Opinion

In a recent New York Times opinion article, author Aubrey Gordon claims that since a visit to her pediatrician in fourth grade she has felt like an “enemy combatant in the nation’s war on childhood obesity.” (“Leave Fat Kids Alone,” Nov. 13, 2020).

At that unfortunate encounter, she recalls being told that “You’ll be thin and beautiful ... If you can just stay the same weight.” In retrospect she feels that the comment by her well-meaning but misguided physician “planted the seeds of depression” that have plagued her ever since.

Ms. Gordon goes on to list the many national and local initiatives that have done little to bend the curve in this country’s obesity trajectory but have succeeded in targeting bodies like hers as an epidemic and have resulted in her and thousands of other children being treated as “its virus personified.”

It is deeply troubling to read of her journey through life as collateral damage in a failed war effort, but Ms. Gordon offers little advice to us other than that we stop doing what we have been doing. It hasn’t been helping and it’s not working.

I suspect she would agree that obesity is one of our nation’s most serious public health problems. There is voluminous evidence of the association of obesity with cardiac disease, cancer, mental health challenges, and more recently COVID-19 – just to name a few. If blaming obese children who are the victims is counterproductive where do we point the finger? It is tempting to blame parents and certainly they deserve some culpability. Some parents could have created less obesity-enabling environments through healthier menu choices and done a better job discouraging sedentary behaviors. However, some families lack the access to, or the resources to, provide less calorie-dense food options. We know that many obese children have parents who have been obese themselves since childhood and we know that breaking the obesity cycle can be extremely difficult. Do we extend the sweep of our finger-pointing to include grandparents and great grandparents?

While guilt can be a powerful motivating force, obesity seems to be one of those conditions in which by the time it becomes obvious to a family, the die is cast and blaming the victim or her parents is going to do little more than engender bad feelings. We have done more than enough. In fact, Ms. Gordon’s commentary suggests we have gone too far in creating public opinion that being lean is healthy and being overweight is bad. More motivational testimonials will merely add to the shaming.

Obesity is clearly a societal problem and selectively targeting the victims is not the answer. A famine would certainly lower our national body mass index, but not even the most callous among us would include it on the list of options. Attempts at levying a hefty tax on sweetened beverages have been attempted sporadically around the country without much success. We are a nation that cherishes our personal freedoms and unfortunately this includes the freedom to do some things the aren’t in our own best interests.

You could argue that this leaves us with education as our only hope of turning the tide. However, educating without characterizing the obese among us as bad, ugly, and undisciplined people is a public relations challenge of heroic proportions. Choosing language and images that somehow convey the idea that although obesity is bad being obese doesn’t make you a bad or ugly person is walking along a fine semantic edge.

If I sound discouraged, you are reading me correctly. As pediatricians, we are left doing the few things that have been shown to make a difference. This means promoting breastfeeding and encouraging thoughtful introduction of solid foods; both strategies can be done before the child can hear our well-intentioned but misguided words of encouragement.
 

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

In a recent New York Times opinion article, author Aubrey Gordon claims that since a visit to her pediatrician in fourth grade she has felt like an “enemy combatant in the nation’s war on childhood obesity.” (“Leave Fat Kids Alone,” Nov. 13, 2020).

At that unfortunate encounter, she recalls being told that “You’ll be thin and beautiful ... If you can just stay the same weight.” In retrospect she feels that the comment by her well-meaning but misguided physician “planted the seeds of depression” that have plagued her ever since.

Ms. Gordon goes on to list the many national and local initiatives that have done little to bend the curve in this country’s obesity trajectory but have succeeded in targeting bodies like hers as an epidemic and have resulted in her and thousands of other children being treated as “its virus personified.”

It is deeply troubling to read of her journey through life as collateral damage in a failed war effort, but Ms. Gordon offers little advice to us other than that we stop doing what we have been doing. It hasn’t been helping and it’s not working.

I suspect she would agree that obesity is one of our nation’s most serious public health problems. There is voluminous evidence of the association of obesity with cardiac disease, cancer, mental health challenges, and more recently COVID-19 – just to name a few. If blaming obese children who are the victims is counterproductive where do we point the finger? It is tempting to blame parents and certainly they deserve some culpability. Some parents could have created less obesity-enabling environments through healthier menu choices and done a better job discouraging sedentary behaviors. However, some families lack the access to, or the resources to, provide less calorie-dense food options. We know that many obese children have parents who have been obese themselves since childhood and we know that breaking the obesity cycle can be extremely difficult. Do we extend the sweep of our finger-pointing to include grandparents and great grandparents?

While guilt can be a powerful motivating force, obesity seems to be one of those conditions in which by the time it becomes obvious to a family, the die is cast and blaming the victim or her parents is going to do little more than engender bad feelings. We have done more than enough. In fact, Ms. Gordon’s commentary suggests we have gone too far in creating public opinion that being lean is healthy and being overweight is bad. More motivational testimonials will merely add to the shaming.

Obesity is clearly a societal problem and selectively targeting the victims is not the answer. A famine would certainly lower our national body mass index, but not even the most callous among us would include it on the list of options. Attempts at levying a hefty tax on sweetened beverages have been attempted sporadically around the country without much success. We are a nation that cherishes our personal freedoms and unfortunately this includes the freedom to do some things the aren’t in our own best interests.

You could argue that this leaves us with education as our only hope of turning the tide. However, educating without characterizing the obese among us as bad, ugly, and undisciplined people is a public relations challenge of heroic proportions. Choosing language and images that somehow convey the idea that although obesity is bad being obese doesn’t make you a bad or ugly person is walking along a fine semantic edge.

If I sound discouraged, you are reading me correctly. As pediatricians, we are left doing the few things that have been shown to make a difference. This means promoting breastfeeding and encouraging thoughtful introduction of solid foods; both strategies can be done before the child can hear our well-intentioned but misguided words of encouragement.
 

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

In a recent New York Times opinion article, author Aubrey Gordon claims that since a visit to her pediatrician in fourth grade she has felt like an “enemy combatant in the nation’s war on childhood obesity.” (“Leave Fat Kids Alone,” Nov. 13, 2020).

At that unfortunate encounter, she recalls being told that “You’ll be thin and beautiful ... If you can just stay the same weight.” In retrospect she feels that the comment by her well-meaning but misguided physician “planted the seeds of depression” that have plagued her ever since.

Ms. Gordon goes on to list the many national and local initiatives that have done little to bend the curve in this country’s obesity trajectory but have succeeded in targeting bodies like hers as an epidemic and have resulted in her and thousands of other children being treated as “its virus personified.”

It is deeply troubling to read of her journey through life as collateral damage in a failed war effort, but Ms. Gordon offers little advice to us other than that we stop doing what we have been doing. It hasn’t been helping and it’s not working.

I suspect she would agree that obesity is one of our nation’s most serious public health problems. There is voluminous evidence of the association of obesity with cardiac disease, cancer, mental health challenges, and more recently COVID-19 – just to name a few. If blaming obese children who are the victims is counterproductive where do we point the finger? It is tempting to blame parents and certainly they deserve some culpability. Some parents could have created less obesity-enabling environments through healthier menu choices and done a better job discouraging sedentary behaviors. However, some families lack the access to, or the resources to, provide less calorie-dense food options. We know that many obese children have parents who have been obese themselves since childhood and we know that breaking the obesity cycle can be extremely difficult. Do we extend the sweep of our finger-pointing to include grandparents and great grandparents?

While guilt can be a powerful motivating force, obesity seems to be one of those conditions in which by the time it becomes obvious to a family, the die is cast and blaming the victim or her parents is going to do little more than engender bad feelings. We have done more than enough. In fact, Ms. Gordon’s commentary suggests we have gone too far in creating public opinion that being lean is healthy and being overweight is bad. More motivational testimonials will merely add to the shaming.

Obesity is clearly a societal problem and selectively targeting the victims is not the answer. A famine would certainly lower our national body mass index, but not even the most callous among us would include it on the list of options. Attempts at levying a hefty tax on sweetened beverages have been attempted sporadically around the country without much success. We are a nation that cherishes our personal freedoms and unfortunately this includes the freedom to do some things the aren’t in our own best interests.

You could argue that this leaves us with education as our only hope of turning the tide. However, educating without characterizing the obese among us as bad, ugly, and undisciplined people is a public relations challenge of heroic proportions. Choosing language and images that somehow convey the idea that although obesity is bad being obese doesn’t make you a bad or ugly person is walking along a fine semantic edge.

If I sound discouraged, you are reading me correctly. As pediatricians, we are left doing the few things that have been shown to make a difference. This means promoting breastfeeding and encouraging thoughtful introduction of solid foods; both strategies can be done before the child can hear our well-intentioned but misguided words of encouragement.
 

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

When the long-awaited news of a Food and Drug Administration–approved vaccine came on Dec. 11, 2020, my first thought was that I would wait. I can manage a few more months of Zooming for work, my household is down to two people, I’m not at high risk of dying from COVID, and my husband is not going to be vaccinated any time soon, so a change in my status wouldn’t “free” me. I would rather have “my” vaccine go to a 70-year-old ICU janitor or a bus driver.

South_agency/Getty Images

The weeks have gone by. I expected there would be kinks, but it has now been a month – one in which COVID rates have soared, and hospitalizations and deaths have risen to unmanageable numbers in some places. Still, vaccines remain in freezers – people are dying while vials of prevention sit unused. I began to think that, when my “turn” came, the better thing was to be vaccinated. We need to have a large segment of the population vaccinated to squelch this virus, and it’s become much less clear to me that, if I yield my turn, it will go into the arm of a bus driver. The process has not been fair, and there are moments of media outrage when one group gets vaccinated before another, so perhaps we have reached point where the goal should not be to get the vaccine into the exact right person in the exact right order, but to get the vaccine into arms according to the protocol that has already been set. Anyone who does not end up in a hospital bed is doing the system a favor.

Mahmood Jahromi, MD, a psychiatrist in private practice in Towson, Md., described the process of vaccination as being similar to a bottleneck traffic jam. “Yes, one must be courteous to the car trying to but in, but no, don’t jam the glue because you are excessively kind. Let the traffic police do their job. When your name is called, go ahead and take it. The system needs to know people are accepting the vaccine, not by begging the authorities to be called ahead of others, but with respect for what is already designed.”

On Friday, Jan. 8, I received information on how to get vaccinated – it seems my “turn” has arrived. An email from the board of physicians informed me that I am in the “1A” category and included a link to sign up for a vaccine in Baltimore – vaccinations would be given until Jan. 29, Mondays to Thursdays from 10 a.m. to 4 p.m. and Fridays from 10 a.m. to 1 p.m. There are no weekend or evening hours, and one might think there would be enough urgency to call for this. The Maryland Psychiatric Society sent out a notice that Sheppard Pratt would be offering vaccines to all behavioral health providers in the state of Maryland during a 2-day clinic. I heard from others that health care workers can now get vaccinated at the Cow Palace (how great is that?) at the Maryland State Fairgrounds and another link was sent for those in Howard County, between Baltimore and Washington.

As I discussed this with colleagues, a couple of issues came up – the most common was one of not wanting to get the vaccine yet because there are others who need it more. Others voiced concern about a vaccine where the long-term effects remain unknown: Is this vaccine safe, might it spur autoimmune problems in the months or years to come? Is it safe for women who plan to become pregnant? Some have insisted it is safe. They say “follow the science” and have dismissed the skepticism. To my read, it makes perfect sense to be wary, but COVID spreads silently and it kills.

With a vaccine where so many are reluctant to get it, including many health care workers, Sue Kim, MD, a psychiatrist in private practice in Lutherville, Md., noted that she has concerns about the safety of the vaccine. “Getting it now is both altruistic and selfish, but letting others go first is also altruistic and selfish. In the meantime, if I get sick, I was too smart for my own good. How do you weigh this ethically?”

My personal feelings have been influenced by a few things. An article in the New York Times highlighted how New York City vaccinated 5 million people for smallpox in just 2 weeks in 1947. I am frustrated knowing that, a month after approval of the first vaccine, only 7 million people have received it in the entire United States. In that time period, millions have contracted COVID and thousands have died. Closer to home, a 45-year-old psychiatrist in Maryland died of COVID, and I have heard more stories about younger people with long-haul neurologic and vascular symptoms. The risk of COVID is feeling higher than it did, and the fact that the first vaccine was authorized after the election somehow makes me feel that it might be safer. Had it been approved right before, I would have worried – perhaps wrongly – that the authorization was a political maneuver, not one based on science.

As we think about what is best for ourselves, our families, our patients, and society as a whole, I believe that those who want the vaccine but don’t feel they should take their place in line before others who are higher risk must ask if it makes sense to wait. Each state is different. While Houston Methodist Hospital is reportedly giving its health care workers a $500 bonus to get the vaccine, Gov. Andrew Cuomo of New York announced that hospitals would be fined $100,000 if they don’t use all of their vaccines within 7 days of receipt and $1 million if they vaccinate anyone out of order. Gov. Cuomo later broadened who could be vaccinated to prevent wasting the vaccine, but there remains an element of being damned if you do and damned if you don’t.

Paul Nestadt, MD, a psychiatrist at Johns Hopkins University, Baltimore, noted that one distribution site initially had to waste unused vaccine when people did not come for their appointments. A waiting list was created for people who could come right away if called to prevent this waste. “To me, this only highlighted that the tier system, while a good idea, does not need to be written in stone. The goal needs to be getting shots in arms, building herd immunity. If there are two arms in front of you, shoot the health care worker or those who are vulnerable. But if there is a healthy arm in reach, it should get any shot made available.”

I registered to be vaccinated. Maryland is still vaccinating only health care workers and people in long-term care facilities – senior citizens and essential workers are not yet eligible. In Baltimore, vaccinations are available Mondays to Thursdays from 10 a.m. to 4 p.m. and on Fridays from 10 a.m. to 1 p.m. There are no options for early morning or weekend times, but there are slots still available for the coming week. As of this writing, there are 6,100 Marylanders dead, and more than 1,800 COVID patients in hospital beds, and our governor, Larry Hogan, has commercials to “Mask On Maryland” and “Wear the Damn Mask.” I’ll offer some changes: “Wake Up, World” and “Offer the Damn Shot.”

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

When the long-awaited news of a Food and Drug Administration–approved vaccine came on Dec. 11, 2020, my first thought was that I would wait. I can manage a few more months of Zooming for work, my household is down to two people, I’m not at high risk of dying from COVID, and my husband is not going to be vaccinated any time soon, so a change in my status wouldn’t “free” me. I would rather have “my” vaccine go to a 70-year-old ICU janitor or a bus driver.

South_agency/Getty Images

The weeks have gone by. I expected there would be kinks, but it has now been a month – one in which COVID rates have soared, and hospitalizations and deaths have risen to unmanageable numbers in some places. Still, vaccines remain in freezers – people are dying while vials of prevention sit unused. I began to think that, when my “turn” came, the better thing was to be vaccinated. We need to have a large segment of the population vaccinated to squelch this virus, and it’s become much less clear to me that, if I yield my turn, it will go into the arm of a bus driver. The process has not been fair, and there are moments of media outrage when one group gets vaccinated before another, so perhaps we have reached point where the goal should not be to get the vaccine into the exact right person in the exact right order, but to get the vaccine into arms according to the protocol that has already been set. Anyone who does not end up in a hospital bed is doing the system a favor.

Mahmood Jahromi, MD, a psychiatrist in private practice in Towson, Md., described the process of vaccination as being similar to a bottleneck traffic jam. “Yes, one must be courteous to the car trying to but in, but no, don’t jam the glue because you are excessively kind. Let the traffic police do their job. When your name is called, go ahead and take it. The system needs to know people are accepting the vaccine, not by begging the authorities to be called ahead of others, but with respect for what is already designed.”

On Friday, Jan. 8, I received information on how to get vaccinated – it seems my “turn” has arrived. An email from the board of physicians informed me that I am in the “1A” category and included a link to sign up for a vaccine in Baltimore – vaccinations would be given until Jan. 29, Mondays to Thursdays from 10 a.m. to 4 p.m. and Fridays from 10 a.m. to 1 p.m. There are no weekend or evening hours, and one might think there would be enough urgency to call for this. The Maryland Psychiatric Society sent out a notice that Sheppard Pratt would be offering vaccines to all behavioral health providers in the state of Maryland during a 2-day clinic. I heard from others that health care workers can now get vaccinated at the Cow Palace (how great is that?) at the Maryland State Fairgrounds and another link was sent for those in Howard County, between Baltimore and Washington.

As I discussed this with colleagues, a couple of issues came up – the most common was one of not wanting to get the vaccine yet because there are others who need it more. Others voiced concern about a vaccine where the long-term effects remain unknown: Is this vaccine safe, might it spur autoimmune problems in the months or years to come? Is it safe for women who plan to become pregnant? Some have insisted it is safe. They say “follow the science” and have dismissed the skepticism. To my read, it makes perfect sense to be wary, but COVID spreads silently and it kills.

With a vaccine where so many are reluctant to get it, including many health care workers, Sue Kim, MD, a psychiatrist in private practice in Lutherville, Md., noted that she has concerns about the safety of the vaccine. “Getting it now is both altruistic and selfish, but letting others go first is also altruistic and selfish. In the meantime, if I get sick, I was too smart for my own good. How do you weigh this ethically?”

My personal feelings have been influenced by a few things. An article in the New York Times highlighted how New York City vaccinated 5 million people for smallpox in just 2 weeks in 1947. I am frustrated knowing that, a month after approval of the first vaccine, only 7 million people have received it in the entire United States. In that time period, millions have contracted COVID and thousands have died. Closer to home, a 45-year-old psychiatrist in Maryland died of COVID, and I have heard more stories about younger people with long-haul neurologic and vascular symptoms. The risk of COVID is feeling higher than it did, and the fact that the first vaccine was authorized after the election somehow makes me feel that it might be safer. Had it been approved right before, I would have worried – perhaps wrongly – that the authorization was a political maneuver, not one based on science.

As we think about what is best for ourselves, our families, our patients, and society as a whole, I believe that those who want the vaccine but don’t feel they should take their place in line before others who are higher risk must ask if it makes sense to wait. Each state is different. While Houston Methodist Hospital is reportedly giving its health care workers a $500 bonus to get the vaccine, Gov. Andrew Cuomo of New York announced that hospitals would be fined $100,000 if they don’t use all of their vaccines within 7 days of receipt and $1 million if they vaccinate anyone out of order. Gov. Cuomo later broadened who could be vaccinated to prevent wasting the vaccine, but there remains an element of being damned if you do and damned if you don’t.

Paul Nestadt, MD, a psychiatrist at Johns Hopkins University, Baltimore, noted that one distribution site initially had to waste unused vaccine when people did not come for their appointments. A waiting list was created for people who could come right away if called to prevent this waste. “To me, this only highlighted that the tier system, while a good idea, does not need to be written in stone. The goal needs to be getting shots in arms, building herd immunity. If there are two arms in front of you, shoot the health care worker or those who are vulnerable. But if there is a healthy arm in reach, it should get any shot made available.”

I registered to be vaccinated. Maryland is still vaccinating only health care workers and people in long-term care facilities – senior citizens and essential workers are not yet eligible. In Baltimore, vaccinations are available Mondays to Thursdays from 10 a.m. to 4 p.m. and on Fridays from 10 a.m. to 1 p.m. There are no options for early morning or weekend times, but there are slots still available for the coming week. As of this writing, there are 6,100 Marylanders dead, and more than 1,800 COVID patients in hospital beds, and our governor, Larry Hogan, has commercials to “Mask On Maryland” and “Wear the Damn Mask.” I’ll offer some changes: “Wake Up, World” and “Offer the Damn Shot.”

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

When the long-awaited news of a Food and Drug Administration–approved vaccine came on Dec. 11, 2020, my first thought was that I would wait. I can manage a few more months of Zooming for work, my household is down to two people, I’m not at high risk of dying from COVID, and my husband is not going to be vaccinated any time soon, so a change in my status wouldn’t “free” me. I would rather have “my” vaccine go to a 70-year-old ICU janitor or a bus driver.

South_agency/Getty Images

The weeks have gone by. I expected there would be kinks, but it has now been a month – one in which COVID rates have soared, and hospitalizations and deaths have risen to unmanageable numbers in some places. Still, vaccines remain in freezers – people are dying while vials of prevention sit unused. I began to think that, when my “turn” came, the better thing was to be vaccinated. We need to have a large segment of the population vaccinated to squelch this virus, and it’s become much less clear to me that, if I yield my turn, it will go into the arm of a bus driver. The process has not been fair, and there are moments of media outrage when one group gets vaccinated before another, so perhaps we have reached point where the goal should not be to get the vaccine into the exact right person in the exact right order, but to get the vaccine into arms according to the protocol that has already been set. Anyone who does not end up in a hospital bed is doing the system a favor.

Mahmood Jahromi, MD, a psychiatrist in private practice in Towson, Md., described the process of vaccination as being similar to a bottleneck traffic jam. “Yes, one must be courteous to the car trying to but in, but no, don’t jam the glue because you are excessively kind. Let the traffic police do their job. When your name is called, go ahead and take it. The system needs to know people are accepting the vaccine, not by begging the authorities to be called ahead of others, but with respect for what is already designed.”

On Friday, Jan. 8, I received information on how to get vaccinated – it seems my “turn” has arrived. An email from the board of physicians informed me that I am in the “1A” category and included a link to sign up for a vaccine in Baltimore – vaccinations would be given until Jan. 29, Mondays to Thursdays from 10 a.m. to 4 p.m. and Fridays from 10 a.m. to 1 p.m. There are no weekend or evening hours, and one might think there would be enough urgency to call for this. The Maryland Psychiatric Society sent out a notice that Sheppard Pratt would be offering vaccines to all behavioral health providers in the state of Maryland during a 2-day clinic. I heard from others that health care workers can now get vaccinated at the Cow Palace (how great is that?) at the Maryland State Fairgrounds and another link was sent for those in Howard County, between Baltimore and Washington.

As I discussed this with colleagues, a couple of issues came up – the most common was one of not wanting to get the vaccine yet because there are others who need it more. Others voiced concern about a vaccine where the long-term effects remain unknown: Is this vaccine safe, might it spur autoimmune problems in the months or years to come? Is it safe for women who plan to become pregnant? Some have insisted it is safe. They say “follow the science” and have dismissed the skepticism. To my read, it makes perfect sense to be wary, but COVID spreads silently and it kills.

With a vaccine where so many are reluctant to get it, including many health care workers, Sue Kim, MD, a psychiatrist in private practice in Lutherville, Md., noted that she has concerns about the safety of the vaccine. “Getting it now is both altruistic and selfish, but letting others go first is also altruistic and selfish. In the meantime, if I get sick, I was too smart for my own good. How do you weigh this ethically?”

My personal feelings have been influenced by a few things. An article in the New York Times highlighted how New York City vaccinated 5 million people for smallpox in just 2 weeks in 1947. I am frustrated knowing that, a month after approval of the first vaccine, only 7 million people have received it in the entire United States. In that time period, millions have contracted COVID and thousands have died. Closer to home, a 45-year-old psychiatrist in Maryland died of COVID, and I have heard more stories about younger people with long-haul neurologic and vascular symptoms. The risk of COVID is feeling higher than it did, and the fact that the first vaccine was authorized after the election somehow makes me feel that it might be safer. Had it been approved right before, I would have worried – perhaps wrongly – that the authorization was a political maneuver, not one based on science.

As we think about what is best for ourselves, our families, our patients, and society as a whole, I believe that those who want the vaccine but don’t feel they should take their place in line before others who are higher risk must ask if it makes sense to wait. Each state is different. While Houston Methodist Hospital is reportedly giving its health care workers a $500 bonus to get the vaccine, Gov. Andrew Cuomo of New York announced that hospitals would be fined $100,000 if they don’t use all of their vaccines within 7 days of receipt and $1 million if they vaccinate anyone out of order. Gov. Cuomo later broadened who could be vaccinated to prevent wasting the vaccine, but there remains an element of being damned if you do and damned if you don’t.

Paul Nestadt, MD, a psychiatrist at Johns Hopkins University, Baltimore, noted that one distribution site initially had to waste unused vaccine when people did not come for their appointments. A waiting list was created for people who could come right away if called to prevent this waste. “To me, this only highlighted that the tier system, while a good idea, does not need to be written in stone. The goal needs to be getting shots in arms, building herd immunity. If there are two arms in front of you, shoot the health care worker or those who are vulnerable. But if there is a healthy arm in reach, it should get any shot made available.”

I registered to be vaccinated. Maryland is still vaccinating only health care workers and people in long-term care facilities – senior citizens and essential workers are not yet eligible. In Baltimore, vaccinations are available Mondays to Thursdays from 10 a.m. to 4 p.m. and on Fridays from 10 a.m. to 1 p.m. There are no options for early morning or weekend times, but there are slots still available for the coming week. As of this writing, there are 6,100 Marylanders dead, and more than 1,800 COVID patients in hospital beds, and our governor, Larry Hogan, has commercials to “Mask On Maryland” and “Wear the Damn Mask.” I’ll offer some changes: “Wake Up, World” and “Offer the Damn Shot.”

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

According to data from the American Academy of Pediatrics, over 2,000 physicians – or approximately 70% of all physicians practicing pediatric hospital medicine – do so in a community hospital. Like all areas of hospital medicine, community pediatric hospital medicine (CPHM) strives to fulfill one of our field’s central tenets – providing high-quality, evidence-based care to our patients.

A phrase often used among CPHM practitioners is that, “if you’ve seen one CPHM program, you’ve seen one CPHM program.” Every CPHM program is different. While this phrase may seem rather simplistic, it quite accurately portrays a unique aspect of our place in the hospital medicine field. CPHM programs usually require their practitioners to perform a broader range of roles and responsibilities than our colleagues who practice in university or children’s hospitals. Typically, these roles are aligned with the unique needs of each hospital within which we practice and the communities we serve. Factors such as the distance to a tertiary care referral center, access to subspecialists, availability and expertise of ancillary services for children, and the particular needs of each community further shape the role that CPHM practitioners may be asked to play.

In 2014, the AAP section on hospital medicine’s subcommittee on community hospitalists surveyed all CPHM programs to understand the unique roles that practitioners play within their institutions. Under the leadership of Clota Snow, MD, and Jacques Corriveau, MD, the aim was to contact every hospital in the country using the American Hospital Directory to see if they had a PHM program and to identify what roles the program was responsible for within their hospital.

Of the 535 programs identified, the primary responsibilities included inpatient care (85%), ED consultations (76%) and newborn nursery care (73%). Other common roles not typically associated with a university-based hospitalist’s responsibilities included delivery room attendance/neonatal resuscitations (44%), neonatal ICU management (47%) and subspecialty or surgical comanagement (52%). In some communities, even pediatric ICU management, sedation, and patient transport are part of our role. Because of the large breadth of roles that a CPHM practitioner may cover, we have often been referred to as “pediatric hospital-based generalists.”

Ideally, the presence of a pediatric hospitalist in a community hospital allows children to obtain high-quality, evidence-based care within their home communities. Most hospitalized children do not require direct access to subspecialists or all the pediatric-specific resources only available within a university or children’s hospital. Thus, if these resources are not required for the child’s care, CPHM practitioners can provide the care that a child needs in a setting that is less disruptive to the family and typically more cost effective.

CPHM physicians are often drawn to a career in a community hospital because it allows them to use their entire skill set to care for children with a wide variety of conditions. As they are often the only physicians in an adult hospital with a full understanding of the unique aspects of care that children require, it is important that they be comfortable in their role of managing the majority of pediatric care independently. Yet they also need to understand the limitations of their own ability, as well as their institution’s level of expertise in pediatric-specific care. They must be confident and vocal advocates for pediatric-specific needs throughout their institution and its numerous committees, and form close working relationships with colleagues and administrators in the different fields with whom we share care of our patients (e.g., ED, obstetrics, radiology, trauma, and other medical and surgical subspecialties).

CPHM physicians are particularly well suited to partner with local outpatient providers as well as tertiary care physicians to provide coordinated transitions between the inpatient and outpatient management of a child’s illness. In addition, a CPHM physician can often bring a unique and valuable perspective of the particular ethnic, cultural, and socioeconomic diversity of their community, as well as its available resources, to facilitate a greater level of engagement with the child’s needs and ultimate success of their care.

The 2014 survey of CPHM programs identified several major challenges to recruitment and career satisfaction as a CPHM physician. These include a lack of access to subspecialists, a lack of pediatric-specific ancillary services and the perception that our importance as community hospital providers was not valued as much in the PHM community as PHM physicians working in a university/children’s hospital setting. With the recent recognition of PHM as an official subspecialty by the American Board of Pediatrics, the concern has intensified within our field that a two-tiered system will develop with some PHM physicians being board certified and others not.

While the development of board subspecialization was not meant to limit the pool of providers available to staff community hospital sites, there is nowhere near the number of fellowship trained physicians to provide an adequate workforce to staff CPHM programs. This means that many CPHM physicians will not be board certified in pediatric hospital medicine but does not mean that CPHM programs will be unable to provide high-quality local care that benefits children and their families, including safe care for children who require the skills that an immediately available CPHM physician can provide.

Many pediatric residency programs do not currently provide their trainees with exposure to community hospital medicine. Further, with increased sub-specialization throughout pediatrics, fewer residents are developing the necessary skill set to perform roles integral to a caring for children in community hospitals such as stabilization of a critically ill child prior to transport and complex neonatal resuscitation.

A career in CPHM provides physicians with the opportunity to work together with a close-knit group to provide exceptional care to children and to advocate for the medical needs of children in their hospital and their community. The AAP’s subcommittee has made it a priority to engage physicians during all parts of their pediatric training about why a career in CPHM is exciting, fulfilling and a great life, as well as continuing to educate training programs at every level – as well as the larger PHM community – about why CPHM is a valuable and important part of pediatric medicine.
 

Dr. Welsh is a clinical associate professor of pediatrics at the Stanford (Calif.) University in the division of pediatric hospital medicine. He has practiced community pediatric hospital medicine for over 27 years in Washington state and the San Francisco Bay Area. He is the chair of the working group of the Future of Community Pediatric Hospital Medicine for the AAP section on hospital medicine’s subcommittee on community hospitalists.

According to data from the American Academy of Pediatrics, over 2,000 physicians – or approximately 70% of all physicians practicing pediatric hospital medicine – do so in a community hospital. Like all areas of hospital medicine, community pediatric hospital medicine (CPHM) strives to fulfill one of our field’s central tenets – providing high-quality, evidence-based care to our patients.

A phrase often used among CPHM practitioners is that, “if you’ve seen one CPHM program, you’ve seen one CPHM program.” Every CPHM program is different. While this phrase may seem rather simplistic, it quite accurately portrays a unique aspect of our place in the hospital medicine field. CPHM programs usually require their practitioners to perform a broader range of roles and responsibilities than our colleagues who practice in university or children’s hospitals. Typically, these roles are aligned with the unique needs of each hospital within which we practice and the communities we serve. Factors such as the distance to a tertiary care referral center, access to subspecialists, availability and expertise of ancillary services for children, and the particular needs of each community further shape the role that CPHM practitioners may be asked to play.

In 2014, the AAP section on hospital medicine’s subcommittee on community hospitalists surveyed all CPHM programs to understand the unique roles that practitioners play within their institutions. Under the leadership of Clota Snow, MD, and Jacques Corriveau, MD, the aim was to contact every hospital in the country using the American Hospital Directory to see if they had a PHM program and to identify what roles the program was responsible for within their hospital.

Of the 535 programs identified, the primary responsibilities included inpatient care (85%), ED consultations (76%) and newborn nursery care (73%). Other common roles not typically associated with a university-based hospitalist’s responsibilities included delivery room attendance/neonatal resuscitations (44%), neonatal ICU management (47%) and subspecialty or surgical comanagement (52%). In some communities, even pediatric ICU management, sedation, and patient transport are part of our role. Because of the large breadth of roles that a CPHM practitioner may cover, we have often been referred to as “pediatric hospital-based generalists.”

Ideally, the presence of a pediatric hospitalist in a community hospital allows children to obtain high-quality, evidence-based care within their home communities. Most hospitalized children do not require direct access to subspecialists or all the pediatric-specific resources only available within a university or children’s hospital. Thus, if these resources are not required for the child’s care, CPHM practitioners can provide the care that a child needs in a setting that is less disruptive to the family and typically more cost effective.

CPHM physicians are often drawn to a career in a community hospital because it allows them to use their entire skill set to care for children with a wide variety of conditions. As they are often the only physicians in an adult hospital with a full understanding of the unique aspects of care that children require, it is important that they be comfortable in their role of managing the majority of pediatric care independently. Yet they also need to understand the limitations of their own ability, as well as their institution’s level of expertise in pediatric-specific care. They must be confident and vocal advocates for pediatric-specific needs throughout their institution and its numerous committees, and form close working relationships with colleagues and administrators in the different fields with whom we share care of our patients (e.g., ED, obstetrics, radiology, trauma, and other medical and surgical subspecialties).

CPHM physicians are particularly well suited to partner with local outpatient providers as well as tertiary care physicians to provide coordinated transitions between the inpatient and outpatient management of a child’s illness. In addition, a CPHM physician can often bring a unique and valuable perspective of the particular ethnic, cultural, and socioeconomic diversity of their community, as well as its available resources, to facilitate a greater level of engagement with the child’s needs and ultimate success of their care.

The 2014 survey of CPHM programs identified several major challenges to recruitment and career satisfaction as a CPHM physician. These include a lack of access to subspecialists, a lack of pediatric-specific ancillary services and the perception that our importance as community hospital providers was not valued as much in the PHM community as PHM physicians working in a university/children’s hospital setting. With the recent recognition of PHM as an official subspecialty by the American Board of Pediatrics, the concern has intensified within our field that a two-tiered system will develop with some PHM physicians being board certified and others not.

While the development of board subspecialization was not meant to limit the pool of providers available to staff community hospital sites, there is nowhere near the number of fellowship trained physicians to provide an adequate workforce to staff CPHM programs. This means that many CPHM physicians will not be board certified in pediatric hospital medicine but does not mean that CPHM programs will be unable to provide high-quality local care that benefits children and their families, including safe care for children who require the skills that an immediately available CPHM physician can provide.

Many pediatric residency programs do not currently provide their trainees with exposure to community hospital medicine. Further, with increased sub-specialization throughout pediatrics, fewer residents are developing the necessary skill set to perform roles integral to a caring for children in community hospitals such as stabilization of a critically ill child prior to transport and complex neonatal resuscitation.

A career in CPHM provides physicians with the opportunity to work together with a close-knit group to provide exceptional care to children and to advocate for the medical needs of children in their hospital and their community. The AAP’s subcommittee has made it a priority to engage physicians during all parts of their pediatric training about why a career in CPHM is exciting, fulfilling and a great life, as well as continuing to educate training programs at every level – as well as the larger PHM community – about why CPHM is a valuable and important part of pediatric medicine.
 

Dr. Welsh is a clinical associate professor of pediatrics at the Stanford (Calif.) University in the division of pediatric hospital medicine. He has practiced community pediatric hospital medicine for over 27 years in Washington state and the San Francisco Bay Area. He is the chair of the working group of the Future of Community Pediatric Hospital Medicine for the AAP section on hospital medicine’s subcommittee on community hospitalists.

According to data from the American Academy of Pediatrics, over 2,000 physicians – or approximately 70% of all physicians practicing pediatric hospital medicine – do so in a community hospital. Like all areas of hospital medicine, community pediatric hospital medicine (CPHM) strives to fulfill one of our field’s central tenets – providing high-quality, evidence-based care to our patients.

A phrase often used among CPHM practitioners is that, “if you’ve seen one CPHM program, you’ve seen one CPHM program.” Every CPHM program is different. While this phrase may seem rather simplistic, it quite accurately portrays a unique aspect of our place in the hospital medicine field. CPHM programs usually require their practitioners to perform a broader range of roles and responsibilities than our colleagues who practice in university or children’s hospitals. Typically, these roles are aligned with the unique needs of each hospital within which we practice and the communities we serve. Factors such as the distance to a tertiary care referral center, access to subspecialists, availability and expertise of ancillary services for children, and the particular needs of each community further shape the role that CPHM practitioners may be asked to play.

In 2014, the AAP section on hospital medicine’s subcommittee on community hospitalists surveyed all CPHM programs to understand the unique roles that practitioners play within their institutions. Under the leadership of Clota Snow, MD, and Jacques Corriveau, MD, the aim was to contact every hospital in the country using the American Hospital Directory to see if they had a PHM program and to identify what roles the program was responsible for within their hospital.

Of the 535 programs identified, the primary responsibilities included inpatient care (85%), ED consultations (76%) and newborn nursery care (73%). Other common roles not typically associated with a university-based hospitalist’s responsibilities included delivery room attendance/neonatal resuscitations (44%), neonatal ICU management (47%) and subspecialty or surgical comanagement (52%). In some communities, even pediatric ICU management, sedation, and patient transport are part of our role. Because of the large breadth of roles that a CPHM practitioner may cover, we have often been referred to as “pediatric hospital-based generalists.”

Ideally, the presence of a pediatric hospitalist in a community hospital allows children to obtain high-quality, evidence-based care within their home communities. Most hospitalized children do not require direct access to subspecialists or all the pediatric-specific resources only available within a university or children’s hospital. Thus, if these resources are not required for the child’s care, CPHM practitioners can provide the care that a child needs in a setting that is less disruptive to the family and typically more cost effective.

CPHM physicians are often drawn to a career in a community hospital because it allows them to use their entire skill set to care for children with a wide variety of conditions. As they are often the only physicians in an adult hospital with a full understanding of the unique aspects of care that children require, it is important that they be comfortable in their role of managing the majority of pediatric care independently. Yet they also need to understand the limitations of their own ability, as well as their institution’s level of expertise in pediatric-specific care. They must be confident and vocal advocates for pediatric-specific needs throughout their institution and its numerous committees, and form close working relationships with colleagues and administrators in the different fields with whom we share care of our patients (e.g., ED, obstetrics, radiology, trauma, and other medical and surgical subspecialties).

CPHM physicians are particularly well suited to partner with local outpatient providers as well as tertiary care physicians to provide coordinated transitions between the inpatient and outpatient management of a child’s illness. In addition, a CPHM physician can often bring a unique and valuable perspective of the particular ethnic, cultural, and socioeconomic diversity of their community, as well as its available resources, to facilitate a greater level of engagement with the child’s needs and ultimate success of their care.

The 2014 survey of CPHM programs identified several major challenges to recruitment and career satisfaction as a CPHM physician. These include a lack of access to subspecialists, a lack of pediatric-specific ancillary services and the perception that our importance as community hospital providers was not valued as much in the PHM community as PHM physicians working in a university/children’s hospital setting. With the recent recognition of PHM as an official subspecialty by the American Board of Pediatrics, the concern has intensified within our field that a two-tiered system will develop with some PHM physicians being board certified and others not.

While the development of board subspecialization was not meant to limit the pool of providers available to staff community hospital sites, there is nowhere near the number of fellowship trained physicians to provide an adequate workforce to staff CPHM programs. This means that many CPHM physicians will not be board certified in pediatric hospital medicine but does not mean that CPHM programs will be unable to provide high-quality local care that benefits children and their families, including safe care for children who require the skills that an immediately available CPHM physician can provide.

Many pediatric residency programs do not currently provide their trainees with exposure to community hospital medicine. Further, with increased sub-specialization throughout pediatrics, fewer residents are developing the necessary skill set to perform roles integral to a caring for children in community hospitals such as stabilization of a critically ill child prior to transport and complex neonatal resuscitation.

A career in CPHM provides physicians with the opportunity to work together with a close-knit group to provide exceptional care to children and to advocate for the medical needs of children in their hospital and their community. The AAP’s subcommittee has made it a priority to engage physicians during all parts of their pediatric training about why a career in CPHM is exciting, fulfilling and a great life, as well as continuing to educate training programs at every level – as well as the larger PHM community – about why CPHM is a valuable and important part of pediatric medicine.
 

Dr. Welsh is a clinical associate professor of pediatrics at the Stanford (Calif.) University in the division of pediatric hospital medicine. He has practiced community pediatric hospital medicine for over 27 years in Washington state and the San Francisco Bay Area. He is the chair of the working group of the Future of Community Pediatric Hospital Medicine for the AAP section on hospital medicine’s subcommittee on community hospitalists.

Isolation in response to COVID-19 pandemic has driven many people to reestablish long forgotten connections between old friends and geographically distant relatives. Fed by the ease in which Zoom and other electronic miracles can bring once familiar voices and faces into our homes, we no longer need to wait until our high school or college reunions to reconnect.

The Class of 1962 at Pleasantville (N.Y.) High School has always attracted an unusually large number of attendees at its reunions, and its exuberant response to pandemic-fueled mini Zoom reunions is not surprising. With each virtual gathering we learn and relearn more about each other. I had always felt that because my birthday was in December that I was among the very youngest in my class. (New York’s school enrollment calendar cutoff is in December.) However, I recently learned that some of my classmates were even younger, having been born in the following spring.

This revelation prompted a discussion among the younger septuagenarians about whether we felt that our relative immaturity, at least as measured by the calendar, affected us. It was generally agreed that for the women, being younger seemed to present little problem. For, the men there were a few for whom immaturity put them at an athletic disadvantage. But, there was uniform agreement that social immaturity made dating an uncomfortable adventure. No one felt that his or her immaturity placed them at an academic disadvantage. Of course, all of these observations are heavily colored by the bias of those who have chosen to maintain contact with classmates.

A recent flurry of papers and commentaries about relative age at school entry and the diagnosis of attention deficit/hyperactivity disorder prompted me to ask my Zoom mates if they could recall anyone whom they would label as having exhibited the behavior we have all come to associate with ADHD (Vuori M et al. Children’s relative age and ADHD medication use: A Finnish population-based study. Pediatrics 2020 Oct. doi: 10.1542/peds.2019-4046, and Butter EM. Keeping relative age effects and ADHD care in context. Pediatrics. 2020;146[4]:e2020022798).

We could all recall classmates who struggled academically and seemed to not be paying attention. However, when one includes the hyperactivity descriptor we couldn’t recall anyone whose in-classroom physical activity drew our attention. Of course, there were many shared anecdotes about note passing, spitball throwing, and out-of-class shenanigans. But, from the perspective of behavior that disrupted the classroom there were very few. And, not surprisingly, given the intervening 6 decades, none of us could make an association between immaturity and the behavior.

While I have very few memories of what happened when I was in grade school, many of my classmates have vivid recollections of events both mundane and dramatic even as far back as first and second grade. Why do none of them recall classmates whose behavior would in current terminology be labeled as ADHD?

Were most of us that age bouncing off the walls and so there were no outliers? Were the teachers more tolerant because they expected that many children, particularly the younger ones, would be more physically active? Or, maybe we arrived at school, even those who were chronologically less mature, having already been settled down by home environments that neither fostered nor tolerated hyperactivity?

If you ask a pediatrician over the age of 70 if he or she recalls being taught anything about ADHD in medical school or seeing any children in his or her first years of practice who would fit the current diagnostic criteria, you will see them simply shrug. ADHD was simply not on our radar in the 1970s and 1980s. And it’s not because radar hadn’t been invented. We pediatricians were paying attention, and I trust in my high school classmates’ observations. I am sure there were isolated cases that could easily have been labeled as ADHD if the term had existed. But, the volume of hyperactive children a pediatrician sees today in the course of a normal office day just didn’t exist.

I have trouble believing that this dramatic increase in frequency is the result of accumulating genetic damage from Teflon cookware or climate change or air pollution. Although I am open to any serious attempt to explain the phenomenon I think we should look first into the home environment in which children are being raised. Sleep schedules, activity, and amusement opportunities as well as discipline styles – just to name a few – are far different now than before the ADHD diagnosis overtook the landscape.
 

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

Isolation in response to COVID-19 pandemic has driven many people to reestablish long forgotten connections between old friends and geographically distant relatives. Fed by the ease in which Zoom and other electronic miracles can bring once familiar voices and faces into our homes, we no longer need to wait until our high school or college reunions to reconnect.

The Class of 1962 at Pleasantville (N.Y.) High School has always attracted an unusually large number of attendees at its reunions, and its exuberant response to pandemic-fueled mini Zoom reunions is not surprising. With each virtual gathering we learn and relearn more about each other. I had always felt that because my birthday was in December that I was among the very youngest in my class. (New York’s school enrollment calendar cutoff is in December.) However, I recently learned that some of my classmates were even younger, having been born in the following spring.

This revelation prompted a discussion among the younger septuagenarians about whether we felt that our relative immaturity, at least as measured by the calendar, affected us. It was generally agreed that for the women, being younger seemed to present little problem. For, the men there were a few for whom immaturity put them at an athletic disadvantage. But, there was uniform agreement that social immaturity made dating an uncomfortable adventure. No one felt that his or her immaturity placed them at an academic disadvantage. Of course, all of these observations are heavily colored by the bias of those who have chosen to maintain contact with classmates.

A recent flurry of papers and commentaries about relative age at school entry and the diagnosis of attention deficit/hyperactivity disorder prompted me to ask my Zoom mates if they could recall anyone whom they would label as having exhibited the behavior we have all come to associate with ADHD (Vuori M et al. Children’s relative age and ADHD medication use: A Finnish population-based study. Pediatrics 2020 Oct. doi: 10.1542/peds.2019-4046, and Butter EM. Keeping relative age effects and ADHD care in context. Pediatrics. 2020;146[4]:e2020022798).

We could all recall classmates who struggled academically and seemed to not be paying attention. However, when one includes the hyperactivity descriptor we couldn’t recall anyone whose in-classroom physical activity drew our attention. Of course, there were many shared anecdotes about note passing, spitball throwing, and out-of-class shenanigans. But, from the perspective of behavior that disrupted the classroom there were very few. And, not surprisingly, given the intervening 6 decades, none of us could make an association between immaturity and the behavior.

While I have very few memories of what happened when I was in grade school, many of my classmates have vivid recollections of events both mundane and dramatic even as far back as first and second grade. Why do none of them recall classmates whose behavior would in current terminology be labeled as ADHD?

Were most of us that age bouncing off the walls and so there were no outliers? Were the teachers more tolerant because they expected that many children, particularly the younger ones, would be more physically active? Or, maybe we arrived at school, even those who were chronologically less mature, having already been settled down by home environments that neither fostered nor tolerated hyperactivity?

If you ask a pediatrician over the age of 70 if he or she recalls being taught anything about ADHD in medical school or seeing any children in his or her first years of practice who would fit the current diagnostic criteria, you will see them simply shrug. ADHD was simply not on our radar in the 1970s and 1980s. And it’s not because radar hadn’t been invented. We pediatricians were paying attention, and I trust in my high school classmates’ observations. I am sure there were isolated cases that could easily have been labeled as ADHD if the term had existed. But, the volume of hyperactive children a pediatrician sees today in the course of a normal office day just didn’t exist.

I have trouble believing that this dramatic increase in frequency is the result of accumulating genetic damage from Teflon cookware or climate change or air pollution. Although I am open to any serious attempt to explain the phenomenon I think we should look first into the home environment in which children are being raised. Sleep schedules, activity, and amusement opportunities as well as discipline styles – just to name a few – are far different now than before the ADHD diagnosis overtook the landscape.
 

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

Isolation in response to COVID-19 pandemic has driven many people to reestablish long forgotten connections between old friends and geographically distant relatives. Fed by the ease in which Zoom and other electronic miracles can bring once familiar voices and faces into our homes, we no longer need to wait until our high school or college reunions to reconnect.

The Class of 1962 at Pleasantville (N.Y.) High School has always attracted an unusually large number of attendees at its reunions, and its exuberant response to pandemic-fueled mini Zoom reunions is not surprising. With each virtual gathering we learn and relearn more about each other. I had always felt that because my birthday was in December that I was among the very youngest in my class. (New York’s school enrollment calendar cutoff is in December.) However, I recently learned that some of my classmates were even younger, having been born in the following spring.

This revelation prompted a discussion among the younger septuagenarians about whether we felt that our relative immaturity, at least as measured by the calendar, affected us. It was generally agreed that for the women, being younger seemed to present little problem. For, the men there were a few for whom immaturity put them at an athletic disadvantage. But, there was uniform agreement that social immaturity made dating an uncomfortable adventure. No one felt that his or her immaturity placed them at an academic disadvantage. Of course, all of these observations are heavily colored by the bias of those who have chosen to maintain contact with classmates.

A recent flurry of papers and commentaries about relative age at school entry and the diagnosis of attention deficit/hyperactivity disorder prompted me to ask my Zoom mates if they could recall anyone whom they would label as having exhibited the behavior we have all come to associate with ADHD (Vuori M et al. Children’s relative age and ADHD medication use: A Finnish population-based study. Pediatrics 2020 Oct. doi: 10.1542/peds.2019-4046, and Butter EM. Keeping relative age effects and ADHD care in context. Pediatrics. 2020;146[4]:e2020022798).

We could all recall classmates who struggled academically and seemed to not be paying attention. However, when one includes the hyperactivity descriptor we couldn’t recall anyone whose in-classroom physical activity drew our attention. Of course, there were many shared anecdotes about note passing, spitball throwing, and out-of-class shenanigans. But, from the perspective of behavior that disrupted the classroom there were very few. And, not surprisingly, given the intervening 6 decades, none of us could make an association between immaturity and the behavior.

While I have very few memories of what happened when I was in grade school, many of my classmates have vivid recollections of events both mundane and dramatic even as far back as first and second grade. Why do none of them recall classmates whose behavior would in current terminology be labeled as ADHD?

Were most of us that age bouncing off the walls and so there were no outliers? Were the teachers more tolerant because they expected that many children, particularly the younger ones, would be more physically active? Or, maybe we arrived at school, even those who were chronologically less mature, having already been settled down by home environments that neither fostered nor tolerated hyperactivity?

If you ask a pediatrician over the age of 70 if he or she recalls being taught anything about ADHD in medical school or seeing any children in his or her first years of practice who would fit the current diagnostic criteria, you will see them simply shrug. ADHD was simply not on our radar in the 1970s and 1980s. And it’s not because radar hadn’t been invented. We pediatricians were paying attention, and I trust in my high school classmates’ observations. I am sure there were isolated cases that could easily have been labeled as ADHD if the term had existed. But, the volume of hyperactive children a pediatrician sees today in the course of a normal office day just didn’t exist.

I have trouble believing that this dramatic increase in frequency is the result of accumulating genetic damage from Teflon cookware or climate change or air pollution. Although I am open to any serious attempt to explain the phenomenon I think we should look first into the home environment in which children are being raised. Sleep schedules, activity, and amusement opportunities as well as discipline styles – just to name a few – are far different now than before the ADHD diagnosis overtook the landscape.
 

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

During a busy morning of rounds, our patient, Mrs. M., appeared distraught. She was diagnosed with COVID-19 2 weeks prior and remained inpatient because of medicosocial reasons. Since admission she remained on the same ward, in the same room, cared for by the same group of providers donned in masks, gowns, gloves, and face shields. The personal protective equipment helped to shield us from the virus, but it also shielded Mrs. M. from us.

During initial interaction, Mrs. M. appeared anxious, tearful, and detached. It seemed that she recognized a new voice; however, she did not express much interest in engaging during the visit. When she realized that she was not being discharged, Mrs. M. appeared to lose further interest. She wanted to go home. Her outpatient dialysis arrangements were not complete, and that precluded hospital discharge. Prescribed anxiolytics were doing little to relieve her symptoms.

The next day, Mrs. M. continued to ask if she could go home. She stated that there was nothing for her to do while in the hospital. She was tired of watching TV, she was unable to call her friends, and was not able to see her family. Because of COVID-19 status, Mrs. M was not permitted to leave her hospital room, and she was transported to the dialysis unit via stretcher, being unable to walk. The more we talked, the more engaged Mrs. M. had become. When it was time to complete the encounter, Mrs. M. started pleading with us to “stay a little longer, please don’t leave.”

Throughout her hospitalization, Mrs. M. had an extremely limited number of human encounters. Those encounters were fragmented and brief, centered on the infection mitigation. The chaplain was not permitted to enter her room, and she was unwilling to use the phone. The subspecialty consultants utilized telemedicine visits. As a result, Mrs. M. felt isolated and lonely. Social distancing in the hospital makes human interactions particularly challenging and contributes to the development of isolation, loneliness, and fear.
 

Loneliness is real

Loneliness is the “subjective experience of involuntary social isolation.”¹ As the COVID-19 pandemic began to entrap the world in early 2020, many people have faced new challenges – loneliness and its impact on physical and mental health. The prevalence of loneliness nearly tripled in the early months of the pandemic, leading to psychological distress and reopening conversations on ethical issues.²

Ethical implications of loneliness

Social distancing challenges all four main ethical principles: autonomy, beneficence, nonmaleficence, and justice. How do we reconcile these principles from the standpoint of each affected individual, their caregivers, health care providers, and public health at large? How can we continue to mitigate the spread of COVID-19, but also remain attentive to our patients who are still in need of human interactions to recover and thrive?

Social distancing is important, but so is social interaction. What strategies do we have in place to combat loneliness? How do we help our hospitalized patients who feel connected to the “outside world?” Is battling loneliness worth the risks of additional exposure to COVID-19? These dilemmas cannot be easily resolved. However, it is important for us to recognize the negative impacts of loneliness and identify measures to help our patients.

In our mission to fulfill the beneficence and nonmaleficence principles of caring for patients affected by COVID-19, patients like Mrs. M. lose much of their autonomy during hospital admission. Despite our best efforts, our isolated patients during the pandemic, remain alone, which further heightens their feeling of loneliness.
 

 

Clinical implications of loneliness

With the advancements in technology, our capabilities to substitute personal human interactions have grown exponentially. The use of telemedicine, video- and audio-conferencing communications have changed the landscape of our capacities to exchange information. This could be a blessing and a curse. While the use of digital platforms for virtual communication is tempting, we should preserve human interactions as much as possible, particularly when caring for patients affected by COVID-19. Interpersonal “connectedness” plays a crucial role in providing psychological and psychotherapeutic support, particularly when the number of human encounters is already limited.

Social distancing requirements have magnified loneliness. Several studies demonstrate that the perception of loneliness leads to poor health outcomes, including lower immunity, increased peripheral vascular resistance,³ and higher overall mortality.⁴ Loneliness can lead to functional impairment, such as poor social skills, and even increased inflammation.⁵ The negative emotional impact of SARS-CoV-2 echoes the experiences of patients affected by the severe acute respiratory syndrome (SARS) outbreak in 2003. However, with COVID-19, we are witnessing the amplified effects of loneliness on a global scale. The majority of affected patients during the 2003 SARS outbreak in Canada reported loneliness, fear, aggression, and boredom: They had concerns about the impacts of the infection on loved ones, and psychological support was required for many patients with mild to moderate SARS disease.⁶
 

Nonpharmacological management strategies for battling loneliness

Utilization of early supportive services has been well described in literature and includes extending additional resources such as books, newspapers and, most importantly, additional in-person time to our patients.⁶ Maintaining rapport with patients’ families is also helpful in reducing anxiety and fear. The following measures have been suggested to prevent the negative impacts of loneliness and should be considered when caring for hospitalized patients diagnosed with COVID-19.⁷

• Screen patients for depression and delirium and utilize delirium prevention measures throughout the hospitalization.
• Educate patients about the signs and symptoms of loneliness, fear, and anxiety.
• Extend additional resources to patients, including books, magazines, and newspapers.
• Keep the patient’s cell or hospital phone within their reach.
• Adequately manage pain and prevent insomnia.
• Communicate frequently, utilizing audio- and visual-teleconferencing platforms that simultaneously include the patient and their loved ones.
• For patients who continue to exhibit feelings of loneliness despite the above interventions, consider consultations with psychiatry to offer additional coping strategies.
• Ensure a multidisciplinary approach when applicable – proactive consultation with the members of a palliative care team, ethics, spiritual health, social and ancillary services.

It is important to recognize how vulnerable our patients are. Diagnosed with COVID-19, and caught in the midst of the current pandemic, not only do they suffer from the physical effects of this novel disease, but they also have to endure prolonged confinement, social isolation, and uncertainty – all wrapped in a cloak of loneliness and fear.

With our main focus being on the management of a largely unknown viral illness, patients’ personal experiences can be easily overlooked. It is vital for us as health care providers on the front lines to recognize, reflect, and reform to ease our patients’ journey through COVID-19.

Dr. Burklin is an assistant professor of medicine, division of hospital medicine, at the department of medicine, Emory University, Atlanta. Dr. Wiley is an assistant professor of medicine, division of infectious disease, at the department of Medicine, Emory University, Atlanta.

References

1. Schlomann A et al. Use of information and communication technology (ICT) devices among the oldest-old: Loneliness, anomie, and autonomy. Innov Aging. 2020 Jan 1;4(2):igz050.

2. McGinty E et al. Psychological distress and loneliness reported by U.S. adults in 2018 and April 2020. JAMA. 2020 Jun 3. doi: 10.1001/jama.2020.9740. 3. Wang J et al. Associations between loneliness and perceived social support and outcomes of mental health problems: A systematic review. BMC Psychiatry. 2018 May 29;18(1):156.

4. Luo Y et al. Loneliness, health, and mortality in old age: A national longitudinal study. Soc Sci Med. 2012 Mar;74(6):907-14.

5. Smith KJ et al. The association between loneliness, social isolation, and inflammation: A systematic review and meta-analysis. Neurosci Biobehav Rev. 2020 Feb 21; 112:519-41.

6. Maunder R et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ. 2003 May 13;168(10):1245-51.

7. Masi CM et al. A meta-analysis of interventions to reduce loneliness. Pers Soc Psychol Rev. 2011 Aug;15(3):219-66.

During a busy morning of rounds, our patient, Mrs. M., appeared distraught. She was diagnosed with COVID-19 2 weeks prior and remained inpatient because of medicosocial reasons. Since admission she remained on the same ward, in the same room, cared for by the same group of providers donned in masks, gowns, gloves, and face shields. The personal protective equipment helped to shield us from the virus, but it also shielded Mrs. M. from us.

During initial interaction, Mrs. M. appeared anxious, tearful, and detached. It seemed that she recognized a new voice; however, she did not express much interest in engaging during the visit. When she realized that she was not being discharged, Mrs. M. appeared to lose further interest. She wanted to go home. Her outpatient dialysis arrangements were not complete, and that precluded hospital discharge. Prescribed anxiolytics were doing little to relieve her symptoms.

The next day, Mrs. M. continued to ask if she could go home. She stated that there was nothing for her to do while in the hospital. She was tired of watching TV, she was unable to call her friends, and was not able to see her family. Because of COVID-19 status, Mrs. M was not permitted to leave her hospital room, and she was transported to the dialysis unit via stretcher, being unable to walk. The more we talked, the more engaged Mrs. M. had become. When it was time to complete the encounter, Mrs. M. started pleading with us to “stay a little longer, please don’t leave.”

Throughout her hospitalization, Mrs. M. had an extremely limited number of human encounters. Those encounters were fragmented and brief, centered on the infection mitigation. The chaplain was not permitted to enter her room, and she was unwilling to use the phone. The subspecialty consultants utilized telemedicine visits. As a result, Mrs. M. felt isolated and lonely. Social distancing in the hospital makes human interactions particularly challenging and contributes to the development of isolation, loneliness, and fear.
 

Loneliness is real

Loneliness is the “subjective experience of involuntary social isolation.”¹ As the COVID-19 pandemic began to entrap the world in early 2020, many people have faced new challenges – loneliness and its impact on physical and mental health. The prevalence of loneliness nearly tripled in the early months of the pandemic, leading to psychological distress and reopening conversations on ethical issues.²

Ethical implications of loneliness

Social distancing challenges all four main ethical principles: autonomy, beneficence, nonmaleficence, and justice. How do we reconcile these principles from the standpoint of each affected individual, their caregivers, health care providers, and public health at large? How can we continue to mitigate the spread of COVID-19, but also remain attentive to our patients who are still in need of human interactions to recover and thrive?

Social distancing is important, but so is social interaction. What strategies do we have in place to combat loneliness? How do we help our hospitalized patients who feel connected to the “outside world?” Is battling loneliness worth the risks of additional exposure to COVID-19? These dilemmas cannot be easily resolved. However, it is important for us to recognize the negative impacts of loneliness and identify measures to help our patients.

In our mission to fulfill the beneficence and nonmaleficence principles of caring for patients affected by COVID-19, patients like Mrs. M. lose much of their autonomy during hospital admission. Despite our best efforts, our isolated patients during the pandemic, remain alone, which further heightens their feeling of loneliness.
 

 

Clinical implications of loneliness

With the advancements in technology, our capabilities to substitute personal human interactions have grown exponentially. The use of telemedicine, video- and audio-conferencing communications have changed the landscape of our capacities to exchange information. This could be a blessing and a curse. While the use of digital platforms for virtual communication is tempting, we should preserve human interactions as much as possible, particularly when caring for patients affected by COVID-19. Interpersonal “connectedness” plays a crucial role in providing psychological and psychotherapeutic support, particularly when the number of human encounters is already limited.

Social distancing requirements have magnified loneliness. Several studies demonstrate that the perception of loneliness leads to poor health outcomes, including lower immunity, increased peripheral vascular resistance,³ and higher overall mortality.⁴ Loneliness can lead to functional impairment, such as poor social skills, and even increased inflammation.⁵ The negative emotional impact of SARS-CoV-2 echoes the experiences of patients affected by the severe acute respiratory syndrome (SARS) outbreak in 2003. However, with COVID-19, we are witnessing the amplified effects of loneliness on a global scale. The majority of affected patients during the 2003 SARS outbreak in Canada reported loneliness, fear, aggression, and boredom: They had concerns about the impacts of the infection on loved ones, and psychological support was required for many patients with mild to moderate SARS disease.⁶
 

Nonpharmacological management strategies for battling loneliness

Utilization of early supportive services has been well described in literature and includes extending additional resources such as books, newspapers and, most importantly, additional in-person time to our patients.⁶ Maintaining rapport with patients’ families is also helpful in reducing anxiety and fear. The following measures have been suggested to prevent the negative impacts of loneliness and should be considered when caring for hospitalized patients diagnosed with COVID-19.⁷

• Screen patients for depression and delirium and utilize delirium prevention measures throughout the hospitalization.
• Educate patients about the signs and symptoms of loneliness, fear, and anxiety.
• Extend additional resources to patients, including books, magazines, and newspapers.
• Keep the patient’s cell or hospital phone within their reach.
• Adequately manage pain and prevent insomnia.
• Communicate frequently, utilizing audio- and visual-teleconferencing platforms that simultaneously include the patient and their loved ones.
• For patients who continue to exhibit feelings of loneliness despite the above interventions, consider consultations with psychiatry to offer additional coping strategies.
• Ensure a multidisciplinary approach when applicable – proactive consultation with the members of a palliative care team, ethics, spiritual health, social and ancillary services.

It is important to recognize how vulnerable our patients are. Diagnosed with COVID-19, and caught in the midst of the current pandemic, not only do they suffer from the physical effects of this novel disease, but they also have to endure prolonged confinement, social isolation, and uncertainty – all wrapped in a cloak of loneliness and fear.

With our main focus being on the management of a largely unknown viral illness, patients’ personal experiences can be easily overlooked. It is vital for us as health care providers on the front lines to recognize, reflect, and reform to ease our patients’ journey through COVID-19.

Dr. Burklin is an assistant professor of medicine, division of hospital medicine, at the department of medicine, Emory University, Atlanta. Dr. Wiley is an assistant professor of medicine, division of infectious disease, at the department of Medicine, Emory University, Atlanta.

References

1. Schlomann A et al. Use of information and communication technology (ICT) devices among the oldest-old: Loneliness, anomie, and autonomy. Innov Aging. 2020 Jan 1;4(2):igz050.

2. McGinty E et al. Psychological distress and loneliness reported by U.S. adults in 2018 and April 2020. JAMA. 2020 Jun 3. doi: 10.1001/jama.2020.9740. 3. Wang J et al. Associations between loneliness and perceived social support and outcomes of mental health problems: A systematic review. BMC Psychiatry. 2018 May 29;18(1):156.

4. Luo Y et al. Loneliness, health, and mortality in old age: A national longitudinal study. Soc Sci Med. 2012 Mar;74(6):907-14.

5. Smith KJ et al. The association between loneliness, social isolation, and inflammation: A systematic review and meta-analysis. Neurosci Biobehav Rev. 2020 Feb 21; 112:519-41.

6. Maunder R et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ. 2003 May 13;168(10):1245-51.

7. Masi CM et al. A meta-analysis of interventions to reduce loneliness. Pers Soc Psychol Rev. 2011 Aug;15(3):219-66.

During a busy morning of rounds, our patient, Mrs. M., appeared distraught. She was diagnosed with COVID-19 2 weeks prior and remained inpatient because of medicosocial reasons. Since admission she remained on the same ward, in the same room, cared for by the same group of providers donned in masks, gowns, gloves, and face shields. The personal protective equipment helped to shield us from the virus, but it also shielded Mrs. M. from us.

During initial interaction, Mrs. M. appeared anxious, tearful, and detached. It seemed that she recognized a new voice; however, she did not express much interest in engaging during the visit. When she realized that she was not being discharged, Mrs. M. appeared to lose further interest. She wanted to go home. Her outpatient dialysis arrangements were not complete, and that precluded hospital discharge. Prescribed anxiolytics were doing little to relieve her symptoms.

The next day, Mrs. M. continued to ask if she could go home. She stated that there was nothing for her to do while in the hospital. She was tired of watching TV, she was unable to call her friends, and was not able to see her family. Because of COVID-19 status, Mrs. M was not permitted to leave her hospital room, and she was transported to the dialysis unit via stretcher, being unable to walk. The more we talked, the more engaged Mrs. M. had become. When it was time to complete the encounter, Mrs. M. started pleading with us to “stay a little longer, please don’t leave.”

Throughout her hospitalization, Mrs. M. had an extremely limited number of human encounters. Those encounters were fragmented and brief, centered on the infection mitigation. The chaplain was not permitted to enter her room, and she was unwilling to use the phone. The subspecialty consultants utilized telemedicine visits. As a result, Mrs. M. felt isolated and lonely. Social distancing in the hospital makes human interactions particularly challenging and contributes to the development of isolation, loneliness, and fear.
 

Loneliness is real

Loneliness is the “subjective experience of involuntary social isolation.”¹ As the COVID-19 pandemic began to entrap the world in early 2020, many people have faced new challenges – loneliness and its impact on physical and mental health. The prevalence of loneliness nearly tripled in the early months of the pandemic, leading to psychological distress and reopening conversations on ethical issues.²

Ethical implications of loneliness

Social distancing challenges all four main ethical principles: autonomy, beneficence, nonmaleficence, and justice. How do we reconcile these principles from the standpoint of each affected individual, their caregivers, health care providers, and public health at large? How can we continue to mitigate the spread of COVID-19, but also remain attentive to our patients who are still in need of human interactions to recover and thrive?

Social distancing is important, but so is social interaction. What strategies do we have in place to combat loneliness? How do we help our hospitalized patients who feel connected to the “outside world?” Is battling loneliness worth the risks of additional exposure to COVID-19? These dilemmas cannot be easily resolved. However, it is important for us to recognize the negative impacts of loneliness and identify measures to help our patients.

In our mission to fulfill the beneficence and nonmaleficence principles of caring for patients affected by COVID-19, patients like Mrs. M. lose much of their autonomy during hospital admission. Despite our best efforts, our isolated patients during the pandemic, remain alone, which further heightens their feeling of loneliness.
 

 

Clinical implications of loneliness

With the advancements in technology, our capabilities to substitute personal human interactions have grown exponentially. The use of telemedicine, video- and audio-conferencing communications have changed the landscape of our capacities to exchange information. This could be a blessing and a curse. While the use of digital platforms for virtual communication is tempting, we should preserve human interactions as much as possible, particularly when caring for patients affected by COVID-19. Interpersonal “connectedness” plays a crucial role in providing psychological and psychotherapeutic support, particularly when the number of human encounters is already limited.

Social distancing requirements have magnified loneliness. Several studies demonstrate that the perception of loneliness leads to poor health outcomes, including lower immunity, increased peripheral vascular resistance,³ and higher overall mortality.⁴ Loneliness can lead to functional impairment, such as poor social skills, and even increased inflammation.⁵ The negative emotional impact of SARS-CoV-2 echoes the experiences of patients affected by the severe acute respiratory syndrome (SARS) outbreak in 2003. However, with COVID-19, we are witnessing the amplified effects of loneliness on a global scale. The majority of affected patients during the 2003 SARS outbreak in Canada reported loneliness, fear, aggression, and boredom: They had concerns about the impacts of the infection on loved ones, and psychological support was required for many patients with mild to moderate SARS disease.⁶
 

Nonpharmacological management strategies for battling loneliness

Utilization of early supportive services has been well described in literature and includes extending additional resources such as books, newspapers and, most importantly, additional in-person time to our patients.⁶ Maintaining rapport with patients’ families is also helpful in reducing anxiety and fear. The following measures have been suggested to prevent the negative impacts of loneliness and should be considered when caring for hospitalized patients diagnosed with COVID-19.⁷

• Screen patients for depression and delirium and utilize delirium prevention measures throughout the hospitalization.
• Educate patients about the signs and symptoms of loneliness, fear, and anxiety.
• Extend additional resources to patients, including books, magazines, and newspapers.
• Keep the patient’s cell or hospital phone within their reach.
• Adequately manage pain and prevent insomnia.
• Communicate frequently, utilizing audio- and visual-teleconferencing platforms that simultaneously include the patient and their loved ones.
• For patients who continue to exhibit feelings of loneliness despite the above interventions, consider consultations with psychiatry to offer additional coping strategies.
• Ensure a multidisciplinary approach when applicable – proactive consultation with the members of a palliative care team, ethics, spiritual health, social and ancillary services.

It is important to recognize how vulnerable our patients are. Diagnosed with COVID-19, and caught in the midst of the current pandemic, not only do they suffer from the physical effects of this novel disease, but they also have to endure prolonged confinement, social isolation, and uncertainty – all wrapped in a cloak of loneliness and fear.

With our main focus being on the management of a largely unknown viral illness, patients’ personal experiences can be easily overlooked. It is vital for us as health care providers on the front lines to recognize, reflect, and reform to ease our patients’ journey through COVID-19.

Dr. Burklin is an assistant professor of medicine, division of hospital medicine, at the department of medicine, Emory University, Atlanta. Dr. Wiley is an assistant professor of medicine, division of infectious disease, at the department of Medicine, Emory University, Atlanta.

References

1. Schlomann A et al. Use of information and communication technology (ICT) devices among the oldest-old: Loneliness, anomie, and autonomy. Innov Aging. 2020 Jan 1;4(2):igz050.

2. McGinty E et al. Psychological distress and loneliness reported by U.S. adults in 2018 and April 2020. JAMA. 2020 Jun 3. doi: 10.1001/jama.2020.9740. 3. Wang J et al. Associations between loneliness and perceived social support and outcomes of mental health problems: A systematic review. BMC Psychiatry. 2018 May 29;18(1):156.

4. Luo Y et al. Loneliness, health, and mortality in old age: A national longitudinal study. Soc Sci Med. 2012 Mar;74(6):907-14.

5. Smith KJ et al. The association between loneliness, social isolation, and inflammation: A systematic review and meta-analysis. Neurosci Biobehav Rev. 2020 Feb 21; 112:519-41.

6. Maunder R et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ. 2003 May 13;168(10):1245-51.

7. Masi CM et al. A meta-analysis of interventions to reduce loneliness. Pers Soc Psychol Rev. 2011 Aug;15(3):219-66.

Incorporating gender-nonconforming patients into practice can seem like a daunting task at first. However, obstetricians/gynecologists, midwives, and other advanced women’s health care practitioners can provide quality care for both transgender men and women. Basic preventative services such as routine health and cancer screening and testing for sexually transmitted infections does not require specialized training in transgender health. In fact, administration of hormonal therapy and some surgical interventions are well within the scope of practice of the general obstetrician/gynecologist, as long as the provider has undergone appropriate training to achieve expertise. For example, organizations such as the World Professional Association for Transgender Health (WPATH) not only provides standards of care regarding the treatment of transgender individuals, but they also have training and educational opportunities targeted at providers who wish to become certified in more advanced care of the transgender patient. If an obstetrician/gynecologist is interested in prescribing hormone therapy, seeking further training within the field is a must.

It is important to remember that the process by which transgender individuals express their gender is a spectrum. Not all patients who identify as transgender will seek hormone therapy or surgical procedures. However, even if a provider has not undergone more specific training to administer hormone therapy, it is still very important to have a basic understanding of the hormones, routes of administration, and side effects.

While cross-sex hormone therapy does differ in practice, compared with hormone replacement therapy in cisgender counterparts, the principles are relatively similar. Testosterone therapy is the mainstay treatment for transgender men who desire medical transition.^1,2 The overall goal of therapy is to achieve testosterone levels within the cisgender male physiologic range (300-1000 ng/dL). While the most common route of administration is subcutaneous or intramuscular injections in weekly, biweekly, or quarterly intervals, other routes may include daily transdermal patches and gels or oral formulations.1 Within the first few months of use, patients will notice signs of masculinization such as increased facial and body hair, increased muscle mass, increased libido, and amenorrhea. Other changes include male-pattern hair loss, clitoromegaly, redistribution of fat, voice deepening, and mood changes.¹

Hormone therapy for transgender women is a bit more complicated as estrogen alone will often not achieve feminizing characteristics that are satisfying for patients.³ Estrogen therapy can include oral formulations of 17-beta estradiol or conjugated estrogens, although the latter is typically avoided because of the marked increase in thromboembolic events. Estrogens can also be administered in sublingual, intramuscular, or transdermal forms. Antiandrogens are often required to help decrease endogenous testosterone levels to cisgender female levels (30-100 ng/dL).³ Spironolactone is most commonly prescribed as an adjunct to estrogen therapy. Finasteride and GnRH agonists like leuprolide acetate can also be added if spironolactone is not effective or not tolerated by the patient. Feminizing effects of estrogen can take several months and most commonly include decreased spontaneous erections, decreased libido, breast growth, redistribution of fat to the waist and hips, decreased skin oiliness, and softening of the skin.³

Overall, hormone therapy for both transgender men and women is considered effective, safe, and well tolerated.⁴ Monitoring is typically performed every 3 months within the first year after initiating hormone therapy, and then continued every 6-12 months thereafter. Routine screening for all organs and tissues present (e.g. prostate, breast) should be undertaken.³ While this simply highlights the therapy and surveillance for patients, it is important to remember that many transgender men and women will see an obstetrician/gynecologist at some interval during their transition. Ultimately, it is paramount that we as obstetricians/gynecologists have a basic understanding of the treatments available so we can provide our patients with competent and compassionate care.
 

Dr. Brandt is an obstetrician/gynecologist and a plastic surgeon at Reading Hospital/Tower Health System in West Reading, Pa., where she has developed a gender-affirming medical and surgical clinic for ob.gyn. residents and plastic surgeon fellows.

References

1. World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people. 7th version. Accessed 10/15/20.

2. Joint meeting of the International Society of Endocrinology and the Endocrine Society 2014; ICE/ENDO 2014, Paper 14354. Accessed 01/08/16.

3. Qian R, Safer JD. Hormone treatment for the adult transgender patient, in “Comprehensive Care of the Transgender Patient,” 1st ed. Philadelphia: Elsevier, 2020, pp. 34-6.

4. Weinand JD and Safer JD. Hormone therapy in transgender adults is safe with provider supervision: A review of hormone therapy sequelae for transgender individuals. J Clin Transl Endocrinol. 2015;2(2):55-60.
 

Incorporating gender-nonconforming patients into practice can seem like a daunting task at first. However, obstetricians/gynecologists, midwives, and other advanced women’s health care practitioners can provide quality care for both transgender men and women. Basic preventative services such as routine health and cancer screening and testing for sexually transmitted infections does not require specialized training in transgender health. In fact, administration of hormonal therapy and some surgical interventions are well within the scope of practice of the general obstetrician/gynecologist, as long as the provider has undergone appropriate training to achieve expertise. For example, organizations such as the World Professional Association for Transgender Health (WPATH) not only provides standards of care regarding the treatment of transgender individuals, but they also have training and educational opportunities targeted at providers who wish to become certified in more advanced care of the transgender patient. If an obstetrician/gynecologist is interested in prescribing hormone therapy, seeking further training within the field is a must.

It is important to remember that the process by which transgender individuals express their gender is a spectrum. Not all patients who identify as transgender will seek hormone therapy or surgical procedures. However, even if a provider has not undergone more specific training to administer hormone therapy, it is still very important to have a basic understanding of the hormones, routes of administration, and side effects.

While cross-sex hormone therapy does differ in practice, compared with hormone replacement therapy in cisgender counterparts, the principles are relatively similar. Testosterone therapy is the mainstay treatment for transgender men who desire medical transition.^1,2 The overall goal of therapy is to achieve testosterone levels within the cisgender male physiologic range (300-1000 ng/dL). While the most common route of administration is subcutaneous or intramuscular injections in weekly, biweekly, or quarterly intervals, other routes may include daily transdermal patches and gels or oral formulations.1 Within the first few months of use, patients will notice signs of masculinization such as increased facial and body hair, increased muscle mass, increased libido, and amenorrhea. Other changes include male-pattern hair loss, clitoromegaly, redistribution of fat, voice deepening, and mood changes.¹

Hormone therapy for transgender women is a bit more complicated as estrogen alone will often not achieve feminizing characteristics that are satisfying for patients.³ Estrogen therapy can include oral formulations of 17-beta estradiol or conjugated estrogens, although the latter is typically avoided because of the marked increase in thromboembolic events. Estrogens can also be administered in sublingual, intramuscular, or transdermal forms. Antiandrogens are often required to help decrease endogenous testosterone levels to cisgender female levels (30-100 ng/dL).³ Spironolactone is most commonly prescribed as an adjunct to estrogen therapy. Finasteride and GnRH agonists like leuprolide acetate can also be added if spironolactone is not effective or not tolerated by the patient. Feminizing effects of estrogen can take several months and most commonly include decreased spontaneous erections, decreased libido, breast growth, redistribution of fat to the waist and hips, decreased skin oiliness, and softening of the skin.³

Overall, hormone therapy for both transgender men and women is considered effective, safe, and well tolerated.⁴ Monitoring is typically performed every 3 months within the first year after initiating hormone therapy, and then continued every 6-12 months thereafter. Routine screening for all organs and tissues present (e.g. prostate, breast) should be undertaken.³ While this simply highlights the therapy and surveillance for patients, it is important to remember that many transgender men and women will see an obstetrician/gynecologist at some interval during their transition. Ultimately, it is paramount that we as obstetricians/gynecologists have a basic understanding of the treatments available so we can provide our patients with competent and compassionate care.
 

Dr. Brandt is an obstetrician/gynecologist and a plastic surgeon at Reading Hospital/Tower Health System in West Reading, Pa., where she has developed a gender-affirming medical and surgical clinic for ob.gyn. residents and plastic surgeon fellows.

References

1. World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people. 7th version. Accessed 10/15/20.

2. Joint meeting of the International Society of Endocrinology and the Endocrine Society 2014; ICE/ENDO 2014, Paper 14354. Accessed 01/08/16.

3. Qian R, Safer JD. Hormone treatment for the adult transgender patient, in “Comprehensive Care of the Transgender Patient,” 1st ed. Philadelphia: Elsevier, 2020, pp. 34-6.

4. Weinand JD and Safer JD. Hormone therapy in transgender adults is safe with provider supervision: A review of hormone therapy sequelae for transgender individuals. J Clin Transl Endocrinol. 2015;2(2):55-60.
 

Incorporating gender-nonconforming patients into practice can seem like a daunting task at first. However, obstetricians/gynecologists, midwives, and other advanced women’s health care practitioners can provide quality care for both transgender men and women. Basic preventative services such as routine health and cancer screening and testing for sexually transmitted infections does not require specialized training in transgender health. In fact, administration of hormonal therapy and some surgical interventions are well within the scope of practice of the general obstetrician/gynecologist, as long as the provider has undergone appropriate training to achieve expertise. For example, organizations such as the World Professional Association for Transgender Health (WPATH) not only provides standards of care regarding the treatment of transgender individuals, but they also have training and educational opportunities targeted at providers who wish to become certified in more advanced care of the transgender patient. If an obstetrician/gynecologist is interested in prescribing hormone therapy, seeking further training within the field is a must.

It is important to remember that the process by which transgender individuals express their gender is a spectrum. Not all patients who identify as transgender will seek hormone therapy or surgical procedures. However, even if a provider has not undergone more specific training to administer hormone therapy, it is still very important to have a basic understanding of the hormones, routes of administration, and side effects.

While cross-sex hormone therapy does differ in practice, compared with hormone replacement therapy in cisgender counterparts, the principles are relatively similar. Testosterone therapy is the mainstay treatment for transgender men who desire medical transition.^1,2 The overall goal of therapy is to achieve testosterone levels within the cisgender male physiologic range (300-1000 ng/dL). While the most common route of administration is subcutaneous or intramuscular injections in weekly, biweekly, or quarterly intervals, other routes may include daily transdermal patches and gels or oral formulations.1 Within the first few months of use, patients will notice signs of masculinization such as increased facial and body hair, increased muscle mass, increased libido, and amenorrhea. Other changes include male-pattern hair loss, clitoromegaly, redistribution of fat, voice deepening, and mood changes.¹

Hormone therapy for transgender women is a bit more complicated as estrogen alone will often not achieve feminizing characteristics that are satisfying for patients.³ Estrogen therapy can include oral formulations of 17-beta estradiol or conjugated estrogens, although the latter is typically avoided because of the marked increase in thromboembolic events. Estrogens can also be administered in sublingual, intramuscular, or transdermal forms. Antiandrogens are often required to help decrease endogenous testosterone levels to cisgender female levels (30-100 ng/dL).³ Spironolactone is most commonly prescribed as an adjunct to estrogen therapy. Finasteride and GnRH agonists like leuprolide acetate can also be added if spironolactone is not effective or not tolerated by the patient. Feminizing effects of estrogen can take several months and most commonly include decreased spontaneous erections, decreased libido, breast growth, redistribution of fat to the waist and hips, decreased skin oiliness, and softening of the skin.³

Overall, hormone therapy for both transgender men and women is considered effective, safe, and well tolerated.⁴ Monitoring is typically performed every 3 months within the first year after initiating hormone therapy, and then continued every 6-12 months thereafter. Routine screening for all organs and tissues present (e.g. prostate, breast) should be undertaken.³ While this simply highlights the therapy and surveillance for patients, it is important to remember that many transgender men and women will see an obstetrician/gynecologist at some interval during their transition. Ultimately, it is paramount that we as obstetricians/gynecologists have a basic understanding of the treatments available so we can provide our patients with competent and compassionate care.
 

Dr. Brandt is an obstetrician/gynecologist and a plastic surgeon at Reading Hospital/Tower Health System in West Reading, Pa., where she has developed a gender-affirming medical and surgical clinic for ob.gyn. residents and plastic surgeon fellows.

References

1. World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people. 7th version. Accessed 10/15/20.

2. Joint meeting of the International Society of Endocrinology and the Endocrine Society 2014; ICE/ENDO 2014, Paper 14354. Accessed 01/08/16.

3. Qian R, Safer JD. Hormone treatment for the adult transgender patient, in “Comprehensive Care of the Transgender Patient,” 1st ed. Philadelphia: Elsevier, 2020, pp. 34-6.

4. Weinand JD and Safer JD. Hormone therapy in transgender adults is safe with provider supervision: A review of hormone therapy sequelae for transgender individuals. J Clin Transl Endocrinol. 2015;2(2):55-60.
 

In reproductive medicine, there are few, if any, more pressing concerns from our patients than the biological clock, i.e., ovarian aging. While addressing this issue with women can be challenging, particularly for those who are anxious regarding their advanced maternal age, gynecologists must possess a thorough understanding of available diagnostic testing. This article will review the various methods to assess ovarian age and appropriate clinical management.

Ovarian reserve tests

Ovarian reserve represents the quality and quantity of oocytes. The former is defined by the woman’s chronologic age, which is the greatest predictor of fertility. From a peak monthly fecundity rate at age 30 of approximately 20%, the slow and steady decline of fertility ensues. Quantity represents the number of oocytes remaining from the original cohort.

Ovarian reserve is most provocatively gauged by the follicle response to gonadotropin stimulation, typically during an in vitro fertilization (IVF) cycle.

Several biomarkers have been used to assess ovarian age. These include FSH, estradiol, and inhibin B. In general, these tests are more specific than sensitive, i.e., “normal” results do not necessarily exclude decreased ovarian reserve. But as a screening tool for decreased ovarian reserve, the most important factor is the positive predictive value (PPV). Statistically, in a population of women at low risk for decreased ovarian reserve, the PPV will be low despite sensitivity and specificity.

While inhibin B is a more direct and earlier reflection of ovarian function produced by granulose cells, assays lacked consistent results and a standardized cut-off value. FSH is the last biomarker to be affected by decreased ovarian reserve so elevations reflect more “end-stage” ovarian aging.

Additional tests for decreased ovarian reserve include antral follicle count (AFC) and the clomiphene citrate challenge test (CCCT). AFC is determined by using transvaginal ultrasound to count the number of follicular cysts in the 2- to 9-mm range. While AFC can be performed on any day of the cycle, the ovary is most optimally measured on menses because of less cystic activity. A combined AFC of 3-6 is considered severe decreased ovarian reserve. The CCCT involves prescribing clomiphene citrate 100 mg daily from cycle day 5-9 to measure FSH on cycle days 3 and 10. An FSH level greater than 10 IU/L or any elevation in FSH following CCCT is considered decreased ovarian reserve.

FSH had been the standard but levels may dramatically change monthly, making testing only valuable if it is elevated. Consequently, antimüllerian hormone (AMH) and AFC are considered the most useful tools to determine decreased ovarian reserve because of less variability. The other distinct advantage is the ability to obtain AMH any day in the menstrual cycle. Recently, in women undergoing IVF, AMH was superior to FSH in predicting live birth, particularly when their values were discordant (J Ovarian Res. 2018;11:60). While there is no established consensus, the ideal interval for repeating AMH appears to be approximately 3 months (Obstet Gynecol 2016;127:65S-6S).
 

 

AMH

AMH is expressed in the embryo at 8 weeks by the Sertoli cells of the testis causing the female reproductive internal system (müllerian) to regress. Without AMH expression, the müllerian system remains and the male (woffian duct system) regresses. The discovery of AMH production by the granulosa cells of the ovary launched a new era in the evaluation and management of infertile women. First reported in Fertility & Sterility in 2002 as a much earlier potential marker of ovarian aging, low levels of AMH predict a lower number of eggs in IVF.

AMH levels are produced in the embryo at 36 weeks’ gestation and increase up to the age of 24.5 years, decreasing thereafter. AMH reflects primordial (early) follicles that are FSH independent. The median AMH level decreases per year according to age groups are: 0.25 ng/mL in ages 26-30; 0.2 ng/mL in ages 31-36 years; and 0.1 ng/mL above age 36. (PLOS ONE 2015 doi: 10.1371/journal.pone.0125216).

AMH has also been studied as a potential biomarker to diagnose PCOS. While many women with PCOS have elevated AMH levels (typically greater than 3 ng/mL), there is no consensus on an AMH value that would be a criterion.

Many women, particularly those electing to defer fertility, express interest in obtaining their AMH level to consider planned oocyte cryopreservation, AKA, social egg freezing. While it is possible the results of AMH screening may compel women to electively freeze their eggs, extensive counseling on the implications and pitfalls of AMH levels is essential. Further, AMH cannot be used to accurately predict menopause.
 

Predicting outcomes

No biomarker is necessarily predictive of pregnancy but more a gauge of gonadotropin dosage to induce multifollicular development. AMH is a great predictor of oocyte yield with IVF (J Assist Reprod Genet. 2009;26[7]:383-9). However, in women older than 35 undergoing IVF, low AMH levels have been shown to reduce pregnancy rates (J Hum Reprod Sci. 2017;10:24–30). During IVF cycle attempts, an ultra-low AMH (≤0.4) resulted in high cancellation rates, reduced the number of oocytes retrieved and embryos developed, and lowered pregnancy rates in women of advanced reproductive age.

Alternatively, a study of 750 women who were not infertile and were actively trying to conceive demonstrated no difference in natural pregnancy rates in women aged 30-44 irrespective of AMH levels (JAMA. 2017;318[14]:1367-76).

A special consideration is for cancer patients who are status postgonadotoxic chemotherapy. Their oocyte attrition can be accelerated and AMH levels can become profoundly low. In those patients, current data suggest there is a modest recovery of postchemotherapy AMH levels up to 1 year. Further, oocyte yield following stimulation may be higher than expected despite a poor AMH level.
 

Conclusion

Ovarian aging is currently best measured by combining chronologic age, AFC, and AMH. There is no current evidence that AMH levels should be used to exclude patients from undergoing IVF or to recommend egg donation. Random screening of AMH levels in a low-risk population for decreased ovarian reserve may result in unnecessary alarm.

Dr. Trolice is director of Fertility CARE - The IVF Center in Winter Park, Fla., and associate professor of obstetrics and gynecology at the University of Central Florida, Orlando.

In reproductive medicine, there are few, if any, more pressing concerns from our patients than the biological clock, i.e., ovarian aging. While addressing this issue with women can be challenging, particularly for those who are anxious regarding their advanced maternal age, gynecologists must possess a thorough understanding of available diagnostic testing. This article will review the various methods to assess ovarian age and appropriate clinical management.

Ovarian reserve tests

Ovarian reserve represents the quality and quantity of oocytes. The former is defined by the woman’s chronologic age, which is the greatest predictor of fertility. From a peak monthly fecundity rate at age 30 of approximately 20%, the slow and steady decline of fertility ensues. Quantity represents the number of oocytes remaining from the original cohort.

Ovarian reserve is most provocatively gauged by the follicle response to gonadotropin stimulation, typically during an in vitro fertilization (IVF) cycle.

Several biomarkers have been used to assess ovarian age. These include FSH, estradiol, and inhibin B. In general, these tests are more specific than sensitive, i.e., “normal” results do not necessarily exclude decreased ovarian reserve. But as a screening tool for decreased ovarian reserve, the most important factor is the positive predictive value (PPV). Statistically, in a population of women at low risk for decreased ovarian reserve, the PPV will be low despite sensitivity and specificity.

While inhibin B is a more direct and earlier reflection of ovarian function produced by granulose cells, assays lacked consistent results and a standardized cut-off value. FSH is the last biomarker to be affected by decreased ovarian reserve so elevations reflect more “end-stage” ovarian aging.

Additional tests for decreased ovarian reserve include antral follicle count (AFC) and the clomiphene citrate challenge test (CCCT). AFC is determined by using transvaginal ultrasound to count the number of follicular cysts in the 2- to 9-mm range. While AFC can be performed on any day of the cycle, the ovary is most optimally measured on menses because of less cystic activity. A combined AFC of 3-6 is considered severe decreased ovarian reserve. The CCCT involves prescribing clomiphene citrate 100 mg daily from cycle day 5-9 to measure FSH on cycle days 3 and 10. An FSH level greater than 10 IU/L or any elevation in FSH following CCCT is considered decreased ovarian reserve.

FSH had been the standard but levels may dramatically change monthly, making testing only valuable if it is elevated. Consequently, antimüllerian hormone (AMH) and AFC are considered the most useful tools to determine decreased ovarian reserve because of less variability. The other distinct advantage is the ability to obtain AMH any day in the menstrual cycle. Recently, in women undergoing IVF, AMH was superior to FSH in predicting live birth, particularly when their values were discordant (J Ovarian Res. 2018;11:60). While there is no established consensus, the ideal interval for repeating AMH appears to be approximately 3 months (Obstet Gynecol 2016;127:65S-6S).
 

 

AMH

AMH is expressed in the embryo at 8 weeks by the Sertoli cells of the testis causing the female reproductive internal system (müllerian) to regress. Without AMH expression, the müllerian system remains and the male (woffian duct system) regresses. The discovery of AMH production by the granulosa cells of the ovary launched a new era in the evaluation and management of infertile women. First reported in Fertility & Sterility in 2002 as a much earlier potential marker of ovarian aging, low levels of AMH predict a lower number of eggs in IVF.

AMH levels are produced in the embryo at 36 weeks’ gestation and increase up to the age of 24.5 years, decreasing thereafter. AMH reflects primordial (early) follicles that are FSH independent. The median AMH level decreases per year according to age groups are: 0.25 ng/mL in ages 26-30; 0.2 ng/mL in ages 31-36 years; and 0.1 ng/mL above age 36. (PLOS ONE 2015 doi: 10.1371/journal.pone.0125216).

AMH has also been studied as a potential biomarker to diagnose PCOS. While many women with PCOS have elevated AMH levels (typically greater than 3 ng/mL), there is no consensus on an AMH value that would be a criterion.

Many women, particularly those electing to defer fertility, express interest in obtaining their AMH level to consider planned oocyte cryopreservation, AKA, social egg freezing. While it is possible the results of AMH screening may compel women to electively freeze their eggs, extensive counseling on the implications and pitfalls of AMH levels is essential. Further, AMH cannot be used to accurately predict menopause.
 

Predicting outcomes

No biomarker is necessarily predictive of pregnancy but more a gauge of gonadotropin dosage to induce multifollicular development. AMH is a great predictor of oocyte yield with IVF (J Assist Reprod Genet. 2009;26[7]:383-9). However, in women older than 35 undergoing IVF, low AMH levels have been shown to reduce pregnancy rates (J Hum Reprod Sci. 2017;10:24–30). During IVF cycle attempts, an ultra-low AMH (≤0.4) resulted in high cancellation rates, reduced the number of oocytes retrieved and embryos developed, and lowered pregnancy rates in women of advanced reproductive age.

Alternatively, a study of 750 women who were not infertile and were actively trying to conceive demonstrated no difference in natural pregnancy rates in women aged 30-44 irrespective of AMH levels (JAMA. 2017;318[14]:1367-76).

A special consideration is for cancer patients who are status postgonadotoxic chemotherapy. Their oocyte attrition can be accelerated and AMH levels can become profoundly low. In those patients, current data suggest there is a modest recovery of postchemotherapy AMH levels up to 1 year. Further, oocyte yield following stimulation may be higher than expected despite a poor AMH level.
 

Conclusion

Ovarian aging is currently best measured by combining chronologic age, AFC, and AMH. There is no current evidence that AMH levels should be used to exclude patients from undergoing IVF or to recommend egg donation. Random screening of AMH levels in a low-risk population for decreased ovarian reserve may result in unnecessary alarm.

Dr. Trolice is director of Fertility CARE - The IVF Center in Winter Park, Fla., and associate professor of obstetrics and gynecology at the University of Central Florida, Orlando.

In reproductive medicine, there are few, if any, more pressing concerns from our patients than the biological clock, i.e., ovarian aging. While addressing this issue with women can be challenging, particularly for those who are anxious regarding their advanced maternal age, gynecologists must possess a thorough understanding of available diagnostic testing. This article will review the various methods to assess ovarian age and appropriate clinical management.

Ovarian reserve tests

Ovarian reserve represents the quality and quantity of oocytes. The former is defined by the woman’s chronologic age, which is the greatest predictor of fertility. From a peak monthly fecundity rate at age 30 of approximately 20%, the slow and steady decline of fertility ensues. Quantity represents the number of oocytes remaining from the original cohort.

Ovarian reserve is most provocatively gauged by the follicle response to gonadotropin stimulation, typically during an in vitro fertilization (IVF) cycle.

Several biomarkers have been used to assess ovarian age. These include FSH, estradiol, and inhibin B. In general, these tests are more specific than sensitive, i.e., “normal” results do not necessarily exclude decreased ovarian reserve. But as a screening tool for decreased ovarian reserve, the most important factor is the positive predictive value (PPV). Statistically, in a population of women at low risk for decreased ovarian reserve, the PPV will be low despite sensitivity and specificity.

While inhibin B is a more direct and earlier reflection of ovarian function produced by granulose cells, assays lacked consistent results and a standardized cut-off value. FSH is the last biomarker to be affected by decreased ovarian reserve so elevations reflect more “end-stage” ovarian aging.

Additional tests for decreased ovarian reserve include antral follicle count (AFC) and the clomiphene citrate challenge test (CCCT). AFC is determined by using transvaginal ultrasound to count the number of follicular cysts in the 2- to 9-mm range. While AFC can be performed on any day of the cycle, the ovary is most optimally measured on menses because of less cystic activity. A combined AFC of 3-6 is considered severe decreased ovarian reserve. The CCCT involves prescribing clomiphene citrate 100 mg daily from cycle day 5-9 to measure FSH on cycle days 3 and 10. An FSH level greater than 10 IU/L or any elevation in FSH following CCCT is considered decreased ovarian reserve.

FSH had been the standard but levels may dramatically change monthly, making testing only valuable if it is elevated. Consequently, antimüllerian hormone (AMH) and AFC are considered the most useful tools to determine decreased ovarian reserve because of less variability. The other distinct advantage is the ability to obtain AMH any day in the menstrual cycle. Recently, in women undergoing IVF, AMH was superior to FSH in predicting live birth, particularly when their values were discordant (J Ovarian Res. 2018;11:60). While there is no established consensus, the ideal interval for repeating AMH appears to be approximately 3 months (Obstet Gynecol 2016;127:65S-6S).
 

 

AMH

AMH is expressed in the embryo at 8 weeks by the Sertoli cells of the testis causing the female reproductive internal system (müllerian) to regress. Without AMH expression, the müllerian system remains and the male (woffian duct system) regresses. The discovery of AMH production by the granulosa cells of the ovary launched a new era in the evaluation and management of infertile women. First reported in Fertility & Sterility in 2002 as a much earlier potential marker of ovarian aging, low levels of AMH predict a lower number of eggs in IVF.

AMH levels are produced in the embryo at 36 weeks’ gestation and increase up to the age of 24.5 years, decreasing thereafter. AMH reflects primordial (early) follicles that are FSH independent. The median AMH level decreases per year according to age groups are: 0.25 ng/mL in ages 26-30; 0.2 ng/mL in ages 31-36 years; and 0.1 ng/mL above age 36. (PLOS ONE 2015 doi: 10.1371/journal.pone.0125216).

AMH has also been studied as a potential biomarker to diagnose PCOS. While many women with PCOS have elevated AMH levels (typically greater than 3 ng/mL), there is no consensus on an AMH value that would be a criterion.

Many women, particularly those electing to defer fertility, express interest in obtaining their AMH level to consider planned oocyte cryopreservation, AKA, social egg freezing. While it is possible the results of AMH screening may compel women to electively freeze their eggs, extensive counseling on the implications and pitfalls of AMH levels is essential. Further, AMH cannot be used to accurately predict menopause.
 

Predicting outcomes

No biomarker is necessarily predictive of pregnancy but more a gauge of gonadotropin dosage to induce multifollicular development. AMH is a great predictor of oocyte yield with IVF (J Assist Reprod Genet. 2009;26[7]:383-9). However, in women older than 35 undergoing IVF, low AMH levels have been shown to reduce pregnancy rates (J Hum Reprod Sci. 2017;10:24–30). During IVF cycle attempts, an ultra-low AMH (≤0.4) resulted in high cancellation rates, reduced the number of oocytes retrieved and embryos developed, and lowered pregnancy rates in women of advanced reproductive age.

Alternatively, a study of 750 women who were not infertile and were actively trying to conceive demonstrated no difference in natural pregnancy rates in women aged 30-44 irrespective of AMH levels (JAMA. 2017;318[14]:1367-76).

A special consideration is for cancer patients who are status postgonadotoxic chemotherapy. Their oocyte attrition can be accelerated and AMH levels can become profoundly low. In those patients, current data suggest there is a modest recovery of postchemotherapy AMH levels up to 1 year. Further, oocyte yield following stimulation may be higher than expected despite a poor AMH level.
 

Conclusion

Ovarian aging is currently best measured by combining chronologic age, AFC, and AMH. There is no current evidence that AMH levels should be used to exclude patients from undergoing IVF or to recommend egg donation. Random screening of AMH levels in a low-risk population for decreased ovarian reserve may result in unnecessary alarm.

Dr. Trolice is director of Fertility CARE - The IVF Center in Winter Park, Fla., and associate professor of obstetrics and gynecology at the University of Central Florida, Orlando.

Nearly 10 months since the onset of the COVID-19 pandemic in the United States, ICUs across the country are reaching maximum capacity and hospitalizations are outnumbering the available providers and staff to care for them. Clinicians everywhere are becoming exhausted and frustrated, and the world is all asking when an end to this pandemic will be in sight? The Food and Drug Administration issued emergency authorization for two multidose COVID-19 vaccines that are now being deployed across the country.

At this writing, 2.8 million Americans have received their first COVID-19 vaccine dose, a number far short of the projected 100 million. The limited production capacity and tiered distribution are the main determinants of who gets the vaccine and when, but a third and extremely important factor in whether people will choose to get vaccinated is their level of awareness of and trust in the scientific and medical processes behind wide-scale vaccination.

As medical professionals, many of us wouldn’t hesitate to get vaccinated against a pandemic virus. Concerns about safety and the integrity of the COVID-19 vaccine development process in light of the “warp speed” of its production has many Americans concerned about getting vaccinated. We may not be able to relate to some patients’ reluctance to receive a vaccine that has been confirmed by phase 3 clinical trials with collectively over 66,000 participants (nearly 10% African American in each study) to have an effectiveness of over 90%. We are so intimately familiar with the vaccine development process, the medical terminology used to describe these results and the effectiveness of vaccines overall in eliminating infectious diseases like polio and smallpox. To many of us, receiving the COVID-19 vaccine may be considered a no-brainer. However, and especially for BIPOC (Black, Indigenous, and people of color) patients with sickle cell disease or other hematologic disorders, the history of medical racism and a pattern of negative health care experiences have sown a distrust of the medical research community that spurs vaccine hesitancy despite the far-reaching impact of this pandemic.

I asked an African American friend of mine who is a pediatrician if she would get the vaccine, to which she replied: “People of color are already aware of the experiments and trials performed on our communities without the knowledge and informed consent of those being tested – many of whom were children, impoverished or disenfranchised – so while I personally will get vaccinated, I understand why some wouldn’t be as trusting.”

In December 2020, a poll by the Kaiser Family Foundation found that a primary factor behind COVID-19 vaccine hesitancy among Black respondents was the fear of catching the virus from the vaccine.¹ While this is an understandable concern for the general public, there needs to be a wide-reaching patient education effort to teach about the vaccine and how it was designed to work, (especially around the use of messenger RNA technology) so as to put such fears to rest and empower patients to go into this process as knowledgeable advocates for their own health.

With so many sources of information about the pandemic, there are just as many sources of misinformation being spouted by biased outlets on all sides of the political spectrum.

Physicians are most likely to influence their patients’ willingness to take the flu vaccine, accept treatment recommendations as well as potentially accept the COVID-19 vaccine. Our responsibility as care providers is to help our patients filter through the information and provide them with the tools, they need to understand what is fact and what is fiction. We are to answer their questions and concerns, correct any misunderstandings, and address their individual reasons for hesitancy. We must also pay particular attention to our BIPOC patient populations who may have unique reasons for declining the vaccine, compared with the general population. Our conversations should not only reassure patients that the vaccines currently available won’t give them COVID-19, but also address concerns about the efficacy and safety of the vaccine and reiterate that no corners were cut in the development and approval process.

As a hematologist I have had to become very comfortable with having uncomfortable conversations with my patients about the history of maltreatment and discrimination toward minorities in health care, while reassuring them of the current attempts to right those wrongs and the major wins we have had in research when it comes to adapting therapeutics to diverse populations for optimal outcomes.

The conversation about vaccine hesitancy should be held with patience and humility, acknowledging the past and validating patient concerns that will influence their decisions. We need to be more humane and relatable, and use real-world language to clearly share the facts without buzzwords and jargon that may confuse or even reinforce perceptions of lack of transparency.

I received my COVID-19 vaccine on Dec. 29, 2020, and my experience was similar to that of anyone else’s. I had the same concerns most of my patients and colleagues have expressed, but when I saw my sister share her “postvax selfie” on WhatsApp and discussed her experience with her, I felt more comfortable. I then spoke with my allergist, my primary care provider, my husband, and other people in my personal circles before I scheduled my appointment. After my first dose, I called my sister-in-law, a nurse in Canada, who expressed the same concerns that I had and was about to cancel her appointment for that afternoon. I shared my selfie, I shared my experience, and that afternoon she got her vaccine.

The best way to restore a fundamental trust in science and medicine in our patients is to relate to them as humans. Our patients need to know we have the same concerns and fears that they do and that sometimes we have just as many questions too. Communicating openly and authentically, not only with our patients but in all our spheres of influence, can help rebuild the relationship between the public and the health care system. By giving them a glimpse of our humanity, we can support each other as we hopefully eventually see an end to this pandemic.

Ifeyinwa (Ify) Osunkwo, MD, MPH, is a professor of medicine and the director of the Sickle Cell Disease Enterprise at the Levine Cancer Institute, Atrium Health, Charlotte, N.C. She is the editor in chief of Hematology News.

References

1. www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/

Nearly 10 months since the onset of the COVID-19 pandemic in the United States, ICUs across the country are reaching maximum capacity and hospitalizations are outnumbering the available providers and staff to care for them. Clinicians everywhere are becoming exhausted and frustrated, and the world is all asking when an end to this pandemic will be in sight? The Food and Drug Administration issued emergency authorization for two multidose COVID-19 vaccines that are now being deployed across the country.

At this writing, 2.8 million Americans have received their first COVID-19 vaccine dose, a number far short of the projected 100 million. The limited production capacity and tiered distribution are the main determinants of who gets the vaccine and when, but a third and extremely important factor in whether people will choose to get vaccinated is their level of awareness of and trust in the scientific and medical processes behind wide-scale vaccination.

As medical professionals, many of us wouldn’t hesitate to get vaccinated against a pandemic virus. Concerns about safety and the integrity of the COVID-19 vaccine development process in light of the “warp speed” of its production has many Americans concerned about getting vaccinated. We may not be able to relate to some patients’ reluctance to receive a vaccine that has been confirmed by phase 3 clinical trials with collectively over 66,000 participants (nearly 10% African American in each study) to have an effectiveness of over 90%. We are so intimately familiar with the vaccine development process, the medical terminology used to describe these results and the effectiveness of vaccines overall in eliminating infectious diseases like polio and smallpox. To many of us, receiving the COVID-19 vaccine may be considered a no-brainer. However, and especially for BIPOC (Black, Indigenous, and people of color) patients with sickle cell disease or other hematologic disorders, the history of medical racism and a pattern of negative health care experiences have sown a distrust of the medical research community that spurs vaccine hesitancy despite the far-reaching impact of this pandemic.

I asked an African American friend of mine who is a pediatrician if she would get the vaccine, to which she replied: “People of color are already aware of the experiments and trials performed on our communities without the knowledge and informed consent of those being tested – many of whom were children, impoverished or disenfranchised – so while I personally will get vaccinated, I understand why some wouldn’t be as trusting.”

In December 2020, a poll by the Kaiser Family Foundation found that a primary factor behind COVID-19 vaccine hesitancy among Black respondents was the fear of catching the virus from the vaccine.¹ While this is an understandable concern for the general public, there needs to be a wide-reaching patient education effort to teach about the vaccine and how it was designed to work, (especially around the use of messenger RNA technology) so as to put such fears to rest and empower patients to go into this process as knowledgeable advocates for their own health.

With so many sources of information about the pandemic, there are just as many sources of misinformation being spouted by biased outlets on all sides of the political spectrum.

Physicians are most likely to influence their patients’ willingness to take the flu vaccine, accept treatment recommendations as well as potentially accept the COVID-19 vaccine. Our responsibility as care providers is to help our patients filter through the information and provide them with the tools, they need to understand what is fact and what is fiction. We are to answer their questions and concerns, correct any misunderstandings, and address their individual reasons for hesitancy. We must also pay particular attention to our BIPOC patient populations who may have unique reasons for declining the vaccine, compared with the general population. Our conversations should not only reassure patients that the vaccines currently available won’t give them COVID-19, but also address concerns about the efficacy and safety of the vaccine and reiterate that no corners were cut in the development and approval process.

As a hematologist I have had to become very comfortable with having uncomfortable conversations with my patients about the history of maltreatment and discrimination toward minorities in health care, while reassuring them of the current attempts to right those wrongs and the major wins we have had in research when it comes to adapting therapeutics to diverse populations for optimal outcomes.

The conversation about vaccine hesitancy should be held with patience and humility, acknowledging the past and validating patient concerns that will influence their decisions. We need to be more humane and relatable, and use real-world language to clearly share the facts without buzzwords and jargon that may confuse or even reinforce perceptions of lack of transparency.

I received my COVID-19 vaccine on Dec. 29, 2020, and my experience was similar to that of anyone else’s. I had the same concerns most of my patients and colleagues have expressed, but when I saw my sister share her “postvax selfie” on WhatsApp and discussed her experience with her, I felt more comfortable. I then spoke with my allergist, my primary care provider, my husband, and other people in my personal circles before I scheduled my appointment. After my first dose, I called my sister-in-law, a nurse in Canada, who expressed the same concerns that I had and was about to cancel her appointment for that afternoon. I shared my selfie, I shared my experience, and that afternoon she got her vaccine.

The best way to restore a fundamental trust in science and medicine in our patients is to relate to them as humans. Our patients need to know we have the same concerns and fears that they do and that sometimes we have just as many questions too. Communicating openly and authentically, not only with our patients but in all our spheres of influence, can help rebuild the relationship between the public and the health care system. By giving them a glimpse of our humanity, we can support each other as we hopefully eventually see an end to this pandemic.

Ifeyinwa (Ify) Osunkwo, MD, MPH, is a professor of medicine and the director of the Sickle Cell Disease Enterprise at the Levine Cancer Institute, Atrium Health, Charlotte, N.C. She is the editor in chief of Hematology News.

References

1. www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/

Nearly 10 months since the onset of the COVID-19 pandemic in the United States, ICUs across the country are reaching maximum capacity and hospitalizations are outnumbering the available providers and staff to care for them. Clinicians everywhere are becoming exhausted and frustrated, and the world is all asking when an end to this pandemic will be in sight? The Food and Drug Administration issued emergency authorization for two multidose COVID-19 vaccines that are now being deployed across the country.

At this writing, 2.8 million Americans have received their first COVID-19 vaccine dose, a number far short of the projected 100 million. The limited production capacity and tiered distribution are the main determinants of who gets the vaccine and when, but a third and extremely important factor in whether people will choose to get vaccinated is their level of awareness of and trust in the scientific and medical processes behind wide-scale vaccination.

As medical professionals, many of us wouldn’t hesitate to get vaccinated against a pandemic virus. Concerns about safety and the integrity of the COVID-19 vaccine development process in light of the “warp speed” of its production has many Americans concerned about getting vaccinated. We may not be able to relate to some patients’ reluctance to receive a vaccine that has been confirmed by phase 3 clinical trials with collectively over 66,000 participants (nearly 10% African American in each study) to have an effectiveness of over 90%. We are so intimately familiar with the vaccine development process, the medical terminology used to describe these results and the effectiveness of vaccines overall in eliminating infectious diseases like polio and smallpox. To many of us, receiving the COVID-19 vaccine may be considered a no-brainer. However, and especially for BIPOC (Black, Indigenous, and people of color) patients with sickle cell disease or other hematologic disorders, the history of medical racism and a pattern of negative health care experiences have sown a distrust of the medical research community that spurs vaccine hesitancy despite the far-reaching impact of this pandemic.

I asked an African American friend of mine who is a pediatrician if she would get the vaccine, to which she replied: “People of color are already aware of the experiments and trials performed on our communities without the knowledge and informed consent of those being tested – many of whom were children, impoverished or disenfranchised – so while I personally will get vaccinated, I understand why some wouldn’t be as trusting.”

In December 2020, a poll by the Kaiser Family Foundation found that a primary factor behind COVID-19 vaccine hesitancy among Black respondents was the fear of catching the virus from the vaccine.¹ While this is an understandable concern for the general public, there needs to be a wide-reaching patient education effort to teach about the vaccine and how it was designed to work, (especially around the use of messenger RNA technology) so as to put such fears to rest and empower patients to go into this process as knowledgeable advocates for their own health.

With so many sources of information about the pandemic, there are just as many sources of misinformation being spouted by biased outlets on all sides of the political spectrum.

Physicians are most likely to influence their patients’ willingness to take the flu vaccine, accept treatment recommendations as well as potentially accept the COVID-19 vaccine. Our responsibility as care providers is to help our patients filter through the information and provide them with the tools, they need to understand what is fact and what is fiction. We are to answer their questions and concerns, correct any misunderstandings, and address their individual reasons for hesitancy. We must also pay particular attention to our BIPOC patient populations who may have unique reasons for declining the vaccine, compared with the general population. Our conversations should not only reassure patients that the vaccines currently available won’t give them COVID-19, but also address concerns about the efficacy and safety of the vaccine and reiterate that no corners were cut in the development and approval process.

As a hematologist I have had to become very comfortable with having uncomfortable conversations with my patients about the history of maltreatment and discrimination toward minorities in health care, while reassuring them of the current attempts to right those wrongs and the major wins we have had in research when it comes to adapting therapeutics to diverse populations for optimal outcomes.

The conversation about vaccine hesitancy should be held with patience and humility, acknowledging the past and validating patient concerns that will influence their decisions. We need to be more humane and relatable, and use real-world language to clearly share the facts without buzzwords and jargon that may confuse or even reinforce perceptions of lack of transparency.

I received my COVID-19 vaccine on Dec. 29, 2020, and my experience was similar to that of anyone else’s. I had the same concerns most of my patients and colleagues have expressed, but when I saw my sister share her “postvax selfie” on WhatsApp and discussed her experience with her, I felt more comfortable. I then spoke with my allergist, my primary care provider, my husband, and other people in my personal circles before I scheduled my appointment. After my first dose, I called my sister-in-law, a nurse in Canada, who expressed the same concerns that I had and was about to cancel her appointment for that afternoon. I shared my selfie, I shared my experience, and that afternoon she got her vaccine.

The best way to restore a fundamental trust in science and medicine in our patients is to relate to them as humans. Our patients need to know we have the same concerns and fears that they do and that sometimes we have just as many questions too. Communicating openly and authentically, not only with our patients but in all our spheres of influence, can help rebuild the relationship between the public and the health care system. By giving them a glimpse of our humanity, we can support each other as we hopefully eventually see an end to this pandemic.

Ifeyinwa (Ify) Osunkwo, MD, MPH, is a professor of medicine and the director of the Sickle Cell Disease Enterprise at the Levine Cancer Institute, Atrium Health, Charlotte, N.C. She is the editor in chief of Hematology News.

References

1. www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/

Recently I got a referral from another office and skimmed through it, as I always do, to make sure it’s something I handle in my little practice.

Overall it seemed pretty straightforward, but on page 3 were multiple notes that the patient adamantly refused to wear a mask to visits, or took one off as soon as she got back to an exam room and refused to put it back on. She also insisted on in-person, not video, visits. Staff members had documented that she told them masks were “stupid and worthless” and called people who insisted on them “idiots.”

I looked at the notes for a minute, then flagged them to indicate she is someone who shouldn’t be scheduled if she calls, forwarded them to my secretary, and moved on to my next patient.

Some might say this is discrimination, but I disagree. Although studies vary on the degree of efficacy, the overall data show that masks help prevent the wearer from spreading COVID-19 to others, to a lesser degree protect you from catching it from others, and are safe to use.

So I insist on patients wearing masks when they come to see me. The data on COVID-19 spreading through asymptomatic people is pretty solid, so those who say “I feel fine, so I don’t need to wear a mask” are only endangering others.

Certainly, people have the right to refuse masks, but currently the laws in my area require them in public, and I definitely require them in my little practice. I’m not calling the police if someone doesn’t wear one, but I’m not going to see them in my practice, either.

Like all other doctors, health care workers, and patients, I’m as susceptible to infectious disease as everyone else. If I’m sick, I can’t take care of others.

I’m not refusing to see the sick—far from it—but if I’m going to try to help you get better, then you should be willing to wear a mask to help protect me, too.

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

Recently I got a referral from another office and skimmed through it, as I always do, to make sure it’s something I handle in my little practice.

Overall it seemed pretty straightforward, but on page 3 were multiple notes that the patient adamantly refused to wear a mask to visits, or took one off as soon as she got back to an exam room and refused to put it back on. She also insisted on in-person, not video, visits. Staff members had documented that she told them masks were “stupid and worthless” and called people who insisted on them “idiots.”

I looked at the notes for a minute, then flagged them to indicate she is someone who shouldn’t be scheduled if she calls, forwarded them to my secretary, and moved on to my next patient.

Some might say this is discrimination, but I disagree. Although studies vary on the degree of efficacy, the overall data show that masks help prevent the wearer from spreading COVID-19 to others, to a lesser degree protect you from catching it from others, and are safe to use.

So I insist on patients wearing masks when they come to see me. The data on COVID-19 spreading through asymptomatic people is pretty solid, so those who say “I feel fine, so I don’t need to wear a mask” are only endangering others.

Certainly, people have the right to refuse masks, but currently the laws in my area require them in public, and I definitely require them in my little practice. I’m not calling the police if someone doesn’t wear one, but I’m not going to see them in my practice, either.

Like all other doctors, health care workers, and patients, I’m as susceptible to infectious disease as everyone else. If I’m sick, I can’t take care of others.

I’m not refusing to see the sick—far from it—but if I’m going to try to help you get better, then you should be willing to wear a mask to help protect me, too.

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

Recently I got a referral from another office and skimmed through it, as I always do, to make sure it’s something I handle in my little practice.

Overall it seemed pretty straightforward, but on page 3 were multiple notes that the patient adamantly refused to wear a mask to visits, or took one off as soon as she got back to an exam room and refused to put it back on. She also insisted on in-person, not video, visits. Staff members had documented that she told them masks were “stupid and worthless” and called people who insisted on them “idiots.”

I looked at the notes for a minute, then flagged them to indicate she is someone who shouldn’t be scheduled if she calls, forwarded them to my secretary, and moved on to my next patient.

Some might say this is discrimination, but I disagree. Although studies vary on the degree of efficacy, the overall data show that masks help prevent the wearer from spreading COVID-19 to others, to a lesser degree protect you from catching it from others, and are safe to use.

So I insist on patients wearing masks when they come to see me. The data on COVID-19 spreading through asymptomatic people is pretty solid, so those who say “I feel fine, so I don’t need to wear a mask” are only endangering others.

Certainly, people have the right to refuse masks, but currently the laws in my area require them in public, and I definitely require them in my little practice. I’m not calling the police if someone doesn’t wear one, but I’m not going to see them in my practice, either.

Like all other doctors, health care workers, and patients, I’m as susceptible to infectious disease as everyone else. If I’m sick, I can’t take care of others.

I’m not refusing to see the sick—far from it—but if I’m going to try to help you get better, then you should be willing to wear a mask to help protect me, too.

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

When we went to medical school, how many of us thought we would practice through a pandemic? For most of us, 2020 was the most challenging professional year of our lives. As a psychiatrist, I found it particularly odd to be struggling with the same issues as all of my patients and to have all my patients in crisis at the same time. I was repeatedly asked by friends, “How are your patients doing?” My reply, “About the same as the rest of us.” After a period of adapting, I felt truly blessed to be able to practice online. I know many of my colleagues did not have that luxury, and the stress you endured is hard to fathom.

Yet, as Friedrich Nietzsche said in so many words, “What doesn’t kill you, makes you stronger,” and here we are in a new year. As we enter 2021, we know so much more about COVID-19 than we did mere months ago, and many of us have been fortunate enough to be vaccinated already.

We should be very proud of our medical and scientific community, which has worked so hard to prevent and treat COVID-19. It is indeed a miracle of modern medicine that two vaccines made their way through development to distribution in under a year. It is a great relief that health care workers are first in line: Of the 4 million vaccine doses given worldwide, 2 million were to U.S. medical personnel. We can now track the number of people vaccinated around the globe.

Yet, “the darkest hour is just before the dawn.” We are currently in the riskiest part of the pandemic, and we must continue to work hard.

RelaxFoto.de/Getty Images

As 2021 progresses, we can expect to begin the long recovery process. We know we are innately wired to adapt to adversity and are therefore resilient. The key is to tap into this wiring by developing behaviors, habits, and strategies that support us.

Posttraumatic growth (PTG) is a theory in mental health that explains a kind of transformation following trauma. It was developed by psychologists Richard Tedeschi, PhD, and Lawrence Calhoun, PhD, in the mid-1990s. They studied how people experienced positive growth following adversity. Dr. Tedeschi has said: “People develop new understandings of themselves, the world they live in, how to relate to other people, the kind of future they might have and a better understanding of how to live life.” One-half to two-thirds of individuals experiencing trauma will experience PTG. Given that our entire profession has gone through this collective trauma, far better times may indeed be ahead.

Resilience expert Eva Selhub, MD, suggests cultivating these six pillars:

• Physical vitality: The toll of 2020 has been enormous. If we are to rebound, we must care for ourselves. In our training, we were taught to put our health aside and work grueling hours. But to recover from trauma, we must attend to our own needs. Even after we are vaccinated, we must keep our nutritional status and immunity functioning at optimal levels. Let’s not get COVID-19 complacency. Clearly, health matters most. Ours included!
• Mental toughness: We made it through an incredibly grueling year, and we had to “build it as we sailed.” We figured out how to save as many lives as we could and simultaneously keep ourselves and our families safe. We have seen things previously unimaginable. We have adjusted to telemedicine. We have lived with far fewer pleasures. We have cultivated multiple ways to tame our anxieties. The year 2020 is one we can be proud of for ourselves and our colleagues. We have come a long way in a short time.
• Emotional balance: Anxiety and depression were easy to fall into in 2020. But as the pandemic subsides, the pendulum will swing the other way. The 1918 pandemic gave rise to the Roaring Twenties. What will the next chapter in our civilization bring? We can choose to actively cultivate positive emotions, such as joy, gratitude, and optimism as we move forward.
• Loving and strong connections. Our relationships are what give depth and meaning to our lives, and these relationships are crucial now so we can heal. How can we nourish our connections? What toll has the pandemic taken on those closest to you? Did some friends or family step up and help? Can we move out of our caretaker role and allow others to care for us?
• Spiritual connection: Facing so much grief and suffering, we have had an opportunity to look at our own lives from a different perspective. It has been an important year for reflection. How can we cultivate a deeper appreciation recognizing that every day is truly a gift? Did you find more purpose in your work last year? What sustained you in your time of need?
• Inspiring leadership: As health care professionals, we must set an example. We must show our patients and our families how resilient we can be. Let’s grow from trauma and avoid succumbing to depression, self-destructive tendencies, and divisiveness. We must continue to care for ourselves, our patients, and our community and work together to ensure a brighter and safer future for all.

Wishing you a safe, happy and healthy 2021.



“I am not what happened to me, I am what I choose to become.”

– Carl Jung, PhD
 

Dr. Ritvo, a psychiatrist with more than 25 years’ experience, practices in Miami Beach. She is the author of “Bekindr – The Transformative Power of Kindness” (Hellertown, Pa.: Mimosa Publishing, 2018). She has no conflicts of interest.

When we went to medical school, how many of us thought we would practice through a pandemic? For most of us, 2020 was the most challenging professional year of our lives. As a psychiatrist, I found it particularly odd to be struggling with the same issues as all of my patients and to have all my patients in crisis at the same time. I was repeatedly asked by friends, “How are your patients doing?” My reply, “About the same as the rest of us.” After a period of adapting, I felt truly blessed to be able to practice online. I know many of my colleagues did not have that luxury, and the stress you endured is hard to fathom.

Yet, as Friedrich Nietzsche said in so many words, “What doesn’t kill you, makes you stronger,” and here we are in a new year. As we enter 2021, we know so much more about COVID-19 than we did mere months ago, and many of us have been fortunate enough to be vaccinated already.

We should be very proud of our medical and scientific community, which has worked so hard to prevent and treat COVID-19. It is indeed a miracle of modern medicine that two vaccines made their way through development to distribution in under a year. It is a great relief that health care workers are first in line: Of the 4 million vaccine doses given worldwide, 2 million were to U.S. medical personnel. We can now track the number of people vaccinated around the globe.

Yet, “the darkest hour is just before the dawn.” We are currently in the riskiest part of the pandemic, and we must continue to work hard.

RelaxFoto.de/Getty Images

As 2021 progresses, we can expect to begin the long recovery process. We know we are innately wired to adapt to adversity and are therefore resilient. The key is to tap into this wiring by developing behaviors, habits, and strategies that support us.

Posttraumatic growth (PTG) is a theory in mental health that explains a kind of transformation following trauma. It was developed by psychologists Richard Tedeschi, PhD, and Lawrence Calhoun, PhD, in the mid-1990s. They studied how people experienced positive growth following adversity. Dr. Tedeschi has said: “People develop new understandings of themselves, the world they live in, how to relate to other people, the kind of future they might have and a better understanding of how to live life.” One-half to two-thirds of individuals experiencing trauma will experience PTG. Given that our entire profession has gone through this collective trauma, far better times may indeed be ahead.

Resilience expert Eva Selhub, MD, suggests cultivating these six pillars:

• Physical vitality: The toll of 2020 has been enormous. If we are to rebound, we must care for ourselves. In our training, we were taught to put our health aside and work grueling hours. But to recover from trauma, we must attend to our own needs. Even after we are vaccinated, we must keep our nutritional status and immunity functioning at optimal levels. Let’s not get COVID-19 complacency. Clearly, health matters most. Ours included!
• Mental toughness: We made it through an incredibly grueling year, and we had to “build it as we sailed.” We figured out how to save as many lives as we could and simultaneously keep ourselves and our families safe. We have seen things previously unimaginable. We have adjusted to telemedicine. We have lived with far fewer pleasures. We have cultivated multiple ways to tame our anxieties. The year 2020 is one we can be proud of for ourselves and our colleagues. We have come a long way in a short time.
• Emotional balance: Anxiety and depression were easy to fall into in 2020. But as the pandemic subsides, the pendulum will swing the other way. The 1918 pandemic gave rise to the Roaring Twenties. What will the next chapter in our civilization bring? We can choose to actively cultivate positive emotions, such as joy, gratitude, and optimism as we move forward.
• Loving and strong connections. Our relationships are what give depth and meaning to our lives, and these relationships are crucial now so we can heal. How can we nourish our connections? What toll has the pandemic taken on those closest to you? Did some friends or family step up and help? Can we move out of our caretaker role and allow others to care for us?
• Spiritual connection: Facing so much grief and suffering, we have had an opportunity to look at our own lives from a different perspective. It has been an important year for reflection. How can we cultivate a deeper appreciation recognizing that every day is truly a gift? Did you find more purpose in your work last year? What sustained you in your time of need?
• Inspiring leadership: As health care professionals, we must set an example. We must show our patients and our families how resilient we can be. Let’s grow from trauma and avoid succumbing to depression, self-destructive tendencies, and divisiveness. We must continue to care for ourselves, our patients, and our community and work together to ensure a brighter and safer future for all.

Wishing you a safe, happy and healthy 2021.



“I am not what happened to me, I am what I choose to become.”

– Carl Jung, PhD
 

Dr. Ritvo, a psychiatrist with more than 25 years’ experience, practices in Miami Beach. She is the author of “Bekindr – The Transformative Power of Kindness” (Hellertown, Pa.: Mimosa Publishing, 2018). She has no conflicts of interest.

When we went to medical school, how many of us thought we would practice through a pandemic? For most of us, 2020 was the most challenging professional year of our lives. As a psychiatrist, I found it particularly odd to be struggling with the same issues as all of my patients and to have all my patients in crisis at the same time. I was repeatedly asked by friends, “How are your patients doing?” My reply, “About the same as the rest of us.” After a period of adapting, I felt truly blessed to be able to practice online. I know many of my colleagues did not have that luxury, and the stress you endured is hard to fathom.

Yet, as Friedrich Nietzsche said in so many words, “What doesn’t kill you, makes you stronger,” and here we are in a new year. As we enter 2021, we know so much more about COVID-19 than we did mere months ago, and many of us have been fortunate enough to be vaccinated already.

We should be very proud of our medical and scientific community, which has worked so hard to prevent and treat COVID-19. It is indeed a miracle of modern medicine that two vaccines made their way through development to distribution in under a year. It is a great relief that health care workers are first in line: Of the 4 million vaccine doses given worldwide, 2 million were to U.S. medical personnel. We can now track the number of people vaccinated around the globe.

Yet, “the darkest hour is just before the dawn.” We are currently in the riskiest part of the pandemic, and we must continue to work hard.

RelaxFoto.de/Getty Images

As 2021 progresses, we can expect to begin the long recovery process. We know we are innately wired to adapt to adversity and are therefore resilient. The key is to tap into this wiring by developing behaviors, habits, and strategies that support us.

Posttraumatic growth (PTG) is a theory in mental health that explains a kind of transformation following trauma. It was developed by psychologists Richard Tedeschi, PhD, and Lawrence Calhoun, PhD, in the mid-1990s. They studied how people experienced positive growth following adversity. Dr. Tedeschi has said: “People develop new understandings of themselves, the world they live in, how to relate to other people, the kind of future they might have and a better understanding of how to live life.” One-half to two-thirds of individuals experiencing trauma will experience PTG. Given that our entire profession has gone through this collective trauma, far better times may indeed be ahead.

Resilience expert Eva Selhub, MD, suggests cultivating these six pillars:

• Physical vitality: The toll of 2020 has been enormous. If we are to rebound, we must care for ourselves. In our training, we were taught to put our health aside and work grueling hours. But to recover from trauma, we must attend to our own needs. Even after we are vaccinated, we must keep our nutritional status and immunity functioning at optimal levels. Let’s not get COVID-19 complacency. Clearly, health matters most. Ours included!
• Mental toughness: We made it through an incredibly grueling year, and we had to “build it as we sailed.” We figured out how to save as many lives as we could and simultaneously keep ourselves and our families safe. We have seen things previously unimaginable. We have adjusted to telemedicine. We have lived with far fewer pleasures. We have cultivated multiple ways to tame our anxieties. The year 2020 is one we can be proud of for ourselves and our colleagues. We have come a long way in a short time.
• Emotional balance: Anxiety and depression were easy to fall into in 2020. But as the pandemic subsides, the pendulum will swing the other way. The 1918 pandemic gave rise to the Roaring Twenties. What will the next chapter in our civilization bring? We can choose to actively cultivate positive emotions, such as joy, gratitude, and optimism as we move forward.
• Loving and strong connections. Our relationships are what give depth and meaning to our lives, and these relationships are crucial now so we can heal. How can we nourish our connections? What toll has the pandemic taken on those closest to you? Did some friends or family step up and help? Can we move out of our caretaker role and allow others to care for us?
• Spiritual connection: Facing so much grief and suffering, we have had an opportunity to look at our own lives from a different perspective. It has been an important year for reflection. How can we cultivate a deeper appreciation recognizing that every day is truly a gift? Did you find more purpose in your work last year? What sustained you in your time of need?
• Inspiring leadership: As health care professionals, we must set an example. We must show our patients and our families how resilient we can be. Let’s grow from trauma and avoid succumbing to depression, self-destructive tendencies, and divisiveness. We must continue to care for ourselves, our patients, and our community and work together to ensure a brighter and safer future for all.

Wishing you a safe, happy and healthy 2021.



“I am not what happened to me, I am what I choose to become.”

– Carl Jung, PhD
 

Dr. Ritvo, a psychiatrist with more than 25 years’ experience, practices in Miami Beach. She is the author of “Bekindr – The Transformative Power of Kindness” (Hellertown, Pa.: Mimosa Publishing, 2018). She has no conflicts of interest.