Opinion

In March 2020, following the announcement of the United States’ first death related to COVID-19, many physicians began using their voices to discuss the shortage of personal protective equipment (PPE). Many physicians, myself included, petitioned elected leaders at the community, state, and federal levels to address the PPE shortage.

Historically, physicians have advocated for improved public health. From seat belt laws in the 1980s and 1990s to the Affordable Care Act in the 2000s, physicians have testified at the community, state, and federal levels to advocate for the health and safety of our patients and the public. Yet while we have been making our voices heard, we are often silent at the ballot box.

In the 1996 and 2000 elections, physicians voted 9% less often than the general public, and compared with lawyers – professionals with similar educational attainment and finances – physicians voted 22% less often.¹ It is unclear why physicians are less likely to vote. In a 2016 article, David Grande, MD, and Katrina Armstrong, MD, postulated that physicians may not vote because our work hours create barriers to visiting polls.²

Despite our lack of engagement at the ballot box, voting is important to improving our patients’ social determinants of health. In a recently published systematic review, the authors found several studies supporting the association between voting and social determinants of health. Their review found that, when large numbers of people from communities participated in voting, it translated into greater influence over determining who held political power in that community. Those with power introduced and supported policies responding to their constituents’ needs, ultimately influencing their constituents’ social determinants of health.³ By voting, we as physicians are helping to address the social determinants of health in our communities.

Many medical students have been doing their part to improve the social determinants of health in their communities by pledging to vote. In 2018, the American Medical Student Association launched their “Med Out the Vote” initiative prior to the election. The organization called on all health care providers and providers in training to pledge to vote in the election.⁴ They are continuing these efforts for the 2020 elections.

We should join our nation’s medical students by also pledging to vote. To begin, we can all Make A Plan To Vote. Each plan should include the following:

• Register to vote: In many states eligible voters can register online.
• Request an absentee ballot: Many states require registered voters to request absentee ballots online or by mail.
• Vote: Submit an absentee ballot prior to election or vote in-person on election day. Some counties allow voting early in person.

In practice, our plans will differ slightly because each state has its own election laws.

This election season let us ensure all physician voices are heard. Make A Plan To Vote for your patients and communities.
 

Dr. Kumar is the pediatric editor of The Hospitalist. She is clinical assistant professor of pediatrics at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University and a pediatric hospitalist at Cleveland Clinic Children’s.

References

1. Grande D et al. Do Doctors Vote? J Gen Intern Med. 2007 May;22(5):585-9.

2. Grande D, Armstrong K. Will Physicians Vote? Ann Intern Med. 2016;165:814-5.

3. Brown CL et al. Voting, health and interventions in healthcare settings: A scoping review. Public Health Rev. 2020 Jul. doi: 10.1186/s40985-020-00133-6.

4. American Medical Student Association. AMSA Launches Med Out the Vote Campaign, Call to Action. 2018 Jul 29. Accessed 2020 Sep 14. https://www.amsa.org/about/amsa-press-room/amsa-launches-med-out-the-vote-campaign-call-to-action/

In March 2020, following the announcement of the United States’ first death related to COVID-19, many physicians began using their voices to discuss the shortage of personal protective equipment (PPE). Many physicians, myself included, petitioned elected leaders at the community, state, and federal levels to address the PPE shortage.

Historically, physicians have advocated for improved public health. From seat belt laws in the 1980s and 1990s to the Affordable Care Act in the 2000s, physicians have testified at the community, state, and federal levels to advocate for the health and safety of our patients and the public. Yet while we have been making our voices heard, we are often silent at the ballot box.

In the 1996 and 2000 elections, physicians voted 9% less often than the general public, and compared with lawyers – professionals with similar educational attainment and finances – physicians voted 22% less often.¹ It is unclear why physicians are less likely to vote. In a 2016 article, David Grande, MD, and Katrina Armstrong, MD, postulated that physicians may not vote because our work hours create barriers to visiting polls.²

Despite our lack of engagement at the ballot box, voting is important to improving our patients’ social determinants of health. In a recently published systematic review, the authors found several studies supporting the association between voting and social determinants of health. Their review found that, when large numbers of people from communities participated in voting, it translated into greater influence over determining who held political power in that community. Those with power introduced and supported policies responding to their constituents’ needs, ultimately influencing their constituents’ social determinants of health.³ By voting, we as physicians are helping to address the social determinants of health in our communities.

Many medical students have been doing their part to improve the social determinants of health in their communities by pledging to vote. In 2018, the American Medical Student Association launched their “Med Out the Vote” initiative prior to the election. The organization called on all health care providers and providers in training to pledge to vote in the election.⁴ They are continuing these efforts for the 2020 elections.

We should join our nation’s medical students by also pledging to vote. To begin, we can all Make A Plan To Vote. Each plan should include the following:

• Register to vote: In many states eligible voters can register online.
• Request an absentee ballot: Many states require registered voters to request absentee ballots online or by mail.
• Vote: Submit an absentee ballot prior to election or vote in-person on election day. Some counties allow voting early in person.

In practice, our plans will differ slightly because each state has its own election laws.

This election season let us ensure all physician voices are heard. Make A Plan To Vote for your patients and communities.
 

Dr. Kumar is the pediatric editor of The Hospitalist. She is clinical assistant professor of pediatrics at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University and a pediatric hospitalist at Cleveland Clinic Children’s.

References

1. Grande D et al. Do Doctors Vote? J Gen Intern Med. 2007 May;22(5):585-9.

2. Grande D, Armstrong K. Will Physicians Vote? Ann Intern Med. 2016;165:814-5.

3. Brown CL et al. Voting, health and interventions in healthcare settings: A scoping review. Public Health Rev. 2020 Jul. doi: 10.1186/s40985-020-00133-6.

4. American Medical Student Association. AMSA Launches Med Out the Vote Campaign, Call to Action. 2018 Jul 29. Accessed 2020 Sep 14. https://www.amsa.org/about/amsa-press-room/amsa-launches-med-out-the-vote-campaign-call-to-action/

In March 2020, following the announcement of the United States’ first death related to COVID-19, many physicians began using their voices to discuss the shortage of personal protective equipment (PPE). Many physicians, myself included, petitioned elected leaders at the community, state, and federal levels to address the PPE shortage.

Historically, physicians have advocated for improved public health. From seat belt laws in the 1980s and 1990s to the Affordable Care Act in the 2000s, physicians have testified at the community, state, and federal levels to advocate for the health and safety of our patients and the public. Yet while we have been making our voices heard, we are often silent at the ballot box.

In the 1996 and 2000 elections, physicians voted 9% less often than the general public, and compared with lawyers – professionals with similar educational attainment and finances – physicians voted 22% less often.¹ It is unclear why physicians are less likely to vote. In a 2016 article, David Grande, MD, and Katrina Armstrong, MD, postulated that physicians may not vote because our work hours create barriers to visiting polls.²

Despite our lack of engagement at the ballot box, voting is important to improving our patients’ social determinants of health. In a recently published systematic review, the authors found several studies supporting the association between voting and social determinants of health. Their review found that, when large numbers of people from communities participated in voting, it translated into greater influence over determining who held political power in that community. Those with power introduced and supported policies responding to their constituents’ needs, ultimately influencing their constituents’ social determinants of health.³ By voting, we as physicians are helping to address the social determinants of health in our communities.

Many medical students have been doing their part to improve the social determinants of health in their communities by pledging to vote. In 2018, the American Medical Student Association launched their “Med Out the Vote” initiative prior to the election. The organization called on all health care providers and providers in training to pledge to vote in the election.⁴ They are continuing these efforts for the 2020 elections.

We should join our nation’s medical students by also pledging to vote. To begin, we can all Make A Plan To Vote. Each plan should include the following:

• Register to vote: In many states eligible voters can register online.
• Request an absentee ballot: Many states require registered voters to request absentee ballots online or by mail.
• Vote: Submit an absentee ballot prior to election or vote in-person on election day. Some counties allow voting early in person.

In practice, our plans will differ slightly because each state has its own election laws.

This election season let us ensure all physician voices are heard. Make A Plan To Vote for your patients and communities.
 

Dr. Kumar is the pediatric editor of The Hospitalist. She is clinical assistant professor of pediatrics at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University and a pediatric hospitalist at Cleveland Clinic Children’s.

References

1. Grande D et al. Do Doctors Vote? J Gen Intern Med. 2007 May;22(5):585-9.

2. Grande D, Armstrong K. Will Physicians Vote? Ann Intern Med. 2016;165:814-5.

3. Brown CL et al. Voting, health and interventions in healthcare settings: A scoping review. Public Health Rev. 2020 Jul. doi: 10.1186/s40985-020-00133-6.

4. American Medical Student Association. AMSA Launches Med Out the Vote Campaign, Call to Action. 2018 Jul 29. Accessed 2020 Sep 14. https://www.amsa.org/about/amsa-press-room/amsa-launches-med-out-the-vote-campaign-call-to-action/

Below is a case involving a patient who is not yet ready to quit smoking. We later provide treatment recommendations for this patient based on a new guideline from the American Thoracic Society.

Case

A 58-year-old female comes into the office for a physical exam. She has been smoking two packs a day since she was 23 years of age. You have tried at previous visits to get her to quit, but she hasn’t been interested. The patient says she has a lot of stress, and that it is still not the right time for her to stop smoking. You tell her she needs to quit and, though the patient understands that quitting would be beneficial for her health, she just isn’t ready to try to kick the habit. How do you proceed?

The Guideline in context

Even though this patient stated that she is not ready to stop smoking, she is still a candidate for pharmacological treatment for her tobacco dependence and can be offered varenicline, according to the ATS guideline.¹

It is imperative that tobacco cessation is addressed with patients in the most effective and comprehensive ways possible. In a previously published column, we have discussed the ATS’ recommended approaches for treating patients who are ready to stop smoking cigarettes. The reality is that many patients, if not most, are not ready to quit when we speak to them during any given office visit. The ATS guideline addresses this critical issue by recommending treatment with varenicline in patients who are not ready to stop smoking. It also states that this is a better strategy than waiting to start treatment until patients say they are ready for it.

This recommendation – to prescribe varenicline to smokers even when they are not ready to quit smoking – is based on solid clinical trial evidence. Research has shown that behavior change is dynamic and that the decision to stop smoking is not always a planned one.¹ Patients often make quit attempts between office visits, and are often successful in those attempts. Because the decision to try to stop smoking is influenced by the satisfaction and physical addiction that comes from smoking, a medication such as varenicline that is a partial agonist/antagonist at the alpha4-beta2 nicotinic receptor might increase the likelihood that a patient would decide to try to stop smoking. This is because taking this type of a drug would lead the patient to no longer experience the reinforcing effects of nicotine.² This hypothesis was examined in five randomized trials.¹

In these studies, regular smokers who were not ready to make a quit attempt were randomized to varenicline versus placebo. Twice as many individuals who took varenicline stopped smoking 6 months after starting treatment.¹

Suggested treatment

This patient should be offered varenicline. This individual meets the criteria for this treatment according to the ATS guideline in that the patient is a regular smoker who doesn’t think she is ready to stop smoking but understands she needs to stop and is open to taking medication to assist her with quitting.

Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Hospital–Jefferson Health. Dr. Sprogell is a third-year resident in the family medicine residency program at Abington Jefferson Health. They have no conflicts related to the content of this piece. For questions or comments, feel free to contact Dr. Skolnik on Twitter @NeilSkolnik.

References

1. Leone F T et al. Initiating pharmacologic treatment in tobacco-dependent adults: An official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2020 Jul 15;202(2):e5–e31.

2. Ebbert JO et al. Varenicline for smoking cessation: Efficacy, safety, and treatment recommendations. Patient Prefer Adherence. 2010;4:355-62.
 

Below is a case involving a patient who is not yet ready to quit smoking. We later provide treatment recommendations for this patient based on a new guideline from the American Thoracic Society.

Case

A 58-year-old female comes into the office for a physical exam. She has been smoking two packs a day since she was 23 years of age. You have tried at previous visits to get her to quit, but she hasn’t been interested. The patient says she has a lot of stress, and that it is still not the right time for her to stop smoking. You tell her she needs to quit and, though the patient understands that quitting would be beneficial for her health, she just isn’t ready to try to kick the habit. How do you proceed?

The Guideline in context

Even though this patient stated that she is not ready to stop smoking, she is still a candidate for pharmacological treatment for her tobacco dependence and can be offered varenicline, according to the ATS guideline.¹

It is imperative that tobacco cessation is addressed with patients in the most effective and comprehensive ways possible. In a previously published column, we have discussed the ATS’ recommended approaches for treating patients who are ready to stop smoking cigarettes. The reality is that many patients, if not most, are not ready to quit when we speak to them during any given office visit. The ATS guideline addresses this critical issue by recommending treatment with varenicline in patients who are not ready to stop smoking. It also states that this is a better strategy than waiting to start treatment until patients say they are ready for it.

This recommendation – to prescribe varenicline to smokers even when they are not ready to quit smoking – is based on solid clinical trial evidence. Research has shown that behavior change is dynamic and that the decision to stop smoking is not always a planned one.¹ Patients often make quit attempts between office visits, and are often successful in those attempts. Because the decision to try to stop smoking is influenced by the satisfaction and physical addiction that comes from smoking, a medication such as varenicline that is a partial agonist/antagonist at the alpha4-beta2 nicotinic receptor might increase the likelihood that a patient would decide to try to stop smoking. This is because taking this type of a drug would lead the patient to no longer experience the reinforcing effects of nicotine.² This hypothesis was examined in five randomized trials.¹

In these studies, regular smokers who were not ready to make a quit attempt were randomized to varenicline versus placebo. Twice as many individuals who took varenicline stopped smoking 6 months after starting treatment.¹

Suggested treatment

This patient should be offered varenicline. This individual meets the criteria for this treatment according to the ATS guideline in that the patient is a regular smoker who doesn’t think she is ready to stop smoking but understands she needs to stop and is open to taking medication to assist her with quitting.

Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Hospital–Jefferson Health. Dr. Sprogell is a third-year resident in the family medicine residency program at Abington Jefferson Health. They have no conflicts related to the content of this piece. For questions or comments, feel free to contact Dr. Skolnik on Twitter @NeilSkolnik.

References

1. Leone F T et al. Initiating pharmacologic treatment in tobacco-dependent adults: An official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2020 Jul 15;202(2):e5–e31.

2. Ebbert JO et al. Varenicline for smoking cessation: Efficacy, safety, and treatment recommendations. Patient Prefer Adherence. 2010;4:355-62.
 

Below is a case involving a patient who is not yet ready to quit smoking. We later provide treatment recommendations for this patient based on a new guideline from the American Thoracic Society.

Case

A 58-year-old female comes into the office for a physical exam. She has been smoking two packs a day since she was 23 years of age. You have tried at previous visits to get her to quit, but she hasn’t been interested. The patient says she has a lot of stress, and that it is still not the right time for her to stop smoking. You tell her she needs to quit and, though the patient understands that quitting would be beneficial for her health, she just isn’t ready to try to kick the habit. How do you proceed?

The Guideline in context

Even though this patient stated that she is not ready to stop smoking, she is still a candidate for pharmacological treatment for her tobacco dependence and can be offered varenicline, according to the ATS guideline.¹

It is imperative that tobacco cessation is addressed with patients in the most effective and comprehensive ways possible. In a previously published column, we have discussed the ATS’ recommended approaches for treating patients who are ready to stop smoking cigarettes. The reality is that many patients, if not most, are not ready to quit when we speak to them during any given office visit. The ATS guideline addresses this critical issue by recommending treatment with varenicline in patients who are not ready to stop smoking. It also states that this is a better strategy than waiting to start treatment until patients say they are ready for it.

This recommendation – to prescribe varenicline to smokers even when they are not ready to quit smoking – is based on solid clinical trial evidence. Research has shown that behavior change is dynamic and that the decision to stop smoking is not always a planned one.¹ Patients often make quit attempts between office visits, and are often successful in those attempts. Because the decision to try to stop smoking is influenced by the satisfaction and physical addiction that comes from smoking, a medication such as varenicline that is a partial agonist/antagonist at the alpha4-beta2 nicotinic receptor might increase the likelihood that a patient would decide to try to stop smoking. This is because taking this type of a drug would lead the patient to no longer experience the reinforcing effects of nicotine.² This hypothesis was examined in five randomized trials.¹

In these studies, regular smokers who were not ready to make a quit attempt were randomized to varenicline versus placebo. Twice as many individuals who took varenicline stopped smoking 6 months after starting treatment.¹

Suggested treatment

This patient should be offered varenicline. This individual meets the criteria for this treatment according to the ATS guideline in that the patient is a regular smoker who doesn’t think she is ready to stop smoking but understands she needs to stop and is open to taking medication to assist her with quitting.

Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Hospital–Jefferson Health. Dr. Sprogell is a third-year resident in the family medicine residency program at Abington Jefferson Health. They have no conflicts related to the content of this piece. For questions or comments, feel free to contact Dr. Skolnik on Twitter @NeilSkolnik.

References

1. Leone F T et al. Initiating pharmacologic treatment in tobacco-dependent adults: An official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2020 Jul 15;202(2):e5–e31.

2. Ebbert JO et al. Varenicline for smoking cessation: Efficacy, safety, and treatment recommendations. Patient Prefer Adherence. 2010;4:355-62.
 

America has been struggling to understand its racial dynamics since the arrival of enslaved Africans more than 400 years ago. Today, with much of the world more polarized than ever, and certainly in our United States, there is a need for something to shift us from our fear and survival paranoid schizoid (us-vs.-them) position to an integrated form if we are to come out of this unusual democratic and societal unrest whole.

Courtesy Random House

Yet, we’ve never had the lexicon to adequately describe the sociopolitical dynamics rooted in race and racism and their power to shape the thinking of all who originate in this country and all who enter its self-made borders whether forcefully or voluntarily. Enter Isabel Wilkerson, a Pulitzer Prize–winning, former New York Times Chicago bureau chief, and author of “The Warmth of Other Suns: The Epic Story of America’s Great Migration” (New York: Random House, 2010) with her second book, “Caste: The Origins of Our Discontents” (New York: Random House, 2020).

Ms. Wilkerson quickly gets to work in an engaging storytelling style of weaving past to present with ideas she supports with letters from the past, historians’ impressions, research studies, and data. Her observations and research are bookended by the lead up to the 2016 presidential election and its aftermath on the one end, and the impending 2020 presidential election on the other. In her view, the reemergence of violence that has accelerated in the 21st century and the renewed commitment to promote white supremacy can be understood if we expand our view of race and racism to consider the enduring power of caste. For, in Ms. Wilkerson’s view, the fear of the 2042 U.S. census (which is predicted to reflect for the first time a non-White majority) is a driving force behind the dominant caste’s determination to maintain the status quo power dynamics in the United States.

In an effort to explain American’s racial hierarchy, Ms. Wilkerson explains the need for a new lexicon “that may sound like a foreign language,” but this is intentional on her part. She writes:

“To recalibrate how we see ourselves, I use language that may be more commonly associated with people in other cultures, to suggest a new way of understanding our hierarchy: Dominant caste, ruling majority, favored caste, or upper caste, instead of, or in addition to, white. Middle castes instead of, or in addition to, Asian or Latino. Subordinate caste, lowest caste, bottom caste, disfavored caste, historically stigmatized instead of African-American. Original, conquered, or indigenous peoples instead of, or in addition to, Native American. Marginalized people in addition to, or instead of, women of any race, or minorities of any kind.”

Early in the book Ms. Wilkerson anchors her argument in Rev. Dr. Martin Luther King Jr.’s sojourn to India. Rather than focus on the known history of Dr. King’s admiration of Mohandas Gandhi, Ms. Wilkerson directs our attention to Dr. King’s discovery of his connection to Dalits, those who had been considered “untouchables” until Bhimrao Ramji Ambedkar, the Indian economist, jurist, social reformer, and Dalit leader, fiercely and successfully advocated for a rebranding of his caste of origin; instead of “untouchables” they would be considered Dalits or “broken people.” Dr. King did not meet Mr. Ambedkar, who died 3 years before this journey, but Ms. Wilkerson writes that Dr. King acknowledged the kinship, “And he said unto himself, Yes, I am an untouchable, and every Negro in the United States is an untouchable.” The Dalits and Dr. King recognized in each other their shared positions as subordinates in a global caste system.

In answering the question about the difference between racism and casteism, Ms. Wilkerson writes:

“Because caste and race are interwoven in America, it can be hard to separate the two. ... Casteism is the investment in keeping the hierarchy as it is in order to maintain your own ranking, advantage, privilege, or to elevate yourself above others or to keep others beneath you.”

Reading “Caste: The Origins of Our Discontents” is akin to the experience of gaining relief after struggling for years with a chronic malady that has a fluctuating course: Under the surface is low-grade pain that is compartmentalized and often met with denial or gaslighting when symptoms and systems are reported to members of the dominant caste. Yet, when there are acute flare-ups and increasingly frequent deadly encounters, the defenses of denial are painfully revealed; structures are broken and sometimes burned down. This has been the clinical course of racism, particularly in the United States. In that vein, an early reaction while reading “Caste” might be comparable to hearing an interpretation that educates, clarifies, resonates, and lands perfectly on the right diagnosis at the right moment.
 

Approach proves clarifying

In conceptualizing the malady as one of caste, Ms. Wilkerson achieves several things simultaneously – she names the malady, thus providing a lexicon, describes its symptoms, and most importantly, in our opinion, shares some of the compelling data from her field studies. By focusing on India, Nazi Germany, and the United States, she describes how easily one system influences another in the global effort to maintain power among the privileged.

This is not a new way of conceptualizing racial hierarchy; however, what is truly persuasive is Ms. Wilkerson’s ability to weave her rigorous research, sociopolitical analysis, and cogent psychological insights and interpretations to explain the 400-year trajectory of racialized caste in the United States. She achieves this exigent task with beautiful prose that motivates the reader to return time and time again to learn gut-wrenching painful historical details. She summarizes truths that have been unearthed (again) about Germany, India, and, in particular, the United States during her research and travels around the world. In doing so, she provides vivid examples of racism layered on caste. Consider the following:

“The Nazis were impressed by the American custom of lynching its subordinate caste of African-Americans, having become aware of the ritual torture and mutilations that typically accompanied them. Hitler especially marveled at the American ‘knack for maintaining an air of robust innocence in the wake of mass death.’ ” Ms. Wilkerson informs us that Hitler sent emissaries to study America’s Jim Crow system and then imported some features to orchestrate the Holocaust in Nazi Germany.

Her most vivid example of internalized casteism is the experience of a Dalit scholar who still experiences anxiety and a corresponding sense of inadequacy in the presence of someone who is considered to be from a higher caste.

A painful account of interpersonal racism is captured as Ms. Wilkerson recounts her experience after a routine business flight from Chicago to Detroit. She details her difficulty leaving a rental car parking lot because she had become so disoriented after being profiled and accosted by Drug Enforcement Administration agents who had intercepted her in the airport terminal and followed her onto the airport shuttle bus as she attempted to reach her destination. She provides a description of “getting turned around in a parking lot that I had been to dozens of times, going in circles, not able to get out, not registering the signs to the exit, not seeing how to get to Interstate 94, when I knew full well how to get to I-94 after all the times I’d driven it. ... This was the thievery of caste, stealing the time and psychic resources of the marginalized, draining energy in an already uphill competition. They were not, like me, frozen and disoriented, trying to make sense of a public violation that seemed all the more menacing now that I could see it in full. The quiet mundanity of that terror has never left me, the scars outliving the cut.”

This account is consistent with the dissociative, disorienting dynamics of race-based trauma. Her experience is not uncommon and helps to explain the activism of those in the subordinate caste who have attained some measure of wealth, power, and influence, and are motivated to expend their resources (energy, time, fame, and/or wealth) to raise awareness about social and political injustices by calling out structural racism in medicine, protesting police use of force by taking a knee, boycotting sporting events, and even demanding that football stadiums be used as polling sites. At the end of the day, all of us who have “made it” know that when we leave our homes, our relegation to the subordinate caste determines how we are perceived and what landmines we must navigate to make it through the day and that determine whether we will make it home.

This tour de force work of art has the potential to be a game changer in the way that we think about racial polarization in the United States. It is hoped that this new language opens up a space that allows each of us to explore this hegemony while identifying our placement and actions we take to maintain it, for each of us undeniably has a position in this caste system.

Having this new lexicon summons to mind the reactions of patients who gain immediate relief from having their illnesses named. In the case of the U.S. malady that has gripped us all, Ms. Wilkerson reiterates the importance of naming the condition. She writes:

“Because, to truly understand America, we must open our eyes to the hidden work of a caste system that has gone unnamed but prevails among us to our collective detriment, to see that we have more in common with each other and with cultures that we might otherwise dismiss, and to summon the courage to consider that therein may lie the answers.”

The naming allows both doctor and patient to have greater insight, understanding its origins and course, as well as having hope that there is a remedy. Naming facilitates the space for a shift in thinking and implementation of treatment protocols, such as Nazi Germany’s “zero tolerance policy” of swastikas in comparison to the ongoing U.S. controversy about the display of Confederate symbols. At this point in history, we welcome a diagnosis that has the potential to shift us from these poles of dominant and subordinate, black and white, good and bad, toward integration and wholeness of the individual psyche and collective global community. This is similar to what Melanie Klein calls the depressive position. Ms. Wilkerson suggests, in relinquishing these polar splits, we increase our capacity to shift to a space where our psychic integration occurs and our inextricable interdependence and responsibility for one another are honored.
 

Dr. Dunlap is a psychiatrist and psychoanalyst, and clinical professor of psychiatry and behavioral sciences at George Washington University. She is interested in the management of “difference” – race, gender, ethnicity, and intersectionality – in dyadic relationships and group dynamics; and the impact of racism on interpersonal relationships in institutional structures. Dr. Dunlap practices in Washington and has no disclosures. Dr. Dennis is a clinical psychologist and psychoanalyst. Her interests are in gender and ethnic diversity, health equity, and supervision and training. Dr. Dennis practices in Washington and has no disclosures.

America has been struggling to understand its racial dynamics since the arrival of enslaved Africans more than 400 years ago. Today, with much of the world more polarized than ever, and certainly in our United States, there is a need for something to shift us from our fear and survival paranoid schizoid (us-vs.-them) position to an integrated form if we are to come out of this unusual democratic and societal unrest whole.

Courtesy Random House

Yet, we’ve never had the lexicon to adequately describe the sociopolitical dynamics rooted in race and racism and their power to shape the thinking of all who originate in this country and all who enter its self-made borders whether forcefully or voluntarily. Enter Isabel Wilkerson, a Pulitzer Prize–winning, former New York Times Chicago bureau chief, and author of “The Warmth of Other Suns: The Epic Story of America’s Great Migration” (New York: Random House, 2010) with her second book, “Caste: The Origins of Our Discontents” (New York: Random House, 2020).

Ms. Wilkerson quickly gets to work in an engaging storytelling style of weaving past to present with ideas she supports with letters from the past, historians’ impressions, research studies, and data. Her observations and research are bookended by the lead up to the 2016 presidential election and its aftermath on the one end, and the impending 2020 presidential election on the other. In her view, the reemergence of violence that has accelerated in the 21st century and the renewed commitment to promote white supremacy can be understood if we expand our view of race and racism to consider the enduring power of caste. For, in Ms. Wilkerson’s view, the fear of the 2042 U.S. census (which is predicted to reflect for the first time a non-White majority) is a driving force behind the dominant caste’s determination to maintain the status quo power dynamics in the United States.

In an effort to explain American’s racial hierarchy, Ms. Wilkerson explains the need for a new lexicon “that may sound like a foreign language,” but this is intentional on her part. She writes:

“To recalibrate how we see ourselves, I use language that may be more commonly associated with people in other cultures, to suggest a new way of understanding our hierarchy: Dominant caste, ruling majority, favored caste, or upper caste, instead of, or in addition to, white. Middle castes instead of, or in addition to, Asian or Latino. Subordinate caste, lowest caste, bottom caste, disfavored caste, historically stigmatized instead of African-American. Original, conquered, or indigenous peoples instead of, or in addition to, Native American. Marginalized people in addition to, or instead of, women of any race, or minorities of any kind.”

Early in the book Ms. Wilkerson anchors her argument in Rev. Dr. Martin Luther King Jr.’s sojourn to India. Rather than focus on the known history of Dr. King’s admiration of Mohandas Gandhi, Ms. Wilkerson directs our attention to Dr. King’s discovery of his connection to Dalits, those who had been considered “untouchables” until Bhimrao Ramji Ambedkar, the Indian economist, jurist, social reformer, and Dalit leader, fiercely and successfully advocated for a rebranding of his caste of origin; instead of “untouchables” they would be considered Dalits or “broken people.” Dr. King did not meet Mr. Ambedkar, who died 3 years before this journey, but Ms. Wilkerson writes that Dr. King acknowledged the kinship, “And he said unto himself, Yes, I am an untouchable, and every Negro in the United States is an untouchable.” The Dalits and Dr. King recognized in each other their shared positions as subordinates in a global caste system.

In answering the question about the difference between racism and casteism, Ms. Wilkerson writes:

“Because caste and race are interwoven in America, it can be hard to separate the two. ... Casteism is the investment in keeping the hierarchy as it is in order to maintain your own ranking, advantage, privilege, or to elevate yourself above others or to keep others beneath you.”

Reading “Caste: The Origins of Our Discontents” is akin to the experience of gaining relief after struggling for years with a chronic malady that has a fluctuating course: Under the surface is low-grade pain that is compartmentalized and often met with denial or gaslighting when symptoms and systems are reported to members of the dominant caste. Yet, when there are acute flare-ups and increasingly frequent deadly encounters, the defenses of denial are painfully revealed; structures are broken and sometimes burned down. This has been the clinical course of racism, particularly in the United States. In that vein, an early reaction while reading “Caste” might be comparable to hearing an interpretation that educates, clarifies, resonates, and lands perfectly on the right diagnosis at the right moment.
 

Approach proves clarifying

In conceptualizing the malady as one of caste, Ms. Wilkerson achieves several things simultaneously – she names the malady, thus providing a lexicon, describes its symptoms, and most importantly, in our opinion, shares some of the compelling data from her field studies. By focusing on India, Nazi Germany, and the United States, she describes how easily one system influences another in the global effort to maintain power among the privileged.

This is not a new way of conceptualizing racial hierarchy; however, what is truly persuasive is Ms. Wilkerson’s ability to weave her rigorous research, sociopolitical analysis, and cogent psychological insights and interpretations to explain the 400-year trajectory of racialized caste in the United States. She achieves this exigent task with beautiful prose that motivates the reader to return time and time again to learn gut-wrenching painful historical details. She summarizes truths that have been unearthed (again) about Germany, India, and, in particular, the United States during her research and travels around the world. In doing so, she provides vivid examples of racism layered on caste. Consider the following:

“The Nazis were impressed by the American custom of lynching its subordinate caste of African-Americans, having become aware of the ritual torture and mutilations that typically accompanied them. Hitler especially marveled at the American ‘knack for maintaining an air of robust innocence in the wake of mass death.’ ” Ms. Wilkerson informs us that Hitler sent emissaries to study America’s Jim Crow system and then imported some features to orchestrate the Holocaust in Nazi Germany.

Her most vivid example of internalized casteism is the experience of a Dalit scholar who still experiences anxiety and a corresponding sense of inadequacy in the presence of someone who is considered to be from a higher caste.

A painful account of interpersonal racism is captured as Ms. Wilkerson recounts her experience after a routine business flight from Chicago to Detroit. She details her difficulty leaving a rental car parking lot because she had become so disoriented after being profiled and accosted by Drug Enforcement Administration agents who had intercepted her in the airport terminal and followed her onto the airport shuttle bus as she attempted to reach her destination. She provides a description of “getting turned around in a parking lot that I had been to dozens of times, going in circles, not able to get out, not registering the signs to the exit, not seeing how to get to Interstate 94, when I knew full well how to get to I-94 after all the times I’d driven it. ... This was the thievery of caste, stealing the time and psychic resources of the marginalized, draining energy in an already uphill competition. They were not, like me, frozen and disoriented, trying to make sense of a public violation that seemed all the more menacing now that I could see it in full. The quiet mundanity of that terror has never left me, the scars outliving the cut.”

This account is consistent with the dissociative, disorienting dynamics of race-based trauma. Her experience is not uncommon and helps to explain the activism of those in the subordinate caste who have attained some measure of wealth, power, and influence, and are motivated to expend their resources (energy, time, fame, and/or wealth) to raise awareness about social and political injustices by calling out structural racism in medicine, protesting police use of force by taking a knee, boycotting sporting events, and even demanding that football stadiums be used as polling sites. At the end of the day, all of us who have “made it” know that when we leave our homes, our relegation to the subordinate caste determines how we are perceived and what landmines we must navigate to make it through the day and that determine whether we will make it home.

This tour de force work of art has the potential to be a game changer in the way that we think about racial polarization in the United States. It is hoped that this new language opens up a space that allows each of us to explore this hegemony while identifying our placement and actions we take to maintain it, for each of us undeniably has a position in this caste system.

Having this new lexicon summons to mind the reactions of patients who gain immediate relief from having their illnesses named. In the case of the U.S. malady that has gripped us all, Ms. Wilkerson reiterates the importance of naming the condition. She writes:

“Because, to truly understand America, we must open our eyes to the hidden work of a caste system that has gone unnamed but prevails among us to our collective detriment, to see that we have more in common with each other and with cultures that we might otherwise dismiss, and to summon the courage to consider that therein may lie the answers.”

The naming allows both doctor and patient to have greater insight, understanding its origins and course, as well as having hope that there is a remedy. Naming facilitates the space for a shift in thinking and implementation of treatment protocols, such as Nazi Germany’s “zero tolerance policy” of swastikas in comparison to the ongoing U.S. controversy about the display of Confederate symbols. At this point in history, we welcome a diagnosis that has the potential to shift us from these poles of dominant and subordinate, black and white, good and bad, toward integration and wholeness of the individual psyche and collective global community. This is similar to what Melanie Klein calls the depressive position. Ms. Wilkerson suggests, in relinquishing these polar splits, we increase our capacity to shift to a space where our psychic integration occurs and our inextricable interdependence and responsibility for one another are honored.
 

Dr. Dunlap is a psychiatrist and psychoanalyst, and clinical professor of psychiatry and behavioral sciences at George Washington University. She is interested in the management of “difference” – race, gender, ethnicity, and intersectionality – in dyadic relationships and group dynamics; and the impact of racism on interpersonal relationships in institutional structures. Dr. Dunlap practices in Washington and has no disclosures. Dr. Dennis is a clinical psychologist and psychoanalyst. Her interests are in gender and ethnic diversity, health equity, and supervision and training. Dr. Dennis practices in Washington and has no disclosures.

America has been struggling to understand its racial dynamics since the arrival of enslaved Africans more than 400 years ago. Today, with much of the world more polarized than ever, and certainly in our United States, there is a need for something to shift us from our fear and survival paranoid schizoid (us-vs.-them) position to an integrated form if we are to come out of this unusual democratic and societal unrest whole.

Courtesy Random House

Yet, we’ve never had the lexicon to adequately describe the sociopolitical dynamics rooted in race and racism and their power to shape the thinking of all who originate in this country and all who enter its self-made borders whether forcefully or voluntarily. Enter Isabel Wilkerson, a Pulitzer Prize–winning, former New York Times Chicago bureau chief, and author of “The Warmth of Other Suns: The Epic Story of America’s Great Migration” (New York: Random House, 2010) with her second book, “Caste: The Origins of Our Discontents” (New York: Random House, 2020).

Ms. Wilkerson quickly gets to work in an engaging storytelling style of weaving past to present with ideas she supports with letters from the past, historians’ impressions, research studies, and data. Her observations and research are bookended by the lead up to the 2016 presidential election and its aftermath on the one end, and the impending 2020 presidential election on the other. In her view, the reemergence of violence that has accelerated in the 21st century and the renewed commitment to promote white supremacy can be understood if we expand our view of race and racism to consider the enduring power of caste. For, in Ms. Wilkerson’s view, the fear of the 2042 U.S. census (which is predicted to reflect for the first time a non-White majority) is a driving force behind the dominant caste’s determination to maintain the status quo power dynamics in the United States.

In an effort to explain American’s racial hierarchy, Ms. Wilkerson explains the need for a new lexicon “that may sound like a foreign language,” but this is intentional on her part. She writes:

“To recalibrate how we see ourselves, I use language that may be more commonly associated with people in other cultures, to suggest a new way of understanding our hierarchy: Dominant caste, ruling majority, favored caste, or upper caste, instead of, or in addition to, white. Middle castes instead of, or in addition to, Asian or Latino. Subordinate caste, lowest caste, bottom caste, disfavored caste, historically stigmatized instead of African-American. Original, conquered, or indigenous peoples instead of, or in addition to, Native American. Marginalized people in addition to, or instead of, women of any race, or minorities of any kind.”

Early in the book Ms. Wilkerson anchors her argument in Rev. Dr. Martin Luther King Jr.’s sojourn to India. Rather than focus on the known history of Dr. King’s admiration of Mohandas Gandhi, Ms. Wilkerson directs our attention to Dr. King’s discovery of his connection to Dalits, those who had been considered “untouchables” until Bhimrao Ramji Ambedkar, the Indian economist, jurist, social reformer, and Dalit leader, fiercely and successfully advocated for a rebranding of his caste of origin; instead of “untouchables” they would be considered Dalits or “broken people.” Dr. King did not meet Mr. Ambedkar, who died 3 years before this journey, but Ms. Wilkerson writes that Dr. King acknowledged the kinship, “And he said unto himself, Yes, I am an untouchable, and every Negro in the United States is an untouchable.” The Dalits and Dr. King recognized in each other their shared positions as subordinates in a global caste system.

In answering the question about the difference between racism and casteism, Ms. Wilkerson writes:

“Because caste and race are interwoven in America, it can be hard to separate the two. ... Casteism is the investment in keeping the hierarchy as it is in order to maintain your own ranking, advantage, privilege, or to elevate yourself above others or to keep others beneath you.”

Reading “Caste: The Origins of Our Discontents” is akin to the experience of gaining relief after struggling for years with a chronic malady that has a fluctuating course: Under the surface is low-grade pain that is compartmentalized and often met with denial or gaslighting when symptoms and systems are reported to members of the dominant caste. Yet, when there are acute flare-ups and increasingly frequent deadly encounters, the defenses of denial are painfully revealed; structures are broken and sometimes burned down. This has been the clinical course of racism, particularly in the United States. In that vein, an early reaction while reading “Caste” might be comparable to hearing an interpretation that educates, clarifies, resonates, and lands perfectly on the right diagnosis at the right moment.
 

Approach proves clarifying

In conceptualizing the malady as one of caste, Ms. Wilkerson achieves several things simultaneously – she names the malady, thus providing a lexicon, describes its symptoms, and most importantly, in our opinion, shares some of the compelling data from her field studies. By focusing on India, Nazi Germany, and the United States, she describes how easily one system influences another in the global effort to maintain power among the privileged.

This is not a new way of conceptualizing racial hierarchy; however, what is truly persuasive is Ms. Wilkerson’s ability to weave her rigorous research, sociopolitical analysis, and cogent psychological insights and interpretations to explain the 400-year trajectory of racialized caste in the United States. She achieves this exigent task with beautiful prose that motivates the reader to return time and time again to learn gut-wrenching painful historical details. She summarizes truths that have been unearthed (again) about Germany, India, and, in particular, the United States during her research and travels around the world. In doing so, she provides vivid examples of racism layered on caste. Consider the following:

“The Nazis were impressed by the American custom of lynching its subordinate caste of African-Americans, having become aware of the ritual torture and mutilations that typically accompanied them. Hitler especially marveled at the American ‘knack for maintaining an air of robust innocence in the wake of mass death.’ ” Ms. Wilkerson informs us that Hitler sent emissaries to study America’s Jim Crow system and then imported some features to orchestrate the Holocaust in Nazi Germany.

Her most vivid example of internalized casteism is the experience of a Dalit scholar who still experiences anxiety and a corresponding sense of inadequacy in the presence of someone who is considered to be from a higher caste.

A painful account of interpersonal racism is captured as Ms. Wilkerson recounts her experience after a routine business flight from Chicago to Detroit. She details her difficulty leaving a rental car parking lot because she had become so disoriented after being profiled and accosted by Drug Enforcement Administration agents who had intercepted her in the airport terminal and followed her onto the airport shuttle bus as she attempted to reach her destination. She provides a description of “getting turned around in a parking lot that I had been to dozens of times, going in circles, not able to get out, not registering the signs to the exit, not seeing how to get to Interstate 94, when I knew full well how to get to I-94 after all the times I’d driven it. ... This was the thievery of caste, stealing the time and psychic resources of the marginalized, draining energy in an already uphill competition. They were not, like me, frozen and disoriented, trying to make sense of a public violation that seemed all the more menacing now that I could see it in full. The quiet mundanity of that terror has never left me, the scars outliving the cut.”

This account is consistent with the dissociative, disorienting dynamics of race-based trauma. Her experience is not uncommon and helps to explain the activism of those in the subordinate caste who have attained some measure of wealth, power, and influence, and are motivated to expend their resources (energy, time, fame, and/or wealth) to raise awareness about social and political injustices by calling out structural racism in medicine, protesting police use of force by taking a knee, boycotting sporting events, and even demanding that football stadiums be used as polling sites. At the end of the day, all of us who have “made it” know that when we leave our homes, our relegation to the subordinate caste determines how we are perceived and what landmines we must navigate to make it through the day and that determine whether we will make it home.

This tour de force work of art has the potential to be a game changer in the way that we think about racial polarization in the United States. It is hoped that this new language opens up a space that allows each of us to explore this hegemony while identifying our placement and actions we take to maintain it, for each of us undeniably has a position in this caste system.

Having this new lexicon summons to mind the reactions of patients who gain immediate relief from having their illnesses named. In the case of the U.S. malady that has gripped us all, Ms. Wilkerson reiterates the importance of naming the condition. She writes:

“Because, to truly understand America, we must open our eyes to the hidden work of a caste system that has gone unnamed but prevails among us to our collective detriment, to see that we have more in common with each other and with cultures that we might otherwise dismiss, and to summon the courage to consider that therein may lie the answers.”

The naming allows both doctor and patient to have greater insight, understanding its origins and course, as well as having hope that there is a remedy. Naming facilitates the space for a shift in thinking and implementation of treatment protocols, such as Nazi Germany’s “zero tolerance policy” of swastikas in comparison to the ongoing U.S. controversy about the display of Confederate symbols. At this point in history, we welcome a diagnosis that has the potential to shift us from these poles of dominant and subordinate, black and white, good and bad, toward integration and wholeness of the individual psyche and collective global community. This is similar to what Melanie Klein calls the depressive position. Ms. Wilkerson suggests, in relinquishing these polar splits, we increase our capacity to shift to a space where our psychic integration occurs and our inextricable interdependence and responsibility for one another are honored.
 

Dr. Dunlap is a psychiatrist and psychoanalyst, and clinical professor of psychiatry and behavioral sciences at George Washington University. She is interested in the management of “difference” – race, gender, ethnicity, and intersectionality – in dyadic relationships and group dynamics; and the impact of racism on interpersonal relationships in institutional structures. Dr. Dunlap practices in Washington and has no disclosures. Dr. Dennis is a clinical psychologist and psychoanalyst. Her interests are in gender and ethnic diversity, health equity, and supervision and training. Dr. Dennis practices in Washington and has no disclosures.

A trainee recently observed that psychiatrists frequently seem motivated to protect patients from emotional and internal disruption. He suggested that we often did so by validating their maladaptive perspectives regarding their impaired relationships to society and close attachments. These maneuvers were justified by referring to the need to establish a therapeutic alliance and reduce patients’ suffering.

As an example, he mentioned a patient with alcohol use disorder. The patient came in with complaints that he could not stay sober with his current level of depression. The patient also complained of a family member who was setting limits. To the trainee’s surprise, the patient was not challenged on his perceived victimhood and his fantasy that a sober life should mean a life without negative effect. Instead, the patient was validated in his anger toward the family member. In addition, his medications were adjusted, seemingly confirming to the patient that one could only ask for sobriety once life is empty of pain.

The observation of the trainee reminded us of the three great “untruths” mentioned by Greg Lukianoff and Jonathan Haidt, PhD, in their famous book, “The Coddling of the American Mind.”¹ In the book they warn against the idea of fragility – what doesn’t kill you makes you weaker; emotional reasoning – always trust your feelings; and us-versus-them thinking – life is a battle between good people and evil people. The authors compare these three great untruths with the cognitive distortions of cognitive-behavioral therapy.

We ponder the trainee’s observation that psychiatrists appear to encourage the untruths rather than challenge them. Part of psychiatric and all medical training involves learning nonjudgmental approaches to human suffering and an identification with individual needs over societal demands. Our suspicion is that a nonjudgmental approach to the understanding of the human condition generates a desire to protect patients from a moralistic shaming position. However, we wonder if, at times, psychiatry takes this approach too far.
 

Reconceptualizing shame

Shame can be a toxic presence in the overwhelmed superego of a patient, but it can serve an important role in psychic development and should not be avoided out of hand. We suggest that it can be appropriate for a patient with an alcohol use disorder to feel some shame for the harm caused by their drinking, and we question the limit of psychiatry’s current pursuit of incessant validation. As an extreme example, would modern psychiatry discourage a patient who killed someone while driving in an intoxicated state from feeling remorse and shame?

Modern psychiatry appears to have other examples of the three great untruths on display. In our work, we are often faced with patients who are prematurely placed on disability, an example of fragility. Instead of encouraging patients to return to the workforce, they are “protected” from the emotional difficulty of work. In many patients this results in a decline in functioning and worsening of psychiatric symptoms. We are also confronted with patients who define themselves by how they feel, an example of emotional reasoning. Instead of using our clinical judgments to define and assess symptoms, patients are left to decide for themselves through self-rated scales with questionable validity.2 This can result in patients having their emotional experiences not only validated when inappropriate but can also give emotional reasoning a false sense of medical legitimacy.

Finally, we commonly see patients who endlessly blame family members and others for any life difficulties, a form of us-versus-them thinking. Instead of acknowledging and then integrating life challenges to achieve recovery, patients are affirmed despite clinicians having little evidence on the veracity of the patients’ perspective. As a consequence, patients can be further isolated from their greatest source of support.

In some ways, a mindlessly validating approach in psychiatry is unexpected since the practice of psychiatry would seem to promote the development of strong attachments and resilience. After all, connections to family, employment, social institutions, and even religious worship are associated with vastly better outcomes. Those who have become alienated to these pillars of social cohesion fare much worse. One may deplore the static and at times oppressive nature of these institutions but the empirical experience of practicing psychiatry leads one to a healthy respect for the stabilizing influence they accord for individuals struggling with life’s vicissitudes, unpredictability, and loneliness. Overcoming the fear of responsibility, living up to the demands and expectations of society, and having the strength to overcome difficult emotions should be the standard goals of psychiatric treatment.

From the knowledge gained from working with patients struggling from psychic pain, we wonder how to encourage patients to pursue those adaptive approaches to life. We argue that a stoic emphasis on learning to manage one’s affective and mental response to the inevitable changes of life is key to achieving wisdom and stability in our humble lives. This perspective is a common denominator of multiple different psychotherapies. The goal is to provide patients with the ability to be in a place where they are engaged with the world in a meaningful way that is not overwhelmed by distorted, self-absorbed psychic anguish. This perspective discourages externalization as a relatively low-yield way to understand and overcome one’s problems. One identifies childhood experiences with one’s mother as a source of adult distress not for the purpose of blaming her, but for the purpose of recognizing one’s own childish motivations for making maladaptive decisions as an adult.

For many patients, the goal should be to emphasize an internal locus of control and responsibility. We should also avoid constantly relying on society and government’s role in helping the individual achieve a satisfactory life. We wonder if this endless pursuit of nonjudgment and validation corrupts the doctor-patient interaction. In other words, focusing on medical diagnoses and psychopharmacology may be a counter therapeutic maneuver that compromises a patient’s sense of autonomy and individual responsibility for their own psychic development. Psychotherapy that ends with the patient being able to identify all the traumas that led to their sorrow has simply left the patient in the role of helpless and sorrowful victim. Instead, we should allow patients to proceed to the next step, which is empowerment and transformation. From this angle, the field of psychiatry should be cautious of encouraging movements that promote victimhood and grievance as a meaningful psychic position to take in society.

Mr. Lukianoff and Dr. Haidt use cognitive therapy as an analogy throughout their books for how to confront the great untruths. They perceive those modern forms of thinking as cognitive distortions, which can be remedied using the techniques of cognitive restructuring found in cognitive-behavioral therapy. They encourage us to recognize those maladaptive thoughts, and create more accurate and adaptive ways of viewing the world – a view that would be able to grow from challenges not just survive them; a view referred to as antifragile.3 We believe that those techniques and others would certainly be of assistance in our current times. However, the first step is to recognize our problem – a problem that is not rooted in the DSM, research, or biology but in an exaggerated intention to be patient centered. We should, however, remember that, when a patient has negative schemas, being too patient centered can be encouraging to maladaptive behaviors.

In conclusion, we wonder what modern psychiatry could look like if it made a concerted effort at also treating mental illness by reinforcing the importance of individual agency and responsibility. Modern psychiatry has been so focused on describing biological symptoms needing biological treatments that we sometimes forget that having no symptom (being asymptomatic) is not the only goal. Having a fulfilling and meaningful life, which is resilient to future symptoms is just as important to patients. We seem to have entrenched ourselves so deeply in an overly basic approach of problem-solution and diagnosis-treatment paradigm. However, we don’t need to renege on modern advances to promote the patient’s strength, adaptability, and antifragility. An emphasis on patient growth can complement the medical model. We wonder what effect such an approach would have if the trainee’s patient with alcohol use disorder was instead told: “Given the suffering you have and have caused because of your alcohol use disorder, how do you plan to make changes in your life to help the treatment plan we create together?”

Dr. Lehman is a professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at UCSD and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com.

References

1. Lukianoff G, Haidt J. The Coddling of the American Mind: How Good Intentions and Bad Ideas are Setting Up a Generation for Failure. New York: Penguin Books, 2019.

2. Levis B et al. J Clin Epidemiol. 2020 Jun;122:115-128.e1.,

3. Taleb NN. Antifragile: Things That Gain from Disorder. Vol. 3. New York: Random House, 2012.

A trainee recently observed that psychiatrists frequently seem motivated to protect patients from emotional and internal disruption. He suggested that we often did so by validating their maladaptive perspectives regarding their impaired relationships to society and close attachments. These maneuvers were justified by referring to the need to establish a therapeutic alliance and reduce patients’ suffering.

As an example, he mentioned a patient with alcohol use disorder. The patient came in with complaints that he could not stay sober with his current level of depression. The patient also complained of a family member who was setting limits. To the trainee’s surprise, the patient was not challenged on his perceived victimhood and his fantasy that a sober life should mean a life without negative effect. Instead, the patient was validated in his anger toward the family member. In addition, his medications were adjusted, seemingly confirming to the patient that one could only ask for sobriety once life is empty of pain.

The observation of the trainee reminded us of the three great “untruths” mentioned by Greg Lukianoff and Jonathan Haidt, PhD, in their famous book, “The Coddling of the American Mind.”¹ In the book they warn against the idea of fragility – what doesn’t kill you makes you weaker; emotional reasoning – always trust your feelings; and us-versus-them thinking – life is a battle between good people and evil people. The authors compare these three great untruths with the cognitive distortions of cognitive-behavioral therapy.

We ponder the trainee’s observation that psychiatrists appear to encourage the untruths rather than challenge them. Part of psychiatric and all medical training involves learning nonjudgmental approaches to human suffering and an identification with individual needs over societal demands. Our suspicion is that a nonjudgmental approach to the understanding of the human condition generates a desire to protect patients from a moralistic shaming position. However, we wonder if, at times, psychiatry takes this approach too far.
 

Reconceptualizing shame

Shame can be a toxic presence in the overwhelmed superego of a patient, but it can serve an important role in psychic development and should not be avoided out of hand. We suggest that it can be appropriate for a patient with an alcohol use disorder to feel some shame for the harm caused by their drinking, and we question the limit of psychiatry’s current pursuit of incessant validation. As an extreme example, would modern psychiatry discourage a patient who killed someone while driving in an intoxicated state from feeling remorse and shame?

Modern psychiatry appears to have other examples of the three great untruths on display. In our work, we are often faced with patients who are prematurely placed on disability, an example of fragility. Instead of encouraging patients to return to the workforce, they are “protected” from the emotional difficulty of work. In many patients this results in a decline in functioning and worsening of psychiatric symptoms. We are also confronted with patients who define themselves by how they feel, an example of emotional reasoning. Instead of using our clinical judgments to define and assess symptoms, patients are left to decide for themselves through self-rated scales with questionable validity.2 This can result in patients having their emotional experiences not only validated when inappropriate but can also give emotional reasoning a false sense of medical legitimacy.

Finally, we commonly see patients who endlessly blame family members and others for any life difficulties, a form of us-versus-them thinking. Instead of acknowledging and then integrating life challenges to achieve recovery, patients are affirmed despite clinicians having little evidence on the veracity of the patients’ perspective. As a consequence, patients can be further isolated from their greatest source of support.

In some ways, a mindlessly validating approach in psychiatry is unexpected since the practice of psychiatry would seem to promote the development of strong attachments and resilience. After all, connections to family, employment, social institutions, and even religious worship are associated with vastly better outcomes. Those who have become alienated to these pillars of social cohesion fare much worse. One may deplore the static and at times oppressive nature of these institutions but the empirical experience of practicing psychiatry leads one to a healthy respect for the stabilizing influence they accord for individuals struggling with life’s vicissitudes, unpredictability, and loneliness. Overcoming the fear of responsibility, living up to the demands and expectations of society, and having the strength to overcome difficult emotions should be the standard goals of psychiatric treatment.

From the knowledge gained from working with patients struggling from psychic pain, we wonder how to encourage patients to pursue those adaptive approaches to life. We argue that a stoic emphasis on learning to manage one’s affective and mental response to the inevitable changes of life is key to achieving wisdom and stability in our humble lives. This perspective is a common denominator of multiple different psychotherapies. The goal is to provide patients with the ability to be in a place where they are engaged with the world in a meaningful way that is not overwhelmed by distorted, self-absorbed psychic anguish. This perspective discourages externalization as a relatively low-yield way to understand and overcome one’s problems. One identifies childhood experiences with one’s mother as a source of adult distress not for the purpose of blaming her, but for the purpose of recognizing one’s own childish motivations for making maladaptive decisions as an adult.

For many patients, the goal should be to emphasize an internal locus of control and responsibility. We should also avoid constantly relying on society and government’s role in helping the individual achieve a satisfactory life. We wonder if this endless pursuit of nonjudgment and validation corrupts the doctor-patient interaction. In other words, focusing on medical diagnoses and psychopharmacology may be a counter therapeutic maneuver that compromises a patient’s sense of autonomy and individual responsibility for their own psychic development. Psychotherapy that ends with the patient being able to identify all the traumas that led to their sorrow has simply left the patient in the role of helpless and sorrowful victim. Instead, we should allow patients to proceed to the next step, which is empowerment and transformation. From this angle, the field of psychiatry should be cautious of encouraging movements that promote victimhood and grievance as a meaningful psychic position to take in society.

Mr. Lukianoff and Dr. Haidt use cognitive therapy as an analogy throughout their books for how to confront the great untruths. They perceive those modern forms of thinking as cognitive distortions, which can be remedied using the techniques of cognitive restructuring found in cognitive-behavioral therapy. They encourage us to recognize those maladaptive thoughts, and create more accurate and adaptive ways of viewing the world – a view that would be able to grow from challenges not just survive them; a view referred to as antifragile.3 We believe that those techniques and others would certainly be of assistance in our current times. However, the first step is to recognize our problem – a problem that is not rooted in the DSM, research, or biology but in an exaggerated intention to be patient centered. We should, however, remember that, when a patient has negative schemas, being too patient centered can be encouraging to maladaptive behaviors.

In conclusion, we wonder what modern psychiatry could look like if it made a concerted effort at also treating mental illness by reinforcing the importance of individual agency and responsibility. Modern psychiatry has been so focused on describing biological symptoms needing biological treatments that we sometimes forget that having no symptom (being asymptomatic) is not the only goal. Having a fulfilling and meaningful life, which is resilient to future symptoms is just as important to patients. We seem to have entrenched ourselves so deeply in an overly basic approach of problem-solution and diagnosis-treatment paradigm. However, we don’t need to renege on modern advances to promote the patient’s strength, adaptability, and antifragility. An emphasis on patient growth can complement the medical model. We wonder what effect such an approach would have if the trainee’s patient with alcohol use disorder was instead told: “Given the suffering you have and have caused because of your alcohol use disorder, how do you plan to make changes in your life to help the treatment plan we create together?”

Dr. Lehman is a professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at UCSD and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com.

References

1. Lukianoff G, Haidt J. The Coddling of the American Mind: How Good Intentions and Bad Ideas are Setting Up a Generation for Failure. New York: Penguin Books, 2019.

2. Levis B et al. J Clin Epidemiol. 2020 Jun;122:115-128.e1.,

3. Taleb NN. Antifragile: Things That Gain from Disorder. Vol. 3. New York: Random House, 2012.

A trainee recently observed that psychiatrists frequently seem motivated to protect patients from emotional and internal disruption. He suggested that we often did so by validating their maladaptive perspectives regarding their impaired relationships to society and close attachments. These maneuvers were justified by referring to the need to establish a therapeutic alliance and reduce patients’ suffering.

As an example, he mentioned a patient with alcohol use disorder. The patient came in with complaints that he could not stay sober with his current level of depression. The patient also complained of a family member who was setting limits. To the trainee’s surprise, the patient was not challenged on his perceived victimhood and his fantasy that a sober life should mean a life without negative effect. Instead, the patient was validated in his anger toward the family member. In addition, his medications were adjusted, seemingly confirming to the patient that one could only ask for sobriety once life is empty of pain.

The observation of the trainee reminded us of the three great “untruths” mentioned by Greg Lukianoff and Jonathan Haidt, PhD, in their famous book, “The Coddling of the American Mind.”¹ In the book they warn against the idea of fragility – what doesn’t kill you makes you weaker; emotional reasoning – always trust your feelings; and us-versus-them thinking – life is a battle between good people and evil people. The authors compare these three great untruths with the cognitive distortions of cognitive-behavioral therapy.

We ponder the trainee’s observation that psychiatrists appear to encourage the untruths rather than challenge them. Part of psychiatric and all medical training involves learning nonjudgmental approaches to human suffering and an identification with individual needs over societal demands. Our suspicion is that a nonjudgmental approach to the understanding of the human condition generates a desire to protect patients from a moralistic shaming position. However, we wonder if, at times, psychiatry takes this approach too far.
 

Reconceptualizing shame

Shame can be a toxic presence in the overwhelmed superego of a patient, but it can serve an important role in psychic development and should not be avoided out of hand. We suggest that it can be appropriate for a patient with an alcohol use disorder to feel some shame for the harm caused by their drinking, and we question the limit of psychiatry’s current pursuit of incessant validation. As an extreme example, would modern psychiatry discourage a patient who killed someone while driving in an intoxicated state from feeling remorse and shame?

Modern psychiatry appears to have other examples of the three great untruths on display. In our work, we are often faced with patients who are prematurely placed on disability, an example of fragility. Instead of encouraging patients to return to the workforce, they are “protected” from the emotional difficulty of work. In many patients this results in a decline in functioning and worsening of psychiatric symptoms. We are also confronted with patients who define themselves by how they feel, an example of emotional reasoning. Instead of using our clinical judgments to define and assess symptoms, patients are left to decide for themselves through self-rated scales with questionable validity.2 This can result in patients having their emotional experiences not only validated when inappropriate but can also give emotional reasoning a false sense of medical legitimacy.

Finally, we commonly see patients who endlessly blame family members and others for any life difficulties, a form of us-versus-them thinking. Instead of acknowledging and then integrating life challenges to achieve recovery, patients are affirmed despite clinicians having little evidence on the veracity of the patients’ perspective. As a consequence, patients can be further isolated from their greatest source of support.

In some ways, a mindlessly validating approach in psychiatry is unexpected since the practice of psychiatry would seem to promote the development of strong attachments and resilience. After all, connections to family, employment, social institutions, and even religious worship are associated with vastly better outcomes. Those who have become alienated to these pillars of social cohesion fare much worse. One may deplore the static and at times oppressive nature of these institutions but the empirical experience of practicing psychiatry leads one to a healthy respect for the stabilizing influence they accord for individuals struggling with life’s vicissitudes, unpredictability, and loneliness. Overcoming the fear of responsibility, living up to the demands and expectations of society, and having the strength to overcome difficult emotions should be the standard goals of psychiatric treatment.

From the knowledge gained from working with patients struggling from psychic pain, we wonder how to encourage patients to pursue those adaptive approaches to life. We argue that a stoic emphasis on learning to manage one’s affective and mental response to the inevitable changes of life is key to achieving wisdom and stability in our humble lives. This perspective is a common denominator of multiple different psychotherapies. The goal is to provide patients with the ability to be in a place where they are engaged with the world in a meaningful way that is not overwhelmed by distorted, self-absorbed psychic anguish. This perspective discourages externalization as a relatively low-yield way to understand and overcome one’s problems. One identifies childhood experiences with one’s mother as a source of adult distress not for the purpose of blaming her, but for the purpose of recognizing one’s own childish motivations for making maladaptive decisions as an adult.

For many patients, the goal should be to emphasize an internal locus of control and responsibility. We should also avoid constantly relying on society and government’s role in helping the individual achieve a satisfactory life. We wonder if this endless pursuit of nonjudgment and validation corrupts the doctor-patient interaction. In other words, focusing on medical diagnoses and psychopharmacology may be a counter therapeutic maneuver that compromises a patient’s sense of autonomy and individual responsibility for their own psychic development. Psychotherapy that ends with the patient being able to identify all the traumas that led to their sorrow has simply left the patient in the role of helpless and sorrowful victim. Instead, we should allow patients to proceed to the next step, which is empowerment and transformation. From this angle, the field of psychiatry should be cautious of encouraging movements that promote victimhood and grievance as a meaningful psychic position to take in society.

Mr. Lukianoff and Dr. Haidt use cognitive therapy as an analogy throughout their books for how to confront the great untruths. They perceive those modern forms of thinking as cognitive distortions, which can be remedied using the techniques of cognitive restructuring found in cognitive-behavioral therapy. They encourage us to recognize those maladaptive thoughts, and create more accurate and adaptive ways of viewing the world – a view that would be able to grow from challenges not just survive them; a view referred to as antifragile.3 We believe that those techniques and others would certainly be of assistance in our current times. However, the first step is to recognize our problem – a problem that is not rooted in the DSM, research, or biology but in an exaggerated intention to be patient centered. We should, however, remember that, when a patient has negative schemas, being too patient centered can be encouraging to maladaptive behaviors.

In conclusion, we wonder what modern psychiatry could look like if it made a concerted effort at also treating mental illness by reinforcing the importance of individual agency and responsibility. Modern psychiatry has been so focused on describing biological symptoms needing biological treatments that we sometimes forget that having no symptom (being asymptomatic) is not the only goal. Having a fulfilling and meaningful life, which is resilient to future symptoms is just as important to patients. We seem to have entrenched ourselves so deeply in an overly basic approach of problem-solution and diagnosis-treatment paradigm. However, we don’t need to renege on modern advances to promote the patient’s strength, adaptability, and antifragility. An emphasis on patient growth can complement the medical model. We wonder what effect such an approach would have if the trainee’s patient with alcohol use disorder was instead told: “Given the suffering you have and have caused because of your alcohol use disorder, how do you plan to make changes in your life to help the treatment plan we create together?”

Dr. Lehman is a professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at UCSD and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com.

References

1. Lukianoff G, Haidt J. The Coddling of the American Mind: How Good Intentions and Bad Ideas are Setting Up a Generation for Failure. New York: Penguin Books, 2019.

2. Levis B et al. J Clin Epidemiol. 2020 Jun;122:115-128.e1.,

3. Taleb NN. Antifragile: Things That Gain from Disorder. Vol. 3. New York: Random House, 2012.

Hurricane Sally recently crossed the Gulf of Mexico and landed with torrential rainfalls along the Alabama coast. A little rainfall is important for crops; too much leads to devastation. As physicians, we need data in order to help manage patients’ illnesses and to help to keep them healthy. Our fear though is that too much data provided too quickly may have the opposite effect.

Personal monitoring devices

When I bought my first Fitbit 7 years ago, I was enamored with the technology. The Fitbit was little more than a step tracker, yet I proudly wore its black rubber strap on my wrist. It was my first foray into wearable technology, and it felt quite empowering to have an objective way to track my fitness beyond just using my bathroom scale. Now less than a decade later, that Fitbit looks archaic in comparison with the wrist-top technology currently available.

As I write this, the world’s largest technology company is in the process of releasing its sixth-generation Apple Watch. In addition to acting as a smartphone, this new device, which is barely larger than a postage stamp, offers GPS-based movement tracking, the ability to detect falls, continuous heart rate monitoring, a built-in EKG capable of diagnosing atrial fibrillation, and an oxygen saturation sensor. These features weren’t added thoughtlessly. Apple is marketing this as a health-focused device, with their primary advertising campaign claiming that “the future of health is on your wrist,” and they aren’t the only company making this play.

Along with Apple, Samsung, Withings, Fitbit, and other companies continue to bring products to market that monitor our activity and provide new insights into our health. Typically linked to smartphone-based apps, these devices record all of their measurements for later review, while software helps interpret the findings to make them actionable. From heart rate tracking to sleep analysis, these options now provide access to volumes of data that promise to improve our wellness and change our lives. Of course, those promises will only be fulfilled if our behavior is altered as a consequence of having more detailed information. Whether that will happen remains to be seen.
 

Health system–linked devices

Major advancements in medical monitoring technology are now enabling physicians to get much deeper insight into their patients’ health status. Internet-connected scales, blood pressure cuffs, and exercise equipment offer the ability to upload information into patient portals and integrate that information into EHRs. New devices provide access to information that previously was impossible to obtain. For example, wearable continuous blood glucose monitors, such as the FreeStyle Libre or DexCom’s G6, allow patients and physicians to follow blood sugar readings 24 hours a day. This provides unprecedented awareness of diabetes control and relieves the pain and inconvenience of finger sticks and blood draws. It also aids with compliance because patients don’t need to remember to check their sugar levels on a schedule.

Other compliance-boosting breakthroughs, such as Bluetooth-enabled asthma inhalers and cellular-connected continuous positive airway pressure machines, assist patients with managing chronic respiratory conditions. Many companies are developing technologies to manage acute conditions as well. One such company, an on-demand telemedicine provider called TytoCare, has developed a $299 suite of instruments that includes a digital stethoscope, thermometer, and camera-based otoscope. In concert with a virtual visit, their providers can remotely use these tools to examine and assess sick individuals. This virtual “laying on of hands” may have sounded like science fiction and likely would have been rejected by patients just a few years ago. Now it is becoming commonplace and will soon be an expectation of many seeking care.

We as clinicians need to learn how best to adapt to the new world and integrate these new sources of health data into our practices. But if we are to be successful, everyone must acknowledge that this revolution in health care brings many challenges along with it. One of those is the deluge of data that connected devices provide.
 

Information overload

There is such a thing as “too much of a good thing.” Described by journalist David Shenk as “data smog” in his 1997 book of the same name, the idea is clear: There is only so much information we can assimilate.

Even after years of using EHRs and with government-implemented incentives that promote “meaningful use,” physicians are still struggling with EHRs. Additionally, many have expressed frustration with the connectedness that EHRs provide and lament their inability to ever really “leave the office.” As more and more data become available to physicians, the challenge of how to assimilate and act on those data will continue to grow. The addition of patient-provided health statistics will only make information overload worse, with clinicians will feeling an ever-growing burden to know, understand, and act on this information.

Unless we develop systems to sort, filter, and prioritize the flow of information, there is potential for liability from not acting on the amount of virtual information doctors receive. This new risk for already fatigued and overburdened physicians combined with an increase in the amount of virtual information at doctors’ fingertips may lead to the value of patient data being lost.
 

Dr. Notte is a family physician and chief medical officer of Abington (Pa.) Hospital–Jefferson Health. Follow him on Twitter (@doctornotte). Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington Hospital–Jefferson Health. They have no conflicts related to the content of this piece.

Hurricane Sally recently crossed the Gulf of Mexico and landed with torrential rainfalls along the Alabama coast. A little rainfall is important for crops; too much leads to devastation. As physicians, we need data in order to help manage patients’ illnesses and to help to keep them healthy. Our fear though is that too much data provided too quickly may have the opposite effect.

Personal monitoring devices

When I bought my first Fitbit 7 years ago, I was enamored with the technology. The Fitbit was little more than a step tracker, yet I proudly wore its black rubber strap on my wrist. It was my first foray into wearable technology, and it felt quite empowering to have an objective way to track my fitness beyond just using my bathroom scale. Now less than a decade later, that Fitbit looks archaic in comparison with the wrist-top technology currently available.

As I write this, the world’s largest technology company is in the process of releasing its sixth-generation Apple Watch. In addition to acting as a smartphone, this new device, which is barely larger than a postage stamp, offers GPS-based movement tracking, the ability to detect falls, continuous heart rate monitoring, a built-in EKG capable of diagnosing atrial fibrillation, and an oxygen saturation sensor. These features weren’t added thoughtlessly. Apple is marketing this as a health-focused device, with their primary advertising campaign claiming that “the future of health is on your wrist,” and they aren’t the only company making this play.

Along with Apple, Samsung, Withings, Fitbit, and other companies continue to bring products to market that monitor our activity and provide new insights into our health. Typically linked to smartphone-based apps, these devices record all of their measurements for later review, while software helps interpret the findings to make them actionable. From heart rate tracking to sleep analysis, these options now provide access to volumes of data that promise to improve our wellness and change our lives. Of course, those promises will only be fulfilled if our behavior is altered as a consequence of having more detailed information. Whether that will happen remains to be seen.
 

Health system–linked devices

Major advancements in medical monitoring technology are now enabling physicians to get much deeper insight into their patients’ health status. Internet-connected scales, blood pressure cuffs, and exercise equipment offer the ability to upload information into patient portals and integrate that information into EHRs. New devices provide access to information that previously was impossible to obtain. For example, wearable continuous blood glucose monitors, such as the FreeStyle Libre or DexCom’s G6, allow patients and physicians to follow blood sugar readings 24 hours a day. This provides unprecedented awareness of diabetes control and relieves the pain and inconvenience of finger sticks and blood draws. It also aids with compliance because patients don’t need to remember to check their sugar levels on a schedule.

Other compliance-boosting breakthroughs, such as Bluetooth-enabled asthma inhalers and cellular-connected continuous positive airway pressure machines, assist patients with managing chronic respiratory conditions. Many companies are developing technologies to manage acute conditions as well. One such company, an on-demand telemedicine provider called TytoCare, has developed a $299 suite of instruments that includes a digital stethoscope, thermometer, and camera-based otoscope. In concert with a virtual visit, their providers can remotely use these tools to examine and assess sick individuals. This virtual “laying on of hands” may have sounded like science fiction and likely would have been rejected by patients just a few years ago. Now it is becoming commonplace and will soon be an expectation of many seeking care.

We as clinicians need to learn how best to adapt to the new world and integrate these new sources of health data into our practices. But if we are to be successful, everyone must acknowledge that this revolution in health care brings many challenges along with it. One of those is the deluge of data that connected devices provide.
 

Information overload

There is such a thing as “too much of a good thing.” Described by journalist David Shenk as “data smog” in his 1997 book of the same name, the idea is clear: There is only so much information we can assimilate.

Even after years of using EHRs and with government-implemented incentives that promote “meaningful use,” physicians are still struggling with EHRs. Additionally, many have expressed frustration with the connectedness that EHRs provide and lament their inability to ever really “leave the office.” As more and more data become available to physicians, the challenge of how to assimilate and act on those data will continue to grow. The addition of patient-provided health statistics will only make information overload worse, with clinicians will feeling an ever-growing burden to know, understand, and act on this information.

Unless we develop systems to sort, filter, and prioritize the flow of information, there is potential for liability from not acting on the amount of virtual information doctors receive. This new risk for already fatigued and overburdened physicians combined with an increase in the amount of virtual information at doctors’ fingertips may lead to the value of patient data being lost.
 

Dr. Notte is a family physician and chief medical officer of Abington (Pa.) Hospital–Jefferson Health. Follow him on Twitter (@doctornotte). Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington Hospital–Jefferson Health. They have no conflicts related to the content of this piece.

Hurricane Sally recently crossed the Gulf of Mexico and landed with torrential rainfalls along the Alabama coast. A little rainfall is important for crops; too much leads to devastation. As physicians, we need data in order to help manage patients’ illnesses and to help to keep them healthy. Our fear though is that too much data provided too quickly may have the opposite effect.

Personal monitoring devices

When I bought my first Fitbit 7 years ago, I was enamored with the technology. The Fitbit was little more than a step tracker, yet I proudly wore its black rubber strap on my wrist. It was my first foray into wearable technology, and it felt quite empowering to have an objective way to track my fitness beyond just using my bathroom scale. Now less than a decade later, that Fitbit looks archaic in comparison with the wrist-top technology currently available.

As I write this, the world’s largest technology company is in the process of releasing its sixth-generation Apple Watch. In addition to acting as a smartphone, this new device, which is barely larger than a postage stamp, offers GPS-based movement tracking, the ability to detect falls, continuous heart rate monitoring, a built-in EKG capable of diagnosing atrial fibrillation, and an oxygen saturation sensor. These features weren’t added thoughtlessly. Apple is marketing this as a health-focused device, with their primary advertising campaign claiming that “the future of health is on your wrist,” and they aren’t the only company making this play.

Along with Apple, Samsung, Withings, Fitbit, and other companies continue to bring products to market that monitor our activity and provide new insights into our health. Typically linked to smartphone-based apps, these devices record all of their measurements for later review, while software helps interpret the findings to make them actionable. From heart rate tracking to sleep analysis, these options now provide access to volumes of data that promise to improve our wellness and change our lives. Of course, those promises will only be fulfilled if our behavior is altered as a consequence of having more detailed information. Whether that will happen remains to be seen.
 

Health system–linked devices

Major advancements in medical monitoring technology are now enabling physicians to get much deeper insight into their patients’ health status. Internet-connected scales, blood pressure cuffs, and exercise equipment offer the ability to upload information into patient portals and integrate that information into EHRs. New devices provide access to information that previously was impossible to obtain. For example, wearable continuous blood glucose monitors, such as the FreeStyle Libre or DexCom’s G6, allow patients and physicians to follow blood sugar readings 24 hours a day. This provides unprecedented awareness of diabetes control and relieves the pain and inconvenience of finger sticks and blood draws. It also aids with compliance because patients don’t need to remember to check their sugar levels on a schedule.

Other compliance-boosting breakthroughs, such as Bluetooth-enabled asthma inhalers and cellular-connected continuous positive airway pressure machines, assist patients with managing chronic respiratory conditions. Many companies are developing technologies to manage acute conditions as well. One such company, an on-demand telemedicine provider called TytoCare, has developed a $299 suite of instruments that includes a digital stethoscope, thermometer, and camera-based otoscope. In concert with a virtual visit, their providers can remotely use these tools to examine and assess sick individuals. This virtual “laying on of hands” may have sounded like science fiction and likely would have been rejected by patients just a few years ago. Now it is becoming commonplace and will soon be an expectation of many seeking care.

We as clinicians need to learn how best to adapt to the new world and integrate these new sources of health data into our practices. But if we are to be successful, everyone must acknowledge that this revolution in health care brings many challenges along with it. One of those is the deluge of data that connected devices provide.
 

Information overload

There is such a thing as “too much of a good thing.” Described by journalist David Shenk as “data smog” in his 1997 book of the same name, the idea is clear: There is only so much information we can assimilate.

Even after years of using EHRs and with government-implemented incentives that promote “meaningful use,” physicians are still struggling with EHRs. Additionally, many have expressed frustration with the connectedness that EHRs provide and lament their inability to ever really “leave the office.” As more and more data become available to physicians, the challenge of how to assimilate and act on those data will continue to grow. The addition of patient-provided health statistics will only make information overload worse, with clinicians will feeling an ever-growing burden to know, understand, and act on this information.

Unless we develop systems to sort, filter, and prioritize the flow of information, there is potential for liability from not acting on the amount of virtual information doctors receive. This new risk for already fatigued and overburdened physicians combined with an increase in the amount of virtual information at doctors’ fingertips may lead to the value of patient data being lost.
 

Dr. Notte is a family physician and chief medical officer of Abington (Pa.) Hospital–Jefferson Health. Follow him on Twitter (@doctornotte). Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington Hospital–Jefferson Health. They have no conflicts related to the content of this piece.

During my sophomore year in high school, we had to read a historical essay about cars, the author and name of which I’ve long forgotten. The basic point of it was that, as of 1982, no invention had changed Western culture more than the automobile.

In America, the car is king. A large portion of society revolves around cars and their trappings: modifications, sports, collectors auctions, parking lots and garages, and many others. The city of Detroit has become synonymous with one industry.

A few times a week I have to walk two to three blocks to and from a research office to see patients and do paperwork. This involves me cutting through a series of parking lots, including one garage, that service the office buildings in the area. For years they’ve always been full on weekdays.

Now, after 6 months of pandemic, they’re maybe 10% filled. Rows and rows of empty spaces certainly makes my walks easier.

But each time I walk there now I wonder where this will lead. The people who used to park still work there, just from home now. If they can work from home successfully for 6 months, why should they even come back to the office on a routine basis?

I don’t think it’s the end of the automobile by any means. The majority of us still depend on it for many things and will continue to do so for a long time to come. I need it to get to my office, the hospital, the store, to take my oldest to and from his job, and many other things.

But perhaps the pandemic will also bring a lasting change in how and where many do their jobs. It’s certainly driven a dramatic shift to Zoom, Teams, WebEx, Skype, and other remote platforms.

If they’re not really needed, having fewer cars on the road is probably a good thing. It saves commute time, reduces oil dependence and pollution, and provides a number of other benefits. If sustained, in the long term it will affect the calculus of office space and buildings, parking lot sizes, and a million other details.

My secretary has been working from home since late March now. While I miss having her and her daughter at the office, her lack of a commute means she starts taking calls an hour earlier and isn’t spending $60-$100 a week on gas.

We’ll have to see how it all plays out. Like other adverse events that change society, not all of the changes in the aftermath may be bad ones.

The car will be king in America for a long time to come, but its role in commuting may be fundamentally different after the pandemic, and the ripples from this may bring many more changes – hopefully for the better.

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

During my sophomore year in high school, we had to read a historical essay about cars, the author and name of which I’ve long forgotten. The basic point of it was that, as of 1982, no invention had changed Western culture more than the automobile.

In America, the car is king. A large portion of society revolves around cars and their trappings: modifications, sports, collectors auctions, parking lots and garages, and many others. The city of Detroit has become synonymous with one industry.

A few times a week I have to walk two to three blocks to and from a research office to see patients and do paperwork. This involves me cutting through a series of parking lots, including one garage, that service the office buildings in the area. For years they’ve always been full on weekdays.

Now, after 6 months of pandemic, they’re maybe 10% filled. Rows and rows of empty spaces certainly makes my walks easier.

But each time I walk there now I wonder where this will lead. The people who used to park still work there, just from home now. If they can work from home successfully for 6 months, why should they even come back to the office on a routine basis?

I don’t think it’s the end of the automobile by any means. The majority of us still depend on it for many things and will continue to do so for a long time to come. I need it to get to my office, the hospital, the store, to take my oldest to and from his job, and many other things.

But perhaps the pandemic will also bring a lasting change in how and where many do their jobs. It’s certainly driven a dramatic shift to Zoom, Teams, WebEx, Skype, and other remote platforms.

If they’re not really needed, having fewer cars on the road is probably a good thing. It saves commute time, reduces oil dependence and pollution, and provides a number of other benefits. If sustained, in the long term it will affect the calculus of office space and buildings, parking lot sizes, and a million other details.

My secretary has been working from home since late March now. While I miss having her and her daughter at the office, her lack of a commute means she starts taking calls an hour earlier and isn’t spending $60-$100 a week on gas.

We’ll have to see how it all plays out. Like other adverse events that change society, not all of the changes in the aftermath may be bad ones.

The car will be king in America for a long time to come, but its role in commuting may be fundamentally different after the pandemic, and the ripples from this may bring many more changes – hopefully for the better.

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

During my sophomore year in high school, we had to read a historical essay about cars, the author and name of which I’ve long forgotten. The basic point of it was that, as of 1982, no invention had changed Western culture more than the automobile.

In America, the car is king. A large portion of society revolves around cars and their trappings: modifications, sports, collectors auctions, parking lots and garages, and many others. The city of Detroit has become synonymous with one industry.

A few times a week I have to walk two to three blocks to and from a research office to see patients and do paperwork. This involves me cutting through a series of parking lots, including one garage, that service the office buildings in the area. For years they’ve always been full on weekdays.

Now, after 6 months of pandemic, they’re maybe 10% filled. Rows and rows of empty spaces certainly makes my walks easier.

But each time I walk there now I wonder where this will lead. The people who used to park still work there, just from home now. If they can work from home successfully for 6 months, why should they even come back to the office on a routine basis?

I don’t think it’s the end of the automobile by any means. The majority of us still depend on it for many things and will continue to do so for a long time to come. I need it to get to my office, the hospital, the store, to take my oldest to and from his job, and many other things.

But perhaps the pandemic will also bring a lasting change in how and where many do their jobs. It’s certainly driven a dramatic shift to Zoom, Teams, WebEx, Skype, and other remote platforms.

If they’re not really needed, having fewer cars on the road is probably a good thing. It saves commute time, reduces oil dependence and pollution, and provides a number of other benefits. If sustained, in the long term it will affect the calculus of office space and buildings, parking lot sizes, and a million other details.

My secretary has been working from home since late March now. While I miss having her and her daughter at the office, her lack of a commute means she starts taking calls an hour earlier and isn’t spending $60-$100 a week on gas.

We’ll have to see how it all plays out. Like other adverse events that change society, not all of the changes in the aftermath may be bad ones.

The car will be king in America for a long time to come, but its role in commuting may be fundamentally different after the pandemic, and the ripples from this may bring many more changes – hopefully for the better.

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

It was 6 a.m. on a rainy, cold Pacific Northwest morning as I walked from my apartment to the hospital, dodging puddles and dreaming of the mediocre-yet-hot physician-lounge coffee. Another long day full of clinical and administrative tasks awaited me.

I was 6 months’ pregnant with our first child and working my sixth 12-hour shift in a row. We had recently lost our medical director, and the C-suite had offered me the role. The day ahead seemed like an enormous mountain to climb.

I felt tired and more than a little overwhelmed. But I whispered to myself: “Today is going to be a fantastic day. I will not fail my team. I will not fail my patients!”
 

Physician leadership starts with a decision

The timing of this call to leadership had not been ideal. There’s probably never a perfect time to step into a medical director role. And my situation was no exception.

In addition to the baby on the way, my husband was traveling a lot for work. Also, the job of a medical director seemed a little daunting – especially to a young physician leading a team for the first time.

But I knew that leadership was my calling. While I didn’t yet have decades of experience, I had been selected as the chief resident in internal medicine, completed a nephrology fellowship, and mentored several medical students and residents along my career path.

I also knew that I was passionate about supporting my patients and hospitalist team. I’d previously served as associate medical director in charge of quality, readmission reduction, and patient experience. Having achieved the highest patient satisfaction scores on the team for 2 consecutive years, I was specially tasked to improve our team’s HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores.

These experiences taught me that coaching with positive reinforcement was in my blood. This gave me the courage to face my tallest mountain yet.
 

No one climbs a mountain alone

I also stepped into my new physician leadership role with amazing support. Our outgoing medical director had recommended me, and my entire team was rooting for me. My spouse was 100% behind the idea.

Courtesy Dr. Swati Mehta

What’s more, I had received amazing feedback from patients throughout my 3 years at the hospital. I had papered an entire office wall with their thank-you notes. I even had a quilt that an 85-year-old patient’s wife made to thank me for my compassionate care.

As I weighed my decision, I realized that I had a higher calling to be a true advocate for my patients. I loved what I did. Each day, I resolved to bring my best and most authentic self for them – no matter how drained I felt.

My team and patients needed me now, not at some more convenient time down the road. A medical director job was the natural next step for me. And so, I resolved to climb the mountain.
 

Climbing through storms

Stepping into a medical director job forced me to grow into a completely new person. So maybe starting that role during pregnancy was a great metaphor!

Each day, there was immense pressure to perform, to deliver quality outcomes, and to simultaneously meet expectations of the C-suite as well as my hospitalist team. There was no room for failure, because too much was at stake.

Looking back today, I wouldn’t trade the experience for anything. The medical director role was one of the most gratifying experiences in my life, and I am truly thankful for it.

A leader’s role truly boils down to working tirelessly to collaborate with different care teams. It’s important to care not only about our patients but also about our fellow hospitalists. We can do this by truly leading by example – be it picking up extra shifts, covering holidays so team members can be with family, or coming in at 10 p.m. to round with your night team.

I was also able to bring a unique perspective to the hospital C-suite meetings as a woman, an immigrant, and a true “mama bear” – not only of my infant son but also of my team.

Courtesy Dr. Swati Mehta

My first year as a medical director required more commitment and heart than I could have imagined. But all this hard work paid off when our hospitalist group received the coveted Best Team Award for most improved quality outcomes, financial performance, and patient experience.
 

The summit is the beginning

My first medical director job fueled my passion for patient satisfaction even further. I now serve as the director of patient experience for the more than 4,200 clinicians at Vituity. Together we care for more than 6.5 million lives a year across the country.

In 2019, I coached 300 physicians and hospital leaders on communication, collaboration, and service recovery skills, leading to significant improvement in their HCAHPS scores. I was delighted to receive the Vituity Distinguished Service Award for my contributions. It’s such an honor to be instrumental in impacting patient care at a larger scale.

This year, I was invited to serve as vice chair of the Society for Hospital Medicine’s patient experience committee and to join the executive board of the SHM San Francisco chapter. Together, we have created a COVID-19 patient communication resource and reached out to our hospitalists to provide them with a space to share their stories during this pandemic. I am so excited to share my knowledge and passion with clinicians across the country given the wide reach of Vituity & SHM!

Many hospitalists shy away from leadership roles. The mountain is tough to scale, but the view from the top is worth it. The key is to start, even if you don’t feel ready. I am here to tell you it can be done!

Dr. Mehta is a hospitalist and director of quality & performance and patient experience at Vituity in Emeryville, Calif. She is vice chair of the SHM patient experience committee and executive board member of the SHM San Francisco Bay Area chapter.

It was 6 a.m. on a rainy, cold Pacific Northwest morning as I walked from my apartment to the hospital, dodging puddles and dreaming of the mediocre-yet-hot physician-lounge coffee. Another long day full of clinical and administrative tasks awaited me.

I was 6 months’ pregnant with our first child and working my sixth 12-hour shift in a row. We had recently lost our medical director, and the C-suite had offered me the role. The day ahead seemed like an enormous mountain to climb.

I felt tired and more than a little overwhelmed. But I whispered to myself: “Today is going to be a fantastic day. I will not fail my team. I will not fail my patients!”
 

Physician leadership starts with a decision

The timing of this call to leadership had not been ideal. There’s probably never a perfect time to step into a medical director role. And my situation was no exception.

In addition to the baby on the way, my husband was traveling a lot for work. Also, the job of a medical director seemed a little daunting – especially to a young physician leading a team for the first time.

But I knew that leadership was my calling. While I didn’t yet have decades of experience, I had been selected as the chief resident in internal medicine, completed a nephrology fellowship, and mentored several medical students and residents along my career path.

I also knew that I was passionate about supporting my patients and hospitalist team. I’d previously served as associate medical director in charge of quality, readmission reduction, and patient experience. Having achieved the highest patient satisfaction scores on the team for 2 consecutive years, I was specially tasked to improve our team’s HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores.

These experiences taught me that coaching with positive reinforcement was in my blood. This gave me the courage to face my tallest mountain yet.
 

No one climbs a mountain alone

I also stepped into my new physician leadership role with amazing support. Our outgoing medical director had recommended me, and my entire team was rooting for me. My spouse was 100% behind the idea.

Courtesy Dr. Swati Mehta

What’s more, I had received amazing feedback from patients throughout my 3 years at the hospital. I had papered an entire office wall with their thank-you notes. I even had a quilt that an 85-year-old patient’s wife made to thank me for my compassionate care.

As I weighed my decision, I realized that I had a higher calling to be a true advocate for my patients. I loved what I did. Each day, I resolved to bring my best and most authentic self for them – no matter how drained I felt.

My team and patients needed me now, not at some more convenient time down the road. A medical director job was the natural next step for me. And so, I resolved to climb the mountain.
 

Climbing through storms

Stepping into a medical director job forced me to grow into a completely new person. So maybe starting that role during pregnancy was a great metaphor!

Each day, there was immense pressure to perform, to deliver quality outcomes, and to simultaneously meet expectations of the C-suite as well as my hospitalist team. There was no room for failure, because too much was at stake.

Looking back today, I wouldn’t trade the experience for anything. The medical director role was one of the most gratifying experiences in my life, and I am truly thankful for it.

A leader’s role truly boils down to working tirelessly to collaborate with different care teams. It’s important to care not only about our patients but also about our fellow hospitalists. We can do this by truly leading by example – be it picking up extra shifts, covering holidays so team members can be with family, or coming in at 10 p.m. to round with your night team.

I was also able to bring a unique perspective to the hospital C-suite meetings as a woman, an immigrant, and a true “mama bear” – not only of my infant son but also of my team.

Courtesy Dr. Swati Mehta

My first year as a medical director required more commitment and heart than I could have imagined. But all this hard work paid off when our hospitalist group received the coveted Best Team Award for most improved quality outcomes, financial performance, and patient experience.
 

The summit is the beginning

My first medical director job fueled my passion for patient satisfaction even further. I now serve as the director of patient experience for the more than 4,200 clinicians at Vituity. Together we care for more than 6.5 million lives a year across the country.

In 2019, I coached 300 physicians and hospital leaders on communication, collaboration, and service recovery skills, leading to significant improvement in their HCAHPS scores. I was delighted to receive the Vituity Distinguished Service Award for my contributions. It’s such an honor to be instrumental in impacting patient care at a larger scale.

This year, I was invited to serve as vice chair of the Society for Hospital Medicine’s patient experience committee and to join the executive board of the SHM San Francisco chapter. Together, we have created a COVID-19 patient communication resource and reached out to our hospitalists to provide them with a space to share their stories during this pandemic. I am so excited to share my knowledge and passion with clinicians across the country given the wide reach of Vituity & SHM!

Many hospitalists shy away from leadership roles. The mountain is tough to scale, but the view from the top is worth it. The key is to start, even if you don’t feel ready. I am here to tell you it can be done!

Dr. Mehta is a hospitalist and director of quality & performance and patient experience at Vituity in Emeryville, Calif. She is vice chair of the SHM patient experience committee and executive board member of the SHM San Francisco Bay Area chapter.

It was 6 a.m. on a rainy, cold Pacific Northwest morning as I walked from my apartment to the hospital, dodging puddles and dreaming of the mediocre-yet-hot physician-lounge coffee. Another long day full of clinical and administrative tasks awaited me.

I was 6 months’ pregnant with our first child and working my sixth 12-hour shift in a row. We had recently lost our medical director, and the C-suite had offered me the role. The day ahead seemed like an enormous mountain to climb.

I felt tired and more than a little overwhelmed. But I whispered to myself: “Today is going to be a fantastic day. I will not fail my team. I will not fail my patients!”
 

Physician leadership starts with a decision

The timing of this call to leadership had not been ideal. There’s probably never a perfect time to step into a medical director role. And my situation was no exception.

In addition to the baby on the way, my husband was traveling a lot for work. Also, the job of a medical director seemed a little daunting – especially to a young physician leading a team for the first time.

But I knew that leadership was my calling. While I didn’t yet have decades of experience, I had been selected as the chief resident in internal medicine, completed a nephrology fellowship, and mentored several medical students and residents along my career path.

I also knew that I was passionate about supporting my patients and hospitalist team. I’d previously served as associate medical director in charge of quality, readmission reduction, and patient experience. Having achieved the highest patient satisfaction scores on the team for 2 consecutive years, I was specially tasked to improve our team’s HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores.

These experiences taught me that coaching with positive reinforcement was in my blood. This gave me the courage to face my tallest mountain yet.
 

No one climbs a mountain alone

I also stepped into my new physician leadership role with amazing support. Our outgoing medical director had recommended me, and my entire team was rooting for me. My spouse was 100% behind the idea.

Courtesy Dr. Swati Mehta

What’s more, I had received amazing feedback from patients throughout my 3 years at the hospital. I had papered an entire office wall with their thank-you notes. I even had a quilt that an 85-year-old patient’s wife made to thank me for my compassionate care.

As I weighed my decision, I realized that I had a higher calling to be a true advocate for my patients. I loved what I did. Each day, I resolved to bring my best and most authentic self for them – no matter how drained I felt.

My team and patients needed me now, not at some more convenient time down the road. A medical director job was the natural next step for me. And so, I resolved to climb the mountain.
 

Climbing through storms

Stepping into a medical director job forced me to grow into a completely new person. So maybe starting that role during pregnancy was a great metaphor!

Each day, there was immense pressure to perform, to deliver quality outcomes, and to simultaneously meet expectations of the C-suite as well as my hospitalist team. There was no room for failure, because too much was at stake.

Looking back today, I wouldn’t trade the experience for anything. The medical director role was one of the most gratifying experiences in my life, and I am truly thankful for it.

A leader’s role truly boils down to working tirelessly to collaborate with different care teams. It’s important to care not only about our patients but also about our fellow hospitalists. We can do this by truly leading by example – be it picking up extra shifts, covering holidays so team members can be with family, or coming in at 10 p.m. to round with your night team.

I was also able to bring a unique perspective to the hospital C-suite meetings as a woman, an immigrant, and a true “mama bear” – not only of my infant son but also of my team.

Courtesy Dr. Swati Mehta

My first year as a medical director required more commitment and heart than I could have imagined. But all this hard work paid off when our hospitalist group received the coveted Best Team Award for most improved quality outcomes, financial performance, and patient experience.
 

The summit is the beginning

My first medical director job fueled my passion for patient satisfaction even further. I now serve as the director of patient experience for the more than 4,200 clinicians at Vituity. Together we care for more than 6.5 million lives a year across the country.

In 2019, I coached 300 physicians and hospital leaders on communication, collaboration, and service recovery skills, leading to significant improvement in their HCAHPS scores. I was delighted to receive the Vituity Distinguished Service Award for my contributions. It’s such an honor to be instrumental in impacting patient care at a larger scale.

This year, I was invited to serve as vice chair of the Society for Hospital Medicine’s patient experience committee and to join the executive board of the SHM San Francisco chapter. Together, we have created a COVID-19 patient communication resource and reached out to our hospitalists to provide them with a space to share their stories during this pandemic. I am so excited to share my knowledge and passion with clinicians across the country given the wide reach of Vituity & SHM!

Many hospitalists shy away from leadership roles. The mountain is tough to scale, but the view from the top is worth it. The key is to start, even if you don’t feel ready. I am here to tell you it can be done!

Dr. Mehta is a hospitalist and director of quality & performance and patient experience at Vituity in Emeryville, Calif. She is vice chair of the SHM patient experience committee and executive board member of the SHM San Francisco Bay Area chapter.

On March 3 of this year, Bryant Cameron Webb, MD, JD, won two-thirds of the vote in Virginia’s Democratic primary race. In November, he’ll compete against Republican Bob Good to represent the state’s 5th Congressional District. If he succeeds, he will become the first Black physician ever elected to a seat in Congress.

Courtesy Dr. Bryant Cameron Webb

The political and social unrest across the United States in recent months has resulted in millions of people becoming more proactive: from sports arenas to the halls of Congress, the rally cry of Black Lives Matter has echoed like never before after the killing of George Floyd and Breonna Taylor at the hands of law enforcement. Dr. Webb, a practicing internist and professor at the University of Virginia, Charlottesville, is among many physicians joining the cause. If elected, he hopes to bring a unique perspective to Washington and advocate for racial equity to help combat systemic racist policies that result in health disparities.

“For me as a professor at UVA in both public health sciences and in medicine, I have a lot to bring to this moment,” he commented, “real expertise on issues that are critical to the nation. Beyond my passion for health and wellness, I have a passion for justice.”

Dr. Webb also believes that serving in Congress is a way to help his patients. “I balance the work of direct patient care and patient advocacy in different spaces,” said the Spotsylvania County native. “Working in Congress is patient advocacy to me. It’s where I can be at my highest use to the people I take care of. It is different from direct patient care. I think this [unique] background that I have is needed in Congress.”

Dr. Webb has never held an elected office before, and he’s looking to get elected in a district that voted for President Trump in the past election. He knows challenges lie ahead.
 

A calling

The field of medicine called for Dr. Webb at an early age. He credits his family doctor, a Black man, for inspiring him. “With six kids in our family, we saw the doctor frequently. Dr. Yarboro was a young Black man just a few years out of residency. My mom had supreme confidence in him, and he made us feel at ease. So I wanted to be a doctor ever since I was 5 or 6 years old.”

Dr. Webb earned a bachelor’s degree from the University of Virginia in 2005. He entered medical school at Wake Forest University, Winston-Salem, N.C., the following year. Following his third year of medical training, he heeded another calling: He took time off to attend law school. He enrolled in Loyola University of Chicago School of Law and earned his juris doctorate in 2012.

The move may seem an unexpected turn. But Dr. Webb feels his law degree enhances his work. “I think that it’s because I’m so steeped in the legal resources that folks need to navigate. I think I am able to provide better care. ... It’s a complement and helpful to me professionally, whether it’s fighting with an insurance company or with a prescription drug company.”

After law school, Dr. Webb finished his medical training at Wake Forest and moved north, where he completed an internal medicine residency at New York–Presbyterian Hospital. Then came yet another twist in Dr. Webb’s unconventional career path: in 2016, he was selected by President Obama as a White House fellow. He spent the next 2 years in Washington, where he worked on Mr. Obama’s My Brother’s Keeper Task Force, an initiative that addresses opportunity gaps faced by boys and young men of color.

Adeze Enekwechi, MD, president of Impaq and associate professor at the George Washington University, Washington, worked with Dr. Webb at the White House. “This is the place where he will have the most impact. We’ve been talking and writing about health equity ever since our time [there]. Not everybody can speak that language. Being an African American male physician and an attorney can really help drive change by being the right person at the table.”
 

Why here? Why now?

Dr. Webb sees patients 2-3 days a week on alternating weeks and knows well the concerns of people who struggle with health. Now he’s ready to have those conversations on a larger platform. “As a Black physician, it’s about bringing that healer mindset to these problems. It’s not about just going there to brow beat people or add to that divisive nature in Congress. You acknowledge that the problems exist, and then bridge,” he said, hoping that bridging party divides can be a catalyst for healing.

Carla Boutin-Foster, MD, associate dean, office of diversity education and research at the State University of New York, Brooklyn, has mentored Dr. Webb since 2013. With his credentials, confidence, and persistence, she believes, he will be a great representative of the medical community in D.C. “You need someone who respects the Constitution. When policy needs to be developed, you need a healer, someone who understands the science of vaccines. This is something Cam has been groomed for. It’s something he has been living and practicing for years.”

The killing of George Floyd and the uprising that ensued has opened the dialogue about racial inequality in America. Health care is not immune to racial bias, and the effects are palatable. One survey conducted by the Larry A. Green Center, in collaboration with the Primary Care Collaborative and 3rd Conversation, found that more than 40% of clinicians say Mr. Floyd’s demise has become a topic of concern among patients of all demographics.

When it comes to racism, Dr. Webb understands that he plays a critical role in moving America forward. “We have so many voices that are powerful and important in the highest level of legislation. We have to use those voices to root out the injustices in our society, like in the Breonna Taylor case. We have to do so because that is how you achieve the American dream,” he said.

The social determinants of health – or “ZIP-code risk” – has been proven to influence health outcomes, yet few physicians screen for them during patient visits. For Dr. Webb, discussing things like housing security and interpersonal violence are critical to providing care.

One of Dr. Webb’s biggest supporters is his wife of 11 years, Leigh Ann Webb, MD, MBA, an emergency medicine physician and assistant professor of emergency medicine at UVA. “He is an effective leader and a consensus builder,” she said of her husband, with whom she has two children. “There has always been something very unique and special about him and the way he engages the world. We need more thoughtful, intelligent people like him to help our country move forward.”

In addition to being the director of health policy and equity at UVA this fall, Dr. Webb plans to teach a course at UVA centered around the social determinants of health called Place Matters. “The focus is on understanding how education and housing and food insecurity all come together to cause illness,” he said. “Health doesn’t happen in hospitals and clinics. It happens in the community.”

A version of this article originally appeared on Medscape.com.

On March 3 of this year, Bryant Cameron Webb, MD, JD, won two-thirds of the vote in Virginia’s Democratic primary race. In November, he’ll compete against Republican Bob Good to represent the state’s 5th Congressional District. If he succeeds, he will become the first Black physician ever elected to a seat in Congress.

Courtesy Dr. Bryant Cameron Webb

The political and social unrest across the United States in recent months has resulted in millions of people becoming more proactive: from sports arenas to the halls of Congress, the rally cry of Black Lives Matter has echoed like never before after the killing of George Floyd and Breonna Taylor at the hands of law enforcement. Dr. Webb, a practicing internist and professor at the University of Virginia, Charlottesville, is among many physicians joining the cause. If elected, he hopes to bring a unique perspective to Washington and advocate for racial equity to help combat systemic racist policies that result in health disparities.

“For me as a professor at UVA in both public health sciences and in medicine, I have a lot to bring to this moment,” he commented, “real expertise on issues that are critical to the nation. Beyond my passion for health and wellness, I have a passion for justice.”

Dr. Webb also believes that serving in Congress is a way to help his patients. “I balance the work of direct patient care and patient advocacy in different spaces,” said the Spotsylvania County native. “Working in Congress is patient advocacy to me. It’s where I can be at my highest use to the people I take care of. It is different from direct patient care. I think this [unique] background that I have is needed in Congress.”

Dr. Webb has never held an elected office before, and he’s looking to get elected in a district that voted for President Trump in the past election. He knows challenges lie ahead.
 

A calling

The field of medicine called for Dr. Webb at an early age. He credits his family doctor, a Black man, for inspiring him. “With six kids in our family, we saw the doctor frequently. Dr. Yarboro was a young Black man just a few years out of residency. My mom had supreme confidence in him, and he made us feel at ease. So I wanted to be a doctor ever since I was 5 or 6 years old.”

Dr. Webb earned a bachelor’s degree from the University of Virginia in 2005. He entered medical school at Wake Forest University, Winston-Salem, N.C., the following year. Following his third year of medical training, he heeded another calling: He took time off to attend law school. He enrolled in Loyola University of Chicago School of Law and earned his juris doctorate in 2012.

The move may seem an unexpected turn. But Dr. Webb feels his law degree enhances his work. “I think that it’s because I’m so steeped in the legal resources that folks need to navigate. I think I am able to provide better care. ... It’s a complement and helpful to me professionally, whether it’s fighting with an insurance company or with a prescription drug company.”

After law school, Dr. Webb finished his medical training at Wake Forest and moved north, where he completed an internal medicine residency at New York–Presbyterian Hospital. Then came yet another twist in Dr. Webb’s unconventional career path: in 2016, he was selected by President Obama as a White House fellow. He spent the next 2 years in Washington, where he worked on Mr. Obama’s My Brother’s Keeper Task Force, an initiative that addresses opportunity gaps faced by boys and young men of color.

Adeze Enekwechi, MD, president of Impaq and associate professor at the George Washington University, Washington, worked with Dr. Webb at the White House. “This is the place where he will have the most impact. We’ve been talking and writing about health equity ever since our time [there]. Not everybody can speak that language. Being an African American male physician and an attorney can really help drive change by being the right person at the table.”
 

Why here? Why now?

Dr. Webb sees patients 2-3 days a week on alternating weeks and knows well the concerns of people who struggle with health. Now he’s ready to have those conversations on a larger platform. “As a Black physician, it’s about bringing that healer mindset to these problems. It’s not about just going there to brow beat people or add to that divisive nature in Congress. You acknowledge that the problems exist, and then bridge,” he said, hoping that bridging party divides can be a catalyst for healing.

Carla Boutin-Foster, MD, associate dean, office of diversity education and research at the State University of New York, Brooklyn, has mentored Dr. Webb since 2013. With his credentials, confidence, and persistence, she believes, he will be a great representative of the medical community in D.C. “You need someone who respects the Constitution. When policy needs to be developed, you need a healer, someone who understands the science of vaccines. This is something Cam has been groomed for. It’s something he has been living and practicing for years.”

The killing of George Floyd and the uprising that ensued has opened the dialogue about racial inequality in America. Health care is not immune to racial bias, and the effects are palatable. One survey conducted by the Larry A. Green Center, in collaboration with the Primary Care Collaborative and 3rd Conversation, found that more than 40% of clinicians say Mr. Floyd’s demise has become a topic of concern among patients of all demographics.

When it comes to racism, Dr. Webb understands that he plays a critical role in moving America forward. “We have so many voices that are powerful and important in the highest level of legislation. We have to use those voices to root out the injustices in our society, like in the Breonna Taylor case. We have to do so because that is how you achieve the American dream,” he said.

The social determinants of health – or “ZIP-code risk” – has been proven to influence health outcomes, yet few physicians screen for them during patient visits. For Dr. Webb, discussing things like housing security and interpersonal violence are critical to providing care.

One of Dr. Webb’s biggest supporters is his wife of 11 years, Leigh Ann Webb, MD, MBA, an emergency medicine physician and assistant professor of emergency medicine at UVA. “He is an effective leader and a consensus builder,” she said of her husband, with whom she has two children. “There has always been something very unique and special about him and the way he engages the world. We need more thoughtful, intelligent people like him to help our country move forward.”

In addition to being the director of health policy and equity at UVA this fall, Dr. Webb plans to teach a course at UVA centered around the social determinants of health called Place Matters. “The focus is on understanding how education and housing and food insecurity all come together to cause illness,” he said. “Health doesn’t happen in hospitals and clinics. It happens in the community.”

A version of this article originally appeared on Medscape.com.

On March 3 of this year, Bryant Cameron Webb, MD, JD, won two-thirds of the vote in Virginia’s Democratic primary race. In November, he’ll compete against Republican Bob Good to represent the state’s 5th Congressional District. If he succeeds, he will become the first Black physician ever elected to a seat in Congress.

Courtesy Dr. Bryant Cameron Webb

The political and social unrest across the United States in recent months has resulted in millions of people becoming more proactive: from sports arenas to the halls of Congress, the rally cry of Black Lives Matter has echoed like never before after the killing of George Floyd and Breonna Taylor at the hands of law enforcement. Dr. Webb, a practicing internist and professor at the University of Virginia, Charlottesville, is among many physicians joining the cause. If elected, he hopes to bring a unique perspective to Washington and advocate for racial equity to help combat systemic racist policies that result in health disparities.

“For me as a professor at UVA in both public health sciences and in medicine, I have a lot to bring to this moment,” he commented, “real expertise on issues that are critical to the nation. Beyond my passion for health and wellness, I have a passion for justice.”

Dr. Webb also believes that serving in Congress is a way to help his patients. “I balance the work of direct patient care and patient advocacy in different spaces,” said the Spotsylvania County native. “Working in Congress is patient advocacy to me. It’s where I can be at my highest use to the people I take care of. It is different from direct patient care. I think this [unique] background that I have is needed in Congress.”

Dr. Webb has never held an elected office before, and he’s looking to get elected in a district that voted for President Trump in the past election. He knows challenges lie ahead.
 

A calling

The field of medicine called for Dr. Webb at an early age. He credits his family doctor, a Black man, for inspiring him. “With six kids in our family, we saw the doctor frequently. Dr. Yarboro was a young Black man just a few years out of residency. My mom had supreme confidence in him, and he made us feel at ease. So I wanted to be a doctor ever since I was 5 or 6 years old.”

Dr. Webb earned a bachelor’s degree from the University of Virginia in 2005. He entered medical school at Wake Forest University, Winston-Salem, N.C., the following year. Following his third year of medical training, he heeded another calling: He took time off to attend law school. He enrolled in Loyola University of Chicago School of Law and earned his juris doctorate in 2012.

The move may seem an unexpected turn. But Dr. Webb feels his law degree enhances his work. “I think that it’s because I’m so steeped in the legal resources that folks need to navigate. I think I am able to provide better care. ... It’s a complement and helpful to me professionally, whether it’s fighting with an insurance company or with a prescription drug company.”

After law school, Dr. Webb finished his medical training at Wake Forest and moved north, where he completed an internal medicine residency at New York–Presbyterian Hospital. Then came yet another twist in Dr. Webb’s unconventional career path: in 2016, he was selected by President Obama as a White House fellow. He spent the next 2 years in Washington, where he worked on Mr. Obama’s My Brother’s Keeper Task Force, an initiative that addresses opportunity gaps faced by boys and young men of color.

Adeze Enekwechi, MD, president of Impaq and associate professor at the George Washington University, Washington, worked with Dr. Webb at the White House. “This is the place where he will have the most impact. We’ve been talking and writing about health equity ever since our time [there]. Not everybody can speak that language. Being an African American male physician and an attorney can really help drive change by being the right person at the table.”
 

Why here? Why now?

Dr. Webb sees patients 2-3 days a week on alternating weeks and knows well the concerns of people who struggle with health. Now he’s ready to have those conversations on a larger platform. “As a Black physician, it’s about bringing that healer mindset to these problems. It’s not about just going there to brow beat people or add to that divisive nature in Congress. You acknowledge that the problems exist, and then bridge,” he said, hoping that bridging party divides can be a catalyst for healing.

Carla Boutin-Foster, MD, associate dean, office of diversity education and research at the State University of New York, Brooklyn, has mentored Dr. Webb since 2013. With his credentials, confidence, and persistence, she believes, he will be a great representative of the medical community in D.C. “You need someone who respects the Constitution. When policy needs to be developed, you need a healer, someone who understands the science of vaccines. This is something Cam has been groomed for. It’s something he has been living and practicing for years.”

The killing of George Floyd and the uprising that ensued has opened the dialogue about racial inequality in America. Health care is not immune to racial bias, and the effects are palatable. One survey conducted by the Larry A. Green Center, in collaboration with the Primary Care Collaborative and 3rd Conversation, found that more than 40% of clinicians say Mr. Floyd’s demise has become a topic of concern among patients of all demographics.

When it comes to racism, Dr. Webb understands that he plays a critical role in moving America forward. “We have so many voices that are powerful and important in the highest level of legislation. We have to use those voices to root out the injustices in our society, like in the Breonna Taylor case. We have to do so because that is how you achieve the American dream,” he said.

The social determinants of health – or “ZIP-code risk” – has been proven to influence health outcomes, yet few physicians screen for them during patient visits. For Dr. Webb, discussing things like housing security and interpersonal violence are critical to providing care.

One of Dr. Webb’s biggest supporters is his wife of 11 years, Leigh Ann Webb, MD, MBA, an emergency medicine physician and assistant professor of emergency medicine at UVA. “He is an effective leader and a consensus builder,” she said of her husband, with whom she has two children. “There has always been something very unique and special about him and the way he engages the world. We need more thoughtful, intelligent people like him to help our country move forward.”

In addition to being the director of health policy and equity at UVA this fall, Dr. Webb plans to teach a course at UVA centered around the social determinants of health called Place Matters. “The focus is on understanding how education and housing and food insecurity all come together to cause illness,” he said. “Health doesn’t happen in hospitals and clinics. It happens in the community.”

A version of this article originally appeared on Medscape.com.

On Feb. 27, 2018, I got an email from the Heritage Foundation that alerted me to a news conference that afternoon held by Republican attorneys general of Texas and other states. It was referred to only as a “discussion about the Affordable Care Act lawsuit.”

Supreme Court of the United States

I sent the following note to my editor: “I’m off to the Hill anyway. I could stop by this. You never know what it might morph into.”

Few people took that case very seriously – barely a handful of reporters attended the news conference. But it has now “morphed into” the latest existential threat to the Affordable Care Act, scheduled for oral arguments at the Supreme Court a week after the general election in November. And with the death of Justice Ruth Bader Ginsburg on Friday, that case could well morph into the threat that brings down the law in its entirety.

Democrats are raising alarms about the future of the law without Ms. Ginsburg. House Speaker Nancy Pelosi, speaking on ABC’s “This Week” Sunday morning, said that part of the strategy by President Trump and Senate Republicans to quickly fill her seat was to help undermine the ACA.

“The president is rushing to make some kind of a decision because … Nov. 10 is when the arguments begin on the Affordable Care Act,” she said. “He doesn’t want to crush the virus. He wants to crush the Affordable Care Act.”

Ms. Ginsburg’s death could throw an already chaotic general election campaign during a pandemic into even more turmoil. But in the longer term, her absence from the bench could accelerate a trend underway to get cases to the Supreme Court toward invalidating the ACA and rolling back reproductive freedoms for women.

Let’s take them one at a time.
 

The ACA under fire – again

The GOP attorneys general argued in February 2018 that the Republican-sponsored tax cut bill Congress passed two months earlier had rendered the ACA unconstitutional by reducing to zero the ACA’s penalty for not having insurance. They based their argument on Chief Justice John Roberts’ 2012 conclusion that the ACA was valid, interpreting that penalty as a constitutionally appropriate tax.

Most legal scholars, including several who challenged the law before the Supreme Court in 2012 and again in 2015, find the argument that the entire law should fall to be unconvincing. “If courts invalidate an entire law merely because Congress eliminates or revises one part, as happened here, that may well inhibit necessary reform of federal legislation in the future by turning it into an ‘all or nothing’ proposition,” wrote a group of conservative and liberal law professors in a brief filed in the case.

Still, in December 2018, U.S. District Judge Reed O’Connor in Texas accepted the GOP argument and declared the law unconstitutional. In December 2019, a three-judge 5th Circuit appeals court panel in New Orleans agreed that without the penalty the requirement to buy insurance is unconstitutional. But it sent the case back to Mr. O’Connor to suggest that perhaps the entire law need not fall.

Not wanting to wait the months or years that reconsideration would take, Democratic attorneys general defending the ACA asked the Supreme Court to hear the case this year. (Democrats are defending the law in court because the Trump administration decided to support the GOP attorneys general’s case.) The court agreed to take the case but scheduled arguments for the week after the November election.

While the fate of the ACA was and is a live political issue, few legal observers were terribly worried about the legal outcome of the case, now known as Texas v. California, if only because the case seemed much weaker than the 2012 and 2015 cases in which Mr. Roberts joined the court’s four liberals. In the 2015 case, which challenged the validity of federal tax subsidies helping millions of Americans buy health insurance on the ACA’s marketplaces, both Mr. Roberts and now-retired Justice Anthony Kennedy voted to uphold the law.

But without Ms. Ginsburg, the case could wind up in a 4-4 tie, even if Mr. Roberts supports the law’s constitutionality. That could let the lower-court ruling stand, although it would not be binding on other courts outside of the 5th Circuit. The court could also put off the arguments or, if the Republican Senate replaces Ms. Ginsburg with another conservative justice before arguments are heard, Republicans could secure a 5-4 ruling against the law. Some court observers argue that Justice Brett Kavanaugh has not favored invalidating an entire statute if only part of it is flawed and might not approve overturning the ACA. Still, what started out as an effort to energize Republican voters for the 2018 midterms after Congress failed to “repeal and replace” the health law in 2017 could end up throwing the nation’s entire health system into chaos.

At least 20 million Americans – and likely many more who sought coverage since the start of the coronavirus pandemic — who buy insurance through the ACA marketplaces or have Medicaid through the law’s expansion could lose coverage right away. Many millions more would lose the law’s popular protections guaranteeing coverage for people with preexisting health conditions, including those who have had COVID-19.

Adult children under age 26 years would no longer be guaranteed the right to remain on their parents’ health plans, and Medicare patients would lose enhanced prescription drug coverage. Women would lose guaranteed access to birth control at no out-of-pocket cost.

But a sudden elimination would affect more than just health care consumers. Insurance companies, drug companies, hospitals, and doctors have all changed the way they do business because of incentives and penalties in the health law. If it’s struck down, many of the “rules of the road” would literally be wiped away, including billing and payment mechanisms.

A new Democratic president could not drop the lawsuit because the Trump administration is not the plaintiff (the GOP attorneys general are). But a Democratic Congress and president could in theory make the entire issue go away by reinstating the penalty for failure to have insurance, even at a minimal amount. However, as far as the health law goes, for now, nothing is a sure thing.

As Nicholas Bagley, a law professor at the University of Michigan, Ann Arbor, who specializes in health issues, tweeted: “Among other things, the Affordable Care Act now dangles from a thread.”
 

Reproductive rights

A woman’s right to abortion – and even to birth control – also has been hanging by a thread at the high court for more than a decade. This past term, Mr. Roberts joined the liberals to invalidate a Louisiana law that would have closed most of the state’s abortion clinics, but he made it clear it was not a vote for abortion rights. The Louisiana law was too similar to a Texas law the court (without his vote) struck down in 2016, Mr. Roberts argued.

Ms. Ginsburg had been a stalwart supporter of reproductive freedom for women. In her nearly 3 decades on the court, she always voted with backers of abortion rights and birth control and led the dissenters in 2007 when the court upheld a federal ban on a specific abortion procedure.

Adding a justice opposed to abortion to the bench – which is what Trump has promised his supporters – would almost certainly tilt the court in favor of far more dramatic restrictions on the procedure and possibly an overturn of the landmark 1973 ruling Roe v. Wade.

But not only is abortion on the line: The court in recent years has repeatedly ruled that employers with religious objections can refuse to provide contraception.

And waiting in the lower-court pipeline are cases involving federal funding of Planned Parenthood in both the Medicaid and federal family planning programs, and the ability of individual health workers to decline to participate in abortion and other procedures.

For Ms. Ginsburg, those issues came down to a clear question of a woman’s guarantee of equal status under the law.

“Women, it is now acknowledged, have the talent, capacity, and right ‘to participate equally in the economic and social life of the Nation,’ ” she wrote in her dissent in that 2007 abortion case. “Their ability to realize their full potential, the Court recognized, is intimately connected to ‘their ability to control their reproductive lives.’ ”

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.

On Feb. 27, 2018, I got an email from the Heritage Foundation that alerted me to a news conference that afternoon held by Republican attorneys general of Texas and other states. It was referred to only as a “discussion about the Affordable Care Act lawsuit.”

Supreme Court of the United States

I sent the following note to my editor: “I’m off to the Hill anyway. I could stop by this. You never know what it might morph into.”

Few people took that case very seriously – barely a handful of reporters attended the news conference. But it has now “morphed into” the latest existential threat to the Affordable Care Act, scheduled for oral arguments at the Supreme Court a week after the general election in November. And with the death of Justice Ruth Bader Ginsburg on Friday, that case could well morph into the threat that brings down the law in its entirety.

Democrats are raising alarms about the future of the law without Ms. Ginsburg. House Speaker Nancy Pelosi, speaking on ABC’s “This Week” Sunday morning, said that part of the strategy by President Trump and Senate Republicans to quickly fill her seat was to help undermine the ACA.

“The president is rushing to make some kind of a decision because … Nov. 10 is when the arguments begin on the Affordable Care Act,” she said. “He doesn’t want to crush the virus. He wants to crush the Affordable Care Act.”

Ms. Ginsburg’s death could throw an already chaotic general election campaign during a pandemic into even more turmoil. But in the longer term, her absence from the bench could accelerate a trend underway to get cases to the Supreme Court toward invalidating the ACA and rolling back reproductive freedoms for women.

Let’s take them one at a time.
 

The ACA under fire – again

The GOP attorneys general argued in February 2018 that the Republican-sponsored tax cut bill Congress passed two months earlier had rendered the ACA unconstitutional by reducing to zero the ACA’s penalty for not having insurance. They based their argument on Chief Justice John Roberts’ 2012 conclusion that the ACA was valid, interpreting that penalty as a constitutionally appropriate tax.

Most legal scholars, including several who challenged the law before the Supreme Court in 2012 and again in 2015, find the argument that the entire law should fall to be unconvincing. “If courts invalidate an entire law merely because Congress eliminates or revises one part, as happened here, that may well inhibit necessary reform of federal legislation in the future by turning it into an ‘all or nothing’ proposition,” wrote a group of conservative and liberal law professors in a brief filed in the case.

Still, in December 2018, U.S. District Judge Reed O’Connor in Texas accepted the GOP argument and declared the law unconstitutional. In December 2019, a three-judge 5th Circuit appeals court panel in New Orleans agreed that without the penalty the requirement to buy insurance is unconstitutional. But it sent the case back to Mr. O’Connor to suggest that perhaps the entire law need not fall.

Not wanting to wait the months or years that reconsideration would take, Democratic attorneys general defending the ACA asked the Supreme Court to hear the case this year. (Democrats are defending the law in court because the Trump administration decided to support the GOP attorneys general’s case.) The court agreed to take the case but scheduled arguments for the week after the November election.

While the fate of the ACA was and is a live political issue, few legal observers were terribly worried about the legal outcome of the case, now known as Texas v. California, if only because the case seemed much weaker than the 2012 and 2015 cases in which Mr. Roberts joined the court’s four liberals. In the 2015 case, which challenged the validity of federal tax subsidies helping millions of Americans buy health insurance on the ACA’s marketplaces, both Mr. Roberts and now-retired Justice Anthony Kennedy voted to uphold the law.

But without Ms. Ginsburg, the case could wind up in a 4-4 tie, even if Mr. Roberts supports the law’s constitutionality. That could let the lower-court ruling stand, although it would not be binding on other courts outside of the 5th Circuit. The court could also put off the arguments or, if the Republican Senate replaces Ms. Ginsburg with another conservative justice before arguments are heard, Republicans could secure a 5-4 ruling against the law. Some court observers argue that Justice Brett Kavanaugh has not favored invalidating an entire statute if only part of it is flawed and might not approve overturning the ACA. Still, what started out as an effort to energize Republican voters for the 2018 midterms after Congress failed to “repeal and replace” the health law in 2017 could end up throwing the nation’s entire health system into chaos.

At least 20 million Americans – and likely many more who sought coverage since the start of the coronavirus pandemic — who buy insurance through the ACA marketplaces or have Medicaid through the law’s expansion could lose coverage right away. Many millions more would lose the law’s popular protections guaranteeing coverage for people with preexisting health conditions, including those who have had COVID-19.

Adult children under age 26 years would no longer be guaranteed the right to remain on their parents’ health plans, and Medicare patients would lose enhanced prescription drug coverage. Women would lose guaranteed access to birth control at no out-of-pocket cost.

But a sudden elimination would affect more than just health care consumers. Insurance companies, drug companies, hospitals, and doctors have all changed the way they do business because of incentives and penalties in the health law. If it’s struck down, many of the “rules of the road” would literally be wiped away, including billing and payment mechanisms.

A new Democratic president could not drop the lawsuit because the Trump administration is not the plaintiff (the GOP attorneys general are). But a Democratic Congress and president could in theory make the entire issue go away by reinstating the penalty for failure to have insurance, even at a minimal amount. However, as far as the health law goes, for now, nothing is a sure thing.

As Nicholas Bagley, a law professor at the University of Michigan, Ann Arbor, who specializes in health issues, tweeted: “Among other things, the Affordable Care Act now dangles from a thread.”
 

Reproductive rights

A woman’s right to abortion – and even to birth control – also has been hanging by a thread at the high court for more than a decade. This past term, Mr. Roberts joined the liberals to invalidate a Louisiana law that would have closed most of the state’s abortion clinics, but he made it clear it was not a vote for abortion rights. The Louisiana law was too similar to a Texas law the court (without his vote) struck down in 2016, Mr. Roberts argued.

Ms. Ginsburg had been a stalwart supporter of reproductive freedom for women. In her nearly 3 decades on the court, she always voted with backers of abortion rights and birth control and led the dissenters in 2007 when the court upheld a federal ban on a specific abortion procedure.

Adding a justice opposed to abortion to the bench – which is what Trump has promised his supporters – would almost certainly tilt the court in favor of far more dramatic restrictions on the procedure and possibly an overturn of the landmark 1973 ruling Roe v. Wade.

But not only is abortion on the line: The court in recent years has repeatedly ruled that employers with religious objections can refuse to provide contraception.

And waiting in the lower-court pipeline are cases involving federal funding of Planned Parenthood in both the Medicaid and federal family planning programs, and the ability of individual health workers to decline to participate in abortion and other procedures.

For Ms. Ginsburg, those issues came down to a clear question of a woman’s guarantee of equal status under the law.

“Women, it is now acknowledged, have the talent, capacity, and right ‘to participate equally in the economic and social life of the Nation,’ ” she wrote in her dissent in that 2007 abortion case. “Their ability to realize their full potential, the Court recognized, is intimately connected to ‘their ability to control their reproductive lives.’ ”

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.

On Feb. 27, 2018, I got an email from the Heritage Foundation that alerted me to a news conference that afternoon held by Republican attorneys general of Texas and other states. It was referred to only as a “discussion about the Affordable Care Act lawsuit.”

Supreme Court of the United States

I sent the following note to my editor: “I’m off to the Hill anyway. I could stop by this. You never know what it might morph into.”

Few people took that case very seriously – barely a handful of reporters attended the news conference. But it has now “morphed into” the latest existential threat to the Affordable Care Act, scheduled for oral arguments at the Supreme Court a week after the general election in November. And with the death of Justice Ruth Bader Ginsburg on Friday, that case could well morph into the threat that brings down the law in its entirety.

Democrats are raising alarms about the future of the law without Ms. Ginsburg. House Speaker Nancy Pelosi, speaking on ABC’s “This Week” Sunday morning, said that part of the strategy by President Trump and Senate Republicans to quickly fill her seat was to help undermine the ACA.

“The president is rushing to make some kind of a decision because … Nov. 10 is when the arguments begin on the Affordable Care Act,” she said. “He doesn’t want to crush the virus. He wants to crush the Affordable Care Act.”

Ms. Ginsburg’s death could throw an already chaotic general election campaign during a pandemic into even more turmoil. But in the longer term, her absence from the bench could accelerate a trend underway to get cases to the Supreme Court toward invalidating the ACA and rolling back reproductive freedoms for women.

Let’s take them one at a time.
 

The ACA under fire – again

The GOP attorneys general argued in February 2018 that the Republican-sponsored tax cut bill Congress passed two months earlier had rendered the ACA unconstitutional by reducing to zero the ACA’s penalty for not having insurance. They based their argument on Chief Justice John Roberts’ 2012 conclusion that the ACA was valid, interpreting that penalty as a constitutionally appropriate tax.

Most legal scholars, including several who challenged the law before the Supreme Court in 2012 and again in 2015, find the argument that the entire law should fall to be unconvincing. “If courts invalidate an entire law merely because Congress eliminates or revises one part, as happened here, that may well inhibit necessary reform of federal legislation in the future by turning it into an ‘all or nothing’ proposition,” wrote a group of conservative and liberal law professors in a brief filed in the case.

Still, in December 2018, U.S. District Judge Reed O’Connor in Texas accepted the GOP argument and declared the law unconstitutional. In December 2019, a three-judge 5th Circuit appeals court panel in New Orleans agreed that without the penalty the requirement to buy insurance is unconstitutional. But it sent the case back to Mr. O’Connor to suggest that perhaps the entire law need not fall.

Not wanting to wait the months or years that reconsideration would take, Democratic attorneys general defending the ACA asked the Supreme Court to hear the case this year. (Democrats are defending the law in court because the Trump administration decided to support the GOP attorneys general’s case.) The court agreed to take the case but scheduled arguments for the week after the November election.

While the fate of the ACA was and is a live political issue, few legal observers were terribly worried about the legal outcome of the case, now known as Texas v. California, if only because the case seemed much weaker than the 2012 and 2015 cases in which Mr. Roberts joined the court’s four liberals. In the 2015 case, which challenged the validity of federal tax subsidies helping millions of Americans buy health insurance on the ACA’s marketplaces, both Mr. Roberts and now-retired Justice Anthony Kennedy voted to uphold the law.

But without Ms. Ginsburg, the case could wind up in a 4-4 tie, even if Mr. Roberts supports the law’s constitutionality. That could let the lower-court ruling stand, although it would not be binding on other courts outside of the 5th Circuit. The court could also put off the arguments or, if the Republican Senate replaces Ms. Ginsburg with another conservative justice before arguments are heard, Republicans could secure a 5-4 ruling against the law. Some court observers argue that Justice Brett Kavanaugh has not favored invalidating an entire statute if only part of it is flawed and might not approve overturning the ACA. Still, what started out as an effort to energize Republican voters for the 2018 midterms after Congress failed to “repeal and replace” the health law in 2017 could end up throwing the nation’s entire health system into chaos.

At least 20 million Americans – and likely many more who sought coverage since the start of the coronavirus pandemic — who buy insurance through the ACA marketplaces or have Medicaid through the law’s expansion could lose coverage right away. Many millions more would lose the law’s popular protections guaranteeing coverage for people with preexisting health conditions, including those who have had COVID-19.

Adult children under age 26 years would no longer be guaranteed the right to remain on their parents’ health plans, and Medicare patients would lose enhanced prescription drug coverage. Women would lose guaranteed access to birth control at no out-of-pocket cost.

But a sudden elimination would affect more than just health care consumers. Insurance companies, drug companies, hospitals, and doctors have all changed the way they do business because of incentives and penalties in the health law. If it’s struck down, many of the “rules of the road” would literally be wiped away, including billing and payment mechanisms.

A new Democratic president could not drop the lawsuit because the Trump administration is not the plaintiff (the GOP attorneys general are). But a Democratic Congress and president could in theory make the entire issue go away by reinstating the penalty for failure to have insurance, even at a minimal amount. However, as far as the health law goes, for now, nothing is a sure thing.

As Nicholas Bagley, a law professor at the University of Michigan, Ann Arbor, who specializes in health issues, tweeted: “Among other things, the Affordable Care Act now dangles from a thread.”
 

Reproductive rights

A woman’s right to abortion – and even to birth control – also has been hanging by a thread at the high court for more than a decade. This past term, Mr. Roberts joined the liberals to invalidate a Louisiana law that would have closed most of the state’s abortion clinics, but he made it clear it was not a vote for abortion rights. The Louisiana law was too similar to a Texas law the court (without his vote) struck down in 2016, Mr. Roberts argued.

Ms. Ginsburg had been a stalwart supporter of reproductive freedom for women. In her nearly 3 decades on the court, she always voted with backers of abortion rights and birth control and led the dissenters in 2007 when the court upheld a federal ban on a specific abortion procedure.

Adding a justice opposed to abortion to the bench – which is what Trump has promised his supporters – would almost certainly tilt the court in favor of far more dramatic restrictions on the procedure and possibly an overturn of the landmark 1973 ruling Roe v. Wade.

But not only is abortion on the line: The court in recent years has repeatedly ruled that employers with religious objections can refuse to provide contraception.

And waiting in the lower-court pipeline are cases involving federal funding of Planned Parenthood in both the Medicaid and federal family planning programs, and the ability of individual health workers to decline to participate in abortion and other procedures.

For Ms. Ginsburg, those issues came down to a clear question of a woman’s guarantee of equal status under the law.

“Women, it is now acknowledged, have the talent, capacity, and right ‘to participate equally in the economic and social life of the Nation,’ ” she wrote in her dissent in that 2007 abortion case. “Their ability to realize their full potential, the Court recognized, is intimately connected to ‘their ability to control their reproductive lives.’ ”

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.

The American College of Physicians and the American Academy of Family Physicians recently authored a guideline regarding the treatment of acute, non–low back, musculoskeletal injuries in adults in the outpatient setting. While their recommendations mirror what most clinicians currently do in their medical practices, they don’t address the multiple components of pain that include sensory, emotional, cognitive, and behavioral processes in addition to the physical discomfort.

According to the authors, musculoskeletal injuries result in more than 65 million medical visits a year with an annual estimated cost of $176.1 billion in 2010.

In summary, the guideline, which was published in the Annals of Internal Medicine, is based on a review of the best available evidence. The research reviewed by the guideline authors showed favorable results with topical NSAIDs, oral NSAIDs, oral acetaminophen, acupressure, and transcutaneous electrical nerve stimulation in reducing pain and/or improving function. The guideline authors “recommend that clinicians treat patients with acute pain from non–low back, musculoskeletal injuries with topical [NSAIDs] with or without gel as first-line therapy to reduce or relieve symptoms, including pain; improve physical function; and improve the patient’s treatment satisfaction (Grade: strong recommendation; moderate-certainty evidence).” Additionally, the guideline recommends against treating acute pain from non–low back, musculoskeletal injuries with opioids, including tramadol (Grade: conditional recommendation; low-certainty evidence).

The guideline also mentions improving function in relation to decreasing pain, which can be multifactorial.

Treating pain requires a multipronged approach. Many patients require more than one therapy to treat their pain, such as NSAIDs plus physical therapy. The ACP and AAFP did not make any recommendations for combination therapies in this guideline.

When physical therapy is needed

Nonopioid pain medications can do a great job of reducing a patient’s physical discomfort, which the evidence for these guideline demonstrates. However, much of the dysfunction caused by musculoskeletal injuries will not improve by reducing the pain alone. Physical therapy, exercise, and mobilization did not show a significant benefit in reducing symptoms in the systematic review and meta-analysis of randomized trials that appeared alongside the guideline. The type of pain, however, was not evaluated in relation to the effectiveness of these treatments. A fractured bone, for example, may heal just fine with casting and pain management, without the need for additional therapies. However, the muscles surrounding that bone can atrophy and become weak from not being used. Physical therapy may be needed to restrengthen those muscles. Therefore, a multifaceted approach is often needed, even for uncomplicated conditions.

Mental pain often comes with physical pain, and this is an aspect of care that is often neglected. It can be quite devastating for patients to not be able to do the things they were previously able to do. While this is easily recognized in professional athletes when they can no longer play, it is not so readily apparent with a mother who is just trying to take care of her kids. As doctors, especially those of us in family medicine, we should be addressing more than just physical pain.

Patients can also do activities that exacerbate their pain. As doctors, we need to be asking questions that help us determine whether a patient’s pain is caused by a particular action. Maybe that increase in shoulder pain is due to nothing more than lifting something heavy rather than a failure in a prescribed medication. Pain diaries are helpful, and clinicians don’t use them often enough.
 

How pain affects mental health

Acute injuries can also lead to disability. Many patients become quite distressed about being unable to work. They often need Famiy & Medical Leave Act forms filled out, and this task usually falls to the primary care doctor. In addition to assessing the pain, we need to be evaluating, at each visit, a patient’s level of functioning and their ability to do their job.

Every patient responds to pain differently, and it is important to evaluate patients’ mindsets regarding theirs. A patient may be in severe pain and may try to ignore it for a variety of reasons. A patient may “catastrophize” their pain, believing only the worst outcome will happen to them. Helping patients set appropriate expectations and having a positive mindset can help.

Overall, the new recommendations are a great tool as a guideline, but they are not complete enough to be the only ones used in managing acute, non–low back, musculoskeletal pain in adults.

They are very important for clinicians who may be prescribing opioid medications for patients with this type of pain. Amid an opioid crisis, it is the responsibility of every doctor to prescribe these medications appropriately. The evidence clearly shows they provide little benefit and place patients at risk of addiction.

We should all be following these recommendations as the baseline of care for acute pain. However, we need to delve deeper and manage all the components involved. We would be ignoring very real suffering in our patients if we limited our focus to only the physical discomfort.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Rutgers RWJ Medical School.

SOURCE: Ann Intern Med. 2020 Aug 18. doi: 10.7326/M19-3602.

The American College of Physicians and the American Academy of Family Physicians recently authored a guideline regarding the treatment of acute, non–low back, musculoskeletal injuries in adults in the outpatient setting. While their recommendations mirror what most clinicians currently do in their medical practices, they don’t address the multiple components of pain that include sensory, emotional, cognitive, and behavioral processes in addition to the physical discomfort.

According to the authors, musculoskeletal injuries result in more than 65 million medical visits a year with an annual estimated cost of $176.1 billion in 2010.

In summary, the guideline, which was published in the Annals of Internal Medicine, is based on a review of the best available evidence. The research reviewed by the guideline authors showed favorable results with topical NSAIDs, oral NSAIDs, oral acetaminophen, acupressure, and transcutaneous electrical nerve stimulation in reducing pain and/or improving function. The guideline authors “recommend that clinicians treat patients with acute pain from non–low back, musculoskeletal injuries with topical [NSAIDs] with or without gel as first-line therapy to reduce or relieve symptoms, including pain; improve physical function; and improve the patient’s treatment satisfaction (Grade: strong recommendation; moderate-certainty evidence).” Additionally, the guideline recommends against treating acute pain from non–low back, musculoskeletal injuries with opioids, including tramadol (Grade: conditional recommendation; low-certainty evidence).

The guideline also mentions improving function in relation to decreasing pain, which can be multifactorial.

Treating pain requires a multipronged approach. Many patients require more than one therapy to treat their pain, such as NSAIDs plus physical therapy. The ACP and AAFP did not make any recommendations for combination therapies in this guideline.

When physical therapy is needed

Nonopioid pain medications can do a great job of reducing a patient’s physical discomfort, which the evidence for these guideline demonstrates. However, much of the dysfunction caused by musculoskeletal injuries will not improve by reducing the pain alone. Physical therapy, exercise, and mobilization did not show a significant benefit in reducing symptoms in the systematic review and meta-analysis of randomized trials that appeared alongside the guideline. The type of pain, however, was not evaluated in relation to the effectiveness of these treatments. A fractured bone, for example, may heal just fine with casting and pain management, without the need for additional therapies. However, the muscles surrounding that bone can atrophy and become weak from not being used. Physical therapy may be needed to restrengthen those muscles. Therefore, a multifaceted approach is often needed, even for uncomplicated conditions.

Mental pain often comes with physical pain, and this is an aspect of care that is often neglected. It can be quite devastating for patients to not be able to do the things they were previously able to do. While this is easily recognized in professional athletes when they can no longer play, it is not so readily apparent with a mother who is just trying to take care of her kids. As doctors, especially those of us in family medicine, we should be addressing more than just physical pain.

Patients can also do activities that exacerbate their pain. As doctors, we need to be asking questions that help us determine whether a patient’s pain is caused by a particular action. Maybe that increase in shoulder pain is due to nothing more than lifting something heavy rather than a failure in a prescribed medication. Pain diaries are helpful, and clinicians don’t use them often enough.
 

How pain affects mental health

Acute injuries can also lead to disability. Many patients become quite distressed about being unable to work. They often need Famiy & Medical Leave Act forms filled out, and this task usually falls to the primary care doctor. In addition to assessing the pain, we need to be evaluating, at each visit, a patient’s level of functioning and their ability to do their job.

Every patient responds to pain differently, and it is important to evaluate patients’ mindsets regarding theirs. A patient may be in severe pain and may try to ignore it for a variety of reasons. A patient may “catastrophize” their pain, believing only the worst outcome will happen to them. Helping patients set appropriate expectations and having a positive mindset can help.

Overall, the new recommendations are a great tool as a guideline, but they are not complete enough to be the only ones used in managing acute, non–low back, musculoskeletal pain in adults.

They are very important for clinicians who may be prescribing opioid medications for patients with this type of pain. Amid an opioid crisis, it is the responsibility of every doctor to prescribe these medications appropriately. The evidence clearly shows they provide little benefit and place patients at risk of addiction.

We should all be following these recommendations as the baseline of care for acute pain. However, we need to delve deeper and manage all the components involved. We would be ignoring very real suffering in our patients if we limited our focus to only the physical discomfort.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Rutgers RWJ Medical School.

SOURCE: Ann Intern Med. 2020 Aug 18. doi: 10.7326/M19-3602.

The American College of Physicians and the American Academy of Family Physicians recently authored a guideline regarding the treatment of acute, non–low back, musculoskeletal injuries in adults in the outpatient setting. While their recommendations mirror what most clinicians currently do in their medical practices, they don’t address the multiple components of pain that include sensory, emotional, cognitive, and behavioral processes in addition to the physical discomfort.

According to the authors, musculoskeletal injuries result in more than 65 million medical visits a year with an annual estimated cost of $176.1 billion in 2010.

In summary, the guideline, which was published in the Annals of Internal Medicine, is based on a review of the best available evidence. The research reviewed by the guideline authors showed favorable results with topical NSAIDs, oral NSAIDs, oral acetaminophen, acupressure, and transcutaneous electrical nerve stimulation in reducing pain and/or improving function. The guideline authors “recommend that clinicians treat patients with acute pain from non–low back, musculoskeletal injuries with topical [NSAIDs] with or without gel as first-line therapy to reduce or relieve symptoms, including pain; improve physical function; and improve the patient’s treatment satisfaction (Grade: strong recommendation; moderate-certainty evidence).” Additionally, the guideline recommends against treating acute pain from non–low back, musculoskeletal injuries with opioids, including tramadol (Grade: conditional recommendation; low-certainty evidence).

The guideline also mentions improving function in relation to decreasing pain, which can be multifactorial.

Treating pain requires a multipronged approach. Many patients require more than one therapy to treat their pain, such as NSAIDs plus physical therapy. The ACP and AAFP did not make any recommendations for combination therapies in this guideline.

When physical therapy is needed

Nonopioid pain medications can do a great job of reducing a patient’s physical discomfort, which the evidence for these guideline demonstrates. However, much of the dysfunction caused by musculoskeletal injuries will not improve by reducing the pain alone. Physical therapy, exercise, and mobilization did not show a significant benefit in reducing symptoms in the systematic review and meta-analysis of randomized trials that appeared alongside the guideline. The type of pain, however, was not evaluated in relation to the effectiveness of these treatments. A fractured bone, for example, may heal just fine with casting and pain management, without the need for additional therapies. However, the muscles surrounding that bone can atrophy and become weak from not being used. Physical therapy may be needed to restrengthen those muscles. Therefore, a multifaceted approach is often needed, even for uncomplicated conditions.

Mental pain often comes with physical pain, and this is an aspect of care that is often neglected. It can be quite devastating for patients to not be able to do the things they were previously able to do. While this is easily recognized in professional athletes when they can no longer play, it is not so readily apparent with a mother who is just trying to take care of her kids. As doctors, especially those of us in family medicine, we should be addressing more than just physical pain.

Patients can also do activities that exacerbate their pain. As doctors, we need to be asking questions that help us determine whether a patient’s pain is caused by a particular action. Maybe that increase in shoulder pain is due to nothing more than lifting something heavy rather than a failure in a prescribed medication. Pain diaries are helpful, and clinicians don’t use them often enough.
 

How pain affects mental health

Acute injuries can also lead to disability. Many patients become quite distressed about being unable to work. They often need Famiy & Medical Leave Act forms filled out, and this task usually falls to the primary care doctor. In addition to assessing the pain, we need to be evaluating, at each visit, a patient’s level of functioning and their ability to do their job.

Every patient responds to pain differently, and it is important to evaluate patients’ mindsets regarding theirs. A patient may be in severe pain and may try to ignore it for a variety of reasons. A patient may “catastrophize” their pain, believing only the worst outcome will happen to them. Helping patients set appropriate expectations and having a positive mindset can help.

Overall, the new recommendations are a great tool as a guideline, but they are not complete enough to be the only ones used in managing acute, non–low back, musculoskeletal pain in adults.

They are very important for clinicians who may be prescribing opioid medications for patients with this type of pain. Amid an opioid crisis, it is the responsibility of every doctor to prescribe these medications appropriately. The evidence clearly shows they provide little benefit and place patients at risk of addiction.

We should all be following these recommendations as the baseline of care for acute pain. However, we need to delve deeper and manage all the components involved. We would be ignoring very real suffering in our patients if we limited our focus to only the physical discomfort.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Rutgers RWJ Medical School.

SOURCE: Ann Intern Med. 2020 Aug 18. doi: 10.7326/M19-3602.