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There is no cure for gullibility
Metformin, oleander extract, azithromycin, famotidine, fluvoxamine, hydroxychloroquine, indomethacin, remdesivir, different vaccines, and many others. What does this disparate group of agents have in common? They’re all being bandied about as treatments for COVID-19.
This sort of thing makes big headlines in the news when someone even mentions them as a possible treatment, but so do proposed treatments for Alzheimer’s disease, various cancers, and other devastating illnesses. It triggers calls to doctors’ offices by patients wanting to be put on them, demands for them to be sold over the counter, and less-then-scrupulous people selling all kinds of things claiming to contain them and cure the disease for only $89.95 with free shipping if you act now.
Even in ordinary times (whatever that means anymore) it doesn’t take much for even a hint of success to make the news, spiking calls to doctors’ offices asking about “that new treatment I saw.” Of course, the number of drugs that are proven to be successful and come to market is a fraction of what’s actually tested.
Since the many failures don’t make headlines like successes do, the general public moves on and doesn’t even remember the initial story after a while. Only the medical and pharmaceutical professions are left to remember “we tried that, it didn’t work.”
We learn as much from failure as we do from success – sometimes more – but failure doesn’t make headlines or sell papers or get clicks.
The research scientists and physicians know this and how long it can take to find something that works. In some diseases it still hasn’t happened, in spite of billions spent and decades going by.
Unfortunately, nonscientific people (which is most of the population) just see our remarkable breakthroughs evidenced by shiny equipment and new drugs, and only read the headlines about successes. They don’t realize the many years and failures behind them.
It doesn’t help to have nonmedical talking heads on the news egging this belief on. The few voices of reason are drowned out.
The polio virus was identified in 1908 (the disease is thousands of years old). The Salk vaccine came out in 1955. That’s a 47-year gap. I doubt it will take that long for COVID-19, but the point is that these things never have, and never will, happen overnight.
The problem isn’t science or medicine. It’s unreasonable expectations for immediate success. While science and diseases may change over time, human nature doesn’t.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Metformin, oleander extract, azithromycin, famotidine, fluvoxamine, hydroxychloroquine, indomethacin, remdesivir, different vaccines, and many others. What does this disparate group of agents have in common? They’re all being bandied about as treatments for COVID-19.
This sort of thing makes big headlines in the news when someone even mentions them as a possible treatment, but so do proposed treatments for Alzheimer’s disease, various cancers, and other devastating illnesses. It triggers calls to doctors’ offices by patients wanting to be put on them, demands for them to be sold over the counter, and less-then-scrupulous people selling all kinds of things claiming to contain them and cure the disease for only $89.95 with free shipping if you act now.
Even in ordinary times (whatever that means anymore) it doesn’t take much for even a hint of success to make the news, spiking calls to doctors’ offices asking about “that new treatment I saw.” Of course, the number of drugs that are proven to be successful and come to market is a fraction of what’s actually tested.
Since the many failures don’t make headlines like successes do, the general public moves on and doesn’t even remember the initial story after a while. Only the medical and pharmaceutical professions are left to remember “we tried that, it didn’t work.”
We learn as much from failure as we do from success – sometimes more – but failure doesn’t make headlines or sell papers or get clicks.
The research scientists and physicians know this and how long it can take to find something that works. In some diseases it still hasn’t happened, in spite of billions spent and decades going by.
Unfortunately, nonscientific people (which is most of the population) just see our remarkable breakthroughs evidenced by shiny equipment and new drugs, and only read the headlines about successes. They don’t realize the many years and failures behind them.
It doesn’t help to have nonmedical talking heads on the news egging this belief on. The few voices of reason are drowned out.
The polio virus was identified in 1908 (the disease is thousands of years old). The Salk vaccine came out in 1955. That’s a 47-year gap. I doubt it will take that long for COVID-19, but the point is that these things never have, and never will, happen overnight.
The problem isn’t science or medicine. It’s unreasonable expectations for immediate success. While science and diseases may change over time, human nature doesn’t.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Metformin, oleander extract, azithromycin, famotidine, fluvoxamine, hydroxychloroquine, indomethacin, remdesivir, different vaccines, and many others. What does this disparate group of agents have in common? They’re all being bandied about as treatments for COVID-19.
This sort of thing makes big headlines in the news when someone even mentions them as a possible treatment, but so do proposed treatments for Alzheimer’s disease, various cancers, and other devastating illnesses. It triggers calls to doctors’ offices by patients wanting to be put on them, demands for them to be sold over the counter, and less-then-scrupulous people selling all kinds of things claiming to contain them and cure the disease for only $89.95 with free shipping if you act now.
Even in ordinary times (whatever that means anymore) it doesn’t take much for even a hint of success to make the news, spiking calls to doctors’ offices asking about “that new treatment I saw.” Of course, the number of drugs that are proven to be successful and come to market is a fraction of what’s actually tested.
Since the many failures don’t make headlines like successes do, the general public moves on and doesn’t even remember the initial story after a while. Only the medical and pharmaceutical professions are left to remember “we tried that, it didn’t work.”
We learn as much from failure as we do from success – sometimes more – but failure doesn’t make headlines or sell papers or get clicks.
The research scientists and physicians know this and how long it can take to find something that works. In some diseases it still hasn’t happened, in spite of billions spent and decades going by.
Unfortunately, nonscientific people (which is most of the population) just see our remarkable breakthroughs evidenced by shiny equipment and new drugs, and only read the headlines about successes. They don’t realize the many years and failures behind them.
It doesn’t help to have nonmedical talking heads on the news egging this belief on. The few voices of reason are drowned out.
The polio virus was identified in 1908 (the disease is thousands of years old). The Salk vaccine came out in 1955. That’s a 47-year gap. I doubt it will take that long for COVID-19, but the point is that these things never have, and never will, happen overnight.
The problem isn’t science or medicine. It’s unreasonable expectations for immediate success. While science and diseases may change over time, human nature doesn’t.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Reducing maternal mortality with prenatal care
As in its typical fashion, the question sprang out from a young Black patient after some meandering conversation during preconception counseling: “How do y’all prevent Black maternal mortality?” At the beginning of my career, I used to think preparing a patient for pregnancy involved recommending prenatal vitamins and rubella immunity screening. Now, having worked in a society with substantial racial health disparities for 14 years, there is greater awareness that pregnancy can be a matter of life or death that disproportionately affects people of color.
For Black patients in the United States, the maternal mortality ratio is almost four times higher than the ratio for White patients, 42 deaths versus 13 deaths per 100,000 live births, respectively.1 Georgia has the highest maternal mortality ratio in the United States at 67 maternal deaths per 100,000 live births. However, if you are a Black woman in Georgia, your chance of dying of pregnancy-related causes is 2.7 times that of a non-Hispanic White woman living in Georgia.2
Black patients often are not taken seriously, even when they are wealthy, have attained high levels of education, or are famous. Serena Williams, a Black woman and one of the most talented tennis players of all time, was ignored when complaining that she felt a blood clot had returned in her lungs post partum. As a recognition of this crisis, the Centers for Disease Control and Prevention has a new campaign to improve recognition of the warning signs of problems in pregnancy called the HEAR HER campaign. This issue is a pervasive problem in our lives that runs across the spectrum of Black experience. I have had Black friends, patients, and colleagues who have been ignored when complaining about labor pain, workplace discrimination, and even when trying to advocate for their patients. We need to uplift Black voices so they can be heard and support the initiatives and interventions they are asking for.
We practice standardized responses to emergencies and to health conditions. We use drills to practice our responses to life-threatening emergencies such as STAT cesarean delivery, shoulder dystocia, obstetrical hemorrhage, or treatment of preeclampsia and eclampsia. The Alliance for Innovation on Maternal Health has organized evidence-driven protocols called AIM bundles to reduce preventable maternal morbidity and mortality when implemented. Standardization is an important component of equitable treatment and reduction of disparities. The concept has been used across industries to reduce error and bias. The Alliance for Innovation on Maternal Health bundles even include a section on Reduction of Peripartum and Ethnic Disparities.
We admit that bias exists and that we need training to recognize and eliminate it. According to a study in the Proceedings of the National Academy of Sciences of the United States of America about racial bias in pain assessment more than 20% of White residents and medical students surveyed believed that Black people had less sensitive nerve endings than Whites.3 Studies show that this stereotype leads to inappropriate pain management in Black patients, a chief concern when considering how patients are treated on labor and delivery or after surgery.4 Additionally, unconscious bias can be addressed by hiring a diverse workforce at all levels. Familiarity with a diverse group can help us learn from one another in our day-to-day lives.
We need to offer the same high-quality preconception counseling to all of our patients. A patient’s perceived race or ethnicity is a poor indicator of their actual health needs. The amount of melanin in our skin is highly variable but our genetics are remarkably similar, therefore our health concerns are similar. All patients deserve a focus on prevention. Folic acid supplements in the form of prenatal vitamins should be recommended. Routine vaccinations and rubella immunity checks should be offered. Basic carrier screening for diseases of hemoglobin (which includes sickle cell trait), fragile X, spinomuscular atrophy, and cystic fibrosis should be offered. Finally, an emphasis on safety, mental health, and daily low-level exercise (i.e., walking) should be promoted to help prevent illness and injury in this age group. The leading causes of death for people of reproductive age are accidents, suicide, homicide, and heart disease – all preventable.
We treat the social determinants of health, not just the patient in front of us. When “race” is a risk factor for disease, it’s usually racism that’s the problem. As stated earlier, how much melanin is in our skin has little to do with our genetics – if we removed our skin, we’d have similar life expectancies and die of similar things. However, it has everything to do with how we navigate our society and access health care. The stress associated with being Black in America is the likely cause of preterm birth rates – leading to infant illness and death – and maternal mortality being higher in Black patients. This is referred to as “weathering” – the cumulative effects of stress as we age. It explains why Black women are more likely to die in pregnancy despite higher levels of education and increasing age – factors that are protective for other groups. Improving access to quality education, reforming the criminal justice system, affordable housing and child care, living wages, family planning, and universal basic health care exemplify the intersectionality of some of our greatest societal challenges. Addressing these root causes will reduce weathering and ultimately, save Black lives.
We strive to train more “underrepresented minorities” in medicine. According to the American Association of Medical Colleges, only 7.3% of medical students in 2019-2020 identified as Black or African American. This is way below their representation of 13% of the U.S. population. I’m proud that my division and department as a whole have hired and promoted diverse faculty with 30% of my generalist ob.gyn. colleagues being people of color. This shows that we have the input of diverse experiences as well as recognize the special concerns of patients of color. Underrepresented students interested in the health professions need us to do more to get their “foot in the door.” They are less likely to have connections to the field of medicine (family members, mentors), have access to prep courses or advisors, or have the finances to support the expensive application process. Reach out to your alma maters and ask how you can help mentor students at a young age and continue through adulthood, support scholarships, support unpaid internship recipients, and promote interconnectedness throughout this community.
I hope I answered my patient’s question in that moment, but I know what needs to be done is bigger that taking care of one patient. It will require small progress, by us, every single day. Until these interventions and others reshape our society, I’ll still have Black patients who say: “Don’t let me die, okay?” with a look right into my soul and a tight grip on my hand. And I’ll feel the immense weight of that trust, and squeeze the hand back.
Dr. Collins (she/her/hers) is assistant professor of obstetrics and gynecology, generalist division, at Emory University, Atlanta. She has no relevant financial disclosures. Email Dr. Collins at [email protected].
References
1. CDC Pregnancy Mortality Surveillance System, 2016. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm.
2. Maternal Mortality Fact Sheet, 2012-2015. https://dph.georgia.gov/maternal-mortality.
3. Proc Natl Acad Sci U S A. 2016 Apr 19;113(16):4296-301.
4. Pain Med. 2012 Feb;13(2):150-74.
As in its typical fashion, the question sprang out from a young Black patient after some meandering conversation during preconception counseling: “How do y’all prevent Black maternal mortality?” At the beginning of my career, I used to think preparing a patient for pregnancy involved recommending prenatal vitamins and rubella immunity screening. Now, having worked in a society with substantial racial health disparities for 14 years, there is greater awareness that pregnancy can be a matter of life or death that disproportionately affects people of color.
For Black patients in the United States, the maternal mortality ratio is almost four times higher than the ratio for White patients, 42 deaths versus 13 deaths per 100,000 live births, respectively.1 Georgia has the highest maternal mortality ratio in the United States at 67 maternal deaths per 100,000 live births. However, if you are a Black woman in Georgia, your chance of dying of pregnancy-related causes is 2.7 times that of a non-Hispanic White woman living in Georgia.2
Black patients often are not taken seriously, even when they are wealthy, have attained high levels of education, or are famous. Serena Williams, a Black woman and one of the most talented tennis players of all time, was ignored when complaining that she felt a blood clot had returned in her lungs post partum. As a recognition of this crisis, the Centers for Disease Control and Prevention has a new campaign to improve recognition of the warning signs of problems in pregnancy called the HEAR HER campaign. This issue is a pervasive problem in our lives that runs across the spectrum of Black experience. I have had Black friends, patients, and colleagues who have been ignored when complaining about labor pain, workplace discrimination, and even when trying to advocate for their patients. We need to uplift Black voices so they can be heard and support the initiatives and interventions they are asking for.
We practice standardized responses to emergencies and to health conditions. We use drills to practice our responses to life-threatening emergencies such as STAT cesarean delivery, shoulder dystocia, obstetrical hemorrhage, or treatment of preeclampsia and eclampsia. The Alliance for Innovation on Maternal Health has organized evidence-driven protocols called AIM bundles to reduce preventable maternal morbidity and mortality when implemented. Standardization is an important component of equitable treatment and reduction of disparities. The concept has been used across industries to reduce error and bias. The Alliance for Innovation on Maternal Health bundles even include a section on Reduction of Peripartum and Ethnic Disparities.
We admit that bias exists and that we need training to recognize and eliminate it. According to a study in the Proceedings of the National Academy of Sciences of the United States of America about racial bias in pain assessment more than 20% of White residents and medical students surveyed believed that Black people had less sensitive nerve endings than Whites.3 Studies show that this stereotype leads to inappropriate pain management in Black patients, a chief concern when considering how patients are treated on labor and delivery or after surgery.4 Additionally, unconscious bias can be addressed by hiring a diverse workforce at all levels. Familiarity with a diverse group can help us learn from one another in our day-to-day lives.
We need to offer the same high-quality preconception counseling to all of our patients. A patient’s perceived race or ethnicity is a poor indicator of their actual health needs. The amount of melanin in our skin is highly variable but our genetics are remarkably similar, therefore our health concerns are similar. All patients deserve a focus on prevention. Folic acid supplements in the form of prenatal vitamins should be recommended. Routine vaccinations and rubella immunity checks should be offered. Basic carrier screening for diseases of hemoglobin (which includes sickle cell trait), fragile X, spinomuscular atrophy, and cystic fibrosis should be offered. Finally, an emphasis on safety, mental health, and daily low-level exercise (i.e., walking) should be promoted to help prevent illness and injury in this age group. The leading causes of death for people of reproductive age are accidents, suicide, homicide, and heart disease – all preventable.
We treat the social determinants of health, not just the patient in front of us. When “race” is a risk factor for disease, it’s usually racism that’s the problem. As stated earlier, how much melanin is in our skin has little to do with our genetics – if we removed our skin, we’d have similar life expectancies and die of similar things. However, it has everything to do with how we navigate our society and access health care. The stress associated with being Black in America is the likely cause of preterm birth rates – leading to infant illness and death – and maternal mortality being higher in Black patients. This is referred to as “weathering” – the cumulative effects of stress as we age. It explains why Black women are more likely to die in pregnancy despite higher levels of education and increasing age – factors that are protective for other groups. Improving access to quality education, reforming the criminal justice system, affordable housing and child care, living wages, family planning, and universal basic health care exemplify the intersectionality of some of our greatest societal challenges. Addressing these root causes will reduce weathering and ultimately, save Black lives.
We strive to train more “underrepresented minorities” in medicine. According to the American Association of Medical Colleges, only 7.3% of medical students in 2019-2020 identified as Black or African American. This is way below their representation of 13% of the U.S. population. I’m proud that my division and department as a whole have hired and promoted diverse faculty with 30% of my generalist ob.gyn. colleagues being people of color. This shows that we have the input of diverse experiences as well as recognize the special concerns of patients of color. Underrepresented students interested in the health professions need us to do more to get their “foot in the door.” They are less likely to have connections to the field of medicine (family members, mentors), have access to prep courses or advisors, or have the finances to support the expensive application process. Reach out to your alma maters and ask how you can help mentor students at a young age and continue through adulthood, support scholarships, support unpaid internship recipients, and promote interconnectedness throughout this community.
I hope I answered my patient’s question in that moment, but I know what needs to be done is bigger that taking care of one patient. It will require small progress, by us, every single day. Until these interventions and others reshape our society, I’ll still have Black patients who say: “Don’t let me die, okay?” with a look right into my soul and a tight grip on my hand. And I’ll feel the immense weight of that trust, and squeeze the hand back.
Dr. Collins (she/her/hers) is assistant professor of obstetrics and gynecology, generalist division, at Emory University, Atlanta. She has no relevant financial disclosures. Email Dr. Collins at [email protected].
References
1. CDC Pregnancy Mortality Surveillance System, 2016. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm.
2. Maternal Mortality Fact Sheet, 2012-2015. https://dph.georgia.gov/maternal-mortality.
3. Proc Natl Acad Sci U S A. 2016 Apr 19;113(16):4296-301.
4. Pain Med. 2012 Feb;13(2):150-74.
As in its typical fashion, the question sprang out from a young Black patient after some meandering conversation during preconception counseling: “How do y’all prevent Black maternal mortality?” At the beginning of my career, I used to think preparing a patient for pregnancy involved recommending prenatal vitamins and rubella immunity screening. Now, having worked in a society with substantial racial health disparities for 14 years, there is greater awareness that pregnancy can be a matter of life or death that disproportionately affects people of color.
For Black patients in the United States, the maternal mortality ratio is almost four times higher than the ratio for White patients, 42 deaths versus 13 deaths per 100,000 live births, respectively.1 Georgia has the highest maternal mortality ratio in the United States at 67 maternal deaths per 100,000 live births. However, if you are a Black woman in Georgia, your chance of dying of pregnancy-related causes is 2.7 times that of a non-Hispanic White woman living in Georgia.2
Black patients often are not taken seriously, even when they are wealthy, have attained high levels of education, or are famous. Serena Williams, a Black woman and one of the most talented tennis players of all time, was ignored when complaining that she felt a blood clot had returned in her lungs post partum. As a recognition of this crisis, the Centers for Disease Control and Prevention has a new campaign to improve recognition of the warning signs of problems in pregnancy called the HEAR HER campaign. This issue is a pervasive problem in our lives that runs across the spectrum of Black experience. I have had Black friends, patients, and colleagues who have been ignored when complaining about labor pain, workplace discrimination, and even when trying to advocate for their patients. We need to uplift Black voices so they can be heard and support the initiatives and interventions they are asking for.
We practice standardized responses to emergencies and to health conditions. We use drills to practice our responses to life-threatening emergencies such as STAT cesarean delivery, shoulder dystocia, obstetrical hemorrhage, or treatment of preeclampsia and eclampsia. The Alliance for Innovation on Maternal Health has organized evidence-driven protocols called AIM bundles to reduce preventable maternal morbidity and mortality when implemented. Standardization is an important component of equitable treatment and reduction of disparities. The concept has been used across industries to reduce error and bias. The Alliance for Innovation on Maternal Health bundles even include a section on Reduction of Peripartum and Ethnic Disparities.
We admit that bias exists and that we need training to recognize and eliminate it. According to a study in the Proceedings of the National Academy of Sciences of the United States of America about racial bias in pain assessment more than 20% of White residents and medical students surveyed believed that Black people had less sensitive nerve endings than Whites.3 Studies show that this stereotype leads to inappropriate pain management in Black patients, a chief concern when considering how patients are treated on labor and delivery or after surgery.4 Additionally, unconscious bias can be addressed by hiring a diverse workforce at all levels. Familiarity with a diverse group can help us learn from one another in our day-to-day lives.
We need to offer the same high-quality preconception counseling to all of our patients. A patient’s perceived race or ethnicity is a poor indicator of their actual health needs. The amount of melanin in our skin is highly variable but our genetics are remarkably similar, therefore our health concerns are similar. All patients deserve a focus on prevention. Folic acid supplements in the form of prenatal vitamins should be recommended. Routine vaccinations and rubella immunity checks should be offered. Basic carrier screening for diseases of hemoglobin (which includes sickle cell trait), fragile X, spinomuscular atrophy, and cystic fibrosis should be offered. Finally, an emphasis on safety, mental health, and daily low-level exercise (i.e., walking) should be promoted to help prevent illness and injury in this age group. The leading causes of death for people of reproductive age are accidents, suicide, homicide, and heart disease – all preventable.
We treat the social determinants of health, not just the patient in front of us. When “race” is a risk factor for disease, it’s usually racism that’s the problem. As stated earlier, how much melanin is in our skin has little to do with our genetics – if we removed our skin, we’d have similar life expectancies and die of similar things. However, it has everything to do with how we navigate our society and access health care. The stress associated with being Black in America is the likely cause of preterm birth rates – leading to infant illness and death – and maternal mortality being higher in Black patients. This is referred to as “weathering” – the cumulative effects of stress as we age. It explains why Black women are more likely to die in pregnancy despite higher levels of education and increasing age – factors that are protective for other groups. Improving access to quality education, reforming the criminal justice system, affordable housing and child care, living wages, family planning, and universal basic health care exemplify the intersectionality of some of our greatest societal challenges. Addressing these root causes will reduce weathering and ultimately, save Black lives.
We strive to train more “underrepresented minorities” in medicine. According to the American Association of Medical Colleges, only 7.3% of medical students in 2019-2020 identified as Black or African American. This is way below their representation of 13% of the U.S. population. I’m proud that my division and department as a whole have hired and promoted diverse faculty with 30% of my generalist ob.gyn. colleagues being people of color. This shows that we have the input of diverse experiences as well as recognize the special concerns of patients of color. Underrepresented students interested in the health professions need us to do more to get their “foot in the door.” They are less likely to have connections to the field of medicine (family members, mentors), have access to prep courses or advisors, or have the finances to support the expensive application process. Reach out to your alma maters and ask how you can help mentor students at a young age and continue through adulthood, support scholarships, support unpaid internship recipients, and promote interconnectedness throughout this community.
I hope I answered my patient’s question in that moment, but I know what needs to be done is bigger that taking care of one patient. It will require small progress, by us, every single day. Until these interventions and others reshape our society, I’ll still have Black patients who say: “Don’t let me die, okay?” with a look right into my soul and a tight grip on my hand. And I’ll feel the immense weight of that trust, and squeeze the hand back.
Dr. Collins (she/her/hers) is assistant professor of obstetrics and gynecology, generalist division, at Emory University, Atlanta. She has no relevant financial disclosures. Email Dr. Collins at [email protected].
References
1. CDC Pregnancy Mortality Surveillance System, 2016. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm.
2. Maternal Mortality Fact Sheet, 2012-2015. https://dph.georgia.gov/maternal-mortality.
3. Proc Natl Acad Sci U S A. 2016 Apr 19;113(16):4296-301.
4. Pain Med. 2012 Feb;13(2):150-74.
Rooting out systemic racism: Equal access to maternal, prenatal care
Against the backdrop of the COVID-19 pandemic and ongoing national conversations around racial injustice, it is more important than ever that we identify and root out systemic discrimination – including in our health care system. As an ob.gyn., I’ve spent my entire career making sure that women receive the best care, and have witnessed firsthand the results of a system that provides differing levels of care based on one’s socioeconomic level, race, or ethnicity.
This disparity is borne out in this country’s maternal health outcomes. For example, the latest figures from the Centers for Disease Control and Prevention indicate that the maternal mortality rate for black women, 37.1 deaths per 100,000 live births, is more than double the rate for white women at 14.7. In addition, the black infant mortality rate, at 11.4 per 1,000 live births, is also more than double the white infant mortality rate, 4.9. While many of these differences stem from discriminatory levels of coverage and care after delivery, just as important is the coverage and care before delivery: prenatal care.
Prenatal care includes a variety of screening tests, including those that can help expecting mothers identify whether the baby is more or less likely to have certain genetic disorders. These tests include traditional and less accurate options like serum or combined screening, and newer noninvasive prenatal testing (NIPT) options that use blood samples from the mother to analyze the baby’s DNA.
Research already has demonstrated that NIPT is the most accurate and effective screening option for common chromosomal abnormalities (Ont Health Technol Assess Ser. 2019;19[4]:1-166). A 2015 New England Journal of Medicine study showed that, without access to NIPT, 22% of pregnancies with Down syndrome were missed. With older screening methods, 5.4% of positive results for Down syndrome were false, compared with 0.06% of the NIPT tests (N Engl J Med 2015;372:1589-97). Older, less accurate screening tests cause unnecessary referrals to specialists for possible invasive testing, resulting in additional costs and undue stress on women and their families.
And yet, troubling new data have shown that black and Hispanic women have less access to NIPT than white women. Currently, NIPT is available to all California women through the state-funded prenatal screening program as a second-tier test. Many women, however, decide to opt out or go outside of the state program to have NIPT as a first-tier test, choosing private payer or other plans instead. New data shared by the California Department of Public Health with ob.gyns. and maternal-fetal medicine physicians in California showed that white women who opted out of California’s state-funded prenatal screening program were more than twice as likely to gain access to NIPT as black and Hispanic women (39%-17%). We can assume this to be true of women outside California as well – women who have no access to a state-funded program like California’s and depend solely on private payer or other health care plans. In fact, although some commercial insurance companies do cover NIPT, noninvasive prenatal screening is not covered by large insurance companies like Aetna and UnitedHealthcare.
As ob.gyns., physicians, and health professionals, we need to ask ourselves: Why is there such a great disparity in the access of superior and more effective NIPT options for black and Hispanic women?
Many reasons are apparent. There are significant differences by ethnic and racial groups in their knowledge of the availability of prenatal testing. Furthermore, there are higher levels of mistrust along certain racial and ethnic lines of the medical system in this country; specific religious or ethnic beliefs also may obviate the use of prenatal testing or diagnosis. Significant differences also exist in the types of health coverage by race and ethnicity, ultimately impacting the ability to have prenatal testing. Finally, there are different physician group recommendations. While medical societies such as the American College of Medical Genetics, International Society for Prenatal Diagnosis, and the American Society of Human Genetics all have long endorsed newer NIPT option for all pregnant women, two of the national physician groups that make recommendations about what care pregnant women should be able to access – the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine – only recently have recommended broad access to NIPT. As a result, some state Medicaid programs have not made NIPT available to patients.
We know that racial disparities are a public health crisis in America. The recent data from the California Department of Public Health, paired with COVID-19’s disproportionate impact on blacks and Hispanics, only further illustrate the existing health disparities experienced by this country’s communities of color.
We need to root out systemic discrimination in health care and we can begin with our maternal health care. Providing equitable access to the most accurate and consistent prenatal screenings, including NIPT options, regardless of insurance plan, socioeconomic level, race, or ethnicity is paramount in starting this work.
Dr. Gaither is a double board–certified physician in ob.gyn. and maternal-fetal medicine. She is director of perinatal services for NYC Health+Hospitals/Lincoln. She reports no conflicts of interest. Email her at [email protected].
Against the backdrop of the COVID-19 pandemic and ongoing national conversations around racial injustice, it is more important than ever that we identify and root out systemic discrimination – including in our health care system. As an ob.gyn., I’ve spent my entire career making sure that women receive the best care, and have witnessed firsthand the results of a system that provides differing levels of care based on one’s socioeconomic level, race, or ethnicity.
This disparity is borne out in this country’s maternal health outcomes. For example, the latest figures from the Centers for Disease Control and Prevention indicate that the maternal mortality rate for black women, 37.1 deaths per 100,000 live births, is more than double the rate for white women at 14.7. In addition, the black infant mortality rate, at 11.4 per 1,000 live births, is also more than double the white infant mortality rate, 4.9. While many of these differences stem from discriminatory levels of coverage and care after delivery, just as important is the coverage and care before delivery: prenatal care.
Prenatal care includes a variety of screening tests, including those that can help expecting mothers identify whether the baby is more or less likely to have certain genetic disorders. These tests include traditional and less accurate options like serum or combined screening, and newer noninvasive prenatal testing (NIPT) options that use blood samples from the mother to analyze the baby’s DNA.
Research already has demonstrated that NIPT is the most accurate and effective screening option for common chromosomal abnormalities (Ont Health Technol Assess Ser. 2019;19[4]:1-166). A 2015 New England Journal of Medicine study showed that, without access to NIPT, 22% of pregnancies with Down syndrome were missed. With older screening methods, 5.4% of positive results for Down syndrome were false, compared with 0.06% of the NIPT tests (N Engl J Med 2015;372:1589-97). Older, less accurate screening tests cause unnecessary referrals to specialists for possible invasive testing, resulting in additional costs and undue stress on women and their families.
And yet, troubling new data have shown that black and Hispanic women have less access to NIPT than white women. Currently, NIPT is available to all California women through the state-funded prenatal screening program as a second-tier test. Many women, however, decide to opt out or go outside of the state program to have NIPT as a first-tier test, choosing private payer or other plans instead. New data shared by the California Department of Public Health with ob.gyns. and maternal-fetal medicine physicians in California showed that white women who opted out of California’s state-funded prenatal screening program were more than twice as likely to gain access to NIPT as black and Hispanic women (39%-17%). We can assume this to be true of women outside California as well – women who have no access to a state-funded program like California’s and depend solely on private payer or other health care plans. In fact, although some commercial insurance companies do cover NIPT, noninvasive prenatal screening is not covered by large insurance companies like Aetna and UnitedHealthcare.
As ob.gyns., physicians, and health professionals, we need to ask ourselves: Why is there such a great disparity in the access of superior and more effective NIPT options for black and Hispanic women?
Many reasons are apparent. There are significant differences by ethnic and racial groups in their knowledge of the availability of prenatal testing. Furthermore, there are higher levels of mistrust along certain racial and ethnic lines of the medical system in this country; specific religious or ethnic beliefs also may obviate the use of prenatal testing or diagnosis. Significant differences also exist in the types of health coverage by race and ethnicity, ultimately impacting the ability to have prenatal testing. Finally, there are different physician group recommendations. While medical societies such as the American College of Medical Genetics, International Society for Prenatal Diagnosis, and the American Society of Human Genetics all have long endorsed newer NIPT option for all pregnant women, two of the national physician groups that make recommendations about what care pregnant women should be able to access – the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine – only recently have recommended broad access to NIPT. As a result, some state Medicaid programs have not made NIPT available to patients.
We know that racial disparities are a public health crisis in America. The recent data from the California Department of Public Health, paired with COVID-19’s disproportionate impact on blacks and Hispanics, only further illustrate the existing health disparities experienced by this country’s communities of color.
We need to root out systemic discrimination in health care and we can begin with our maternal health care. Providing equitable access to the most accurate and consistent prenatal screenings, including NIPT options, regardless of insurance plan, socioeconomic level, race, or ethnicity is paramount in starting this work.
Dr. Gaither is a double board–certified physician in ob.gyn. and maternal-fetal medicine. She is director of perinatal services for NYC Health+Hospitals/Lincoln. She reports no conflicts of interest. Email her at [email protected].
Against the backdrop of the COVID-19 pandemic and ongoing national conversations around racial injustice, it is more important than ever that we identify and root out systemic discrimination – including in our health care system. As an ob.gyn., I’ve spent my entire career making sure that women receive the best care, and have witnessed firsthand the results of a system that provides differing levels of care based on one’s socioeconomic level, race, or ethnicity.
This disparity is borne out in this country’s maternal health outcomes. For example, the latest figures from the Centers for Disease Control and Prevention indicate that the maternal mortality rate for black women, 37.1 deaths per 100,000 live births, is more than double the rate for white women at 14.7. In addition, the black infant mortality rate, at 11.4 per 1,000 live births, is also more than double the white infant mortality rate, 4.9. While many of these differences stem from discriminatory levels of coverage and care after delivery, just as important is the coverage and care before delivery: prenatal care.
Prenatal care includes a variety of screening tests, including those that can help expecting mothers identify whether the baby is more or less likely to have certain genetic disorders. These tests include traditional and less accurate options like serum or combined screening, and newer noninvasive prenatal testing (NIPT) options that use blood samples from the mother to analyze the baby’s DNA.
Research already has demonstrated that NIPT is the most accurate and effective screening option for common chromosomal abnormalities (Ont Health Technol Assess Ser. 2019;19[4]:1-166). A 2015 New England Journal of Medicine study showed that, without access to NIPT, 22% of pregnancies with Down syndrome were missed. With older screening methods, 5.4% of positive results for Down syndrome were false, compared with 0.06% of the NIPT tests (N Engl J Med 2015;372:1589-97). Older, less accurate screening tests cause unnecessary referrals to specialists for possible invasive testing, resulting in additional costs and undue stress on women and their families.
And yet, troubling new data have shown that black and Hispanic women have less access to NIPT than white women. Currently, NIPT is available to all California women through the state-funded prenatal screening program as a second-tier test. Many women, however, decide to opt out or go outside of the state program to have NIPT as a first-tier test, choosing private payer or other plans instead. New data shared by the California Department of Public Health with ob.gyns. and maternal-fetal medicine physicians in California showed that white women who opted out of California’s state-funded prenatal screening program were more than twice as likely to gain access to NIPT as black and Hispanic women (39%-17%). We can assume this to be true of women outside California as well – women who have no access to a state-funded program like California’s and depend solely on private payer or other health care plans. In fact, although some commercial insurance companies do cover NIPT, noninvasive prenatal screening is not covered by large insurance companies like Aetna and UnitedHealthcare.
As ob.gyns., physicians, and health professionals, we need to ask ourselves: Why is there such a great disparity in the access of superior and more effective NIPT options for black and Hispanic women?
Many reasons are apparent. There are significant differences by ethnic and racial groups in their knowledge of the availability of prenatal testing. Furthermore, there are higher levels of mistrust along certain racial and ethnic lines of the medical system in this country; specific religious or ethnic beliefs also may obviate the use of prenatal testing or diagnosis. Significant differences also exist in the types of health coverage by race and ethnicity, ultimately impacting the ability to have prenatal testing. Finally, there are different physician group recommendations. While medical societies such as the American College of Medical Genetics, International Society for Prenatal Diagnosis, and the American Society of Human Genetics all have long endorsed newer NIPT option for all pregnant women, two of the national physician groups that make recommendations about what care pregnant women should be able to access – the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine – only recently have recommended broad access to NIPT. As a result, some state Medicaid programs have not made NIPT available to patients.
We know that racial disparities are a public health crisis in America. The recent data from the California Department of Public Health, paired with COVID-19’s disproportionate impact on blacks and Hispanics, only further illustrate the existing health disparities experienced by this country’s communities of color.
We need to root out systemic discrimination in health care and we can begin with our maternal health care. Providing equitable access to the most accurate and consistent prenatal screenings, including NIPT options, regardless of insurance plan, socioeconomic level, race, or ethnicity is paramount in starting this work.
Dr. Gaither is a double board–certified physician in ob.gyn. and maternal-fetal medicine. She is director of perinatal services for NYC Health+Hospitals/Lincoln. She reports no conflicts of interest. Email her at [email protected].
Vitamin D pearls
Case: A 56-year-old man with a history of type 2 diabetes, hypertension, hyperlipidemia, and obesity calls clinic to discuss concerns about COVID-19, stating: “I want to do everything I can to reduce my risk of infection.” In addition to physical distancing, mask wearing, hand hygiene, and control of chronic conditions, which of the following supplements would you recommend for this patient?
1. Coenzyme Q10 160 mg twice a day
2. Vitamin D 2,000 IU daily
3. Vitamin E 400 IU daily
4. Vitamin B12 1,000 mcg daily
Of these choices, vitamin D supplementation is likely the best option, based on the limited data that is available.
Risk factors for worse COVID-19 outcome, such as older age, obesity, and more pigmented skin are also risk factors for vitamin D deficiency. This makes the study of vitamin D and COVID-19 both challenging and relevant.
In a recent study of 7,807 people living in Israel, Merzon and colleagues found that low plasma vitamin D level was an independent risk factor for COVID-19 infection. Mean plasma vitamin D level was significantly lower among those who tested positive for COVID-19 (19.00 ng/mL) than negative (20.55 ng/ mL). After controlling for demographic variables and several medical conditions, the adjusted odds ratio of COVID-19 infection in those with lower vitamin D was 1.45 (95% confidence interval, 1.08-1.95; P < .001). However, the odds of hospitalization for COVID-19 was not significantly associated with vitamin D level.1
Prior studies have also looked at vitamin D and respiratory infection. Martineau and colleagues analyzed 25 randomized, controlled trials with a pooled number of 11,321 individuals, including healthy ones and those with comorbidities, and found that oral vitamin D supplementation in daily or weekly doses had a protective effect against acute respiratory infection (adjusted odds ratio, 0.88; 95% CI, 0.81-0.96; P < .001). Patients with vitamin D deficiency (less than 25 nmol/L) experienced the most protective benefit. Vitamin D did not influence respiratory infection outcome.2
These studies suggest an adequate vitamin D level may be protective against infection with COVID-19, but who will benefit from vitamin D supplementation, and in what dose? Per U.S. Preventive Services Task Force guidelines, there is insufficient evidence to recommend screening for vitamin D deficiency in asymptomatic adults. Regarding daily dietary intake, the Institute of Medicine recommends 600 IU for persons aged 1-70, and 800 IU for those aged over 70 years. Salmon (447 IU per 3 oz serving), tuna (154 IU), and fortified milk (116 IU) are among the most vitamin D–rich foods.3 The recommended upper level of intake is 4,000 IU/day.
Too much of a good thing?
Extra vitamin D is stored in adipose tissue. If it builds up over time, storage sites may be overwhelmed, causing a rise in serum D level. While one might expect a subsequent rise in calcium levels, studies have shown this happens inconsistently, and at very high vitamin D levels, over 120 ng/mL.4 Most people would have to take at least 50,000 IU daily for several months to see an effect. The main adverse outcome of vitamin D toxicity is kidney stones, mediated by increased calcium in the blood and urine.
Several animal models have demonstrated hypervitaminosis D–induced aortic and coronary artery calcification. Like with kidney stones, the mechanism appears to be through increased calcium and phosphate levels. Shroff and colleagues studied serum vitamin D levels and vascular disease in children with renal disease on dialysis and found a U-shaped distribution: Children with both low and high vitamin D levels had significantly increased carotid artery intima-media thickness and calcification.5 Given the specialized nature of this population, it’s unclear whether these results can be generalized to most people. More studies are warranted on this topic.
Other benefits
Vitamin D is perhaps most famous for helping to build strong bones. Avenell and colleagues performed a Cochrane meta-analysis of vitamin D supplementation in older adults and found that vitamin D alone did not significantly reduce the risk of hip or other new fracture. Vitamin D plus calcium supplementation did reduce the risk of hip fracture (nine trials, pooled number of individuals was 49,853; relative risk, 0.84; P = .01).6
A lesser-known benefit of vitamin D is muscle protection. A prospective study out of the Jewish Hospital of Cincinnati followed 146 adults who were intolerant to two or more statins because of muscle side effects and found to have a vitamin D level below 32 ng per mL. Subjects were given vitamin D replacement (50,000 units weekly) and followed for 2 years. On statin rechallenge, 88-95% tolerated a statin with vitamin D levels 53-55 ng/mL.7
Pearl
Vitamin D supplementation may protect against COVID-19 infection and has very low chance of harm at daily doses at or below 4,000 IU. Other benefits of taking vitamin D include bone protection and reduction in statin-induced myopathy. The main adverse effect is kidney stones.
Ms. Sharninghausen is a medical student at the University of Washington, Seattle. Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington and serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].
References
1. Merzon E et al. Low plasma 25(OH) vitamin D level is associated with increased risk of COVID‐19 infection: An Israeli population‐based study. FEBS J. 2020. doi: 10.1111/febs.15495.
2. Martineau AR et al. Vitamin D supplementation to prevent acute respiratory tract infections: Systematic review and meta-analysis of individual participant data. BMJ. 2017;356:i6583. doi:10.1136/bmj.i6583
3. “How to Get More Vitamin D From Your Food,” Cleveland Clinic. 2019 Oct 23. https://health.clevelandclinic.org/how-to-get-more-vitamin-d-from-your-food/.
4. Galior K et al. Development of vitamin d toxicity from overcorrection of vitamin D Deficiency: A review of case reports. Nutrients. 2018;10(8):953. doi: 10.3390/nu10080953
5. Shroff R et al. A bimodal association of vitamin D levels and vascular disease in children on dialysis. J Am Soc Nephrol. 2008;19(6):1239-46. doi: 10.1681/ASN.2007090993.
6. Avenell A et al. Vitamin D and vitamin D analogues for preventing fractures in post‐menopausal women and older men. Cochrane Database Syst Rev. 2014 Apr 14;2014(4):CD000227. doi: 10.1002/14651858.CD000227.pub4.
7. Khayznikov M et al. Statin intolerance because of myalgia, myositis, myopathy, or myonecrosis can in most cases be safely resolved by vitamin D supplementation. N Am J Med Sci. 2015;7(3):86-93. doi:10.4103/1947-2714.153919
Case: A 56-year-old man with a history of type 2 diabetes, hypertension, hyperlipidemia, and obesity calls clinic to discuss concerns about COVID-19, stating: “I want to do everything I can to reduce my risk of infection.” In addition to physical distancing, mask wearing, hand hygiene, and control of chronic conditions, which of the following supplements would you recommend for this patient?
1. Coenzyme Q10 160 mg twice a day
2. Vitamin D 2,000 IU daily
3. Vitamin E 400 IU daily
4. Vitamin B12 1,000 mcg daily
Of these choices, vitamin D supplementation is likely the best option, based on the limited data that is available.
Risk factors for worse COVID-19 outcome, such as older age, obesity, and more pigmented skin are also risk factors for vitamin D deficiency. This makes the study of vitamin D and COVID-19 both challenging and relevant.
In a recent study of 7,807 people living in Israel, Merzon and colleagues found that low plasma vitamin D level was an independent risk factor for COVID-19 infection. Mean plasma vitamin D level was significantly lower among those who tested positive for COVID-19 (19.00 ng/mL) than negative (20.55 ng/ mL). After controlling for demographic variables and several medical conditions, the adjusted odds ratio of COVID-19 infection in those with lower vitamin D was 1.45 (95% confidence interval, 1.08-1.95; P < .001). However, the odds of hospitalization for COVID-19 was not significantly associated with vitamin D level.1
Prior studies have also looked at vitamin D and respiratory infection. Martineau and colleagues analyzed 25 randomized, controlled trials with a pooled number of 11,321 individuals, including healthy ones and those with comorbidities, and found that oral vitamin D supplementation in daily or weekly doses had a protective effect against acute respiratory infection (adjusted odds ratio, 0.88; 95% CI, 0.81-0.96; P < .001). Patients with vitamin D deficiency (less than 25 nmol/L) experienced the most protective benefit. Vitamin D did not influence respiratory infection outcome.2
These studies suggest an adequate vitamin D level may be protective against infection with COVID-19, but who will benefit from vitamin D supplementation, and in what dose? Per U.S. Preventive Services Task Force guidelines, there is insufficient evidence to recommend screening for vitamin D deficiency in asymptomatic adults. Regarding daily dietary intake, the Institute of Medicine recommends 600 IU for persons aged 1-70, and 800 IU for those aged over 70 years. Salmon (447 IU per 3 oz serving), tuna (154 IU), and fortified milk (116 IU) are among the most vitamin D–rich foods.3 The recommended upper level of intake is 4,000 IU/day.
Too much of a good thing?
Extra vitamin D is stored in adipose tissue. If it builds up over time, storage sites may be overwhelmed, causing a rise in serum D level. While one might expect a subsequent rise in calcium levels, studies have shown this happens inconsistently, and at very high vitamin D levels, over 120 ng/mL.4 Most people would have to take at least 50,000 IU daily for several months to see an effect. The main adverse outcome of vitamin D toxicity is kidney stones, mediated by increased calcium in the blood and urine.
Several animal models have demonstrated hypervitaminosis D–induced aortic and coronary artery calcification. Like with kidney stones, the mechanism appears to be through increased calcium and phosphate levels. Shroff and colleagues studied serum vitamin D levels and vascular disease in children with renal disease on dialysis and found a U-shaped distribution: Children with both low and high vitamin D levels had significantly increased carotid artery intima-media thickness and calcification.5 Given the specialized nature of this population, it’s unclear whether these results can be generalized to most people. More studies are warranted on this topic.
Other benefits
Vitamin D is perhaps most famous for helping to build strong bones. Avenell and colleagues performed a Cochrane meta-analysis of vitamin D supplementation in older adults and found that vitamin D alone did not significantly reduce the risk of hip or other new fracture. Vitamin D plus calcium supplementation did reduce the risk of hip fracture (nine trials, pooled number of individuals was 49,853; relative risk, 0.84; P = .01).6
A lesser-known benefit of vitamin D is muscle protection. A prospective study out of the Jewish Hospital of Cincinnati followed 146 adults who were intolerant to two or more statins because of muscle side effects and found to have a vitamin D level below 32 ng per mL. Subjects were given vitamin D replacement (50,000 units weekly) and followed for 2 years. On statin rechallenge, 88-95% tolerated a statin with vitamin D levels 53-55 ng/mL.7
Pearl
Vitamin D supplementation may protect against COVID-19 infection and has very low chance of harm at daily doses at or below 4,000 IU. Other benefits of taking vitamin D include bone protection and reduction in statin-induced myopathy. The main adverse effect is kidney stones.
Ms. Sharninghausen is a medical student at the University of Washington, Seattle. Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington and serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].
References
1. Merzon E et al. Low plasma 25(OH) vitamin D level is associated with increased risk of COVID‐19 infection: An Israeli population‐based study. FEBS J. 2020. doi: 10.1111/febs.15495.
2. Martineau AR et al. Vitamin D supplementation to prevent acute respiratory tract infections: Systematic review and meta-analysis of individual participant data. BMJ. 2017;356:i6583. doi:10.1136/bmj.i6583
3. “How to Get More Vitamin D From Your Food,” Cleveland Clinic. 2019 Oct 23. https://health.clevelandclinic.org/how-to-get-more-vitamin-d-from-your-food/.
4. Galior K et al. Development of vitamin d toxicity from overcorrection of vitamin D Deficiency: A review of case reports. Nutrients. 2018;10(8):953. doi: 10.3390/nu10080953
5. Shroff R et al. A bimodal association of vitamin D levels and vascular disease in children on dialysis. J Am Soc Nephrol. 2008;19(6):1239-46. doi: 10.1681/ASN.2007090993.
6. Avenell A et al. Vitamin D and vitamin D analogues for preventing fractures in post‐menopausal women and older men. Cochrane Database Syst Rev. 2014 Apr 14;2014(4):CD000227. doi: 10.1002/14651858.CD000227.pub4.
7. Khayznikov M et al. Statin intolerance because of myalgia, myositis, myopathy, or myonecrosis can in most cases be safely resolved by vitamin D supplementation. N Am J Med Sci. 2015;7(3):86-93. doi:10.4103/1947-2714.153919
Case: A 56-year-old man with a history of type 2 diabetes, hypertension, hyperlipidemia, and obesity calls clinic to discuss concerns about COVID-19, stating: “I want to do everything I can to reduce my risk of infection.” In addition to physical distancing, mask wearing, hand hygiene, and control of chronic conditions, which of the following supplements would you recommend for this patient?
1. Coenzyme Q10 160 mg twice a day
2. Vitamin D 2,000 IU daily
3. Vitamin E 400 IU daily
4. Vitamin B12 1,000 mcg daily
Of these choices, vitamin D supplementation is likely the best option, based on the limited data that is available.
Risk factors for worse COVID-19 outcome, such as older age, obesity, and more pigmented skin are also risk factors for vitamin D deficiency. This makes the study of vitamin D and COVID-19 both challenging and relevant.
In a recent study of 7,807 people living in Israel, Merzon and colleagues found that low plasma vitamin D level was an independent risk factor for COVID-19 infection. Mean plasma vitamin D level was significantly lower among those who tested positive for COVID-19 (19.00 ng/mL) than negative (20.55 ng/ mL). After controlling for demographic variables and several medical conditions, the adjusted odds ratio of COVID-19 infection in those with lower vitamin D was 1.45 (95% confidence interval, 1.08-1.95; P < .001). However, the odds of hospitalization for COVID-19 was not significantly associated with vitamin D level.1
Prior studies have also looked at vitamin D and respiratory infection. Martineau and colleagues analyzed 25 randomized, controlled trials with a pooled number of 11,321 individuals, including healthy ones and those with comorbidities, and found that oral vitamin D supplementation in daily or weekly doses had a protective effect against acute respiratory infection (adjusted odds ratio, 0.88; 95% CI, 0.81-0.96; P < .001). Patients with vitamin D deficiency (less than 25 nmol/L) experienced the most protective benefit. Vitamin D did not influence respiratory infection outcome.2
These studies suggest an adequate vitamin D level may be protective against infection with COVID-19, but who will benefit from vitamin D supplementation, and in what dose? Per U.S. Preventive Services Task Force guidelines, there is insufficient evidence to recommend screening for vitamin D deficiency in asymptomatic adults. Regarding daily dietary intake, the Institute of Medicine recommends 600 IU for persons aged 1-70, and 800 IU for those aged over 70 years. Salmon (447 IU per 3 oz serving), tuna (154 IU), and fortified milk (116 IU) are among the most vitamin D–rich foods.3 The recommended upper level of intake is 4,000 IU/day.
Too much of a good thing?
Extra vitamin D is stored in adipose tissue. If it builds up over time, storage sites may be overwhelmed, causing a rise in serum D level. While one might expect a subsequent rise in calcium levels, studies have shown this happens inconsistently, and at very high vitamin D levels, over 120 ng/mL.4 Most people would have to take at least 50,000 IU daily for several months to see an effect. The main adverse outcome of vitamin D toxicity is kidney stones, mediated by increased calcium in the blood and urine.
Several animal models have demonstrated hypervitaminosis D–induced aortic and coronary artery calcification. Like with kidney stones, the mechanism appears to be through increased calcium and phosphate levels. Shroff and colleagues studied serum vitamin D levels and vascular disease in children with renal disease on dialysis and found a U-shaped distribution: Children with both low and high vitamin D levels had significantly increased carotid artery intima-media thickness and calcification.5 Given the specialized nature of this population, it’s unclear whether these results can be generalized to most people. More studies are warranted on this topic.
Other benefits
Vitamin D is perhaps most famous for helping to build strong bones. Avenell and colleagues performed a Cochrane meta-analysis of vitamin D supplementation in older adults and found that vitamin D alone did not significantly reduce the risk of hip or other new fracture. Vitamin D plus calcium supplementation did reduce the risk of hip fracture (nine trials, pooled number of individuals was 49,853; relative risk, 0.84; P = .01).6
A lesser-known benefit of vitamin D is muscle protection. A prospective study out of the Jewish Hospital of Cincinnati followed 146 adults who were intolerant to two or more statins because of muscle side effects and found to have a vitamin D level below 32 ng per mL. Subjects were given vitamin D replacement (50,000 units weekly) and followed for 2 years. On statin rechallenge, 88-95% tolerated a statin with vitamin D levels 53-55 ng/mL.7
Pearl
Vitamin D supplementation may protect against COVID-19 infection and has very low chance of harm at daily doses at or below 4,000 IU. Other benefits of taking vitamin D include bone protection and reduction in statin-induced myopathy. The main adverse effect is kidney stones.
Ms. Sharninghausen is a medical student at the University of Washington, Seattle. Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington and serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].
References
1. Merzon E et al. Low plasma 25(OH) vitamin D level is associated with increased risk of COVID‐19 infection: An Israeli population‐based study. FEBS J. 2020. doi: 10.1111/febs.15495.
2. Martineau AR et al. Vitamin D supplementation to prevent acute respiratory tract infections: Systematic review and meta-analysis of individual participant data. BMJ. 2017;356:i6583. doi:10.1136/bmj.i6583
3. “How to Get More Vitamin D From Your Food,” Cleveland Clinic. 2019 Oct 23. https://health.clevelandclinic.org/how-to-get-more-vitamin-d-from-your-food/.
4. Galior K et al. Development of vitamin d toxicity from overcorrection of vitamin D Deficiency: A review of case reports. Nutrients. 2018;10(8):953. doi: 10.3390/nu10080953
5. Shroff R et al. A bimodal association of vitamin D levels and vascular disease in children on dialysis. J Am Soc Nephrol. 2008;19(6):1239-46. doi: 10.1681/ASN.2007090993.
6. Avenell A et al. Vitamin D and vitamin D analogues for preventing fractures in post‐menopausal women and older men. Cochrane Database Syst Rev. 2014 Apr 14;2014(4):CD000227. doi: 10.1002/14651858.CD000227.pub4.
7. Khayznikov M et al. Statin intolerance because of myalgia, myositis, myopathy, or myonecrosis can in most cases be safely resolved by vitamin D supplementation. N Am J Med Sci. 2015;7(3):86-93. doi:10.4103/1947-2714.153919
What have we learned? HM20 Virtual edition
The last session of each SHM Annual Conference is traditionally a short presentation titled “What Have We Learned?” that is delivered by next year’s course director (and this year, that is me!).
We’ve learned that by making the heartbreaking decision to cancel the HM20 in-person conference and convert to a virtual platform, SHM leadership is not afraid to do the right thing to protect the health of its members and staff, even when such a decision comes at significant cost to the organization. We’ve learned that the SHM staff are flexible and innovative and are masters of logistics – their ability to pivot so quickly into a virtual format on such short notice is nothing short of amazing. On the Annual Conference Committee (ACC), we already knew that Benji Mathews, the HM20 course director, was an outstanding leader. True to form, despite facing unprecedented uncertainty and tremendous disappointment, Benji continued to lead with the steady, eloquent presence and poise he’s known for, delivering an outstanding HM20 Virtual.
We’ve learned that SHM members can enjoy and engage meaningfully in a virtual format, as evidenced by well-attended sessions, including robust Q&A exchanges that took place during HM20 Virtual’s simulive offerings. Not seeing each other in person this year has reminded us how much the sense of community we enjoy through SHM means to so many of us. I missed catching up with so many colleagues that have become true friends over the years, and I know you did as well.
We also saw how SHM does not hesitate to provide a platform to shine a spotlight on the critical issues of the day. The double pandemic of COVID-19 and structural racism that we face was addressed head-on by expert faculty in sessions such as “Structural Racism and Bias in Hospital Medicine During Two Pandemics,” “The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19,” and “When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics.” Sessions on different aspects of COVID-19 enabled our members to stay up to date on the continually evolving knowledge base of this new disease.
We are so excited as we look ahead to HM21. There will be content on COVID-19 at HM21 … but not too much COVID. The ACC is mindful that our members come to the Annual Conference to hear experts speak on a broad range of clinical topics, and HM21 will be sure to deliver. An innovative new track on Diagnostic Safety will address this critical aspect of high-quality care. We will also debut a new leadership track. At HM21, the ACC is also proud to introduce a dedicated track that will include sessions that address diversity, disparities, and equity. And if what happens in Vegas cannot stay in Vegas (does that make some of you nervous …?), and a virtual element needs to be part of HM21, we will utilize a sophisticated and highly functional platform that will provide some things that our HM20 Virtual platform didn’t.
Couldn’t make HM20 Virtual? Don’t worry! You can still experience the in-depth, immersive education courtesy of some of the most knowledgeable faculty in the field through HM20 Virtual On Demand.
It has indeed been a year in which we have learned a lot. Most importantly, we have learned that we are resilient and that we are stronger together. That SHM and the Annual Conference – be it virtual or in person – is a place where we value, respect, and support each other. Have a great year. I look forward to welcoming you to HM21 in May 2021!
Dr. Steinberg is associate chair for education and residency program director in the department of medicine at Mount Sinai Beth Israel, New York, and course director of HM21.
The last session of each SHM Annual Conference is traditionally a short presentation titled “What Have We Learned?” that is delivered by next year’s course director (and this year, that is me!).
We’ve learned that by making the heartbreaking decision to cancel the HM20 in-person conference and convert to a virtual platform, SHM leadership is not afraid to do the right thing to protect the health of its members and staff, even when such a decision comes at significant cost to the organization. We’ve learned that the SHM staff are flexible and innovative and are masters of logistics – their ability to pivot so quickly into a virtual format on such short notice is nothing short of amazing. On the Annual Conference Committee (ACC), we already knew that Benji Mathews, the HM20 course director, was an outstanding leader. True to form, despite facing unprecedented uncertainty and tremendous disappointment, Benji continued to lead with the steady, eloquent presence and poise he’s known for, delivering an outstanding HM20 Virtual.
We’ve learned that SHM members can enjoy and engage meaningfully in a virtual format, as evidenced by well-attended sessions, including robust Q&A exchanges that took place during HM20 Virtual’s simulive offerings. Not seeing each other in person this year has reminded us how much the sense of community we enjoy through SHM means to so many of us. I missed catching up with so many colleagues that have become true friends over the years, and I know you did as well.
We also saw how SHM does not hesitate to provide a platform to shine a spotlight on the critical issues of the day. The double pandemic of COVID-19 and structural racism that we face was addressed head-on by expert faculty in sessions such as “Structural Racism and Bias in Hospital Medicine During Two Pandemics,” “The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19,” and “When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics.” Sessions on different aspects of COVID-19 enabled our members to stay up to date on the continually evolving knowledge base of this new disease.
We are so excited as we look ahead to HM21. There will be content on COVID-19 at HM21 … but not too much COVID. The ACC is mindful that our members come to the Annual Conference to hear experts speak on a broad range of clinical topics, and HM21 will be sure to deliver. An innovative new track on Diagnostic Safety will address this critical aspect of high-quality care. We will also debut a new leadership track. At HM21, the ACC is also proud to introduce a dedicated track that will include sessions that address diversity, disparities, and equity. And if what happens in Vegas cannot stay in Vegas (does that make some of you nervous …?), and a virtual element needs to be part of HM21, we will utilize a sophisticated and highly functional platform that will provide some things that our HM20 Virtual platform didn’t.
Couldn’t make HM20 Virtual? Don’t worry! You can still experience the in-depth, immersive education courtesy of some of the most knowledgeable faculty in the field through HM20 Virtual On Demand.
It has indeed been a year in which we have learned a lot. Most importantly, we have learned that we are resilient and that we are stronger together. That SHM and the Annual Conference – be it virtual or in person – is a place where we value, respect, and support each other. Have a great year. I look forward to welcoming you to HM21 in May 2021!
Dr. Steinberg is associate chair for education and residency program director in the department of medicine at Mount Sinai Beth Israel, New York, and course director of HM21.
The last session of each SHM Annual Conference is traditionally a short presentation titled “What Have We Learned?” that is delivered by next year’s course director (and this year, that is me!).
We’ve learned that by making the heartbreaking decision to cancel the HM20 in-person conference and convert to a virtual platform, SHM leadership is not afraid to do the right thing to protect the health of its members and staff, even when such a decision comes at significant cost to the organization. We’ve learned that the SHM staff are flexible and innovative and are masters of logistics – their ability to pivot so quickly into a virtual format on such short notice is nothing short of amazing. On the Annual Conference Committee (ACC), we already knew that Benji Mathews, the HM20 course director, was an outstanding leader. True to form, despite facing unprecedented uncertainty and tremendous disappointment, Benji continued to lead with the steady, eloquent presence and poise he’s known for, delivering an outstanding HM20 Virtual.
We’ve learned that SHM members can enjoy and engage meaningfully in a virtual format, as evidenced by well-attended sessions, including robust Q&A exchanges that took place during HM20 Virtual’s simulive offerings. Not seeing each other in person this year has reminded us how much the sense of community we enjoy through SHM means to so many of us. I missed catching up with so many colleagues that have become true friends over the years, and I know you did as well.
We also saw how SHM does not hesitate to provide a platform to shine a spotlight on the critical issues of the day. The double pandemic of COVID-19 and structural racism that we face was addressed head-on by expert faculty in sessions such as “Structural Racism and Bias in Hospital Medicine During Two Pandemics,” “The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19,” and “When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics.” Sessions on different aspects of COVID-19 enabled our members to stay up to date on the continually evolving knowledge base of this new disease.
We are so excited as we look ahead to HM21. There will be content on COVID-19 at HM21 … but not too much COVID. The ACC is mindful that our members come to the Annual Conference to hear experts speak on a broad range of clinical topics, and HM21 will be sure to deliver. An innovative new track on Diagnostic Safety will address this critical aspect of high-quality care. We will also debut a new leadership track. At HM21, the ACC is also proud to introduce a dedicated track that will include sessions that address diversity, disparities, and equity. And if what happens in Vegas cannot stay in Vegas (does that make some of you nervous …?), and a virtual element needs to be part of HM21, we will utilize a sophisticated and highly functional platform that will provide some things that our HM20 Virtual platform didn’t.
Couldn’t make HM20 Virtual? Don’t worry! You can still experience the in-depth, immersive education courtesy of some of the most knowledgeable faculty in the field through HM20 Virtual On Demand.
It has indeed been a year in which we have learned a lot. Most importantly, we have learned that we are resilient and that we are stronger together. That SHM and the Annual Conference – be it virtual or in person – is a place where we value, respect, and support each other. Have a great year. I look forward to welcoming you to HM21 in May 2021!
Dr. Steinberg is associate chair for education and residency program director in the department of medicine at Mount Sinai Beth Israel, New York, and course director of HM21.
Mitigating psychiatric disorder relapse in pregnancy during pandemic
In a previous column, I addressed some of the issues that quickly arose in the context of the COVID-19 pandemic and their implications for reproductive psychiatry. These issues ranged from the importance of sustaining well-being in pregnant and postpartum women during the pandemic, to temporary restrictions that were in place during the early part of the pandemic with respect to performing infertility procedures, to the practical issues of limiting the number of people who could attend to women during labor and delivery in the hospital.
Five months later, we’ve learned a great deal about trying to sustain emotional well-being among pregnant women during COVID-19. There is a high rate of anxiety among women who are pregnant and women who have particularly young children around the various issues of juggling activities of daily living during the pandemic, including switching to remote work and homeschooling children. There is fear of contracting COVID-19 during pregnancy, the exact effects of which are still somewhat unknown. We have seen a shift to telemedicine for prenatal and postpartum obstetrics visits, and a change with respect to visitors and even in-home nurses that would help during the first weeks of life for some couples.
We wondered whether we would see a falloff in the numbers of women presenting to our clinic with questions about the reproductive safety of taking psychiatric medications during pregnancy. We were unclear as to whether women would defer plans to get pregnant given some of the uncertainties that have come with COVID-19. What we’ve seen, at least early on in the pandemic in Massachusetts, has been the opposite. More women during the first 4 months of the pandemic have been seen in our center compared with the same corresponding period over the last 5 years. The precise reasons for this are unclear, but one reason may be that shifting the practice of reproductive psychiatry and pregnancy planning for reproductive-age women to full virtual care has dropped the number of missed appointments to essentially zero. Women perhaps feel an urgency to have a plan for using psychiatric medication during pregnancy. They may also see the benefit of being able to have extended telemedicine consultations that frequently involve their partners, a practice we have always supported, but posed logistical challenges for some.
As our colleagues learned that we had shifted our clinical rounds at the Center for Women’s Mental Health, which we’ve been doing for 25 years, to a virtual format, we began offering a free 1-hour forum to discuss relevant issues around caring for psychiatrically ill women, with a focus on some of the issues that were particularly relevant during the pandemic. The most common reasons for consultation on our service are the appropriate, safest use of antidepressants and mood stabilizers during pregnancy, and that continues to be the case.
If there has been one guiding principle in treating perinatal depression during pregnancy, it has been our long-standing, laser-like focus on keeping women emotionally well during pregnancy, and to highlight the importance of this with women during consultations prior to and during pregnancy. Relapse of psychiatric disorder during pregnancy is one the strongest predictors of postpartum depression, and the impact of untreated depression during pregnancy has been described in the literature and over the years in this column. However, where we want to minimize, if possible, severe onset of illness requiring hospitalization or emergent attention considering it may make social distancing and some of the other mitigating factors vis-à-vis COVID-19 more challenging.
Despite the accumulated data over the last 2 decades on the reproductive safety of antidepressants, women continue to have questions about the safety of these medications during pregnancy. Studies show now that many women would prefer, if at all possible, to defer treatment with antidepressants, and so they come to us with questions about their reproductive safety, the potential of switching to nonpharmacologic interventions, and the use of alternative interventions that might be used to treat their underlying mood disorder.
Investigators at the University of British Columbia recently have tried to inform the field with still another look, not at reproductive safety per se, but at risk of relapse of depression if women discontinue those medicines during pregnancy.1 There is a timeliness to this investigation, which was a systematic review and meta-analysis of studies that met a priori criteria for inclusion. Since some of our own group’s early work over 15 years ago on relapse of psychiatric disorder during pregnancy,2 which indicated a substantial difference in risk of relapse between women who continued versus who discontinued antidepressants, other investigators have showed the difference in risk for relapse is not as substantial, and that continuation of medication did not appear to mitigate risk for relapse. In fact, in the systematic review, the investigators demonstrated that as a group, maintaining medicine did not appear to confer particular benefit to patients relative to risk for relapse compared to discontinuation of antidepressants.
However, looking more closely, Bayrampour and colleagues note for women with histories of more severe recurrent, major depression, relapse did in fact appear to be greater in women who discontinued compared with those with cases of mild to moderate depression. It is noteworthy that in both our early and later work, and certainly dovetailing with our clinical practice, we have noted severity of illness does not appear to correlate with the actual decisions women ultimately make regarding what they will do with antidepressants. Specifically, some women with very severe illness histories will discontinue antidepressants regardless of their risk for relapse. Alternatively, women with mild to moderate illness will sometimes elect to stay on antidepressant therapy. With all the information that we have about fetal exposure to antidepressants on one hand, the “unknown unknowns” are an understandable concern to both patients and clinicians. Clinicians are faced with the dilemma of how to best counsel women on continuing or discontinuing antidepressants as they plan to conceive or during pregnancy and in the postpartum period.
The literature cited and clinical experience over the last 3 decades suggests rather strongly that there is a relatively low likelihood women with histories of severe recurrent disease will be able to successfully discontinue antidepressants in the absence of relapse. A greater question is, what is the best way to proceed for women who have been on maintenance therapy and had more moderate symptoms?
I am inspired by some of the more recent literature that has tried to elucidate the role of nonpharmacologic interventions such as mindfulness-based cognitive therapy (MBCT) in an effort to mitigate risk for depressive relapse in pregnant women who are well with histories of depression. To date, data do not inform the question as to whether MBCT can be used to mitigate risk of depressive relapse in pregnant women who continue or discontinue antidepressants. That research question is actively being studied by several investigators, including ourselves.
Of particular interest is whether the addition of mindfulness practices such as MBCT in treatment could mitigate risk for depressive relapse in pregnant women who continue or discontinue antidepressant treatment, as that would certainly be a no-harm intervention that could mitigate risk even in a lower risk sample of patients. The question of how to “thread the needle” during the pandemic and best approach woman with a history of recurrent major depression on antidepressants is particularly timely and critical.
Regardless, we make clinical decisions collaboratively with patients based on their histories and individual wishes, and perhaps what we have learned over the last 5 months is the use of telemedicine does afford us the opportunity, regardless of the decisions that patients make, to more closely follow the clinical trajectory of women during pregnancy and the postpartum period so that regardless of treatment, we have an opportunity to intervene early when needed and to ascertain changes in clinical status early to mitigate the risk of frank relapse. From a reproductive psychiatric point of view, that is a silver lining with respect to the associated challenges that have come along with the pandemic.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at [email protected].
References
1. J Clin Psychiatry 2020;81(4):19r13134.
2. JAMA. 2006 Feb 1;295(5):499-507.
In a previous column, I addressed some of the issues that quickly arose in the context of the COVID-19 pandemic and their implications for reproductive psychiatry. These issues ranged from the importance of sustaining well-being in pregnant and postpartum women during the pandemic, to temporary restrictions that were in place during the early part of the pandemic with respect to performing infertility procedures, to the practical issues of limiting the number of people who could attend to women during labor and delivery in the hospital.
Five months later, we’ve learned a great deal about trying to sustain emotional well-being among pregnant women during COVID-19. There is a high rate of anxiety among women who are pregnant and women who have particularly young children around the various issues of juggling activities of daily living during the pandemic, including switching to remote work and homeschooling children. There is fear of contracting COVID-19 during pregnancy, the exact effects of which are still somewhat unknown. We have seen a shift to telemedicine for prenatal and postpartum obstetrics visits, and a change with respect to visitors and even in-home nurses that would help during the first weeks of life for some couples.
We wondered whether we would see a falloff in the numbers of women presenting to our clinic with questions about the reproductive safety of taking psychiatric medications during pregnancy. We were unclear as to whether women would defer plans to get pregnant given some of the uncertainties that have come with COVID-19. What we’ve seen, at least early on in the pandemic in Massachusetts, has been the opposite. More women during the first 4 months of the pandemic have been seen in our center compared with the same corresponding period over the last 5 years. The precise reasons for this are unclear, but one reason may be that shifting the practice of reproductive psychiatry and pregnancy planning for reproductive-age women to full virtual care has dropped the number of missed appointments to essentially zero. Women perhaps feel an urgency to have a plan for using psychiatric medication during pregnancy. They may also see the benefit of being able to have extended telemedicine consultations that frequently involve their partners, a practice we have always supported, but posed logistical challenges for some.
As our colleagues learned that we had shifted our clinical rounds at the Center for Women’s Mental Health, which we’ve been doing for 25 years, to a virtual format, we began offering a free 1-hour forum to discuss relevant issues around caring for psychiatrically ill women, with a focus on some of the issues that were particularly relevant during the pandemic. The most common reasons for consultation on our service are the appropriate, safest use of antidepressants and mood stabilizers during pregnancy, and that continues to be the case.
If there has been one guiding principle in treating perinatal depression during pregnancy, it has been our long-standing, laser-like focus on keeping women emotionally well during pregnancy, and to highlight the importance of this with women during consultations prior to and during pregnancy. Relapse of psychiatric disorder during pregnancy is one the strongest predictors of postpartum depression, and the impact of untreated depression during pregnancy has been described in the literature and over the years in this column. However, where we want to minimize, if possible, severe onset of illness requiring hospitalization or emergent attention considering it may make social distancing and some of the other mitigating factors vis-à-vis COVID-19 more challenging.
Despite the accumulated data over the last 2 decades on the reproductive safety of antidepressants, women continue to have questions about the safety of these medications during pregnancy. Studies show now that many women would prefer, if at all possible, to defer treatment with antidepressants, and so they come to us with questions about their reproductive safety, the potential of switching to nonpharmacologic interventions, and the use of alternative interventions that might be used to treat their underlying mood disorder.
Investigators at the University of British Columbia recently have tried to inform the field with still another look, not at reproductive safety per se, but at risk of relapse of depression if women discontinue those medicines during pregnancy.1 There is a timeliness to this investigation, which was a systematic review and meta-analysis of studies that met a priori criteria for inclusion. Since some of our own group’s early work over 15 years ago on relapse of psychiatric disorder during pregnancy,2 which indicated a substantial difference in risk of relapse between women who continued versus who discontinued antidepressants, other investigators have showed the difference in risk for relapse is not as substantial, and that continuation of medication did not appear to mitigate risk for relapse. In fact, in the systematic review, the investigators demonstrated that as a group, maintaining medicine did not appear to confer particular benefit to patients relative to risk for relapse compared to discontinuation of antidepressants.
However, looking more closely, Bayrampour and colleagues note for women with histories of more severe recurrent, major depression, relapse did in fact appear to be greater in women who discontinued compared with those with cases of mild to moderate depression. It is noteworthy that in both our early and later work, and certainly dovetailing with our clinical practice, we have noted severity of illness does not appear to correlate with the actual decisions women ultimately make regarding what they will do with antidepressants. Specifically, some women with very severe illness histories will discontinue antidepressants regardless of their risk for relapse. Alternatively, women with mild to moderate illness will sometimes elect to stay on antidepressant therapy. With all the information that we have about fetal exposure to antidepressants on one hand, the “unknown unknowns” are an understandable concern to both patients and clinicians. Clinicians are faced with the dilemma of how to best counsel women on continuing or discontinuing antidepressants as they plan to conceive or during pregnancy and in the postpartum period.
The literature cited and clinical experience over the last 3 decades suggests rather strongly that there is a relatively low likelihood women with histories of severe recurrent disease will be able to successfully discontinue antidepressants in the absence of relapse. A greater question is, what is the best way to proceed for women who have been on maintenance therapy and had more moderate symptoms?
I am inspired by some of the more recent literature that has tried to elucidate the role of nonpharmacologic interventions such as mindfulness-based cognitive therapy (MBCT) in an effort to mitigate risk for depressive relapse in pregnant women who are well with histories of depression. To date, data do not inform the question as to whether MBCT can be used to mitigate risk of depressive relapse in pregnant women who continue or discontinue antidepressants. That research question is actively being studied by several investigators, including ourselves.
Of particular interest is whether the addition of mindfulness practices such as MBCT in treatment could mitigate risk for depressive relapse in pregnant women who continue or discontinue antidepressant treatment, as that would certainly be a no-harm intervention that could mitigate risk even in a lower risk sample of patients. The question of how to “thread the needle” during the pandemic and best approach woman with a history of recurrent major depression on antidepressants is particularly timely and critical.
Regardless, we make clinical decisions collaboratively with patients based on their histories and individual wishes, and perhaps what we have learned over the last 5 months is the use of telemedicine does afford us the opportunity, regardless of the decisions that patients make, to more closely follow the clinical trajectory of women during pregnancy and the postpartum period so that regardless of treatment, we have an opportunity to intervene early when needed and to ascertain changes in clinical status early to mitigate the risk of frank relapse. From a reproductive psychiatric point of view, that is a silver lining with respect to the associated challenges that have come along with the pandemic.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at [email protected].
References
1. J Clin Psychiatry 2020;81(4):19r13134.
2. JAMA. 2006 Feb 1;295(5):499-507.
In a previous column, I addressed some of the issues that quickly arose in the context of the COVID-19 pandemic and their implications for reproductive psychiatry. These issues ranged from the importance of sustaining well-being in pregnant and postpartum women during the pandemic, to temporary restrictions that were in place during the early part of the pandemic with respect to performing infertility procedures, to the practical issues of limiting the number of people who could attend to women during labor and delivery in the hospital.
Five months later, we’ve learned a great deal about trying to sustain emotional well-being among pregnant women during COVID-19. There is a high rate of anxiety among women who are pregnant and women who have particularly young children around the various issues of juggling activities of daily living during the pandemic, including switching to remote work and homeschooling children. There is fear of contracting COVID-19 during pregnancy, the exact effects of which are still somewhat unknown. We have seen a shift to telemedicine for prenatal and postpartum obstetrics visits, and a change with respect to visitors and even in-home nurses that would help during the first weeks of life for some couples.
We wondered whether we would see a falloff in the numbers of women presenting to our clinic with questions about the reproductive safety of taking psychiatric medications during pregnancy. We were unclear as to whether women would defer plans to get pregnant given some of the uncertainties that have come with COVID-19. What we’ve seen, at least early on in the pandemic in Massachusetts, has been the opposite. More women during the first 4 months of the pandemic have been seen in our center compared with the same corresponding period over the last 5 years. The precise reasons for this are unclear, but one reason may be that shifting the practice of reproductive psychiatry and pregnancy planning for reproductive-age women to full virtual care has dropped the number of missed appointments to essentially zero. Women perhaps feel an urgency to have a plan for using psychiatric medication during pregnancy. They may also see the benefit of being able to have extended telemedicine consultations that frequently involve their partners, a practice we have always supported, but posed logistical challenges for some.
As our colleagues learned that we had shifted our clinical rounds at the Center for Women’s Mental Health, which we’ve been doing for 25 years, to a virtual format, we began offering a free 1-hour forum to discuss relevant issues around caring for psychiatrically ill women, with a focus on some of the issues that were particularly relevant during the pandemic. The most common reasons for consultation on our service are the appropriate, safest use of antidepressants and mood stabilizers during pregnancy, and that continues to be the case.
If there has been one guiding principle in treating perinatal depression during pregnancy, it has been our long-standing, laser-like focus on keeping women emotionally well during pregnancy, and to highlight the importance of this with women during consultations prior to and during pregnancy. Relapse of psychiatric disorder during pregnancy is one the strongest predictors of postpartum depression, and the impact of untreated depression during pregnancy has been described in the literature and over the years in this column. However, where we want to minimize, if possible, severe onset of illness requiring hospitalization or emergent attention considering it may make social distancing and some of the other mitigating factors vis-à-vis COVID-19 more challenging.
Despite the accumulated data over the last 2 decades on the reproductive safety of antidepressants, women continue to have questions about the safety of these medications during pregnancy. Studies show now that many women would prefer, if at all possible, to defer treatment with antidepressants, and so they come to us with questions about their reproductive safety, the potential of switching to nonpharmacologic interventions, and the use of alternative interventions that might be used to treat their underlying mood disorder.
Investigators at the University of British Columbia recently have tried to inform the field with still another look, not at reproductive safety per se, but at risk of relapse of depression if women discontinue those medicines during pregnancy.1 There is a timeliness to this investigation, which was a systematic review and meta-analysis of studies that met a priori criteria for inclusion. Since some of our own group’s early work over 15 years ago on relapse of psychiatric disorder during pregnancy,2 which indicated a substantial difference in risk of relapse between women who continued versus who discontinued antidepressants, other investigators have showed the difference in risk for relapse is not as substantial, and that continuation of medication did not appear to mitigate risk for relapse. In fact, in the systematic review, the investigators demonstrated that as a group, maintaining medicine did not appear to confer particular benefit to patients relative to risk for relapse compared to discontinuation of antidepressants.
However, looking more closely, Bayrampour and colleagues note for women with histories of more severe recurrent, major depression, relapse did in fact appear to be greater in women who discontinued compared with those with cases of mild to moderate depression. It is noteworthy that in both our early and later work, and certainly dovetailing with our clinical practice, we have noted severity of illness does not appear to correlate with the actual decisions women ultimately make regarding what they will do with antidepressants. Specifically, some women with very severe illness histories will discontinue antidepressants regardless of their risk for relapse. Alternatively, women with mild to moderate illness will sometimes elect to stay on antidepressant therapy. With all the information that we have about fetal exposure to antidepressants on one hand, the “unknown unknowns” are an understandable concern to both patients and clinicians. Clinicians are faced with the dilemma of how to best counsel women on continuing or discontinuing antidepressants as they plan to conceive or during pregnancy and in the postpartum period.
The literature cited and clinical experience over the last 3 decades suggests rather strongly that there is a relatively low likelihood women with histories of severe recurrent disease will be able to successfully discontinue antidepressants in the absence of relapse. A greater question is, what is the best way to proceed for women who have been on maintenance therapy and had more moderate symptoms?
I am inspired by some of the more recent literature that has tried to elucidate the role of nonpharmacologic interventions such as mindfulness-based cognitive therapy (MBCT) in an effort to mitigate risk for depressive relapse in pregnant women who are well with histories of depression. To date, data do not inform the question as to whether MBCT can be used to mitigate risk of depressive relapse in pregnant women who continue or discontinue antidepressants. That research question is actively being studied by several investigators, including ourselves.
Of particular interest is whether the addition of mindfulness practices such as MBCT in treatment could mitigate risk for depressive relapse in pregnant women who continue or discontinue antidepressant treatment, as that would certainly be a no-harm intervention that could mitigate risk even in a lower risk sample of patients. The question of how to “thread the needle” during the pandemic and best approach woman with a history of recurrent major depression on antidepressants is particularly timely and critical.
Regardless, we make clinical decisions collaboratively with patients based on their histories and individual wishes, and perhaps what we have learned over the last 5 months is the use of telemedicine does afford us the opportunity, regardless of the decisions that patients make, to more closely follow the clinical trajectory of women during pregnancy and the postpartum period so that regardless of treatment, we have an opportunity to intervene early when needed and to ascertain changes in clinical status early to mitigate the risk of frank relapse. From a reproductive psychiatric point of view, that is a silver lining with respect to the associated challenges that have come along with the pandemic.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at [email protected].
References
1. J Clin Psychiatry 2020;81(4):19r13134.
2. JAMA. 2006 Feb 1;295(5):499-507.
The interesting history of dermatologist-developed skin care
Those of you who have visited my dermatology practice in Miami know that the art in my office is dedicated to the history of the skin care industry. I collect , and I have written this historical column in honor of the 50th anniversary of Dermatology News.
The first doctor to market his own cosmetic product, Erasmus Wilson, MD, faced scrutiny from his colleagues. Although he had contributed much to the field of dermatology, he was criticized by other dermatologists when he promoted a hair wash. The next doctor in my story, William Pusey, MD, was criticized for helping the company that manufactured Camay soap because he allowed his name to be used in Camay advertisements. The scrutiny that these two well-respected dermatologists endured from their colleagues deterred dermatologists from entering the skin care business for decades. The professional jealousy from dermatologic colleagues left the skin care field wide open for imposters, charlatans, and nondermatologists who had no concern for efficacy and patient outcomes to flourish. This is the story of a group of brilliant entrepreneurial dermatologists and one chiropractor who misrepresented himself as a dermatologist and how they influenced skin care as we know it.
Erasmus Wilson, MD1 (1809-1884): In 1840, Erasmus Wilson2 was a physician in London who chose to specialize in dermatology at a time when that specialization was frowned upon. He was a subeditor for The Lancet and wrote several books on dermatology including “Diseases of the Skin – A Practical and Theoretical Treatise,” “Portraits of the Diseases of the Skin,” and “Student’s Book on Diseases of the Skin.” He was the first professor of dermatology in the College of Surgeons and by 1869, was the leading English-speaking dermatologist in the world. He contributed much to dermatology, including his pioneering characterizations of Demodex mites, lichen planus, exfoliative dermatitis, neurotic excoriations, and roseola. Dr. Wilson was knighted in 1881 for his good works and notable generosity. (He was known for giving his poor patients money for food, endowing chairs in dermatology, and donating a famous obelisk in London).
In 1854, Dr. Wilson wrote a book for laypeople called “Healthy Skin: A Popular Treatise on the Skin and Hair, Their Preservation and Management,” in which he advocated cleanliness and bathing, which led to the popularity of Turkish baths and bathing resorts in Europe. Despite his undeniable contributions to dermatology, he was widely criticized by his colleagues for promoting a “Hair Wash” and a turtle oil soap. I cannot find any information about whether or not he developed the hair wash and turtle soap himself, but it seems that he earned income from sales of these two products, even though he was said to have donated it all to charities.
William A. Pusey MD (1865-1940): Dr. Pusey was the first chairman of dermatology at the University of Illinois College of Medicine, Chicago. He published several books, including “Care of the Skin and Hair,” “Syphilis as a Modern Problem,” “The Principles and Practices of Dermatology,” and “History of Dermatology” among others. He is best known for his work in developing the use of x-rays (roentgen rays) and phototherapy in dermatology, and in 1907, he was the first dermatologist to describe the use of solid carbon dioxide to treat skin lesions. He was president of the American Dermatological Association in 1910, president of the Chicago Medical Society in 1918, editor of the Archives of Dermatology in 1920, and president of the American Medical Association in 1924.
In the early 1920s, skin care companies were beginning to advertise their products using endorsements from celebrities and socialites, and were making misleading claims. Dr. Pusey wanted to work with these companies to help them perform evidence-based trials so they could make scientifically correct claims. Proctor & Gamble asked Dr. Pusey to advise them on how they could advertise honestly about their new soap, “Camay.” In Dr. Pusey’s words,3 “they (Proctor & Gamble) wanted to give the public authoritative advice about the use of soap and water. They suggested that I get a group of dermatologists of my selection to examine the soap and prepare instructions for bathing and the use of soap, and, if they found this soap was of high quality, to certify to that effect.” The research was performed as he suggested, and he allowed his name to be used in the Camay soap ads from 1926 to 1929. He said that he allowed them to use his name hoping to promote the need for evidence-based research, in contrast to the skin care products endorsed by socialites and celebrities that were flooding the market around that time.
Herbert Rattner, MD, at Northwestern University, Chicago, was his friend and one of the many dermatologists who criticized Dr. Pusey for allowing his name to be used in the Camay ads. Dr. Pusey’s reply to the criticism (according to Dr. Rattner) was that Proctor & Gamble was “proposing to do what the medical profession always is criticizing commercial concerns for not doing, namely, coming to physicians for information on medical matters. Could the profession hope to have any influence with business concerns if it was always eager to criticize bad commercial practices but never willing to support good ones?”3
While Dr. Pusey felt his reasons for adding his name to the Camay ads and research were justified, many of his friends stated that in hindsight, he regretted the action because of the negative response of his colleagues. It was years before dermatologists began providing input again into the skin care industry. During that time, radio, television and print ads were rampant with misleading claims – which led the way for a dermatologic imposter to make a fortune on skin care.
John Woodbury (1851-1909): John Woodbury, a chiropractor, never went to medical school, but that did not stop him from claiming he was a dermatologist and cosmetic surgeon. In 1889, he opened the John H. Woodbury Dermatological Institute in New York City, and over the next few years, opened Woodbury Dermatological Institutes in at least 5 states and employed 25 “physicians” who were not licensed to practice medicine. He came out with face soaps, tonics, and cold creams and spent a fortune on advertising these products and his institutes. In 1901, he sold his “Woodbury Soap” to the Andrew Jergens Company for $212,500 and 10% in royalties.
Multiple lawsuits occurred from 1898 to 1907 because he continued using the Woodbury name on his own products, despite having sold the “Woodbury” trademark to Jergens. He was sued for practicing medicine without a medical license and claiming to be a dermatologist when he was not. He lost most of these lawsuits, including one in 1907 in which the court ruled that corporations may not employ unlicensed professionals to practice medicine. In 1909, John Woodbury committed suicide. The Woodbury Soap company flourished in the 1930s and 1940s, as part of Jergens, until the brand was discontinued in 1970 when Jergens was acquired by American Brands.
The next dermatologists to come along did not make the same mistakes as those of their predecessors. They all made scientific discoveries through their basic science research in the laboratory, filed patents, formed skin care companies, perfected the formulations, and conducted research trials of the final product. Their marketing focused on science and efficacy and only rarely used their names and images in advertising, allowing them to maintain their reputations in the dermatology field.
Eugene Van Scott, MD (1922-present): Dermatologist Dr. Van Scott and dermatopharmacologist Ruey Yu, PhD, filed a method patent in the early 1970s on the effectiveness of alpha hydroxy acids to treat ichthyosis. They invented the abbreviation “AHA” and have continued their work on organic acids to this day. They now have more than 125 patents, which they have licensed to 60 companies in the cosmetics and pharmaceutical industries.
In 1988, 14 years after their initial publication, they founded the company they named Polystrata, which grew into today’s NeoStrata.4 Over the years, they had to defend their patents because many personal care companies used their technologies without licensing them. In 2007, they won a $41 million settlement in a patent infringement suit against Mary Kay filed in March 2005. They have both been very philanthropic in the dermatology world5 and are highly respected in the field. Among many other honors, Dr. Van Scott was named a Master Dermatologist by the American Academy of Dermatology in 1998 and received the Dermatology Foundation’s Distinguished Service Medallion in 2004.
Sheldon Pinnell, MD (1937-2013): After Dr. Pinnell completed his dermatology residency at Harvard Medical School, he spent 2 years studying collagen chemistry at the Max Planck Institute in Munich, Germany. In 1973, he returned to Duke University where he had earned his undergraduate degree before attending Yale University. He remained at Duke for the duration of his career and was professor and chief of dermatology there for many years. Early in his career, he focused on the role of vitamin C in collagen biosynthesis and discovered some of the mechanisms by which sun exposure causes photoaging. He described the use of the first (and most popular) topically applied L-ascorbic acid (vitamin C) to prevent and treat skin aging.
Dr. Pinnell’s many discoveries include showing that the addition of ascorbic acid to fibroblast cultures increases collagen production and that topically applied L-ascorbic acid penetrates into the skin best at a pH of 2-2.5. Dr. Pinnell changed the way the world uses topical antioxidants today; he was widely respected and was a member of the American Dermatological Association and an honorary member of the Society of Investigative Dermatology. He published more than 200 scientific articles and held 10 patents. He started the skin care company Skinceuticals, based on his antioxidant technologies. It was acquired by L’Oreal in 2005.
Richard Fitzpatrick, MD (1944-2014): The dermatologist affectionately known as “Fitz” is credited with being the first to use lasers for skin resurfacing. He went to medical school at Emory University and did his dermatology residency at the University of California, Los Angeles. He authored more than 130 publications and was one of the first doctors to specialize in cosmetic dermatology. He realized that fibroblast cell cultures used to produce the collagen filler CosmoPlast (no longer on the market) generated many growth factors that could rejuvenate the skin, and in 1999, he launched the skin care brand SkinMedica. In 2000, he received a patent for fibroblast-derived growth factors used topically for antiaging – a formula he called Tissue Nutrient Solution. In 2001, the popular product TNS Recovery Complex was launched based on the patented growth factor technology. It is still the most popular growth factor technology on the market.
What can we learn from these pioneers? I have had several interesting discussions about this topic with Leonard Hoenig, MD, section editor for Reflections on Dermatology: Past, Present, and Future, in Clinics in Dermatology. (Dr. Hoenig told me the interesting story that Listerine mouthwash was named in honor of Joseph Lister but accounts vary as to whether he gave permission to do so. This makes Dr. Lister the most famous physician to endorse a personal care product.) When Dr. Hoenig and I discussed the ethics of dermatologists creating a skin care line or retailing skin care in their medical practice, he stated my sentiments perfectly: “We should rely on professional, ethical, and legal guidelines to help us do what is right. Most importantly, we should have the best interests of our patients at heart when recommending any treatments.”
Dermatologists have unique knowledge, experience, and perspective on treating the skin with topical agents and have the true desire to improve skin health. If we do not discover, research, patent, and develop efficacious skin care products, someone else will do it – and I do not think they will do it as well as a dermatologist can.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan and Burt’s Bees. She is the CEO of Skin Type Solutions Inc., a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at [email protected].
References
1. Everett MA. Int J Dermatol. 1978 May;17(4):345-52.
2. Moxon RK. N Engl J Med. 1976 Apr 1;294(14):762-4.
3. Rattner H. Arch Derm Syphilol. 1937;35(1):25-66.
4. Neostrata: More than Hope, by Elaine Strauss, U.S. 1 Newspaper, Feb. 24, 1999.
5. Two legends in the field of dermatology provide $1 million gift to Temple University school of medicine’s department of dermatology, Temple University, June 5, 2015.
Those of you who have visited my dermatology practice in Miami know that the art in my office is dedicated to the history of the skin care industry. I collect , and I have written this historical column in honor of the 50th anniversary of Dermatology News.
The first doctor to market his own cosmetic product, Erasmus Wilson, MD, faced scrutiny from his colleagues. Although he had contributed much to the field of dermatology, he was criticized by other dermatologists when he promoted a hair wash. The next doctor in my story, William Pusey, MD, was criticized for helping the company that manufactured Camay soap because he allowed his name to be used in Camay advertisements. The scrutiny that these two well-respected dermatologists endured from their colleagues deterred dermatologists from entering the skin care business for decades. The professional jealousy from dermatologic colleagues left the skin care field wide open for imposters, charlatans, and nondermatologists who had no concern for efficacy and patient outcomes to flourish. This is the story of a group of brilliant entrepreneurial dermatologists and one chiropractor who misrepresented himself as a dermatologist and how they influenced skin care as we know it.
Erasmus Wilson, MD1 (1809-1884): In 1840, Erasmus Wilson2 was a physician in London who chose to specialize in dermatology at a time when that specialization was frowned upon. He was a subeditor for The Lancet and wrote several books on dermatology including “Diseases of the Skin – A Practical and Theoretical Treatise,” “Portraits of the Diseases of the Skin,” and “Student’s Book on Diseases of the Skin.” He was the first professor of dermatology in the College of Surgeons and by 1869, was the leading English-speaking dermatologist in the world. He contributed much to dermatology, including his pioneering characterizations of Demodex mites, lichen planus, exfoliative dermatitis, neurotic excoriations, and roseola. Dr. Wilson was knighted in 1881 for his good works and notable generosity. (He was known for giving his poor patients money for food, endowing chairs in dermatology, and donating a famous obelisk in London).
In 1854, Dr. Wilson wrote a book for laypeople called “Healthy Skin: A Popular Treatise on the Skin and Hair, Their Preservation and Management,” in which he advocated cleanliness and bathing, which led to the popularity of Turkish baths and bathing resorts in Europe. Despite his undeniable contributions to dermatology, he was widely criticized by his colleagues for promoting a “Hair Wash” and a turtle oil soap. I cannot find any information about whether or not he developed the hair wash and turtle soap himself, but it seems that he earned income from sales of these two products, even though he was said to have donated it all to charities.
William A. Pusey MD (1865-1940): Dr. Pusey was the first chairman of dermatology at the University of Illinois College of Medicine, Chicago. He published several books, including “Care of the Skin and Hair,” “Syphilis as a Modern Problem,” “The Principles and Practices of Dermatology,” and “History of Dermatology” among others. He is best known for his work in developing the use of x-rays (roentgen rays) and phototherapy in dermatology, and in 1907, he was the first dermatologist to describe the use of solid carbon dioxide to treat skin lesions. He was president of the American Dermatological Association in 1910, president of the Chicago Medical Society in 1918, editor of the Archives of Dermatology in 1920, and president of the American Medical Association in 1924.
In the early 1920s, skin care companies were beginning to advertise their products using endorsements from celebrities and socialites, and were making misleading claims. Dr. Pusey wanted to work with these companies to help them perform evidence-based trials so they could make scientifically correct claims. Proctor & Gamble asked Dr. Pusey to advise them on how they could advertise honestly about their new soap, “Camay.” In Dr. Pusey’s words,3 “they (Proctor & Gamble) wanted to give the public authoritative advice about the use of soap and water. They suggested that I get a group of dermatologists of my selection to examine the soap and prepare instructions for bathing and the use of soap, and, if they found this soap was of high quality, to certify to that effect.” The research was performed as he suggested, and he allowed his name to be used in the Camay soap ads from 1926 to 1929. He said that he allowed them to use his name hoping to promote the need for evidence-based research, in contrast to the skin care products endorsed by socialites and celebrities that were flooding the market around that time.
Herbert Rattner, MD, at Northwestern University, Chicago, was his friend and one of the many dermatologists who criticized Dr. Pusey for allowing his name to be used in the Camay ads. Dr. Pusey’s reply to the criticism (according to Dr. Rattner) was that Proctor & Gamble was “proposing to do what the medical profession always is criticizing commercial concerns for not doing, namely, coming to physicians for information on medical matters. Could the profession hope to have any influence with business concerns if it was always eager to criticize bad commercial practices but never willing to support good ones?”3
While Dr. Pusey felt his reasons for adding his name to the Camay ads and research were justified, many of his friends stated that in hindsight, he regretted the action because of the negative response of his colleagues. It was years before dermatologists began providing input again into the skin care industry. During that time, radio, television and print ads were rampant with misleading claims – which led the way for a dermatologic imposter to make a fortune on skin care.
John Woodbury (1851-1909): John Woodbury, a chiropractor, never went to medical school, but that did not stop him from claiming he was a dermatologist and cosmetic surgeon. In 1889, he opened the John H. Woodbury Dermatological Institute in New York City, and over the next few years, opened Woodbury Dermatological Institutes in at least 5 states and employed 25 “physicians” who were not licensed to practice medicine. He came out with face soaps, tonics, and cold creams and spent a fortune on advertising these products and his institutes. In 1901, he sold his “Woodbury Soap” to the Andrew Jergens Company for $212,500 and 10% in royalties.
Multiple lawsuits occurred from 1898 to 1907 because he continued using the Woodbury name on his own products, despite having sold the “Woodbury” trademark to Jergens. He was sued for practicing medicine without a medical license and claiming to be a dermatologist when he was not. He lost most of these lawsuits, including one in 1907 in which the court ruled that corporations may not employ unlicensed professionals to practice medicine. In 1909, John Woodbury committed suicide. The Woodbury Soap company flourished in the 1930s and 1940s, as part of Jergens, until the brand was discontinued in 1970 when Jergens was acquired by American Brands.
The next dermatologists to come along did not make the same mistakes as those of their predecessors. They all made scientific discoveries through their basic science research in the laboratory, filed patents, formed skin care companies, perfected the formulations, and conducted research trials of the final product. Their marketing focused on science and efficacy and only rarely used their names and images in advertising, allowing them to maintain their reputations in the dermatology field.
Eugene Van Scott, MD (1922-present): Dermatologist Dr. Van Scott and dermatopharmacologist Ruey Yu, PhD, filed a method patent in the early 1970s on the effectiveness of alpha hydroxy acids to treat ichthyosis. They invented the abbreviation “AHA” and have continued their work on organic acids to this day. They now have more than 125 patents, which they have licensed to 60 companies in the cosmetics and pharmaceutical industries.
In 1988, 14 years after their initial publication, they founded the company they named Polystrata, which grew into today’s NeoStrata.4 Over the years, they had to defend their patents because many personal care companies used their technologies without licensing them. In 2007, they won a $41 million settlement in a patent infringement suit against Mary Kay filed in March 2005. They have both been very philanthropic in the dermatology world5 and are highly respected in the field. Among many other honors, Dr. Van Scott was named a Master Dermatologist by the American Academy of Dermatology in 1998 and received the Dermatology Foundation’s Distinguished Service Medallion in 2004.
Sheldon Pinnell, MD (1937-2013): After Dr. Pinnell completed his dermatology residency at Harvard Medical School, he spent 2 years studying collagen chemistry at the Max Planck Institute in Munich, Germany. In 1973, he returned to Duke University where he had earned his undergraduate degree before attending Yale University. He remained at Duke for the duration of his career and was professor and chief of dermatology there for many years. Early in his career, he focused on the role of vitamin C in collagen biosynthesis and discovered some of the mechanisms by which sun exposure causes photoaging. He described the use of the first (and most popular) topically applied L-ascorbic acid (vitamin C) to prevent and treat skin aging.
Dr. Pinnell’s many discoveries include showing that the addition of ascorbic acid to fibroblast cultures increases collagen production and that topically applied L-ascorbic acid penetrates into the skin best at a pH of 2-2.5. Dr. Pinnell changed the way the world uses topical antioxidants today; he was widely respected and was a member of the American Dermatological Association and an honorary member of the Society of Investigative Dermatology. He published more than 200 scientific articles and held 10 patents. He started the skin care company Skinceuticals, based on his antioxidant technologies. It was acquired by L’Oreal in 2005.
Richard Fitzpatrick, MD (1944-2014): The dermatologist affectionately known as “Fitz” is credited with being the first to use lasers for skin resurfacing. He went to medical school at Emory University and did his dermatology residency at the University of California, Los Angeles. He authored more than 130 publications and was one of the first doctors to specialize in cosmetic dermatology. He realized that fibroblast cell cultures used to produce the collagen filler CosmoPlast (no longer on the market) generated many growth factors that could rejuvenate the skin, and in 1999, he launched the skin care brand SkinMedica. In 2000, he received a patent for fibroblast-derived growth factors used topically for antiaging – a formula he called Tissue Nutrient Solution. In 2001, the popular product TNS Recovery Complex was launched based on the patented growth factor technology. It is still the most popular growth factor technology on the market.
What can we learn from these pioneers? I have had several interesting discussions about this topic with Leonard Hoenig, MD, section editor for Reflections on Dermatology: Past, Present, and Future, in Clinics in Dermatology. (Dr. Hoenig told me the interesting story that Listerine mouthwash was named in honor of Joseph Lister but accounts vary as to whether he gave permission to do so. This makes Dr. Lister the most famous physician to endorse a personal care product.) When Dr. Hoenig and I discussed the ethics of dermatologists creating a skin care line or retailing skin care in their medical practice, he stated my sentiments perfectly: “We should rely on professional, ethical, and legal guidelines to help us do what is right. Most importantly, we should have the best interests of our patients at heart when recommending any treatments.”
Dermatologists have unique knowledge, experience, and perspective on treating the skin with topical agents and have the true desire to improve skin health. If we do not discover, research, patent, and develop efficacious skin care products, someone else will do it – and I do not think they will do it as well as a dermatologist can.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan and Burt’s Bees. She is the CEO of Skin Type Solutions Inc., a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at [email protected].
References
1. Everett MA. Int J Dermatol. 1978 May;17(4):345-52.
2. Moxon RK. N Engl J Med. 1976 Apr 1;294(14):762-4.
3. Rattner H. Arch Derm Syphilol. 1937;35(1):25-66.
4. Neostrata: More than Hope, by Elaine Strauss, U.S. 1 Newspaper, Feb. 24, 1999.
5. Two legends in the field of dermatology provide $1 million gift to Temple University school of medicine’s department of dermatology, Temple University, June 5, 2015.
Those of you who have visited my dermatology practice in Miami know that the art in my office is dedicated to the history of the skin care industry. I collect , and I have written this historical column in honor of the 50th anniversary of Dermatology News.
The first doctor to market his own cosmetic product, Erasmus Wilson, MD, faced scrutiny from his colleagues. Although he had contributed much to the field of dermatology, he was criticized by other dermatologists when he promoted a hair wash. The next doctor in my story, William Pusey, MD, was criticized for helping the company that manufactured Camay soap because he allowed his name to be used in Camay advertisements. The scrutiny that these two well-respected dermatologists endured from their colleagues deterred dermatologists from entering the skin care business for decades. The professional jealousy from dermatologic colleagues left the skin care field wide open for imposters, charlatans, and nondermatologists who had no concern for efficacy and patient outcomes to flourish. This is the story of a group of brilliant entrepreneurial dermatologists and one chiropractor who misrepresented himself as a dermatologist and how they influenced skin care as we know it.
Erasmus Wilson, MD1 (1809-1884): In 1840, Erasmus Wilson2 was a physician in London who chose to specialize in dermatology at a time when that specialization was frowned upon. He was a subeditor for The Lancet and wrote several books on dermatology including “Diseases of the Skin – A Practical and Theoretical Treatise,” “Portraits of the Diseases of the Skin,” and “Student’s Book on Diseases of the Skin.” He was the first professor of dermatology in the College of Surgeons and by 1869, was the leading English-speaking dermatologist in the world. He contributed much to dermatology, including his pioneering characterizations of Demodex mites, lichen planus, exfoliative dermatitis, neurotic excoriations, and roseola. Dr. Wilson was knighted in 1881 for his good works and notable generosity. (He was known for giving his poor patients money for food, endowing chairs in dermatology, and donating a famous obelisk in London).
In 1854, Dr. Wilson wrote a book for laypeople called “Healthy Skin: A Popular Treatise on the Skin and Hair, Their Preservation and Management,” in which he advocated cleanliness and bathing, which led to the popularity of Turkish baths and bathing resorts in Europe. Despite his undeniable contributions to dermatology, he was widely criticized by his colleagues for promoting a “Hair Wash” and a turtle oil soap. I cannot find any information about whether or not he developed the hair wash and turtle soap himself, but it seems that he earned income from sales of these two products, even though he was said to have donated it all to charities.
William A. Pusey MD (1865-1940): Dr. Pusey was the first chairman of dermatology at the University of Illinois College of Medicine, Chicago. He published several books, including “Care of the Skin and Hair,” “Syphilis as a Modern Problem,” “The Principles and Practices of Dermatology,” and “History of Dermatology” among others. He is best known for his work in developing the use of x-rays (roentgen rays) and phototherapy in dermatology, and in 1907, he was the first dermatologist to describe the use of solid carbon dioxide to treat skin lesions. He was president of the American Dermatological Association in 1910, president of the Chicago Medical Society in 1918, editor of the Archives of Dermatology in 1920, and president of the American Medical Association in 1924.
In the early 1920s, skin care companies were beginning to advertise their products using endorsements from celebrities and socialites, and were making misleading claims. Dr. Pusey wanted to work with these companies to help them perform evidence-based trials so they could make scientifically correct claims. Proctor & Gamble asked Dr. Pusey to advise them on how they could advertise honestly about their new soap, “Camay.” In Dr. Pusey’s words,3 “they (Proctor & Gamble) wanted to give the public authoritative advice about the use of soap and water. They suggested that I get a group of dermatologists of my selection to examine the soap and prepare instructions for bathing and the use of soap, and, if they found this soap was of high quality, to certify to that effect.” The research was performed as he suggested, and he allowed his name to be used in the Camay soap ads from 1926 to 1929. He said that he allowed them to use his name hoping to promote the need for evidence-based research, in contrast to the skin care products endorsed by socialites and celebrities that were flooding the market around that time.
Herbert Rattner, MD, at Northwestern University, Chicago, was his friend and one of the many dermatologists who criticized Dr. Pusey for allowing his name to be used in the Camay ads. Dr. Pusey’s reply to the criticism (according to Dr. Rattner) was that Proctor & Gamble was “proposing to do what the medical profession always is criticizing commercial concerns for not doing, namely, coming to physicians for information on medical matters. Could the profession hope to have any influence with business concerns if it was always eager to criticize bad commercial practices but never willing to support good ones?”3
While Dr. Pusey felt his reasons for adding his name to the Camay ads and research were justified, many of his friends stated that in hindsight, he regretted the action because of the negative response of his colleagues. It was years before dermatologists began providing input again into the skin care industry. During that time, radio, television and print ads were rampant with misleading claims – which led the way for a dermatologic imposter to make a fortune on skin care.
John Woodbury (1851-1909): John Woodbury, a chiropractor, never went to medical school, but that did not stop him from claiming he was a dermatologist and cosmetic surgeon. In 1889, he opened the John H. Woodbury Dermatological Institute in New York City, and over the next few years, opened Woodbury Dermatological Institutes in at least 5 states and employed 25 “physicians” who were not licensed to practice medicine. He came out with face soaps, tonics, and cold creams and spent a fortune on advertising these products and his institutes. In 1901, he sold his “Woodbury Soap” to the Andrew Jergens Company for $212,500 and 10% in royalties.
Multiple lawsuits occurred from 1898 to 1907 because he continued using the Woodbury name on his own products, despite having sold the “Woodbury” trademark to Jergens. He was sued for practicing medicine without a medical license and claiming to be a dermatologist when he was not. He lost most of these lawsuits, including one in 1907 in which the court ruled that corporations may not employ unlicensed professionals to practice medicine. In 1909, John Woodbury committed suicide. The Woodbury Soap company flourished in the 1930s and 1940s, as part of Jergens, until the brand was discontinued in 1970 when Jergens was acquired by American Brands.
The next dermatologists to come along did not make the same mistakes as those of their predecessors. They all made scientific discoveries through their basic science research in the laboratory, filed patents, formed skin care companies, perfected the formulations, and conducted research trials of the final product. Their marketing focused on science and efficacy and only rarely used their names and images in advertising, allowing them to maintain their reputations in the dermatology field.
Eugene Van Scott, MD (1922-present): Dermatologist Dr. Van Scott and dermatopharmacologist Ruey Yu, PhD, filed a method patent in the early 1970s on the effectiveness of alpha hydroxy acids to treat ichthyosis. They invented the abbreviation “AHA” and have continued their work on organic acids to this day. They now have more than 125 patents, which they have licensed to 60 companies in the cosmetics and pharmaceutical industries.
In 1988, 14 years after their initial publication, they founded the company they named Polystrata, which grew into today’s NeoStrata.4 Over the years, they had to defend their patents because many personal care companies used their technologies without licensing them. In 2007, they won a $41 million settlement in a patent infringement suit against Mary Kay filed in March 2005. They have both been very philanthropic in the dermatology world5 and are highly respected in the field. Among many other honors, Dr. Van Scott was named a Master Dermatologist by the American Academy of Dermatology in 1998 and received the Dermatology Foundation’s Distinguished Service Medallion in 2004.
Sheldon Pinnell, MD (1937-2013): After Dr. Pinnell completed his dermatology residency at Harvard Medical School, he spent 2 years studying collagen chemistry at the Max Planck Institute in Munich, Germany. In 1973, he returned to Duke University where he had earned his undergraduate degree before attending Yale University. He remained at Duke for the duration of his career and was professor and chief of dermatology there for many years. Early in his career, he focused on the role of vitamin C in collagen biosynthesis and discovered some of the mechanisms by which sun exposure causes photoaging. He described the use of the first (and most popular) topically applied L-ascorbic acid (vitamin C) to prevent and treat skin aging.
Dr. Pinnell’s many discoveries include showing that the addition of ascorbic acid to fibroblast cultures increases collagen production and that topically applied L-ascorbic acid penetrates into the skin best at a pH of 2-2.5. Dr. Pinnell changed the way the world uses topical antioxidants today; he was widely respected and was a member of the American Dermatological Association and an honorary member of the Society of Investigative Dermatology. He published more than 200 scientific articles and held 10 patents. He started the skin care company Skinceuticals, based on his antioxidant technologies. It was acquired by L’Oreal in 2005.
Richard Fitzpatrick, MD (1944-2014): The dermatologist affectionately known as “Fitz” is credited with being the first to use lasers for skin resurfacing. He went to medical school at Emory University and did his dermatology residency at the University of California, Los Angeles. He authored more than 130 publications and was one of the first doctors to specialize in cosmetic dermatology. He realized that fibroblast cell cultures used to produce the collagen filler CosmoPlast (no longer on the market) generated many growth factors that could rejuvenate the skin, and in 1999, he launched the skin care brand SkinMedica. In 2000, he received a patent for fibroblast-derived growth factors used topically for antiaging – a formula he called Tissue Nutrient Solution. In 2001, the popular product TNS Recovery Complex was launched based on the patented growth factor technology. It is still the most popular growth factor technology on the market.
What can we learn from these pioneers? I have had several interesting discussions about this topic with Leonard Hoenig, MD, section editor for Reflections on Dermatology: Past, Present, and Future, in Clinics in Dermatology. (Dr. Hoenig told me the interesting story that Listerine mouthwash was named in honor of Joseph Lister but accounts vary as to whether he gave permission to do so. This makes Dr. Lister the most famous physician to endorse a personal care product.) When Dr. Hoenig and I discussed the ethics of dermatologists creating a skin care line or retailing skin care in their medical practice, he stated my sentiments perfectly: “We should rely on professional, ethical, and legal guidelines to help us do what is right. Most importantly, we should have the best interests of our patients at heart when recommending any treatments.”
Dermatologists have unique knowledge, experience, and perspective on treating the skin with topical agents and have the true desire to improve skin health. If we do not discover, research, patent, and develop efficacious skin care products, someone else will do it – and I do not think they will do it as well as a dermatologist can.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan and Burt’s Bees. She is the CEO of Skin Type Solutions Inc., a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at [email protected].
References
1. Everett MA. Int J Dermatol. 1978 May;17(4):345-52.
2. Moxon RK. N Engl J Med. 1976 Apr 1;294(14):762-4.
3. Rattner H. Arch Derm Syphilol. 1937;35(1):25-66.
4. Neostrata: More than Hope, by Elaine Strauss, U.S. 1 Newspaper, Feb. 24, 1999.
5. Two legends in the field of dermatology provide $1 million gift to Temple University school of medicine’s department of dermatology, Temple University, June 5, 2015.
Why are many of my patients doing better during the pandemic?
The COVID-19 pandemic has, like it or not, made experimental labs rats out of us all.
Since the U.S. “shutdown” began in March, we have all had to adjust to a situation in which we are home more, stuck seeing less of our friends, exercising less, often eating and drinking more, or using recreational substances more – in part because of the severe stress. We have been ripped away from many of the social “anchors” of our weeks; that is, the spiritual, social and physical, and tactile supports that sustain and motivate us in our lives.
And yet, many of us, of all ages, stripes, and colors are thriving. Why is that so? Without necessarily being fully fledged, card carrying misanthropes, many of us are actually not bereft when forced to spend some alone time.
We may be self-starters and have hobbies and interests that we may have neglected but can fall back on with alacrity. Activities such as gardening, cooking, reading, working at our day jobs, listening to music, streaming TV, and so on are now more available to us.
The pandemic has produced unforeseen side effects, such as decreased pollution, less seismic “noise” on our planet, increasingly bold activity by wild life, and we can actually hear bird songs in our yards. Likewise, the social isolation has enabled us to focus more on “back burner” projects and to motivate us toward accessing and achieving other internally driven goals.
Also, to many, it has provided a surprising and unexpected privilege to meaningfully connect while in close quarters with spouses, children, and other loved ones, which has improved and cemented relationships under some level of duress, perhaps.
Similarly, and perhaps surprisingly, in addition to the above reasons, many of our patients with chronic mental illness may be functioning reasonably well, too, even better than their “walking wounded” loved ones and peers. They may be reaping the rewards of many years of consistent biopsychosocial support in strong mental health programs.
But another reason might be the lowered expectations. I’m just so much more relaxed; I’ve got this.” And certainly the Freudian “schadenfreude” defense has something to do with this as well. Seeing family members lose their jobs, become financially vulnerable, being unable to or stymied from demonstrating mastery in many different situations and skill sets elicit the empathy and galvanizes the support of well-managed patients with mental illness – already used to existential threats – for their generally higher functioning loved ones.
As one of my struggling patients said, “Welcome to my world!” Years of hardship, lack of intimate relationships because of social anxiety, and psychotic level obsessive-compulsive disorder have trained, indeed, inured her to the daily pain, constriction, and misery of social isolation. Her life, despite working full time, has remained static, while younger siblings have married, started a family, moved away. She is still living at home with her elderly parents. They now worry about catching COVID-19, while she is now their protector with roles reversed, doing their shopping, and providing moral support and encouragement for the whole family.
Many of us have lost jobs, been furloughed, seen our dreams disappear, and are unable to pay rent or mortgages. Those with chronic mental illness, especially those living in states with a strong social safety net, are continuing to receive their Social Security disability checks, and maintain their in-home health and family supports. They also have continued their adherence with the mental health system structure by continuing with telemedicine therapy and regular medications or monthly intramuscular shots. Their families are especially cognizant of the need for ongoing structure and stability, which is now easier to provide. And what of those patients who endured severe anxiety and panic disorders in their prepandemic states? It is true that many do require higher doses of their anxiolytics, especially benzodiazepines. They do know how to “roll with the punches” with their lifetime experience, as opposed to the “newbies” whose incipient anxiety is brought to the forefront and who might not even recognize these debilitating symptoms and are not keen, for reasons of stigma, to be seen by a mental health expert unless compelled to.
It is up to us as psychiatrists and other mental health clinicians to minimize dependence on those medications by using alternative non–dependence-forming anxiolytics and encouraging our patients to hone and develop the skills from cognitive-behavioral therapy. COVID-19 is just one more stressor, superimposed on many others, and unlikely to precipitate any “tipping point” in functioning, even if there are significant losses among loved ones to the virus.
How about our child and adolescent patients? As a rule of thumb, those with anxiety disorders, social anxiety, selective mutism – and those experiencing challenges and bullying in the rough and tumble world of schools – are doing significantly better. Those with ADHD and impulse control disorders, however, might be struggling with school, especially with Zoom calls and very high distractibility, boredom, and motivational challenges. They may need their doses of medications adjusted up, and their parents are struggling. The risk for unwitnessed and unmonitored abuse in home situations is higher.
Those with chronic mental illness often do have increased risk factors for COVID-19 that might be compounded by their psychopharmacologic treatment for conditions/behaviors such as diabetes, obesity, cardiovascular disease, and substance use. By proactively monitoring those comorbid disorders in a multimodal treatment program, we can help mitigate those baseline challenges.
This aspect of the COVID-19 pandemic is, alas, likely to prove to be an illusory positive “blip” on the radar screen for many with chronic mental illness. Nevertheless, the self-knowledge and awareness of hidden strengths rather than weakness, resilience rather than shrinking from challenges, is not insignificant. This “flight into normality” may be a change that can be internalized and nurtured once vaccines are available and life on planet Earth returns to a new normal.
Dr. Tofler is affiliated with Kaiser Permanente Psychiatry in Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.
The COVID-19 pandemic has, like it or not, made experimental labs rats out of us all.
Since the U.S. “shutdown” began in March, we have all had to adjust to a situation in which we are home more, stuck seeing less of our friends, exercising less, often eating and drinking more, or using recreational substances more – in part because of the severe stress. We have been ripped away from many of the social “anchors” of our weeks; that is, the spiritual, social and physical, and tactile supports that sustain and motivate us in our lives.
And yet, many of us, of all ages, stripes, and colors are thriving. Why is that so? Without necessarily being fully fledged, card carrying misanthropes, many of us are actually not bereft when forced to spend some alone time.
We may be self-starters and have hobbies and interests that we may have neglected but can fall back on with alacrity. Activities such as gardening, cooking, reading, working at our day jobs, listening to music, streaming TV, and so on are now more available to us.
The pandemic has produced unforeseen side effects, such as decreased pollution, less seismic “noise” on our planet, increasingly bold activity by wild life, and we can actually hear bird songs in our yards. Likewise, the social isolation has enabled us to focus more on “back burner” projects and to motivate us toward accessing and achieving other internally driven goals.
Also, to many, it has provided a surprising and unexpected privilege to meaningfully connect while in close quarters with spouses, children, and other loved ones, which has improved and cemented relationships under some level of duress, perhaps.
Similarly, and perhaps surprisingly, in addition to the above reasons, many of our patients with chronic mental illness may be functioning reasonably well, too, even better than their “walking wounded” loved ones and peers. They may be reaping the rewards of many years of consistent biopsychosocial support in strong mental health programs.
But another reason might be the lowered expectations. I’m just so much more relaxed; I’ve got this.” And certainly the Freudian “schadenfreude” defense has something to do with this as well. Seeing family members lose their jobs, become financially vulnerable, being unable to or stymied from demonstrating mastery in many different situations and skill sets elicit the empathy and galvanizes the support of well-managed patients with mental illness – already used to existential threats – for their generally higher functioning loved ones.
As one of my struggling patients said, “Welcome to my world!” Years of hardship, lack of intimate relationships because of social anxiety, and psychotic level obsessive-compulsive disorder have trained, indeed, inured her to the daily pain, constriction, and misery of social isolation. Her life, despite working full time, has remained static, while younger siblings have married, started a family, moved away. She is still living at home with her elderly parents. They now worry about catching COVID-19, while she is now their protector with roles reversed, doing their shopping, and providing moral support and encouragement for the whole family.
Many of us have lost jobs, been furloughed, seen our dreams disappear, and are unable to pay rent or mortgages. Those with chronic mental illness, especially those living in states with a strong social safety net, are continuing to receive their Social Security disability checks, and maintain their in-home health and family supports. They also have continued their adherence with the mental health system structure by continuing with telemedicine therapy and regular medications or monthly intramuscular shots. Their families are especially cognizant of the need for ongoing structure and stability, which is now easier to provide. And what of those patients who endured severe anxiety and panic disorders in their prepandemic states? It is true that many do require higher doses of their anxiolytics, especially benzodiazepines. They do know how to “roll with the punches” with their lifetime experience, as opposed to the “newbies” whose incipient anxiety is brought to the forefront and who might not even recognize these debilitating symptoms and are not keen, for reasons of stigma, to be seen by a mental health expert unless compelled to.
It is up to us as psychiatrists and other mental health clinicians to minimize dependence on those medications by using alternative non–dependence-forming anxiolytics and encouraging our patients to hone and develop the skills from cognitive-behavioral therapy. COVID-19 is just one more stressor, superimposed on many others, and unlikely to precipitate any “tipping point” in functioning, even if there are significant losses among loved ones to the virus.
How about our child and adolescent patients? As a rule of thumb, those with anxiety disorders, social anxiety, selective mutism – and those experiencing challenges and bullying in the rough and tumble world of schools – are doing significantly better. Those with ADHD and impulse control disorders, however, might be struggling with school, especially with Zoom calls and very high distractibility, boredom, and motivational challenges. They may need their doses of medications adjusted up, and their parents are struggling. The risk for unwitnessed and unmonitored abuse in home situations is higher.
Those with chronic mental illness often do have increased risk factors for COVID-19 that might be compounded by their psychopharmacologic treatment for conditions/behaviors such as diabetes, obesity, cardiovascular disease, and substance use. By proactively monitoring those comorbid disorders in a multimodal treatment program, we can help mitigate those baseline challenges.
This aspect of the COVID-19 pandemic is, alas, likely to prove to be an illusory positive “blip” on the radar screen for many with chronic mental illness. Nevertheless, the self-knowledge and awareness of hidden strengths rather than weakness, resilience rather than shrinking from challenges, is not insignificant. This “flight into normality” may be a change that can be internalized and nurtured once vaccines are available and life on planet Earth returns to a new normal.
Dr. Tofler is affiliated with Kaiser Permanente Psychiatry in Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.
The COVID-19 pandemic has, like it or not, made experimental labs rats out of us all.
Since the U.S. “shutdown” began in March, we have all had to adjust to a situation in which we are home more, stuck seeing less of our friends, exercising less, often eating and drinking more, or using recreational substances more – in part because of the severe stress. We have been ripped away from many of the social “anchors” of our weeks; that is, the spiritual, social and physical, and tactile supports that sustain and motivate us in our lives.
And yet, many of us, of all ages, stripes, and colors are thriving. Why is that so? Without necessarily being fully fledged, card carrying misanthropes, many of us are actually not bereft when forced to spend some alone time.
We may be self-starters and have hobbies and interests that we may have neglected but can fall back on with alacrity. Activities such as gardening, cooking, reading, working at our day jobs, listening to music, streaming TV, and so on are now more available to us.
The pandemic has produced unforeseen side effects, such as decreased pollution, less seismic “noise” on our planet, increasingly bold activity by wild life, and we can actually hear bird songs in our yards. Likewise, the social isolation has enabled us to focus more on “back burner” projects and to motivate us toward accessing and achieving other internally driven goals.
Also, to many, it has provided a surprising and unexpected privilege to meaningfully connect while in close quarters with spouses, children, and other loved ones, which has improved and cemented relationships under some level of duress, perhaps.
Similarly, and perhaps surprisingly, in addition to the above reasons, many of our patients with chronic mental illness may be functioning reasonably well, too, even better than their “walking wounded” loved ones and peers. They may be reaping the rewards of many years of consistent biopsychosocial support in strong mental health programs.
But another reason might be the lowered expectations. I’m just so much more relaxed; I’ve got this.” And certainly the Freudian “schadenfreude” defense has something to do with this as well. Seeing family members lose their jobs, become financially vulnerable, being unable to or stymied from demonstrating mastery in many different situations and skill sets elicit the empathy and galvanizes the support of well-managed patients with mental illness – already used to existential threats – for their generally higher functioning loved ones.
As one of my struggling patients said, “Welcome to my world!” Years of hardship, lack of intimate relationships because of social anxiety, and psychotic level obsessive-compulsive disorder have trained, indeed, inured her to the daily pain, constriction, and misery of social isolation. Her life, despite working full time, has remained static, while younger siblings have married, started a family, moved away. She is still living at home with her elderly parents. They now worry about catching COVID-19, while she is now their protector with roles reversed, doing their shopping, and providing moral support and encouragement for the whole family.
Many of us have lost jobs, been furloughed, seen our dreams disappear, and are unable to pay rent or mortgages. Those with chronic mental illness, especially those living in states with a strong social safety net, are continuing to receive their Social Security disability checks, and maintain their in-home health and family supports. They also have continued their adherence with the mental health system structure by continuing with telemedicine therapy and regular medications or monthly intramuscular shots. Their families are especially cognizant of the need for ongoing structure and stability, which is now easier to provide. And what of those patients who endured severe anxiety and panic disorders in their prepandemic states? It is true that many do require higher doses of their anxiolytics, especially benzodiazepines. They do know how to “roll with the punches” with their lifetime experience, as opposed to the “newbies” whose incipient anxiety is brought to the forefront and who might not even recognize these debilitating symptoms and are not keen, for reasons of stigma, to be seen by a mental health expert unless compelled to.
It is up to us as psychiatrists and other mental health clinicians to minimize dependence on those medications by using alternative non–dependence-forming anxiolytics and encouraging our patients to hone and develop the skills from cognitive-behavioral therapy. COVID-19 is just one more stressor, superimposed on many others, and unlikely to precipitate any “tipping point” in functioning, even if there are significant losses among loved ones to the virus.
How about our child and adolescent patients? As a rule of thumb, those with anxiety disorders, social anxiety, selective mutism – and those experiencing challenges and bullying in the rough and tumble world of schools – are doing significantly better. Those with ADHD and impulse control disorders, however, might be struggling with school, especially with Zoom calls and very high distractibility, boredom, and motivational challenges. They may need their doses of medications adjusted up, and their parents are struggling. The risk for unwitnessed and unmonitored abuse in home situations is higher.
Those with chronic mental illness often do have increased risk factors for COVID-19 that might be compounded by their psychopharmacologic treatment for conditions/behaviors such as diabetes, obesity, cardiovascular disease, and substance use. By proactively monitoring those comorbid disorders in a multimodal treatment program, we can help mitigate those baseline challenges.
This aspect of the COVID-19 pandemic is, alas, likely to prove to be an illusory positive “blip” on the radar screen for many with chronic mental illness. Nevertheless, the self-knowledge and awareness of hidden strengths rather than weakness, resilience rather than shrinking from challenges, is not insignificant. This “flight into normality” may be a change that can be internalized and nurtured once vaccines are available and life on planet Earth returns to a new normal.
Dr. Tofler is affiliated with Kaiser Permanente Psychiatry in Los Angeles. He also is a visiting faculty member in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles. Dr. Tofler has no conflicts of interest.
Being a pediatric hospitalist during the COVID-19 pandemic
“Times of great calamity and confusion have been productive for the greatest minds. The purest ore is produced from the hottest furnace. The brightest thunderbolt is elicited from the darkest storm.” – Charles Caleb Colton
I walk inside the pediatric unit of our hospital, only to be welcomed by an eerie silence. There are a handful of nurses at the nursing station, faces covered with masks sitting 6 feet apart and quietly working on their computers. The resident work lounge also depicts a similar picture of emptiness. Just over a month ago, these halls were bustling with children, parents, consultants, and a host of ancillary staff. I recall times in which I was running around from one patient room to another talking to families and attending to patient needs. For the past 2 months I have often spent hours alone in my office waiting to see a patient. This is the new norm for many of us.
Across the board in hospitals, pediatric census has dropped since the start of the COVID-19 pandemic. Reasons for these are nonspecific but may include fear among parents of “exposure” to the virus by bringing their sick children to the hospital to get evaluated for other concerns. A few patients that we have seen in our hospital are sicker when they have arrived because their parents avoided seeking medical care earlier, plagued by the same fear. Social distancing and school closure have also limited the amount of infectious diseases going around, which are responsible for a bulk of pediatric admissions.
While many of us are still coming in to see the limited number of patients we have, we are not in the true sense frontline providers during this pandemic. There have been limited cases of COVID-19 in children, most of which – fortunately – present with mild symptoms. Although multisystem inflammatory syndrome in children (MIS-C) is a new disease that COVID-19 has brought us closer to, many of us have yet to see our first case because of its rarity.
I have read through the news daily in the past few months to find many adult provider physicians succumbing to COVID-19 and felt a pang of guilt. My social media is full of heartbreaking stories as adult hospitalists are having difficult conversations with families and supporting them through this unknown territory, often sacrificing their own safety. I feel so proud of them and my profession. My heart tells me, though, I personally may not be living up to the true calling I was expected to have as a physician.
As pediatric hospitalists, while we sit and wait for this pandemic to pass, we have been ruminating on and anxious about our future. As census drops, there is a financial strain that many of us are feeling. Job cuts and furloughing of health care workers in our surroundings leave us with a sense of insecurity and low morale. Many small inpatient pediatric units have had to be shut down temporarily either so they could be used for adult patients or because of lack of pediatric patients. Limiting staffing to avoid exposure and cohorting providers has also been a challenge.
A big question that has risen in these times is how to ensure productivity and stay useful while at the same time being prepared for the unknown that lies ahead. The economics of medicine is staring hard at our years of hard work, questioning the need for our specialty in the first place.
In smaller community settings, the closure of pediatric units has put an additional strain on the overall framework of the community, parents, and referring primary care providers. With the absence of local resources, children who have needed care have had to be transferred to bigger referral centers that are still taking care of pediatric patients. On one end of the spectrum there is concern for pediatric inpatient units not being productive enough for the hospital, but that coexists with a worry that, as we pass through this pandemic, we could see more hospitalizations for vaccine-preventable illnesses, child abuse/medical neglect, and respiratory syncytial virus plus COVID.
The question remains about how best to cope and use this time of uncertainty to be productive and prepare for the worst. A few solutions and suggestions are highlighted below.
- Helping adult providers: Many pediatric hospitalist colleagues in highly affected states have filled the increasing need for clinicians and taken care of adult patients. As pediatric units have closed, providers have continued to offer care where it is needed. Pediatric hospitalists have used this time to take urgent refresher courses in advanced cardiac life support and adult critical care. In states that are not as severely hit, many pediatric hospitalists have utilized this time to plan and prepare protocols for the future as information continues coming in regarding MIS-C and COVID-19 in pediatric patients.
- Use of telemedicine: With the ease in restrictions for use of telemedicine in many states, pediatric hospitalists can consider using it to restructure their staffing model whenever feasible. This can help in cohorting and allowing high risk and quarantined providers to work from home. This model simultaneously provides opportunities for pediatric hospitalists to continue providing their services, while at the same time decreasing financial burden on their institution.
- Reaching out to the community: Engaging with the community during these times can help ensure services and options remain available to our referral providers and patients for pediatric services. Information about COVID-19 can be widely disseminated. We can also play our part by continuing to encourage parents in our maximum capacity to obtain care for their children when needed and to not avoid the hospital because of fears of exposure.
- Supporting each other: There is no doubt that these times are unsettling for the pediatric hospitalist community, and the uncertainty that surrounds us can feel crippling. Strong team building is imperative in these times. While we may not be frequently meeting in work lounges and sharing meals, a good sense of support and camaraderie will go a long way in building morale for the future. Seeking mental health resources if needed is essential for us and should not be looked at with shame or guilt. This is something that many of us have never seen before, and it is okay to ask for help. Seeking help is and always will be a sign of strength.
Today, as I envision myself walking in the hospital on the other side of this pandemic I see a cheerful pediatric unit, smiling faces without masks, my 3-year-old patient cruising around the hallways in a toy car, our therapy dog walking around bringing joy to many, and many healthy patients feeling better and ready to go home. A time when we are not scared to hug each other, shake hands, or share emotion. When our teams are stronger and more well bonded. A time when parents are not scared to bring their sick children to the hospital. Will it be many months before this happens? I don’t know. But I do know that the children I take care of are known for their resilience. I will live up to them today by practicing the same.
Dr. Fatima is a pediatric hospitalist at Wesley Children’s Hospital and assistant professor of pediatrics at Kansas University School of Medicine, both in Wichita. Her research interests include medical errors, medical education, and high-value care.
“Times of great calamity and confusion have been productive for the greatest minds. The purest ore is produced from the hottest furnace. The brightest thunderbolt is elicited from the darkest storm.” – Charles Caleb Colton
I walk inside the pediatric unit of our hospital, only to be welcomed by an eerie silence. There are a handful of nurses at the nursing station, faces covered with masks sitting 6 feet apart and quietly working on their computers. The resident work lounge also depicts a similar picture of emptiness. Just over a month ago, these halls were bustling with children, parents, consultants, and a host of ancillary staff. I recall times in which I was running around from one patient room to another talking to families and attending to patient needs. For the past 2 months I have often spent hours alone in my office waiting to see a patient. This is the new norm for many of us.
Across the board in hospitals, pediatric census has dropped since the start of the COVID-19 pandemic. Reasons for these are nonspecific but may include fear among parents of “exposure” to the virus by bringing their sick children to the hospital to get evaluated for other concerns. A few patients that we have seen in our hospital are sicker when they have arrived because their parents avoided seeking medical care earlier, plagued by the same fear. Social distancing and school closure have also limited the amount of infectious diseases going around, which are responsible for a bulk of pediatric admissions.
While many of us are still coming in to see the limited number of patients we have, we are not in the true sense frontline providers during this pandemic. There have been limited cases of COVID-19 in children, most of which – fortunately – present with mild symptoms. Although multisystem inflammatory syndrome in children (MIS-C) is a new disease that COVID-19 has brought us closer to, many of us have yet to see our first case because of its rarity.
I have read through the news daily in the past few months to find many adult provider physicians succumbing to COVID-19 and felt a pang of guilt. My social media is full of heartbreaking stories as adult hospitalists are having difficult conversations with families and supporting them through this unknown territory, often sacrificing their own safety. I feel so proud of them and my profession. My heart tells me, though, I personally may not be living up to the true calling I was expected to have as a physician.
As pediatric hospitalists, while we sit and wait for this pandemic to pass, we have been ruminating on and anxious about our future. As census drops, there is a financial strain that many of us are feeling. Job cuts and furloughing of health care workers in our surroundings leave us with a sense of insecurity and low morale. Many small inpatient pediatric units have had to be shut down temporarily either so they could be used for adult patients or because of lack of pediatric patients. Limiting staffing to avoid exposure and cohorting providers has also been a challenge.
A big question that has risen in these times is how to ensure productivity and stay useful while at the same time being prepared for the unknown that lies ahead. The economics of medicine is staring hard at our years of hard work, questioning the need for our specialty in the first place.
In smaller community settings, the closure of pediatric units has put an additional strain on the overall framework of the community, parents, and referring primary care providers. With the absence of local resources, children who have needed care have had to be transferred to bigger referral centers that are still taking care of pediatric patients. On one end of the spectrum there is concern for pediatric inpatient units not being productive enough for the hospital, but that coexists with a worry that, as we pass through this pandemic, we could see more hospitalizations for vaccine-preventable illnesses, child abuse/medical neglect, and respiratory syncytial virus plus COVID.
The question remains about how best to cope and use this time of uncertainty to be productive and prepare for the worst. A few solutions and suggestions are highlighted below.
- Helping adult providers: Many pediatric hospitalist colleagues in highly affected states have filled the increasing need for clinicians and taken care of adult patients. As pediatric units have closed, providers have continued to offer care where it is needed. Pediatric hospitalists have used this time to take urgent refresher courses in advanced cardiac life support and adult critical care. In states that are not as severely hit, many pediatric hospitalists have utilized this time to plan and prepare protocols for the future as information continues coming in regarding MIS-C and COVID-19 in pediatric patients.
- Use of telemedicine: With the ease in restrictions for use of telemedicine in many states, pediatric hospitalists can consider using it to restructure their staffing model whenever feasible. This can help in cohorting and allowing high risk and quarantined providers to work from home. This model simultaneously provides opportunities for pediatric hospitalists to continue providing their services, while at the same time decreasing financial burden on their institution.
- Reaching out to the community: Engaging with the community during these times can help ensure services and options remain available to our referral providers and patients for pediatric services. Information about COVID-19 can be widely disseminated. We can also play our part by continuing to encourage parents in our maximum capacity to obtain care for their children when needed and to not avoid the hospital because of fears of exposure.
- Supporting each other: There is no doubt that these times are unsettling for the pediatric hospitalist community, and the uncertainty that surrounds us can feel crippling. Strong team building is imperative in these times. While we may not be frequently meeting in work lounges and sharing meals, a good sense of support and camaraderie will go a long way in building morale for the future. Seeking mental health resources if needed is essential for us and should not be looked at with shame or guilt. This is something that many of us have never seen before, and it is okay to ask for help. Seeking help is and always will be a sign of strength.
Today, as I envision myself walking in the hospital on the other side of this pandemic I see a cheerful pediatric unit, smiling faces without masks, my 3-year-old patient cruising around the hallways in a toy car, our therapy dog walking around bringing joy to many, and many healthy patients feeling better and ready to go home. A time when we are not scared to hug each other, shake hands, or share emotion. When our teams are stronger and more well bonded. A time when parents are not scared to bring their sick children to the hospital. Will it be many months before this happens? I don’t know. But I do know that the children I take care of are known for their resilience. I will live up to them today by practicing the same.
Dr. Fatima is a pediatric hospitalist at Wesley Children’s Hospital and assistant professor of pediatrics at Kansas University School of Medicine, both in Wichita. Her research interests include medical errors, medical education, and high-value care.
“Times of great calamity and confusion have been productive for the greatest minds. The purest ore is produced from the hottest furnace. The brightest thunderbolt is elicited from the darkest storm.” – Charles Caleb Colton
I walk inside the pediatric unit of our hospital, only to be welcomed by an eerie silence. There are a handful of nurses at the nursing station, faces covered with masks sitting 6 feet apart and quietly working on their computers. The resident work lounge also depicts a similar picture of emptiness. Just over a month ago, these halls were bustling with children, parents, consultants, and a host of ancillary staff. I recall times in which I was running around from one patient room to another talking to families and attending to patient needs. For the past 2 months I have often spent hours alone in my office waiting to see a patient. This is the new norm for many of us.
Across the board in hospitals, pediatric census has dropped since the start of the COVID-19 pandemic. Reasons for these are nonspecific but may include fear among parents of “exposure” to the virus by bringing their sick children to the hospital to get evaluated for other concerns. A few patients that we have seen in our hospital are sicker when they have arrived because their parents avoided seeking medical care earlier, plagued by the same fear. Social distancing and school closure have also limited the amount of infectious diseases going around, which are responsible for a bulk of pediatric admissions.
While many of us are still coming in to see the limited number of patients we have, we are not in the true sense frontline providers during this pandemic. There have been limited cases of COVID-19 in children, most of which – fortunately – present with mild symptoms. Although multisystem inflammatory syndrome in children (MIS-C) is a new disease that COVID-19 has brought us closer to, many of us have yet to see our first case because of its rarity.
I have read through the news daily in the past few months to find many adult provider physicians succumbing to COVID-19 and felt a pang of guilt. My social media is full of heartbreaking stories as adult hospitalists are having difficult conversations with families and supporting them through this unknown territory, often sacrificing their own safety. I feel so proud of them and my profession. My heart tells me, though, I personally may not be living up to the true calling I was expected to have as a physician.
As pediatric hospitalists, while we sit and wait for this pandemic to pass, we have been ruminating on and anxious about our future. As census drops, there is a financial strain that many of us are feeling. Job cuts and furloughing of health care workers in our surroundings leave us with a sense of insecurity and low morale. Many small inpatient pediatric units have had to be shut down temporarily either so they could be used for adult patients or because of lack of pediatric patients. Limiting staffing to avoid exposure and cohorting providers has also been a challenge.
A big question that has risen in these times is how to ensure productivity and stay useful while at the same time being prepared for the unknown that lies ahead. The economics of medicine is staring hard at our years of hard work, questioning the need for our specialty in the first place.
In smaller community settings, the closure of pediatric units has put an additional strain on the overall framework of the community, parents, and referring primary care providers. With the absence of local resources, children who have needed care have had to be transferred to bigger referral centers that are still taking care of pediatric patients. On one end of the spectrum there is concern for pediatric inpatient units not being productive enough for the hospital, but that coexists with a worry that, as we pass through this pandemic, we could see more hospitalizations for vaccine-preventable illnesses, child abuse/medical neglect, and respiratory syncytial virus plus COVID.
The question remains about how best to cope and use this time of uncertainty to be productive and prepare for the worst. A few solutions and suggestions are highlighted below.
- Helping adult providers: Many pediatric hospitalist colleagues in highly affected states have filled the increasing need for clinicians and taken care of adult patients. As pediatric units have closed, providers have continued to offer care where it is needed. Pediatric hospitalists have used this time to take urgent refresher courses in advanced cardiac life support and adult critical care. In states that are not as severely hit, many pediatric hospitalists have utilized this time to plan and prepare protocols for the future as information continues coming in regarding MIS-C and COVID-19 in pediatric patients.
- Use of telemedicine: With the ease in restrictions for use of telemedicine in many states, pediatric hospitalists can consider using it to restructure their staffing model whenever feasible. This can help in cohorting and allowing high risk and quarantined providers to work from home. This model simultaneously provides opportunities for pediatric hospitalists to continue providing their services, while at the same time decreasing financial burden on their institution.
- Reaching out to the community: Engaging with the community during these times can help ensure services and options remain available to our referral providers and patients for pediatric services. Information about COVID-19 can be widely disseminated. We can also play our part by continuing to encourage parents in our maximum capacity to obtain care for their children when needed and to not avoid the hospital because of fears of exposure.
- Supporting each other: There is no doubt that these times are unsettling for the pediatric hospitalist community, and the uncertainty that surrounds us can feel crippling. Strong team building is imperative in these times. While we may not be frequently meeting in work lounges and sharing meals, a good sense of support and camaraderie will go a long way in building morale for the future. Seeking mental health resources if needed is essential for us and should not be looked at with shame or guilt. This is something that many of us have never seen before, and it is okay to ask for help. Seeking help is and always will be a sign of strength.
Today, as I envision myself walking in the hospital on the other side of this pandemic I see a cheerful pediatric unit, smiling faces without masks, my 3-year-old patient cruising around the hallways in a toy car, our therapy dog walking around bringing joy to many, and many healthy patients feeling better and ready to go home. A time when we are not scared to hug each other, shake hands, or share emotion. When our teams are stronger and more well bonded. A time when parents are not scared to bring their sick children to the hospital. Will it be many months before this happens? I don’t know. But I do know that the children I take care of are known for their resilience. I will live up to them today by practicing the same.
Dr. Fatima is a pediatric hospitalist at Wesley Children’s Hospital and assistant professor of pediatrics at Kansas University School of Medicine, both in Wichita. Her research interests include medical errors, medical education, and high-value care.
Reflections on life before and during COVID-19
I wrote these poems in mid-March, when fear of COVID-19 struck and New York City locked down. Nearly a half-year later, the impact continues with uncertainty everywhere.
Before and After
Before – there were trees,
I hardly noticed them.
There were buses and newspapers.
Should I read a book or the Post?
Am I wasting time looking
out the window at crowds
milling into Central Park?
The tourists walk to Strawberry Fields,
and the bus turns to Central Park West.
I hardly noticed
because I had plans.
After – it ended, first slowly,
then abruptly. We sat together
in the shop, knitting,
only three of us
before the store shut.
After that –
In the park daffodils radiate gold
and grow in groups.
And the magnolia trees
flaunt their succulent petals.
The fragile cherry blossoms float flowers
Still – it is after
And before, there were trees
I hardly noticed.
War Means Nothing to Them
The birds and the trees know nothing.
They are not embarrassed.
The birds chirp, the trees flower;
War means nothing to them.
Grass grows thick and green,
welcomes the spring.
Babies too, even toddlers,
go about their infant business.
They play or coo or smile
as happy as the birds, the trees,
the grass, flush with life.
Dr. Cohen is in private practice and is a clinical assistant professor of psychiatry at Weill Cornell Medical Center of New York-Presbyterian Hospital, and psychiatric consultant at the Hospital for Special Surgery, also in New York.
I wrote these poems in mid-March, when fear of COVID-19 struck and New York City locked down. Nearly a half-year later, the impact continues with uncertainty everywhere.
Before and After
Before – there were trees,
I hardly noticed them.
There were buses and newspapers.
Should I read a book or the Post?
Am I wasting time looking
out the window at crowds
milling into Central Park?
The tourists walk to Strawberry Fields,
and the bus turns to Central Park West.
I hardly noticed
because I had plans.
After – it ended, first slowly,
then abruptly. We sat together
in the shop, knitting,
only three of us
before the store shut.
After that –
In the park daffodils radiate gold
and grow in groups.
And the magnolia trees
flaunt their succulent petals.
The fragile cherry blossoms float flowers
Still – it is after
And before, there were trees
I hardly noticed.
War Means Nothing to Them
The birds and the trees know nothing.
They are not embarrassed.
The birds chirp, the trees flower;
War means nothing to them.
Grass grows thick and green,
welcomes the spring.
Babies too, even toddlers,
go about their infant business.
They play or coo or smile
as happy as the birds, the trees,
the grass, flush with life.
Dr. Cohen is in private practice and is a clinical assistant professor of psychiatry at Weill Cornell Medical Center of New York-Presbyterian Hospital, and psychiatric consultant at the Hospital for Special Surgery, also in New York.
I wrote these poems in mid-March, when fear of COVID-19 struck and New York City locked down. Nearly a half-year later, the impact continues with uncertainty everywhere.
Before and After
Before – there were trees,
I hardly noticed them.
There were buses and newspapers.
Should I read a book or the Post?
Am I wasting time looking
out the window at crowds
milling into Central Park?
The tourists walk to Strawberry Fields,
and the bus turns to Central Park West.
I hardly noticed
because I had plans.
After – it ended, first slowly,
then abruptly. We sat together
in the shop, knitting,
only three of us
before the store shut.
After that –
In the park daffodils radiate gold
and grow in groups.
And the magnolia trees
flaunt their succulent petals.
The fragile cherry blossoms float flowers
Still – it is after
And before, there were trees
I hardly noticed.
War Means Nothing to Them
The birds and the trees know nothing.
They are not embarrassed.
The birds chirp, the trees flower;
War means nothing to them.
Grass grows thick and green,
welcomes the spring.
Babies too, even toddlers,
go about their infant business.
They play or coo or smile
as happy as the birds, the trees,
the grass, flush with life.
Dr. Cohen is in private practice and is a clinical assistant professor of psychiatry at Weill Cornell Medical Center of New York-Presbyterian Hospital, and psychiatric consultant at the Hospital for Special Surgery, also in New York.