Opinion

Happy New Year! We all are counting on 2021 to be much different and better than 2020. As politics and politicians enhance divisiveness in our country, science and scientists will save us. The power of collective science, careful data analysis, and cautious interpretation has never been more evident than during this pandemic. Unfortunately, we still are learning the most effective means of communicating scientific knowledge where development is iterative and rarely definitive in the early stages of hypothesis testing. Once again, we see the destructive power and effectiveness of the techniques detailed in The Merchants of Doubt.

I choose to focus on successes of scientists and our care delivery workforce. In a mere 11 months, researchers created a new vaccine methodology, tested its safety and efficacy against COVID-19, and provided it to experts building the logistic infrastructure to vaccinate billions of people. Simultaneously, thousands of health care workers risked their lives in a daily battle against Coronavirus and saved countless lives. This is why we became scientists and providers.

I had difficulty choosing page one articles this month because of the wealth of material. On page one, we read about the most dramatic changes to Medicare E/M documentation in the last 30 years (resulting in an estimated 4% decrease in overall GI reimbursements). Another article reports on real reductions in liver-related deaths in states that expanded Medicaid coverage, once again demonstrating that we save lives if people have access to health care. The third article on page one discusses seronegative enteropathy – a difficult diagnosis but one with emerging answers.

Elsewhere in GI and Hepatology News, read about best practices to care for elderly IBD patients, EUS interventional advances, and interesting information that may lead to more targeted obesity therapies.

Articles highlighted above and others in this month’s issue show us that scientific inquiry, research and solution-finding is alive and well.

“The good thing about science is that it’s true whether or not you believe in it.” -- Neil deGrasse Tyson

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

Happy New Year! We all are counting on 2021 to be much different and better than 2020. As politics and politicians enhance divisiveness in our country, science and scientists will save us. The power of collective science, careful data analysis, and cautious interpretation has never been more evident than during this pandemic. Unfortunately, we still are learning the most effective means of communicating scientific knowledge where development is iterative and rarely definitive in the early stages of hypothesis testing. Once again, we see the destructive power and effectiveness of the techniques detailed in The Merchants of Doubt.

I choose to focus on successes of scientists and our care delivery workforce. In a mere 11 months, researchers created a new vaccine methodology, tested its safety and efficacy against COVID-19, and provided it to experts building the logistic infrastructure to vaccinate billions of people. Simultaneously, thousands of health care workers risked their lives in a daily battle against Coronavirus and saved countless lives. This is why we became scientists and providers.

I had difficulty choosing page one articles this month because of the wealth of material. On page one, we read about the most dramatic changes to Medicare E/M documentation in the last 30 years (resulting in an estimated 4% decrease in overall GI reimbursements). Another article reports on real reductions in liver-related deaths in states that expanded Medicaid coverage, once again demonstrating that we save lives if people have access to health care. The third article on page one discusses seronegative enteropathy – a difficult diagnosis but one with emerging answers.

Elsewhere in GI and Hepatology News, read about best practices to care for elderly IBD patients, EUS interventional advances, and interesting information that may lead to more targeted obesity therapies.

Articles highlighted above and others in this month’s issue show us that scientific inquiry, research and solution-finding is alive and well.

“The good thing about science is that it’s true whether or not you believe in it.” -- Neil deGrasse Tyson

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

Happy New Year! We all are counting on 2021 to be much different and better than 2020. As politics and politicians enhance divisiveness in our country, science and scientists will save us. The power of collective science, careful data analysis, and cautious interpretation has never been more evident than during this pandemic. Unfortunately, we still are learning the most effective means of communicating scientific knowledge where development is iterative and rarely definitive in the early stages of hypothesis testing. Once again, we see the destructive power and effectiveness of the techniques detailed in The Merchants of Doubt.

I choose to focus on successes of scientists and our care delivery workforce. In a mere 11 months, researchers created a new vaccine methodology, tested its safety and efficacy against COVID-19, and provided it to experts building the logistic infrastructure to vaccinate billions of people. Simultaneously, thousands of health care workers risked their lives in a daily battle against Coronavirus and saved countless lives. This is why we became scientists and providers.

I had difficulty choosing page one articles this month because of the wealth of material. On page one, we read about the most dramatic changes to Medicare E/M documentation in the last 30 years (resulting in an estimated 4% decrease in overall GI reimbursements). Another article reports on real reductions in liver-related deaths in states that expanded Medicaid coverage, once again demonstrating that we save lives if people have access to health care. The third article on page one discusses seronegative enteropathy – a difficult diagnosis but one with emerging answers.

Elsewhere in GI and Hepatology News, read about best practices to care for elderly IBD patients, EUS interventional advances, and interesting information that may lead to more targeted obesity therapies.

Articles highlighted above and others in this month’s issue show us that scientific inquiry, research and solution-finding is alive and well.

“The good thing about science is that it’s true whether or not you believe in it.” -- Neil deGrasse Tyson

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

In mid-April, a month into pandemic life with a stay-at-home order, I wrote about my experiences as a virtual outpatient psychiatrist in private practice. It’s been 10 months now and with this tragic year drawing to a close, it seems like a good time for an update.

FatCamera/E+

In that April column, I describe how I created a makeshift home office. This entailed pushing my son’s baseball card collection and dusty sports trophies to the side of the room, bringing in a desk and a rug, a house plant, and a statue of a Buddha. I enjoyed watching out the window behind my computer screen as the neighbors and their dogs walked by, and I loved seeing the tree out the window blossom into gorgeous flowers.

With time, my physical space has changed. The remnants of my son’s childhood have all been moved to a closet, artwork has been added to the wall behind me, and the space is now clearly an office, though my laptop remains propped on a pile of books so that no one is looking up my nose. The room, with four large windows facing north and west, has issues with temperature control. In an old house, the heat works all too well in the adjacent bedroom (while the rest of the occupants in other rooms freeze), but the office itself has no heat: I have added both a fan and a space heater, and there are some very cold days where I’ve propped open one of the windows. And with the shortened days, large windows on two walls have presented a challenge as the sun changes positions throughout the day – there are times when the sun’s rays streak across my face in such a way that I look rather ethereal, and between sessions I have lowered, raised, and adjusted the blinds to avoid this. I finally pulled off the thin metal venetian blinds and took them to Lowe’s, where a partially masked young woman cut me new blinds with larger slats. An ergonomic office chair has replaced the wicker Ikea chair I was using, and between all these machinations, I am now physically comfortable most of the time. I believe I am still a bit too pixelated on the screen, but my patients are not complaining, and when the natural lighting fades at 4:30 p.m., the overhead lighting is all wrong again. These all are things I never considered – or long ago addressed – in my real-life practice of psychiatry in a office I have loved for years.

With time, I’ve grown more comfortable working from home on a screen and there are things about this life I’ve grown to like. My husband no longer travels, my daughter – my gift of the pandemic – returned home from New York City where she was in her final months of graduate school, and these unexpected months with her (and her cat) have been a pleasure. There is something nice about being trapped at home with people I love, even if we are all in our respective places, in front of our separate screens. There has been time for long walks, trips to the beach, and long bike rides. And as my daughter now prepares to move to Denver, I have been heartened by the hope of vaccines, and the knowledge that I will likely be able to see her again in the coming months. The people are not the only ones who have benefited from this time at home together – I have no idea how we would have managed with our elderly dog if we were not home to care for him.

My life has become more efficient. I used to find myself aggravated when patients forgot their appointments, a not-infrequent occurrence. “No shows” are now extremely rare – if a patient forgets, I call and they sign on to their screen and have their session. People no longer get caught in traffic, they come on time, and they don’t complain about my crowded parking lot. When there is down time, I use it more efficiently at home – a load of laundry gets done, I get a chance to turn on the news or exercise, or make dinner early. And because I have two other family members working from home, I am not the only one mixing work with chores or exercise.

While my medical colleagues who work in settings where they must see patients in person have struggled or functioned in some state of denial, I have felt safe and protected, a bit cocooned with my family in a house big enough to give us all space, in a neighborhood with sidewalks and places to walk, and to protect my sanity, I am lucky to have a patio that has now been equipped with lights, patio heaters, a fire pit, and socially distanced tables so that I can still see friends outside.

Telemedicine has added a new dimension to treatment. I’ve had family sessions with multiple people joining a zoom link from different locations – so much easier than coordinating a time when everyone can travel to my office. I’ve had patients call in from cars and from closets in search of privacy, and from their gardens and poolsides. I’ve met spouses, children, many a dog and cat, plus the more unusual of pets and farm animals, including a goat, ferret, lizard, African grey parrot, and guinea pigs.

These are the good things, and while I wish I could say it was all good, so much of what remains is laden with anxiety. My son lives nearby, but he has shared a house with a hospital worker for much of the past year and there were COVID scares, months at a time without so much as a hug, and my husband has not seen his parents or brother for a year now. There are the awkward waves or salutes with friends I once gave carefree hugs, the constant thoughts of how far away is that person standing, and each person’s “beliefs” about what is safe when we still don’t fully understand how this virus spreads. I worry for myself, I worry for my family and friends, and I worry for my patients when they tell me about behaviors that clearly are not safe.

At first, I found my work as a telepsychiatrist to be exhausting, and I assumed it was because my patients were now just faces, inches from my own eyes, and no longer diffused by a visual field that included my whole office and the opportunity to break eye contact while I still listened with full attention. This has gotten much better – I’ve adjusted to my on-screen relationships, but what has not gotten better is both the acuity, and sometimes the boredom.

Patients are struggling; they are sad, lonely, and missing the richness of their former lives. They miss friends, meeting new people, cultural experiences, diversity in how they spend their time, and travel. They have all the same human experiences of loss, illness, and grief, but with the added burden of struggling alone or within the confines of pandemic life that has destroyed our ability to mark events with social and religious customs that guide healing. People who had done well for years are now needing more, and those who were not doing well are doing worse. It makes for long days.

I mentioned boredom: With less time spent with other people, so many sessions are about COVID – who has it, who might have it, what people are doing to avoid it, and still, how they get their groceries. The second most popular psychotherapy topic includes what they are watching on Netflix, and as human beings trudging through this together, I have appreciated my patients’ suggestions as much as they have appreciated mine.* Life for all of us has come to be more about survival, and less about self-discovery and striving. Many sessions have started to feel the same from 1 hour to the next, in ways they never did before.

There are other aspects to telepsychiatry that I have found difficult. The site I have used most – Doxy.me – works well with some patients, but with others there are technical problems. Sessions freeze, the sound goes in or out, and we end up switching to another platform, which may or may not work better. Sometimes patients have the camera at odd angles, or they bounce a laptop on their knees to the point that I get seasick. One of my family members has said that I can sometimes be overheard, so I now have a radio playing classical music outside my door, and I often use earbuds so that the patient can’t be overheard and I speak more softly with them – this has all been good in terms of improving privacy, but after a while I find that it’s stressful to have people talking to me inside my own ears! These are little kinks, but when you do it for hours a day, they add up to a sense of being stressed in ways that in-person psychiatry does not lend itself to.

Finally, three seasons into my work-at-home life, I still have not found a new rhythm for some of the logistical aspects of private practice that came so easily in my office. My mail still goes to the office, the plants there still need water, my files and computer are there, but tasks that were once a seamless part of my work day now spill into my time off and I go into the office each week to file, log medications, and attend to the business of my practice. My smartphone, with its ability to e-prescribe, invoice, and fax, has made it possible for me to manage and certainly, outpatient psychiatrists are very lucky that we have the option to continue our work with patients remotely during such difficult times.

I have sent people for virtual intensive substance treatment, and to virtual couples’ counseling, and these remote treatments have been useful. The one treatment that has been very difficult for patients to negotiate has been outpatient electroconvulsive therapy – this requires coordination with another person to drive the patient to treatments (and to wait outside in the parking lot), and also for separate weekly COVID testing. Transcranial magnetic stimulation, which also is still being done in person, has not been any different – patients can drive themselves and the one center I referred to has not required preprocedure COVID testing.

What does the future hold? Will we ever go back to practicing the way we did? While some of my patients miss real-life therapy, most do not; they too like the added efficiency, getting treatment from the comfort of their home without the stress of finding the time to travel. I’ve taken on new patients during this time, and while I anticipated that it would be difficult, it has gone surprisingly well – people I have never met in real life talk to me with ease, and both psychotherapy and medication management have gone well. The one area that I have found most difficult is assessing tremors and dyskinesias, and one patient mentioned she has gained nearly 50 pounds over the past year – something I certainly would have noticed and attended to sooner in real life. I have mixed feelings about returning to a completely live practice. I think I would like a combination where I see all my patients in person once in a while, but would like to be able to offer some times where I see people virtually from home at least one day a week.

Time will tell how that plays out with insurers. My best guess is that, with the lowered no-show rates that everyone is seeing and the higher levels of depression and anxiety that people are having, this may have been a costly time for mental health care. At the same time, inpatient psychiatric units have decreased their capacity, and perhaps more efficient delivery of outpatient care has lowered the overall cost. I suppose we will wait to hear, but for many, the transition to virtual care has allowed many people to get treatment who would have otherwise gone without care.

In my April article, I mentioned that I was having daily Facetime check-in visits with a distressed patient who was on a COVID unit with pneumonia. Since then, I have had several more patients contract COVID, and many of my patients have had family members who have tested positive or become symptomatic with COVID. It has been nice to have sessions with people during this time, and thankfully, I have not had any more patients who have required hospitalization for the virus.

I still catch myself thinking that, of all the things I have worried about over the years, “pandemic” was never on my list. It seems so strange that I left my office on a Friday with no idea that I would not be returning to work the following Monday, or that life would change in such a radical way. As we leave this awful year behind and greet the new one with the hope that vaccines and a new administration might offer solutions, I’d like to wish my readers the best for a healthy, safe, and gentle New Year.



*My top viewing picks for now are “The Queen’s Gambit” (Netflix), and “A Place to Call Home” (Acorn).

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

In mid-April, a month into pandemic life with a stay-at-home order, I wrote about my experiences as a virtual outpatient psychiatrist in private practice. It’s been 10 months now and with this tragic year drawing to a close, it seems like a good time for an update.

FatCamera/E+

In that April column, I describe how I created a makeshift home office. This entailed pushing my son’s baseball card collection and dusty sports trophies to the side of the room, bringing in a desk and a rug, a house plant, and a statue of a Buddha. I enjoyed watching out the window behind my computer screen as the neighbors and their dogs walked by, and I loved seeing the tree out the window blossom into gorgeous flowers.

With time, my physical space has changed. The remnants of my son’s childhood have all been moved to a closet, artwork has been added to the wall behind me, and the space is now clearly an office, though my laptop remains propped on a pile of books so that no one is looking up my nose. The room, with four large windows facing north and west, has issues with temperature control. In an old house, the heat works all too well in the adjacent bedroom (while the rest of the occupants in other rooms freeze), but the office itself has no heat: I have added both a fan and a space heater, and there are some very cold days where I’ve propped open one of the windows. And with the shortened days, large windows on two walls have presented a challenge as the sun changes positions throughout the day – there are times when the sun’s rays streak across my face in such a way that I look rather ethereal, and between sessions I have lowered, raised, and adjusted the blinds to avoid this. I finally pulled off the thin metal venetian blinds and took them to Lowe’s, where a partially masked young woman cut me new blinds with larger slats. An ergonomic office chair has replaced the wicker Ikea chair I was using, and between all these machinations, I am now physically comfortable most of the time. I believe I am still a bit too pixelated on the screen, but my patients are not complaining, and when the natural lighting fades at 4:30 p.m., the overhead lighting is all wrong again. These all are things I never considered – or long ago addressed – in my real-life practice of psychiatry in a office I have loved for years.

With time, I’ve grown more comfortable working from home on a screen and there are things about this life I’ve grown to like. My husband no longer travels, my daughter – my gift of the pandemic – returned home from New York City where she was in her final months of graduate school, and these unexpected months with her (and her cat) have been a pleasure. There is something nice about being trapped at home with people I love, even if we are all in our respective places, in front of our separate screens. There has been time for long walks, trips to the beach, and long bike rides. And as my daughter now prepares to move to Denver, I have been heartened by the hope of vaccines, and the knowledge that I will likely be able to see her again in the coming months. The people are not the only ones who have benefited from this time at home together – I have no idea how we would have managed with our elderly dog if we were not home to care for him.

My life has become more efficient. I used to find myself aggravated when patients forgot their appointments, a not-infrequent occurrence. “No shows” are now extremely rare – if a patient forgets, I call and they sign on to their screen and have their session. People no longer get caught in traffic, they come on time, and they don’t complain about my crowded parking lot. When there is down time, I use it more efficiently at home – a load of laundry gets done, I get a chance to turn on the news or exercise, or make dinner early. And because I have two other family members working from home, I am not the only one mixing work with chores or exercise.

While my medical colleagues who work in settings where they must see patients in person have struggled or functioned in some state of denial, I have felt safe and protected, a bit cocooned with my family in a house big enough to give us all space, in a neighborhood with sidewalks and places to walk, and to protect my sanity, I am lucky to have a patio that has now been equipped with lights, patio heaters, a fire pit, and socially distanced tables so that I can still see friends outside.

Telemedicine has added a new dimension to treatment. I’ve had family sessions with multiple people joining a zoom link from different locations – so much easier than coordinating a time when everyone can travel to my office. I’ve had patients call in from cars and from closets in search of privacy, and from their gardens and poolsides. I’ve met spouses, children, many a dog and cat, plus the more unusual of pets and farm animals, including a goat, ferret, lizard, African grey parrot, and guinea pigs.

These are the good things, and while I wish I could say it was all good, so much of what remains is laden with anxiety. My son lives nearby, but he has shared a house with a hospital worker for much of the past year and there were COVID scares, months at a time without so much as a hug, and my husband has not seen his parents or brother for a year now. There are the awkward waves or salutes with friends I once gave carefree hugs, the constant thoughts of how far away is that person standing, and each person’s “beliefs” about what is safe when we still don’t fully understand how this virus spreads. I worry for myself, I worry for my family and friends, and I worry for my patients when they tell me about behaviors that clearly are not safe.

At first, I found my work as a telepsychiatrist to be exhausting, and I assumed it was because my patients were now just faces, inches from my own eyes, and no longer diffused by a visual field that included my whole office and the opportunity to break eye contact while I still listened with full attention. This has gotten much better – I’ve adjusted to my on-screen relationships, but what has not gotten better is both the acuity, and sometimes the boredom.

Patients are struggling; they are sad, lonely, and missing the richness of their former lives. They miss friends, meeting new people, cultural experiences, diversity in how they spend their time, and travel. They have all the same human experiences of loss, illness, and grief, but with the added burden of struggling alone or within the confines of pandemic life that has destroyed our ability to mark events with social and religious customs that guide healing. People who had done well for years are now needing more, and those who were not doing well are doing worse. It makes for long days.

I mentioned boredom: With less time spent with other people, so many sessions are about COVID – who has it, who might have it, what people are doing to avoid it, and still, how they get their groceries. The second most popular psychotherapy topic includes what they are watching on Netflix, and as human beings trudging through this together, I have appreciated my patients’ suggestions as much as they have appreciated mine.* Life for all of us has come to be more about survival, and less about self-discovery and striving. Many sessions have started to feel the same from 1 hour to the next, in ways they never did before.

There are other aspects to telepsychiatry that I have found difficult. The site I have used most – Doxy.me – works well with some patients, but with others there are technical problems. Sessions freeze, the sound goes in or out, and we end up switching to another platform, which may or may not work better. Sometimes patients have the camera at odd angles, or they bounce a laptop on their knees to the point that I get seasick. One of my family members has said that I can sometimes be overheard, so I now have a radio playing classical music outside my door, and I often use earbuds so that the patient can’t be overheard and I speak more softly with them – this has all been good in terms of improving privacy, but after a while I find that it’s stressful to have people talking to me inside my own ears! These are little kinks, but when you do it for hours a day, they add up to a sense of being stressed in ways that in-person psychiatry does not lend itself to.

Finally, three seasons into my work-at-home life, I still have not found a new rhythm for some of the logistical aspects of private practice that came so easily in my office. My mail still goes to the office, the plants there still need water, my files and computer are there, but tasks that were once a seamless part of my work day now spill into my time off and I go into the office each week to file, log medications, and attend to the business of my practice. My smartphone, with its ability to e-prescribe, invoice, and fax, has made it possible for me to manage and certainly, outpatient psychiatrists are very lucky that we have the option to continue our work with patients remotely during such difficult times.

I have sent people for virtual intensive substance treatment, and to virtual couples’ counseling, and these remote treatments have been useful. The one treatment that has been very difficult for patients to negotiate has been outpatient electroconvulsive therapy – this requires coordination with another person to drive the patient to treatments (and to wait outside in the parking lot), and also for separate weekly COVID testing. Transcranial magnetic stimulation, which also is still being done in person, has not been any different – patients can drive themselves and the one center I referred to has not required preprocedure COVID testing.

What does the future hold? Will we ever go back to practicing the way we did? While some of my patients miss real-life therapy, most do not; they too like the added efficiency, getting treatment from the comfort of their home without the stress of finding the time to travel. I’ve taken on new patients during this time, and while I anticipated that it would be difficult, it has gone surprisingly well – people I have never met in real life talk to me with ease, and both psychotherapy and medication management have gone well. The one area that I have found most difficult is assessing tremors and dyskinesias, and one patient mentioned she has gained nearly 50 pounds over the past year – something I certainly would have noticed and attended to sooner in real life. I have mixed feelings about returning to a completely live practice. I think I would like a combination where I see all my patients in person once in a while, but would like to be able to offer some times where I see people virtually from home at least one day a week.

Time will tell how that plays out with insurers. My best guess is that, with the lowered no-show rates that everyone is seeing and the higher levels of depression and anxiety that people are having, this may have been a costly time for mental health care. At the same time, inpatient psychiatric units have decreased their capacity, and perhaps more efficient delivery of outpatient care has lowered the overall cost. I suppose we will wait to hear, but for many, the transition to virtual care has allowed many people to get treatment who would have otherwise gone without care.

In my April article, I mentioned that I was having daily Facetime check-in visits with a distressed patient who was on a COVID unit with pneumonia. Since then, I have had several more patients contract COVID, and many of my patients have had family members who have tested positive or become symptomatic with COVID. It has been nice to have sessions with people during this time, and thankfully, I have not had any more patients who have required hospitalization for the virus.

I still catch myself thinking that, of all the things I have worried about over the years, “pandemic” was never on my list. It seems so strange that I left my office on a Friday with no idea that I would not be returning to work the following Monday, or that life would change in such a radical way. As we leave this awful year behind and greet the new one with the hope that vaccines and a new administration might offer solutions, I’d like to wish my readers the best for a healthy, safe, and gentle New Year.



*My top viewing picks for now are “The Queen’s Gambit” (Netflix), and “A Place to Call Home” (Acorn).

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

In mid-April, a month into pandemic life with a stay-at-home order, I wrote about my experiences as a virtual outpatient psychiatrist in private practice. It’s been 10 months now and with this tragic year drawing to a close, it seems like a good time for an update.

FatCamera/E+

In that April column, I describe how I created a makeshift home office. This entailed pushing my son’s baseball card collection and dusty sports trophies to the side of the room, bringing in a desk and a rug, a house plant, and a statue of a Buddha. I enjoyed watching out the window behind my computer screen as the neighbors and their dogs walked by, and I loved seeing the tree out the window blossom into gorgeous flowers.

With time, my physical space has changed. The remnants of my son’s childhood have all been moved to a closet, artwork has been added to the wall behind me, and the space is now clearly an office, though my laptop remains propped on a pile of books so that no one is looking up my nose. The room, with four large windows facing north and west, has issues with temperature control. In an old house, the heat works all too well in the adjacent bedroom (while the rest of the occupants in other rooms freeze), but the office itself has no heat: I have added both a fan and a space heater, and there are some very cold days where I’ve propped open one of the windows. And with the shortened days, large windows on two walls have presented a challenge as the sun changes positions throughout the day – there are times when the sun’s rays streak across my face in such a way that I look rather ethereal, and between sessions I have lowered, raised, and adjusted the blinds to avoid this. I finally pulled off the thin metal venetian blinds and took them to Lowe’s, where a partially masked young woman cut me new blinds with larger slats. An ergonomic office chair has replaced the wicker Ikea chair I was using, and between all these machinations, I am now physically comfortable most of the time. I believe I am still a bit too pixelated on the screen, but my patients are not complaining, and when the natural lighting fades at 4:30 p.m., the overhead lighting is all wrong again. These all are things I never considered – or long ago addressed – in my real-life practice of psychiatry in a office I have loved for years.

With time, I’ve grown more comfortable working from home on a screen and there are things about this life I’ve grown to like. My husband no longer travels, my daughter – my gift of the pandemic – returned home from New York City where she was in her final months of graduate school, and these unexpected months with her (and her cat) have been a pleasure. There is something nice about being trapped at home with people I love, even if we are all in our respective places, in front of our separate screens. There has been time for long walks, trips to the beach, and long bike rides. And as my daughter now prepares to move to Denver, I have been heartened by the hope of vaccines, and the knowledge that I will likely be able to see her again in the coming months. The people are not the only ones who have benefited from this time at home together – I have no idea how we would have managed with our elderly dog if we were not home to care for him.

My life has become more efficient. I used to find myself aggravated when patients forgot their appointments, a not-infrequent occurrence. “No shows” are now extremely rare – if a patient forgets, I call and they sign on to their screen and have their session. People no longer get caught in traffic, they come on time, and they don’t complain about my crowded parking lot. When there is down time, I use it more efficiently at home – a load of laundry gets done, I get a chance to turn on the news or exercise, or make dinner early. And because I have two other family members working from home, I am not the only one mixing work with chores or exercise.

While my medical colleagues who work in settings where they must see patients in person have struggled or functioned in some state of denial, I have felt safe and protected, a bit cocooned with my family in a house big enough to give us all space, in a neighborhood with sidewalks and places to walk, and to protect my sanity, I am lucky to have a patio that has now been equipped with lights, patio heaters, a fire pit, and socially distanced tables so that I can still see friends outside.

Telemedicine has added a new dimension to treatment. I’ve had family sessions with multiple people joining a zoom link from different locations – so much easier than coordinating a time when everyone can travel to my office. I’ve had patients call in from cars and from closets in search of privacy, and from their gardens and poolsides. I’ve met spouses, children, many a dog and cat, plus the more unusual of pets and farm animals, including a goat, ferret, lizard, African grey parrot, and guinea pigs.

These are the good things, and while I wish I could say it was all good, so much of what remains is laden with anxiety. My son lives nearby, but he has shared a house with a hospital worker for much of the past year and there were COVID scares, months at a time without so much as a hug, and my husband has not seen his parents or brother for a year now. There are the awkward waves or salutes with friends I once gave carefree hugs, the constant thoughts of how far away is that person standing, and each person’s “beliefs” about what is safe when we still don’t fully understand how this virus spreads. I worry for myself, I worry for my family and friends, and I worry for my patients when they tell me about behaviors that clearly are not safe.

At first, I found my work as a telepsychiatrist to be exhausting, and I assumed it was because my patients were now just faces, inches from my own eyes, and no longer diffused by a visual field that included my whole office and the opportunity to break eye contact while I still listened with full attention. This has gotten much better – I’ve adjusted to my on-screen relationships, but what has not gotten better is both the acuity, and sometimes the boredom.

Patients are struggling; they are sad, lonely, and missing the richness of their former lives. They miss friends, meeting new people, cultural experiences, diversity in how they spend their time, and travel. They have all the same human experiences of loss, illness, and grief, but with the added burden of struggling alone or within the confines of pandemic life that has destroyed our ability to mark events with social and religious customs that guide healing. People who had done well for years are now needing more, and those who were not doing well are doing worse. It makes for long days.

I mentioned boredom: With less time spent with other people, so many sessions are about COVID – who has it, who might have it, what people are doing to avoid it, and still, how they get their groceries. The second most popular psychotherapy topic includes what they are watching on Netflix, and as human beings trudging through this together, I have appreciated my patients’ suggestions as much as they have appreciated mine.* Life for all of us has come to be more about survival, and less about self-discovery and striving. Many sessions have started to feel the same from 1 hour to the next, in ways they never did before.

There are other aspects to telepsychiatry that I have found difficult. The site I have used most – Doxy.me – works well with some patients, but with others there are technical problems. Sessions freeze, the sound goes in or out, and we end up switching to another platform, which may or may not work better. Sometimes patients have the camera at odd angles, or they bounce a laptop on their knees to the point that I get seasick. One of my family members has said that I can sometimes be overheard, so I now have a radio playing classical music outside my door, and I often use earbuds so that the patient can’t be overheard and I speak more softly with them – this has all been good in terms of improving privacy, but after a while I find that it’s stressful to have people talking to me inside my own ears! These are little kinks, but when you do it for hours a day, they add up to a sense of being stressed in ways that in-person psychiatry does not lend itself to.

Finally, three seasons into my work-at-home life, I still have not found a new rhythm for some of the logistical aspects of private practice that came so easily in my office. My mail still goes to the office, the plants there still need water, my files and computer are there, but tasks that were once a seamless part of my work day now spill into my time off and I go into the office each week to file, log medications, and attend to the business of my practice. My smartphone, with its ability to e-prescribe, invoice, and fax, has made it possible for me to manage and certainly, outpatient psychiatrists are very lucky that we have the option to continue our work with patients remotely during such difficult times.

I have sent people for virtual intensive substance treatment, and to virtual couples’ counseling, and these remote treatments have been useful. The one treatment that has been very difficult for patients to negotiate has been outpatient electroconvulsive therapy – this requires coordination with another person to drive the patient to treatments (and to wait outside in the parking lot), and also for separate weekly COVID testing. Transcranial magnetic stimulation, which also is still being done in person, has not been any different – patients can drive themselves and the one center I referred to has not required preprocedure COVID testing.

What does the future hold? Will we ever go back to practicing the way we did? While some of my patients miss real-life therapy, most do not; they too like the added efficiency, getting treatment from the comfort of their home without the stress of finding the time to travel. I’ve taken on new patients during this time, and while I anticipated that it would be difficult, it has gone surprisingly well – people I have never met in real life talk to me with ease, and both psychotherapy and medication management have gone well. The one area that I have found most difficult is assessing tremors and dyskinesias, and one patient mentioned she has gained nearly 50 pounds over the past year – something I certainly would have noticed and attended to sooner in real life. I have mixed feelings about returning to a completely live practice. I think I would like a combination where I see all my patients in person once in a while, but would like to be able to offer some times where I see people virtually from home at least one day a week.

Time will tell how that plays out with insurers. My best guess is that, with the lowered no-show rates that everyone is seeing and the higher levels of depression and anxiety that people are having, this may have been a costly time for mental health care. At the same time, inpatient psychiatric units have decreased their capacity, and perhaps more efficient delivery of outpatient care has lowered the overall cost. I suppose we will wait to hear, but for many, the transition to virtual care has allowed many people to get treatment who would have otherwise gone without care.

In my April article, I mentioned that I was having daily Facetime check-in visits with a distressed patient who was on a COVID unit with pneumonia. Since then, I have had several more patients contract COVID, and many of my patients have had family members who have tested positive or become symptomatic with COVID. It has been nice to have sessions with people during this time, and thankfully, I have not had any more patients who have required hospitalization for the virus.

I still catch myself thinking that, of all the things I have worried about over the years, “pandemic” was never on my list. It seems so strange that I left my office on a Friday with no idea that I would not be returning to work the following Monday, or that life would change in such a radical way. As we leave this awful year behind and greet the new one with the hope that vaccines and a new administration might offer solutions, I’d like to wish my readers the best for a healthy, safe, and gentle New Year.



*My top viewing picks for now are “The Queen’s Gambit” (Netflix), and “A Place to Call Home” (Acorn).

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

As 2020 comes to a close, most of us are looking forward to a (hopefully) brighter 2021. This year has been full of challenges and new experiences, but we have learned a lot. Pandemic or not, there are some things that you and your practice can do to ensure that you are prepared to make 2021 a success.

Tips for your practice

Assess staff morale: It seems simple but checking in with your staff can go a long way. Everyone is dealing with challenges both in and out of the workplace. Check in, show them you care, and think of ways that you can make their work a positive experience in the new year. During our May 2020 GI division chief townhall, John Inadomi, MD, gave a great presentation on the importance of staff morale during the pandemic.

Listen to colleagues: Find out about their experiences, challenges, and solutions. In October, the American Gastroenterological Association held a town hall with some great information and resources called “Adapting to Changing Practice Paradigms.” The agenda covered topics from telehealth to private equity and planning for the next potential wave of COVID-19.

Celebrate the wins: It can often feel like not much went right in 2020, but we did accomplish significant wins for GIs, including achieving payment parity for telephone evaluation and management (E/M) visits with video visits, increases in digestive disease and GI cancer research funding, and inclusion/expansion of GI cancers research opportunities. We couldn’t have done it without you, though, and we will continue to need your help to move important issues forward in 2021. Get involved today! Visit “Get Involved” under Advocacy and Policy on www.gastro.org.

Prepare for E/M changes: The Current Procedural Terminology (CPT) E/M for new and established patient office/outpatient codes (99201-99205, 99211-99215), guidelines, and Medicare payments will undergo major changes beginning Jan. 1, 2021. See the AGA’s coding and reimbursement experts’ article from the March 2020 issue of GI & Hepatology News, “Prepare for major changes to E/M coding starting in 2021,” to learn about the changes and get resources to help practices prepare.

Keep up with new Medicare payment rules: The release of the 2021 physician payments and rules for the Medicare program was delayed this year because of the COVID-19 public health emergency. We were dismayed to learn that Medicare did not make any changes that substantively mitigated the expected cuts to most specialties. Instead of a 5% cut for GI, the Centers for Medicare & Medicaid Services now projects GI will experience a 4% payment cut for 2021. AGA is calling on Congress to pass legislation to stop the cuts. This situation is evolving quickly. Watch for AGA member alerts for breaking news and resources, including the AGA’s “Medicare plans significant payment cuts for 2021.”

Stay current on telehealth and telephone E/M coverage: The commercial payer community came together to cover telehealth (video visits) and telephone E/M at the beginning of the COVID-19 pandemic but have since regularly teased the end of coverage only to extend it just before it expires. It’s impossible to predict what each payer will do, but you can use the following resources to keep current on most payers’ policies and correct coding/reporting for telehealth and telephone E/M:

• “Current State Laws & Reimbursement Policies ” from the Center for Connected Health.
• “Coding for Telehealth & Virtual Visits During COVID-19” from the AGA University.

Check to see if you can report on additional quality measures: AGA has expanded the Merit-Based Incentive Payment System (MIPS) measure portfolio by assuming ownership and stewardship of two hepatitis C virus (HCV) measures from PCPI, including annually checking for HCV in active injection drug users (measure 387) and performing a one-time screening for HCV among patients at risk (measure 400). As a result, gastroenterologists can now report on even more GI-specific measures. There have been the following two changes to GI-specific measures in 2021:

• Measure 275: “Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy” now includes coding to allow reporting for all age groups, including pediatric populations.
• Measure 439: “Age Appropriate Screening Colonoscopy” now includes all colonoscopies for patients 50 years and older; however, there’s an exclusion for those patients between the ages of 50 and 85 years.

These changes will help more gastroenterologists qualify for these measures.

Dates and deadlines to remember

January 2021

• Jan. 1 – MIPS Performance Year 2021 begins.
• Jan. 4 – Submission window opens for MIPS Performance Year 2020.
• Changes to Improvement Activity category go into effect (if approved in final rule).

March 2021

• March 31 – First snapshot for Qualifying Participant (QP) determinations and MIPS APM participation.

April 2021

• April 1 – Registration begins for CMS web interface and Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey.

June 2021

• June 30 – Second snapshot for QP determinations and MIPS APM participation.
• June 30 – Registration ends for CMS web interface and CAHPS for MIPS survey.

July 2021

• CMS publishes proposed reimbursement values for 2022 in the Medicare Physician Fee Schedule proposed rule.
• CMS “Targeted Review” opens once CMS makes your MIPS payment adjustment available.
• July 1 - MIPS Performance Feedback Available. CMS will provide you with performance feedback based on the data you submitted for Performance Year 2020. You can use this feedback to improve your care and optimize the payments you receive from CMS in the future.

August 2021

• Aug. 31 - Targeted Review period closes (appeals process).

September 2021

• AMA releases CPT 2022 book, including a new CPT code for Peroral Endoscopic Myotomy (POEM).

October 2021

• Oct. 3 - Last day to start a 90-day performance period for promoting Interoperability and Improvement Activities.

November 2021

• CMS finalizes reimbursement values for 2022 in the MPFS final rule. New payment rates take effect Jan. 1, 2022.

December 2021

• Dec. 31 – Quality Payment Program Exception Applications window closes.
• Dec. 31 – MIPS Performance year 2020 ends.
• Dec. 31 – Fourth snapshot for full TIN APMs (Medicare Shared Savings Program).

G. Anton Decker, MD, is chair of the AGA Practice Management and Economics Committee, Mayo Clinic International; Dawn Francis, MD, is chair-elect of the AGA Practice Management and Economics Committee, Mayo Clinic, Jacksonville, Fla.

They have no conflicts of interest.

As 2020 comes to a close, most of us are looking forward to a (hopefully) brighter 2021. This year has been full of challenges and new experiences, but we have learned a lot. Pandemic or not, there are some things that you and your practice can do to ensure that you are prepared to make 2021 a success.

Tips for your practice

Assess staff morale: It seems simple but checking in with your staff can go a long way. Everyone is dealing with challenges both in and out of the workplace. Check in, show them you care, and think of ways that you can make their work a positive experience in the new year. During our May 2020 GI division chief townhall, John Inadomi, MD, gave a great presentation on the importance of staff morale during the pandemic.

Listen to colleagues: Find out about their experiences, challenges, and solutions. In October, the American Gastroenterological Association held a town hall with some great information and resources called “Adapting to Changing Practice Paradigms.” The agenda covered topics from telehealth to private equity and planning for the next potential wave of COVID-19.

Celebrate the wins: It can often feel like not much went right in 2020, but we did accomplish significant wins for GIs, including achieving payment parity for telephone evaluation and management (E/M) visits with video visits, increases in digestive disease and GI cancer research funding, and inclusion/expansion of GI cancers research opportunities. We couldn’t have done it without you, though, and we will continue to need your help to move important issues forward in 2021. Get involved today! Visit “Get Involved” under Advocacy and Policy on www.gastro.org.

Prepare for E/M changes: The Current Procedural Terminology (CPT) E/M for new and established patient office/outpatient codes (99201-99205, 99211-99215), guidelines, and Medicare payments will undergo major changes beginning Jan. 1, 2021. See the AGA’s coding and reimbursement experts’ article from the March 2020 issue of GI & Hepatology News, “Prepare for major changes to E/M coding starting in 2021,” to learn about the changes and get resources to help practices prepare.

Keep up with new Medicare payment rules: The release of the 2021 physician payments and rules for the Medicare program was delayed this year because of the COVID-19 public health emergency. We were dismayed to learn that Medicare did not make any changes that substantively mitigated the expected cuts to most specialties. Instead of a 5% cut for GI, the Centers for Medicare & Medicaid Services now projects GI will experience a 4% payment cut for 2021. AGA is calling on Congress to pass legislation to stop the cuts. This situation is evolving quickly. Watch for AGA member alerts for breaking news and resources, including the AGA’s “Medicare plans significant payment cuts for 2021.”

Stay current on telehealth and telephone E/M coverage: The commercial payer community came together to cover telehealth (video visits) and telephone E/M at the beginning of the COVID-19 pandemic but have since regularly teased the end of coverage only to extend it just before it expires. It’s impossible to predict what each payer will do, but you can use the following resources to keep current on most payers’ policies and correct coding/reporting for telehealth and telephone E/M:

• “Current State Laws & Reimbursement Policies ” from the Center for Connected Health.
• “Coding for Telehealth & Virtual Visits During COVID-19” from the AGA University.

Check to see if you can report on additional quality measures: AGA has expanded the Merit-Based Incentive Payment System (MIPS) measure portfolio by assuming ownership and stewardship of two hepatitis C virus (HCV) measures from PCPI, including annually checking for HCV in active injection drug users (measure 387) and performing a one-time screening for HCV among patients at risk (measure 400). As a result, gastroenterologists can now report on even more GI-specific measures. There have been the following two changes to GI-specific measures in 2021:

• Measure 275: “Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy” now includes coding to allow reporting for all age groups, including pediatric populations.
• Measure 439: “Age Appropriate Screening Colonoscopy” now includes all colonoscopies for patients 50 years and older; however, there’s an exclusion for those patients between the ages of 50 and 85 years.

These changes will help more gastroenterologists qualify for these measures.

Dates and deadlines to remember

January 2021

• Jan. 1 – MIPS Performance Year 2021 begins.
• Jan. 4 – Submission window opens for MIPS Performance Year 2020.
• Changes to Improvement Activity category go into effect (if approved in final rule).

March 2021

• March 31 – First snapshot for Qualifying Participant (QP) determinations and MIPS APM participation.

April 2021

• April 1 – Registration begins for CMS web interface and Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey.

June 2021

• June 30 – Second snapshot for QP determinations and MIPS APM participation.
• June 30 – Registration ends for CMS web interface and CAHPS for MIPS survey.

July 2021

• CMS publishes proposed reimbursement values for 2022 in the Medicare Physician Fee Schedule proposed rule.
• CMS “Targeted Review” opens once CMS makes your MIPS payment adjustment available.
• July 1 - MIPS Performance Feedback Available. CMS will provide you with performance feedback based on the data you submitted for Performance Year 2020. You can use this feedback to improve your care and optimize the payments you receive from CMS in the future.

August 2021

• Aug. 31 - Targeted Review period closes (appeals process).

September 2021

• AMA releases CPT 2022 book, including a new CPT code for Peroral Endoscopic Myotomy (POEM).

October 2021

• Oct. 3 - Last day to start a 90-day performance period for promoting Interoperability and Improvement Activities.

November 2021

• CMS finalizes reimbursement values for 2022 in the MPFS final rule. New payment rates take effect Jan. 1, 2022.

December 2021

• Dec. 31 – Quality Payment Program Exception Applications window closes.
• Dec. 31 – MIPS Performance year 2020 ends.
• Dec. 31 – Fourth snapshot for full TIN APMs (Medicare Shared Savings Program).

G. Anton Decker, MD, is chair of the AGA Practice Management and Economics Committee, Mayo Clinic International; Dawn Francis, MD, is chair-elect of the AGA Practice Management and Economics Committee, Mayo Clinic, Jacksonville, Fla.

They have no conflicts of interest.

As 2020 comes to a close, most of us are looking forward to a (hopefully) brighter 2021. This year has been full of challenges and new experiences, but we have learned a lot. Pandemic or not, there are some things that you and your practice can do to ensure that you are prepared to make 2021 a success.

Tips for your practice

Assess staff morale: It seems simple but checking in with your staff can go a long way. Everyone is dealing with challenges both in and out of the workplace. Check in, show them you care, and think of ways that you can make their work a positive experience in the new year. During our May 2020 GI division chief townhall, John Inadomi, MD, gave a great presentation on the importance of staff morale during the pandemic.

Listen to colleagues: Find out about their experiences, challenges, and solutions. In October, the American Gastroenterological Association held a town hall with some great information and resources called “Adapting to Changing Practice Paradigms.” The agenda covered topics from telehealth to private equity and planning for the next potential wave of COVID-19.

Celebrate the wins: It can often feel like not much went right in 2020, but we did accomplish significant wins for GIs, including achieving payment parity for telephone evaluation and management (E/M) visits with video visits, increases in digestive disease and GI cancer research funding, and inclusion/expansion of GI cancers research opportunities. We couldn’t have done it without you, though, and we will continue to need your help to move important issues forward in 2021. Get involved today! Visit “Get Involved” under Advocacy and Policy on www.gastro.org.

Prepare for E/M changes: The Current Procedural Terminology (CPT) E/M for new and established patient office/outpatient codes (99201-99205, 99211-99215), guidelines, and Medicare payments will undergo major changes beginning Jan. 1, 2021. See the AGA’s coding and reimbursement experts’ article from the March 2020 issue of GI & Hepatology News, “Prepare for major changes to E/M coding starting in 2021,” to learn about the changes and get resources to help practices prepare.

Keep up with new Medicare payment rules: The release of the 2021 physician payments and rules for the Medicare program was delayed this year because of the COVID-19 public health emergency. We were dismayed to learn that Medicare did not make any changes that substantively mitigated the expected cuts to most specialties. Instead of a 5% cut for GI, the Centers for Medicare & Medicaid Services now projects GI will experience a 4% payment cut for 2021. AGA is calling on Congress to pass legislation to stop the cuts. This situation is evolving quickly. Watch for AGA member alerts for breaking news and resources, including the AGA’s “Medicare plans significant payment cuts for 2021.”

Stay current on telehealth and telephone E/M coverage: The commercial payer community came together to cover telehealth (video visits) and telephone E/M at the beginning of the COVID-19 pandemic but have since regularly teased the end of coverage only to extend it just before it expires. It’s impossible to predict what each payer will do, but you can use the following resources to keep current on most payers’ policies and correct coding/reporting for telehealth and telephone E/M:

• “Current State Laws & Reimbursement Policies ” from the Center for Connected Health.
• “Coding for Telehealth & Virtual Visits During COVID-19” from the AGA University.

Check to see if you can report on additional quality measures: AGA has expanded the Merit-Based Incentive Payment System (MIPS) measure portfolio by assuming ownership and stewardship of two hepatitis C virus (HCV) measures from PCPI, including annually checking for HCV in active injection drug users (measure 387) and performing a one-time screening for HCV among patients at risk (measure 400). As a result, gastroenterologists can now report on even more GI-specific measures. There have been the following two changes to GI-specific measures in 2021:

• Measure 275: “Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy” now includes coding to allow reporting for all age groups, including pediatric populations.
• Measure 439: “Age Appropriate Screening Colonoscopy” now includes all colonoscopies for patients 50 years and older; however, there’s an exclusion for those patients between the ages of 50 and 85 years.

These changes will help more gastroenterologists qualify for these measures.

Dates and deadlines to remember

January 2021

• Jan. 1 – MIPS Performance Year 2021 begins.
• Jan. 4 – Submission window opens for MIPS Performance Year 2020.
• Changes to Improvement Activity category go into effect (if approved in final rule).

March 2021

• March 31 – First snapshot for Qualifying Participant (QP) determinations and MIPS APM participation.

April 2021

• April 1 – Registration begins for CMS web interface and Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey.

June 2021

• June 30 – Second snapshot for QP determinations and MIPS APM participation.
• June 30 – Registration ends for CMS web interface and CAHPS for MIPS survey.

July 2021

• CMS publishes proposed reimbursement values for 2022 in the Medicare Physician Fee Schedule proposed rule.
• CMS “Targeted Review” opens once CMS makes your MIPS payment adjustment available.
• July 1 - MIPS Performance Feedback Available. CMS will provide you with performance feedback based on the data you submitted for Performance Year 2020. You can use this feedback to improve your care and optimize the payments you receive from CMS in the future.

August 2021

• Aug. 31 - Targeted Review period closes (appeals process).

September 2021

• AMA releases CPT 2022 book, including a new CPT code for Peroral Endoscopic Myotomy (POEM).

October 2021

• Oct. 3 - Last day to start a 90-day performance period for promoting Interoperability and Improvement Activities.

November 2021

• CMS finalizes reimbursement values for 2022 in the MPFS final rule. New payment rates take effect Jan. 1, 2022.

December 2021

• Dec. 31 – Quality Payment Program Exception Applications window closes.
• Dec. 31 – MIPS Performance year 2020 ends.
• Dec. 31 – Fourth snapshot for full TIN APMs (Medicare Shared Savings Program).

G. Anton Decker, MD, is chair of the AGA Practice Management and Economics Committee, Mayo Clinic International; Dawn Francis, MD, is chair-elect of the AGA Practice Management and Economics Committee, Mayo Clinic, Jacksonville, Fla.

They have no conflicts of interest.

I have learned a lot about crisis management and leadership in the rapidly changing COVID health care environment. I have learned how to make quick and imperfect decisions with limited information, and how to move on swiftly. I have learned how to quickly fade out memories of how we used to run our business, and pivot to unknown and untested delivery modalities. I have learned how to take regulatory standards as guidance, not doctrine. And I have learned how tell longstanding loyal colleagues that they are being laid off.

Many of these leadership challenges are not new, but the rapidity of change and the weight and magnitude of decision making is unparalleled in my relatively short career. In some ways, it reminds me of some solid lessons I have learned over time as a lifetime runner, with many analogies and applications to leadership.

Some people ask me why I run. “You must get a runner’s high.” The truth is, I have never had a runner’s high. I feel every step. In fact, the very nature of running makes a person feel like they are being pulled under water. Runners are typically tachycardic and short of breath the whole time they are running. But what running does allow for is to ignore some of the signals your body is sending, and wholly and completely focus on other things. I often have my most creative and innovative thoughts while running. So that is why I run. But back to the point of what running and leadership have in common – and how lessons learned can translate between the two:

They are both really hard. As I mentioned above, running literally makes you feel like you are drowning. But when you finish running, it is amazing how easy everything else feels! Similar to leadership, it should feel hard, but not too hard. I have seen firsthand the effects of under- and over-delegating, and both are dysfunctional. Good leadership is a blend of being humble and servant, but also ensuring self-care and endurance. It is also important to acknowledge the difficulty of leadership. Dr. Tom Lee, currently chief medical officer at Press Ganey, is a leader I have always admired. He once said, “Leadership can be very lonely.” At the time, I did not quite understand that, but I have come to experience that feeling occasionally. The other aspect of leadership that I find really hard is that often, people’s anger is misdirected at leaders as a natural outlet for that anger. Part of being a leader is enduring such anger, gaining an understanding for it, and doing what you can to help people through it.

They both work better when you are restored. It sounds generic and cliché, but you can’t be a good runner or a good leader when you are totally depleted.

They both require efficiency. When I was running my first marathon, a complete stranger ran up beside me and started giving me advice. I thought it was sort of strange advice at the time, but it turned out to be sound and useful. He noticed my running pattern of “sticking to the road,” and he told me I should rather “run as the crow flies.” What he meant was to run in as straight of a line as possible, regardless of the road, to preserve energy and save steps. He recommended picking a point on the horizon and running toward that point as straight as possible. As he sped off ahead of me in the next mile, his parting words were, “You’ll thank me at mile 24…” To this day, I still use that tactic, which I find very steadying and calming during running. The same can be said for leadership; as you pick a point on the horizon, keep yourself and your team heading toward that point with intense focus, and before you realize it, you’ve reached your destination.

They both require having a goal. That same stranger who gave me advice on running efficiently also asked what my goal was. It caught me off guard a bit, as I realized my only goal was to finish. He encouraged me to make a goal for the run, which could serve as a motivator when the going got tough. This was another piece of lasting advice I have used for both running and for leadership.

They both can be endured by committing to continuous forward motion. Running and leadership both become psychologically much easier when you realize all you really have to do is maintain continuous forward motion. Some days require less effort than others, but I can always convince myself I am capable of some forward motion.

They both are easier if you don’t overthink things. When I first started in a leadership position, I would have moments of anxiety if I thought too hard about what I was responsible for. Similar to running, it works best if you don’t overthink what difficulties it may bring; rather, just put on your shoes and get going.

In the end, leading during COVID is like stepping onto a new trail. Despite the new terrain and foreign path, my prior training and trusty pair of sneakers – like my leadership skills and past experiences – will get me through this journey, one step at a time.

Dr. Scheurer is chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is president of SHM.

I have learned a lot about crisis management and leadership in the rapidly changing COVID health care environment. I have learned how to make quick and imperfect decisions with limited information, and how to move on swiftly. I have learned how to quickly fade out memories of how we used to run our business, and pivot to unknown and untested delivery modalities. I have learned how to take regulatory standards as guidance, not doctrine. And I have learned how tell longstanding loyal colleagues that they are being laid off.

Many of these leadership challenges are not new, but the rapidity of change and the weight and magnitude of decision making is unparalleled in my relatively short career. In some ways, it reminds me of some solid lessons I have learned over time as a lifetime runner, with many analogies and applications to leadership.

Some people ask me why I run. “You must get a runner’s high.” The truth is, I have never had a runner’s high. I feel every step. In fact, the very nature of running makes a person feel like they are being pulled under water. Runners are typically tachycardic and short of breath the whole time they are running. But what running does allow for is to ignore some of the signals your body is sending, and wholly and completely focus on other things. I often have my most creative and innovative thoughts while running. So that is why I run. But back to the point of what running and leadership have in common – and how lessons learned can translate between the two:

They are both really hard. As I mentioned above, running literally makes you feel like you are drowning. But when you finish running, it is amazing how easy everything else feels! Similar to leadership, it should feel hard, but not too hard. I have seen firsthand the effects of under- and over-delegating, and both are dysfunctional. Good leadership is a blend of being humble and servant, but also ensuring self-care and endurance. It is also important to acknowledge the difficulty of leadership. Dr. Tom Lee, currently chief medical officer at Press Ganey, is a leader I have always admired. He once said, “Leadership can be very lonely.” At the time, I did not quite understand that, but I have come to experience that feeling occasionally. The other aspect of leadership that I find really hard is that often, people’s anger is misdirected at leaders as a natural outlet for that anger. Part of being a leader is enduring such anger, gaining an understanding for it, and doing what you can to help people through it.

They both work better when you are restored. It sounds generic and cliché, but you can’t be a good runner or a good leader when you are totally depleted.

They both require efficiency. When I was running my first marathon, a complete stranger ran up beside me and started giving me advice. I thought it was sort of strange advice at the time, but it turned out to be sound and useful. He noticed my running pattern of “sticking to the road,” and he told me I should rather “run as the crow flies.” What he meant was to run in as straight of a line as possible, regardless of the road, to preserve energy and save steps. He recommended picking a point on the horizon and running toward that point as straight as possible. As he sped off ahead of me in the next mile, his parting words were, “You’ll thank me at mile 24…” To this day, I still use that tactic, which I find very steadying and calming during running. The same can be said for leadership; as you pick a point on the horizon, keep yourself and your team heading toward that point with intense focus, and before you realize it, you’ve reached your destination.

They both require having a goal. That same stranger who gave me advice on running efficiently also asked what my goal was. It caught me off guard a bit, as I realized my only goal was to finish. He encouraged me to make a goal for the run, which could serve as a motivator when the going got tough. This was another piece of lasting advice I have used for both running and for leadership.

They both can be endured by committing to continuous forward motion. Running and leadership both become psychologically much easier when you realize all you really have to do is maintain continuous forward motion. Some days require less effort than others, but I can always convince myself I am capable of some forward motion.

They both are easier if you don’t overthink things. When I first started in a leadership position, I would have moments of anxiety if I thought too hard about what I was responsible for. Similar to running, it works best if you don’t overthink what difficulties it may bring; rather, just put on your shoes and get going.

In the end, leading during COVID is like stepping onto a new trail. Despite the new terrain and foreign path, my prior training and trusty pair of sneakers – like my leadership skills and past experiences – will get me through this journey, one step at a time.

Dr. Scheurer is chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is president of SHM.

I have learned a lot about crisis management and leadership in the rapidly changing COVID health care environment. I have learned how to make quick and imperfect decisions with limited information, and how to move on swiftly. I have learned how to quickly fade out memories of how we used to run our business, and pivot to unknown and untested delivery modalities. I have learned how to take regulatory standards as guidance, not doctrine. And I have learned how tell longstanding loyal colleagues that they are being laid off.

Many of these leadership challenges are not new, but the rapidity of change and the weight and magnitude of decision making is unparalleled in my relatively short career. In some ways, it reminds me of some solid lessons I have learned over time as a lifetime runner, with many analogies and applications to leadership.

Some people ask me why I run. “You must get a runner’s high.” The truth is, I have never had a runner’s high. I feel every step. In fact, the very nature of running makes a person feel like they are being pulled under water. Runners are typically tachycardic and short of breath the whole time they are running. But what running does allow for is to ignore some of the signals your body is sending, and wholly and completely focus on other things. I often have my most creative and innovative thoughts while running. So that is why I run. But back to the point of what running and leadership have in common – and how lessons learned can translate between the two:

They are both really hard. As I mentioned above, running literally makes you feel like you are drowning. But when you finish running, it is amazing how easy everything else feels! Similar to leadership, it should feel hard, but not too hard. I have seen firsthand the effects of under- and over-delegating, and both are dysfunctional. Good leadership is a blend of being humble and servant, but also ensuring self-care and endurance. It is also important to acknowledge the difficulty of leadership. Dr. Tom Lee, currently chief medical officer at Press Ganey, is a leader I have always admired. He once said, “Leadership can be very lonely.” At the time, I did not quite understand that, but I have come to experience that feeling occasionally. The other aspect of leadership that I find really hard is that often, people’s anger is misdirected at leaders as a natural outlet for that anger. Part of being a leader is enduring such anger, gaining an understanding for it, and doing what you can to help people through it.

They both work better when you are restored. It sounds generic and cliché, but you can’t be a good runner or a good leader when you are totally depleted.

They both require efficiency. When I was running my first marathon, a complete stranger ran up beside me and started giving me advice. I thought it was sort of strange advice at the time, but it turned out to be sound and useful. He noticed my running pattern of “sticking to the road,” and he told me I should rather “run as the crow flies.” What he meant was to run in as straight of a line as possible, regardless of the road, to preserve energy and save steps. He recommended picking a point on the horizon and running toward that point as straight as possible. As he sped off ahead of me in the next mile, his parting words were, “You’ll thank me at mile 24…” To this day, I still use that tactic, which I find very steadying and calming during running. The same can be said for leadership; as you pick a point on the horizon, keep yourself and your team heading toward that point with intense focus, and before you realize it, you’ve reached your destination.

They both require having a goal. That same stranger who gave me advice on running efficiently also asked what my goal was. It caught me off guard a bit, as I realized my only goal was to finish. He encouraged me to make a goal for the run, which could serve as a motivator when the going got tough. This was another piece of lasting advice I have used for both running and for leadership.

They both can be endured by committing to continuous forward motion. Running and leadership both become psychologically much easier when you realize all you really have to do is maintain continuous forward motion. Some days require less effort than others, but I can always convince myself I am capable of some forward motion.

They both are easier if you don’t overthink things. When I first started in a leadership position, I would have moments of anxiety if I thought too hard about what I was responsible for. Similar to running, it works best if you don’t overthink what difficulties it may bring; rather, just put on your shoes and get going.

In the end, leading during COVID is like stepping onto a new trail. Despite the new terrain and foreign path, my prior training and trusty pair of sneakers – like my leadership skills and past experiences – will get me through this journey, one step at a time.

Dr. Scheurer is chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is president of SHM.

What is more stressful in the mind of a patient – a diagnosis of cancer or infertility? An infertile woman’s anxiety and depression scores are equivalent to one with cancer (J Psychosom Obstet Gynecol. 1993;14 Suppl:45-52). These two diseases intersect in the burgeoning field of oncofertility, the collaboration of oncology with reproductive endocrinology to offer patients the option of fertility preservation. The term oncofertility was first coined by Teresa Woodruff, PhD, in 2005 during her invited lecture at the University of Calgary symposium called “Pushing the Boundaries – Advances that Will Change the World in 20 Years.” Her prediction has reached its fruition. This article will review fertility preservation options for female oncology patients.

The ability for oncofertility to exist is the result of improved cancer survival rates and advances in reproductive medicine. Improvements in the treatment of cancer enable many young women to survive and focus on the potential of having a family. Malignancies striking young people, particularly breast, lymphoma, and melanoma, have encouraging 5-year survival rates. If invasive cancer is located only in the breast (affecting 62% of women diagnosed), the 5-year survival rate is 99%. For all with Hodgkin lymphoma, the 5-year survival is 87%, increasing to 92% if the cancer is found in its earliest stages. Among all people with melanoma of the skin, from the time of initial diagnosis, the 5-year survival is 92%.

Long-term survival is expected for 80% of children and adolescents diagnosed with cancer (Obstet Gynecol. 2010;116: 1171-83).
 

Iatrogenic effects

The reproductive risk of cancer treatment is gonadotoxicity and the subsequent iatrogenic primary ovarian insufficiency (POI, prior termed premature ovarian failure) or infertility.

Chemotherapy with alkylating agents, such as cyclophosphamide, is associated with the greatest chance of amenorrhea (Breast Cancer Res Treat. 2014;145:113-28). Chemotherapy with cyclophosphamide, methotrexate, and 5 fluorouracil (CMF – commonly used for the treatment of breast cancer) will usually result in loss of ovarian function in 33% of women under age 30, 50% of women aged 30-35, 75% of women aged 35-40, and 95% of women over age 40 (J Clin Oncol. 2006;24:5769-79).

The dose at which 50% of oocytes are lost due to radiation is under 2 Gy (Hum Reprod. 2003;18:117-21). Unfortunately, the minimum dose decreases with advancing age of the woman, contributed by natural diminishing reserve and an increase in radiosensitivity of oocytes. Age, proximity of the radiation field to the ovaries, and total dose are important factors determining risk of POI. For brain tumors, cranial irradiation may result in hypothalamic amenorrhea.
 

Protection

The use of GnRH agonist for 6 months during chemotherapy has been controversial with mixed results in avoiding ovarian failure. A recent study suggests a GnRH agonist does reduce the prevalence of POI (J Clin Oncol. 2018;36:1981-90) in women treated for breast cancer but the subsequent ovarian reserve is low (Ann Oncol. 2017;28:1811-6). There are not enough data now to consider this the sole viable option for all patients to preserve fertility.

Patients requiring local pelvic radiation treatment may benefit from transposition of the ovaries to sites away from maximal radiation exposure.
 

Oocyte cryopreservation (OC) and ovarian tissue cryopreservation (OTC)

Since 2012, the American Society for Reproductive Medicine lifted the experimental designation on OC and, last year, the society removed the same label for OTC, providing an additional fertility preservation option.

Ovarian stimulation and egg retrieval for OC can now occur literally within 2 weeks because of a random start protocol whereby women are stimulated any day in their cycle, pre- and post ovulation. Studies have shown equivalent yield of oocytes.

OC followed by thawing for subsequent fertilization and embryo transfer is employed as a routine matter with egg donation cycles. While there remains debate over whether live birth rates using frozen eggs are inferior to fresh eggs, a learning curve with the new technology may be the important factor (Obstet Gynecol. 2020;135:709-16).

When urgent cancer treatment precludes ovarian stimulation for OC, then OTC is a viable option. Another population that could benefit from OTC are prepubertal girls facing gonadotoxic therapy. More research is required to determine the quality of eggs obtained through ovarian stimulation in adolescent and young adult patients. While leukemic patients are eligible for OTC, there is concern about reseeding malignant cells with future autologous transplantation of tissue.

OTC involves obtaining ovarian cortical tissue, dissecting the tissue into small fragments, and cryopreserving it using either a slow-cool technique or vitrification. Orthotopic transplantation has been the most successful method for using ovarian tissue in humans. To date, live birth rates are modest (Fertil Steril. 2015;104:1097-8).

Recent research has combined the freezing of both mature and immature eggs, the latter undergoing IVM (in-vitro maturation) to maximize the potential for fertilizable eggs. Women with polycystic ovary syndrome and certain cancers or medical conditions that warrant avoiding supraphysiologic levels of estradiol from ovarian stimulation, may benefit from the retrieval of immature eggs from unstimulated ovaries.

Pregnancy outcomes using embryos created from ovaries recently exposed to chemotherapy in humans are not known but animal studies suggest there may be higher rates of miscarriage and birth defects.
 

Breast cancer – a special scenario

With every breast cancer patient, I review the theoretical concern over increasing estradiol levels during an IVF stimulation cycle with the potential impact on her cancer prognosis. Fortunately, the literature has not demonstrated an increased risk of breast cancer or recurrence after undergoing an IVF cycle. Currently, the use of aromatase inhibitors with gonadotropins along with a GnRH-antagonist is the protocol to maintain a lower estradiol level during stimulation, which may be of benefit for breast cancer prognosis. The use of aromatase inhibitors is an off-label indication for fertility with no definitive evidence of teratogenicity. Preimplantation genetic testing of embryos is available and approved by the American Society for Reproductive Medicine for BRCA gene mutation patients.

Oncofertility is an exciting field to allow cancer survivors the option for a biological child. We recommend all our cancer patients meet with our reproductive psychologist to assist in coping with the overwhelming information presented in a short time frame.
 

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.

What is more stressful in the mind of a patient – a diagnosis of cancer or infertility? An infertile woman’s anxiety and depression scores are equivalent to one with cancer (J Psychosom Obstet Gynecol. 1993;14 Suppl:45-52). These two diseases intersect in the burgeoning field of oncofertility, the collaboration of oncology with reproductive endocrinology to offer patients the option of fertility preservation. The term oncofertility was first coined by Teresa Woodruff, PhD, in 2005 during her invited lecture at the University of Calgary symposium called “Pushing the Boundaries – Advances that Will Change the World in 20 Years.” Her prediction has reached its fruition. This article will review fertility preservation options for female oncology patients.

The ability for oncofertility to exist is the result of improved cancer survival rates and advances in reproductive medicine. Improvements in the treatment of cancer enable many young women to survive and focus on the potential of having a family. Malignancies striking young people, particularly breast, lymphoma, and melanoma, have encouraging 5-year survival rates. If invasive cancer is located only in the breast (affecting 62% of women diagnosed), the 5-year survival rate is 99%. For all with Hodgkin lymphoma, the 5-year survival is 87%, increasing to 92% if the cancer is found in its earliest stages. Among all people with melanoma of the skin, from the time of initial diagnosis, the 5-year survival is 92%.

Long-term survival is expected for 80% of children and adolescents diagnosed with cancer (Obstet Gynecol. 2010;116: 1171-83).
 

Iatrogenic effects

The reproductive risk of cancer treatment is gonadotoxicity and the subsequent iatrogenic primary ovarian insufficiency (POI, prior termed premature ovarian failure) or infertility.

Chemotherapy with alkylating agents, such as cyclophosphamide, is associated with the greatest chance of amenorrhea (Breast Cancer Res Treat. 2014;145:113-28). Chemotherapy with cyclophosphamide, methotrexate, and 5 fluorouracil (CMF – commonly used for the treatment of breast cancer) will usually result in loss of ovarian function in 33% of women under age 30, 50% of women aged 30-35, 75% of women aged 35-40, and 95% of women over age 40 (J Clin Oncol. 2006;24:5769-79).

The dose at which 50% of oocytes are lost due to radiation is under 2 Gy (Hum Reprod. 2003;18:117-21). Unfortunately, the minimum dose decreases with advancing age of the woman, contributed by natural diminishing reserve and an increase in radiosensitivity of oocytes. Age, proximity of the radiation field to the ovaries, and total dose are important factors determining risk of POI. For brain tumors, cranial irradiation may result in hypothalamic amenorrhea.
 

Protection

The use of GnRH agonist for 6 months during chemotherapy has been controversial with mixed results in avoiding ovarian failure. A recent study suggests a GnRH agonist does reduce the prevalence of POI (J Clin Oncol. 2018;36:1981-90) in women treated for breast cancer but the subsequent ovarian reserve is low (Ann Oncol. 2017;28:1811-6). There are not enough data now to consider this the sole viable option for all patients to preserve fertility.

Patients requiring local pelvic radiation treatment may benefit from transposition of the ovaries to sites away from maximal radiation exposure.
 

Oocyte cryopreservation (OC) and ovarian tissue cryopreservation (OTC)

Since 2012, the American Society for Reproductive Medicine lifted the experimental designation on OC and, last year, the society removed the same label for OTC, providing an additional fertility preservation option.

Ovarian stimulation and egg retrieval for OC can now occur literally within 2 weeks because of a random start protocol whereby women are stimulated any day in their cycle, pre- and post ovulation. Studies have shown equivalent yield of oocytes.

OC followed by thawing for subsequent fertilization and embryo transfer is employed as a routine matter with egg donation cycles. While there remains debate over whether live birth rates using frozen eggs are inferior to fresh eggs, a learning curve with the new technology may be the important factor (Obstet Gynecol. 2020;135:709-16).

When urgent cancer treatment precludes ovarian stimulation for OC, then OTC is a viable option. Another population that could benefit from OTC are prepubertal girls facing gonadotoxic therapy. More research is required to determine the quality of eggs obtained through ovarian stimulation in adolescent and young adult patients. While leukemic patients are eligible for OTC, there is concern about reseeding malignant cells with future autologous transplantation of tissue.

OTC involves obtaining ovarian cortical tissue, dissecting the tissue into small fragments, and cryopreserving it using either a slow-cool technique or vitrification. Orthotopic transplantation has been the most successful method for using ovarian tissue in humans. To date, live birth rates are modest (Fertil Steril. 2015;104:1097-8).

Recent research has combined the freezing of both mature and immature eggs, the latter undergoing IVM (in-vitro maturation) to maximize the potential for fertilizable eggs. Women with polycystic ovary syndrome and certain cancers or medical conditions that warrant avoiding supraphysiologic levels of estradiol from ovarian stimulation, may benefit from the retrieval of immature eggs from unstimulated ovaries.

Pregnancy outcomes using embryos created from ovaries recently exposed to chemotherapy in humans are not known but animal studies suggest there may be higher rates of miscarriage and birth defects.
 

Breast cancer – a special scenario

With every breast cancer patient, I review the theoretical concern over increasing estradiol levels during an IVF stimulation cycle with the potential impact on her cancer prognosis. Fortunately, the literature has not demonstrated an increased risk of breast cancer or recurrence after undergoing an IVF cycle. Currently, the use of aromatase inhibitors with gonadotropins along with a GnRH-antagonist is the protocol to maintain a lower estradiol level during stimulation, which may be of benefit for breast cancer prognosis. The use of aromatase inhibitors is an off-label indication for fertility with no definitive evidence of teratogenicity. Preimplantation genetic testing of embryos is available and approved by the American Society for Reproductive Medicine for BRCA gene mutation patients.

Oncofertility is an exciting field to allow cancer survivors the option for a biological child. We recommend all our cancer patients meet with our reproductive psychologist to assist in coping with the overwhelming information presented in a short time frame.
 

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.

What is more stressful in the mind of a patient – a diagnosis of cancer or infertility? An infertile woman’s anxiety and depression scores are equivalent to one with cancer (J Psychosom Obstet Gynecol. 1993;14 Suppl:45-52). These two diseases intersect in the burgeoning field of oncofertility, the collaboration of oncology with reproductive endocrinology to offer patients the option of fertility preservation. The term oncofertility was first coined by Teresa Woodruff, PhD, in 2005 during her invited lecture at the University of Calgary symposium called “Pushing the Boundaries – Advances that Will Change the World in 20 Years.” Her prediction has reached its fruition. This article will review fertility preservation options for female oncology patients.

The ability for oncofertility to exist is the result of improved cancer survival rates and advances in reproductive medicine. Improvements in the treatment of cancer enable many young women to survive and focus on the potential of having a family. Malignancies striking young people, particularly breast, lymphoma, and melanoma, have encouraging 5-year survival rates. If invasive cancer is located only in the breast (affecting 62% of women diagnosed), the 5-year survival rate is 99%. For all with Hodgkin lymphoma, the 5-year survival is 87%, increasing to 92% if the cancer is found in its earliest stages. Among all people with melanoma of the skin, from the time of initial diagnosis, the 5-year survival is 92%.

Long-term survival is expected for 80% of children and adolescents diagnosed with cancer (Obstet Gynecol. 2010;116: 1171-83).
 

Iatrogenic effects

The reproductive risk of cancer treatment is gonadotoxicity and the subsequent iatrogenic primary ovarian insufficiency (POI, prior termed premature ovarian failure) or infertility.

Chemotherapy with alkylating agents, such as cyclophosphamide, is associated with the greatest chance of amenorrhea (Breast Cancer Res Treat. 2014;145:113-28). Chemotherapy with cyclophosphamide, methotrexate, and 5 fluorouracil (CMF – commonly used for the treatment of breast cancer) will usually result in loss of ovarian function in 33% of women under age 30, 50% of women aged 30-35, 75% of women aged 35-40, and 95% of women over age 40 (J Clin Oncol. 2006;24:5769-79).

The dose at which 50% of oocytes are lost due to radiation is under 2 Gy (Hum Reprod. 2003;18:117-21). Unfortunately, the minimum dose decreases with advancing age of the woman, contributed by natural diminishing reserve and an increase in radiosensitivity of oocytes. Age, proximity of the radiation field to the ovaries, and total dose are important factors determining risk of POI. For brain tumors, cranial irradiation may result in hypothalamic amenorrhea.
 

Protection

The use of GnRH agonist for 6 months during chemotherapy has been controversial with mixed results in avoiding ovarian failure. A recent study suggests a GnRH agonist does reduce the prevalence of POI (J Clin Oncol. 2018;36:1981-90) in women treated for breast cancer but the subsequent ovarian reserve is low (Ann Oncol. 2017;28:1811-6). There are not enough data now to consider this the sole viable option for all patients to preserve fertility.

Patients requiring local pelvic radiation treatment may benefit from transposition of the ovaries to sites away from maximal radiation exposure.
 

Oocyte cryopreservation (OC) and ovarian tissue cryopreservation (OTC)

Since 2012, the American Society for Reproductive Medicine lifted the experimental designation on OC and, last year, the society removed the same label for OTC, providing an additional fertility preservation option.

Ovarian stimulation and egg retrieval for OC can now occur literally within 2 weeks because of a random start protocol whereby women are stimulated any day in their cycle, pre- and post ovulation. Studies have shown equivalent yield of oocytes.

OC followed by thawing for subsequent fertilization and embryo transfer is employed as a routine matter with egg donation cycles. While there remains debate over whether live birth rates using frozen eggs are inferior to fresh eggs, a learning curve with the new technology may be the important factor (Obstet Gynecol. 2020;135:709-16).

When urgent cancer treatment precludes ovarian stimulation for OC, then OTC is a viable option. Another population that could benefit from OTC are prepubertal girls facing gonadotoxic therapy. More research is required to determine the quality of eggs obtained through ovarian stimulation in adolescent and young adult patients. While leukemic patients are eligible for OTC, there is concern about reseeding malignant cells with future autologous transplantation of tissue.

OTC involves obtaining ovarian cortical tissue, dissecting the tissue into small fragments, and cryopreserving it using either a slow-cool technique or vitrification. Orthotopic transplantation has been the most successful method for using ovarian tissue in humans. To date, live birth rates are modest (Fertil Steril. 2015;104:1097-8).

Recent research has combined the freezing of both mature and immature eggs, the latter undergoing IVM (in-vitro maturation) to maximize the potential for fertilizable eggs. Women with polycystic ovary syndrome and certain cancers or medical conditions that warrant avoiding supraphysiologic levels of estradiol from ovarian stimulation, may benefit from the retrieval of immature eggs from unstimulated ovaries.

Pregnancy outcomes using embryos created from ovaries recently exposed to chemotherapy in humans are not known but animal studies suggest there may be higher rates of miscarriage and birth defects.
 

Breast cancer – a special scenario

With every breast cancer patient, I review the theoretical concern over increasing estradiol levels during an IVF stimulation cycle with the potential impact on her cancer prognosis. Fortunately, the literature has not demonstrated an increased risk of breast cancer or recurrence after undergoing an IVF cycle. Currently, the use of aromatase inhibitors with gonadotropins along with a GnRH-antagonist is the protocol to maintain a lower estradiol level during stimulation, which may be of benefit for breast cancer prognosis. The use of aromatase inhibitors is an off-label indication for fertility with no definitive evidence of teratogenicity. Preimplantation genetic testing of embryos is available and approved by the American Society for Reproductive Medicine for BRCA gene mutation patients.

Oncofertility is an exciting field to allow cancer survivors the option for a biological child. We recommend all our cancer patients meet with our reproductive psychologist to assist in coping with the overwhelming information presented in a short time frame.
 

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.

It’s not unusual when I run into a former patient that I am addressed as “Doctor” Wilkoff. I guess that is to be expected because when I was in practice I seldom introduced myself as Will. However, I will admit now that I never quite felt comfortable with the “Doctor” label. Today, if you addressed me as “Doctor” I would correct you and refer to myself as the “ex-Doctor Wilkoff.”

The term doctor derived from the Latin word to teach and eventually morphed into an academic title. In common parlance it is sometimes used as verb meaning to treat, e.g., “he doctored the wound.” Regardless of what academic field we are talking about, the title “doctor” has become a term of respect for someone who has spent an unusually long time learning his or her subject or craft. The holder of a doctorate, particularly in medicine, receives a rank, earned or unearned, near the top of the social hierarchy.

When I look back at more than 50 years of doing pediatrics I’m not sure that “doctor” really captures what I was up to. I will grant you that it is nice that folks want to acknowledge all those years I spent in training. But I don’t think one could say that what I did as a primary care small town pediatrician fits in with the original definition “to teach.” I did spend a few hours teaching students every so often but my primary time was spent with patients and I don’t consider what I was doing with them as teaching. There just wasn’t enough time. I had to take as a given that families who came to see me already had a basic knowledge base either as the result of their schooling, family lore, or public service announcements from the American Academy of Pediatrics.

I certainly wasn’t doing much doctoring in the sense of treating or curing disease. If one removes administering immunizations and delivery room resuscitations, I saved very few lives.

So you may ask, if not as “doctor,” how would I prefer to be labeled? Good question, but easy for me to answer. The term “coach” quickly comes to mind. As someone who played a variety of team sports there is no term that I can think of that commands more respect than “Coach.” While the term doesn’t carry the burden of a particularly long educational journey it does imply the person is wise, observant, and experienced.

There is some teaching involved but primarily a coach is going to assess the players (or in this cases the families) he is presented with and then do the best he can to guide them toward good decisions they can make themselves given their specific situations. This requires spending most of one’s time getting to know each family and understanding their strengths and limitations. One can’t coach speed to an athlete who is slow footed. And, one isn’t going to get a family that is dominated by anxiety to become bold risk takers. The best you can do is to help them learn strategies to minimize their anxieties.

A good coach can help his players learn to set reasonable goals given their skill sets. And, a good pediatrician can coach his families how to adapt their strengths and weakness to the challenges of each of their children. For example, for a physician faced with a mother-infant dyad that is struggling with breastfeeding, once the education piece is in place, it is up to him or her to function as a coach and assist the team in setting a reasonable goal that can result in a win-win for the family.

A coach must be humble, putting his or her players’ needs first and flexible enough to adjust his or her goals to define success in terms for what is best for each individual team. “Coach” may not carry the ring of authority that can come with “Doctor” but it is a role equally as challenging and rewarding.
 

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].

It’s not unusual when I run into a former patient that I am addressed as “Doctor” Wilkoff. I guess that is to be expected because when I was in practice I seldom introduced myself as Will. However, I will admit now that I never quite felt comfortable with the “Doctor” label. Today, if you addressed me as “Doctor” I would correct you and refer to myself as the “ex-Doctor Wilkoff.”

The term doctor derived from the Latin word to teach and eventually morphed into an academic title. In common parlance it is sometimes used as verb meaning to treat, e.g., “he doctored the wound.” Regardless of what academic field we are talking about, the title “doctor” has become a term of respect for someone who has spent an unusually long time learning his or her subject or craft. The holder of a doctorate, particularly in medicine, receives a rank, earned or unearned, near the top of the social hierarchy.

When I look back at more than 50 years of doing pediatrics I’m not sure that “doctor” really captures what I was up to. I will grant you that it is nice that folks want to acknowledge all those years I spent in training. But I don’t think one could say that what I did as a primary care small town pediatrician fits in with the original definition “to teach.” I did spend a few hours teaching students every so often but my primary time was spent with patients and I don’t consider what I was doing with them as teaching. There just wasn’t enough time. I had to take as a given that families who came to see me already had a basic knowledge base either as the result of their schooling, family lore, or public service announcements from the American Academy of Pediatrics.

I certainly wasn’t doing much doctoring in the sense of treating or curing disease. If one removes administering immunizations and delivery room resuscitations, I saved very few lives.

So you may ask, if not as “doctor,” how would I prefer to be labeled? Good question, but easy for me to answer. The term “coach” quickly comes to mind. As someone who played a variety of team sports there is no term that I can think of that commands more respect than “Coach.” While the term doesn’t carry the burden of a particularly long educational journey it does imply the person is wise, observant, and experienced.

There is some teaching involved but primarily a coach is going to assess the players (or in this cases the families) he is presented with and then do the best he can to guide them toward good decisions they can make themselves given their specific situations. This requires spending most of one’s time getting to know each family and understanding their strengths and limitations. One can’t coach speed to an athlete who is slow footed. And, one isn’t going to get a family that is dominated by anxiety to become bold risk takers. The best you can do is to help them learn strategies to minimize their anxieties.

A good coach can help his players learn to set reasonable goals given their skill sets. And, a good pediatrician can coach his families how to adapt their strengths and weakness to the challenges of each of their children. For example, for a physician faced with a mother-infant dyad that is struggling with breastfeeding, once the education piece is in place, it is up to him or her to function as a coach and assist the team in setting a reasonable goal that can result in a win-win for the family.

A coach must be humble, putting his or her players’ needs first and flexible enough to adjust his or her goals to define success in terms for what is best for each individual team. “Coach” may not carry the ring of authority that can come with “Doctor” but it is a role equally as challenging and rewarding.
 

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].

It’s not unusual when I run into a former patient that I am addressed as “Doctor” Wilkoff. I guess that is to be expected because when I was in practice I seldom introduced myself as Will. However, I will admit now that I never quite felt comfortable with the “Doctor” label. Today, if you addressed me as “Doctor” I would correct you and refer to myself as the “ex-Doctor Wilkoff.”

The term doctor derived from the Latin word to teach and eventually morphed into an academic title. In common parlance it is sometimes used as verb meaning to treat, e.g., “he doctored the wound.” Regardless of what academic field we are talking about, the title “doctor” has become a term of respect for someone who has spent an unusually long time learning his or her subject or craft. The holder of a doctorate, particularly in medicine, receives a rank, earned or unearned, near the top of the social hierarchy.

When I look back at more than 50 years of doing pediatrics I’m not sure that “doctor” really captures what I was up to. I will grant you that it is nice that folks want to acknowledge all those years I spent in training. But I don’t think one could say that what I did as a primary care small town pediatrician fits in with the original definition “to teach.” I did spend a few hours teaching students every so often but my primary time was spent with patients and I don’t consider what I was doing with them as teaching. There just wasn’t enough time. I had to take as a given that families who came to see me already had a basic knowledge base either as the result of their schooling, family lore, or public service announcements from the American Academy of Pediatrics.

I certainly wasn’t doing much doctoring in the sense of treating or curing disease. If one removes administering immunizations and delivery room resuscitations, I saved very few lives.

So you may ask, if not as “doctor,” how would I prefer to be labeled? Good question, but easy for me to answer. The term “coach” quickly comes to mind. As someone who played a variety of team sports there is no term that I can think of that commands more respect than “Coach.” While the term doesn’t carry the burden of a particularly long educational journey it does imply the person is wise, observant, and experienced.

There is some teaching involved but primarily a coach is going to assess the players (or in this cases the families) he is presented with and then do the best he can to guide them toward good decisions they can make themselves given their specific situations. This requires spending most of one’s time getting to know each family and understanding their strengths and limitations. One can’t coach speed to an athlete who is slow footed. And, one isn’t going to get a family that is dominated by anxiety to become bold risk takers. The best you can do is to help them learn strategies to minimize their anxieties.

A good coach can help his players learn to set reasonable goals given their skill sets. And, a good pediatrician can coach his families how to adapt their strengths and weakness to the challenges of each of their children. For example, for a physician faced with a mother-infant dyad that is struggling with breastfeeding, once the education piece is in place, it is up to him or her to function as a coach and assist the team in setting a reasonable goal that can result in a win-win for the family.

A coach must be humble, putting his or her players’ needs first and flexible enough to adjust his or her goals to define success in terms for what is best for each individual team. “Coach” may not carry the ring of authority that can come with “Doctor” but it is a role equally as challenging and rewarding.
 

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].

Each year in the United States, approximately one to two out of every thousand people suffer from venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism. The American Society of Hematology (ASH) issued new guidelines for the management of VTE, including primary treatment, secondary prevention, and treatment of recurrent events, earlier this year.

These guidelines, which were recently published in Blood Advances (Ortel T L et al. Blood Adv 2020 doi: 10.1182/bloodadvances.2020001830), include 28 recommendations.

How to treat uncomplicated patients

For uncomplicated deep vein thrombosis (DVT) and/or pulmonary embolism (PE), the guidelines suggest treating patients at home rather than in the hospital. This is especially important for family physicians to note as many of these patients will now be the responsibility of the primary care doctor to treat and follow. Patients treated at home can avoid the risk of nosocomial infections, especially in the days of COVID-19. Evidence also suggests that being treated at home was shown to reduce the risk of PE versus being treated in the hospital. It is, therefore, crucial that family physicians know which patients are low versus high risk.

Further, the guidelines suggest that these patients with low risk of complications are better treated with direct oral anticoagulants (DOACs) instead of vitamin K antagonists, such as Coumadin.

Medication-related suggestions

The guidelines also suggest that no DOAC is preferred over another. Since DOACs are relatively newer agents, family doctors need to become comfortable with their use. For proximal DVTs, anticoagulation alone can be used without thrombolytics.

Family physicians are often tasked with the decision on when to stop anticoagulation. The authors recommend against using diagnostic tests such as D-Dimer or ultrasound to decide when to stop these medications in low-risk patients. In patients at risk of recurrent VTE due to chronic medical conditions, it is suggested to continue anti-coagulants indefinitely. While anticoagulant therapy effectively reduces risk of VTE, it does increase the risk of bleeding events.

The guidelines are quite extensive and specific in their recommendations and family physicians need to understand them. We are often the first ones in the medical system to diagnose VTE, and it is quite possible to keep these patients home, thereby eliminating risks they may encounter by being hospitalized. In addition, the recommendation regarding the use of DOACs may ease some of the burden of monitoring patients on long-term Coumadin. These medications do not come without risks, and we must be comfortable evaluating for any complications. In our current health care system, different insurance companies have different formularies making it necessary for us to know all these medications.

In the past, the diagnosis of PE and even a DVT would mean a hospital stay. We now know, and these guidelines reaffirm, that this is not necessary in uncomplicated cases.

In addition to diagnosing VTE, family physicians are also tasked with following up with patients who were hospitalized or started on treatment by other physicians. We need to know the plan on when to stop the medication or when to reevaluate its use. Patients often bring this question to us, and these guidelines will help us answer that question.

Many patients who have more complicated medical conditions often see multiple specialists. The ASH recommendations help standardize the care of these patients across specialties.

What the recommendations are missing

As family doctors, we often treat patients with multiple comorbidities. These guidelines do not make recommendations for patients with cancer, who are at high risk of VTE events. Some patients also have conditions that increase their risk of bleeding or have contraindications to the use of anticoagulants. It would be helpful to have more recommendations for both of these types of patients in addition to the use of inferior vena cava filter in patients with proximal DVT. The document is also missing recommendations for pregnant patients, which would be useful.

Overall, these guidelines include much of what we already do in our practices while doing a great job of incorporating the newer DOACs. These guidelines are easy for family physicians to put into practice.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. You can contact her at [email protected].

Each year in the United States, approximately one to two out of every thousand people suffer from venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism. The American Society of Hematology (ASH) issued new guidelines for the management of VTE, including primary treatment, secondary prevention, and treatment of recurrent events, earlier this year.

These guidelines, which were recently published in Blood Advances (Ortel T L et al. Blood Adv 2020 doi: 10.1182/bloodadvances.2020001830), include 28 recommendations.

How to treat uncomplicated patients

For uncomplicated deep vein thrombosis (DVT) and/or pulmonary embolism (PE), the guidelines suggest treating patients at home rather than in the hospital. This is especially important for family physicians to note as many of these patients will now be the responsibility of the primary care doctor to treat and follow. Patients treated at home can avoid the risk of nosocomial infections, especially in the days of COVID-19. Evidence also suggests that being treated at home was shown to reduce the risk of PE versus being treated in the hospital. It is, therefore, crucial that family physicians know which patients are low versus high risk.

Further, the guidelines suggest that these patients with low risk of complications are better treated with direct oral anticoagulants (DOACs) instead of vitamin K antagonists, such as Coumadin.

Medication-related suggestions

The guidelines also suggest that no DOAC is preferred over another. Since DOACs are relatively newer agents, family doctors need to become comfortable with their use. For proximal DVTs, anticoagulation alone can be used without thrombolytics.

Family physicians are often tasked with the decision on when to stop anticoagulation. The authors recommend against using diagnostic tests such as D-Dimer or ultrasound to decide when to stop these medications in low-risk patients. In patients at risk of recurrent VTE due to chronic medical conditions, it is suggested to continue anti-coagulants indefinitely. While anticoagulant therapy effectively reduces risk of VTE, it does increase the risk of bleeding events.

The guidelines are quite extensive and specific in their recommendations and family physicians need to understand them. We are often the first ones in the medical system to diagnose VTE, and it is quite possible to keep these patients home, thereby eliminating risks they may encounter by being hospitalized. In addition, the recommendation regarding the use of DOACs may ease some of the burden of monitoring patients on long-term Coumadin. These medications do not come without risks, and we must be comfortable evaluating for any complications. In our current health care system, different insurance companies have different formularies making it necessary for us to know all these medications.

In the past, the diagnosis of PE and even a DVT would mean a hospital stay. We now know, and these guidelines reaffirm, that this is not necessary in uncomplicated cases.

In addition to diagnosing VTE, family physicians are also tasked with following up with patients who were hospitalized or started on treatment by other physicians. We need to know the plan on when to stop the medication or when to reevaluate its use. Patients often bring this question to us, and these guidelines will help us answer that question.

Many patients who have more complicated medical conditions often see multiple specialists. The ASH recommendations help standardize the care of these patients across specialties.

What the recommendations are missing

As family doctors, we often treat patients with multiple comorbidities. These guidelines do not make recommendations for patients with cancer, who are at high risk of VTE events. Some patients also have conditions that increase their risk of bleeding or have contraindications to the use of anticoagulants. It would be helpful to have more recommendations for both of these types of patients in addition to the use of inferior vena cava filter in patients with proximal DVT. The document is also missing recommendations for pregnant patients, which would be useful.

Overall, these guidelines include much of what we already do in our practices while doing a great job of incorporating the newer DOACs. These guidelines are easy for family physicians to put into practice.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. You can contact her at [email protected].

Each year in the United States, approximately one to two out of every thousand people suffer from venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism. The American Society of Hematology (ASH) issued new guidelines for the management of VTE, including primary treatment, secondary prevention, and treatment of recurrent events, earlier this year.

These guidelines, which were recently published in Blood Advances (Ortel T L et al. Blood Adv 2020 doi: 10.1182/bloodadvances.2020001830), include 28 recommendations.

How to treat uncomplicated patients

For uncomplicated deep vein thrombosis (DVT) and/or pulmonary embolism (PE), the guidelines suggest treating patients at home rather than in the hospital. This is especially important for family physicians to note as many of these patients will now be the responsibility of the primary care doctor to treat and follow. Patients treated at home can avoid the risk of nosocomial infections, especially in the days of COVID-19. Evidence also suggests that being treated at home was shown to reduce the risk of PE versus being treated in the hospital. It is, therefore, crucial that family physicians know which patients are low versus high risk.

Further, the guidelines suggest that these patients with low risk of complications are better treated with direct oral anticoagulants (DOACs) instead of vitamin K antagonists, such as Coumadin.

Medication-related suggestions

The guidelines also suggest that no DOAC is preferred over another. Since DOACs are relatively newer agents, family doctors need to become comfortable with their use. For proximal DVTs, anticoagulation alone can be used without thrombolytics.

Family physicians are often tasked with the decision on when to stop anticoagulation. The authors recommend against using diagnostic tests such as D-Dimer or ultrasound to decide when to stop these medications in low-risk patients. In patients at risk of recurrent VTE due to chronic medical conditions, it is suggested to continue anti-coagulants indefinitely. While anticoagulant therapy effectively reduces risk of VTE, it does increase the risk of bleeding events.

The guidelines are quite extensive and specific in their recommendations and family physicians need to understand them. We are often the first ones in the medical system to diagnose VTE, and it is quite possible to keep these patients home, thereby eliminating risks they may encounter by being hospitalized. In addition, the recommendation regarding the use of DOACs may ease some of the burden of monitoring patients on long-term Coumadin. These medications do not come without risks, and we must be comfortable evaluating for any complications. In our current health care system, different insurance companies have different formularies making it necessary for us to know all these medications.

In the past, the diagnosis of PE and even a DVT would mean a hospital stay. We now know, and these guidelines reaffirm, that this is not necessary in uncomplicated cases.

In addition to diagnosing VTE, family physicians are also tasked with following up with patients who were hospitalized or started on treatment by other physicians. We need to know the plan on when to stop the medication or when to reevaluate its use. Patients often bring this question to us, and these guidelines will help us answer that question.

Many patients who have more complicated medical conditions often see multiple specialists. The ASH recommendations help standardize the care of these patients across specialties.

What the recommendations are missing

As family doctors, we often treat patients with multiple comorbidities. These guidelines do not make recommendations for patients with cancer, who are at high risk of VTE events. Some patients also have conditions that increase their risk of bleeding or have contraindications to the use of anticoagulants. It would be helpful to have more recommendations for both of these types of patients in addition to the use of inferior vena cava filter in patients with proximal DVT. The document is also missing recommendations for pregnant patients, which would be useful.

Overall, these guidelines include much of what we already do in our practices while doing a great job of incorporating the newer DOACs. These guidelines are easy for family physicians to put into practice.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. You can contact her at [email protected].

In this day and age, a new question should make its way to the top of the list for new parents and their pediatricians: How will the family approach the issue of household technology use – for their children as well as themselves?

Yuji_Karaki/Getty Images

Managing screen time is one of the most vexing challenges facing today’s parents. Even the most vigilant among them will find much available guidance conflicting – and a good deal of it may feel oblivious to their day-to-day realities. This is especially true now, as many families face the daunting demands of pandemic parenting – juggling full-time jobs with childcare and distance learning.

While the American Academy of Pediatrics still specifies daily time limits by age (difficult for many families to achieve even in “normal” times), pediatricians and other child development experts now recognize that a host of factors should inform decisions about healthy screen use. There’s no one “magic number” for acceptable daily use, as not all screen time is the same (particularly during the pandemic) – and different children will experience the effects of technology usage differently.

The quality of content the child engages with; the degree of parental involvement; and the individual cognitive and behavioral considerations of a child are just some of the factors that should be considered. Given the complexities, it’s unfortunate that many parents will not have discussed screen use with their pediatrician or even their partner before their child first reaches for that glowing screen – and certainly not before they are using technology to multitask work, social connections, and day-to-day child rearing. Screen habits form early for both children and families.
 

An early well-visit priority

Pediatricians have an important role to play in helping families develop a more purposeful approach to household technology by providing them with trusted, evidence-based information on screens and the potential impact on children’s development. This is not information parents should receive when a child is 2 or 3 years of age. By then, toddlers are often already avid tablet users and parents may have come to rely on technology as a parenting aid.

Parents also need to know that, from birth, they can influence their child’s brain and communication development through undistracted time for talking, reading, singing, and interacting with their baby. Though the way children develop speech and language skills has not changed, the level of distraction posed by technology has grown immensely. It is much more difficult for parents to notice a baby’s subtle communication attempts – a coo or a smile, for instance, and respond accordingly – with a smartphone in hand. Rather than admonish parents for overusing their devices, we can focus them on what supports healthy child development instead.

By talking to parents earlier, pediatricians can help prevent premature or excessive exposure to technology – as well as encourage parents to dedicate “unplugged” times of day with their baby, such as during feeding time or before bedtime. By accenting the positive – educating parents about how they can encourage development and growth, how they can bond with their baby, and how they can establish a loving and nurturing relationship – pediatricians can motivate them towards simple steps that limit technology’s disruption of daily developmental opportunities. They can also help them lay a solid foundation for healthy screen time habits in the long term for their family.
 

The critical period for speech and language development is early

The impact of screen use on a child’s communication development is a significant concern. The critical time window for the development of speech, language, and social skills is between birth and 3 years. What happens then is the precursor for later reading and writing skills that are key to academic and vocational success.

A meta-analysis published in JAMA Pediatrics in July 2020 found that greater quantity of screen use was associated with poorer language skills – while screen-use onset at later ages was also associated with stronger child language skills. A November 2019 JAMA Pediatrics study using brain imaging in pre–school age children found an association between increased screen-based media use, compared with the AAP guidelines, and lower integrity of white matter tracts supporting language and emergent literacy skills. That study also used several language and literacy tests, finding that children with higher screen exposure had poorer expressive language and worse language processing speed. A 2017 study of 900 children between 18 and 24 months found that every 30-minute increase in daily screen time was linked to a 49% increased risk of expressive speech delay. And on the parental side, numerous studies have documented decreased verbal and nonverbal interactions initiated by parents when they are using a device.
 

Be tech wise with baby

AAP offers many resources in its Media and Children Communication Toolkit that serve as helpful starting points for conversations, including its family media use plan templates. However, more resources tailored to parents of newborns and very young children are needed.

One new option recently developed by the American Speech-Language-Hearing Association (ASHA) and the Children’s Screen Time Action Network is Be Tech Wise With Baby! Aimed at prospective and new parents, this simple handout, available for free in English and Spanish, is an easy takeaway from early well-child visits that pediatricians and pediatric nurses can distribute.

Pediatricians have a vital role to play championing healthy, balanced screen time use for children and adults – starting from baby’s first moments of life. By guiding new parents towards simple steps, such as carving out tech-free times of day and delaying introduction of screens, they can positively influence the screen-time habits of the next generation of connected kids.
 

Mark Bertin, MD, is a developmental pediatrician and author of numerous parenting books, including “How Children Thrive: The Practical Science of Raising Independent, Resilient, and Happy Kids” and “Mindful Parenting for ADHD.” Diane Paul, PhD, CCC-SLP, is the director of clinical issues in speech-language pathology for the American Speech-Language-Hearing Association (ASHA) and author of numerous books, including “Talking on the Go: Everyday Activities to Enhance Speech and Language Development.” Email them at [email protected].

In this day and age, a new question should make its way to the top of the list for new parents and their pediatricians: How will the family approach the issue of household technology use – for their children as well as themselves?

Yuji_Karaki/Getty Images

Managing screen time is one of the most vexing challenges facing today’s parents. Even the most vigilant among them will find much available guidance conflicting – and a good deal of it may feel oblivious to their day-to-day realities. This is especially true now, as many families face the daunting demands of pandemic parenting – juggling full-time jobs with childcare and distance learning.

While the American Academy of Pediatrics still specifies daily time limits by age (difficult for many families to achieve even in “normal” times), pediatricians and other child development experts now recognize that a host of factors should inform decisions about healthy screen use. There’s no one “magic number” for acceptable daily use, as not all screen time is the same (particularly during the pandemic) – and different children will experience the effects of technology usage differently.

The quality of content the child engages with; the degree of parental involvement; and the individual cognitive and behavioral considerations of a child are just some of the factors that should be considered. Given the complexities, it’s unfortunate that many parents will not have discussed screen use with their pediatrician or even their partner before their child first reaches for that glowing screen – and certainly not before they are using technology to multitask work, social connections, and day-to-day child rearing. Screen habits form early for both children and families.
 

An early well-visit priority

Pediatricians have an important role to play in helping families develop a more purposeful approach to household technology by providing them with trusted, evidence-based information on screens and the potential impact on children’s development. This is not information parents should receive when a child is 2 or 3 years of age. By then, toddlers are often already avid tablet users and parents may have come to rely on technology as a parenting aid.

Parents also need to know that, from birth, they can influence their child’s brain and communication development through undistracted time for talking, reading, singing, and interacting with their baby. Though the way children develop speech and language skills has not changed, the level of distraction posed by technology has grown immensely. It is much more difficult for parents to notice a baby’s subtle communication attempts – a coo or a smile, for instance, and respond accordingly – with a smartphone in hand. Rather than admonish parents for overusing their devices, we can focus them on what supports healthy child development instead.

By talking to parents earlier, pediatricians can help prevent premature or excessive exposure to technology – as well as encourage parents to dedicate “unplugged” times of day with their baby, such as during feeding time or before bedtime. By accenting the positive – educating parents about how they can encourage development and growth, how they can bond with their baby, and how they can establish a loving and nurturing relationship – pediatricians can motivate them towards simple steps that limit technology’s disruption of daily developmental opportunities. They can also help them lay a solid foundation for healthy screen time habits in the long term for their family.
 

The critical period for speech and language development is early

The impact of screen use on a child’s communication development is a significant concern. The critical time window for the development of speech, language, and social skills is between birth and 3 years. What happens then is the precursor for later reading and writing skills that are key to academic and vocational success.

A meta-analysis published in JAMA Pediatrics in July 2020 found that greater quantity of screen use was associated with poorer language skills – while screen-use onset at later ages was also associated with stronger child language skills. A November 2019 JAMA Pediatrics study using brain imaging in pre–school age children found an association between increased screen-based media use, compared with the AAP guidelines, and lower integrity of white matter tracts supporting language and emergent literacy skills. That study also used several language and literacy tests, finding that children with higher screen exposure had poorer expressive language and worse language processing speed. A 2017 study of 900 children between 18 and 24 months found that every 30-minute increase in daily screen time was linked to a 49% increased risk of expressive speech delay. And on the parental side, numerous studies have documented decreased verbal and nonverbal interactions initiated by parents when they are using a device.
 

Be tech wise with baby

AAP offers many resources in its Media and Children Communication Toolkit that serve as helpful starting points for conversations, including its family media use plan templates. However, more resources tailored to parents of newborns and very young children are needed.

One new option recently developed by the American Speech-Language-Hearing Association (ASHA) and the Children’s Screen Time Action Network is Be Tech Wise With Baby! Aimed at prospective and new parents, this simple handout, available for free in English and Spanish, is an easy takeaway from early well-child visits that pediatricians and pediatric nurses can distribute.

Pediatricians have a vital role to play championing healthy, balanced screen time use for children and adults – starting from baby’s first moments of life. By guiding new parents towards simple steps, such as carving out tech-free times of day and delaying introduction of screens, they can positively influence the screen-time habits of the next generation of connected kids.
 

Mark Bertin, MD, is a developmental pediatrician and author of numerous parenting books, including “How Children Thrive: The Practical Science of Raising Independent, Resilient, and Happy Kids” and “Mindful Parenting for ADHD.” Diane Paul, PhD, CCC-SLP, is the director of clinical issues in speech-language pathology for the American Speech-Language-Hearing Association (ASHA) and author of numerous books, including “Talking on the Go: Everyday Activities to Enhance Speech and Language Development.” Email them at [email protected].

In this day and age, a new question should make its way to the top of the list for new parents and their pediatricians: How will the family approach the issue of household technology use – for their children as well as themselves?

Yuji_Karaki/Getty Images

Managing screen time is one of the most vexing challenges facing today’s parents. Even the most vigilant among them will find much available guidance conflicting – and a good deal of it may feel oblivious to their day-to-day realities. This is especially true now, as many families face the daunting demands of pandemic parenting – juggling full-time jobs with childcare and distance learning.

While the American Academy of Pediatrics still specifies daily time limits by age (difficult for many families to achieve even in “normal” times), pediatricians and other child development experts now recognize that a host of factors should inform decisions about healthy screen use. There’s no one “magic number” for acceptable daily use, as not all screen time is the same (particularly during the pandemic) – and different children will experience the effects of technology usage differently.

The quality of content the child engages with; the degree of parental involvement; and the individual cognitive and behavioral considerations of a child are just some of the factors that should be considered. Given the complexities, it’s unfortunate that many parents will not have discussed screen use with their pediatrician or even their partner before their child first reaches for that glowing screen – and certainly not before they are using technology to multitask work, social connections, and day-to-day child rearing. Screen habits form early for both children and families.
 

An early well-visit priority

Pediatricians have an important role to play in helping families develop a more purposeful approach to household technology by providing them with trusted, evidence-based information on screens and the potential impact on children’s development. This is not information parents should receive when a child is 2 or 3 years of age. By then, toddlers are often already avid tablet users and parents may have come to rely on technology as a parenting aid.

Parents also need to know that, from birth, they can influence their child’s brain and communication development through undistracted time for talking, reading, singing, and interacting with their baby. Though the way children develop speech and language skills has not changed, the level of distraction posed by technology has grown immensely. It is much more difficult for parents to notice a baby’s subtle communication attempts – a coo or a smile, for instance, and respond accordingly – with a smartphone in hand. Rather than admonish parents for overusing their devices, we can focus them on what supports healthy child development instead.

By talking to parents earlier, pediatricians can help prevent premature or excessive exposure to technology – as well as encourage parents to dedicate “unplugged” times of day with their baby, such as during feeding time or before bedtime. By accenting the positive – educating parents about how they can encourage development and growth, how they can bond with their baby, and how they can establish a loving and nurturing relationship – pediatricians can motivate them towards simple steps that limit technology’s disruption of daily developmental opportunities. They can also help them lay a solid foundation for healthy screen time habits in the long term for their family.
 

The critical period for speech and language development is early

The impact of screen use on a child’s communication development is a significant concern. The critical time window for the development of speech, language, and social skills is between birth and 3 years. What happens then is the precursor for later reading and writing skills that are key to academic and vocational success.

A meta-analysis published in JAMA Pediatrics in July 2020 found that greater quantity of screen use was associated with poorer language skills – while screen-use onset at later ages was also associated with stronger child language skills. A November 2019 JAMA Pediatrics study using brain imaging in pre–school age children found an association between increased screen-based media use, compared with the AAP guidelines, and lower integrity of white matter tracts supporting language and emergent literacy skills. That study also used several language and literacy tests, finding that children with higher screen exposure had poorer expressive language and worse language processing speed. A 2017 study of 900 children between 18 and 24 months found that every 30-minute increase in daily screen time was linked to a 49% increased risk of expressive speech delay. And on the parental side, numerous studies have documented decreased verbal and nonverbal interactions initiated by parents when they are using a device.
 

Be tech wise with baby

AAP offers many resources in its Media and Children Communication Toolkit that serve as helpful starting points for conversations, including its family media use plan templates. However, more resources tailored to parents of newborns and very young children are needed.

One new option recently developed by the American Speech-Language-Hearing Association (ASHA) and the Children’s Screen Time Action Network is Be Tech Wise With Baby! Aimed at prospective and new parents, this simple handout, available for free in English and Spanish, is an easy takeaway from early well-child visits that pediatricians and pediatric nurses can distribute.

Pediatricians have a vital role to play championing healthy, balanced screen time use for children and adults – starting from baby’s first moments of life. By guiding new parents towards simple steps, such as carving out tech-free times of day and delaying introduction of screens, they can positively influence the screen-time habits of the next generation of connected kids.
 

Mark Bertin, MD, is a developmental pediatrician and author of numerous parenting books, including “How Children Thrive: The Practical Science of Raising Independent, Resilient, and Happy Kids” and “Mindful Parenting for ADHD.” Diane Paul, PhD, CCC-SLP, is the director of clinical issues in speech-language pathology for the American Speech-Language-Hearing Association (ASHA) and author of numerous books, including “Talking on the Go: Everyday Activities to Enhance Speech and Language Development.” Email them at [email protected].

Regardless of who received the most electoral votes it is pretty clear that each candidate has millions of supporters, and that they are separated by only a few percentage points. I guess one could argue that so many people being able to express their opinions is healthy. However, from my side of the divide I have difficulty understanding how so many of my fellow citizens could arrive at an opinion so diametrically opposed to my own.

Since the 2016 election I have tried to read as many articles as I could find in search of an explanation for that outcome and continuing partisan support. I have never had much interest in political science because it always sounded like an oxymoron. But I am willing to listen to anyone who claims to understand how so many other citizens can see the world so differently from the way I do. It simply may be that for whatever reason one person, in this case one man, has such charismatic power that his supporters willingly abandon the moral skeleton on which their lives had been draped. Or is this us versus them primarily a chasm between the elites and the nonelites?

I don’t know much about you but the fact that you are reading this column means that, like me, you are an elite. Even if you are a woman of color and the daughter of immigrants you have taken advantage of what opportunities you have been offered, stayed in school long enough to adopt a reverence for the scientific method, and have a job that pays well because you have acquired some expertise.

Tom Nichols, a political scientist teaching at Harvard Extension School, says that “expertise is a very exclusionary idea because it’s supposed to be: Not everybody gets a vote on how to fly the plane” (Why isn’t the right more afraid of COVID-19? by Christina Pazzanese, Harvard Gazette, Oct 30, 2020) This exclusivity may in part explain the cultural trend that has eroded faith in experts in general, but particularly around issues such as climate change. Ironically, although science continues to be held in esteem in our culture, many scientists have become targets for those citizens who wish to attack authority figures.

How is it that you and I as pediatricians have avoided those attacks and the derogatory label as “so-called experts”? We are scientists and elites. But, we have expertise in areas in which people often feel a critical need.

You may live and practice in a community where many of your patients’ families don’t share your political views. But you have probably been successful at maintaining a trusting relationship with them in large part because you have cast yourself in the role of an adviser and not a dictator. And, although at times it has been difficult, you have been careful to avoid sharing your advice in a manner that sounds condescending. You have succeeded in functioning as an expert while carefully disguising yourself as a nonelite.

However, you are skating on thin ice if you venture into topics that run counter to your patients’ religious beliefs. Theda Skocpol, professor of government and psychology at Harvard University, Cambridge, Mass., has observed that studies have shown that while religious conservatives are aware of the science and don’t reject the finding, “they resent the use of experts as political authorities.” This may explain why all across this diverse country, our patients are eager for and accepting of our advice on all manners of health-related issues until we step into a swampy area that threatens their political views – such as vaccination or gun control.

With one misstep in the wrong direction, you can go from being a compassionate adviser to an elitist “so-called expert.”
 

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].

Regardless of who received the most electoral votes it is pretty clear that each candidate has millions of supporters, and that they are separated by only a few percentage points. I guess one could argue that so many people being able to express their opinions is healthy. However, from my side of the divide I have difficulty understanding how so many of my fellow citizens could arrive at an opinion so diametrically opposed to my own.

Since the 2016 election I have tried to read as many articles as I could find in search of an explanation for that outcome and continuing partisan support. I have never had much interest in political science because it always sounded like an oxymoron. But I am willing to listen to anyone who claims to understand how so many other citizens can see the world so differently from the way I do. It simply may be that for whatever reason one person, in this case one man, has such charismatic power that his supporters willingly abandon the moral skeleton on which their lives had been draped. Or is this us versus them primarily a chasm between the elites and the nonelites?

I don’t know much about you but the fact that you are reading this column means that, like me, you are an elite. Even if you are a woman of color and the daughter of immigrants you have taken advantage of what opportunities you have been offered, stayed in school long enough to adopt a reverence for the scientific method, and have a job that pays well because you have acquired some expertise.

Tom Nichols, a political scientist teaching at Harvard Extension School, says that “expertise is a very exclusionary idea because it’s supposed to be: Not everybody gets a vote on how to fly the plane” (Why isn’t the right more afraid of COVID-19? by Christina Pazzanese, Harvard Gazette, Oct 30, 2020) This exclusivity may in part explain the cultural trend that has eroded faith in experts in general, but particularly around issues such as climate change. Ironically, although science continues to be held in esteem in our culture, many scientists have become targets for those citizens who wish to attack authority figures.

How is it that you and I as pediatricians have avoided those attacks and the derogatory label as “so-called experts”? We are scientists and elites. But, we have expertise in areas in which people often feel a critical need.

You may live and practice in a community where many of your patients’ families don’t share your political views. But you have probably been successful at maintaining a trusting relationship with them in large part because you have cast yourself in the role of an adviser and not a dictator. And, although at times it has been difficult, you have been careful to avoid sharing your advice in a manner that sounds condescending. You have succeeded in functioning as an expert while carefully disguising yourself as a nonelite.

However, you are skating on thin ice if you venture into topics that run counter to your patients’ religious beliefs. Theda Skocpol, professor of government and psychology at Harvard University, Cambridge, Mass., has observed that studies have shown that while religious conservatives are aware of the science and don’t reject the finding, “they resent the use of experts as political authorities.” This may explain why all across this diverse country, our patients are eager for and accepting of our advice on all manners of health-related issues until we step into a swampy area that threatens their political views – such as vaccination or gun control.

With one misstep in the wrong direction, you can go from being a compassionate adviser to an elitist “so-called expert.”
 

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].

Regardless of who received the most electoral votes it is pretty clear that each candidate has millions of supporters, and that they are separated by only a few percentage points. I guess one could argue that so many people being able to express their opinions is healthy. However, from my side of the divide I have difficulty understanding how so many of my fellow citizens could arrive at an opinion so diametrically opposed to my own.

Since the 2016 election I have tried to read as many articles as I could find in search of an explanation for that outcome and continuing partisan support. I have never had much interest in political science because it always sounded like an oxymoron. But I am willing to listen to anyone who claims to understand how so many other citizens can see the world so differently from the way I do. It simply may be that for whatever reason one person, in this case one man, has such charismatic power that his supporters willingly abandon the moral skeleton on which their lives had been draped. Or is this us versus them primarily a chasm between the elites and the nonelites?

I don’t know much about you but the fact that you are reading this column means that, like me, you are an elite. Even if you are a woman of color and the daughter of immigrants you have taken advantage of what opportunities you have been offered, stayed in school long enough to adopt a reverence for the scientific method, and have a job that pays well because you have acquired some expertise.

Tom Nichols, a political scientist teaching at Harvard Extension School, says that “expertise is a very exclusionary idea because it’s supposed to be: Not everybody gets a vote on how to fly the plane” (Why isn’t the right more afraid of COVID-19? by Christina Pazzanese, Harvard Gazette, Oct 30, 2020) This exclusivity may in part explain the cultural trend that has eroded faith in experts in general, but particularly around issues such as climate change. Ironically, although science continues to be held in esteem in our culture, many scientists have become targets for those citizens who wish to attack authority figures.

How is it that you and I as pediatricians have avoided those attacks and the derogatory label as “so-called experts”? We are scientists and elites. But, we have expertise in areas in which people often feel a critical need.

You may live and practice in a community where many of your patients’ families don’t share your political views. But you have probably been successful at maintaining a trusting relationship with them in large part because you have cast yourself in the role of an adviser and not a dictator. And, although at times it has been difficult, you have been careful to avoid sharing your advice in a manner that sounds condescending. You have succeeded in functioning as an expert while carefully disguising yourself as a nonelite.

However, you are skating on thin ice if you venture into topics that run counter to your patients’ religious beliefs. Theda Skocpol, professor of government and psychology at Harvard University, Cambridge, Mass., has observed that studies have shown that while religious conservatives are aware of the science and don’t reject the finding, “they resent the use of experts as political authorities.” This may explain why all across this diverse country, our patients are eager for and accepting of our advice on all manners of health-related issues until we step into a swampy area that threatens their political views – such as vaccination or gun control.

With one misstep in the wrong direction, you can go from being a compassionate adviser to an elitist “so-called expert.”
 

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].

I am reading an excellent book called “Choosing Civility,” by P. M. Forni, cofounder of the John Hopkins Civility Project. It is a quick read and is a book that, in particular, all politicians, reporters, and political pundits should read. Most of it deals with common-sense good manners – things your mother taught you. The chapter that has been the most difficult for me to read (and to apply in practice) was the one on listening. I must admit I have been, or am guilty of being, a poor listener. I often try to expedite things by jumping ahead of where the speaker is going, my logic being that I am saving everyone time. In reality, I am probably distorting what the speaker intends to say and certainly not endearing myself to the speaker.

This is, of course, a classic example of attention deficit disorder with which I am certain I am afflicted. I have to make a deliberate effort to pause in my responses to speakers so that they can finish what they have to say. This is extremely hard for those of us who have this problem. I have made progress over the years and can attend committee meetings and say very little, except an occasional clarification query. I make a deliberate attempt to be civil and respect other’s comments. I have learned to let meetings reach their natural conclusion, which takes great patience when we could have arrived there hours earlier if I had interrupted and been less civil. If that course is taken, you will not have the buy in from all participants, and any decision made might not stick.

Luckily, almost all our discussions in organized medicine are civil, and our behavior has improved. The attending surgeon throwing instruments at the nurse or hitting the resident with a retractor – incidents that I have personally witnessed – would not be tolerated today. Our medical meetings are usually civil, if not downright boring.

Of course, patients who are ill or anxious are exempt from any civility requirement. They need comfort and reassurance, as much as a discussion of their diagnosis and treatment plan. They are allowed to be uncivil in their questions and responses. Physicians must leave their preconceptions and civilized expectations at the door. However, there are exceptions.

A few years ago, when I was training a fellow who was Black, I was horrified when one of my patients treated him with disdain and a gross racist attitude. This patient was uncivil, which of course had nothing to do with his diagnosis or treatment. I excused the fellow, discussed this with the patient, and tried to explain that the doctor’s skin color had nothing to do with his training or competence. I went further and told him that if this continued, he would be excused from my practice, which he eventually was. I apologized to the fellow, who, after living in his skin his whole life, had already shaken it off, having heard it all before. Living in my bubble I had thought this type of uncivil behavior was long gone, but not so.

This topic has received discussion and policy action at the American Medical Association. The AMA has adopted a new policy that “recognizes racism as a public health threat and commits to actively work on dismantling racist policies and practices across all of health care,” according to an AMA press release. This includes a recommendation to “clearly and openly support physicians, trainees, and facility personnel who experience prejudiced behavior and discrimination by patients, including allowing physicians, trainees, and facility personnel to decline to care for those patients, without penalty, who have exhibited discriminatory behavior specifically toward them,” according to the AMA report.

As far as I go, not to worry; I still have personal issues to work on. My wife’s favorite song is by Alison Krauss when she sings, “you say it best when you say nothing at all.”

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

I am reading an excellent book called “Choosing Civility,” by P. M. Forni, cofounder of the John Hopkins Civility Project. It is a quick read and is a book that, in particular, all politicians, reporters, and political pundits should read. Most of it deals with common-sense good manners – things your mother taught you. The chapter that has been the most difficult for me to read (and to apply in practice) was the one on listening. I must admit I have been, or am guilty of being, a poor listener. I often try to expedite things by jumping ahead of where the speaker is going, my logic being that I am saving everyone time. In reality, I am probably distorting what the speaker intends to say and certainly not endearing myself to the speaker.

This is, of course, a classic example of attention deficit disorder with which I am certain I am afflicted. I have to make a deliberate effort to pause in my responses to speakers so that they can finish what they have to say. This is extremely hard for those of us who have this problem. I have made progress over the years and can attend committee meetings and say very little, except an occasional clarification query. I make a deliberate attempt to be civil and respect other’s comments. I have learned to let meetings reach their natural conclusion, which takes great patience when we could have arrived there hours earlier if I had interrupted and been less civil. If that course is taken, you will not have the buy in from all participants, and any decision made might not stick.

Luckily, almost all our discussions in organized medicine are civil, and our behavior has improved. The attending surgeon throwing instruments at the nurse or hitting the resident with a retractor – incidents that I have personally witnessed – would not be tolerated today. Our medical meetings are usually civil, if not downright boring.

Of course, patients who are ill or anxious are exempt from any civility requirement. They need comfort and reassurance, as much as a discussion of their diagnosis and treatment plan. They are allowed to be uncivil in their questions and responses. Physicians must leave their preconceptions and civilized expectations at the door. However, there are exceptions.

A few years ago, when I was training a fellow who was Black, I was horrified when one of my patients treated him with disdain and a gross racist attitude. This patient was uncivil, which of course had nothing to do with his diagnosis or treatment. I excused the fellow, discussed this with the patient, and tried to explain that the doctor’s skin color had nothing to do with his training or competence. I went further and told him that if this continued, he would be excused from my practice, which he eventually was. I apologized to the fellow, who, after living in his skin his whole life, had already shaken it off, having heard it all before. Living in my bubble I had thought this type of uncivil behavior was long gone, but not so.

This topic has received discussion and policy action at the American Medical Association. The AMA has adopted a new policy that “recognizes racism as a public health threat and commits to actively work on dismantling racist policies and practices across all of health care,” according to an AMA press release. This includes a recommendation to “clearly and openly support physicians, trainees, and facility personnel who experience prejudiced behavior and discrimination by patients, including allowing physicians, trainees, and facility personnel to decline to care for those patients, without penalty, who have exhibited discriminatory behavior specifically toward them,” according to the AMA report.

As far as I go, not to worry; I still have personal issues to work on. My wife’s favorite song is by Alison Krauss when she sings, “you say it best when you say nothing at all.”

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

I am reading an excellent book called “Choosing Civility,” by P. M. Forni, cofounder of the John Hopkins Civility Project. It is a quick read and is a book that, in particular, all politicians, reporters, and political pundits should read. Most of it deals with common-sense good manners – things your mother taught you. The chapter that has been the most difficult for me to read (and to apply in practice) was the one on listening. I must admit I have been, or am guilty of being, a poor listener. I often try to expedite things by jumping ahead of where the speaker is going, my logic being that I am saving everyone time. In reality, I am probably distorting what the speaker intends to say and certainly not endearing myself to the speaker.

This is, of course, a classic example of attention deficit disorder with which I am certain I am afflicted. I have to make a deliberate effort to pause in my responses to speakers so that they can finish what they have to say. This is extremely hard for those of us who have this problem. I have made progress over the years and can attend committee meetings and say very little, except an occasional clarification query. I make a deliberate attempt to be civil and respect other’s comments. I have learned to let meetings reach their natural conclusion, which takes great patience when we could have arrived there hours earlier if I had interrupted and been less civil. If that course is taken, you will not have the buy in from all participants, and any decision made might not stick.

Luckily, almost all our discussions in organized medicine are civil, and our behavior has improved. The attending surgeon throwing instruments at the nurse or hitting the resident with a retractor – incidents that I have personally witnessed – would not be tolerated today. Our medical meetings are usually civil, if not downright boring.

Of course, patients who are ill or anxious are exempt from any civility requirement. They need comfort and reassurance, as much as a discussion of their diagnosis and treatment plan. They are allowed to be uncivil in their questions and responses. Physicians must leave their preconceptions and civilized expectations at the door. However, there are exceptions.

A few years ago, when I was training a fellow who was Black, I was horrified when one of my patients treated him with disdain and a gross racist attitude. This patient was uncivil, which of course had nothing to do with his diagnosis or treatment. I excused the fellow, discussed this with the patient, and tried to explain that the doctor’s skin color had nothing to do with his training or competence. I went further and told him that if this continued, he would be excused from my practice, which he eventually was. I apologized to the fellow, who, after living in his skin his whole life, had already shaken it off, having heard it all before. Living in my bubble I had thought this type of uncivil behavior was long gone, but not so.

This topic has received discussion and policy action at the American Medical Association. The AMA has adopted a new policy that “recognizes racism as a public health threat and commits to actively work on dismantling racist policies and practices across all of health care,” according to an AMA press release. This includes a recommendation to “clearly and openly support physicians, trainees, and facility personnel who experience prejudiced behavior and discrimination by patients, including allowing physicians, trainees, and facility personnel to decline to care for those patients, without penalty, who have exhibited discriminatory behavior specifically toward them,” according to the AMA report.

As far as I go, not to worry; I still have personal issues to work on. My wife’s favorite song is by Alison Krauss when she sings, “you say it best when you say nothing at all.”

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].