new provider when someone is taken off an insurance panel? Who makes the patient feel cared for? I am often confronted by this situation when TMS or ketamine providers say, “I just give the procedure/medication that was ordered by the referring psychiatrist.” This response disturbs me in that I could not imagine myself being so hands off in the care of a patient. There is an implication of projected immunity and lack of responsibility that bothers me.

But my concerns are also practical. From my forensic experience, I am well aware that the larger the number of providers treating a patient, the larger the number of inconsistent diagnoses, the more likely medication reconciliations are not kept up to date or incorrect, and the more likely intervention recommendations are contrary to one another. A disengaged ketamine provider may not realize that the patient was more recently enrolled in a substance use disorder program, a potential contraindication for ketamine, if not well-abreast of the patient’s continued evolution. A disengaged therapist may not realize that a patient appears unmotivated because of an increasing dose of medication rather than poor effort. A substance use disorder psychiatric specialist may be at odds with a substance use disorder counselor who worries about the message of treating psychiatric symptoms with chemical substances if they don’t communicate.

As with polypharmacy, “polydoctoring” has negative effects. While the field of psychiatry’s advancing knowledge may encourage providers to specialize, patients still desire and benefit from an intimate and close relationship with one provider who is warm, concerned, and hopeful. Those traits can theoretically be provided by anyone and there is not something inherently wrong with having more than one provider. However, psychiatry would be wise to recognize this concerning trend, especially at a time when we all feel lonely, disconnected, and depersonalized.
 

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.

 

Bullous arthropod assault

Insect-bite reactions are commonly seen in dermatology practice. Most often, they present as pruritic papules. Vesicles and bullae can be seen as well but are less common. Flea bites are the most likely to cause blisters.¹ Lesions may be grouped or in a linear pattern. Children tend to have more severe reactions than adults. Body temperature and odor may make some people more susceptible than others to bites. Of note, patients with chronic lymphocytic leukemia tend to have more severe, bullous reactions.² The differential diagnosis includes bullous pemphigoid, bullous impetigo, bullous tinea, bullous fixed drug, and bullous diabeticorum.
 

In general, bullous arthropod reactions begin as intraepidermal vesicles that can progress to subepidermal blisters. Eosinophils can be present. Flame figures are often seen in patients with chronic lymphocytic leukemia.³ Histopathology in this patient revealed a subepidermal vesicular dermatitis with minimal inflammation. Periodic acid–Schiff (PAS) stain was negative. Direct immunofluorescence was negative for IgG, C3, IgA, IgM, and fibrinogen. Of note, systemic steroids may alter histologic and immunologic findings.

Bullous pemphigoid is an autoimmune blistering disorder where patients develop widespread tense bullae. Histopathology revealed a subepidermal blister with numerous eosinophils. Direct immunofluorescence study of perilesional skin showed linear IgG and C3 deposits at the basal membrane level. Systemic steroids, tetracyclines, and immunosuppressive medications are a mainstay of treatment. In bullous impetigo, the toxin of Staphylococcus aureus causes blister formation. It is treated with antistaphylococcal antibiotics. Bullous tinea reveals hyphae with PAS staining. Topical or systemic antifungals are used for treatment.

Arthropod eruptions can be treated with antihistamines, ice, and topical steroids. Drainage of bullae can provide relief. In severe cases, systemic steroids can be used as well. Bacterial culture was negative in this patient. The patient was treated with 1 week of oral prednisone prior to biopsy and topical betamethasone ointment. Her lesions subsequently resolved with no recurrence.

This case and photo were submitted by Brooke Resh Sateesh, MD, San Diego Family Dermatology.

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].

References

1-3. “Dermatology” 2nd ed. (Maryland Heights, Mo.: Mosby, 2008).

 

Bullous arthropod assault

Insect-bite reactions are commonly seen in dermatology practice. Most often, they present as pruritic papules. Vesicles and bullae can be seen as well but are less common. Flea bites are the most likely to cause blisters.¹ Lesions may be grouped or in a linear pattern. Children tend to have more severe reactions than adults. Body temperature and odor may make some people more susceptible than others to bites. Of note, patients with chronic lymphocytic leukemia tend to have more severe, bullous reactions.² The differential diagnosis includes bullous pemphigoid, bullous impetigo, bullous tinea, bullous fixed drug, and bullous diabeticorum.
 

In general, bullous arthropod reactions begin as intraepidermal vesicles that can progress to subepidermal blisters. Eosinophils can be present. Flame figures are often seen in patients with chronic lymphocytic leukemia.³ Histopathology in this patient revealed a subepidermal vesicular dermatitis with minimal inflammation. Periodic acid–Schiff (PAS) stain was negative. Direct immunofluorescence was negative for IgG, C3, IgA, IgM, and fibrinogen. Of note, systemic steroids may alter histologic and immunologic findings.

Bullous pemphigoid is an autoimmune blistering disorder where patients develop widespread tense bullae. Histopathology revealed a subepidermal blister with numerous eosinophils. Direct immunofluorescence study of perilesional skin showed linear IgG and C3 deposits at the basal membrane level. Systemic steroids, tetracyclines, and immunosuppressive medications are a mainstay of treatment. In bullous impetigo, the toxin of Staphylococcus aureus causes blister formation. It is treated with antistaphylococcal antibiotics. Bullous tinea reveals hyphae with PAS staining. Topical or systemic antifungals are used for treatment.

Arthropod eruptions can be treated with antihistamines, ice, and topical steroids. Drainage of bullae can provide relief. In severe cases, systemic steroids can be used as well. Bacterial culture was negative in this patient. The patient was treated with 1 week of oral prednisone prior to biopsy and topical betamethasone ointment. Her lesions subsequently resolved with no recurrence.

This case and photo were submitted by Brooke Resh Sateesh, MD, San Diego Family Dermatology.

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].

References

1-3. “Dermatology” 2nd ed. (Maryland Heights, Mo.: Mosby, 2008).

 

Bullous arthropod assault

Insect-bite reactions are commonly seen in dermatology practice. Most often, they present as pruritic papules. Vesicles and bullae can be seen as well but are less common. Flea bites are the most likely to cause blisters.¹ Lesions may be grouped or in a linear pattern. Children tend to have more severe reactions than adults. Body temperature and odor may make some people more susceptible than others to bites. Of note, patients with chronic lymphocytic leukemia tend to have more severe, bullous reactions.² The differential diagnosis includes bullous pemphigoid, bullous impetigo, bullous tinea, bullous fixed drug, and bullous diabeticorum.
 

In general, bullous arthropod reactions begin as intraepidermal vesicles that can progress to subepidermal blisters. Eosinophils can be present. Flame figures are often seen in patients with chronic lymphocytic leukemia.³ Histopathology in this patient revealed a subepidermal vesicular dermatitis with minimal inflammation. Periodic acid–Schiff (PAS) stain was negative. Direct immunofluorescence was negative for IgG, C3, IgA, IgM, and fibrinogen. Of note, systemic steroids may alter histologic and immunologic findings.

Bullous pemphigoid is an autoimmune blistering disorder where patients develop widespread tense bullae. Histopathology revealed a subepidermal blister with numerous eosinophils. Direct immunofluorescence study of perilesional skin showed linear IgG and C3 deposits at the basal membrane level. Systemic steroids, tetracyclines, and immunosuppressive medications are a mainstay of treatment. In bullous impetigo, the toxin of Staphylococcus aureus causes blister formation. It is treated with antistaphylococcal antibiotics. Bullous tinea reveals hyphae with PAS staining. Topical or systemic antifungals are used for treatment.

Arthropod eruptions can be treated with antihistamines, ice, and topical steroids. Drainage of bullae can provide relief. In severe cases, systemic steroids can be used as well. Bacterial culture was negative in this patient. The patient was treated with 1 week of oral prednisone prior to biopsy and topical betamethasone ointment. Her lesions subsequently resolved with no recurrence.

This case and photo were submitted by Brooke Resh Sateesh, MD, San Diego Family Dermatology.

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].

References

1-3. “Dermatology” 2nd ed. (Maryland Heights, Mo.: Mosby, 2008).

In these pandemic times, there is much discussion about public skepticism toward scientists and doctors. Many decry this distrust. They think people should accept what experts advise. After all, experts work hard to learn accurate facts to promote the public’s best interests.

Those who disagree and justify their reluctance – to be vaccinated against COVID-19, for instance – are unrepentant. First of all, they are not so sure experts are public spirited. Perhaps doctors have something to gain from illness and approve vaccines for political reasons, or assign certain diagnoses to get higher reimbursement.

In this contentious climate, peculiar treatments and unproved “cures” are claimed to deserve more respect than so-called experts are willing to grant them: hydroxychloroquine, bleach, and so on.

From my perspective, what is notable about such public disputes with medical experts is not that they exist but that they are public. In private, people have always argued with doctors. Most of those arguments don’t reach public notice. They are not interesting enough.

For instance, as I think back over the years, I can recall:

• A man who preferred to treat his eczema using topical yogurt. And not just any yogurt: only low-fat, plain Market Basket. He had tried them all.
• The woman with perioral scarring. She had let an unlicensed practitioner apply a painful acid on her face – he never told her what the acid was, and she hadn’t asked – as she lay on a neighbor’s living room floor to have her “skin cancer” treated.
• The man with an obvious melanoma on his chest. He did not want to treat it, because his faith healer in Milwaukee, whom he had never met in person, assured him that “it’s all taken care of.”

I could go on.

I cite these examples only because they are striking. They are far from unique.

People argue with doctors for the same reason they argue with anybody – because they think they know better. They may have heard otherwise from a friend, a magazine article, a blog, a different kind of practitioner.

Many such disagreements are never spoken out loud, because people who expect to argue usually don’t show up at their doctors’ offices. They either stay home or see a different kind of healer. If they do visit a doctor whose point of view differs from their own, most keep disagreements to themselves, because few people relish in-person confrontation. Instead they go home and ignore medical advice there.

Even when overt disagreements do erupt at a medical visit, the doctor can often find a way to convince the patient to reconsider, or somehow deflect the clash. The physician has to at least try to convince a patient who thinks his melanoma has “been taken care of” to have it removed. Whereas if someone really prefers low-fat yogurt to topical steroids, there is no need to win the argument. If the patient decides at some point that his eczema is out of control, he can call and request a prescription. He usually won’t.

For dermatologists, medical arguments rarely involve stakes high enough to force the doctor to try changing patients’ minds or discharging them from the practice. Had I stayed in my original field of pediatrics, I would have confronted patients who refused to vaccinate their children. I would have had to negotiate a compromise – vaccinate “more slowly” – or else part ways with the family.

I always advised medical students, when they found themselves argued with, to separate patients’ needs from their own egos. Being challenged in a small room can be challenging. Still, what matters is how the patient fares, not how the doctor feels.

Public disputes with scientists during the COVID-19 pandemic strike me as being motivated by the same factors behind private disputes in physicians’ offices: skepticism, resentment, suspicion, and – often underlying all these – fear.

Public disputes carried out over social media allow for posturing and aggression. A tweet is a better medium behind which to cloak opinions in the mantle of a noble cause, such as personal freedom. It is also easier to express derision and hostility toward opponents, expert or otherwise, from behind the screen of a Twitter handle.

Fortunately, in everyday medical practice, in-your-face disputes don’t happen very often.

You do remember them, though.
 

Dr. Rockoff, who wrote the Dermatology News column “Under My Skin,” is now semiretired, after 40 years of practice in Brookline, Mass. He served on the clinical faculty at Tufts University, Boston, and taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at online. Write to him at [email protected].

In these pandemic times, there is much discussion about public skepticism toward scientists and doctors. Many decry this distrust. They think people should accept what experts advise. After all, experts work hard to learn accurate facts to promote the public’s best interests.

Those who disagree and justify their reluctance – to be vaccinated against COVID-19, for instance – are unrepentant. First of all, they are not so sure experts are public spirited. Perhaps doctors have something to gain from illness and approve vaccines for political reasons, or assign certain diagnoses to get higher reimbursement.

In this contentious climate, peculiar treatments and unproved “cures” are claimed to deserve more respect than so-called experts are willing to grant them: hydroxychloroquine, bleach, and so on.

From my perspective, what is notable about such public disputes with medical experts is not that they exist but that they are public. In private, people have always argued with doctors. Most of those arguments don’t reach public notice. They are not interesting enough.

For instance, as I think back over the years, I can recall:

• A man who preferred to treat his eczema using topical yogurt. And not just any yogurt: only low-fat, plain Market Basket. He had tried them all.
• The woman with perioral scarring. She had let an unlicensed practitioner apply a painful acid on her face – he never told her what the acid was, and she hadn’t asked – as she lay on a neighbor’s living room floor to have her “skin cancer” treated.
• The man with an obvious melanoma on his chest. He did not want to treat it, because his faith healer in Milwaukee, whom he had never met in person, assured him that “it’s all taken care of.”

I could go on.

I cite these examples only because they are striking. They are far from unique.

People argue with doctors for the same reason they argue with anybody – because they think they know better. They may have heard otherwise from a friend, a magazine article, a blog, a different kind of practitioner.

Many such disagreements are never spoken out loud, because people who expect to argue usually don’t show up at their doctors’ offices. They either stay home or see a different kind of healer. If they do visit a doctor whose point of view differs from their own, most keep disagreements to themselves, because few people relish in-person confrontation. Instead they go home and ignore medical advice there.

Even when overt disagreements do erupt at a medical visit, the doctor can often find a way to convince the patient to reconsider, or somehow deflect the clash. The physician has to at least try to convince a patient who thinks his melanoma has “been taken care of” to have it removed. Whereas if someone really prefers low-fat yogurt to topical steroids, there is no need to win the argument. If the patient decides at some point that his eczema is out of control, he can call and request a prescription. He usually won’t.

For dermatologists, medical arguments rarely involve stakes high enough to force the doctor to try changing patients’ minds or discharging them from the practice. Had I stayed in my original field of pediatrics, I would have confronted patients who refused to vaccinate their children. I would have had to negotiate a compromise – vaccinate “more slowly” – or else part ways with the family.

I always advised medical students, when they found themselves argued with, to separate patients’ needs from their own egos. Being challenged in a small room can be challenging. Still, what matters is how the patient fares, not how the doctor feels.

Public disputes with scientists during the COVID-19 pandemic strike me as being motivated by the same factors behind private disputes in physicians’ offices: skepticism, resentment, suspicion, and – often underlying all these – fear.

Public disputes carried out over social media allow for posturing and aggression. A tweet is a better medium behind which to cloak opinions in the mantle of a noble cause, such as personal freedom. It is also easier to express derision and hostility toward opponents, expert or otherwise, from behind the screen of a Twitter handle.

Fortunately, in everyday medical practice, in-your-face disputes don’t happen very often.

You do remember them, though.
 

Dr. Rockoff, who wrote the Dermatology News column “Under My Skin,” is now semiretired, after 40 years of practice in Brookline, Mass. He served on the clinical faculty at Tufts University, Boston, and taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at online. Write to him at [email protected].

In these pandemic times, there is much discussion about public skepticism toward scientists and doctors. Many decry this distrust. They think people should accept what experts advise. After all, experts work hard to learn accurate facts to promote the public’s best interests.

Those who disagree and justify their reluctance – to be vaccinated against COVID-19, for instance – are unrepentant. First of all, they are not so sure experts are public spirited. Perhaps doctors have something to gain from illness and approve vaccines for political reasons, or assign certain diagnoses to get higher reimbursement.

In this contentious climate, peculiar treatments and unproved “cures” are claimed to deserve more respect than so-called experts are willing to grant them: hydroxychloroquine, bleach, and so on.

From my perspective, what is notable about such public disputes with medical experts is not that they exist but that they are public. In private, people have always argued with doctors. Most of those arguments don’t reach public notice. They are not interesting enough.

For instance, as I think back over the years, I can recall:

• A man who preferred to treat his eczema using topical yogurt. And not just any yogurt: only low-fat, plain Market Basket. He had tried them all.
• The woman with perioral scarring. She had let an unlicensed practitioner apply a painful acid on her face – he never told her what the acid was, and she hadn’t asked – as she lay on a neighbor’s living room floor to have her “skin cancer” treated.
• The man with an obvious melanoma on his chest. He did not want to treat it, because his faith healer in Milwaukee, whom he had never met in person, assured him that “it’s all taken care of.”

I could go on.

I cite these examples only because they are striking. They are far from unique.

People argue with doctors for the same reason they argue with anybody – because they think they know better. They may have heard otherwise from a friend, a magazine article, a blog, a different kind of practitioner.

Many such disagreements are never spoken out loud, because people who expect to argue usually don’t show up at their doctors’ offices. They either stay home or see a different kind of healer. If they do visit a doctor whose point of view differs from their own, most keep disagreements to themselves, because few people relish in-person confrontation. Instead they go home and ignore medical advice there.

Even when overt disagreements do erupt at a medical visit, the doctor can often find a way to convince the patient to reconsider, or somehow deflect the clash. The physician has to at least try to convince a patient who thinks his melanoma has “been taken care of” to have it removed. Whereas if someone really prefers low-fat yogurt to topical steroids, there is no need to win the argument. If the patient decides at some point that his eczema is out of control, he can call and request a prescription. He usually won’t.

For dermatologists, medical arguments rarely involve stakes high enough to force the doctor to try changing patients’ minds or discharging them from the practice. Had I stayed in my original field of pediatrics, I would have confronted patients who refused to vaccinate their children. I would have had to negotiate a compromise – vaccinate “more slowly” – or else part ways with the family.

I always advised medical students, when they found themselves argued with, to separate patients’ needs from their own egos. Being challenged in a small room can be challenging. Still, what matters is how the patient fares, not how the doctor feels.

Public disputes with scientists during the COVID-19 pandemic strike me as being motivated by the same factors behind private disputes in physicians’ offices: skepticism, resentment, suspicion, and – often underlying all these – fear.

Public disputes carried out over social media allow for posturing and aggression. A tweet is a better medium behind which to cloak opinions in the mantle of a noble cause, such as personal freedom. It is also easier to express derision and hostility toward opponents, expert or otherwise, from behind the screen of a Twitter handle.

Fortunately, in everyday medical practice, in-your-face disputes don’t happen very often.

You do remember them, though.
 

Dr. Rockoff, who wrote the Dermatology News column “Under My Skin,” is now semiretired, after 40 years of practice in Brookline, Mass. He served on the clinical faculty at Tufts University, Boston, and taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at online. Write to him at [email protected].

An alarming number of additional Alzheimer’s disease (AD) deaths have been reported across various states within the past several months, according to the Alzheimer’s Association. Centers for Disease Control and Prevention data indicate that no less than 31,000 additional people with the neurodegenerative condition had died from the beginning of the pandemic through the end of September 2020. We know that long-term care facilities have been hit hardest, and access to adequate and/or prompt testing has been cited as the most pressing issue during the onset of the pandemic.¹

 

When ADLs become a matter of survival

For individuals affected with Alzheimer’s disease and other types of dementia, performing routine tasks may seem cumbersome and overwhelming. Many of these patients are dependent upon caregivers and family support to facilitate their activities of daily living (ADLs).

Transitioning into the “new normal” set by the pandemic milieu is not an easy task for the average AD individual, because they are now expected to comply with numerous safety instructions (for example, maintaining hygiene, social distancing, etc.). They are also expected to monitor and communicate information about the onset of any suspected symptom to their caregiver or health care clinician.

The additional tasks added to their list of ADLs are particularly distressing given their already compromised short-term memory and overall cognitive decline. Individuals with AD may also be dealing with a host of psychobehavioral challenges, such as the presence of depression, anxiety, and/or agitation amid self-isolation. Enforced social isolation tied to COVID-19 may compound those issues.
 

Resource diversion and mitigation strategies

Unfortunately, any disruption in services within a long-term care setting may lead to a suboptimal therapeutic environment for patients. The Washington State LTC, for example, reported experiencing a case fatality rate (CFR) exceeding more than a third of its residents; essential staff and health care clinicians were duly affected from exposure to the virus (the risk of transmission increases considerably during transport between facilities). Access to personal protective equipment (PPE) might have been hindered by availability.

Another issue with far-reaching consequences is diversion of resources for urgent care. Health care professionals may simply not be readily available for those with chronic care needs because of the enormous scale of the impact of COVID-19 upon health care systems.

Continuity of therapy might include evaluations or follow-up services via teleconferencing modalities, but an exhaustive initial onsite physical examination is often necessary for accurate diagnostics and care. Medication management for the newly diagnosed AD or dementia patient necessitates a thorough screening process involving appropriate in-person blood or laboratory work. It is for this reason that clinicians will need to plan ahead by preparing a contingency plan with the corresponding mitigation strategies (for example, telemedicine, proposed solutions to anticipated disruption of services, extended support, and feedback from family members, etc.).²
 

Resilience and recovery in a retrospective study

A research team from Wuhan Red Cross Hospital in China performed a retrospective cohort study on a sample of patients (n = 42) to determine the severity and prognostic features of COVID-19 pneumonia; 19 AD patients (as per National Institute on Aging/Alzheimer’s Association diagnostic guidelines) were directly compared with 23 age-matched non-AD COVID-19 patients in a similar treatment context.

The study yielded some rather unexpected findings, namely, AD patients experienced remarkably shorter hospital stays and better appetites, especially with respect to their non-AD counterparts. This is even more puzzling when considering that previous studies indicated that dementia patients with concomitant COVID-19 pneumonia are twice as likely to die as those without neurodegenerative compromise.

Aside from a seemingly inexplicable interest in food, the observable positive changes may be attributable to such factors that are particular to the nursing home – residents have immediate access to health care services, which generally allows for timely diagnosis and care. However, the authors of the study speculate that the pathophysiological response of angiotensin-converting enzyme 2 (ACE2) confers to AD patients a therapeutic advantage as they have reduced expression.³ Despite the notoriously high mortality rates of COVID-19 pneumonia among the elderly population, AD patients may prove to be unusually resilient with respect to the recovery process, which underscores the importance of early diagnosis and intervention.
 

Genetic and environmental susceptibility

One of the more devastating observations about the ongoing pandemic environment is that a whopping 80% of dying patients committed to a long-term facility also include those with AD; it has been reported that almost half of all patients in nursing homes and related services have the neurodegenerative condition. The grim scenario is brought about by several factors, chief of which is the proximity of shared living arrangements within the context of a residential care setting. It should be noted that patients with AD exhibit comorbid conditions (for example, diabetes, cardiovascular disease, and/or respiratory issues) that immediately put them at high risk for COVID exposure. Interestingly enough, the ApoE4 genotype, which is associated with an increased susceptibility for AD, is also correlated with COVID-19 prognosis and severity. Although exact numbers are difficult to come by, it is of utmost importance for clinicians to evaluate the overall scope of the situation, identify at-risk patients such as individuals with AD and related dementias, and work with caregivers to afford care to patients who need it the most.⁴

Transcending research design

The elderly population, unsurprisingly, experiences the highest COVID-19 mortality rate because of the presence of multiple risk factors, namely, compromised immunity and difficulties maintaining ADLs, and thereby adhering to safety protocols. As far as Alzheimer’s patients are concerned, numerous hurdles affect the domain of neurodegenerative research.

To safeguard the health and well-being of the participants and caregivers, site sponsors and investigators must explore various communication avenues with the goal of facilitating health education (for example, mitigation strategies, adverse effects monitoring, etc.), as well as implementing contingency plans in the event that a site becomes inaccessible (for example, site closure, traveling regulations, lockdowns, etc.).

Alternatives such as telemedicine present viable solutions for ensuring completion of studies. Given the nature of the pandemic, there is a possibility that a research participant may contract the virus, necessitating a break from the established protocol. It is for this reason that site sponsors and corresponding regulatory bodies are advised to proactively engage in dialogue and transparent communications with respect to ensuing protocol deviations. Institutional Review Boards can expedite the review process by making the necessary changes in a timely manner.⁵

 

References

1. Ritchie K. KJZZ. 2020 Nov 16.

2. Brown EE et al. Am J Geriatr Psychiatry. 2020 Jul;28(7):712-21.

3. Li J et al. J Alzheimers Dis. 2020;77(1):67-73.

4. Perry G. J Alzheimers Dis. 2020 Jan 1;76(1):1.

5. Alzheimers Dement. 2020 Apr;16(4):587-8.

Dr. Islam is a medical adviser for the International Maternal and Child Health Foundation, Montreal, and is based in New York. He also is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Islam disclosed no relevant financial relationships.

Dr. Dhillon is a staff neurologist at Brigham and Women’s Hospital in Boston. Dr. Dhillon is currently on the speaker bureau/advisory board for Biogen, Bristol Myers Squibb, Genzyme, and Teva Neuroscience.

Dr. Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the International Maternal and Child Health Foundation. He has no disclosures.

An alarming number of additional Alzheimer’s disease (AD) deaths have been reported across various states within the past several months, according to the Alzheimer’s Association. Centers for Disease Control and Prevention data indicate that no less than 31,000 additional people with the neurodegenerative condition had died from the beginning of the pandemic through the end of September 2020. We know that long-term care facilities have been hit hardest, and access to adequate and/or prompt testing has been cited as the most pressing issue during the onset of the pandemic.¹

 

When ADLs become a matter of survival

For individuals affected with Alzheimer’s disease and other types of dementia, performing routine tasks may seem cumbersome and overwhelming. Many of these patients are dependent upon caregivers and family support to facilitate their activities of daily living (ADLs).

Transitioning into the “new normal” set by the pandemic milieu is not an easy task for the average AD individual, because they are now expected to comply with numerous safety instructions (for example, maintaining hygiene, social distancing, etc.). They are also expected to monitor and communicate information about the onset of any suspected symptom to their caregiver or health care clinician.

The additional tasks added to their list of ADLs are particularly distressing given their already compromised short-term memory and overall cognitive decline. Individuals with AD may also be dealing with a host of psychobehavioral challenges, such as the presence of depression, anxiety, and/or agitation amid self-isolation. Enforced social isolation tied to COVID-19 may compound those issues.
 

Resource diversion and mitigation strategies

Unfortunately, any disruption in services within a long-term care setting may lead to a suboptimal therapeutic environment for patients. The Washington State LTC, for example, reported experiencing a case fatality rate (CFR) exceeding more than a third of its residents; essential staff and health care clinicians were duly affected from exposure to the virus (the risk of transmission increases considerably during transport between facilities). Access to personal protective equipment (PPE) might have been hindered by availability.

Another issue with far-reaching consequences is diversion of resources for urgent care. Health care professionals may simply not be readily available for those with chronic care needs because of the enormous scale of the impact of COVID-19 upon health care systems.

Continuity of therapy might include evaluations or follow-up services via teleconferencing modalities, but an exhaustive initial onsite physical examination is often necessary for accurate diagnostics and care. Medication management for the newly diagnosed AD or dementia patient necessitates a thorough screening process involving appropriate in-person blood or laboratory work. It is for this reason that clinicians will need to plan ahead by preparing a contingency plan with the corresponding mitigation strategies (for example, telemedicine, proposed solutions to anticipated disruption of services, extended support, and feedback from family members, etc.).²
 

Resilience and recovery in a retrospective study

A research team from Wuhan Red Cross Hospital in China performed a retrospective cohort study on a sample of patients (n = 42) to determine the severity and prognostic features of COVID-19 pneumonia; 19 AD patients (as per National Institute on Aging/Alzheimer’s Association diagnostic guidelines) were directly compared with 23 age-matched non-AD COVID-19 patients in a similar treatment context.

The study yielded some rather unexpected findings, namely, AD patients experienced remarkably shorter hospital stays and better appetites, especially with respect to their non-AD counterparts. This is even more puzzling when considering that previous studies indicated that dementia patients with concomitant COVID-19 pneumonia are twice as likely to die as those without neurodegenerative compromise.

Aside from a seemingly inexplicable interest in food, the observable positive changes may be attributable to such factors that are particular to the nursing home – residents have immediate access to health care services, which generally allows for timely diagnosis and care. However, the authors of the study speculate that the pathophysiological response of angiotensin-converting enzyme 2 (ACE2) confers to AD patients a therapeutic advantage as they have reduced expression.³ Despite the notoriously high mortality rates of COVID-19 pneumonia among the elderly population, AD patients may prove to be unusually resilient with respect to the recovery process, which underscores the importance of early diagnosis and intervention.
 

Genetic and environmental susceptibility

One of the more devastating observations about the ongoing pandemic environment is that a whopping 80% of dying patients committed to a long-term facility also include those with AD; it has been reported that almost half of all patients in nursing homes and related services have the neurodegenerative condition. The grim scenario is brought about by several factors, chief of which is the proximity of shared living arrangements within the context of a residential care setting. It should be noted that patients with AD exhibit comorbid conditions (for example, diabetes, cardiovascular disease, and/or respiratory issues) that immediately put them at high risk for COVID exposure. Interestingly enough, the ApoE4 genotype, which is associated with an increased susceptibility for AD, is also correlated with COVID-19 prognosis and severity. Although exact numbers are difficult to come by, it is of utmost importance for clinicians to evaluate the overall scope of the situation, identify at-risk patients such as individuals with AD and related dementias, and work with caregivers to afford care to patients who need it the most.⁴

Transcending research design

The elderly population, unsurprisingly, experiences the highest COVID-19 mortality rate because of the presence of multiple risk factors, namely, compromised immunity and difficulties maintaining ADLs, and thereby adhering to safety protocols. As far as Alzheimer’s patients are concerned, numerous hurdles affect the domain of neurodegenerative research.

To safeguard the health and well-being of the participants and caregivers, site sponsors and investigators must explore various communication avenues with the goal of facilitating health education (for example, mitigation strategies, adverse effects monitoring, etc.), as well as implementing contingency plans in the event that a site becomes inaccessible (for example, site closure, traveling regulations, lockdowns, etc.).

Alternatives such as telemedicine present viable solutions for ensuring completion of studies. Given the nature of the pandemic, there is a possibility that a research participant may contract the virus, necessitating a break from the established protocol. It is for this reason that site sponsors and corresponding regulatory bodies are advised to proactively engage in dialogue and transparent communications with respect to ensuing protocol deviations. Institutional Review Boards can expedite the review process by making the necessary changes in a timely manner.⁵

 

References

1. Ritchie K. KJZZ. 2020 Nov 16.

2. Brown EE et al. Am J Geriatr Psychiatry. 2020 Jul;28(7):712-21.

3. Li J et al. J Alzheimers Dis. 2020;77(1):67-73.

4. Perry G. J Alzheimers Dis. 2020 Jan 1;76(1):1.

5. Alzheimers Dement. 2020 Apr;16(4):587-8.

Dr. Islam is a medical adviser for the International Maternal and Child Health Foundation, Montreal, and is based in New York. He also is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Islam disclosed no relevant financial relationships.

Dr. Dhillon is a staff neurologist at Brigham and Women’s Hospital in Boston. Dr. Dhillon is currently on the speaker bureau/advisory board for Biogen, Bristol Myers Squibb, Genzyme, and Teva Neuroscience.

Dr. Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the International Maternal and Child Health Foundation. He has no disclosures.

An alarming number of additional Alzheimer’s disease (AD) deaths have been reported across various states within the past several months, according to the Alzheimer’s Association. Centers for Disease Control and Prevention data indicate that no less than 31,000 additional people with the neurodegenerative condition had died from the beginning of the pandemic through the end of September 2020. We know that long-term care facilities have been hit hardest, and access to adequate and/or prompt testing has been cited as the most pressing issue during the onset of the pandemic.¹

 

When ADLs become a matter of survival

For individuals affected with Alzheimer’s disease and other types of dementia, performing routine tasks may seem cumbersome and overwhelming. Many of these patients are dependent upon caregivers and family support to facilitate their activities of daily living (ADLs).

Transitioning into the “new normal” set by the pandemic milieu is not an easy task for the average AD individual, because they are now expected to comply with numerous safety instructions (for example, maintaining hygiene, social distancing, etc.). They are also expected to monitor and communicate information about the onset of any suspected symptom to their caregiver or health care clinician.

The additional tasks added to their list of ADLs are particularly distressing given their already compromised short-term memory and overall cognitive decline. Individuals with AD may also be dealing with a host of psychobehavioral challenges, such as the presence of depression, anxiety, and/or agitation amid self-isolation. Enforced social isolation tied to COVID-19 may compound those issues.
 

Resource diversion and mitigation strategies

Unfortunately, any disruption in services within a long-term care setting may lead to a suboptimal therapeutic environment for patients. The Washington State LTC, for example, reported experiencing a case fatality rate (CFR) exceeding more than a third of its residents; essential staff and health care clinicians were duly affected from exposure to the virus (the risk of transmission increases considerably during transport between facilities). Access to personal protective equipment (PPE) might have been hindered by availability.

Another issue with far-reaching consequences is diversion of resources for urgent care. Health care professionals may simply not be readily available for those with chronic care needs because of the enormous scale of the impact of COVID-19 upon health care systems.

Continuity of therapy might include evaluations or follow-up services via teleconferencing modalities, but an exhaustive initial onsite physical examination is often necessary for accurate diagnostics and care. Medication management for the newly diagnosed AD or dementia patient necessitates a thorough screening process involving appropriate in-person blood or laboratory work. It is for this reason that clinicians will need to plan ahead by preparing a contingency plan with the corresponding mitigation strategies (for example, telemedicine, proposed solutions to anticipated disruption of services, extended support, and feedback from family members, etc.).²
 

Resilience and recovery in a retrospective study

A research team from Wuhan Red Cross Hospital in China performed a retrospective cohort study on a sample of patients (n = 42) to determine the severity and prognostic features of COVID-19 pneumonia; 19 AD patients (as per National Institute on Aging/Alzheimer’s Association diagnostic guidelines) were directly compared with 23 age-matched non-AD COVID-19 patients in a similar treatment context.

The study yielded some rather unexpected findings, namely, AD patients experienced remarkably shorter hospital stays and better appetites, especially with respect to their non-AD counterparts. This is even more puzzling when considering that previous studies indicated that dementia patients with concomitant COVID-19 pneumonia are twice as likely to die as those without neurodegenerative compromise.

Aside from a seemingly inexplicable interest in food, the observable positive changes may be attributable to such factors that are particular to the nursing home – residents have immediate access to health care services, which generally allows for timely diagnosis and care. However, the authors of the study speculate that the pathophysiological response of angiotensin-converting enzyme 2 (ACE2) confers to AD patients a therapeutic advantage as they have reduced expression.³ Despite the notoriously high mortality rates of COVID-19 pneumonia among the elderly population, AD patients may prove to be unusually resilient with respect to the recovery process, which underscores the importance of early diagnosis and intervention.
 

Genetic and environmental susceptibility

One of the more devastating observations about the ongoing pandemic environment is that a whopping 80% of dying patients committed to a long-term facility also include those with AD; it has been reported that almost half of all patients in nursing homes and related services have the neurodegenerative condition. The grim scenario is brought about by several factors, chief of which is the proximity of shared living arrangements within the context of a residential care setting. It should be noted that patients with AD exhibit comorbid conditions (for example, diabetes, cardiovascular disease, and/or respiratory issues) that immediately put them at high risk for COVID exposure. Interestingly enough, the ApoE4 genotype, which is associated with an increased susceptibility for AD, is also correlated with COVID-19 prognosis and severity. Although exact numbers are difficult to come by, it is of utmost importance for clinicians to evaluate the overall scope of the situation, identify at-risk patients such as individuals with AD and related dementias, and work with caregivers to afford care to patients who need it the most.⁴

Transcending research design

The elderly population, unsurprisingly, experiences the highest COVID-19 mortality rate because of the presence of multiple risk factors, namely, compromised immunity and difficulties maintaining ADLs, and thereby adhering to safety protocols. As far as Alzheimer’s patients are concerned, numerous hurdles affect the domain of neurodegenerative research.

To safeguard the health and well-being of the participants and caregivers, site sponsors and investigators must explore various communication avenues with the goal of facilitating health education (for example, mitigation strategies, adverse effects monitoring, etc.), as well as implementing contingency plans in the event that a site becomes inaccessible (for example, site closure, traveling regulations, lockdowns, etc.).

Alternatives such as telemedicine present viable solutions for ensuring completion of studies. Given the nature of the pandemic, there is a possibility that a research participant may contract the virus, necessitating a break from the established protocol. It is for this reason that site sponsors and corresponding regulatory bodies are advised to proactively engage in dialogue and transparent communications with respect to ensuing protocol deviations. Institutional Review Boards can expedite the review process by making the necessary changes in a timely manner.⁵

 

References

1. Ritchie K. KJZZ. 2020 Nov 16.

2. Brown EE et al. Am J Geriatr Psychiatry. 2020 Jul;28(7):712-21.

3. Li J et al. J Alzheimers Dis. 2020;77(1):67-73.

4. Perry G. J Alzheimers Dis. 2020 Jan 1;76(1):1.

5. Alzheimers Dement. 2020 Apr;16(4):587-8.

Dr. Islam is a medical adviser for the International Maternal and Child Health Foundation, Montreal, and is based in New York. He also is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Islam disclosed no relevant financial relationships.

Dr. Dhillon is a staff neurologist at Brigham and Women’s Hospital in Boston. Dr. Dhillon is currently on the speaker bureau/advisory board for Biogen, Bristol Myers Squibb, Genzyme, and Teva Neuroscience.

Dr. Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the International Maternal and Child Health Foundation. He has no disclosures.

There’s little doubt that the COVID-19 pandemic has been hard on many children and adolescents just as it has been difficult for adults. The disruption of routines, reduced contact with friends, concern over getting ill, and financial turmoil suffered by many families is exacting a toll on our mental health, as has been documented by a number of recent surveys and studies.^1,2

Quite understandably, concern about rising levels of anxiety and depression in youth prompts additional worries about suicide, the second leading cause of death in adolescents and young adults. In response, many organizations have rallied to provide additional resources to help prevent suicidal thinking and actions. Online mental health tips, support phone and text lines, and the availability of telemedicine have all been mobilized to help people cope and stay safe both physically and psychologically.

But what are the actual numbers when it comes to youth suicide during COVID-19? According to many headlines in the press, the statistics are grim and support many of distressing predictions that have been made. A December story in an Arizona newspaper, “With Teen Suicides on the Rise, Tucson Educators Struggle to Prioritize Mental Health,” described a 67% increase in teen suicides in 2020 compared with 2019 in one county.³ Another post from Psychology Today, “America is Facing a Teen Suicide Pandemic,” raised similar alarms.⁴ Concern over suicide has even been used politically to argue against restrictions that could reduce the spread of COVID-19 infections.

But despite this common perception shared by both health care professionals and the public, there actually is not evidence at this point that the COVID-19 pandemic has led to a broad spike in youth suicide deaths or attempts. A recent study published in the journal Pediatrics compared suicide screening results on youth presenting to emergency departments for any reason in 2020 to the same month in 2019.⁵ The authors found no consistent increases in reported suicidal ideation or suicide attempts with scattered elevations found in some months during 2020 compared with the previous year (including February 2020 before the pandemic really began) but not others. Internationally, newly analyzed data from 2020 with regard to suicide deaths have suggested “either no rise in suicide rates ... or a fall in the early months of the pandemic.” In my home and, admittedly small, state of Vermont, data from the Department of Health have shown 93 suicide deaths across all ages as of mid-November 2020 compared with a 5-year average of 96.

Why don’t the data match the headlines? There are a number of possibilities.

1. Suicide rates in youth were going up before the pandemic. As it takes time to verify and analyze data from large populations, many of the reports on suicide that have been published and released in 2020 summarize data from prior years. Without looking closely, a news organization can easily slap on a headline that implies that the data were obtained during the pandemic.

2. Fluctuations tend to occur from year to year. Thankfully, youth suicide remains rare (although not rare enough). With small numbers, regular variations from year to year can look huge in terms of percentages, especially if one doesn’t pull back and look at longer trends over time.

3. People are reaching out for mental health services. The public health message to access support and treatment for COVID 19–related mental health struggles appears to be having an effect, but this increased demand should not necessarily be viewed as a proxy for suicidal ideation and attempts.

While the understanding that we are not actually in the midst of a surge in COVID 19–related youth suicide is reassuring, it is important not to get complacent. Much of the data remains preliminary, and, even if these numbers hold up, there is no guarantee that things will continue this way, especially if the pandemic and it restrictions continue to drag on for many more months. And of course, whether or not the pandemic is making things significantly worse, youth suicide remains an enormous public health imperative with every one being a human tragedy.

It is also quite possible that more detailed analyses will eventually reveal a more complex association between youth suicide and COVID-19, with effects of the pandemic being realized regionally or more for some groups than others. Data from before the pandemic indicated, for example, that suicide rates are increasing more rapidly among African American youth compared with white children and adolescents.⁶ With the COVID-19 pandemic itself affecting disadvantaged communities more strongly, one could readily expect variable impacts in mental health related to race or socioeconomic status. A recent article voices these concerns for indigenous youth in Montana: a state with one of the highest per capita suicide rates in the country.⁷ The article notes, however, that the rate of suicide overall in Montana in 2020 is comparable to those of previous years.

Overall, pediatricians should not be needlessly panicked that the COVID-19 pandemic has sparked a surge in youth suicide. The data at this point simply don’t support that assertion despite many headlines to the contrary. At the same time, many children and adolescents are certainly struggling with the stresses the pandemic has created and continue to need our close monitoring and support.
 

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont Larner College of Medicine. Follow him on Twitter @PediPsych. His new book, “Parenting Made Complicated: What Science Really Knows About the Greatest Debates of Early Childhood,” launches Feb. 1, 2021.

References

1. Copeland WE et al. Impact of COVID-19 pandemic on college student mental health and wellness. J Am Acad Child Adolesc Psychiatry. 2020;60(1):134-41. doi: 10.1016/j.jaac.2020.08.466.

2. Qiu J et al. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: Implications and policy recommendations. Gen Psychiatry. 2020;33:e100213. doi: 10.1136/gpsych-2020-100213.

3. Dhmara K. With teen suicides on the rise, Tucson educators struggle to prioritize mental health. Tuscon.com. Dec. 27, 2020.

4. Chafouleas, SM. America is facing a suicide epidemic: New data confirm the urgency of confronting it now. Psychology Today blog. Sept. 4, 2020.

5. Hill RM et al. Suicide ideation and attempts in a pediatric emergency department before and after COVID-19. Pediatrics. 2020. doi: 10.1542/peds.2020-029280.

6. John A et al. Trends in suicide during the covid-19 pandemic. BMJ 2020;371:m4352. doi: 10.1136/bmj.m4352.

7. Reardon S. Health officials fear COVID-19 pandemic-related suicide spike among indigenous youth. Time Magazine. December 2020.

There’s little doubt that the COVID-19 pandemic has been hard on many children and adolescents just as it has been difficult for adults. The disruption of routines, reduced contact with friends, concern over getting ill, and financial turmoil suffered by many families is exacting a toll on our mental health, as has been documented by a number of recent surveys and studies.^1,2

Quite understandably, concern about rising levels of anxiety and depression in youth prompts additional worries about suicide, the second leading cause of death in adolescents and young adults. In response, many organizations have rallied to provide additional resources to help prevent suicidal thinking and actions. Online mental health tips, support phone and text lines, and the availability of telemedicine have all been mobilized to help people cope and stay safe both physically and psychologically.

But what are the actual numbers when it comes to youth suicide during COVID-19? According to many headlines in the press, the statistics are grim and support many of distressing predictions that have been made. A December story in an Arizona newspaper, “With Teen Suicides on the Rise, Tucson Educators Struggle to Prioritize Mental Health,” described a 67% increase in teen suicides in 2020 compared with 2019 in one county.³ Another post from Psychology Today, “America is Facing a Teen Suicide Pandemic,” raised similar alarms.⁴ Concern over suicide has even been used politically to argue against restrictions that could reduce the spread of COVID-19 infections.

But despite this common perception shared by both health care professionals and the public, there actually is not evidence at this point that the COVID-19 pandemic has led to a broad spike in youth suicide deaths or attempts. A recent study published in the journal Pediatrics compared suicide screening results on youth presenting to emergency departments for any reason in 2020 to the same month in 2019.⁵ The authors found no consistent increases in reported suicidal ideation or suicide attempts with scattered elevations found in some months during 2020 compared with the previous year (including February 2020 before the pandemic really began) but not others. Internationally, newly analyzed data from 2020 with regard to suicide deaths have suggested “either no rise in suicide rates ... or a fall in the early months of the pandemic.” In my home and, admittedly small, state of Vermont, data from the Department of Health have shown 93 suicide deaths across all ages as of mid-November 2020 compared with a 5-year average of 96.

Why don’t the data match the headlines? There are a number of possibilities.

1. Suicide rates in youth were going up before the pandemic. As it takes time to verify and analyze data from large populations, many of the reports on suicide that have been published and released in 2020 summarize data from prior years. Without looking closely, a news organization can easily slap on a headline that implies that the data were obtained during the pandemic.

2. Fluctuations tend to occur from year to year. Thankfully, youth suicide remains rare (although not rare enough). With small numbers, regular variations from year to year can look huge in terms of percentages, especially if one doesn’t pull back and look at longer trends over time.

3. People are reaching out for mental health services. The public health message to access support and treatment for COVID 19–related mental health struggles appears to be having an effect, but this increased demand should not necessarily be viewed as a proxy for suicidal ideation and attempts.

While the understanding that we are not actually in the midst of a surge in COVID 19–related youth suicide is reassuring, it is important not to get complacent. Much of the data remains preliminary, and, even if these numbers hold up, there is no guarantee that things will continue this way, especially if the pandemic and it restrictions continue to drag on for many more months. And of course, whether or not the pandemic is making things significantly worse, youth suicide remains an enormous public health imperative with every one being a human tragedy.

It is also quite possible that more detailed analyses will eventually reveal a more complex association between youth suicide and COVID-19, with effects of the pandemic being realized regionally or more for some groups than others. Data from before the pandemic indicated, for example, that suicide rates are increasing more rapidly among African American youth compared with white children and adolescents.⁶ With the COVID-19 pandemic itself affecting disadvantaged communities more strongly, one could readily expect variable impacts in mental health related to race or socioeconomic status. A recent article voices these concerns for indigenous youth in Montana: a state with one of the highest per capita suicide rates in the country.⁷ The article notes, however, that the rate of suicide overall in Montana in 2020 is comparable to those of previous years.

Overall, pediatricians should not be needlessly panicked that the COVID-19 pandemic has sparked a surge in youth suicide. The data at this point simply don’t support that assertion despite many headlines to the contrary. At the same time, many children and adolescents are certainly struggling with the stresses the pandemic has created and continue to need our close monitoring and support.
 

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont Larner College of Medicine. Follow him on Twitter @PediPsych. His new book, “Parenting Made Complicated: What Science Really Knows About the Greatest Debates of Early Childhood,” launches Feb. 1, 2021.

References

1. Copeland WE et al. Impact of COVID-19 pandemic on college student mental health and wellness. J Am Acad Child Adolesc Psychiatry. 2020;60(1):134-41. doi: 10.1016/j.jaac.2020.08.466.

2. Qiu J et al. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: Implications and policy recommendations. Gen Psychiatry. 2020;33:e100213. doi: 10.1136/gpsych-2020-100213.

3. Dhmara K. With teen suicides on the rise, Tucson educators struggle to prioritize mental health. Tuscon.com. Dec. 27, 2020.

4. Chafouleas, SM. America is facing a suicide epidemic: New data confirm the urgency of confronting it now. Psychology Today blog. Sept. 4, 2020.

5. Hill RM et al. Suicide ideation and attempts in a pediatric emergency department before and after COVID-19. Pediatrics. 2020. doi: 10.1542/peds.2020-029280.

6. John A et al. Trends in suicide during the covid-19 pandemic. BMJ 2020;371:m4352. doi: 10.1136/bmj.m4352.

7. Reardon S. Health officials fear COVID-19 pandemic-related suicide spike among indigenous youth. Time Magazine. December 2020.

There’s little doubt that the COVID-19 pandemic has been hard on many children and adolescents just as it has been difficult for adults. The disruption of routines, reduced contact with friends, concern over getting ill, and financial turmoil suffered by many families is exacting a toll on our mental health, as has been documented by a number of recent surveys and studies.^1,2

Quite understandably, concern about rising levels of anxiety and depression in youth prompts additional worries about suicide, the second leading cause of death in adolescents and young adults. In response, many organizations have rallied to provide additional resources to help prevent suicidal thinking and actions. Online mental health tips, support phone and text lines, and the availability of telemedicine have all been mobilized to help people cope and stay safe both physically and psychologically.

But what are the actual numbers when it comes to youth suicide during COVID-19? According to many headlines in the press, the statistics are grim and support many of distressing predictions that have been made. A December story in an Arizona newspaper, “With Teen Suicides on the Rise, Tucson Educators Struggle to Prioritize Mental Health,” described a 67% increase in teen suicides in 2020 compared with 2019 in one county.³ Another post from Psychology Today, “America is Facing a Teen Suicide Pandemic,” raised similar alarms.⁴ Concern over suicide has even been used politically to argue against restrictions that could reduce the spread of COVID-19 infections.

But despite this common perception shared by both health care professionals and the public, there actually is not evidence at this point that the COVID-19 pandemic has led to a broad spike in youth suicide deaths or attempts. A recent study published in the journal Pediatrics compared suicide screening results on youth presenting to emergency departments for any reason in 2020 to the same month in 2019.⁵ The authors found no consistent increases in reported suicidal ideation or suicide attempts with scattered elevations found in some months during 2020 compared with the previous year (including February 2020 before the pandemic really began) but not others. Internationally, newly analyzed data from 2020 with regard to suicide deaths have suggested “either no rise in suicide rates ... or a fall in the early months of the pandemic.” In my home and, admittedly small, state of Vermont, data from the Department of Health have shown 93 suicide deaths across all ages as of mid-November 2020 compared with a 5-year average of 96.

Why don’t the data match the headlines? There are a number of possibilities.

1. Suicide rates in youth were going up before the pandemic. As it takes time to verify and analyze data from large populations, many of the reports on suicide that have been published and released in 2020 summarize data from prior years. Without looking closely, a news organization can easily slap on a headline that implies that the data were obtained during the pandemic.

2. Fluctuations tend to occur from year to year. Thankfully, youth suicide remains rare (although not rare enough). With small numbers, regular variations from year to year can look huge in terms of percentages, especially if one doesn’t pull back and look at longer trends over time.

3. People are reaching out for mental health services. The public health message to access support and treatment for COVID 19–related mental health struggles appears to be having an effect, but this increased demand should not necessarily be viewed as a proxy for suicidal ideation and attempts.

While the understanding that we are not actually in the midst of a surge in COVID 19–related youth suicide is reassuring, it is important not to get complacent. Much of the data remains preliminary, and, even if these numbers hold up, there is no guarantee that things will continue this way, especially if the pandemic and it restrictions continue to drag on for many more months. And of course, whether or not the pandemic is making things significantly worse, youth suicide remains an enormous public health imperative with every one being a human tragedy.

It is also quite possible that more detailed analyses will eventually reveal a more complex association between youth suicide and COVID-19, with effects of the pandemic being realized regionally or more for some groups than others. Data from before the pandemic indicated, for example, that suicide rates are increasing more rapidly among African American youth compared with white children and adolescents.⁶ With the COVID-19 pandemic itself affecting disadvantaged communities more strongly, one could readily expect variable impacts in mental health related to race or socioeconomic status. A recent article voices these concerns for indigenous youth in Montana: a state with one of the highest per capita suicide rates in the country.⁷ The article notes, however, that the rate of suicide overall in Montana in 2020 is comparable to those of previous years.

Overall, pediatricians should not be needlessly panicked that the COVID-19 pandemic has sparked a surge in youth suicide. The data at this point simply don’t support that assertion despite many headlines to the contrary. At the same time, many children and adolescents are certainly struggling with the stresses the pandemic has created and continue to need our close monitoring and support.
 

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont Larner College of Medicine. Follow him on Twitter @PediPsych. His new book, “Parenting Made Complicated: What Science Really Knows About the Greatest Debates of Early Childhood,” launches Feb. 1, 2021.

References

1. Copeland WE et al. Impact of COVID-19 pandemic on college student mental health and wellness. J Am Acad Child Adolesc Psychiatry. 2020;60(1):134-41. doi: 10.1016/j.jaac.2020.08.466.

2. Qiu J et al. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: Implications and policy recommendations. Gen Psychiatry. 2020;33:e100213. doi: 10.1136/gpsych-2020-100213.

3. Dhmara K. With teen suicides on the rise, Tucson educators struggle to prioritize mental health. Tuscon.com. Dec. 27, 2020.

4. Chafouleas, SM. America is facing a suicide epidemic: New data confirm the urgency of confronting it now. Psychology Today blog. Sept. 4, 2020.

5. Hill RM et al. Suicide ideation and attempts in a pediatric emergency department before and after COVID-19. Pediatrics. 2020. doi: 10.1542/peds.2020-029280.

6. John A et al. Trends in suicide during the covid-19 pandemic. BMJ 2020;371:m4352. doi: 10.1136/bmj.m4352.

7. Reardon S. Health officials fear COVID-19 pandemic-related suicide spike among indigenous youth. Time Magazine. December 2020.