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Pharmacologic Management of COPD
A Discussion of the new American Thoracic Society Clinical Practice Guideline
Chronic obstructive pulmonary disease (COPD) is caused by airway and alveolar abnormalities and is the third most common cause of death worldwide. COPD results in airflow obstruction that is not fully reversible. The diagnosis of COPD should be considered in patients over 40 years who have chronic cough and/or dyspnea, particularly if they have a history of tobacco use. The diagnosis is confirmed by a diminished forced expiratory volume in 1 second (FEV1) that is not fully reversible with the use of a bronchodilator and an FEV1/forced vital capacity ratio of less than or equal to 0.7.1
Recommendation 1
Patients with COPD who report dyspnea or exercise intolerance should be treated with both a long-acting muscarinic antagonist (LAMA) and a long-acting beta agonist (LABA) (dual LAMA/LABA therapy) instead of monotherapy, the guideline says.
This recommendation represents a critical change in care and is based on strong evidence. For years practitioners have been using single bronchodilator therapy, often a LAMA as the entrance to treatment for patients with symptomatic COPD. The recommendation to begin treatment with dual bronchodilator therapy is an important one. This is the only recommendation that received a “strong” grade.
The evidence comes from the compilation of 24 randomized controlled trials that altogether included 45,441 patients. Dual therapy versus monotherapy was evaluated by examining differences in dyspnea, health-related quality of life, exacerbations (which were defined as requiring antibiotics, oral steroids, or hospitalizations), and hospitalizations independently. Marked improvements were observed for exacerbations and hospitalizations in the dual LAMA/LABA group, compared with treatment with use of a single bronchodilator. In 22,733 patients across 15 RCTs, there were 88 fewer exacerbations per 1,000 patients with a rate ratio (RR) of 0.80 (P < .002), the guideline states.
The decrease in exacerbations is a critical factor in treating patients with COPD because each exacerbation can lead to a sustained decrease in airflow and increases the risk of future exacerbations.
Recommendation 2
In COPD patients who report dyspnea or exercise intolerance, with an exacerbation in the last year, the guideline recommends triple therapy with an inhaled corticosteroid (ICS) instead of just dual LAMA/LABA therapy.
In the past many clinicians have relegated triple therapy to a “last ditch resort.” This recommendation makes it clear that triple therapy is appropriate for a broad range of patients with moderate to severe COPD.
Recommendation 3
In patients with COPD who are on triple therapy, the inhaled corticosteroid component can be withdrawn if patients have not had an exacerbation within the last year, according to the guideline.
It should be noted that the committee said that the ICS can be withdrawn, not that it necessarily needs to be withdrawn. The data showed that it would be safe to withdraw the ICS, but the data is limited in time to 1 year’s follow-up.
Recommendation 4
ATS was not able to make a recommendation for or against ICS as an additive therapy to LAMA/LABA in those without an exacerbation and elevated blood eosinophilia (defined as ≥2% blood eosinophils or >149 cell/mcL). In those with at least one exacerbation and increased blood eosinophilia, the society does recommend addition of ICS to dual LAMA/LABA therapy.
An area of ongoing discussion is at what point in disease severity, before exacerbations occur, might ICS be useful in preventing a first exacerbation. This awaits further studies and evidence.
Recommendation 5
In COPD patients with frequent and severe exacerbations who are otherwise medically optimized, the ATS advises against the use of maintenance oral corticosteroid therapy.
It has been known and accepted for years that oral steroids should be avoided if at all possible because they have little benefit and can cause significant harm. The guideline reinforces this.
The Bottom Line
Dual LAMA/LABA therapy in symptomatic patients is the standard of care. If a patient has had an exacerbation within the last year, add an ICS to the LAMA/LABA, most conveniently given in the form of triple therapy in one inhaler. Finally, even in refractory COPD, maintenance oral corticosteroids bring more harm than benefit.
Dr. Skolnik is professor of family and community medicine at the Thomas Jefferson University, Philadelphia, and associate director of the Family Medicine Residency Program at Abington (Pa.) Jefferson Health. Dr. Matthews is a second-year resident in the family medicine residency program at Abington Jefferson Health.
References
1. Wells C, Joo MJ. COPD and asthma: Diagnostic accuracy requires spirometry. J Fam Pract. 2019;68(2):76-81.
2. Nici L, Mammen MJ, Charbek E, et al. Pharmacologic management of chronic obstructive pulmonary disease. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2020;201(9):e56-69.
A Discussion of the new American Thoracic Society Clinical Practice Guideline
A Discussion of the new American Thoracic Society Clinical Practice Guideline
Chronic obstructive pulmonary disease (COPD) is caused by airway and alveolar abnormalities and is the third most common cause of death worldwide. COPD results in airflow obstruction that is not fully reversible. The diagnosis of COPD should be considered in patients over 40 years who have chronic cough and/or dyspnea, particularly if they have a history of tobacco use. The diagnosis is confirmed by a diminished forced expiratory volume in 1 second (FEV1) that is not fully reversible with the use of a bronchodilator and an FEV1/forced vital capacity ratio of less than or equal to 0.7.1
Recommendation 1
Patients with COPD who report dyspnea or exercise intolerance should be treated with both a long-acting muscarinic antagonist (LAMA) and a long-acting beta agonist (LABA) (dual LAMA/LABA therapy) instead of monotherapy, the guideline says.
This recommendation represents a critical change in care and is based on strong evidence. For years practitioners have been using single bronchodilator therapy, often a LAMA as the entrance to treatment for patients with symptomatic COPD. The recommendation to begin treatment with dual bronchodilator therapy is an important one. This is the only recommendation that received a “strong” grade.
The evidence comes from the compilation of 24 randomized controlled trials that altogether included 45,441 patients. Dual therapy versus monotherapy was evaluated by examining differences in dyspnea, health-related quality of life, exacerbations (which were defined as requiring antibiotics, oral steroids, or hospitalizations), and hospitalizations independently. Marked improvements were observed for exacerbations and hospitalizations in the dual LAMA/LABA group, compared with treatment with use of a single bronchodilator. In 22,733 patients across 15 RCTs, there were 88 fewer exacerbations per 1,000 patients with a rate ratio (RR) of 0.80 (P < .002), the guideline states.
The decrease in exacerbations is a critical factor in treating patients with COPD because each exacerbation can lead to a sustained decrease in airflow and increases the risk of future exacerbations.
Recommendation 2
In COPD patients who report dyspnea or exercise intolerance, with an exacerbation in the last year, the guideline recommends triple therapy with an inhaled corticosteroid (ICS) instead of just dual LAMA/LABA therapy.
In the past many clinicians have relegated triple therapy to a “last ditch resort.” This recommendation makes it clear that triple therapy is appropriate for a broad range of patients with moderate to severe COPD.
Recommendation 3
In patients with COPD who are on triple therapy, the inhaled corticosteroid component can be withdrawn if patients have not had an exacerbation within the last year, according to the guideline.
It should be noted that the committee said that the ICS can be withdrawn, not that it necessarily needs to be withdrawn. The data showed that it would be safe to withdraw the ICS, but the data is limited in time to 1 year’s follow-up.
Recommendation 4
ATS was not able to make a recommendation for or against ICS as an additive therapy to LAMA/LABA in those without an exacerbation and elevated blood eosinophilia (defined as ≥2% blood eosinophils or >149 cell/mcL). In those with at least one exacerbation and increased blood eosinophilia, the society does recommend addition of ICS to dual LAMA/LABA therapy.
An area of ongoing discussion is at what point in disease severity, before exacerbations occur, might ICS be useful in preventing a first exacerbation. This awaits further studies and evidence.
Recommendation 5
In COPD patients with frequent and severe exacerbations who are otherwise medically optimized, the ATS advises against the use of maintenance oral corticosteroid therapy.
It has been known and accepted for years that oral steroids should be avoided if at all possible because they have little benefit and can cause significant harm. The guideline reinforces this.
The Bottom Line
Dual LAMA/LABA therapy in symptomatic patients is the standard of care. If a patient has had an exacerbation within the last year, add an ICS to the LAMA/LABA, most conveniently given in the form of triple therapy in one inhaler. Finally, even in refractory COPD, maintenance oral corticosteroids bring more harm than benefit.
Dr. Skolnik is professor of family and community medicine at the Thomas Jefferson University, Philadelphia, and associate director of the Family Medicine Residency Program at Abington (Pa.) Jefferson Health. Dr. Matthews is a second-year resident in the family medicine residency program at Abington Jefferson Health.
References
1. Wells C, Joo MJ. COPD and asthma: Diagnostic accuracy requires spirometry. J Fam Pract. 2019;68(2):76-81.
2. Nici L, Mammen MJ, Charbek E, et al. Pharmacologic management of chronic obstructive pulmonary disease. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2020;201(9):e56-69.
Chronic obstructive pulmonary disease (COPD) is caused by airway and alveolar abnormalities and is the third most common cause of death worldwide. COPD results in airflow obstruction that is not fully reversible. The diagnosis of COPD should be considered in patients over 40 years who have chronic cough and/or dyspnea, particularly if they have a history of tobacco use. The diagnosis is confirmed by a diminished forced expiratory volume in 1 second (FEV1) that is not fully reversible with the use of a bronchodilator and an FEV1/forced vital capacity ratio of less than or equal to 0.7.1
Recommendation 1
Patients with COPD who report dyspnea or exercise intolerance should be treated with both a long-acting muscarinic antagonist (LAMA) and a long-acting beta agonist (LABA) (dual LAMA/LABA therapy) instead of monotherapy, the guideline says.
This recommendation represents a critical change in care and is based on strong evidence. For years practitioners have been using single bronchodilator therapy, often a LAMA as the entrance to treatment for patients with symptomatic COPD. The recommendation to begin treatment with dual bronchodilator therapy is an important one. This is the only recommendation that received a “strong” grade.
The evidence comes from the compilation of 24 randomized controlled trials that altogether included 45,441 patients. Dual therapy versus monotherapy was evaluated by examining differences in dyspnea, health-related quality of life, exacerbations (which were defined as requiring antibiotics, oral steroids, or hospitalizations), and hospitalizations independently. Marked improvements were observed for exacerbations and hospitalizations in the dual LAMA/LABA group, compared with treatment with use of a single bronchodilator. In 22,733 patients across 15 RCTs, there were 88 fewer exacerbations per 1,000 patients with a rate ratio (RR) of 0.80 (P < .002), the guideline states.
The decrease in exacerbations is a critical factor in treating patients with COPD because each exacerbation can lead to a sustained decrease in airflow and increases the risk of future exacerbations.
Recommendation 2
In COPD patients who report dyspnea or exercise intolerance, with an exacerbation in the last year, the guideline recommends triple therapy with an inhaled corticosteroid (ICS) instead of just dual LAMA/LABA therapy.
In the past many clinicians have relegated triple therapy to a “last ditch resort.” This recommendation makes it clear that triple therapy is appropriate for a broad range of patients with moderate to severe COPD.
Recommendation 3
In patients with COPD who are on triple therapy, the inhaled corticosteroid component can be withdrawn if patients have not had an exacerbation within the last year, according to the guideline.
It should be noted that the committee said that the ICS can be withdrawn, not that it necessarily needs to be withdrawn. The data showed that it would be safe to withdraw the ICS, but the data is limited in time to 1 year’s follow-up.
Recommendation 4
ATS was not able to make a recommendation for or against ICS as an additive therapy to LAMA/LABA in those without an exacerbation and elevated blood eosinophilia (defined as ≥2% blood eosinophils or >149 cell/mcL). In those with at least one exacerbation and increased blood eosinophilia, the society does recommend addition of ICS to dual LAMA/LABA therapy.
An area of ongoing discussion is at what point in disease severity, before exacerbations occur, might ICS be useful in preventing a first exacerbation. This awaits further studies and evidence.
Recommendation 5
In COPD patients with frequent and severe exacerbations who are otherwise medically optimized, the ATS advises against the use of maintenance oral corticosteroid therapy.
It has been known and accepted for years that oral steroids should be avoided if at all possible because they have little benefit and can cause significant harm. The guideline reinforces this.
The Bottom Line
Dual LAMA/LABA therapy in symptomatic patients is the standard of care. If a patient has had an exacerbation within the last year, add an ICS to the LAMA/LABA, most conveniently given in the form of triple therapy in one inhaler. Finally, even in refractory COPD, maintenance oral corticosteroids bring more harm than benefit.
Dr. Skolnik is professor of family and community medicine at the Thomas Jefferson University, Philadelphia, and associate director of the Family Medicine Residency Program at Abington (Pa.) Jefferson Health. Dr. Matthews is a second-year resident in the family medicine residency program at Abington Jefferson Health.
References
1. Wells C, Joo MJ. COPD and asthma: Diagnostic accuracy requires spirometry. J Fam Pract. 2019;68(2):76-81.
2. Nici L, Mammen MJ, Charbek E, et al. Pharmacologic management of chronic obstructive pulmonary disease. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2020;201(9):e56-69.
2020-2021 respiratory viral season: Onset, presentations, and testing likely to differ in pandemic
Respiratory virus seasons usually follow a fairly well-known pattern. Enterovirus 68 (EV-D68) is a summer-to-early fall virus with biennial peak years. Rhinovirus (HRv) and adenovirus (Adv) occur nearly year-round but may have small upticks in the first month or so that children return to school. Early in the school year, upper respiratory infections from both HRv and Adv and viral sore throats from Adv are common, with conjunctivitis from Adv outbreaks in some years. October to November is human parainfluenza (HPiV) 1 and 2 season, often presenting as croup. Human metapneumovirus infections span October through April. In late November to December, influenza begins, usually with an A type, later transitioning to a B type in February through April. Also in December, respiratory syncytial virus (RSV) starts, characteristically with bronchiolitis presentations, peaking in February to March and tapering off in May. In late March to April, HPiV 3 also appears for 4-6 weeks.
Will 2020-2021 be different?
Summer was remarkably free of expected enterovirus activity, suggesting that the seasonal parade may differ this year. Remember that the 2019-2020 respiratory season suddenly and nearly completely stopped in March because of social distancing and lockdowns needed to address the SARS-CoV-2 pandemic.
The mild influenza season in the southern hemisphere suggests that our influenza season also could be mild. But perhaps not – most southern hemisphere countries that are surveyed for influenza activities had the most intense SARS-CoV-2 mitigations, making the observed mildness potentially related more to social mitigation than less virulent influenza strains. If so, southern hemisphere influenza data may not apply to the United States, where social distancing and masks are ignored or used inconsistently by almost half the population.
Further, the stop-and-go pattern of in-person school/college attendance adds to uncertainties for the usual orderly virus-specific seasonality. The result may be multiple stop-and-go “pop-up” or “mini” outbreaks for any given virus potentially reflected as exaggerated local or regional differences in circulation of various viruses. The erratic seasonality also would increase coinfections, which could present with more severe or different symptoms.
SARS-CoV-2’s potential interaction
Will the relatively mild presentations for most children with SARS-CoV-2 hold up in the setting of coinfections or sequential respiratory viral infections? Could SARS-CoV-2 cause worse/more prolonged symptoms or more sequelae if paired simultaneously or in tandem with a traditional respiratory virus? To date, data on the frequency and severity of SARS-CoV-2 coinfections are conflicting and sparse, but it appears that non-SARS-CoV-2 viruses can be involved in 15%-50% pediatric acute respiratory infections.1,2
However, it may not be important to know about coinfecting viruses other than influenza (can be treated) or SARS-CoV-2 (needs quarantine and contact tracing), unless symptoms are atypical or more severe than usual. For example, a young child with bronchiolitis is most likely infected with RSV, but HPiV, influenza, metapneumovirus, HRv, and even SARS-CoV-2 can cause bronchiolitis. Even so, testing outpatients for RSV or non-influenza is not routine or even clinically helpful. Supportive treatment and restriction from daycare attendance are sufficient management for outpatient ARIs whether presenting as bronchiolitis or not.
Considerations for SARS-CoV-2 testing: Outpatient bronchiolitis
If a child presents with classic bronchiolitis but has above moderate to severe symptoms, is SARS-CoV-2 a consideration? Perhaps, if SARS-CoV-2 acts similarly to non-SARS-CoV-2s.
A recent report from the 30th Multicenter Airway Research Collaboration (MARC-30) surveillance study (2007-2014) of children hospitalized with clinical bronchiolitis evaluated respiratory viruses, including RSV and the four common non-SARS coronaviruses using molecular testing.3 Among 1,880 subjects, a CoV (alpha CoV: NL63 or 229E, or beta CoV: KKU1 or OC43) was detected in 12%. Yet most had only RSV (n = 1,661); 32 had only CoV (n = 32). But note that 219 had both.
Bronchiolitis subjects with CoV were older – median 3.7 (1.4-5.8) vs. 2.8 (1.9-7.2) years – and more likely male than were RSV subjects (68% vs. 58%). OC43 was most frequent followed by equal numbers of HKU1 and NL63, while 229E was the least frequent. Medical utilization and severity did not differ among the CoVs, or between RSV+CoV vs. RSV alone, unless one considered CoV viral load as a variable. ICU use increased when the polymerase chain reaction cycle threshold result indicated a high CoV viral load.
These data suggest CoVs are not infrequent coinfectors with RSV in bronchiolitis – and that SARS-CoV-2 is the same. Therefore, a bronchiolitis presentation doesn’t necessarily take us off the hook for the need to consider SARS-CoV-2 testing, particularly in the somewhat older bronchiolitis patient with more than mild symptoms.
Considerations for SARS-CoV-2 testing: Outpatient influenza-like illness
In 2020-2021, the Centers for Disease Control and Prevention recommends considering empiric antiviral treatment for ILIs (fever plus either cough or sore throat) based upon our clinical judgement, even in non-high-risk children.4
While pediatric COVID-19 illnesses are predominantly asymptomatic or mild, a febrile ARI is also a SARS-CoV-2 compatible presentation. So, if all we use is our clinical judgment, how do we know if the febrile ARI is due to influenza or SARS-CoV-2 or both? At least one study used a highly sensitive and specific molecular influenza test to show that the accuracy of clinically diagnosing influenza in children is not much better than flipping a coin and would lead to potential antiviral overuse.5
So, it seems ideal to test for influenza when possible. Point-of-care (POC) tests are frequently used for outpatients. Eight POC Clinical Laboratory Improvement Amendments (CLIA)–waived kits, some also detecting RSV, are available but most have modest sensitivity (60%-80%) compared with lab-based molecular tests.6 That said, if supplies and kits for one of the POC tests are available to us during these SARS-CoV-2 stressed times (back orders seem more common this year), a positive influenza test in the first 48 hours of symptoms confirms the option to prescribe an antiviral. Yet how will we have confidence that the febrile ARI is not also partly due to SARS-CoV-2? Currently febrile ARIs usually are considered SARS-CoV-2 and the children are sent for SARS-CoV-2 testing. During influenza season, it seems we will need to continue to send febrile outpatients for SARS-CoV-2 testing, even if POC influenza positive, via whatever mechanisms are available as time goes on.
We expect more rapid pediatric testing modalities for SARS-CoV-2 (maybe even saliva tests) to become available over the next months. Indeed, rapid antigen tests and rapid molecular tests are being evaluated in adults and seem destined for CLIA waivers as POC tests, and even home testing kits. Pediatric approvals hopefully also will occur. So, the pathways for SARS-CoV-2 testing available now will likely change over this winter. But be aware that supplies/kits will be prioritized to locations within high need areas and bulk purchase contracts. So POC kits may remain scarce for practices, meaning a reference laboratory still could be the way to go for SARS-CoV-2 for at least the rest of 2020. Reference labs are becoming creative as well; one combined detection of influenza A, influenza B, RSV, and SARS-CoV-2 into one test, and hopes to get approval for swab collection that can be done by families at home and mailed in.
Summary
Expect variations on the traditional parade of seasonal respiratory viruses, with increased numbers of coinfections. Choosing the outpatient who needs influenza testing is the same as in past years, although we have CDC permissive recommendations to prescribe antivirals for any outpatient ILI within the first 48 hours of symptoms. Still, POC testing for influenza remains potentially valuable in the ILI patient. The choice of whether and how to test for SARS-CoV-2 given its potential to be a primary or coinfecting agent in presentations linked more closely to a traditional virus (e.g. RSV bronchiolitis) will be a test of our clinical judgement until more data and easier testing are available. Further complicating coinfection recognition is the fact that many sick visits occur by telehealth and much testing is done at drive-through SARS-CoV-2 testing facilities with no clinician exam. Unless we are liberal in SARS-CoV-2 testing, detecting SARS-CoV-2 coinfections is easier said than done given its usually mild presentation being overshadowed by any coinfecting virus.
But understanding who has SARS-CoV-2, even as a coinfection, still is essential in controlling the pandemic. We will need to be vigilant for evolving approaches to SARS-CoV-2 testing in the context of symptomatic ARI presentations, knowing this will likely remain a moving target for the foreseeable future.
Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospital-Kansas City, Mo. Children’s Mercy Hospital receives grant funding to study two candidate RSV vaccines. The hospital also receives CDC funding under the New Vaccine Surveillance Network for multicenter surveillance of acute respiratory infections, including influenza, RSV, and parainfluenza virus. Email Dr. Harrison at [email protected].
References
1. Pediatrics. 2020;146(1):e20200961.
2. JAMA. 2020 May 26;323(20):2085-6.
3. Pediatrics. 2020. doi: 10.1542/peds.2020-1267.
4. www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm.
5. J. Pediatr. 2020. doi: 10.1016/j.jpeds.2020.08.007.
6. www.cdc.gov/flu/professionals/diagnosis/table-nucleic-acid-detection.html.
Respiratory virus seasons usually follow a fairly well-known pattern. Enterovirus 68 (EV-D68) is a summer-to-early fall virus with biennial peak years. Rhinovirus (HRv) and adenovirus (Adv) occur nearly year-round but may have small upticks in the first month or so that children return to school. Early in the school year, upper respiratory infections from both HRv and Adv and viral sore throats from Adv are common, with conjunctivitis from Adv outbreaks in some years. October to November is human parainfluenza (HPiV) 1 and 2 season, often presenting as croup. Human metapneumovirus infections span October through April. In late November to December, influenza begins, usually with an A type, later transitioning to a B type in February through April. Also in December, respiratory syncytial virus (RSV) starts, characteristically with bronchiolitis presentations, peaking in February to March and tapering off in May. In late March to April, HPiV 3 also appears for 4-6 weeks.
Will 2020-2021 be different?
Summer was remarkably free of expected enterovirus activity, suggesting that the seasonal parade may differ this year. Remember that the 2019-2020 respiratory season suddenly and nearly completely stopped in March because of social distancing and lockdowns needed to address the SARS-CoV-2 pandemic.
The mild influenza season in the southern hemisphere suggests that our influenza season also could be mild. But perhaps not – most southern hemisphere countries that are surveyed for influenza activities had the most intense SARS-CoV-2 mitigations, making the observed mildness potentially related more to social mitigation than less virulent influenza strains. If so, southern hemisphere influenza data may not apply to the United States, where social distancing and masks are ignored or used inconsistently by almost half the population.
Further, the stop-and-go pattern of in-person school/college attendance adds to uncertainties for the usual orderly virus-specific seasonality. The result may be multiple stop-and-go “pop-up” or “mini” outbreaks for any given virus potentially reflected as exaggerated local or regional differences in circulation of various viruses. The erratic seasonality also would increase coinfections, which could present with more severe or different symptoms.
SARS-CoV-2’s potential interaction
Will the relatively mild presentations for most children with SARS-CoV-2 hold up in the setting of coinfections or sequential respiratory viral infections? Could SARS-CoV-2 cause worse/more prolonged symptoms or more sequelae if paired simultaneously or in tandem with a traditional respiratory virus? To date, data on the frequency and severity of SARS-CoV-2 coinfections are conflicting and sparse, but it appears that non-SARS-CoV-2 viruses can be involved in 15%-50% pediatric acute respiratory infections.1,2
However, it may not be important to know about coinfecting viruses other than influenza (can be treated) or SARS-CoV-2 (needs quarantine and contact tracing), unless symptoms are atypical or more severe than usual. For example, a young child with bronchiolitis is most likely infected with RSV, but HPiV, influenza, metapneumovirus, HRv, and even SARS-CoV-2 can cause bronchiolitis. Even so, testing outpatients for RSV or non-influenza is not routine or even clinically helpful. Supportive treatment and restriction from daycare attendance are sufficient management for outpatient ARIs whether presenting as bronchiolitis or not.
Considerations for SARS-CoV-2 testing: Outpatient bronchiolitis
If a child presents with classic bronchiolitis but has above moderate to severe symptoms, is SARS-CoV-2 a consideration? Perhaps, if SARS-CoV-2 acts similarly to non-SARS-CoV-2s.
A recent report from the 30th Multicenter Airway Research Collaboration (MARC-30) surveillance study (2007-2014) of children hospitalized with clinical bronchiolitis evaluated respiratory viruses, including RSV and the four common non-SARS coronaviruses using molecular testing.3 Among 1,880 subjects, a CoV (alpha CoV: NL63 or 229E, or beta CoV: KKU1 or OC43) was detected in 12%. Yet most had only RSV (n = 1,661); 32 had only CoV (n = 32). But note that 219 had both.
Bronchiolitis subjects with CoV were older – median 3.7 (1.4-5.8) vs. 2.8 (1.9-7.2) years – and more likely male than were RSV subjects (68% vs. 58%). OC43 was most frequent followed by equal numbers of HKU1 and NL63, while 229E was the least frequent. Medical utilization and severity did not differ among the CoVs, or between RSV+CoV vs. RSV alone, unless one considered CoV viral load as a variable. ICU use increased when the polymerase chain reaction cycle threshold result indicated a high CoV viral load.
These data suggest CoVs are not infrequent coinfectors with RSV in bronchiolitis – and that SARS-CoV-2 is the same. Therefore, a bronchiolitis presentation doesn’t necessarily take us off the hook for the need to consider SARS-CoV-2 testing, particularly in the somewhat older bronchiolitis patient with more than mild symptoms.
Considerations for SARS-CoV-2 testing: Outpatient influenza-like illness
In 2020-2021, the Centers for Disease Control and Prevention recommends considering empiric antiviral treatment for ILIs (fever plus either cough or sore throat) based upon our clinical judgement, even in non-high-risk children.4
While pediatric COVID-19 illnesses are predominantly asymptomatic or mild, a febrile ARI is also a SARS-CoV-2 compatible presentation. So, if all we use is our clinical judgment, how do we know if the febrile ARI is due to influenza or SARS-CoV-2 or both? At least one study used a highly sensitive and specific molecular influenza test to show that the accuracy of clinically diagnosing influenza in children is not much better than flipping a coin and would lead to potential antiviral overuse.5
So, it seems ideal to test for influenza when possible. Point-of-care (POC) tests are frequently used for outpatients. Eight POC Clinical Laboratory Improvement Amendments (CLIA)–waived kits, some also detecting RSV, are available but most have modest sensitivity (60%-80%) compared with lab-based molecular tests.6 That said, if supplies and kits for one of the POC tests are available to us during these SARS-CoV-2 stressed times (back orders seem more common this year), a positive influenza test in the first 48 hours of symptoms confirms the option to prescribe an antiviral. Yet how will we have confidence that the febrile ARI is not also partly due to SARS-CoV-2? Currently febrile ARIs usually are considered SARS-CoV-2 and the children are sent for SARS-CoV-2 testing. During influenza season, it seems we will need to continue to send febrile outpatients for SARS-CoV-2 testing, even if POC influenza positive, via whatever mechanisms are available as time goes on.
We expect more rapid pediatric testing modalities for SARS-CoV-2 (maybe even saliva tests) to become available over the next months. Indeed, rapid antigen tests and rapid molecular tests are being evaluated in adults and seem destined for CLIA waivers as POC tests, and even home testing kits. Pediatric approvals hopefully also will occur. So, the pathways for SARS-CoV-2 testing available now will likely change over this winter. But be aware that supplies/kits will be prioritized to locations within high need areas and bulk purchase contracts. So POC kits may remain scarce for practices, meaning a reference laboratory still could be the way to go for SARS-CoV-2 for at least the rest of 2020. Reference labs are becoming creative as well; one combined detection of influenza A, influenza B, RSV, and SARS-CoV-2 into one test, and hopes to get approval for swab collection that can be done by families at home and mailed in.
Summary
Expect variations on the traditional parade of seasonal respiratory viruses, with increased numbers of coinfections. Choosing the outpatient who needs influenza testing is the same as in past years, although we have CDC permissive recommendations to prescribe antivirals for any outpatient ILI within the first 48 hours of symptoms. Still, POC testing for influenza remains potentially valuable in the ILI patient. The choice of whether and how to test for SARS-CoV-2 given its potential to be a primary or coinfecting agent in presentations linked more closely to a traditional virus (e.g. RSV bronchiolitis) will be a test of our clinical judgement until more data and easier testing are available. Further complicating coinfection recognition is the fact that many sick visits occur by telehealth and much testing is done at drive-through SARS-CoV-2 testing facilities with no clinician exam. Unless we are liberal in SARS-CoV-2 testing, detecting SARS-CoV-2 coinfections is easier said than done given its usually mild presentation being overshadowed by any coinfecting virus.
But understanding who has SARS-CoV-2, even as a coinfection, still is essential in controlling the pandemic. We will need to be vigilant for evolving approaches to SARS-CoV-2 testing in the context of symptomatic ARI presentations, knowing this will likely remain a moving target for the foreseeable future.
Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospital-Kansas City, Mo. Children’s Mercy Hospital receives grant funding to study two candidate RSV vaccines. The hospital also receives CDC funding under the New Vaccine Surveillance Network for multicenter surveillance of acute respiratory infections, including influenza, RSV, and parainfluenza virus. Email Dr. Harrison at [email protected].
References
1. Pediatrics. 2020;146(1):e20200961.
2. JAMA. 2020 May 26;323(20):2085-6.
3. Pediatrics. 2020. doi: 10.1542/peds.2020-1267.
4. www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm.
5. J. Pediatr. 2020. doi: 10.1016/j.jpeds.2020.08.007.
6. www.cdc.gov/flu/professionals/diagnosis/table-nucleic-acid-detection.html.
Respiratory virus seasons usually follow a fairly well-known pattern. Enterovirus 68 (EV-D68) is a summer-to-early fall virus with biennial peak years. Rhinovirus (HRv) and adenovirus (Adv) occur nearly year-round but may have small upticks in the first month or so that children return to school. Early in the school year, upper respiratory infections from both HRv and Adv and viral sore throats from Adv are common, with conjunctivitis from Adv outbreaks in some years. October to November is human parainfluenza (HPiV) 1 and 2 season, often presenting as croup. Human metapneumovirus infections span October through April. In late November to December, influenza begins, usually with an A type, later transitioning to a B type in February through April. Also in December, respiratory syncytial virus (RSV) starts, characteristically with bronchiolitis presentations, peaking in February to March and tapering off in May. In late March to April, HPiV 3 also appears for 4-6 weeks.
Will 2020-2021 be different?
Summer was remarkably free of expected enterovirus activity, suggesting that the seasonal parade may differ this year. Remember that the 2019-2020 respiratory season suddenly and nearly completely stopped in March because of social distancing and lockdowns needed to address the SARS-CoV-2 pandemic.
The mild influenza season in the southern hemisphere suggests that our influenza season also could be mild. But perhaps not – most southern hemisphere countries that are surveyed for influenza activities had the most intense SARS-CoV-2 mitigations, making the observed mildness potentially related more to social mitigation than less virulent influenza strains. If so, southern hemisphere influenza data may not apply to the United States, where social distancing and masks are ignored or used inconsistently by almost half the population.
Further, the stop-and-go pattern of in-person school/college attendance adds to uncertainties for the usual orderly virus-specific seasonality. The result may be multiple stop-and-go “pop-up” or “mini” outbreaks for any given virus potentially reflected as exaggerated local or regional differences in circulation of various viruses. The erratic seasonality also would increase coinfections, which could present with more severe or different symptoms.
SARS-CoV-2’s potential interaction
Will the relatively mild presentations for most children with SARS-CoV-2 hold up in the setting of coinfections or sequential respiratory viral infections? Could SARS-CoV-2 cause worse/more prolonged symptoms or more sequelae if paired simultaneously or in tandem with a traditional respiratory virus? To date, data on the frequency and severity of SARS-CoV-2 coinfections are conflicting and sparse, but it appears that non-SARS-CoV-2 viruses can be involved in 15%-50% pediatric acute respiratory infections.1,2
However, it may not be important to know about coinfecting viruses other than influenza (can be treated) or SARS-CoV-2 (needs quarantine and contact tracing), unless symptoms are atypical or more severe than usual. For example, a young child with bronchiolitis is most likely infected with RSV, but HPiV, influenza, metapneumovirus, HRv, and even SARS-CoV-2 can cause bronchiolitis. Even so, testing outpatients for RSV or non-influenza is not routine or even clinically helpful. Supportive treatment and restriction from daycare attendance are sufficient management for outpatient ARIs whether presenting as bronchiolitis or not.
Considerations for SARS-CoV-2 testing: Outpatient bronchiolitis
If a child presents with classic bronchiolitis but has above moderate to severe symptoms, is SARS-CoV-2 a consideration? Perhaps, if SARS-CoV-2 acts similarly to non-SARS-CoV-2s.
A recent report from the 30th Multicenter Airway Research Collaboration (MARC-30) surveillance study (2007-2014) of children hospitalized with clinical bronchiolitis evaluated respiratory viruses, including RSV and the four common non-SARS coronaviruses using molecular testing.3 Among 1,880 subjects, a CoV (alpha CoV: NL63 or 229E, or beta CoV: KKU1 or OC43) was detected in 12%. Yet most had only RSV (n = 1,661); 32 had only CoV (n = 32). But note that 219 had both.
Bronchiolitis subjects with CoV were older – median 3.7 (1.4-5.8) vs. 2.8 (1.9-7.2) years – and more likely male than were RSV subjects (68% vs. 58%). OC43 was most frequent followed by equal numbers of HKU1 and NL63, while 229E was the least frequent. Medical utilization and severity did not differ among the CoVs, or between RSV+CoV vs. RSV alone, unless one considered CoV viral load as a variable. ICU use increased when the polymerase chain reaction cycle threshold result indicated a high CoV viral load.
These data suggest CoVs are not infrequent coinfectors with RSV in bronchiolitis – and that SARS-CoV-2 is the same. Therefore, a bronchiolitis presentation doesn’t necessarily take us off the hook for the need to consider SARS-CoV-2 testing, particularly in the somewhat older bronchiolitis patient with more than mild symptoms.
Considerations for SARS-CoV-2 testing: Outpatient influenza-like illness
In 2020-2021, the Centers for Disease Control and Prevention recommends considering empiric antiviral treatment for ILIs (fever plus either cough or sore throat) based upon our clinical judgement, even in non-high-risk children.4
While pediatric COVID-19 illnesses are predominantly asymptomatic or mild, a febrile ARI is also a SARS-CoV-2 compatible presentation. So, if all we use is our clinical judgment, how do we know if the febrile ARI is due to influenza or SARS-CoV-2 or both? At least one study used a highly sensitive and specific molecular influenza test to show that the accuracy of clinically diagnosing influenza in children is not much better than flipping a coin and would lead to potential antiviral overuse.5
So, it seems ideal to test for influenza when possible. Point-of-care (POC) tests are frequently used for outpatients. Eight POC Clinical Laboratory Improvement Amendments (CLIA)–waived kits, some also detecting RSV, are available but most have modest sensitivity (60%-80%) compared with lab-based molecular tests.6 That said, if supplies and kits for one of the POC tests are available to us during these SARS-CoV-2 stressed times (back orders seem more common this year), a positive influenza test in the first 48 hours of symptoms confirms the option to prescribe an antiviral. Yet how will we have confidence that the febrile ARI is not also partly due to SARS-CoV-2? Currently febrile ARIs usually are considered SARS-CoV-2 and the children are sent for SARS-CoV-2 testing. During influenza season, it seems we will need to continue to send febrile outpatients for SARS-CoV-2 testing, even if POC influenza positive, via whatever mechanisms are available as time goes on.
We expect more rapid pediatric testing modalities for SARS-CoV-2 (maybe even saliva tests) to become available over the next months. Indeed, rapid antigen tests and rapid molecular tests are being evaluated in adults and seem destined for CLIA waivers as POC tests, and even home testing kits. Pediatric approvals hopefully also will occur. So, the pathways for SARS-CoV-2 testing available now will likely change over this winter. But be aware that supplies/kits will be prioritized to locations within high need areas and bulk purchase contracts. So POC kits may remain scarce for practices, meaning a reference laboratory still could be the way to go for SARS-CoV-2 for at least the rest of 2020. Reference labs are becoming creative as well; one combined detection of influenza A, influenza B, RSV, and SARS-CoV-2 into one test, and hopes to get approval for swab collection that can be done by families at home and mailed in.
Summary
Expect variations on the traditional parade of seasonal respiratory viruses, with increased numbers of coinfections. Choosing the outpatient who needs influenza testing is the same as in past years, although we have CDC permissive recommendations to prescribe antivirals for any outpatient ILI within the first 48 hours of symptoms. Still, POC testing for influenza remains potentially valuable in the ILI patient. The choice of whether and how to test for SARS-CoV-2 given its potential to be a primary or coinfecting agent in presentations linked more closely to a traditional virus (e.g. RSV bronchiolitis) will be a test of our clinical judgement until more data and easier testing are available. Further complicating coinfection recognition is the fact that many sick visits occur by telehealth and much testing is done at drive-through SARS-CoV-2 testing facilities with no clinician exam. Unless we are liberal in SARS-CoV-2 testing, detecting SARS-CoV-2 coinfections is easier said than done given its usually mild presentation being overshadowed by any coinfecting virus.
But understanding who has SARS-CoV-2, even as a coinfection, still is essential in controlling the pandemic. We will need to be vigilant for evolving approaches to SARS-CoV-2 testing in the context of symptomatic ARI presentations, knowing this will likely remain a moving target for the foreseeable future.
Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospital-Kansas City, Mo. Children’s Mercy Hospital receives grant funding to study two candidate RSV vaccines. The hospital also receives CDC funding under the New Vaccine Surveillance Network for multicenter surveillance of acute respiratory infections, including influenza, RSV, and parainfluenza virus. Email Dr. Harrison at [email protected].
References
1. Pediatrics. 2020;146(1):e20200961.
2. JAMA. 2020 May 26;323(20):2085-6.
3. Pediatrics. 2020. doi: 10.1542/peds.2020-1267.
4. www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm.
5. J. Pediatr. 2020. doi: 10.1016/j.jpeds.2020.08.007.
6. www.cdc.gov/flu/professionals/diagnosis/table-nucleic-acid-detection.html.
COVID-19 and the psychological side effects of PPE
A few months ago, I published a short thought piece on the use of “sitters” with patients who were COVID-19 positive, or patients under investigation. In it, I recommended the use of telesitters for those who normally would warrant a human sitter, to decrease the discomfort of sitting in full personal protective equipment (PPE) (gown, mask, gloves, etc.) while monitoring a suicidal patient.
I received several queries, which I want to address here. In addition, I want to draw from my Army days in terms of the claustrophobia often experienced with PPE.
The first of the questions was about evidence-based practices. The second was about the discomfort of having sitters sit for many hours in the full gear.
I do not know of any evidence-based practices, but I hope we will develop them.
I agree that spending many hours in full PPE can be discomforting, which is why I wrote the essay.
As far as lessons learned from the Army time, I briefly learned how to wear a “gas mask” or Mission-Oriented Protective Posture (MOPP gear) while at Fort Bragg. We were run through the “gas chamber,” where sergeants released tear gas while we had the mask on. We were then asked to lift it up, and then tearing and sputtering, we could leave the small wooden building.
We wore the mask as part of our Army gear, usually on the right leg. After that, I mainly used the protective mask in its bag as a pillow when I was in the field.
Fast forward to August 1990. I arrived at Camp Casey, near the Korean demilitarized zone. Four days later, Saddam Hussein invaded Kuwait. The gas mask moved from a pillow to something we had to wear while doing 12-mile road marches in “full ruck.” In full ruck, you have your uniform on, with TA-50, knapsack, and weapon. No, I do not remember any more what TA-50 stands for, but essentially it is the webbing that holds your bullets and bandages.
Many could not tolerate it. They developed claustrophobia – sweating, air hunger, and panic. If stationed in the Gulf for Operation Desert Storm, they were evacuated home.
I wrote a couple of short articles on treatment of gas mask phobia.1,2 I basically advised desensitization. Start by watching TV in it for 5 minutes. Graduate to ironing your uniform in the mask. Go then to shorter runs. Work up to the 12-mile road march.
In my second tour in Korea, we had exercises where we simulated being hit by nerve agents and had to operate the hospital for days at a time in partial or full PPE. It was tough but we did it, and felt more confident about surviving attacks from North Korea.
So back to the pandemic present. I have gotten more used to my constant wearing of a surgical mask. I get anxious when I see others with masks below their noses.
The pandemic is not going away anytime soon, in my opinion. Furthermore, there are other viruses that are worse, such as Ebola. It is only a matter of time.
So, let us train with our PPE. If health care workers cannot tolerate them, use desensitization- and anxiety-reducing techniques to help them.
There are no easy answers here, in the time of the COVID pandemic. However, we owe it to ourselves, our patients, and society to do the best we can.
References
1. Ritchie EC. Milit Med. 1992 Feb;157(2):104-6.
2. Ritchie EC. Milit Med. 2001 Dec;166. Suppl. 2(1)83-4.
Dr. Ritchie is chair of psychiatry at Medstar Washington Hospital Center and professor of psychiatry at Georgetown University, Washington. She has no disclosures and can be reached at [email protected].
A few months ago, I published a short thought piece on the use of “sitters” with patients who were COVID-19 positive, or patients under investigation. In it, I recommended the use of telesitters for those who normally would warrant a human sitter, to decrease the discomfort of sitting in full personal protective equipment (PPE) (gown, mask, gloves, etc.) while monitoring a suicidal patient.
I received several queries, which I want to address here. In addition, I want to draw from my Army days in terms of the claustrophobia often experienced with PPE.
The first of the questions was about evidence-based practices. The second was about the discomfort of having sitters sit for many hours in the full gear.
I do not know of any evidence-based practices, but I hope we will develop them.
I agree that spending many hours in full PPE can be discomforting, which is why I wrote the essay.
As far as lessons learned from the Army time, I briefly learned how to wear a “gas mask” or Mission-Oriented Protective Posture (MOPP gear) while at Fort Bragg. We were run through the “gas chamber,” where sergeants released tear gas while we had the mask on. We were then asked to lift it up, and then tearing and sputtering, we could leave the small wooden building.
We wore the mask as part of our Army gear, usually on the right leg. After that, I mainly used the protective mask in its bag as a pillow when I was in the field.
Fast forward to August 1990. I arrived at Camp Casey, near the Korean demilitarized zone. Four days later, Saddam Hussein invaded Kuwait. The gas mask moved from a pillow to something we had to wear while doing 12-mile road marches in “full ruck.” In full ruck, you have your uniform on, with TA-50, knapsack, and weapon. No, I do not remember any more what TA-50 stands for, but essentially it is the webbing that holds your bullets and bandages.
Many could not tolerate it. They developed claustrophobia – sweating, air hunger, and panic. If stationed in the Gulf for Operation Desert Storm, they were evacuated home.
I wrote a couple of short articles on treatment of gas mask phobia.1,2 I basically advised desensitization. Start by watching TV in it for 5 minutes. Graduate to ironing your uniform in the mask. Go then to shorter runs. Work up to the 12-mile road march.
In my second tour in Korea, we had exercises where we simulated being hit by nerve agents and had to operate the hospital for days at a time in partial or full PPE. It was tough but we did it, and felt more confident about surviving attacks from North Korea.
So back to the pandemic present. I have gotten more used to my constant wearing of a surgical mask. I get anxious when I see others with masks below their noses.
The pandemic is not going away anytime soon, in my opinion. Furthermore, there are other viruses that are worse, such as Ebola. It is only a matter of time.
So, let us train with our PPE. If health care workers cannot tolerate them, use desensitization- and anxiety-reducing techniques to help them.
There are no easy answers here, in the time of the COVID pandemic. However, we owe it to ourselves, our patients, and society to do the best we can.
References
1. Ritchie EC. Milit Med. 1992 Feb;157(2):104-6.
2. Ritchie EC. Milit Med. 2001 Dec;166. Suppl. 2(1)83-4.
Dr. Ritchie is chair of psychiatry at Medstar Washington Hospital Center and professor of psychiatry at Georgetown University, Washington. She has no disclosures and can be reached at [email protected].
A few months ago, I published a short thought piece on the use of “sitters” with patients who were COVID-19 positive, or patients under investigation. In it, I recommended the use of telesitters for those who normally would warrant a human sitter, to decrease the discomfort of sitting in full personal protective equipment (PPE) (gown, mask, gloves, etc.) while monitoring a suicidal patient.
I received several queries, which I want to address here. In addition, I want to draw from my Army days in terms of the claustrophobia often experienced with PPE.
The first of the questions was about evidence-based practices. The second was about the discomfort of having sitters sit for many hours in the full gear.
I do not know of any evidence-based practices, but I hope we will develop them.
I agree that spending many hours in full PPE can be discomforting, which is why I wrote the essay.
As far as lessons learned from the Army time, I briefly learned how to wear a “gas mask” or Mission-Oriented Protective Posture (MOPP gear) while at Fort Bragg. We were run through the “gas chamber,” where sergeants released tear gas while we had the mask on. We were then asked to lift it up, and then tearing and sputtering, we could leave the small wooden building.
We wore the mask as part of our Army gear, usually on the right leg. After that, I mainly used the protective mask in its bag as a pillow when I was in the field.
Fast forward to August 1990. I arrived at Camp Casey, near the Korean demilitarized zone. Four days later, Saddam Hussein invaded Kuwait. The gas mask moved from a pillow to something we had to wear while doing 12-mile road marches in “full ruck.” In full ruck, you have your uniform on, with TA-50, knapsack, and weapon. No, I do not remember any more what TA-50 stands for, but essentially it is the webbing that holds your bullets and bandages.
Many could not tolerate it. They developed claustrophobia – sweating, air hunger, and panic. If stationed in the Gulf for Operation Desert Storm, they were evacuated home.
I wrote a couple of short articles on treatment of gas mask phobia.1,2 I basically advised desensitization. Start by watching TV in it for 5 minutes. Graduate to ironing your uniform in the mask. Go then to shorter runs. Work up to the 12-mile road march.
In my second tour in Korea, we had exercises where we simulated being hit by nerve agents and had to operate the hospital for days at a time in partial or full PPE. It was tough but we did it, and felt more confident about surviving attacks from North Korea.
So back to the pandemic present. I have gotten more used to my constant wearing of a surgical mask. I get anxious when I see others with masks below their noses.
The pandemic is not going away anytime soon, in my opinion. Furthermore, there are other viruses that are worse, such as Ebola. It is only a matter of time.
So, let us train with our PPE. If health care workers cannot tolerate them, use desensitization- and anxiety-reducing techniques to help them.
There are no easy answers here, in the time of the COVID pandemic. However, we owe it to ourselves, our patients, and society to do the best we can.
References
1. Ritchie EC. Milit Med. 1992 Feb;157(2):104-6.
2. Ritchie EC. Milit Med. 2001 Dec;166. Suppl. 2(1)83-4.
Dr. Ritchie is chair of psychiatry at Medstar Washington Hospital Center and professor of psychiatry at Georgetown University, Washington. She has no disclosures and can be reached at [email protected].
Conspiracy theories
It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so. – Josh Billings
and intends to use COVID vaccinations as a devious way to implant microchips in us. He will then, of course, use the new 5G towers to track us all (although what Gates will do with the information that I was shopping at a Trader Joe’s yesterday is yet unknown).
It’s easy to dismiss patients with these beliefs as nuts or dumb or both. They’re neither, they’re just human. Conspiracy theories have been shared from the first time two humans met. They are, after all, simply hypotheses to explain an experience that’s difficult to understand. Making up a story to explain things feels safer than living with the unknown, and so we do. Our natural tendency to be suspicious makes conspiracy hypotheses more salient and more likely to spread. The pandemic itself is exacerbating this problem: People are alone and afraid, and dependent on social media for connection. Add a compelling story about a nefarious robber baron plotting to exploit us and you’ve got the conditions for conspiracy theories to explode like wind-driven wildfires. Astonishingly, a Pew Research poll showed 36% of Americans surveyed who have heard something about it say the Bill Gates cabal theory is “probably” or “definitely” true.
That many patients fervently believe conspiracy theories poses several problems for us. First, when a vaccine does become available, some patients will refuse to be vaccinated. The consequences to their health and the health of the community are grave. Secondly, whenever patients have cause to distrust doctors, it makes our jobs more challenging. If they don’t trust us on vaccines, it can spread to not trusting us about wearing masks or sunscreens or taking statins. Lastly, it’s near impossible to have a friendly conversation with a patient carrying forth on why Bill Gates is not in jail or how I’m part of the medical-industrial complex enabling him. Sheesh.
It isn’t their fault. The underpinning of these beliefs can be understood as a cognitive bias. In this case, an idea that is easy to imagine or recall is believed to be true more than an idea that is complex and difficult. Understanding viral replication and R0 numbers or viral vectors and protein subunit vaccines is hard. Imagining a chip being injected into your arm is easy. And, as behavioral economist Daniel Kahneman opined, we humans possess an almost unlimited ability to ignore our ignorance. We physicians can help in a way that friends and family members can’t. Here are ways you can help patients who believe in conspiracy theories:
Approach this problem like any other infirmity, with compassion. No one wants to drink too much and knock out their teeth falling off a bike. It was a mistake. Similarly, when people are steeped in self-delusion, it’s not a misdeed, it’s a lapse. Be kind and respectful.
Meet them where they are. It might be helpful to state with sincerity: So you feel that there is a government plot to use COVID to track us? Have you considered that might not be true?
Have the conversation in private. Harder even than being wrong is being publicly wrong.
Try the Socratic method. (We’re pretty good at this from teaching students and residents.) Conspiracy-believing patients have the illusion of knowledge, yet, like students, it’s often easy to show them their gaps. Do so gently by leading them to discover for themselves.
Stop when you stall. You cannot change someone’s mind by dint of force. However, you surely can damage your relationship if you keep pushing them.
Don’t worry if you fail to break through; you might yet have moved them a bit. This might make it possible for them to discover the truth later. Or, you could simply switch to explain what holds up the ground we walk upon. There’s rumor we’re supported on the backs of turtles, all the way down. Maybe Bill Gates is feeding them.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so. – Josh Billings
and intends to use COVID vaccinations as a devious way to implant microchips in us. He will then, of course, use the new 5G towers to track us all (although what Gates will do with the information that I was shopping at a Trader Joe’s yesterday is yet unknown).
It’s easy to dismiss patients with these beliefs as nuts or dumb or both. They’re neither, they’re just human. Conspiracy theories have been shared from the first time two humans met. They are, after all, simply hypotheses to explain an experience that’s difficult to understand. Making up a story to explain things feels safer than living with the unknown, and so we do. Our natural tendency to be suspicious makes conspiracy hypotheses more salient and more likely to spread. The pandemic itself is exacerbating this problem: People are alone and afraid, and dependent on social media for connection. Add a compelling story about a nefarious robber baron plotting to exploit us and you’ve got the conditions for conspiracy theories to explode like wind-driven wildfires. Astonishingly, a Pew Research poll showed 36% of Americans surveyed who have heard something about it say the Bill Gates cabal theory is “probably” or “definitely” true.
That many patients fervently believe conspiracy theories poses several problems for us. First, when a vaccine does become available, some patients will refuse to be vaccinated. The consequences to their health and the health of the community are grave. Secondly, whenever patients have cause to distrust doctors, it makes our jobs more challenging. If they don’t trust us on vaccines, it can spread to not trusting us about wearing masks or sunscreens or taking statins. Lastly, it’s near impossible to have a friendly conversation with a patient carrying forth on why Bill Gates is not in jail or how I’m part of the medical-industrial complex enabling him. Sheesh.
It isn’t their fault. The underpinning of these beliefs can be understood as a cognitive bias. In this case, an idea that is easy to imagine or recall is believed to be true more than an idea that is complex and difficult. Understanding viral replication and R0 numbers or viral vectors and protein subunit vaccines is hard. Imagining a chip being injected into your arm is easy. And, as behavioral economist Daniel Kahneman opined, we humans possess an almost unlimited ability to ignore our ignorance. We physicians can help in a way that friends and family members can’t. Here are ways you can help patients who believe in conspiracy theories:
Approach this problem like any other infirmity, with compassion. No one wants to drink too much and knock out their teeth falling off a bike. It was a mistake. Similarly, when people are steeped in self-delusion, it’s not a misdeed, it’s a lapse. Be kind and respectful.
Meet them where they are. It might be helpful to state with sincerity: So you feel that there is a government plot to use COVID to track us? Have you considered that might not be true?
Have the conversation in private. Harder even than being wrong is being publicly wrong.
Try the Socratic method. (We’re pretty good at this from teaching students and residents.) Conspiracy-believing patients have the illusion of knowledge, yet, like students, it’s often easy to show them their gaps. Do so gently by leading them to discover for themselves.
Stop when you stall. You cannot change someone’s mind by dint of force. However, you surely can damage your relationship if you keep pushing them.
Don’t worry if you fail to break through; you might yet have moved them a bit. This might make it possible for them to discover the truth later. Or, you could simply switch to explain what holds up the ground we walk upon. There’s rumor we’re supported on the backs of turtles, all the way down. Maybe Bill Gates is feeding them.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so. – Josh Billings
and intends to use COVID vaccinations as a devious way to implant microchips in us. He will then, of course, use the new 5G towers to track us all (although what Gates will do with the information that I was shopping at a Trader Joe’s yesterday is yet unknown).
It’s easy to dismiss patients with these beliefs as nuts or dumb or both. They’re neither, they’re just human. Conspiracy theories have been shared from the first time two humans met. They are, after all, simply hypotheses to explain an experience that’s difficult to understand. Making up a story to explain things feels safer than living with the unknown, and so we do. Our natural tendency to be suspicious makes conspiracy hypotheses more salient and more likely to spread. The pandemic itself is exacerbating this problem: People are alone and afraid, and dependent on social media for connection. Add a compelling story about a nefarious robber baron plotting to exploit us and you’ve got the conditions for conspiracy theories to explode like wind-driven wildfires. Astonishingly, a Pew Research poll showed 36% of Americans surveyed who have heard something about it say the Bill Gates cabal theory is “probably” or “definitely” true.
That many patients fervently believe conspiracy theories poses several problems for us. First, when a vaccine does become available, some patients will refuse to be vaccinated. The consequences to their health and the health of the community are grave. Secondly, whenever patients have cause to distrust doctors, it makes our jobs more challenging. If they don’t trust us on vaccines, it can spread to not trusting us about wearing masks or sunscreens or taking statins. Lastly, it’s near impossible to have a friendly conversation with a patient carrying forth on why Bill Gates is not in jail or how I’m part of the medical-industrial complex enabling him. Sheesh.
It isn’t their fault. The underpinning of these beliefs can be understood as a cognitive bias. In this case, an idea that is easy to imagine or recall is believed to be true more than an idea that is complex and difficult. Understanding viral replication and R0 numbers or viral vectors and protein subunit vaccines is hard. Imagining a chip being injected into your arm is easy. And, as behavioral economist Daniel Kahneman opined, we humans possess an almost unlimited ability to ignore our ignorance. We physicians can help in a way that friends and family members can’t. Here are ways you can help patients who believe in conspiracy theories:
Approach this problem like any other infirmity, with compassion. No one wants to drink too much and knock out their teeth falling off a bike. It was a mistake. Similarly, when people are steeped in self-delusion, it’s not a misdeed, it’s a lapse. Be kind and respectful.
Meet them where they are. It might be helpful to state with sincerity: So you feel that there is a government plot to use COVID to track us? Have you considered that might not be true?
Have the conversation in private. Harder even than being wrong is being publicly wrong.
Try the Socratic method. (We’re pretty good at this from teaching students and residents.) Conspiracy-believing patients have the illusion of knowledge, yet, like students, it’s often easy to show them their gaps. Do so gently by leading them to discover for themselves.
Stop when you stall. You cannot change someone’s mind by dint of force. However, you surely can damage your relationship if you keep pushing them.
Don’t worry if you fail to break through; you might yet have moved them a bit. This might make it possible for them to discover the truth later. Or, you could simply switch to explain what holds up the ground we walk upon. There’s rumor we’re supported on the backs of turtles, all the way down. Maybe Bill Gates is feeding them.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
The importance of character
Early autumn is typically a quiet time for outpatient pediatricians. The school physicals are finished. The last-minute school physicals are finished. The “I forgot to get my child’s physical” physicals are finished. Respiratory syncytial virus and influenza seasons haven’t started. There is time for some self-reflection and sharpening the saw.
My reflective period each year tends to start with the unresolved “What do I want to be when I grow up?” Mind you, just because I’ve grown old doesn’t mean I’ve grown up. I never wanted to be a “grande personne” who, per Antoine de Saint-Exupéry in “Le Petit Prince,” will never understand why a minor item (Did the lamb eat the flower?) makes all the difference in the universe to a child. Awe and wonderment should remain a part of life. I enjoy reading that short story in the original French because, as my high school French vocabulary and conjugation have faded, any word I don’t recognize means exactly what my journey of a lifetime tells me it means, neither more nor less, just as Humpty Dumpty explained to Alice in Lewis Carroll’s “Through the Looking Glass.”
Along with my perennial favorites like “Le Petit Prince” and the Gettysburg Address, in this year’s folder for reflection are two essays I’ve collected this year. The first is a letter addressed from medical ethicist Ira Bedzow, PhD, to this year’s incoming class of medical students.
The essay gives advice to first-year medical students entering the profession of medicine. It talks about finding “something to say that you communicate with the whole and essence of your being.” There is lots of great counsel in the letter. It claims, “Only in a professional does one’s voice sing in harmony with one’s being. Want that for yourselves, for only a life undivided is a life of full integrity.”
I agree with the harmony part. I hesitate with the undivided part. A professional singer could be dedicated to opera but still sing in a barbershop quartet and a church choir, motivated by fun and fellowship. It is important to emphasize integrity and dedication to medical students. The letter does that well, but students must also develop a work-life balance. The ascetic life is not for everyone.
Life needs balance and moderation. I am pretty sure that Aristotle said that, but I never did spend much time studying the Classics. I use my periods of self-reflection to chart my life’s vector. I choose new skills to learn and challenges to meet. But as I grow older, I spend more time pruning those roles that no longer give me joy. Delayed gratification is an important character trait for success, but its value lessens as it becomes clear there are more days behind me than ahead.
The second essay reflects the views of Canon Brodar, a third-year medical student and divinity school graduate.
He attests to the willingness of medical trainees to accept their duties and personal risk during the crisis of the COVID-19 pandemic. He correctly points out the contributions his fellow students could make, but underestimates the negatives. During March 2020 when decisions were made to send third-year medical students home, the administrative focus was on the cost of their participation (consumption of scarce personal protective equipment) and the potential negative consequences (an additional person who might transmit the virus among patients.) Four months later, most medical students were back on the job.
Mr. Brodar’s eloquent description of duty and responsibility complement, and perhaps have evolved from, the integrity and dedication that Dr. Bedzow emphasized to incoming medical students. These are all character traits. These traits are not knowledge of anatomy or skill with a scalpel. With experience come two more key character traits – the moderation of a work-life balance and the judgment to weigh benefits, risks, and costs.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at [email protected].
Early autumn is typically a quiet time for outpatient pediatricians. The school physicals are finished. The last-minute school physicals are finished. The “I forgot to get my child’s physical” physicals are finished. Respiratory syncytial virus and influenza seasons haven’t started. There is time for some self-reflection and sharpening the saw.
My reflective period each year tends to start with the unresolved “What do I want to be when I grow up?” Mind you, just because I’ve grown old doesn’t mean I’ve grown up. I never wanted to be a “grande personne” who, per Antoine de Saint-Exupéry in “Le Petit Prince,” will never understand why a minor item (Did the lamb eat the flower?) makes all the difference in the universe to a child. Awe and wonderment should remain a part of life. I enjoy reading that short story in the original French because, as my high school French vocabulary and conjugation have faded, any word I don’t recognize means exactly what my journey of a lifetime tells me it means, neither more nor less, just as Humpty Dumpty explained to Alice in Lewis Carroll’s “Through the Looking Glass.”
Along with my perennial favorites like “Le Petit Prince” and the Gettysburg Address, in this year’s folder for reflection are two essays I’ve collected this year. The first is a letter addressed from medical ethicist Ira Bedzow, PhD, to this year’s incoming class of medical students.
The essay gives advice to first-year medical students entering the profession of medicine. It talks about finding “something to say that you communicate with the whole and essence of your being.” There is lots of great counsel in the letter. It claims, “Only in a professional does one’s voice sing in harmony with one’s being. Want that for yourselves, for only a life undivided is a life of full integrity.”
I agree with the harmony part. I hesitate with the undivided part. A professional singer could be dedicated to opera but still sing in a barbershop quartet and a church choir, motivated by fun and fellowship. It is important to emphasize integrity and dedication to medical students. The letter does that well, but students must also develop a work-life balance. The ascetic life is not for everyone.
Life needs balance and moderation. I am pretty sure that Aristotle said that, but I never did spend much time studying the Classics. I use my periods of self-reflection to chart my life’s vector. I choose new skills to learn and challenges to meet. But as I grow older, I spend more time pruning those roles that no longer give me joy. Delayed gratification is an important character trait for success, but its value lessens as it becomes clear there are more days behind me than ahead.
The second essay reflects the views of Canon Brodar, a third-year medical student and divinity school graduate.
He attests to the willingness of medical trainees to accept their duties and personal risk during the crisis of the COVID-19 pandemic. He correctly points out the contributions his fellow students could make, but underestimates the negatives. During March 2020 when decisions were made to send third-year medical students home, the administrative focus was on the cost of their participation (consumption of scarce personal protective equipment) and the potential negative consequences (an additional person who might transmit the virus among patients.) Four months later, most medical students were back on the job.
Mr. Brodar’s eloquent description of duty and responsibility complement, and perhaps have evolved from, the integrity and dedication that Dr. Bedzow emphasized to incoming medical students. These are all character traits. These traits are not knowledge of anatomy or skill with a scalpel. With experience come two more key character traits – the moderation of a work-life balance and the judgment to weigh benefits, risks, and costs.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at [email protected].
Early autumn is typically a quiet time for outpatient pediatricians. The school physicals are finished. The last-minute school physicals are finished. The “I forgot to get my child’s physical” physicals are finished. Respiratory syncytial virus and influenza seasons haven’t started. There is time for some self-reflection and sharpening the saw.
My reflective period each year tends to start with the unresolved “What do I want to be when I grow up?” Mind you, just because I’ve grown old doesn’t mean I’ve grown up. I never wanted to be a “grande personne” who, per Antoine de Saint-Exupéry in “Le Petit Prince,” will never understand why a minor item (Did the lamb eat the flower?) makes all the difference in the universe to a child. Awe and wonderment should remain a part of life. I enjoy reading that short story in the original French because, as my high school French vocabulary and conjugation have faded, any word I don’t recognize means exactly what my journey of a lifetime tells me it means, neither more nor less, just as Humpty Dumpty explained to Alice in Lewis Carroll’s “Through the Looking Glass.”
Along with my perennial favorites like “Le Petit Prince” and the Gettysburg Address, in this year’s folder for reflection are two essays I’ve collected this year. The first is a letter addressed from medical ethicist Ira Bedzow, PhD, to this year’s incoming class of medical students.
The essay gives advice to first-year medical students entering the profession of medicine. It talks about finding “something to say that you communicate with the whole and essence of your being.” There is lots of great counsel in the letter. It claims, “Only in a professional does one’s voice sing in harmony with one’s being. Want that for yourselves, for only a life undivided is a life of full integrity.”
I agree with the harmony part. I hesitate with the undivided part. A professional singer could be dedicated to opera but still sing in a barbershop quartet and a church choir, motivated by fun and fellowship. It is important to emphasize integrity and dedication to medical students. The letter does that well, but students must also develop a work-life balance. The ascetic life is not for everyone.
Life needs balance and moderation. I am pretty sure that Aristotle said that, but I never did spend much time studying the Classics. I use my periods of self-reflection to chart my life’s vector. I choose new skills to learn and challenges to meet. But as I grow older, I spend more time pruning those roles that no longer give me joy. Delayed gratification is an important character trait for success, but its value lessens as it becomes clear there are more days behind me than ahead.
The second essay reflects the views of Canon Brodar, a third-year medical student and divinity school graduate.
He attests to the willingness of medical trainees to accept their duties and personal risk during the crisis of the COVID-19 pandemic. He correctly points out the contributions his fellow students could make, but underestimates the negatives. During March 2020 when decisions were made to send third-year medical students home, the administrative focus was on the cost of their participation (consumption of scarce personal protective equipment) and the potential negative consequences (an additional person who might transmit the virus among patients.) Four months later, most medical students were back on the job.
Mr. Brodar’s eloquent description of duty and responsibility complement, and perhaps have evolved from, the integrity and dedication that Dr. Bedzow emphasized to incoming medical students. These are all character traits. These traits are not knowledge of anatomy or skill with a scalpel. With experience come two more key character traits – the moderation of a work-life balance and the judgment to weigh benefits, risks, and costs.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at [email protected].
Virtual school is especially difficult for children with ADHD
The school year has begun, but for most families it is a school year without precedent. Parents have to monitor and support their children through school days that are partially or completely virtual, juggling sudden class transitions, troubleshooting technology, and trying to manage lessons and assignments. Most related activities such as sports and orchestra are cancelled. Parents themselves are anxious about completing their work, if they have jobs at all. On top of this, all of us have faced months of challenge and disruption with virtually no relief, with regard to seeing friends, traveling, or going out to dinner or a movie. For your patients with ADHD, the challenges of this school year will be even more difficult. Offering parents some guidance about how to approach and manage these challenges can support their adaptation and lessen the chances of compounded problems by the time in-person school resumes.
Children with ADHD, particularly those in elementary school, are managing symptoms of difficulty shifting their attention, sustaining focus on less-engaging material, and motor hyperactivity. They often have difficulty with organization and planning, working memory, and impulse control. Even with effective medication management, they typically are dependent on external cues and support to manage the demands of school. They benefit from attentive teachers who can redirect their attention, offer serial prompts before transitions, and provide patient support, reassurance, and confidence when they grow frustrated. And it often is easier for teachers to do this than for parents, as they have years of experience and training, and the support of their professionals in the school setting. And of course they are less likely to personalize these challenges than are parents, who are likely to feel worried, guilty, or discouraged by the child’s persistent difficulties with attention. Parents who are stressed or who may be managing difficulties with attention themselves – as ADHD is one of the more heritable psychiatric disorders – will be vulnerable to feeling frustration and losing their temper.
Suggest to the parents of your patients with ADHD that there will be frustrations and challenges as they manage the learning curve of virtual school with their children. Increasing the dose of an effective stimulant may be tempting, but there are a few strategies that may better help the children adapt to a virtual classroom without too much distress.
Promote good sleep patterns
Adequate, restful sleep is critical to our physical and psychological health and to healthy development. Children with ADHD are prone to sleep difficulties, and stimulants may exacerbate these.
So, it is critical that parents prioritize setting and maintaining healthy routines around sleep. All screens should power down at least 1 hour before lights out, and parents can help their children know when to accept “good enough” homework, so they also may get good enough sleep.
Daily physical activity helps enormously with restful sleep. A warm bath or shower and quiet reading (not homework!) can help wired kids unwind and be truly ready for lights out. Bedtime may start to slide later as life’s routines are disrupted with work and school happening at home, but it is important to maintain a consistent bedtime that will allow for 8-10 hours of sleep.
Create routines around the “school day”
Good schools involve a predictable rhythm and a lot of caring adults engaging with children. They have very consistent routines at the start of each day, and families can create their own to offer structure and cues to their children.
Start the day with a consistent wake up time and routine plus a healthy breakfast. Take advantage of the extra time that no commute to school or bus ride allow, whether by supporting more sleep, cooking a hot breakfast together, or by letting the children engage in a beloved activity, such as listening to music, reading a comic book, or working on a craft before the computer goes on.
The routine should be centered on the rhythm of the school, and realistic for parents. It matters most that it is consistent, incorporates nutritious food and exercise, and is pleasant and even fun.
Set the stage
Teachers will often put their students with ADHD in the front of the class, so they can offer prompts and so the students are less distracted by peers. Consider where in the home is a good spot for the children, one that minimizes distractions and where a parent is near enough to support and monitor them.
Parents might want to avoid rooms with a lot of toys or games that may tempt children, and children will need to be apart from (noisy) siblings. If they forget to mute themselves or are tempted to open another window on their computer, it is helpful for a parent to be near enough to be unobtrusively following along. Parents will hear the sounds of trouble and be able to help if their children get lost in an assignment or are otherwise off-track.
Create reasonable expectations and positive rewards
Reassure parents that this adjustment is going to be hard for all children and families. Now is not the season for perfectionism or focusing too intensely on mastering a challenging subject.
Reasonable goals for the first month might be for the child to get some enjoyment from school and to get better at specific tasks (being on time, managing the technology, asking for help when needed).
Parents may even set this goal with their children: “What do you want to be better at by the end of the first month?” If children with ADHD improve at managing the distractions of a virtual class, they will have accomplished a great deal cognitively. It will be hard work for them.
So parents should think about what reward can come at the end of each school day, whether a walk outside together, a game of Uno, or even an afterschool treat together, so children get a sense of success for even incremental adaptation.
Build in breaks from the screen
Spending much more than an hour in a virtual interaction is taxing even for adult attention spans. Parents should feel empowered to speak with their children’s teachers to find ways to build in regular 10- to 15-minute breaks during which their children can have a snack, take a bathroom break, or get their wiggles out.
Ensure there is some physical activity
Recess is usually the most important class of the day in elementary school, and especially for children with ADHD. If parents can make physical activity part of their children’s routines, breaks, and afterschool rewards, their attention, energy, and sleep will be improved.
They might do a workout with the child for 20 minutes before school starts, go for a short walk, or do jumping jacks during breaks. And getting outside to kick a ball, go for a swim, or otherwise get the heart rate up in the sunshine will be the most important thing parents do for their children after protecting their sleep.
Know your child
Remember parents are the experts on their children. School is the setting in which children are both cultivating their strengths and facing challenges. Ask the parents what has been most challenging for their children about school and what was most cherished about it.
Parents should get creative to cultivate their children’s strengths. If a child adores art, it will be so important to try to provide that experience during this school year. There might be other virtual resources (virtual museum tours, YouTube art lessons), a local teacher who can offer socially distant lessons, or even another student who might be able to safely share a teacher – getting a creative and social outlet together.
Are there special teachers that the children are missing? Maybe there is a way to send them emails or have some virtual time with them each week.
If a child struggles with the classroom but excells on the soccer pitch, it will be critical to find a physically distant way for the child to develop that strength, whether with a small, informal practice or a new physical undertaking.
Likewise, parents may need to look elsewhere to help their children manage important challenges. Whether a child is learning how to face anxiety or improve social skills, virtual school might seem like a relief as it takes the pressure off. Help parents consider alternate ways that their children could continue to work on these developmental projects while school is virtual, so they don’t lose ground developmentally.
If parents can set reasonable goals, be patient, and focus on the daily routines, and consider the child’s individual developmental strengths and challenges, they may be better able to manage this challenging year. They may even find improved connection, patience, and perspective for both themselves and their children.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Neither Dr. Swick nor Dr. Jellinek had any relevant financial disclosures. Email them at [email protected].
The school year has begun, but for most families it is a school year without precedent. Parents have to monitor and support their children through school days that are partially or completely virtual, juggling sudden class transitions, troubleshooting technology, and trying to manage lessons and assignments. Most related activities such as sports and orchestra are cancelled. Parents themselves are anxious about completing their work, if they have jobs at all. On top of this, all of us have faced months of challenge and disruption with virtually no relief, with regard to seeing friends, traveling, or going out to dinner or a movie. For your patients with ADHD, the challenges of this school year will be even more difficult. Offering parents some guidance about how to approach and manage these challenges can support their adaptation and lessen the chances of compounded problems by the time in-person school resumes.
Children with ADHD, particularly those in elementary school, are managing symptoms of difficulty shifting their attention, sustaining focus on less-engaging material, and motor hyperactivity. They often have difficulty with organization and planning, working memory, and impulse control. Even with effective medication management, they typically are dependent on external cues and support to manage the demands of school. They benefit from attentive teachers who can redirect their attention, offer serial prompts before transitions, and provide patient support, reassurance, and confidence when they grow frustrated. And it often is easier for teachers to do this than for parents, as they have years of experience and training, and the support of their professionals in the school setting. And of course they are less likely to personalize these challenges than are parents, who are likely to feel worried, guilty, or discouraged by the child’s persistent difficulties with attention. Parents who are stressed or who may be managing difficulties with attention themselves – as ADHD is one of the more heritable psychiatric disorders – will be vulnerable to feeling frustration and losing their temper.
Suggest to the parents of your patients with ADHD that there will be frustrations and challenges as they manage the learning curve of virtual school with their children. Increasing the dose of an effective stimulant may be tempting, but there are a few strategies that may better help the children adapt to a virtual classroom without too much distress.
Promote good sleep patterns
Adequate, restful sleep is critical to our physical and psychological health and to healthy development. Children with ADHD are prone to sleep difficulties, and stimulants may exacerbate these.
So, it is critical that parents prioritize setting and maintaining healthy routines around sleep. All screens should power down at least 1 hour before lights out, and parents can help their children know when to accept “good enough” homework, so they also may get good enough sleep.
Daily physical activity helps enormously with restful sleep. A warm bath or shower and quiet reading (not homework!) can help wired kids unwind and be truly ready for lights out. Bedtime may start to slide later as life’s routines are disrupted with work and school happening at home, but it is important to maintain a consistent bedtime that will allow for 8-10 hours of sleep.
Create routines around the “school day”
Good schools involve a predictable rhythm and a lot of caring adults engaging with children. They have very consistent routines at the start of each day, and families can create their own to offer structure and cues to their children.
Start the day with a consistent wake up time and routine plus a healthy breakfast. Take advantage of the extra time that no commute to school or bus ride allow, whether by supporting more sleep, cooking a hot breakfast together, or by letting the children engage in a beloved activity, such as listening to music, reading a comic book, or working on a craft before the computer goes on.
The routine should be centered on the rhythm of the school, and realistic for parents. It matters most that it is consistent, incorporates nutritious food and exercise, and is pleasant and even fun.
Set the stage
Teachers will often put their students with ADHD in the front of the class, so they can offer prompts and so the students are less distracted by peers. Consider where in the home is a good spot for the children, one that minimizes distractions and where a parent is near enough to support and monitor them.
Parents might want to avoid rooms with a lot of toys or games that may tempt children, and children will need to be apart from (noisy) siblings. If they forget to mute themselves or are tempted to open another window on their computer, it is helpful for a parent to be near enough to be unobtrusively following along. Parents will hear the sounds of trouble and be able to help if their children get lost in an assignment or are otherwise off-track.
Create reasonable expectations and positive rewards
Reassure parents that this adjustment is going to be hard for all children and families. Now is not the season for perfectionism or focusing too intensely on mastering a challenging subject.
Reasonable goals for the first month might be for the child to get some enjoyment from school and to get better at specific tasks (being on time, managing the technology, asking for help when needed).
Parents may even set this goal with their children: “What do you want to be better at by the end of the first month?” If children with ADHD improve at managing the distractions of a virtual class, they will have accomplished a great deal cognitively. It will be hard work for them.
So parents should think about what reward can come at the end of each school day, whether a walk outside together, a game of Uno, or even an afterschool treat together, so children get a sense of success for even incremental adaptation.
Build in breaks from the screen
Spending much more than an hour in a virtual interaction is taxing even for adult attention spans. Parents should feel empowered to speak with their children’s teachers to find ways to build in regular 10- to 15-minute breaks during which their children can have a snack, take a bathroom break, or get their wiggles out.
Ensure there is some physical activity
Recess is usually the most important class of the day in elementary school, and especially for children with ADHD. If parents can make physical activity part of their children’s routines, breaks, and afterschool rewards, their attention, energy, and sleep will be improved.
They might do a workout with the child for 20 minutes before school starts, go for a short walk, or do jumping jacks during breaks. And getting outside to kick a ball, go for a swim, or otherwise get the heart rate up in the sunshine will be the most important thing parents do for their children after protecting their sleep.
Know your child
Remember parents are the experts on their children. School is the setting in which children are both cultivating their strengths and facing challenges. Ask the parents what has been most challenging for their children about school and what was most cherished about it.
Parents should get creative to cultivate their children’s strengths. If a child adores art, it will be so important to try to provide that experience during this school year. There might be other virtual resources (virtual museum tours, YouTube art lessons), a local teacher who can offer socially distant lessons, or even another student who might be able to safely share a teacher – getting a creative and social outlet together.
Are there special teachers that the children are missing? Maybe there is a way to send them emails or have some virtual time with them each week.
If a child struggles with the classroom but excells on the soccer pitch, it will be critical to find a physically distant way for the child to develop that strength, whether with a small, informal practice or a new physical undertaking.
Likewise, parents may need to look elsewhere to help their children manage important challenges. Whether a child is learning how to face anxiety or improve social skills, virtual school might seem like a relief as it takes the pressure off. Help parents consider alternate ways that their children could continue to work on these developmental projects while school is virtual, so they don’t lose ground developmentally.
If parents can set reasonable goals, be patient, and focus on the daily routines, and consider the child’s individual developmental strengths and challenges, they may be better able to manage this challenging year. They may even find improved connection, patience, and perspective for both themselves and their children.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Neither Dr. Swick nor Dr. Jellinek had any relevant financial disclosures. Email them at [email protected].
The school year has begun, but for most families it is a school year without precedent. Parents have to monitor and support their children through school days that are partially or completely virtual, juggling sudden class transitions, troubleshooting technology, and trying to manage lessons and assignments. Most related activities such as sports and orchestra are cancelled. Parents themselves are anxious about completing their work, if they have jobs at all. On top of this, all of us have faced months of challenge and disruption with virtually no relief, with regard to seeing friends, traveling, or going out to dinner or a movie. For your patients with ADHD, the challenges of this school year will be even more difficult. Offering parents some guidance about how to approach and manage these challenges can support their adaptation and lessen the chances of compounded problems by the time in-person school resumes.
Children with ADHD, particularly those in elementary school, are managing symptoms of difficulty shifting their attention, sustaining focus on less-engaging material, and motor hyperactivity. They often have difficulty with organization and planning, working memory, and impulse control. Even with effective medication management, they typically are dependent on external cues and support to manage the demands of school. They benefit from attentive teachers who can redirect their attention, offer serial prompts before transitions, and provide patient support, reassurance, and confidence when they grow frustrated. And it often is easier for teachers to do this than for parents, as they have years of experience and training, and the support of their professionals in the school setting. And of course they are less likely to personalize these challenges than are parents, who are likely to feel worried, guilty, or discouraged by the child’s persistent difficulties with attention. Parents who are stressed or who may be managing difficulties with attention themselves – as ADHD is one of the more heritable psychiatric disorders – will be vulnerable to feeling frustration and losing their temper.
Suggest to the parents of your patients with ADHD that there will be frustrations and challenges as they manage the learning curve of virtual school with their children. Increasing the dose of an effective stimulant may be tempting, but there are a few strategies that may better help the children adapt to a virtual classroom without too much distress.
Promote good sleep patterns
Adequate, restful sleep is critical to our physical and psychological health and to healthy development. Children with ADHD are prone to sleep difficulties, and stimulants may exacerbate these.
So, it is critical that parents prioritize setting and maintaining healthy routines around sleep. All screens should power down at least 1 hour before lights out, and parents can help their children know when to accept “good enough” homework, so they also may get good enough sleep.
Daily physical activity helps enormously with restful sleep. A warm bath or shower and quiet reading (not homework!) can help wired kids unwind and be truly ready for lights out. Bedtime may start to slide later as life’s routines are disrupted with work and school happening at home, but it is important to maintain a consistent bedtime that will allow for 8-10 hours of sleep.
Create routines around the “school day”
Good schools involve a predictable rhythm and a lot of caring adults engaging with children. They have very consistent routines at the start of each day, and families can create their own to offer structure and cues to their children.
Start the day with a consistent wake up time and routine plus a healthy breakfast. Take advantage of the extra time that no commute to school or bus ride allow, whether by supporting more sleep, cooking a hot breakfast together, or by letting the children engage in a beloved activity, such as listening to music, reading a comic book, or working on a craft before the computer goes on.
The routine should be centered on the rhythm of the school, and realistic for parents. It matters most that it is consistent, incorporates nutritious food and exercise, and is pleasant and even fun.
Set the stage
Teachers will often put their students with ADHD in the front of the class, so they can offer prompts and so the students are less distracted by peers. Consider where in the home is a good spot for the children, one that minimizes distractions and where a parent is near enough to support and monitor them.
Parents might want to avoid rooms with a lot of toys or games that may tempt children, and children will need to be apart from (noisy) siblings. If they forget to mute themselves or are tempted to open another window on their computer, it is helpful for a parent to be near enough to be unobtrusively following along. Parents will hear the sounds of trouble and be able to help if their children get lost in an assignment or are otherwise off-track.
Create reasonable expectations and positive rewards
Reassure parents that this adjustment is going to be hard for all children and families. Now is not the season for perfectionism or focusing too intensely on mastering a challenging subject.
Reasonable goals for the first month might be for the child to get some enjoyment from school and to get better at specific tasks (being on time, managing the technology, asking for help when needed).
Parents may even set this goal with their children: “What do you want to be better at by the end of the first month?” If children with ADHD improve at managing the distractions of a virtual class, they will have accomplished a great deal cognitively. It will be hard work for them.
So parents should think about what reward can come at the end of each school day, whether a walk outside together, a game of Uno, or even an afterschool treat together, so children get a sense of success for even incremental adaptation.
Build in breaks from the screen
Spending much more than an hour in a virtual interaction is taxing even for adult attention spans. Parents should feel empowered to speak with their children’s teachers to find ways to build in regular 10- to 15-minute breaks during which their children can have a snack, take a bathroom break, or get their wiggles out.
Ensure there is some physical activity
Recess is usually the most important class of the day in elementary school, and especially for children with ADHD. If parents can make physical activity part of their children’s routines, breaks, and afterschool rewards, their attention, energy, and sleep will be improved.
They might do a workout with the child for 20 minutes before school starts, go for a short walk, or do jumping jacks during breaks. And getting outside to kick a ball, go for a swim, or otherwise get the heart rate up in the sunshine will be the most important thing parents do for their children after protecting their sleep.
Know your child
Remember parents are the experts on their children. School is the setting in which children are both cultivating their strengths and facing challenges. Ask the parents what has been most challenging for their children about school and what was most cherished about it.
Parents should get creative to cultivate their children’s strengths. If a child adores art, it will be so important to try to provide that experience during this school year. There might be other virtual resources (virtual museum tours, YouTube art lessons), a local teacher who can offer socially distant lessons, or even another student who might be able to safely share a teacher – getting a creative and social outlet together.
Are there special teachers that the children are missing? Maybe there is a way to send them emails or have some virtual time with them each week.
If a child struggles with the classroom but excells on the soccer pitch, it will be critical to find a physically distant way for the child to develop that strength, whether with a small, informal practice or a new physical undertaking.
Likewise, parents may need to look elsewhere to help their children manage important challenges. Whether a child is learning how to face anxiety or improve social skills, virtual school might seem like a relief as it takes the pressure off. Help parents consider alternate ways that their children could continue to work on these developmental projects while school is virtual, so they don’t lose ground developmentally.
If parents can set reasonable goals, be patient, and focus on the daily routines, and consider the child’s individual developmental strengths and challenges, they may be better able to manage this challenging year. They may even find improved connection, patience, and perspective for both themselves and their children.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Neither Dr. Swick nor Dr. Jellinek had any relevant financial disclosures. Email them at [email protected].
Getting the most out of a psychiatric consultation
You’ve been struggling with what to do for a patient who has a significant mental health problem and really would love to have some help. You’re willing to fill out the requisite referral forms and wait your turn for what seems like an excruciating amount of time. But how do you ensure that you, your patient, and the family get the most out of the consultative experience so that everyone’s questions are answered and ongoing care, if needed, can continue?
To be fair, most of the burden of doing a good psychiatric or mental health consultation rests on the consultant, not the person making the request. It is their job to do a thorough evaluation and to identify any additional pieces of information that may be missing before a strong conclusion can be made. That said, however, this is the real world where everyone is busy and few have the time to track down every loose end that may exist regarding a patient’s history.
To that end, here are some recommendations for how to increase the chance that the outcome of your consultation with a child psychiatrist or other mental health professional will be maximally helpful for everyone involved. These tips are based on having been on the receiving end of psychiatric consultations for almost 2 decades and having worked closely with primary care clinicians in a number of different capacities.
The first question to ask yourself, and this may be the most important one of all, is whether or not you really need an actual psychiatrist at all at this stage versus another type of mental health professional. Physicians often are most comfortable dealing with other physicians. If a pediatrician has a question about a patient’s heart, it’s logical to consult a cardiologist. Thus if there’s a question about mental health, the knee-jerk reaction is to consult a psychiatrist. While understandable, looking first to a psychiatrist to help with a patient’s mental health struggles often is not the best move. Psychiatrists make up only one small part of all mental health professionals that also include psychologists, counselors, and clinical social workers, among others. The availability of child and adolescent psychiatrists can been exceedingly sparse while other types of mental health professionals generally are much more available. Moreover, these other types of mental health professionals also can do a great job at assessment and treatment. It is true that most can’t prescribe medication, but best practice recommendations for most of the common mental health diagnoses in youth (anxiety, depression, obsessive compulsive disorder, etc.) explicitly outline that nonpharmacologic treatments should be used first. It breaks my heart every time I do a consult for a family who has waited 6 months only to have me recommend a good therapist they could have seen right off in a week.
Get to know the mental health resources of your community beyond the small number of psychiatrists who might be there. And if you aren’t sure whether or not a referral might best go first to a mental health professional who is not a psychiatrist, just ask. That quick phone call or email might save the family a needless delay in treatment and a lot of aggravation for you.
If you are confident that it is a child & adolescent psychiatrist you want your patient to see, here are some things that will help you get the most out of that consultation and help you avoid the disappointment (for both you and the family) of an evaluation that completely misses the mark.
Select the best site (if you have an option)
Broadly speaking, psychiatrists often can be found in three main areas: academic clinics, private practice, and community mental health centers. While of course there is huge variation of clinicians at each of the sites, some generalizations regarding typical advantages and disadvantages of each setting are probably fair.
Academic settings often have psychiatrists who are local or even national experts on particular topics and can be good places to get evaluations for patients with complicated histories. At the same time, however, these settings typically rely on trainees to do much of the actual work. Many of the residents and fellows are excellent, but they turn over quickly because of graduation and finishing rotations, which can force patients to get to know a lot of different people. Academic centers also can be quite a distance from a family’s home, which often makes follow-up care a challenge (especially when we go back to more in-person visits).
Private practice psychiatrists can provide a more local option and can give families access to experienced clinicians, but many of these practices (especially the ones that take insurance) have practice models that involve seeing a lot of patients for short amounts of time and with less coordination with other types of services.
Finally, psychiatrists working at community mental health centers often work in teams that can help families get access to a lot of useful ancillary services (case management, home supports, etc.) but are part of a public mental health system that sadly is all too often overstretched and underfunded.
If you have choices for where to go for psychiatric services, keeping these things in mind can help you find the best fit for families.
Provide a medication history
While I’m not a big fan of the “what medicine do I try next?” consultation, don’t rely on families to provide this information accurately. Medications are confusing, and I can’t tell you how many times I’ve heard: “I tried the little blue pill and then the big white capsule.” Nobody feels good if the end result of a long consultative process includes a recommendation for a medication that the patient has already tried and failed. Some EMRs now have this information in a way that can be more easily packaged and shared.
State what you are looking for
If you really want the psychiatrist to take over the care of the patient, are just looking for some guidance for what to do next, or are seeking a second opinion for a patient that already works with a psychiatrist, stating so specifically can help tailor the consultation to best address the situation.
Send along past evaluations
Many patients have accumulated detailed psychological or educational evaluations over time that can include some really important information like cognitive profiles, other diagnostic impressions, and past treatment recommendations that may or may not have been implemented. Having these available to the consulting psychiatrist (of course parents need to give permission to send these along) can help the consultant avoid asking redundant questions or recommend things that already have been tried.
Rule outs of medical causes
There are a lot of psychiatric symptoms that can be caused by nonpsychiatric causes. Sometimes, there can be an assumption on the part of the psychiatrist that the pediatrician already has evaluated for these possibilities while the pediatrician assumes that the psychiatrist will work those up if needed. This is how the care of some patients fall through the cracks, and how those unflattering stories of how patients were forced to live with undiagnosed ailments (seizures, encephalopathy, Lyme disease, etc.) for years are generated. Being clear what work-up and tests already have been done to look for other causes can help everyone involved decide what should be done next and who should do it.
Yes, it is true that most of the recommendations specified here involve more work that the quick “behavioral problems: eval and treat” note that may be tempting to write when consulting with a mental health professional, but they will help avoid a lot of headaches for you down the road and, most importantly, get patients and families the timely and comprehensive care they deserve.
Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @PediPsych. Dr. Rettew said he had no relevant financial disclosures. Email Dr. Rettew at [email protected].
You’ve been struggling with what to do for a patient who has a significant mental health problem and really would love to have some help. You’re willing to fill out the requisite referral forms and wait your turn for what seems like an excruciating amount of time. But how do you ensure that you, your patient, and the family get the most out of the consultative experience so that everyone’s questions are answered and ongoing care, if needed, can continue?
To be fair, most of the burden of doing a good psychiatric or mental health consultation rests on the consultant, not the person making the request. It is their job to do a thorough evaluation and to identify any additional pieces of information that may be missing before a strong conclusion can be made. That said, however, this is the real world where everyone is busy and few have the time to track down every loose end that may exist regarding a patient’s history.
To that end, here are some recommendations for how to increase the chance that the outcome of your consultation with a child psychiatrist or other mental health professional will be maximally helpful for everyone involved. These tips are based on having been on the receiving end of psychiatric consultations for almost 2 decades and having worked closely with primary care clinicians in a number of different capacities.
The first question to ask yourself, and this may be the most important one of all, is whether or not you really need an actual psychiatrist at all at this stage versus another type of mental health professional. Physicians often are most comfortable dealing with other physicians. If a pediatrician has a question about a patient’s heart, it’s logical to consult a cardiologist. Thus if there’s a question about mental health, the knee-jerk reaction is to consult a psychiatrist. While understandable, looking first to a psychiatrist to help with a patient’s mental health struggles often is not the best move. Psychiatrists make up only one small part of all mental health professionals that also include psychologists, counselors, and clinical social workers, among others. The availability of child and adolescent psychiatrists can been exceedingly sparse while other types of mental health professionals generally are much more available. Moreover, these other types of mental health professionals also can do a great job at assessment and treatment. It is true that most can’t prescribe medication, but best practice recommendations for most of the common mental health diagnoses in youth (anxiety, depression, obsessive compulsive disorder, etc.) explicitly outline that nonpharmacologic treatments should be used first. It breaks my heart every time I do a consult for a family who has waited 6 months only to have me recommend a good therapist they could have seen right off in a week.
Get to know the mental health resources of your community beyond the small number of psychiatrists who might be there. And if you aren’t sure whether or not a referral might best go first to a mental health professional who is not a psychiatrist, just ask. That quick phone call or email might save the family a needless delay in treatment and a lot of aggravation for you.
If you are confident that it is a child & adolescent psychiatrist you want your patient to see, here are some things that will help you get the most out of that consultation and help you avoid the disappointment (for both you and the family) of an evaluation that completely misses the mark.
Select the best site (if you have an option)
Broadly speaking, psychiatrists often can be found in three main areas: academic clinics, private practice, and community mental health centers. While of course there is huge variation of clinicians at each of the sites, some generalizations regarding typical advantages and disadvantages of each setting are probably fair.
Academic settings often have psychiatrists who are local or even national experts on particular topics and can be good places to get evaluations for patients with complicated histories. At the same time, however, these settings typically rely on trainees to do much of the actual work. Many of the residents and fellows are excellent, but they turn over quickly because of graduation and finishing rotations, which can force patients to get to know a lot of different people. Academic centers also can be quite a distance from a family’s home, which often makes follow-up care a challenge (especially when we go back to more in-person visits).
Private practice psychiatrists can provide a more local option and can give families access to experienced clinicians, but many of these practices (especially the ones that take insurance) have practice models that involve seeing a lot of patients for short amounts of time and with less coordination with other types of services.
Finally, psychiatrists working at community mental health centers often work in teams that can help families get access to a lot of useful ancillary services (case management, home supports, etc.) but are part of a public mental health system that sadly is all too often overstretched and underfunded.
If you have choices for where to go for psychiatric services, keeping these things in mind can help you find the best fit for families.
Provide a medication history
While I’m not a big fan of the “what medicine do I try next?” consultation, don’t rely on families to provide this information accurately. Medications are confusing, and I can’t tell you how many times I’ve heard: “I tried the little blue pill and then the big white capsule.” Nobody feels good if the end result of a long consultative process includes a recommendation for a medication that the patient has already tried and failed. Some EMRs now have this information in a way that can be more easily packaged and shared.
State what you are looking for
If you really want the psychiatrist to take over the care of the patient, are just looking for some guidance for what to do next, or are seeking a second opinion for a patient that already works with a psychiatrist, stating so specifically can help tailor the consultation to best address the situation.
Send along past evaluations
Many patients have accumulated detailed psychological or educational evaluations over time that can include some really important information like cognitive profiles, other diagnostic impressions, and past treatment recommendations that may or may not have been implemented. Having these available to the consulting psychiatrist (of course parents need to give permission to send these along) can help the consultant avoid asking redundant questions or recommend things that already have been tried.
Rule outs of medical causes
There are a lot of psychiatric symptoms that can be caused by nonpsychiatric causes. Sometimes, there can be an assumption on the part of the psychiatrist that the pediatrician already has evaluated for these possibilities while the pediatrician assumes that the psychiatrist will work those up if needed. This is how the care of some patients fall through the cracks, and how those unflattering stories of how patients were forced to live with undiagnosed ailments (seizures, encephalopathy, Lyme disease, etc.) for years are generated. Being clear what work-up and tests already have been done to look for other causes can help everyone involved decide what should be done next and who should do it.
Yes, it is true that most of the recommendations specified here involve more work that the quick “behavioral problems: eval and treat” note that may be tempting to write when consulting with a mental health professional, but they will help avoid a lot of headaches for you down the road and, most importantly, get patients and families the timely and comprehensive care they deserve.
Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @PediPsych. Dr. Rettew said he had no relevant financial disclosures. Email Dr. Rettew at [email protected].
You’ve been struggling with what to do for a patient who has a significant mental health problem and really would love to have some help. You’re willing to fill out the requisite referral forms and wait your turn for what seems like an excruciating amount of time. But how do you ensure that you, your patient, and the family get the most out of the consultative experience so that everyone’s questions are answered and ongoing care, if needed, can continue?
To be fair, most of the burden of doing a good psychiatric or mental health consultation rests on the consultant, not the person making the request. It is their job to do a thorough evaluation and to identify any additional pieces of information that may be missing before a strong conclusion can be made. That said, however, this is the real world where everyone is busy and few have the time to track down every loose end that may exist regarding a patient’s history.
To that end, here are some recommendations for how to increase the chance that the outcome of your consultation with a child psychiatrist or other mental health professional will be maximally helpful for everyone involved. These tips are based on having been on the receiving end of psychiatric consultations for almost 2 decades and having worked closely with primary care clinicians in a number of different capacities.
The first question to ask yourself, and this may be the most important one of all, is whether or not you really need an actual psychiatrist at all at this stage versus another type of mental health professional. Physicians often are most comfortable dealing with other physicians. If a pediatrician has a question about a patient’s heart, it’s logical to consult a cardiologist. Thus if there’s a question about mental health, the knee-jerk reaction is to consult a psychiatrist. While understandable, looking first to a psychiatrist to help with a patient’s mental health struggles often is not the best move. Psychiatrists make up only one small part of all mental health professionals that also include psychologists, counselors, and clinical social workers, among others. The availability of child and adolescent psychiatrists can been exceedingly sparse while other types of mental health professionals generally are much more available. Moreover, these other types of mental health professionals also can do a great job at assessment and treatment. It is true that most can’t prescribe medication, but best practice recommendations for most of the common mental health diagnoses in youth (anxiety, depression, obsessive compulsive disorder, etc.) explicitly outline that nonpharmacologic treatments should be used first. It breaks my heart every time I do a consult for a family who has waited 6 months only to have me recommend a good therapist they could have seen right off in a week.
Get to know the mental health resources of your community beyond the small number of psychiatrists who might be there. And if you aren’t sure whether or not a referral might best go first to a mental health professional who is not a psychiatrist, just ask. That quick phone call or email might save the family a needless delay in treatment and a lot of aggravation for you.
If you are confident that it is a child & adolescent psychiatrist you want your patient to see, here are some things that will help you get the most out of that consultation and help you avoid the disappointment (for both you and the family) of an evaluation that completely misses the mark.
Select the best site (if you have an option)
Broadly speaking, psychiatrists often can be found in three main areas: academic clinics, private practice, and community mental health centers. While of course there is huge variation of clinicians at each of the sites, some generalizations regarding typical advantages and disadvantages of each setting are probably fair.
Academic settings often have psychiatrists who are local or even national experts on particular topics and can be good places to get evaluations for patients with complicated histories. At the same time, however, these settings typically rely on trainees to do much of the actual work. Many of the residents and fellows are excellent, but they turn over quickly because of graduation and finishing rotations, which can force patients to get to know a lot of different people. Academic centers also can be quite a distance from a family’s home, which often makes follow-up care a challenge (especially when we go back to more in-person visits).
Private practice psychiatrists can provide a more local option and can give families access to experienced clinicians, but many of these practices (especially the ones that take insurance) have practice models that involve seeing a lot of patients for short amounts of time and with less coordination with other types of services.
Finally, psychiatrists working at community mental health centers often work in teams that can help families get access to a lot of useful ancillary services (case management, home supports, etc.) but are part of a public mental health system that sadly is all too often overstretched and underfunded.
If you have choices for where to go for psychiatric services, keeping these things in mind can help you find the best fit for families.
Provide a medication history
While I’m not a big fan of the “what medicine do I try next?” consultation, don’t rely on families to provide this information accurately. Medications are confusing, and I can’t tell you how many times I’ve heard: “I tried the little blue pill and then the big white capsule.” Nobody feels good if the end result of a long consultative process includes a recommendation for a medication that the patient has already tried and failed. Some EMRs now have this information in a way that can be more easily packaged and shared.
State what you are looking for
If you really want the psychiatrist to take over the care of the patient, are just looking for some guidance for what to do next, or are seeking a second opinion for a patient that already works with a psychiatrist, stating so specifically can help tailor the consultation to best address the situation.
Send along past evaluations
Many patients have accumulated detailed psychological or educational evaluations over time that can include some really important information like cognitive profiles, other diagnostic impressions, and past treatment recommendations that may or may not have been implemented. Having these available to the consulting psychiatrist (of course parents need to give permission to send these along) can help the consultant avoid asking redundant questions or recommend things that already have been tried.
Rule outs of medical causes
There are a lot of psychiatric symptoms that can be caused by nonpsychiatric causes. Sometimes, there can be an assumption on the part of the psychiatrist that the pediatrician already has evaluated for these possibilities while the pediatrician assumes that the psychiatrist will work those up if needed. This is how the care of some patients fall through the cracks, and how those unflattering stories of how patients were forced to live with undiagnosed ailments (seizures, encephalopathy, Lyme disease, etc.) for years are generated. Being clear what work-up and tests already have been done to look for other causes can help everyone involved decide what should be done next and who should do it.
Yes, it is true that most of the recommendations specified here involve more work that the quick “behavioral problems: eval and treat” note that may be tempting to write when consulting with a mental health professional, but they will help avoid a lot of headaches for you down the road and, most importantly, get patients and families the timely and comprehensive care they deserve.
Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @PediPsych. Dr. Rettew said he had no relevant financial disclosures. Email Dr. Rettew at [email protected].
Evaluate, manage the stress response in susceptible individuals affected by COVID-19
Steroid therapy should be explored for quarantined mental health patients
Psychological First Aid is an innovative program launched by the American Red Cross with the goal of addressing issues of concern such as those stemming from COVID-19–related stress. According to Red Cross mental health volunteer representative Deb Butman-Perkins, the program provides “a general overview of what does stress look like, how do we feel it, how do we recognize it in our bodies ... physical, emotional, spiritual, physiological, where does all that stress occur?”1
The program brings a spotlight to the interdisciplinary nature of the stress response, especially with respect to the importance of developing the necessary coping skills during an ongoing crisis. However, to effectively evaluate and manage the overall stress response for psychiatric patients during quarantine conditions, as well as those who are formally diagnosed with COVID-19, clinicians also will need to revisit what we’ve learned about the hypothalamic-pituitary-adrenal (HPA) axis.
We know that the stress response – which varies somewhat across the spectrum – is necessary to ensure homeostatic regulation. A feedback loop is initiated at the receptor level, involving a myriad of hormones and chemical signals that bring forth the body’s “flight-or-fight” response. Hormones such as epinephrine/norepinephrine and cortisol are secreted by the HPA axis in reaction to the stress response, resulting in a spike in heart rate, blood pressure, and transient hyperglycemia, respectively. In particular, hyperglycemia provides immediate energy to muscles during a perceived crisis.2
In addition, prolonged exposure to living in quarantine can lead to feelings of isolation and estrangement – and excessive anxiety. Combined, those conditions may exert an indelible effect on the HPA axis – leading to a warped pattern of cortisol secretion with respect to baseline.3 (It has been noted in the literature that serum cortisol plays a protective role in thwarting off the effects of PTSD development. Consistent with this line of thinking, military personnel have been preemptively treated with high-dose cortisol during acute exposure.)
Prolonged exposure to psychosocial stressors also increases the overall risk of developing medical comorbidities. Patients who adopt maladaptive responses to traumatic events, for example, may experience dysregulation in eating behaviors and/or disordered sleep.4
In light of those realities, clinicians should explore the role of steroid therapy as a means of treating mental health patients experiencing psychological stress formation tied to ongoing quarantine conditions.
Challenges of neuroendocrine medications for COVID-19
COVID-19, caused by exposure to SARS-CoV-2, adeptly leverages the ACE2 receptor of the lungs as an entry point to evade the host’s defenses. It should be noted that the ACE2 protein is expressed on the cells of multiple organs of the body, including the adrenals, which are largely responsible for coordinating the stress response of the HPA axis.
Postmortem analysis from severe acute respiratory syndrome (SARS-CoV is also from the Coronaviridae family) patients indicates the presence of necrotic adrenal cells, further solidifying the association of the HPA axis to the COVID-19 disease state and pathophysiological course.5 Molecular mimicry of the adrenocorticotropic hormone allows SARS-CoV the ability to infiltrate the host’s defenses, in particular, the ability to mount a clinically apt cortisol stress response (e.g., hypocortisolism).As for those who survived the 2003 SARS outbreak, less than half of the patients have been observed to develop symptoms of frank hypocortisolism within a few months after exposure.
and an ongoing clinical trial is evaluating the safety and efficacy parameters of corticosteroids in COVID-19–exposed patients.
In addition, there is reason to believe that application of prophylactic steroids might affect the overall clinical course of COVID-19, thereby reducing mortality and morbidity rates in patients with severe presentation, such as septic shock. The rationale for this line of thought is based on the ability of glucocorticoids to suppress an ensuing cytokine storm by the virus in question.5,6 In clinical practice, steroids have been used to treat a host of viral diseases, including influenza, respiratory syncytial virus, and Middle East respiratory syndrome coronavirus.
Aside from the selective use of corticosteroids, the medication regimen may incorporate ACE inhibitors and/or angiotensin receptor blockers (ARBs) because of COVID-19’s ability to activate the renin-angiotensin-aldosterone system with respect to the physiological stress response.
The interplay of the HPA axis with the sympathoadrenal system is responsible for adaptive behaviors in the individual. Disrupted feedback loops from prolonged activation are associated with numerous stress-based conditions in mental illness, namely, PTSD, anxiety, and mood disorders. We are concerned about frontline health care workers, who are particularly prone to chronic stress and burnout because of the cumbersome patient load and equipment shortage that have characterized the coronavirus crisis.
Timely administration of corticosteroids on a case-by-case basis would keep the cytokines at bay by precluding their undue activation of the HPA axis and corresponding cascade stress response. Steroids are also known to restore disrupted feedback loops at the level of the immune cells. However, because of conflicting reports concerning viral clearance in some SARS and COVID-19 studies, treatment with steroids may be limited to select patient populations with the necessary dose adjustments. Ongoing clinical trials will further elucidate upon the applicability of steroids as well as the role of other neuroendocrine agents, such as ACE inhibitors or ARBs, in the treatment of COVID-19.
Behavioral manifestations and psychosocial health
As far as the stress response is concerned, an analysis performed by researchers in China after the COVID-19 outbreak found gender disparities in symptom expression. In the study (n = 1,210) the researchers found in female citizens a greater frequency of behavioral manifestations, including acute stress reaction, and symptoms of anxiety and mood disorders – namely, depression.7 Patient perception and awareness of the perils of coronavirus typically varied across the spectrum; some individuals reportedly undermined and devalued their risk of contracting COVID-19 – these patients may benefit from therapeutic modalities, such as cognitive-behavioral therapy (CBT), as a means of challenging their firmly entrenched cognitive distortions. CBT is an effective tool in addressing maladaptive coping responses, because these strategies tend to correspond with poor prognosis with respect to overall mental health. Aside from CBT, the clinician may advise other behavioral techniques, such as relaxation training, with the aim of controlling the symptoms of mood and anxiety disorders.
We often take for granted general pandemic safety precautions, such as maintaining physical distancing coupled with engaging in regular hand hygiene and wearing masks, but these actions also are known to alleviate mental anguish. Access to accurate and easy-to-consume health information regarding COVID-19 is also associated with psychological well-being during the quarantine.8
An intriguing “phenomenon” has emerged in the form of “panic buying.”However, researchers reported in the peer-reviewed journal Nature Human Behaviour that this pattern of behaviors is not typical for those under distress and represents an overstated misnomer of sorts. According to Jay J. Van Bavel, PhD, and associates, prevailing reports from news outlets have skewed the features of a panic. “News stories that employ the language of panic often create the very phenomena that they purport to condemn,” Dr. Van Bavel and associates wrote. “They can foster the very individualism and competitiveness that turn sensible preparations into dysfunctional stockpiling and undermine the sense of collective purpose which facilitates people supporting one another during an emergency.”9
The researchers proceeded to highlight the scope of effective crisis leadership with respect to establishing a sense of communal “self-efficacy and hope.” The influence of organized leadership serves to solidify the structure of the community as a whole, allowing group members the opportunity to address the stressors of interest. Such leadership may mitigate the stress response by fostering a necessary, healthy set for stress management.
Strategies aimed at supporting mental health
Coping and stress management strategies may include the process of building virtual networks (e.g., social media platforms) because physical distancing may contribute toward further isolation and social estrangement. However, it should be noted that ideally social media consumption should be centered upon interactive enrichment activities that provide a suitable substitute for the absence of physical support systems. The goal is to facilitate meaningful relationships and enduring communications that produce healthy and resilient mindsets.
In particular, individuals who possess adaptive mindsets with a realistic view of ongoing psychosocial stressors, be it from the impact of the pandemic or other influential events, are more likely to benefit when moving forward with life. In other words, the individual in question leverages these experiences as a means of “stress-related growth,” thereby enhancing the overall quality of relationships. Tentative studies in stress management have yielded promising support for interventions that aim to modulate mindsets (as a function of the stress response) by proper appraisal of the stress stimuli, according to Dr. Van Bavel and associates.
Employing assessment scales
To mitigate the stress response, clinicians need to use the relevant stress scales for assessing the full impact of distress brought on by COVID-19 and optimizing therapeutic modalities for those who need them most. Again, the stress response would vary, depending on the patient, and may include paranoia, xenophobia, compulsive ritualistic behavior, as well as full-fledged symptoms of acute stress disorder/PTSD.Steven Taylor, PhD, RPsych, and associates, part of a research team funded by the Canadian Institutes of Health Research and the University of Regina (Sask.), formulated their proprietary COVID Stress Scales (CSS) based on 36 items pertaining to individual anxiety and/or stress responses.10
As general purpose pandemic scales, the assessment tools will be transferable to similar outbreaks, and have been examined for validity and reliability. Additional validation scales include the Patient Health Questionnaire–4 for anxiety and depression, the Short Health Anxiety Inventory for anxiety (irrespective of physical condition), and the Marlowe-Crowne Social Desirability Scale–Short Form for psychological well-being based on the presence (or the lack thereof) of desirable characteristics.10 As a composite scale and predictive tool (especially with respect to future pandemics), the CSS allows clinicians a means of identifying the people who are most compliant with safety procedures, social distancing, hygiene expectations, and vaccine protocols – when applicable – reported Dr. Taylor and associates.
Moving forward: The next step in COVID-19 preparedness
As clinicians continue to develop guidelines that are befitting of COVID-19’s “new normal,” a holistic psychosocial framework will need to integrate the various psychometrics gathered from assessment scales, as well as understanding trauma, especially with respect to the HPA axis.
For starters, there is a certain element of “anticipatory anxiety” for those experiencing distress from COVID-19. A highly uncertain future with no immediate cure in the future, isolation and social estrangement, as well as financial setbacks, compound the situation. Moreover, the DSM fails to acknowledge other sources of traumatic experiences that are systemic in nature, such as discriminatory practices, injustice, and/or persecution.
It has also been noted that some distressed individuals experience a hypervigilant state that is comparable with PTSD.11 There may be a push to incorporate machine learning and other modalities to better identify those at risk (for example, health care professionals who perform their duties with limited resources, thereby inducing sleep dysregulation, anxiety, and hopelessness) for mental health deterioration. Interventions may need to be coordinated in a timely manner to disrupt the progression of acute stress disorder to PTSD. Peer support programs and resiliency training – successful therapeutic approaches for PTSD – may prove to have considerable utility for mitigating the overall stress response of COVID-19.12
References
1. “Red Cross offering online course to manage crisis-related stress.” ABC 6 News. kaaltv.com, 2020 Aug 29.
2. Islam FA, Choudhry C. J Psychiatry Psychiatric Disord 2017;1(5): 290-3.
3. Faravelli C et al. World J Psychiatry. 2012 Feb 22;2(1):13-25.
4. Carmassi C et al. Psychiatry Res. 2015 Jan 30;225(1-2):64-9.
5. Pal R. Endocrine. 2020 Apr 28. doi: 10.1007/s12020-020-02325-1.
6. Steenblock C et al. Mol Psychiatry. 2020 May. doi: 10.1038/s41380-020-0758-9.
7. Wang C et al. Int J Environ Res Public Health. 2020 Jan;17(5):1729.
8. Ho CS et al. Ann Acad Med Singap. 2020 Mar 16;49(3):155-60.
9. Van Bavel JJ et al. Nat Hum Behav. 2020 Apr 30. doi: 10.1038/s41562-020-0884-z.
10. Taylor S et al. J Anxiety Disord. 2020 May 4;72:102232.
11. Horesh D, Brown AD. Psychol Trauma. 2020 May;12(4):331-5.
12. Clark H et al. National Health Library and Knowledge Service/Evidence Team. Summary of Evidence: COVID-19, 2020 May 22. Version 2.0.
Dr. Faisal A. Islam is a medical adviser for the International Maternal and Child Health Foundation, Montreal, and is based in New York. He also is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Mohammed S. Islam is a research physician and extern at Interfaith Medical Center, New York. Dr. Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the International Maternal and Child Health Foundation. Dr. Jolayemi is an attending psychiatrist at Interfaith Medical Center. No disclosures were reported.
Steroid therapy should be explored for quarantined mental health patients
Steroid therapy should be explored for quarantined mental health patients
Psychological First Aid is an innovative program launched by the American Red Cross with the goal of addressing issues of concern such as those stemming from COVID-19–related stress. According to Red Cross mental health volunteer representative Deb Butman-Perkins, the program provides “a general overview of what does stress look like, how do we feel it, how do we recognize it in our bodies ... physical, emotional, spiritual, physiological, where does all that stress occur?”1
The program brings a spotlight to the interdisciplinary nature of the stress response, especially with respect to the importance of developing the necessary coping skills during an ongoing crisis. However, to effectively evaluate and manage the overall stress response for psychiatric patients during quarantine conditions, as well as those who are formally diagnosed with COVID-19, clinicians also will need to revisit what we’ve learned about the hypothalamic-pituitary-adrenal (HPA) axis.
We know that the stress response – which varies somewhat across the spectrum – is necessary to ensure homeostatic regulation. A feedback loop is initiated at the receptor level, involving a myriad of hormones and chemical signals that bring forth the body’s “flight-or-fight” response. Hormones such as epinephrine/norepinephrine and cortisol are secreted by the HPA axis in reaction to the stress response, resulting in a spike in heart rate, blood pressure, and transient hyperglycemia, respectively. In particular, hyperglycemia provides immediate energy to muscles during a perceived crisis.2
In addition, prolonged exposure to living in quarantine can lead to feelings of isolation and estrangement – and excessive anxiety. Combined, those conditions may exert an indelible effect on the HPA axis – leading to a warped pattern of cortisol secretion with respect to baseline.3 (It has been noted in the literature that serum cortisol plays a protective role in thwarting off the effects of PTSD development. Consistent with this line of thinking, military personnel have been preemptively treated with high-dose cortisol during acute exposure.)
Prolonged exposure to psychosocial stressors also increases the overall risk of developing medical comorbidities. Patients who adopt maladaptive responses to traumatic events, for example, may experience dysregulation in eating behaviors and/or disordered sleep.4
In light of those realities, clinicians should explore the role of steroid therapy as a means of treating mental health patients experiencing psychological stress formation tied to ongoing quarantine conditions.
Challenges of neuroendocrine medications for COVID-19
COVID-19, caused by exposure to SARS-CoV-2, adeptly leverages the ACE2 receptor of the lungs as an entry point to evade the host’s defenses. It should be noted that the ACE2 protein is expressed on the cells of multiple organs of the body, including the adrenals, which are largely responsible for coordinating the stress response of the HPA axis.
Postmortem analysis from severe acute respiratory syndrome (SARS-CoV is also from the Coronaviridae family) patients indicates the presence of necrotic adrenal cells, further solidifying the association of the HPA axis to the COVID-19 disease state and pathophysiological course.5 Molecular mimicry of the adrenocorticotropic hormone allows SARS-CoV the ability to infiltrate the host’s defenses, in particular, the ability to mount a clinically apt cortisol stress response (e.g., hypocortisolism).As for those who survived the 2003 SARS outbreak, less than half of the patients have been observed to develop symptoms of frank hypocortisolism within a few months after exposure.
and an ongoing clinical trial is evaluating the safety and efficacy parameters of corticosteroids in COVID-19–exposed patients.
In addition, there is reason to believe that application of prophylactic steroids might affect the overall clinical course of COVID-19, thereby reducing mortality and morbidity rates in patients with severe presentation, such as septic shock. The rationale for this line of thought is based on the ability of glucocorticoids to suppress an ensuing cytokine storm by the virus in question.5,6 In clinical practice, steroids have been used to treat a host of viral diseases, including influenza, respiratory syncytial virus, and Middle East respiratory syndrome coronavirus.
Aside from the selective use of corticosteroids, the medication regimen may incorporate ACE inhibitors and/or angiotensin receptor blockers (ARBs) because of COVID-19’s ability to activate the renin-angiotensin-aldosterone system with respect to the physiological stress response.
The interplay of the HPA axis with the sympathoadrenal system is responsible for adaptive behaviors in the individual. Disrupted feedback loops from prolonged activation are associated with numerous stress-based conditions in mental illness, namely, PTSD, anxiety, and mood disorders. We are concerned about frontline health care workers, who are particularly prone to chronic stress and burnout because of the cumbersome patient load and equipment shortage that have characterized the coronavirus crisis.
Timely administration of corticosteroids on a case-by-case basis would keep the cytokines at bay by precluding their undue activation of the HPA axis and corresponding cascade stress response. Steroids are also known to restore disrupted feedback loops at the level of the immune cells. However, because of conflicting reports concerning viral clearance in some SARS and COVID-19 studies, treatment with steroids may be limited to select patient populations with the necessary dose adjustments. Ongoing clinical trials will further elucidate upon the applicability of steroids as well as the role of other neuroendocrine agents, such as ACE inhibitors or ARBs, in the treatment of COVID-19.
Behavioral manifestations and psychosocial health
As far as the stress response is concerned, an analysis performed by researchers in China after the COVID-19 outbreak found gender disparities in symptom expression. In the study (n = 1,210) the researchers found in female citizens a greater frequency of behavioral manifestations, including acute stress reaction, and symptoms of anxiety and mood disorders – namely, depression.7 Patient perception and awareness of the perils of coronavirus typically varied across the spectrum; some individuals reportedly undermined and devalued their risk of contracting COVID-19 – these patients may benefit from therapeutic modalities, such as cognitive-behavioral therapy (CBT), as a means of challenging their firmly entrenched cognitive distortions. CBT is an effective tool in addressing maladaptive coping responses, because these strategies tend to correspond with poor prognosis with respect to overall mental health. Aside from CBT, the clinician may advise other behavioral techniques, such as relaxation training, with the aim of controlling the symptoms of mood and anxiety disorders.
We often take for granted general pandemic safety precautions, such as maintaining physical distancing coupled with engaging in regular hand hygiene and wearing masks, but these actions also are known to alleviate mental anguish. Access to accurate and easy-to-consume health information regarding COVID-19 is also associated with psychological well-being during the quarantine.8
An intriguing “phenomenon” has emerged in the form of “panic buying.”However, researchers reported in the peer-reviewed journal Nature Human Behaviour that this pattern of behaviors is not typical for those under distress and represents an overstated misnomer of sorts. According to Jay J. Van Bavel, PhD, and associates, prevailing reports from news outlets have skewed the features of a panic. “News stories that employ the language of panic often create the very phenomena that they purport to condemn,” Dr. Van Bavel and associates wrote. “They can foster the very individualism and competitiveness that turn sensible preparations into dysfunctional stockpiling and undermine the sense of collective purpose which facilitates people supporting one another during an emergency.”9
The researchers proceeded to highlight the scope of effective crisis leadership with respect to establishing a sense of communal “self-efficacy and hope.” The influence of organized leadership serves to solidify the structure of the community as a whole, allowing group members the opportunity to address the stressors of interest. Such leadership may mitigate the stress response by fostering a necessary, healthy set for stress management.
Strategies aimed at supporting mental health
Coping and stress management strategies may include the process of building virtual networks (e.g., social media platforms) because physical distancing may contribute toward further isolation and social estrangement. However, it should be noted that ideally social media consumption should be centered upon interactive enrichment activities that provide a suitable substitute for the absence of physical support systems. The goal is to facilitate meaningful relationships and enduring communications that produce healthy and resilient mindsets.
In particular, individuals who possess adaptive mindsets with a realistic view of ongoing psychosocial stressors, be it from the impact of the pandemic or other influential events, are more likely to benefit when moving forward with life. In other words, the individual in question leverages these experiences as a means of “stress-related growth,” thereby enhancing the overall quality of relationships. Tentative studies in stress management have yielded promising support for interventions that aim to modulate mindsets (as a function of the stress response) by proper appraisal of the stress stimuli, according to Dr. Van Bavel and associates.
Employing assessment scales
To mitigate the stress response, clinicians need to use the relevant stress scales for assessing the full impact of distress brought on by COVID-19 and optimizing therapeutic modalities for those who need them most. Again, the stress response would vary, depending on the patient, and may include paranoia, xenophobia, compulsive ritualistic behavior, as well as full-fledged symptoms of acute stress disorder/PTSD.Steven Taylor, PhD, RPsych, and associates, part of a research team funded by the Canadian Institutes of Health Research and the University of Regina (Sask.), formulated their proprietary COVID Stress Scales (CSS) based on 36 items pertaining to individual anxiety and/or stress responses.10
As general purpose pandemic scales, the assessment tools will be transferable to similar outbreaks, and have been examined for validity and reliability. Additional validation scales include the Patient Health Questionnaire–4 for anxiety and depression, the Short Health Anxiety Inventory for anxiety (irrespective of physical condition), and the Marlowe-Crowne Social Desirability Scale–Short Form for psychological well-being based on the presence (or the lack thereof) of desirable characteristics.10 As a composite scale and predictive tool (especially with respect to future pandemics), the CSS allows clinicians a means of identifying the people who are most compliant with safety procedures, social distancing, hygiene expectations, and vaccine protocols – when applicable – reported Dr. Taylor and associates.
Moving forward: The next step in COVID-19 preparedness
As clinicians continue to develop guidelines that are befitting of COVID-19’s “new normal,” a holistic psychosocial framework will need to integrate the various psychometrics gathered from assessment scales, as well as understanding trauma, especially with respect to the HPA axis.
For starters, there is a certain element of “anticipatory anxiety” for those experiencing distress from COVID-19. A highly uncertain future with no immediate cure in the future, isolation and social estrangement, as well as financial setbacks, compound the situation. Moreover, the DSM fails to acknowledge other sources of traumatic experiences that are systemic in nature, such as discriminatory practices, injustice, and/or persecution.
It has also been noted that some distressed individuals experience a hypervigilant state that is comparable with PTSD.11 There may be a push to incorporate machine learning and other modalities to better identify those at risk (for example, health care professionals who perform their duties with limited resources, thereby inducing sleep dysregulation, anxiety, and hopelessness) for mental health deterioration. Interventions may need to be coordinated in a timely manner to disrupt the progression of acute stress disorder to PTSD. Peer support programs and resiliency training – successful therapeutic approaches for PTSD – may prove to have considerable utility for mitigating the overall stress response of COVID-19.12
References
1. “Red Cross offering online course to manage crisis-related stress.” ABC 6 News. kaaltv.com, 2020 Aug 29.
2. Islam FA, Choudhry C. J Psychiatry Psychiatric Disord 2017;1(5): 290-3.
3. Faravelli C et al. World J Psychiatry. 2012 Feb 22;2(1):13-25.
4. Carmassi C et al. Psychiatry Res. 2015 Jan 30;225(1-2):64-9.
5. Pal R. Endocrine. 2020 Apr 28. doi: 10.1007/s12020-020-02325-1.
6. Steenblock C et al. Mol Psychiatry. 2020 May. doi: 10.1038/s41380-020-0758-9.
7. Wang C et al. Int J Environ Res Public Health. 2020 Jan;17(5):1729.
8. Ho CS et al. Ann Acad Med Singap. 2020 Mar 16;49(3):155-60.
9. Van Bavel JJ et al. Nat Hum Behav. 2020 Apr 30. doi: 10.1038/s41562-020-0884-z.
10. Taylor S et al. J Anxiety Disord. 2020 May 4;72:102232.
11. Horesh D, Brown AD. Psychol Trauma. 2020 May;12(4):331-5.
12. Clark H et al. National Health Library and Knowledge Service/Evidence Team. Summary of Evidence: COVID-19, 2020 May 22. Version 2.0.
Dr. Faisal A. Islam is a medical adviser for the International Maternal and Child Health Foundation, Montreal, and is based in New York. He also is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Mohammed S. Islam is a research physician and extern at Interfaith Medical Center, New York. Dr. Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the International Maternal and Child Health Foundation. Dr. Jolayemi is an attending psychiatrist at Interfaith Medical Center. No disclosures were reported.
Psychological First Aid is an innovative program launched by the American Red Cross with the goal of addressing issues of concern such as those stemming from COVID-19–related stress. According to Red Cross mental health volunteer representative Deb Butman-Perkins, the program provides “a general overview of what does stress look like, how do we feel it, how do we recognize it in our bodies ... physical, emotional, spiritual, physiological, where does all that stress occur?”1
The program brings a spotlight to the interdisciplinary nature of the stress response, especially with respect to the importance of developing the necessary coping skills during an ongoing crisis. However, to effectively evaluate and manage the overall stress response for psychiatric patients during quarantine conditions, as well as those who are formally diagnosed with COVID-19, clinicians also will need to revisit what we’ve learned about the hypothalamic-pituitary-adrenal (HPA) axis.
We know that the stress response – which varies somewhat across the spectrum – is necessary to ensure homeostatic regulation. A feedback loop is initiated at the receptor level, involving a myriad of hormones and chemical signals that bring forth the body’s “flight-or-fight” response. Hormones such as epinephrine/norepinephrine and cortisol are secreted by the HPA axis in reaction to the stress response, resulting in a spike in heart rate, blood pressure, and transient hyperglycemia, respectively. In particular, hyperglycemia provides immediate energy to muscles during a perceived crisis.2
In addition, prolonged exposure to living in quarantine can lead to feelings of isolation and estrangement – and excessive anxiety. Combined, those conditions may exert an indelible effect on the HPA axis – leading to a warped pattern of cortisol secretion with respect to baseline.3 (It has been noted in the literature that serum cortisol plays a protective role in thwarting off the effects of PTSD development. Consistent with this line of thinking, military personnel have been preemptively treated with high-dose cortisol during acute exposure.)
Prolonged exposure to psychosocial stressors also increases the overall risk of developing medical comorbidities. Patients who adopt maladaptive responses to traumatic events, for example, may experience dysregulation in eating behaviors and/or disordered sleep.4
In light of those realities, clinicians should explore the role of steroid therapy as a means of treating mental health patients experiencing psychological stress formation tied to ongoing quarantine conditions.
Challenges of neuroendocrine medications for COVID-19
COVID-19, caused by exposure to SARS-CoV-2, adeptly leverages the ACE2 receptor of the lungs as an entry point to evade the host’s defenses. It should be noted that the ACE2 protein is expressed on the cells of multiple organs of the body, including the adrenals, which are largely responsible for coordinating the stress response of the HPA axis.
Postmortem analysis from severe acute respiratory syndrome (SARS-CoV is also from the Coronaviridae family) patients indicates the presence of necrotic adrenal cells, further solidifying the association of the HPA axis to the COVID-19 disease state and pathophysiological course.5 Molecular mimicry of the adrenocorticotropic hormone allows SARS-CoV the ability to infiltrate the host’s defenses, in particular, the ability to mount a clinically apt cortisol stress response (e.g., hypocortisolism).As for those who survived the 2003 SARS outbreak, less than half of the patients have been observed to develop symptoms of frank hypocortisolism within a few months after exposure.
and an ongoing clinical trial is evaluating the safety and efficacy parameters of corticosteroids in COVID-19–exposed patients.
In addition, there is reason to believe that application of prophylactic steroids might affect the overall clinical course of COVID-19, thereby reducing mortality and morbidity rates in patients with severe presentation, such as septic shock. The rationale for this line of thought is based on the ability of glucocorticoids to suppress an ensuing cytokine storm by the virus in question.5,6 In clinical practice, steroids have been used to treat a host of viral diseases, including influenza, respiratory syncytial virus, and Middle East respiratory syndrome coronavirus.
Aside from the selective use of corticosteroids, the medication regimen may incorporate ACE inhibitors and/or angiotensin receptor blockers (ARBs) because of COVID-19’s ability to activate the renin-angiotensin-aldosterone system with respect to the physiological stress response.
The interplay of the HPA axis with the sympathoadrenal system is responsible for adaptive behaviors in the individual. Disrupted feedback loops from prolonged activation are associated with numerous stress-based conditions in mental illness, namely, PTSD, anxiety, and mood disorders. We are concerned about frontline health care workers, who are particularly prone to chronic stress and burnout because of the cumbersome patient load and equipment shortage that have characterized the coronavirus crisis.
Timely administration of corticosteroids on a case-by-case basis would keep the cytokines at bay by precluding their undue activation of the HPA axis and corresponding cascade stress response. Steroids are also known to restore disrupted feedback loops at the level of the immune cells. However, because of conflicting reports concerning viral clearance in some SARS and COVID-19 studies, treatment with steroids may be limited to select patient populations with the necessary dose adjustments. Ongoing clinical trials will further elucidate upon the applicability of steroids as well as the role of other neuroendocrine agents, such as ACE inhibitors or ARBs, in the treatment of COVID-19.
Behavioral manifestations and psychosocial health
As far as the stress response is concerned, an analysis performed by researchers in China after the COVID-19 outbreak found gender disparities in symptom expression. In the study (n = 1,210) the researchers found in female citizens a greater frequency of behavioral manifestations, including acute stress reaction, and symptoms of anxiety and mood disorders – namely, depression.7 Patient perception and awareness of the perils of coronavirus typically varied across the spectrum; some individuals reportedly undermined and devalued their risk of contracting COVID-19 – these patients may benefit from therapeutic modalities, such as cognitive-behavioral therapy (CBT), as a means of challenging their firmly entrenched cognitive distortions. CBT is an effective tool in addressing maladaptive coping responses, because these strategies tend to correspond with poor prognosis with respect to overall mental health. Aside from CBT, the clinician may advise other behavioral techniques, such as relaxation training, with the aim of controlling the symptoms of mood and anxiety disorders.
We often take for granted general pandemic safety precautions, such as maintaining physical distancing coupled with engaging in regular hand hygiene and wearing masks, but these actions also are known to alleviate mental anguish. Access to accurate and easy-to-consume health information regarding COVID-19 is also associated with psychological well-being during the quarantine.8
An intriguing “phenomenon” has emerged in the form of “panic buying.”However, researchers reported in the peer-reviewed journal Nature Human Behaviour that this pattern of behaviors is not typical for those under distress and represents an overstated misnomer of sorts. According to Jay J. Van Bavel, PhD, and associates, prevailing reports from news outlets have skewed the features of a panic. “News stories that employ the language of panic often create the very phenomena that they purport to condemn,” Dr. Van Bavel and associates wrote. “They can foster the very individualism and competitiveness that turn sensible preparations into dysfunctional stockpiling and undermine the sense of collective purpose which facilitates people supporting one another during an emergency.”9
The researchers proceeded to highlight the scope of effective crisis leadership with respect to establishing a sense of communal “self-efficacy and hope.” The influence of organized leadership serves to solidify the structure of the community as a whole, allowing group members the opportunity to address the stressors of interest. Such leadership may mitigate the stress response by fostering a necessary, healthy set for stress management.
Strategies aimed at supporting mental health
Coping and stress management strategies may include the process of building virtual networks (e.g., social media platforms) because physical distancing may contribute toward further isolation and social estrangement. However, it should be noted that ideally social media consumption should be centered upon interactive enrichment activities that provide a suitable substitute for the absence of physical support systems. The goal is to facilitate meaningful relationships and enduring communications that produce healthy and resilient mindsets.
In particular, individuals who possess adaptive mindsets with a realistic view of ongoing psychosocial stressors, be it from the impact of the pandemic or other influential events, are more likely to benefit when moving forward with life. In other words, the individual in question leverages these experiences as a means of “stress-related growth,” thereby enhancing the overall quality of relationships. Tentative studies in stress management have yielded promising support for interventions that aim to modulate mindsets (as a function of the stress response) by proper appraisal of the stress stimuli, according to Dr. Van Bavel and associates.
Employing assessment scales
To mitigate the stress response, clinicians need to use the relevant stress scales for assessing the full impact of distress brought on by COVID-19 and optimizing therapeutic modalities for those who need them most. Again, the stress response would vary, depending on the patient, and may include paranoia, xenophobia, compulsive ritualistic behavior, as well as full-fledged symptoms of acute stress disorder/PTSD.Steven Taylor, PhD, RPsych, and associates, part of a research team funded by the Canadian Institutes of Health Research and the University of Regina (Sask.), formulated their proprietary COVID Stress Scales (CSS) based on 36 items pertaining to individual anxiety and/or stress responses.10
As general purpose pandemic scales, the assessment tools will be transferable to similar outbreaks, and have been examined for validity and reliability. Additional validation scales include the Patient Health Questionnaire–4 for anxiety and depression, the Short Health Anxiety Inventory for anxiety (irrespective of physical condition), and the Marlowe-Crowne Social Desirability Scale–Short Form for psychological well-being based on the presence (or the lack thereof) of desirable characteristics.10 As a composite scale and predictive tool (especially with respect to future pandemics), the CSS allows clinicians a means of identifying the people who are most compliant with safety procedures, social distancing, hygiene expectations, and vaccine protocols – when applicable – reported Dr. Taylor and associates.
Moving forward: The next step in COVID-19 preparedness
As clinicians continue to develop guidelines that are befitting of COVID-19’s “new normal,” a holistic psychosocial framework will need to integrate the various psychometrics gathered from assessment scales, as well as understanding trauma, especially with respect to the HPA axis.
For starters, there is a certain element of “anticipatory anxiety” for those experiencing distress from COVID-19. A highly uncertain future with no immediate cure in the future, isolation and social estrangement, as well as financial setbacks, compound the situation. Moreover, the DSM fails to acknowledge other sources of traumatic experiences that are systemic in nature, such as discriminatory practices, injustice, and/or persecution.
It has also been noted that some distressed individuals experience a hypervigilant state that is comparable with PTSD.11 There may be a push to incorporate machine learning and other modalities to better identify those at risk (for example, health care professionals who perform their duties with limited resources, thereby inducing sleep dysregulation, anxiety, and hopelessness) for mental health deterioration. Interventions may need to be coordinated in a timely manner to disrupt the progression of acute stress disorder to PTSD. Peer support programs and resiliency training – successful therapeutic approaches for PTSD – may prove to have considerable utility for mitigating the overall stress response of COVID-19.12
References
1. “Red Cross offering online course to manage crisis-related stress.” ABC 6 News. kaaltv.com, 2020 Aug 29.
2. Islam FA, Choudhry C. J Psychiatry Psychiatric Disord 2017;1(5): 290-3.
3. Faravelli C et al. World J Psychiatry. 2012 Feb 22;2(1):13-25.
4. Carmassi C et al. Psychiatry Res. 2015 Jan 30;225(1-2):64-9.
5. Pal R. Endocrine. 2020 Apr 28. doi: 10.1007/s12020-020-02325-1.
6. Steenblock C et al. Mol Psychiatry. 2020 May. doi: 10.1038/s41380-020-0758-9.
7. Wang C et al. Int J Environ Res Public Health. 2020 Jan;17(5):1729.
8. Ho CS et al. Ann Acad Med Singap. 2020 Mar 16;49(3):155-60.
9. Van Bavel JJ et al. Nat Hum Behav. 2020 Apr 30. doi: 10.1038/s41562-020-0884-z.
10. Taylor S et al. J Anxiety Disord. 2020 May 4;72:102232.
11. Horesh D, Brown AD. Psychol Trauma. 2020 May;12(4):331-5.
12. Clark H et al. National Health Library and Knowledge Service/Evidence Team. Summary of Evidence: COVID-19, 2020 May 22. Version 2.0.
Dr. Faisal A. Islam is a medical adviser for the International Maternal and Child Health Foundation, Montreal, and is based in New York. He also is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Mohammed S. Islam is a research physician and extern at Interfaith Medical Center, New York. Dr. Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the International Maternal and Child Health Foundation. Dr. Jolayemi is an attending psychiatrist at Interfaith Medical Center. No disclosures were reported.
Defining excellence with Dr. Kimberly Manning
2020 SHM Award of Excellence winner: Diversity Leadership
Each year, the Society of Hospital Medicine celebrates the exemplary actions and successes of its members through the Awards of Excellence program. Nominations open every fall, providing the SHM community with the opportunity to nominate a peer, or themselves, to receive an esteemed award of excellence in an array of categories including Teaching, Outstanding Service in Hospital Medicine, Research, and so many others.
While the program and its Awards Committee review nominations with a predetermined set of criteria, excellence is not a ‘one-size-fits-all’ defined term.
Kimberly D. Manning, MD, FACP, FAAP, is a professor of medicine and associate vice chair of Diversity, Equity and Inclusion at the Emory University School of Medicine and a hospitalist at Grady Memorial Hospital, both in Atlanta. She believes that every single person contributes something uniquely meaningful, and that it is up to each person to decide how to use their influence to make an impact.
“To me, being excellent is about discovering your mission and pushing yourself to explore ways to be the best steward of that mission,” Dr. Manning said. “My mission is focused on serving underserved populations, humanizing patients, and amplifying voices of those who have traditionally been silenced.”
Dr. Manning has challenged herself to be the best steward of her evolving mission for equity, representation, and accessibility in medical education and health care innovation for many years. An active member of SHM for 14 years and an inspiring social impact–driven hospitalist of 20 years, Dr. Manning is known for her extensive work in the diversity, equity, and inclusion (DEI) space.
In 2020, Dr. Manning was nominated for and received SHM’s inaugural Excellence in Diversity Leadership Award by her peer and colleague, Dr. Daniel Dressler of Emory University School of Medicine.
She was honored for her commitment to improving the care of underrepresented patient populations, increasing awareness of DEI necessity, and building inclusive communities. In addition to these noteworthy achievements, she demonstrated scholarship on diversity, equity, and inclusion.
One way that Dr. Manning is fusing her love for diversity, equity, and inclusion with innovation is through her role as associate vice chair of the DEI department of Emory University’s School of Medicine. Within the department’s programs, resources and affinity groups, Dr. Manning leads a Virtual Visiting Clerkship Program for underrepresented medical students interested in pursuing a career in internal medicine.
“It includes coaching, mentorship, and diagnostic reasoning in an intimate and personal way,” she explained. “It makes me wish I were a medical student!”
In addition to her patient-centric and student-focused initiatives in Atlanta, Dr. Manning is an active contributor to SHM’s publications, including the Journal of Hospital Medicine and The Hospital Leader blog, in speaking out about racism in medicine, and other social inequities in health care. She even helped to lead a #JHMchat discussion on Twitter around these topics.
In fact, beyond being presented with the Diversity Leadership Award, she says that SHM and JHM have really demonstrated a strong commitment to diversity, equity, and inclusion.
“If you are a person with a lived experience or a person who is underrepresented in medicine, a lot of this work in diversity, equity, and inclusion never really had a name. It was called survival and looking out for each other,” Dr. Manning explained. “It’s exciting to be in this space now where there is focused, professional attention being given to something so important in our clinical and learning environments.”
SHM continues to reaffirm its longstanding commitment to diversity and inclusion and is dedicated to supporting and learning from its diverse member community. While SHM’s new Excellence in Diversity Leadership award is symbolic of a step in the right direction of change, Dr. Manning says that it is also an honor to be recognized for her areas of expertise and passion.
But that recognition moves far beyond this award. With so many more ways to connect with one another, Dr. Manning, a self-proclaimed optimist, says that one of the most exciting changes is centered on communication.
“For us to move the needle on anti-racism and representation, and to do more for our patients and colleagues, it must be a shared conversation. I feel particularly optimistic that I’m able to be more transparent than ever. I’m saying things to people whom I would have been too scared to say them to in the past.
“We’re hungry to grow and learn together,” she continued. “People are interacting in a more positive and constructive way. I’m so glad that we’re pushing diversity and you can see that a lot of people want to see us do better with this. We can continue to do better with this.”
SHM’s 2020-2021 Awards of Excellence nominations are now open with nine unique categories, including Excellence in Diversity, Equity, and Inclusion Leadership. If you have a peer or colleague in mind, like Dr. Manning, who has made exceptional contributions to DEI, or another important domain in hospital medicine, submit your nomination by Sept. 28, 2020.
“I have a feeling that this year has provided a lot of opportunity for people to emerge. The Committee is going to have a very, very tough job,” Dr. Manning said. “They are going to have some exciting nominations on their hands!”
Ms. Cowan is the marketing communications specialist at the Society of Hospital Medicine.
2020 SHM Award of Excellence winner: Diversity Leadership
2020 SHM Award of Excellence winner: Diversity Leadership
Each year, the Society of Hospital Medicine celebrates the exemplary actions and successes of its members through the Awards of Excellence program. Nominations open every fall, providing the SHM community with the opportunity to nominate a peer, or themselves, to receive an esteemed award of excellence in an array of categories including Teaching, Outstanding Service in Hospital Medicine, Research, and so many others.
While the program and its Awards Committee review nominations with a predetermined set of criteria, excellence is not a ‘one-size-fits-all’ defined term.
Kimberly D. Manning, MD, FACP, FAAP, is a professor of medicine and associate vice chair of Diversity, Equity and Inclusion at the Emory University School of Medicine and a hospitalist at Grady Memorial Hospital, both in Atlanta. She believes that every single person contributes something uniquely meaningful, and that it is up to each person to decide how to use their influence to make an impact.
“To me, being excellent is about discovering your mission and pushing yourself to explore ways to be the best steward of that mission,” Dr. Manning said. “My mission is focused on serving underserved populations, humanizing patients, and amplifying voices of those who have traditionally been silenced.”
Dr. Manning has challenged herself to be the best steward of her evolving mission for equity, representation, and accessibility in medical education and health care innovation for many years. An active member of SHM for 14 years and an inspiring social impact–driven hospitalist of 20 years, Dr. Manning is known for her extensive work in the diversity, equity, and inclusion (DEI) space.
In 2020, Dr. Manning was nominated for and received SHM’s inaugural Excellence in Diversity Leadership Award by her peer and colleague, Dr. Daniel Dressler of Emory University School of Medicine.
She was honored for her commitment to improving the care of underrepresented patient populations, increasing awareness of DEI necessity, and building inclusive communities. In addition to these noteworthy achievements, she demonstrated scholarship on diversity, equity, and inclusion.
One way that Dr. Manning is fusing her love for diversity, equity, and inclusion with innovation is through her role as associate vice chair of the DEI department of Emory University’s School of Medicine. Within the department’s programs, resources and affinity groups, Dr. Manning leads a Virtual Visiting Clerkship Program for underrepresented medical students interested in pursuing a career in internal medicine.
“It includes coaching, mentorship, and diagnostic reasoning in an intimate and personal way,” she explained. “It makes me wish I were a medical student!”
In addition to her patient-centric and student-focused initiatives in Atlanta, Dr. Manning is an active contributor to SHM’s publications, including the Journal of Hospital Medicine and The Hospital Leader blog, in speaking out about racism in medicine, and other social inequities in health care. She even helped to lead a #JHMchat discussion on Twitter around these topics.
In fact, beyond being presented with the Diversity Leadership Award, she says that SHM and JHM have really demonstrated a strong commitment to diversity, equity, and inclusion.
“If you are a person with a lived experience or a person who is underrepresented in medicine, a lot of this work in diversity, equity, and inclusion never really had a name. It was called survival and looking out for each other,” Dr. Manning explained. “It’s exciting to be in this space now where there is focused, professional attention being given to something so important in our clinical and learning environments.”
SHM continues to reaffirm its longstanding commitment to diversity and inclusion and is dedicated to supporting and learning from its diverse member community. While SHM’s new Excellence in Diversity Leadership award is symbolic of a step in the right direction of change, Dr. Manning says that it is also an honor to be recognized for her areas of expertise and passion.
But that recognition moves far beyond this award. With so many more ways to connect with one another, Dr. Manning, a self-proclaimed optimist, says that one of the most exciting changes is centered on communication.
“For us to move the needle on anti-racism and representation, and to do more for our patients and colleagues, it must be a shared conversation. I feel particularly optimistic that I’m able to be more transparent than ever. I’m saying things to people whom I would have been too scared to say them to in the past.
“We’re hungry to grow and learn together,” she continued. “People are interacting in a more positive and constructive way. I’m so glad that we’re pushing diversity and you can see that a lot of people want to see us do better with this. We can continue to do better with this.”
SHM’s 2020-2021 Awards of Excellence nominations are now open with nine unique categories, including Excellence in Diversity, Equity, and Inclusion Leadership. If you have a peer or colleague in mind, like Dr. Manning, who has made exceptional contributions to DEI, or another important domain in hospital medicine, submit your nomination by Sept. 28, 2020.
“I have a feeling that this year has provided a lot of opportunity for people to emerge. The Committee is going to have a very, very tough job,” Dr. Manning said. “They are going to have some exciting nominations on their hands!”
Ms. Cowan is the marketing communications specialist at the Society of Hospital Medicine.
Each year, the Society of Hospital Medicine celebrates the exemplary actions and successes of its members through the Awards of Excellence program. Nominations open every fall, providing the SHM community with the opportunity to nominate a peer, or themselves, to receive an esteemed award of excellence in an array of categories including Teaching, Outstanding Service in Hospital Medicine, Research, and so many others.
While the program and its Awards Committee review nominations with a predetermined set of criteria, excellence is not a ‘one-size-fits-all’ defined term.
Kimberly D. Manning, MD, FACP, FAAP, is a professor of medicine and associate vice chair of Diversity, Equity and Inclusion at the Emory University School of Medicine and a hospitalist at Grady Memorial Hospital, both in Atlanta. She believes that every single person contributes something uniquely meaningful, and that it is up to each person to decide how to use their influence to make an impact.
“To me, being excellent is about discovering your mission and pushing yourself to explore ways to be the best steward of that mission,” Dr. Manning said. “My mission is focused on serving underserved populations, humanizing patients, and amplifying voices of those who have traditionally been silenced.”
Dr. Manning has challenged herself to be the best steward of her evolving mission for equity, representation, and accessibility in medical education and health care innovation for many years. An active member of SHM for 14 years and an inspiring social impact–driven hospitalist of 20 years, Dr. Manning is known for her extensive work in the diversity, equity, and inclusion (DEI) space.
In 2020, Dr. Manning was nominated for and received SHM’s inaugural Excellence in Diversity Leadership Award by her peer and colleague, Dr. Daniel Dressler of Emory University School of Medicine.
She was honored for her commitment to improving the care of underrepresented patient populations, increasing awareness of DEI necessity, and building inclusive communities. In addition to these noteworthy achievements, she demonstrated scholarship on diversity, equity, and inclusion.
One way that Dr. Manning is fusing her love for diversity, equity, and inclusion with innovation is through her role as associate vice chair of the DEI department of Emory University’s School of Medicine. Within the department’s programs, resources and affinity groups, Dr. Manning leads a Virtual Visiting Clerkship Program for underrepresented medical students interested in pursuing a career in internal medicine.
“It includes coaching, mentorship, and diagnostic reasoning in an intimate and personal way,” she explained. “It makes me wish I were a medical student!”
In addition to her patient-centric and student-focused initiatives in Atlanta, Dr. Manning is an active contributor to SHM’s publications, including the Journal of Hospital Medicine and The Hospital Leader blog, in speaking out about racism in medicine, and other social inequities in health care. She even helped to lead a #JHMchat discussion on Twitter around these topics.
In fact, beyond being presented with the Diversity Leadership Award, she says that SHM and JHM have really demonstrated a strong commitment to diversity, equity, and inclusion.
“If you are a person with a lived experience or a person who is underrepresented in medicine, a lot of this work in diversity, equity, and inclusion never really had a name. It was called survival and looking out for each other,” Dr. Manning explained. “It’s exciting to be in this space now where there is focused, professional attention being given to something so important in our clinical and learning environments.”
SHM continues to reaffirm its longstanding commitment to diversity and inclusion and is dedicated to supporting and learning from its diverse member community. While SHM’s new Excellence in Diversity Leadership award is symbolic of a step in the right direction of change, Dr. Manning says that it is also an honor to be recognized for her areas of expertise and passion.
But that recognition moves far beyond this award. With so many more ways to connect with one another, Dr. Manning, a self-proclaimed optimist, says that one of the most exciting changes is centered on communication.
“For us to move the needle on anti-racism and representation, and to do more for our patients and colleagues, it must be a shared conversation. I feel particularly optimistic that I’m able to be more transparent than ever. I’m saying things to people whom I would have been too scared to say them to in the past.
“We’re hungry to grow and learn together,” she continued. “People are interacting in a more positive and constructive way. I’m so glad that we’re pushing diversity and you can see that a lot of people want to see us do better with this. We can continue to do better with this.”
SHM’s 2020-2021 Awards of Excellence nominations are now open with nine unique categories, including Excellence in Diversity, Equity, and Inclusion Leadership. If you have a peer or colleague in mind, like Dr. Manning, who has made exceptional contributions to DEI, or another important domain in hospital medicine, submit your nomination by Sept. 28, 2020.
“I have a feeling that this year has provided a lot of opportunity for people to emerge. The Committee is going to have a very, very tough job,” Dr. Manning said. “They are going to have some exciting nominations on their hands!”
Ms. Cowan is the marketing communications specialist at the Society of Hospital Medicine.
Exorcising your ghosts
The COVID-19 pandemic has affected private medical practices on so many levels, not least of which is the loss of employees to illness, fear of illness, early retirement, and other reasons.
If you’re not hip to the slang, “ghosting” is the situation in which an employee disappears without any warning, notice, or explanation. It usually occurs after a candidate accepts a job offer, and you schedule their first day of work. That day dawns, but the new hire never arrives. Less commonly, an employee who has been with you for some time simply stops showing up and cannot be contacted.
Many employers think of ghosting as a relatively new phenomenon, and blame it on the irresponsibility of younger age groups – millennials, in particular. In fact, it has been an issue for many years across all age groups, and employers often share more of the responsibility than they think.
While total prevention is impossible, there are steps you can take as an employer to minimize ghosting in your practice.
- Your hiring process needs to be efficient. If you wait too long to schedule an interview with a promising candidate or to offer them the job, another job offer could lure them away. At the very least, a lengthy process or a lack of transparency may make the applicant apprehensive about accepting a job with you, particularly if other employers are pursuing them.
- Keep applicants in the loop. Follow up with every candidate; let them know where they are in your hiring process. Applicants who have no clue whether they have a shot at the job are going to start looking elsewhere. And make sure they know the job description and starting salary from the outset.
- Talk to new hires before their first day. Contact them personally to see if they have any questions or concerns, and let them know that you’re looking forward to their arrival.
- Once they start, make them feel welcome. An employee’s first few days on the job set the tone for the rest of the employment relationship. During this time, clearly communicate what the employee can expect from you and what you expect from them. Take time to discuss key issues, such as work schedules, timekeeping practices, how performance is measured, and dress codes. Introduce them to coworkers, and get them started shadowing more experienced staff members.
- Take a hard look at your supervision and your supervisors. Business people like to say that employees don’t quit their job, they quit their boss. If an employee quits – with or without notice – it may very well be because of a poor working relationship with you or the supervisor. To be effective, you and your supervisors need to be diligent in setting goals, managing performance, and applying workplace rules and policies. Numerous third-party companies provide training and guidance in these areas when needed.
- Recognize and reward. As I’ve written many times, positive feedback is a simple, low-cost way to improve employee retention. It demonstrates that you value an employee’s contributions and sets an excellent example for other employees. Effective recognition can come from anyone – including patients – and should be given openly. (Another old adage: “Praise publicly, criticize privately.”) It never hurts to catch an employee doing something right and acknowledge it.
- Don’t jump to conclusions. If a new hire or employee is absent without notice, don’t just assume you’ve been ghosted. There may be extenuating circumstances, such as an emergency or illness. In some states, an employee’s absence is protected under a law where the employee may not be required to provide advance notice, and taking adverse action could violate these laws. Establish procedures for attempting to contact absent employees, and make sure you’re complying with all applicable leave laws before taking any action.
If an employee does abandon their job, think before you act. Comply with all applicable laws. Act consistently with how you’ve handled similar situations in the past. Your attorney should be involved, especially if the decision involves termination. Notify the employee in writing. As with all employment decisions, keep adequate documentation in case the decision is ever challenged, or you need it to support future disciplinary decisions.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. He has no disclosures related to this column. Write to him at [email protected].
The COVID-19 pandemic has affected private medical practices on so many levels, not least of which is the loss of employees to illness, fear of illness, early retirement, and other reasons.
If you’re not hip to the slang, “ghosting” is the situation in which an employee disappears without any warning, notice, or explanation. It usually occurs after a candidate accepts a job offer, and you schedule their first day of work. That day dawns, but the new hire never arrives. Less commonly, an employee who has been with you for some time simply stops showing up and cannot be contacted.
Many employers think of ghosting as a relatively new phenomenon, and blame it on the irresponsibility of younger age groups – millennials, in particular. In fact, it has been an issue for many years across all age groups, and employers often share more of the responsibility than they think.
While total prevention is impossible, there are steps you can take as an employer to minimize ghosting in your practice.
- Your hiring process needs to be efficient. If you wait too long to schedule an interview with a promising candidate or to offer them the job, another job offer could lure them away. At the very least, a lengthy process or a lack of transparency may make the applicant apprehensive about accepting a job with you, particularly if other employers are pursuing them.
- Keep applicants in the loop. Follow up with every candidate; let them know where they are in your hiring process. Applicants who have no clue whether they have a shot at the job are going to start looking elsewhere. And make sure they know the job description and starting salary from the outset.
- Talk to new hires before their first day. Contact them personally to see if they have any questions or concerns, and let them know that you’re looking forward to their arrival.
- Once they start, make them feel welcome. An employee’s first few days on the job set the tone for the rest of the employment relationship. During this time, clearly communicate what the employee can expect from you and what you expect from them. Take time to discuss key issues, such as work schedules, timekeeping practices, how performance is measured, and dress codes. Introduce them to coworkers, and get them started shadowing more experienced staff members.
- Take a hard look at your supervision and your supervisors. Business people like to say that employees don’t quit their job, they quit their boss. If an employee quits – with or without notice – it may very well be because of a poor working relationship with you or the supervisor. To be effective, you and your supervisors need to be diligent in setting goals, managing performance, and applying workplace rules and policies. Numerous third-party companies provide training and guidance in these areas when needed.
- Recognize and reward. As I’ve written many times, positive feedback is a simple, low-cost way to improve employee retention. It demonstrates that you value an employee’s contributions and sets an excellent example for other employees. Effective recognition can come from anyone – including patients – and should be given openly. (Another old adage: “Praise publicly, criticize privately.”) It never hurts to catch an employee doing something right and acknowledge it.
- Don’t jump to conclusions. If a new hire or employee is absent without notice, don’t just assume you’ve been ghosted. There may be extenuating circumstances, such as an emergency or illness. In some states, an employee’s absence is protected under a law where the employee may not be required to provide advance notice, and taking adverse action could violate these laws. Establish procedures for attempting to contact absent employees, and make sure you’re complying with all applicable leave laws before taking any action.
If an employee does abandon their job, think before you act. Comply with all applicable laws. Act consistently with how you’ve handled similar situations in the past. Your attorney should be involved, especially if the decision involves termination. Notify the employee in writing. As with all employment decisions, keep adequate documentation in case the decision is ever challenged, or you need it to support future disciplinary decisions.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. He has no disclosures related to this column. Write to him at [email protected].
The COVID-19 pandemic has affected private medical practices on so many levels, not least of which is the loss of employees to illness, fear of illness, early retirement, and other reasons.
If you’re not hip to the slang, “ghosting” is the situation in which an employee disappears without any warning, notice, or explanation. It usually occurs after a candidate accepts a job offer, and you schedule their first day of work. That day dawns, but the new hire never arrives. Less commonly, an employee who has been with you for some time simply stops showing up and cannot be contacted.
Many employers think of ghosting as a relatively new phenomenon, and blame it on the irresponsibility of younger age groups – millennials, in particular. In fact, it has been an issue for many years across all age groups, and employers often share more of the responsibility than they think.
While total prevention is impossible, there are steps you can take as an employer to minimize ghosting in your practice.
- Your hiring process needs to be efficient. If you wait too long to schedule an interview with a promising candidate or to offer them the job, another job offer could lure them away. At the very least, a lengthy process or a lack of transparency may make the applicant apprehensive about accepting a job with you, particularly if other employers are pursuing them.
- Keep applicants in the loop. Follow up with every candidate; let them know where they are in your hiring process. Applicants who have no clue whether they have a shot at the job are going to start looking elsewhere. And make sure they know the job description and starting salary from the outset.
- Talk to new hires before their first day. Contact them personally to see if they have any questions or concerns, and let them know that you’re looking forward to their arrival.
- Once they start, make them feel welcome. An employee’s first few days on the job set the tone for the rest of the employment relationship. During this time, clearly communicate what the employee can expect from you and what you expect from them. Take time to discuss key issues, such as work schedules, timekeeping practices, how performance is measured, and dress codes. Introduce them to coworkers, and get them started shadowing more experienced staff members.
- Take a hard look at your supervision and your supervisors. Business people like to say that employees don’t quit their job, they quit their boss. If an employee quits – with or without notice – it may very well be because of a poor working relationship with you or the supervisor. To be effective, you and your supervisors need to be diligent in setting goals, managing performance, and applying workplace rules and policies. Numerous third-party companies provide training and guidance in these areas when needed.
- Recognize and reward. As I’ve written many times, positive feedback is a simple, low-cost way to improve employee retention. It demonstrates that you value an employee’s contributions and sets an excellent example for other employees. Effective recognition can come from anyone – including patients – and should be given openly. (Another old adage: “Praise publicly, criticize privately.”) It never hurts to catch an employee doing something right and acknowledge it.
- Don’t jump to conclusions. If a new hire or employee is absent without notice, don’t just assume you’ve been ghosted. There may be extenuating circumstances, such as an emergency or illness. In some states, an employee’s absence is protected under a law where the employee may not be required to provide advance notice, and taking adverse action could violate these laws. Establish procedures for attempting to contact absent employees, and make sure you’re complying with all applicable leave laws before taking any action.
If an employee does abandon their job, think before you act. Comply with all applicable laws. Act consistently with how you’ve handled similar situations in the past. Your attorney should be involved, especially if the decision involves termination. Notify the employee in writing. As with all employment decisions, keep adequate documentation in case the decision is ever challenged, or you need it to support future disciplinary decisions.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. He has no disclosures related to this column. Write to him at [email protected].
