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Children who are coughing: Is it flu or bacterial pneumonia?
We are in the middle of flu season, and many of our patients are coughing. Is it the flu or might the child have a secondary bacterial pneumonia? Let’s start with the history for a tip off. The course of flu and respiratory viral infections in general involves a typical pattern of timing for fever and cough.
A late-developing fever or fever that subsides then recurs should raise concern. A prolonged cough or cough that subsides then recurs also should raise concern. The respiratory rate and chest retractions are key physical findings that can aid in distinguishing children with bacterial pneumonia. Rales and decreased breath sounds in lung segments are best heard with deep breaths.
What diagnostic laboratory and imaging tests should be used
Fortunately, rapid tests to detect influenza are available, and many providers have added those to their laboratory evaluation. A complete blood count and differential may be helpful. If a pulse oximeter is available, checking oxygen saturation might be helpful. The American Academy of Pediatrics community pneumonia guideline states that routine chest radiographs are not necessary for the confirmation of suspected community-acquired pneumonia (CAP) in patients well enough to be treated in the outpatient setting (Clin Inf Dis. 2011 Oct;53[7]:e25–e76). Blood cultures should not be performed routinely in nontoxic, fully immunized children with CAP managed in the outpatient setting.
What antibiotic should be used
Antimicrobial therapy is not routinely required for preschool-aged children with cough, even cough caused by CAP, because viral pathogens are responsible for the great majority of clinical disease. If the diagnosis of CAP is made, the AAP endorses amoxicillin as first-line therapy for previously healthy, appropriately immunized infants and preschool children with mild to moderate CAP suspected to be of bacterial origin. For previously healthy, appropriately immunized school-aged children and adolescents with mild to moderate CAP, amoxicillin is recommended for treatment of Streptococcus pneumoniae, the most prominent invasive bacterial pathogen.
However, the treatment paradigm is complicated because Mycoplasma pneumoniae also should be considered in management decisions. Children with signs and symptoms suspicious for M. pneumoniae should be tested to help guide antibiotic selection. This may be a simple bedside cold agglutinin test. The highest incidence of Mycoplasma pneumonia is in 5- to 20-year-olds (51% in 5- to 9-year-olds, 74% in 9- to 15-year-olds, and 3%-18% in adults with pneumonia), but 9% of CAP occurs in patients younger than 5 years old. The clinical features of Mycoplasma pneumonia resemble influenza: The patient has gradual onset of headache, malaise, fever, sore throat, and cough. Mycoplasma pneumonia has a similar incidence of productive cough, rales, and diarrhea as pneumococcal CAP, but with more frequent upper respiratory symptoms and a normal leukocyte count. Mycoplasma bronchopneumonia occurs 30 times more frequently than Mycoplasma lobar pneumonia. The radiologic features of Mycoplasma is typical of a bronchopneumonia, usually involving a single lobe, subsegmental atelectasis, peribronchial thickening, and streaky interstitial densities. While Mycoplasma pneumonia is usually self-limited, the duration of illness is shortened by oral treatment with doxycycline, erythromycin, clarithromycin, or azithromycin.
What is the appropriate duration of antimicrobial therapy
Recommendations by the AAP for CAP note that treatment courses of 10 days have been best studied, although shorter courses may be just as effective, particularly for mild disease managed on an outpatient basis.
When should children be hospitalized
Dr. Pichichero is a specialist in pediatric infectious diseases and director of the Research Institute at Rochester (N.Y.) General Hospital. He had no conflicts to declare. Email him at [email protected].
We are in the middle of flu season, and many of our patients are coughing. Is it the flu or might the child have a secondary bacterial pneumonia? Let’s start with the history for a tip off. The course of flu and respiratory viral infections in general involves a typical pattern of timing for fever and cough.
A late-developing fever or fever that subsides then recurs should raise concern. A prolonged cough or cough that subsides then recurs also should raise concern. The respiratory rate and chest retractions are key physical findings that can aid in distinguishing children with bacterial pneumonia. Rales and decreased breath sounds in lung segments are best heard with deep breaths.
What diagnostic laboratory and imaging tests should be used
Fortunately, rapid tests to detect influenza are available, and many providers have added those to their laboratory evaluation. A complete blood count and differential may be helpful. If a pulse oximeter is available, checking oxygen saturation might be helpful. The American Academy of Pediatrics community pneumonia guideline states that routine chest radiographs are not necessary for the confirmation of suspected community-acquired pneumonia (CAP) in patients well enough to be treated in the outpatient setting (Clin Inf Dis. 2011 Oct;53[7]:e25–e76). Blood cultures should not be performed routinely in nontoxic, fully immunized children with CAP managed in the outpatient setting.
What antibiotic should be used
Antimicrobial therapy is not routinely required for preschool-aged children with cough, even cough caused by CAP, because viral pathogens are responsible for the great majority of clinical disease. If the diagnosis of CAP is made, the AAP endorses amoxicillin as first-line therapy for previously healthy, appropriately immunized infants and preschool children with mild to moderate CAP suspected to be of bacterial origin. For previously healthy, appropriately immunized school-aged children and adolescents with mild to moderate CAP, amoxicillin is recommended for treatment of Streptococcus pneumoniae, the most prominent invasive bacterial pathogen.
However, the treatment paradigm is complicated because Mycoplasma pneumoniae also should be considered in management decisions. Children with signs and symptoms suspicious for M. pneumoniae should be tested to help guide antibiotic selection. This may be a simple bedside cold agglutinin test. The highest incidence of Mycoplasma pneumonia is in 5- to 20-year-olds (51% in 5- to 9-year-olds, 74% in 9- to 15-year-olds, and 3%-18% in adults with pneumonia), but 9% of CAP occurs in patients younger than 5 years old. The clinical features of Mycoplasma pneumonia resemble influenza: The patient has gradual onset of headache, malaise, fever, sore throat, and cough. Mycoplasma pneumonia has a similar incidence of productive cough, rales, and diarrhea as pneumococcal CAP, but with more frequent upper respiratory symptoms and a normal leukocyte count. Mycoplasma bronchopneumonia occurs 30 times more frequently than Mycoplasma lobar pneumonia. The radiologic features of Mycoplasma is typical of a bronchopneumonia, usually involving a single lobe, subsegmental atelectasis, peribronchial thickening, and streaky interstitial densities. While Mycoplasma pneumonia is usually self-limited, the duration of illness is shortened by oral treatment with doxycycline, erythromycin, clarithromycin, or azithromycin.
What is the appropriate duration of antimicrobial therapy
Recommendations by the AAP for CAP note that treatment courses of 10 days have been best studied, although shorter courses may be just as effective, particularly for mild disease managed on an outpatient basis.
When should children be hospitalized
Dr. Pichichero is a specialist in pediatric infectious diseases and director of the Research Institute at Rochester (N.Y.) General Hospital. He had no conflicts to declare. Email him at [email protected].
We are in the middle of flu season, and many of our patients are coughing. Is it the flu or might the child have a secondary bacterial pneumonia? Let’s start with the history for a tip off. The course of flu and respiratory viral infections in general involves a typical pattern of timing for fever and cough.
A late-developing fever or fever that subsides then recurs should raise concern. A prolonged cough or cough that subsides then recurs also should raise concern. The respiratory rate and chest retractions are key physical findings that can aid in distinguishing children with bacterial pneumonia. Rales and decreased breath sounds in lung segments are best heard with deep breaths.
What diagnostic laboratory and imaging tests should be used
Fortunately, rapid tests to detect influenza are available, and many providers have added those to their laboratory evaluation. A complete blood count and differential may be helpful. If a pulse oximeter is available, checking oxygen saturation might be helpful. The American Academy of Pediatrics community pneumonia guideline states that routine chest radiographs are not necessary for the confirmation of suspected community-acquired pneumonia (CAP) in patients well enough to be treated in the outpatient setting (Clin Inf Dis. 2011 Oct;53[7]:e25–e76). Blood cultures should not be performed routinely in nontoxic, fully immunized children with CAP managed in the outpatient setting.
What antibiotic should be used
Antimicrobial therapy is not routinely required for preschool-aged children with cough, even cough caused by CAP, because viral pathogens are responsible for the great majority of clinical disease. If the diagnosis of CAP is made, the AAP endorses amoxicillin as first-line therapy for previously healthy, appropriately immunized infants and preschool children with mild to moderate CAP suspected to be of bacterial origin. For previously healthy, appropriately immunized school-aged children and adolescents with mild to moderate CAP, amoxicillin is recommended for treatment of Streptococcus pneumoniae, the most prominent invasive bacterial pathogen.
However, the treatment paradigm is complicated because Mycoplasma pneumoniae also should be considered in management decisions. Children with signs and symptoms suspicious for M. pneumoniae should be tested to help guide antibiotic selection. This may be a simple bedside cold agglutinin test. The highest incidence of Mycoplasma pneumonia is in 5- to 20-year-olds (51% in 5- to 9-year-olds, 74% in 9- to 15-year-olds, and 3%-18% in adults with pneumonia), but 9% of CAP occurs in patients younger than 5 years old. The clinical features of Mycoplasma pneumonia resemble influenza: The patient has gradual onset of headache, malaise, fever, sore throat, and cough. Mycoplasma pneumonia has a similar incidence of productive cough, rales, and diarrhea as pneumococcal CAP, but with more frequent upper respiratory symptoms and a normal leukocyte count. Mycoplasma bronchopneumonia occurs 30 times more frequently than Mycoplasma lobar pneumonia. The radiologic features of Mycoplasma is typical of a bronchopneumonia, usually involving a single lobe, subsegmental atelectasis, peribronchial thickening, and streaky interstitial densities. While Mycoplasma pneumonia is usually self-limited, the duration of illness is shortened by oral treatment with doxycycline, erythromycin, clarithromycin, or azithromycin.
What is the appropriate duration of antimicrobial therapy
Recommendations by the AAP for CAP note that treatment courses of 10 days have been best studied, although shorter courses may be just as effective, particularly for mild disease managed on an outpatient basis.
When should children be hospitalized
Dr. Pichichero is a specialist in pediatric infectious diseases and director of the Research Institute at Rochester (N.Y.) General Hospital. He had no conflicts to declare. Email him at [email protected].
The risks of intensive parenting
“Parenthood in the United States has become much more demanding than it used to be.” It is hard to argue with this opening sentence in Clair Cain Miller’s op-ed piece titled “The Relentlessness of Modern Parenting,” published in the Dec. 25, 2018, electronic edition of the New York Times. But just in case you don’t agree with her premise, she lays out her case with evidence that parents in this country are investing more time, attention, and money into raising their children than was the norm several decades ago. She goes on to describe how this “intensive parenting” is taking its toll on parents on both sides of our nation’s widening economic divide. I’m sure you have seen it in your office in the tired faces and stooped shoulders of your patients’ parents. You may even be struggling yourself to find the time and energy to be the parent you believe your children need and deserve.
While there is debate on whether “parent” is inherently a verb or a noun (“Parent is a Noun, Not a Verb,” Cliff Price, the Australian Family Association; “Parent is a Verb – and we All do it,” Zaeli Kane, mother.ly), it is clear that “parenting” used as a verb has become one of the hot topics in pediatrics over the last quarter century and with it an epidemic of parental anxiety. What are the driving forces behind this shift in attitude? How has a relatively relaxed nature-will-take-its-course philosophy become an anxiety-provoking, stress-inducing phenomenon that will inevitably result in a disturbed and disappointed adult without a parent’s relentless attention to creating a nurturing and optimally stimulating environment?
Of course, parents have always worried about the health of their children and hope that they will be successful, regardless of how one defines success. But this natural parental concern seems to have gotten out of hand.
Is it because North Americans are having fewer children? Is it because in smaller families children become adults with little or no practical experience with hands-on child rearing? Are parents reacting to the predictions that the next generation may not be able to earn enough to match their parents’ lifestyle?
How much blame should fall on those of us who market ourselves as child health experts? Have we failed to put the research supporting the importance of early life experiences in the proper perspective? Are our recommendations creating unrealistic goals for parents? The American Academy of Pediatrics advice on breastfeeding duration and room sharing come to mind immediately. How realistic is it for parents to coview the majority of television shows their children are watching?
On one hand, we are beginning to realize that free play is important, but for years pediatricians have been one of the loudest voices supporting playground and toy safety. These two initiatives can certainly coexist, but I fear that at times we have begun to sound a bit like that annoying parent who is constantly warning his or her child, “Don’t do that, you’ll hurt yourself?”
Have we become the worry merchants? As a marketing strategy it seems to be working well. If we generate enough advice that supports an intensive parenting style, we can fill our waiting rooms with families struggling to meet the expectations we have been promoting.
A child can thrive without intensive parenting as long as he feels loved and he has been provided an environment with sensible limits to keep him safe.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
“Parenthood in the United States has become much more demanding than it used to be.” It is hard to argue with this opening sentence in Clair Cain Miller’s op-ed piece titled “The Relentlessness of Modern Parenting,” published in the Dec. 25, 2018, electronic edition of the New York Times. But just in case you don’t agree with her premise, she lays out her case with evidence that parents in this country are investing more time, attention, and money into raising their children than was the norm several decades ago. She goes on to describe how this “intensive parenting” is taking its toll on parents on both sides of our nation’s widening economic divide. I’m sure you have seen it in your office in the tired faces and stooped shoulders of your patients’ parents. You may even be struggling yourself to find the time and energy to be the parent you believe your children need and deserve.
While there is debate on whether “parent” is inherently a verb or a noun (“Parent is a Noun, Not a Verb,” Cliff Price, the Australian Family Association; “Parent is a Verb – and we All do it,” Zaeli Kane, mother.ly), it is clear that “parenting” used as a verb has become one of the hot topics in pediatrics over the last quarter century and with it an epidemic of parental anxiety. What are the driving forces behind this shift in attitude? How has a relatively relaxed nature-will-take-its-course philosophy become an anxiety-provoking, stress-inducing phenomenon that will inevitably result in a disturbed and disappointed adult without a parent’s relentless attention to creating a nurturing and optimally stimulating environment?
Of course, parents have always worried about the health of their children and hope that they will be successful, regardless of how one defines success. But this natural parental concern seems to have gotten out of hand.
Is it because North Americans are having fewer children? Is it because in smaller families children become adults with little or no practical experience with hands-on child rearing? Are parents reacting to the predictions that the next generation may not be able to earn enough to match their parents’ lifestyle?
How much blame should fall on those of us who market ourselves as child health experts? Have we failed to put the research supporting the importance of early life experiences in the proper perspective? Are our recommendations creating unrealistic goals for parents? The American Academy of Pediatrics advice on breastfeeding duration and room sharing come to mind immediately. How realistic is it for parents to coview the majority of television shows their children are watching?
On one hand, we are beginning to realize that free play is important, but for years pediatricians have been one of the loudest voices supporting playground and toy safety. These two initiatives can certainly coexist, but I fear that at times we have begun to sound a bit like that annoying parent who is constantly warning his or her child, “Don’t do that, you’ll hurt yourself?”
Have we become the worry merchants? As a marketing strategy it seems to be working well. If we generate enough advice that supports an intensive parenting style, we can fill our waiting rooms with families struggling to meet the expectations we have been promoting.
A child can thrive without intensive parenting as long as he feels loved and he has been provided an environment with sensible limits to keep him safe.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
“Parenthood in the United States has become much more demanding than it used to be.” It is hard to argue with this opening sentence in Clair Cain Miller’s op-ed piece titled “The Relentlessness of Modern Parenting,” published in the Dec. 25, 2018, electronic edition of the New York Times. But just in case you don’t agree with her premise, she lays out her case with evidence that parents in this country are investing more time, attention, and money into raising their children than was the norm several decades ago. She goes on to describe how this “intensive parenting” is taking its toll on parents on both sides of our nation’s widening economic divide. I’m sure you have seen it in your office in the tired faces and stooped shoulders of your patients’ parents. You may even be struggling yourself to find the time and energy to be the parent you believe your children need and deserve.
While there is debate on whether “parent” is inherently a verb or a noun (“Parent is a Noun, Not a Verb,” Cliff Price, the Australian Family Association; “Parent is a Verb – and we All do it,” Zaeli Kane, mother.ly), it is clear that “parenting” used as a verb has become one of the hot topics in pediatrics over the last quarter century and with it an epidemic of parental anxiety. What are the driving forces behind this shift in attitude? How has a relatively relaxed nature-will-take-its-course philosophy become an anxiety-provoking, stress-inducing phenomenon that will inevitably result in a disturbed and disappointed adult without a parent’s relentless attention to creating a nurturing and optimally stimulating environment?
Of course, parents have always worried about the health of their children and hope that they will be successful, regardless of how one defines success. But this natural parental concern seems to have gotten out of hand.
Is it because North Americans are having fewer children? Is it because in smaller families children become adults with little or no practical experience with hands-on child rearing? Are parents reacting to the predictions that the next generation may not be able to earn enough to match their parents’ lifestyle?
How much blame should fall on those of us who market ourselves as child health experts? Have we failed to put the research supporting the importance of early life experiences in the proper perspective? Are our recommendations creating unrealistic goals for parents? The American Academy of Pediatrics advice on breastfeeding duration and room sharing come to mind immediately. How realistic is it for parents to coview the majority of television shows their children are watching?
On one hand, we are beginning to realize that free play is important, but for years pediatricians have been one of the loudest voices supporting playground and toy safety. These two initiatives can certainly coexist, but I fear that at times we have begun to sound a bit like that annoying parent who is constantly warning his or her child, “Don’t do that, you’ll hurt yourself?”
Have we become the worry merchants? As a marketing strategy it seems to be working well. If we generate enough advice that supports an intensive parenting style, we can fill our waiting rooms with families struggling to meet the expectations we have been promoting.
A child can thrive without intensive parenting as long as he feels loved and he has been provided an environment with sensible limits to keep him safe.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
A prescription for ‘deprescribing’: A case report
In 2016, Swapnil Gupta, MD, and John Daniel Cahill, MD, PhD, challenged the field of psychiatry to reexamine our prescribing patterns. They warned against our use of polypharmacy when not attached to improvement in functioning for our patients.1 They were concerned about the lack of evidence for those treatment regimens and for our diagnostic criteria. In their inspiring article, they described how psychiatrists might proceed in the process of “deprescribing” – which they define as a process of pharmacologic regimen optimization through reducing or ending medications for which “benefits no longer outweigh risks.”1
In my practice, I routinely confront medication regimens that I have never encountered in the literature. The evidence for two psychotropics is limited but certainly available, in particular adjunct treatment of antidepressants2 and mood stabilizers.3 The evidence supporting the use of more than two psychotropics, however, is quite sparse. Yet, patients often enter my office on more than five psychotropics. I am also confronted with poorly defined diagnostic labels – which present more as means to justify polypharmacy than a thorough review of the patient’s current state.
Dr. Gupta and Dr. Cahill recommend a series of steps aimed at attempting the deprescription of psychotropics. Those steps include timeliness, knowledge of the patient’s current regimen, discussion about the risk of prescriptions, discussion about deprescribing, choosing the right medications to stop, a plan for describing, and monitoring. In the case presented below, I used some of those steps in an effort to provide the best care for the patient. Key details of the case have been changed, including the name, to protect the patient’s confidentiality.
Overview of the case
Rosalie Bertin is a 54-year-old female who has been treated for depression by a variety of primary care physicians for the better part of the last 30 years. She had tried an array of antidepressants, including sertraline, citalopram, duloxetine, and mirtazapine, over that time. Each seemed to provide some benefit when reviewing the notes, but there is no mention of why she was continued on those medications despite the absence of continuing symptoms. Occasionally, Rosalie would present to her clinician tearful and endorsing sadness, though the record did not comment on reports of energy, concentration, sleep, appetite, and interest.
In 2014, Rosalie’s husband passed away from lung cancer. His death was fairly quick, and initially, Rosalie did not mention any significant emotional complaints. However, when visiting her primary care physician 4 months later, she was noted to experience auditory hallucinations. “Sometimes I hear my husband when I am alone in my home,” she said. Rosalie was referred to a psychiatrist with a diagnosis of “psychosis not otherwise specified.”
When discussing her condition with the psychiatrist, Rosalie mentioned experiencing low mood, and having diminished interest in engaging in activities. “I miss Marc when I go places; I used to do everything with him.” She reported hearing him often but only when at her home. He would say things like, “I miss you,” or ask her about her day. She was diagnosed with “major depressive disorder with psychotic features.” Risperidone was added to the escitalopram, buspirone, and gabapentin that had been started by her primary care physician.
After several months of psychotropic management, the dose of risperidone was titrated to 8 mg per day. Her mood symptoms were unchanged, but she now was complaining of poor concentration and memory. The psychiatrist performed a Mini-Mental State Examination (MMSE). It was noted that taking the MMSE engendered significant anxiety for the patient. Rosalie received a score suggesting mild cognitive impairment. She was started on donepezil for the memory complaint, quetiapine for the continued voices, and recommended for disability.
Once on short-term disability, the patient relocated to live closer to her mother in San Diego and subsequently contacted me about continuing psychiatric care.
Initial visit
Rosalie is a petite white woman, raised in the Midwest, who married her high school sweetheart, and subsequently became an administrative assistant. Rosalie and Marc were unable to have children. Marc was an engineer, and a longtime smoker. She describes their lives as simple – “few friends, few vacations, few problems, few regrets.” She states she misses her husband and often cries when thinking about him.
When asked about psychiatric diagnoses, she answered: “I have psychosis. … My doctor said maybe schizophrenia, but he is not sure yet.” She described schizophrenia as hearing voices. Rosalie also mentioned having memory problems: “They cannot tell if it is Alzheimer’s disease until I die and they look at my brain, but the medication should delay the progression.”
She reported no significant effect from her prior antidepressant trials: “I am not sure if or how they helped.” Rosalie could not explain the role of the medication. “I take medications as prescribed by my doctor,” she said.
When discussing her antipsychotics, she mentioned: “Those are strong medications; it is hard for me to stay awake with them.” She declared having had no changes in the voices while on the risperidone but said they went away since also being on the quetiapine: “I wonder if the combination of the two really fixed my brain imbalance.”
Assessment
I admit that I have a critical bias against the overuse of psychotropics, and this might have painted how I interpreted Rosalie’s story. Nonetheless, I was honest with her and told her of my concerns. I informed her that her diagnosis was not consistent with my understanding of mood and thought disorders. Her initial reports of depression neither met the DSM criteria for depression nor felt consistent with my conceptualization of the illness. She had retained appropriate functioning and seemed to be responding with the sadness expected when facing difficult challenges like grief.
Her subsequent reports of auditory hallucinations were not associated with delusions or forms of disorganization that I would expect in someone with a thought disorder. Furthermore, the context of the onset gave me the impression that this was part of her process of grief. Her poor result in the dementia screen was most surprising and inconsistent with my evaluation. I told her that I suspected that she was not suffering from Alzheimer’s but from being overmedicated and from anxiety at the time of the testing.
She was excited and hesitant about my report. She was surprised by the length of our visit and interested in hearing more from me. Strangely, I wished she had challenged my different approach. I think that I was hoping she would question my conceptualization, the way I hoped she would have done with her prior clinicians. Nonetheless, she agreed to make a plan with me.
Treatment plan
We decided to review each of her medications and discuss their benefits and risks over a couple of visits. She was most eager to discontinue the donepezil, which had caused diarrhea. She was concerned when I informed her of the potential side effects of antipsychotics. “My doctor asked me if I had any side effects at each visit; I answered that I felt nothing wrong; I had not realized that side effects could appear later.”
She was adamant about staying on buspirone, as she felt it helped her the most with her anxiety at social events. She voiced concern about discontinuing the antipsychotics despite being unsettled by my review of their risks. She asked that we taper them slowly.
In regard to receiving psychosocial support throughout this period of deprescribing, Rosalie declined weekly psychotherapy. She reported having a good social network in San Diego that she wanted to rely on.
Outcome
I often worry about consequences of stopping a medication, especially when I was not present at the time of its initiation. I agonize that the patient might relapse from my need to carry out my agenda on deprescribing. I try to remind myself that the evidence supports my decision making. The risks of psychotropics often are slow to show up, making the benefit of deprescribing less tangible. However, this case was straightforward.
Rosalie quickly improved. Tapering the antipsychotics was astonishing to her: “I can think clearly again.” Within 6 months, she was on buspirone only – though willing to discuss its discontinuation. She had a lead for a job and was hoping to return to work soon. Rosalie continued to miss her husband but had not heard him in some time. She has not had symptoms of psychosis or depression. Her cognition and mood were intact on my clinical assessment.
Discussion
Sadly and shockingly, cases like that of Rosalie are common. In my practice, I routinely see patients on multiple psychotropics – often on more than one antipsychotic. Their diagnoses are vague and dubious, and include diagnoses such as “unspecified psychosis” and “cognitive impairments.” Clinicians occasionally worry about relapse and promote a narrative that treatment must be not only long term but lifelong.4 There is some evidence for this perspective in a research context, but the clinical world also is filled with patients like Rosalie.
Her reports of auditory hallucinations were better explained by her grief than by a psychotic process.5 Her memory complaints were better explained by anxiety at the time of her testing while suffering from the side effects from her numerous psychotropics.6 Her depressive complaints were better explained by appropriate sadness in response to stressors. Several months later with fewer diagnoses and far fewer psychotropics, she is functioning better.
Take-home points
- Polypharmacy can lead to psychiatric symptoms and functional impairment.
- Patients often are unaware of the complete risks of psychotropics.
- Psychiatric symptoms are not always associated with a psychiatric disorder.
- Deprescribing can be performed safely and effectively.
- Deprescribing can be performed with the patient’s informed consent and agreement.
References
1. Psychiatr Serv. 2016 Aug 1;67(8):904-7.
2. Focus. 2016 Apr 13; doi: 10.1176/appi.focus.20150041.
3. Bipolar Disord. 2016 Dec;18(8):684-91.
4. Am J Psychiatry. 2017 Sep 1;174(9):840-9.
5. World Psychiatry. 2009 Jun;8(2):67-74.
6. Hosp Community Psychiatry. 1983 Sep;34(9):830-5.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).
*This column was updated 1/11/2019.
In 2016, Swapnil Gupta, MD, and John Daniel Cahill, MD, PhD, challenged the field of psychiatry to reexamine our prescribing patterns. They warned against our use of polypharmacy when not attached to improvement in functioning for our patients.1 They were concerned about the lack of evidence for those treatment regimens and for our diagnostic criteria. In their inspiring article, they described how psychiatrists might proceed in the process of “deprescribing” – which they define as a process of pharmacologic regimen optimization through reducing or ending medications for which “benefits no longer outweigh risks.”1
In my practice, I routinely confront medication regimens that I have never encountered in the literature. The evidence for two psychotropics is limited but certainly available, in particular adjunct treatment of antidepressants2 and mood stabilizers.3 The evidence supporting the use of more than two psychotropics, however, is quite sparse. Yet, patients often enter my office on more than five psychotropics. I am also confronted with poorly defined diagnostic labels – which present more as means to justify polypharmacy than a thorough review of the patient’s current state.
Dr. Gupta and Dr. Cahill recommend a series of steps aimed at attempting the deprescription of psychotropics. Those steps include timeliness, knowledge of the patient’s current regimen, discussion about the risk of prescriptions, discussion about deprescribing, choosing the right medications to stop, a plan for describing, and monitoring. In the case presented below, I used some of those steps in an effort to provide the best care for the patient. Key details of the case have been changed, including the name, to protect the patient’s confidentiality.
Overview of the case
Rosalie Bertin is a 54-year-old female who has been treated for depression by a variety of primary care physicians for the better part of the last 30 years. She had tried an array of antidepressants, including sertraline, citalopram, duloxetine, and mirtazapine, over that time. Each seemed to provide some benefit when reviewing the notes, but there is no mention of why she was continued on those medications despite the absence of continuing symptoms. Occasionally, Rosalie would present to her clinician tearful and endorsing sadness, though the record did not comment on reports of energy, concentration, sleep, appetite, and interest.
In 2014, Rosalie’s husband passed away from lung cancer. His death was fairly quick, and initially, Rosalie did not mention any significant emotional complaints. However, when visiting her primary care physician 4 months later, she was noted to experience auditory hallucinations. “Sometimes I hear my husband when I am alone in my home,” she said. Rosalie was referred to a psychiatrist with a diagnosis of “psychosis not otherwise specified.”
When discussing her condition with the psychiatrist, Rosalie mentioned experiencing low mood, and having diminished interest in engaging in activities. “I miss Marc when I go places; I used to do everything with him.” She reported hearing him often but only when at her home. He would say things like, “I miss you,” or ask her about her day. She was diagnosed with “major depressive disorder with psychotic features.” Risperidone was added to the escitalopram, buspirone, and gabapentin that had been started by her primary care physician.
After several months of psychotropic management, the dose of risperidone was titrated to 8 mg per day. Her mood symptoms were unchanged, but she now was complaining of poor concentration and memory. The psychiatrist performed a Mini-Mental State Examination (MMSE). It was noted that taking the MMSE engendered significant anxiety for the patient. Rosalie received a score suggesting mild cognitive impairment. She was started on donepezil for the memory complaint, quetiapine for the continued voices, and recommended for disability.
Once on short-term disability, the patient relocated to live closer to her mother in San Diego and subsequently contacted me about continuing psychiatric care.
Initial visit
Rosalie is a petite white woman, raised in the Midwest, who married her high school sweetheart, and subsequently became an administrative assistant. Rosalie and Marc were unable to have children. Marc was an engineer, and a longtime smoker. She describes their lives as simple – “few friends, few vacations, few problems, few regrets.” She states she misses her husband and often cries when thinking about him.
When asked about psychiatric diagnoses, she answered: “I have psychosis. … My doctor said maybe schizophrenia, but he is not sure yet.” She described schizophrenia as hearing voices. Rosalie also mentioned having memory problems: “They cannot tell if it is Alzheimer’s disease until I die and they look at my brain, but the medication should delay the progression.”
She reported no significant effect from her prior antidepressant trials: “I am not sure if or how they helped.” Rosalie could not explain the role of the medication. “I take medications as prescribed by my doctor,” she said.
When discussing her antipsychotics, she mentioned: “Those are strong medications; it is hard for me to stay awake with them.” She declared having had no changes in the voices while on the risperidone but said they went away since also being on the quetiapine: “I wonder if the combination of the two really fixed my brain imbalance.”
Assessment
I admit that I have a critical bias against the overuse of psychotropics, and this might have painted how I interpreted Rosalie’s story. Nonetheless, I was honest with her and told her of my concerns. I informed her that her diagnosis was not consistent with my understanding of mood and thought disorders. Her initial reports of depression neither met the DSM criteria for depression nor felt consistent with my conceptualization of the illness. She had retained appropriate functioning and seemed to be responding with the sadness expected when facing difficult challenges like grief.
Her subsequent reports of auditory hallucinations were not associated with delusions or forms of disorganization that I would expect in someone with a thought disorder. Furthermore, the context of the onset gave me the impression that this was part of her process of grief. Her poor result in the dementia screen was most surprising and inconsistent with my evaluation. I told her that I suspected that she was not suffering from Alzheimer’s but from being overmedicated and from anxiety at the time of the testing.
She was excited and hesitant about my report. She was surprised by the length of our visit and interested in hearing more from me. Strangely, I wished she had challenged my different approach. I think that I was hoping she would question my conceptualization, the way I hoped she would have done with her prior clinicians. Nonetheless, she agreed to make a plan with me.
Treatment plan
We decided to review each of her medications and discuss their benefits and risks over a couple of visits. She was most eager to discontinue the donepezil, which had caused diarrhea. She was concerned when I informed her of the potential side effects of antipsychotics. “My doctor asked me if I had any side effects at each visit; I answered that I felt nothing wrong; I had not realized that side effects could appear later.”
She was adamant about staying on buspirone, as she felt it helped her the most with her anxiety at social events. She voiced concern about discontinuing the antipsychotics despite being unsettled by my review of their risks. She asked that we taper them slowly.
In regard to receiving psychosocial support throughout this period of deprescribing, Rosalie declined weekly psychotherapy. She reported having a good social network in San Diego that she wanted to rely on.
Outcome
I often worry about consequences of stopping a medication, especially when I was not present at the time of its initiation. I agonize that the patient might relapse from my need to carry out my agenda on deprescribing. I try to remind myself that the evidence supports my decision making. The risks of psychotropics often are slow to show up, making the benefit of deprescribing less tangible. However, this case was straightforward.
Rosalie quickly improved. Tapering the antipsychotics was astonishing to her: “I can think clearly again.” Within 6 months, she was on buspirone only – though willing to discuss its discontinuation. She had a lead for a job and was hoping to return to work soon. Rosalie continued to miss her husband but had not heard him in some time. She has not had symptoms of psychosis or depression. Her cognition and mood were intact on my clinical assessment.
Discussion
Sadly and shockingly, cases like that of Rosalie are common. In my practice, I routinely see patients on multiple psychotropics – often on more than one antipsychotic. Their diagnoses are vague and dubious, and include diagnoses such as “unspecified psychosis” and “cognitive impairments.” Clinicians occasionally worry about relapse and promote a narrative that treatment must be not only long term but lifelong.4 There is some evidence for this perspective in a research context, but the clinical world also is filled with patients like Rosalie.
Her reports of auditory hallucinations were better explained by her grief than by a psychotic process.5 Her memory complaints were better explained by anxiety at the time of her testing while suffering from the side effects from her numerous psychotropics.6 Her depressive complaints were better explained by appropriate sadness in response to stressors. Several months later with fewer diagnoses and far fewer psychotropics, she is functioning better.
Take-home points
- Polypharmacy can lead to psychiatric symptoms and functional impairment.
- Patients often are unaware of the complete risks of psychotropics.
- Psychiatric symptoms are not always associated with a psychiatric disorder.
- Deprescribing can be performed safely and effectively.
- Deprescribing can be performed with the patient’s informed consent and agreement.
References
1. Psychiatr Serv. 2016 Aug 1;67(8):904-7.
2. Focus. 2016 Apr 13; doi: 10.1176/appi.focus.20150041.
3. Bipolar Disord. 2016 Dec;18(8):684-91.
4. Am J Psychiatry. 2017 Sep 1;174(9):840-9.
5. World Psychiatry. 2009 Jun;8(2):67-74.
6. Hosp Community Psychiatry. 1983 Sep;34(9):830-5.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).
*This column was updated 1/11/2019.
In 2016, Swapnil Gupta, MD, and John Daniel Cahill, MD, PhD, challenged the field of psychiatry to reexamine our prescribing patterns. They warned against our use of polypharmacy when not attached to improvement in functioning for our patients.1 They were concerned about the lack of evidence for those treatment regimens and for our diagnostic criteria. In their inspiring article, they described how psychiatrists might proceed in the process of “deprescribing” – which they define as a process of pharmacologic regimen optimization through reducing or ending medications for which “benefits no longer outweigh risks.”1
In my practice, I routinely confront medication regimens that I have never encountered in the literature. The evidence for two psychotropics is limited but certainly available, in particular adjunct treatment of antidepressants2 and mood stabilizers.3 The evidence supporting the use of more than two psychotropics, however, is quite sparse. Yet, patients often enter my office on more than five psychotropics. I am also confronted with poorly defined diagnostic labels – which present more as means to justify polypharmacy than a thorough review of the patient’s current state.
Dr. Gupta and Dr. Cahill recommend a series of steps aimed at attempting the deprescription of psychotropics. Those steps include timeliness, knowledge of the patient’s current regimen, discussion about the risk of prescriptions, discussion about deprescribing, choosing the right medications to stop, a plan for describing, and monitoring. In the case presented below, I used some of those steps in an effort to provide the best care for the patient. Key details of the case have been changed, including the name, to protect the patient’s confidentiality.
Overview of the case
Rosalie Bertin is a 54-year-old female who has been treated for depression by a variety of primary care physicians for the better part of the last 30 years. She had tried an array of antidepressants, including sertraline, citalopram, duloxetine, and mirtazapine, over that time. Each seemed to provide some benefit when reviewing the notes, but there is no mention of why she was continued on those medications despite the absence of continuing symptoms. Occasionally, Rosalie would present to her clinician tearful and endorsing sadness, though the record did not comment on reports of energy, concentration, sleep, appetite, and interest.
In 2014, Rosalie’s husband passed away from lung cancer. His death was fairly quick, and initially, Rosalie did not mention any significant emotional complaints. However, when visiting her primary care physician 4 months later, she was noted to experience auditory hallucinations. “Sometimes I hear my husband when I am alone in my home,” she said. Rosalie was referred to a psychiatrist with a diagnosis of “psychosis not otherwise specified.”
When discussing her condition with the psychiatrist, Rosalie mentioned experiencing low mood, and having diminished interest in engaging in activities. “I miss Marc when I go places; I used to do everything with him.” She reported hearing him often but only when at her home. He would say things like, “I miss you,” or ask her about her day. She was diagnosed with “major depressive disorder with psychotic features.” Risperidone was added to the escitalopram, buspirone, and gabapentin that had been started by her primary care physician.
After several months of psychotropic management, the dose of risperidone was titrated to 8 mg per day. Her mood symptoms were unchanged, but she now was complaining of poor concentration and memory. The psychiatrist performed a Mini-Mental State Examination (MMSE). It was noted that taking the MMSE engendered significant anxiety for the patient. Rosalie received a score suggesting mild cognitive impairment. She was started on donepezil for the memory complaint, quetiapine for the continued voices, and recommended for disability.
Once on short-term disability, the patient relocated to live closer to her mother in San Diego and subsequently contacted me about continuing psychiatric care.
Initial visit
Rosalie is a petite white woman, raised in the Midwest, who married her high school sweetheart, and subsequently became an administrative assistant. Rosalie and Marc were unable to have children. Marc was an engineer, and a longtime smoker. She describes their lives as simple – “few friends, few vacations, few problems, few regrets.” She states she misses her husband and often cries when thinking about him.
When asked about psychiatric diagnoses, she answered: “I have psychosis. … My doctor said maybe schizophrenia, but he is not sure yet.” She described schizophrenia as hearing voices. Rosalie also mentioned having memory problems: “They cannot tell if it is Alzheimer’s disease until I die and they look at my brain, but the medication should delay the progression.”
She reported no significant effect from her prior antidepressant trials: “I am not sure if or how they helped.” Rosalie could not explain the role of the medication. “I take medications as prescribed by my doctor,” she said.
When discussing her antipsychotics, she mentioned: “Those are strong medications; it is hard for me to stay awake with them.” She declared having had no changes in the voices while on the risperidone but said they went away since also being on the quetiapine: “I wonder if the combination of the two really fixed my brain imbalance.”
Assessment
I admit that I have a critical bias against the overuse of psychotropics, and this might have painted how I interpreted Rosalie’s story. Nonetheless, I was honest with her and told her of my concerns. I informed her that her diagnosis was not consistent with my understanding of mood and thought disorders. Her initial reports of depression neither met the DSM criteria for depression nor felt consistent with my conceptualization of the illness. She had retained appropriate functioning and seemed to be responding with the sadness expected when facing difficult challenges like grief.
Her subsequent reports of auditory hallucinations were not associated with delusions or forms of disorganization that I would expect in someone with a thought disorder. Furthermore, the context of the onset gave me the impression that this was part of her process of grief. Her poor result in the dementia screen was most surprising and inconsistent with my evaluation. I told her that I suspected that she was not suffering from Alzheimer’s but from being overmedicated and from anxiety at the time of the testing.
She was excited and hesitant about my report. She was surprised by the length of our visit and interested in hearing more from me. Strangely, I wished she had challenged my different approach. I think that I was hoping she would question my conceptualization, the way I hoped she would have done with her prior clinicians. Nonetheless, she agreed to make a plan with me.
Treatment plan
We decided to review each of her medications and discuss their benefits and risks over a couple of visits. She was most eager to discontinue the donepezil, which had caused diarrhea. She was concerned when I informed her of the potential side effects of antipsychotics. “My doctor asked me if I had any side effects at each visit; I answered that I felt nothing wrong; I had not realized that side effects could appear later.”
She was adamant about staying on buspirone, as she felt it helped her the most with her anxiety at social events. She voiced concern about discontinuing the antipsychotics despite being unsettled by my review of their risks. She asked that we taper them slowly.
In regard to receiving psychosocial support throughout this period of deprescribing, Rosalie declined weekly psychotherapy. She reported having a good social network in San Diego that she wanted to rely on.
Outcome
I often worry about consequences of stopping a medication, especially when I was not present at the time of its initiation. I agonize that the patient might relapse from my need to carry out my agenda on deprescribing. I try to remind myself that the evidence supports my decision making. The risks of psychotropics often are slow to show up, making the benefit of deprescribing less tangible. However, this case was straightforward.
Rosalie quickly improved. Tapering the antipsychotics was astonishing to her: “I can think clearly again.” Within 6 months, she was on buspirone only – though willing to discuss its discontinuation. She had a lead for a job and was hoping to return to work soon. Rosalie continued to miss her husband but had not heard him in some time. She has not had symptoms of psychosis or depression. Her cognition and mood were intact on my clinical assessment.
Discussion
Sadly and shockingly, cases like that of Rosalie are common. In my practice, I routinely see patients on multiple psychotropics – often on more than one antipsychotic. Their diagnoses are vague and dubious, and include diagnoses such as “unspecified psychosis” and “cognitive impairments.” Clinicians occasionally worry about relapse and promote a narrative that treatment must be not only long term but lifelong.4 There is some evidence for this perspective in a research context, but the clinical world also is filled with patients like Rosalie.
Her reports of auditory hallucinations were better explained by her grief than by a psychotic process.5 Her memory complaints were better explained by anxiety at the time of her testing while suffering from the side effects from her numerous psychotropics.6 Her depressive complaints were better explained by appropriate sadness in response to stressors. Several months later with fewer diagnoses and far fewer psychotropics, she is functioning better.
Take-home points
- Polypharmacy can lead to psychiatric symptoms and functional impairment.
- Patients often are unaware of the complete risks of psychotropics.
- Psychiatric symptoms are not always associated with a psychiatric disorder.
- Deprescribing can be performed safely and effectively.
- Deprescribing can be performed with the patient’s informed consent and agreement.
References
1. Psychiatr Serv. 2016 Aug 1;67(8):904-7.
2. Focus. 2016 Apr 13; doi: 10.1176/appi.focus.20150041.
3. Bipolar Disord. 2016 Dec;18(8):684-91.
4. Am J Psychiatry. 2017 Sep 1;174(9):840-9.
5. World Psychiatry. 2009 Jun;8(2):67-74.
6. Hosp Community Psychiatry. 1983 Sep;34(9):830-5.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).
*This column was updated 1/11/2019.
Mental health patients flocking to emergency departments
Emergency department visits in the United States climbed by 15% overall from 2006 to 2014. Over the same time period, ED visits by people with mental health issues soared by 44%, according to a report from the Agency for Health Care Research & Quality.
“The extent to which ERs are now flooded with patients with mental illness is unprecedented,” David R. Rubinow, MD, chairman of the department of psychiatry at the University of North Carolina, Chapel Hill, said in an interview with CNN.
This overflow is “having a really destructive effect on health care delivery in general,” Dr. Rubinow said. “There are ERs now that are repeatedly on diversion – which means they can’t see any more patients – because there are so many patients with mental illness or behavioral problems [who] are populating the ER.”
Physicians such as Mark D. Pearlmutter, MD, are convinced that EDs have become the medical refuge for many people with mental illness. “We are the safety net,” said Dr. Pearlmutter, an emergency physician affiliated with Steward Health Care in Brighton, Mass. Dr. Pearlmutter said some patients he has seen in the ED often have dual diagnoses, such as “substance abuse and depression, for example.”
As a result of this situation, patients with psychiatric needs might not receive the care that they really need, and care might be delayed for patients with other life-threatening conditions. “The ER is not a great place if you’re a mental health patient; the cardiac patients get put in front of you, and you could end up being there for a really long time, said David Morris, PhD, a psychologist at the O’Donnell Brain Institute in Dallas.
, Dr. Pearlmutter suggested. After all, increasingly, primary care physicians are providing mental health care.
Twists on New Year’s resolutions
Some people bring in each new year by shifting their perspectives – without making resolutions.
Tim Ferriss, an entrepreneur known for blogs and podcasts on work and life, engages in what he calls “past year reviews,” where accomplishments are tallied frequently throughout the year in terms of their positive or negative effect, with the latter being ruled out for the coming year. Over a few years, he hopes, the list of negatives will shrink and the positive items will increase, according to a post on the NBC News website.
Instead of making resolutions, Oprah Winfrey keeps a journal that is updated nightly with five things that spark gratitude. “I live in the present moment. I try to find the good that’s going on in any given situation,” Ms. Winfrey said in a 2017 interview. The practice has taught her to be careful in her personal wishes.
Melinda Gates starts the new year with a single word to provide guidance. Past examples include “gentle,” “spacious,” and, last year, “grace.” Her selections, she said, have helped her sharpen her focus on the really important aspects of her life.
“[Grace] even helped me find a beam of peace through the sadness of a friend’s funeral. When I was upset or distressed, I whispered to myself: ‘Grace.’ That’s the power of a well-chosen word of the year. It makes the year better – and it helps me be better, too, she wrote in a recent LinkedIn post.
20-somethings facing challenges
A recent article in the Guardian lamented a life that is not progressing as expected.
“I am 25 and a half, single, unable to pay my rent, and the closest thing I own to a car is a broken skateboard,” wrote Juliana Piskorz. “I’m in the throes of a quarter-life crisis.”
Ms. Piskorz, who said she suffers from anxiety attacks, said her experience of this crisis manifests itself by making her want to run away, start all over, or distract herself from reality.
She is not alone. According to LinkedIn, about three-quarters of people aged 25-33 share this kind of insecurity and doubt. Low self-esteem is an important culprit, according to James Arkell, MD, a psychiatrist affiliated with the Nightingale Hospital London. “Very often, 20-somethings I see here are beautiful, talented, and have the world on a plate, but they don’t like themselves and that’s got to be about society making them feel as if they have to keep up with these unrelenting standards.”
There are other reasons for millennial despair, Ms. Piskorz speculated.
“Our childhood visions for our lives ... are no longer realistic,” she wrote. “Due to unaffordable housing, less job security, and lower incomes, the traditional ‘markers’ of adulthood, such as owning a home, getting married, and having children, are being pushed back. This has left a vacuum between our teenage years and late 20s with many of us feeling we’re navigating a no man’s land with zero clue when we’ll reach the other side.”
Seeking optimism, Ms. Piskorz noted that, as a community, millennials share many positive characteristics that should serve them well.
“We are not afraid to talk about how we feel, although we should probably talk more,” she wrote. “We stand up for the causes that we think matter; we are not afraid to try new things, and we are not willing to live a life half lived.”
Apps monitor teen angst, depression
The smartphone, often seen as a tool that fuels angst, might be a resource that could identify teenagers in trouble.
According to an article in the Washington Post, research is underway on smartphone apps that can decipher the digital footprints left by users during their Internet ramblings.
“As teens scroll through Instagram or Snapchat, tap out texts, or watch YouTube videos, they also leave digital footprints that might offer clues to their psychological well-being,” wrote article author Lindsey Tanner, of the Associated Press. “Changes in typing speed, voice tone, word choice, and how often kids stay home could signal trouble.”
“We are tracking the equivalent of a heartbeat for the human brain,” said Alex Leow, MD, PhD, an app developer, and associate professor of psychiatry and bioengineering at the University of Illinois at Chicago.
The technology is not ready for deployment because of technical glitches and, more importantly, ethical issues concerning the recording and scrutiny of a user’s personal data being roadblocks. Still, with the permission of the user, mood-detecting apps might one day be a smartphone feature. “[Users] could withdraw permission at any time, said Nick B. Allen, PhD, a psychologist at the University of Oregon, Portland, who has helped create an app that is being tested on young people who have attempted suicide.
He said the biggest hurdle is figuring out “what’s the signal and what’s the noise – what is in this enormous amount of data that people accumulate on their phone that is indicative of a mental health crisis.”
Virtues of “intellectual humility”
Intellectual humility is neither a character flaw nor a sign of being a pushover.
Instead, wrote science reporter Brian Resnick in an article posted on Vox.com, “it’s a method of thinking. It’s about entertaining the possibility that you may be wrong and being open to learning from the experience of others. Intellectual humility is about being actively curious about your blind spots.”
In an effort to promote intellectual humility in psychology, two researchers, Tal Yarkoni, PhD, and Christopher F. Chabris, PhD, launched the Loss-of-Confidence project. The project is a safe space where researchers who doubt a previous finding in psychology can recalibrate. “I do think it’s a cultural issue that people are not willing to admit mistakes,” said Julia M. Rohrer, a PhD candidate and personality psychologist at the Max Planck Institute for Human Development in Berlin who joined the team in 2017. “Our broader goal is to gently nudge the whole scientific system and psychology toward a different culture where it’s okay, normalized, and expected for researchers to admit past mistakes and not get penalized for it.”
Put another way, the aim is to foster a culture where intellectually humble, honest, and curious people can thrive. For that to occur, “we all, even the smartest among us, need to better appreciate our cognitive blind spots,” Mr. Resnick wrote. “Our minds are more imperfect and imprecise than we’d often like to admit.”
In a recent paper, Ms. Rohrer and her associates said the Loss-of-Confidence project grew out of an online discussion in the wake of a post by Dana R. Carney, PhD, and associates on power poses. In that post, Dr. Carney explains why she changed her position on the value of power poses, concluding that the data gathered by her lab at the time leading to the power poses theory (Psychol Sci. 2010 Oct 21 [10]:1363-8) were real but flimsy. “My views have been updated to reflect the evidence,” she wrote. “As such, I do not believe that ‘power pose’ effects are real.”
In the Vox.com article, Mr. Resnick wrote that intellectual humility is needed for two reasons. “One is that our culture promotes and rewards overconfidence and arrogance. At the same time, when we are wrong – out of ignorance or error – and realize it, our culture doesn’t make it easy to admit it. Humbling moments too easily can turn into moments of humiliation.”
Emergency department visits in the United States climbed by 15% overall from 2006 to 2014. Over the same time period, ED visits by people with mental health issues soared by 44%, according to a report from the Agency for Health Care Research & Quality.
“The extent to which ERs are now flooded with patients with mental illness is unprecedented,” David R. Rubinow, MD, chairman of the department of psychiatry at the University of North Carolina, Chapel Hill, said in an interview with CNN.
This overflow is “having a really destructive effect on health care delivery in general,” Dr. Rubinow said. “There are ERs now that are repeatedly on diversion – which means they can’t see any more patients – because there are so many patients with mental illness or behavioral problems [who] are populating the ER.”
Physicians such as Mark D. Pearlmutter, MD, are convinced that EDs have become the medical refuge for many people with mental illness. “We are the safety net,” said Dr. Pearlmutter, an emergency physician affiliated with Steward Health Care in Brighton, Mass. Dr. Pearlmutter said some patients he has seen in the ED often have dual diagnoses, such as “substance abuse and depression, for example.”
As a result of this situation, patients with psychiatric needs might not receive the care that they really need, and care might be delayed for patients with other life-threatening conditions. “The ER is not a great place if you’re a mental health patient; the cardiac patients get put in front of you, and you could end up being there for a really long time, said David Morris, PhD, a psychologist at the O’Donnell Brain Institute in Dallas.
, Dr. Pearlmutter suggested. After all, increasingly, primary care physicians are providing mental health care.
Twists on New Year’s resolutions
Some people bring in each new year by shifting their perspectives – without making resolutions.
Tim Ferriss, an entrepreneur known for blogs and podcasts on work and life, engages in what he calls “past year reviews,” where accomplishments are tallied frequently throughout the year in terms of their positive or negative effect, with the latter being ruled out for the coming year. Over a few years, he hopes, the list of negatives will shrink and the positive items will increase, according to a post on the NBC News website.
Instead of making resolutions, Oprah Winfrey keeps a journal that is updated nightly with five things that spark gratitude. “I live in the present moment. I try to find the good that’s going on in any given situation,” Ms. Winfrey said in a 2017 interview. The practice has taught her to be careful in her personal wishes.
Melinda Gates starts the new year with a single word to provide guidance. Past examples include “gentle,” “spacious,” and, last year, “grace.” Her selections, she said, have helped her sharpen her focus on the really important aspects of her life.
“[Grace] even helped me find a beam of peace through the sadness of a friend’s funeral. When I was upset or distressed, I whispered to myself: ‘Grace.’ That’s the power of a well-chosen word of the year. It makes the year better – and it helps me be better, too, she wrote in a recent LinkedIn post.
20-somethings facing challenges
A recent article in the Guardian lamented a life that is not progressing as expected.
“I am 25 and a half, single, unable to pay my rent, and the closest thing I own to a car is a broken skateboard,” wrote Juliana Piskorz. “I’m in the throes of a quarter-life crisis.”
Ms. Piskorz, who said she suffers from anxiety attacks, said her experience of this crisis manifests itself by making her want to run away, start all over, or distract herself from reality.
She is not alone. According to LinkedIn, about three-quarters of people aged 25-33 share this kind of insecurity and doubt. Low self-esteem is an important culprit, according to James Arkell, MD, a psychiatrist affiliated with the Nightingale Hospital London. “Very often, 20-somethings I see here are beautiful, talented, and have the world on a plate, but they don’t like themselves and that’s got to be about society making them feel as if they have to keep up with these unrelenting standards.”
There are other reasons for millennial despair, Ms. Piskorz speculated.
“Our childhood visions for our lives ... are no longer realistic,” she wrote. “Due to unaffordable housing, less job security, and lower incomes, the traditional ‘markers’ of adulthood, such as owning a home, getting married, and having children, are being pushed back. This has left a vacuum between our teenage years and late 20s with many of us feeling we’re navigating a no man’s land with zero clue when we’ll reach the other side.”
Seeking optimism, Ms. Piskorz noted that, as a community, millennials share many positive characteristics that should serve them well.
“We are not afraid to talk about how we feel, although we should probably talk more,” she wrote. “We stand up for the causes that we think matter; we are not afraid to try new things, and we are not willing to live a life half lived.”
Apps monitor teen angst, depression
The smartphone, often seen as a tool that fuels angst, might be a resource that could identify teenagers in trouble.
According to an article in the Washington Post, research is underway on smartphone apps that can decipher the digital footprints left by users during their Internet ramblings.
“As teens scroll through Instagram or Snapchat, tap out texts, or watch YouTube videos, they also leave digital footprints that might offer clues to their psychological well-being,” wrote article author Lindsey Tanner, of the Associated Press. “Changes in typing speed, voice tone, word choice, and how often kids stay home could signal trouble.”
“We are tracking the equivalent of a heartbeat for the human brain,” said Alex Leow, MD, PhD, an app developer, and associate professor of psychiatry and bioengineering at the University of Illinois at Chicago.
The technology is not ready for deployment because of technical glitches and, more importantly, ethical issues concerning the recording and scrutiny of a user’s personal data being roadblocks. Still, with the permission of the user, mood-detecting apps might one day be a smartphone feature. “[Users] could withdraw permission at any time, said Nick B. Allen, PhD, a psychologist at the University of Oregon, Portland, who has helped create an app that is being tested on young people who have attempted suicide.
He said the biggest hurdle is figuring out “what’s the signal and what’s the noise – what is in this enormous amount of data that people accumulate on their phone that is indicative of a mental health crisis.”
Virtues of “intellectual humility”
Intellectual humility is neither a character flaw nor a sign of being a pushover.
Instead, wrote science reporter Brian Resnick in an article posted on Vox.com, “it’s a method of thinking. It’s about entertaining the possibility that you may be wrong and being open to learning from the experience of others. Intellectual humility is about being actively curious about your blind spots.”
In an effort to promote intellectual humility in psychology, two researchers, Tal Yarkoni, PhD, and Christopher F. Chabris, PhD, launched the Loss-of-Confidence project. The project is a safe space where researchers who doubt a previous finding in psychology can recalibrate. “I do think it’s a cultural issue that people are not willing to admit mistakes,” said Julia M. Rohrer, a PhD candidate and personality psychologist at the Max Planck Institute for Human Development in Berlin who joined the team in 2017. “Our broader goal is to gently nudge the whole scientific system and psychology toward a different culture where it’s okay, normalized, and expected for researchers to admit past mistakes and not get penalized for it.”
Put another way, the aim is to foster a culture where intellectually humble, honest, and curious people can thrive. For that to occur, “we all, even the smartest among us, need to better appreciate our cognitive blind spots,” Mr. Resnick wrote. “Our minds are more imperfect and imprecise than we’d often like to admit.”
In a recent paper, Ms. Rohrer and her associates said the Loss-of-Confidence project grew out of an online discussion in the wake of a post by Dana R. Carney, PhD, and associates on power poses. In that post, Dr. Carney explains why she changed her position on the value of power poses, concluding that the data gathered by her lab at the time leading to the power poses theory (Psychol Sci. 2010 Oct 21 [10]:1363-8) were real but flimsy. “My views have been updated to reflect the evidence,” she wrote. “As such, I do not believe that ‘power pose’ effects are real.”
In the Vox.com article, Mr. Resnick wrote that intellectual humility is needed for two reasons. “One is that our culture promotes and rewards overconfidence and arrogance. At the same time, when we are wrong – out of ignorance or error – and realize it, our culture doesn’t make it easy to admit it. Humbling moments too easily can turn into moments of humiliation.”
Emergency department visits in the United States climbed by 15% overall from 2006 to 2014. Over the same time period, ED visits by people with mental health issues soared by 44%, according to a report from the Agency for Health Care Research & Quality.
“The extent to which ERs are now flooded with patients with mental illness is unprecedented,” David R. Rubinow, MD, chairman of the department of psychiatry at the University of North Carolina, Chapel Hill, said in an interview with CNN.
This overflow is “having a really destructive effect on health care delivery in general,” Dr. Rubinow said. “There are ERs now that are repeatedly on diversion – which means they can’t see any more patients – because there are so many patients with mental illness or behavioral problems [who] are populating the ER.”
Physicians such as Mark D. Pearlmutter, MD, are convinced that EDs have become the medical refuge for many people with mental illness. “We are the safety net,” said Dr. Pearlmutter, an emergency physician affiliated with Steward Health Care in Brighton, Mass. Dr. Pearlmutter said some patients he has seen in the ED often have dual diagnoses, such as “substance abuse and depression, for example.”
As a result of this situation, patients with psychiatric needs might not receive the care that they really need, and care might be delayed for patients with other life-threatening conditions. “The ER is not a great place if you’re a mental health patient; the cardiac patients get put in front of you, and you could end up being there for a really long time, said David Morris, PhD, a psychologist at the O’Donnell Brain Institute in Dallas.
, Dr. Pearlmutter suggested. After all, increasingly, primary care physicians are providing mental health care.
Twists on New Year’s resolutions
Some people bring in each new year by shifting their perspectives – without making resolutions.
Tim Ferriss, an entrepreneur known for blogs and podcasts on work and life, engages in what he calls “past year reviews,” where accomplishments are tallied frequently throughout the year in terms of their positive or negative effect, with the latter being ruled out for the coming year. Over a few years, he hopes, the list of negatives will shrink and the positive items will increase, according to a post on the NBC News website.
Instead of making resolutions, Oprah Winfrey keeps a journal that is updated nightly with five things that spark gratitude. “I live in the present moment. I try to find the good that’s going on in any given situation,” Ms. Winfrey said in a 2017 interview. The practice has taught her to be careful in her personal wishes.
Melinda Gates starts the new year with a single word to provide guidance. Past examples include “gentle,” “spacious,” and, last year, “grace.” Her selections, she said, have helped her sharpen her focus on the really important aspects of her life.
“[Grace] even helped me find a beam of peace through the sadness of a friend’s funeral. When I was upset or distressed, I whispered to myself: ‘Grace.’ That’s the power of a well-chosen word of the year. It makes the year better – and it helps me be better, too, she wrote in a recent LinkedIn post.
20-somethings facing challenges
A recent article in the Guardian lamented a life that is not progressing as expected.
“I am 25 and a half, single, unable to pay my rent, and the closest thing I own to a car is a broken skateboard,” wrote Juliana Piskorz. “I’m in the throes of a quarter-life crisis.”
Ms. Piskorz, who said she suffers from anxiety attacks, said her experience of this crisis manifests itself by making her want to run away, start all over, or distract herself from reality.
She is not alone. According to LinkedIn, about three-quarters of people aged 25-33 share this kind of insecurity and doubt. Low self-esteem is an important culprit, according to James Arkell, MD, a psychiatrist affiliated with the Nightingale Hospital London. “Very often, 20-somethings I see here are beautiful, talented, and have the world on a plate, but they don’t like themselves and that’s got to be about society making them feel as if they have to keep up with these unrelenting standards.”
There are other reasons for millennial despair, Ms. Piskorz speculated.
“Our childhood visions for our lives ... are no longer realistic,” she wrote. “Due to unaffordable housing, less job security, and lower incomes, the traditional ‘markers’ of adulthood, such as owning a home, getting married, and having children, are being pushed back. This has left a vacuum between our teenage years and late 20s with many of us feeling we’re navigating a no man’s land with zero clue when we’ll reach the other side.”
Seeking optimism, Ms. Piskorz noted that, as a community, millennials share many positive characteristics that should serve them well.
“We are not afraid to talk about how we feel, although we should probably talk more,” she wrote. “We stand up for the causes that we think matter; we are not afraid to try new things, and we are not willing to live a life half lived.”
Apps monitor teen angst, depression
The smartphone, often seen as a tool that fuels angst, might be a resource that could identify teenagers in trouble.
According to an article in the Washington Post, research is underway on smartphone apps that can decipher the digital footprints left by users during their Internet ramblings.
“As teens scroll through Instagram or Snapchat, tap out texts, or watch YouTube videos, they also leave digital footprints that might offer clues to their psychological well-being,” wrote article author Lindsey Tanner, of the Associated Press. “Changes in typing speed, voice tone, word choice, and how often kids stay home could signal trouble.”
“We are tracking the equivalent of a heartbeat for the human brain,” said Alex Leow, MD, PhD, an app developer, and associate professor of psychiatry and bioengineering at the University of Illinois at Chicago.
The technology is not ready for deployment because of technical glitches and, more importantly, ethical issues concerning the recording and scrutiny of a user’s personal data being roadblocks. Still, with the permission of the user, mood-detecting apps might one day be a smartphone feature. “[Users] could withdraw permission at any time, said Nick B. Allen, PhD, a psychologist at the University of Oregon, Portland, who has helped create an app that is being tested on young people who have attempted suicide.
He said the biggest hurdle is figuring out “what’s the signal and what’s the noise – what is in this enormous amount of data that people accumulate on their phone that is indicative of a mental health crisis.”
Virtues of “intellectual humility”
Intellectual humility is neither a character flaw nor a sign of being a pushover.
Instead, wrote science reporter Brian Resnick in an article posted on Vox.com, “it’s a method of thinking. It’s about entertaining the possibility that you may be wrong and being open to learning from the experience of others. Intellectual humility is about being actively curious about your blind spots.”
In an effort to promote intellectual humility in psychology, two researchers, Tal Yarkoni, PhD, and Christopher F. Chabris, PhD, launched the Loss-of-Confidence project. The project is a safe space where researchers who doubt a previous finding in psychology can recalibrate. “I do think it’s a cultural issue that people are not willing to admit mistakes,” said Julia M. Rohrer, a PhD candidate and personality psychologist at the Max Planck Institute for Human Development in Berlin who joined the team in 2017. “Our broader goal is to gently nudge the whole scientific system and psychology toward a different culture where it’s okay, normalized, and expected for researchers to admit past mistakes and not get penalized for it.”
Put another way, the aim is to foster a culture where intellectually humble, honest, and curious people can thrive. For that to occur, “we all, even the smartest among us, need to better appreciate our cognitive blind spots,” Mr. Resnick wrote. “Our minds are more imperfect and imprecise than we’d often like to admit.”
In a recent paper, Ms. Rohrer and her associates said the Loss-of-Confidence project grew out of an online discussion in the wake of a post by Dana R. Carney, PhD, and associates on power poses. In that post, Dr. Carney explains why she changed her position on the value of power poses, concluding that the data gathered by her lab at the time leading to the power poses theory (Psychol Sci. 2010 Oct 21 [10]:1363-8) were real but flimsy. “My views have been updated to reflect the evidence,” she wrote. “As such, I do not believe that ‘power pose’ effects are real.”
In the Vox.com article, Mr. Resnick wrote that intellectual humility is needed for two reasons. “One is that our culture promotes and rewards overconfidence and arrogance. At the same time, when we are wrong – out of ignorance or error – and realize it, our culture doesn’t make it easy to admit it. Humbling moments too easily can turn into moments of humiliation.”
Finding your first job: Tips for picking the right practice
Editor’s Note: This is the second installment of the Private Practice Perspectives column, which is a collaboration between the AGA’s The New Gastroenterologist and the Digestive Health Physicians Association (DHPA). In this issue’s column, David Ramsay (Winston Salem, N.C.) provides valuable advice on the very important topic of picking the right practice.
Bryson W. Katona, MD, PhD
Editor in Chief, The New Gastroenterologist
Just 7 years ago, I faced the same difficult decisions many new gastroenterologists have. Like many physicians coming out of a residency and fellowship program, I had loans to repay and family to consider when evaluating the choices about where I would practice.
Looking back, there were several essential questions that helped guide my decision-making process. If you are early in your career as a GI, here are some questions to ask yourself and tips that I’ve learned along the way that may help make the decision about which practice is right for you.
What do you want to do with your training and skills? This may sound obvious, but it’s important to align your interests with the right practice. Did you receive extra training in endoscopic procedures, such as endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography? Do you want to specialize in inflammatory bowel disease? Have a passion for hepatology? Look for a practice that has those specific opportunities available to match your interests.
In addition, some GI docs want to pursue their interest in research. Keep in mind that many independent practices have research arms and offer physicians the opportunity to continue on this path.
Lastly, consider whether you want to be involved in the business of medicine or take on a leadership role. Many practices offer (and even encourage) those opportunities, and you can winnow down your list of practices based on whether they allow you to take on those roles.
Where do you want to live? My wife and I completed our residencies and fellowships in Washington, but when it came time to find a place to practice medicine, we knew we wanted to be near family. We narrowed our search to Tennessee, Florida, and North Carolina, where we eventually ended up.
Of course, wherever you decide to go is a personal choice. Some people prefer living on the coasts or want to reside in a major city. This might come as a surprise to some, but very often you will command a higher salary in rural areas or smaller cities, which are traditionally underserved by our profession. That starts to matter when you think about paying off your student loan debt.
What is the long-term potential of each position? This is perhaps the most important question to ask. Does your new practice offer ownership potential? Are there opportunities to share in the various (ancillary) revenue streams, such as an ambulatory surgery center, anesthesia, or pathology? How soon might you have the opportunity to buy in and what is the buy in structure and cost? What are the practice rules around offering partnerships?
These are all questions that you should ask up front. Remember that the lifestyle you start out with may change over the course of your career. Find a practice that offers opportunities for growth because your long-term income potential is much more important than your starting salary or size of any sign-on bonus.
Once you’ve decided the answers to some of these questions, here are a few tips to help you land a job at the right medical practice.
Talk to your mentors and tap into your connections: Most GI physicians completing a fellowship will have mentors who have connections to practices. Speak with them about where to look. In addition, most medical societies and state-specific GI societies post classified job listings. Use these professional memberships.
Don’t be afraid of the cold call: If you know where you might want to live, you should consider cold calls to practices in the area to see what opportunities are available. That’s how I found my job. I started calling practices in North Carolina. Those that didn’t have openings knew of, and shared names of, practices in the state that did.
Call the local hospitals and ask to speak to the charge nurse in endoscopy: This is one the best tips I got to help narrow the field. These nurses are a great source of information with honest feedback about the reputation of the local GI practices.
Look for collegiality: This can be harder to spot, but it’s a good sign when the CEOs or practice administrators are engaging and take the time to answer questions.
Look for groups that don’t have a lot of turnover: This is another important sign. We call it the churn and burn: We all know of fellows who have joined a practice where they work long hours but never have the opportunity to make partner. You might ask the question directly: How many physicians have come here and left within the first 5 years of employment? A high turnover rate is a red flag. No matter what type of practice you choose, the key is to look at your long-term prospects, not just at short-term rewards. After all, that’s what will give you the greatest opportunities – and likely make you happiest in your career.
David Ramsay, MD, is treasurer of the Digestive Health Physicians Association. He is President of Digestive Health Specialists in Winston Salem, N.C., which he joined in 2012 after working in the Washington area.
Editor’s Note: This is the second installment of the Private Practice Perspectives column, which is a collaboration between the AGA’s The New Gastroenterologist and the Digestive Health Physicians Association (DHPA). In this issue’s column, David Ramsay (Winston Salem, N.C.) provides valuable advice on the very important topic of picking the right practice.
Bryson W. Katona, MD, PhD
Editor in Chief, The New Gastroenterologist
Just 7 years ago, I faced the same difficult decisions many new gastroenterologists have. Like many physicians coming out of a residency and fellowship program, I had loans to repay and family to consider when evaluating the choices about where I would practice.
Looking back, there were several essential questions that helped guide my decision-making process. If you are early in your career as a GI, here are some questions to ask yourself and tips that I’ve learned along the way that may help make the decision about which practice is right for you.
What do you want to do with your training and skills? This may sound obvious, but it’s important to align your interests with the right practice. Did you receive extra training in endoscopic procedures, such as endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography? Do you want to specialize in inflammatory bowel disease? Have a passion for hepatology? Look for a practice that has those specific opportunities available to match your interests.
In addition, some GI docs want to pursue their interest in research. Keep in mind that many independent practices have research arms and offer physicians the opportunity to continue on this path.
Lastly, consider whether you want to be involved in the business of medicine or take on a leadership role. Many practices offer (and even encourage) those opportunities, and you can winnow down your list of practices based on whether they allow you to take on those roles.
Where do you want to live? My wife and I completed our residencies and fellowships in Washington, but when it came time to find a place to practice medicine, we knew we wanted to be near family. We narrowed our search to Tennessee, Florida, and North Carolina, where we eventually ended up.
Of course, wherever you decide to go is a personal choice. Some people prefer living on the coasts or want to reside in a major city. This might come as a surprise to some, but very often you will command a higher salary in rural areas or smaller cities, which are traditionally underserved by our profession. That starts to matter when you think about paying off your student loan debt.
What is the long-term potential of each position? This is perhaps the most important question to ask. Does your new practice offer ownership potential? Are there opportunities to share in the various (ancillary) revenue streams, such as an ambulatory surgery center, anesthesia, or pathology? How soon might you have the opportunity to buy in and what is the buy in structure and cost? What are the practice rules around offering partnerships?
These are all questions that you should ask up front. Remember that the lifestyle you start out with may change over the course of your career. Find a practice that offers opportunities for growth because your long-term income potential is much more important than your starting salary or size of any sign-on bonus.
Once you’ve decided the answers to some of these questions, here are a few tips to help you land a job at the right medical practice.
Talk to your mentors and tap into your connections: Most GI physicians completing a fellowship will have mentors who have connections to practices. Speak with them about where to look. In addition, most medical societies and state-specific GI societies post classified job listings. Use these professional memberships.
Don’t be afraid of the cold call: If you know where you might want to live, you should consider cold calls to practices in the area to see what opportunities are available. That’s how I found my job. I started calling practices in North Carolina. Those that didn’t have openings knew of, and shared names of, practices in the state that did.
Call the local hospitals and ask to speak to the charge nurse in endoscopy: This is one the best tips I got to help narrow the field. These nurses are a great source of information with honest feedback about the reputation of the local GI practices.
Look for collegiality: This can be harder to spot, but it’s a good sign when the CEOs or practice administrators are engaging and take the time to answer questions.
Look for groups that don’t have a lot of turnover: This is another important sign. We call it the churn and burn: We all know of fellows who have joined a practice where they work long hours but never have the opportunity to make partner. You might ask the question directly: How many physicians have come here and left within the first 5 years of employment? A high turnover rate is a red flag. No matter what type of practice you choose, the key is to look at your long-term prospects, not just at short-term rewards. After all, that’s what will give you the greatest opportunities – and likely make you happiest in your career.
David Ramsay, MD, is treasurer of the Digestive Health Physicians Association. He is President of Digestive Health Specialists in Winston Salem, N.C., which he joined in 2012 after working in the Washington area.
Editor’s Note: This is the second installment of the Private Practice Perspectives column, which is a collaboration between the AGA’s The New Gastroenterologist and the Digestive Health Physicians Association (DHPA). In this issue’s column, David Ramsay (Winston Salem, N.C.) provides valuable advice on the very important topic of picking the right practice.
Bryson W. Katona, MD, PhD
Editor in Chief, The New Gastroenterologist
Just 7 years ago, I faced the same difficult decisions many new gastroenterologists have. Like many physicians coming out of a residency and fellowship program, I had loans to repay and family to consider when evaluating the choices about where I would practice.
Looking back, there were several essential questions that helped guide my decision-making process. If you are early in your career as a GI, here are some questions to ask yourself and tips that I’ve learned along the way that may help make the decision about which practice is right for you.
What do you want to do with your training and skills? This may sound obvious, but it’s important to align your interests with the right practice. Did you receive extra training in endoscopic procedures, such as endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography? Do you want to specialize in inflammatory bowel disease? Have a passion for hepatology? Look for a practice that has those specific opportunities available to match your interests.
In addition, some GI docs want to pursue their interest in research. Keep in mind that many independent practices have research arms and offer physicians the opportunity to continue on this path.
Lastly, consider whether you want to be involved in the business of medicine or take on a leadership role. Many practices offer (and even encourage) those opportunities, and you can winnow down your list of practices based on whether they allow you to take on those roles.
Where do you want to live? My wife and I completed our residencies and fellowships in Washington, but when it came time to find a place to practice medicine, we knew we wanted to be near family. We narrowed our search to Tennessee, Florida, and North Carolina, where we eventually ended up.
Of course, wherever you decide to go is a personal choice. Some people prefer living on the coasts or want to reside in a major city. This might come as a surprise to some, but very often you will command a higher salary in rural areas or smaller cities, which are traditionally underserved by our profession. That starts to matter when you think about paying off your student loan debt.
What is the long-term potential of each position? This is perhaps the most important question to ask. Does your new practice offer ownership potential? Are there opportunities to share in the various (ancillary) revenue streams, such as an ambulatory surgery center, anesthesia, or pathology? How soon might you have the opportunity to buy in and what is the buy in structure and cost? What are the practice rules around offering partnerships?
These are all questions that you should ask up front. Remember that the lifestyle you start out with may change over the course of your career. Find a practice that offers opportunities for growth because your long-term income potential is much more important than your starting salary or size of any sign-on bonus.
Once you’ve decided the answers to some of these questions, here are a few tips to help you land a job at the right medical practice.
Talk to your mentors and tap into your connections: Most GI physicians completing a fellowship will have mentors who have connections to practices. Speak with them about where to look. In addition, most medical societies and state-specific GI societies post classified job listings. Use these professional memberships.
Don’t be afraid of the cold call: If you know where you might want to live, you should consider cold calls to practices in the area to see what opportunities are available. That’s how I found my job. I started calling practices in North Carolina. Those that didn’t have openings knew of, and shared names of, practices in the state that did.
Call the local hospitals and ask to speak to the charge nurse in endoscopy: This is one the best tips I got to help narrow the field. These nurses are a great source of information with honest feedback about the reputation of the local GI practices.
Look for collegiality: This can be harder to spot, but it’s a good sign when the CEOs or practice administrators are engaging and take the time to answer questions.
Look for groups that don’t have a lot of turnover: This is another important sign. We call it the churn and burn: We all know of fellows who have joined a practice where they work long hours but never have the opportunity to make partner. You might ask the question directly: How many physicians have come here and left within the first 5 years of employment? A high turnover rate is a red flag. No matter what type of practice you choose, the key is to look at your long-term prospects, not just at short-term rewards. After all, that’s what will give you the greatest opportunities – and likely make you happiest in your career.
David Ramsay, MD, is treasurer of the Digestive Health Physicians Association. He is President of Digestive Health Specialists in Winston Salem, N.C., which he joined in 2012 after working in the Washington area.
Commentary: Improving transgender education for medical students
Despite clinical practice guidelines,1,2 the lack of informed providers remains the greatest barrier to optimal transgender medical care, notable even with improvement with regard to other barriers to care.3 Barriers accessing appropriate care play a significant role in the persistent health disparities experienced by transgender individuals, such as increased rates of certain cancers, substance abuse, mental health concerns, infections, and chronic diseases.
In the United States, transgender people make up an estimated 0.6% of the population.4 Transgender individuals have unique health needs. However, when surveyed, most members of the medical community report that they are not adequately trained to address those needs.5 There is a need for health care providers to be comfortable treating, as well as versed in the health needs of, transgender patients. Physicians and medical students report having knowledge gaps in transgender health care because of insufficient education and exposure.
For medical students, the Association of American Medical Colleges (AAMC) launched a guide for medical schools in 2014 regarding the integration of LGBT-related curricula. Still, in a survey of 4,262 medical students from 170 medical schools in Canada and the United States, 67% of students rated their LGBT-related curriculum as “very poor,” “poor,” or “fair.”6
Data that are transgender specific are scarce. In a transgender medicine education–specific survey done among 365 Canadian medical students attending English-language medical schools, only 24% of them reported that transgender health was proficiently taught and only 6% reported feeling sufficiently knowledgeable to care for transgender individuals.7 Additionally, a survey among 341 United States medical students at a single institution reported that knowledge of transgender health lagged behind knowledge of other LGB health.8
Park et al. reported on the expanded Boston University School of Medicine (BUSM) transgender medical education model which supplemented the AAMC framework with evidence based, transgender-specific medical–education integrated throughout the medical curriculum.9 Beyond the AAMC-suggested program, first-year BUSM students in physiology learn about the biologic evidence for gender identity.10 In the following year, BUSM students are taught both the classic treatment regimens and monitoring requirements for transgender hormone therapy as part of the standard endocrinology curriculum.11 Following the first 2 years, students reported a significant increase in willingness to care for transgender patients and a 67% decrease in discomfort with providing care to transgender patients.
However, the relative comfort with transgender-specific care still lagged behind the comfort for LGB care in general. In 2014, BUSM expanded its transgender programming further to include an experiential component with a clinical elective for 4th-year medical students.9 The transgender medicine elective included direct patient care experiences with transgender individuals in adult primary care, pediatrics, endocrinology, and surgery. Direct patient contact has been demonstrated to facilitate greater confidence in providing transgender medical care for other medical trainees.12
A mechanism for the national adoption of the BUSM approach should be instituted for all medical schools. Such a move could easily result in a significant improvement in reported comfort among students. After that, the goal should be to leverage opportunities to mandate experiential components in transgender medical education.
While aspects of health care for transgender individuals have improved significantly, education among healthcare providers still lags and remains the largest barrier to care for transgender individuals. With the identified transgender population continuing to expand, the gap remains large in the production and training of sufficient numbers of providers proficient in transgender care. Although data for effectiveness are only short term, several interventions among medical students have been shown to be effective and seem logical to adopt universally.
Dr. Safer is executive director, Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine, New York.
References
1. Coleman E et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. Int J Transgend. 2012;13:165.
2. Hembree WC et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102:3869-903.
3. Safer JD et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016;23:168-71.
4. Flores AR et al. How many adults identify as transgender in the United States? The Williams Institute. 2017 Jun. Los Angeles, Calif. (Accessed on Oct. 30, 2018).
5. Irwig MS. Transgender care by endocrinologists in the United States. Endocr Pract. 2016 Jul;22:832-6.
6. White W et al. Lesbian, gay, bisexual, and transgender patient care: Medical students’ preparedness and comfort. Teach Learn Med. 2015 Jul 9;27:254-63.
7. Chan B et al. Gaps in transgender medicine content identified among Canadian medical school curricula. Transgend Health. 2016 Jul 1;1:142-50.
8. Liang JJ et al. Observed deficiencies in medical student knowledge of transgender and intersex health. Endocr Pract. 2017 Aug;23:897-906.
9. Park JA et al. Clinical exposure to transgender medicine improves students’ preparedness above levels seen with didactic teaching alone: A key addition to the Boston University model for teaching transgender healthcare. Transgend Health. 2018 Jan 1;3:10-6.
10. Eriksson SE et al. Evidence-based curricular content improves student knowledge and changes attitudes towards transgender medicine. Endocr Pract. 2016 Jul;22:837-41.
11. Safer JD et al. A simple curriculum content change increased medical student comfort with transgender medicine. Endocr Pract. 2013 Jul-Aug;19:633-7.
12. Morrison SD et al. Transgender-related education in plastic surgery and urology residency programs. J Grad Med Educ. 2017 Apr;9:178-83.
Despite clinical practice guidelines,1,2 the lack of informed providers remains the greatest barrier to optimal transgender medical care, notable even with improvement with regard to other barriers to care.3 Barriers accessing appropriate care play a significant role in the persistent health disparities experienced by transgender individuals, such as increased rates of certain cancers, substance abuse, mental health concerns, infections, and chronic diseases.
In the United States, transgender people make up an estimated 0.6% of the population.4 Transgender individuals have unique health needs. However, when surveyed, most members of the medical community report that they are not adequately trained to address those needs.5 There is a need for health care providers to be comfortable treating, as well as versed in the health needs of, transgender patients. Physicians and medical students report having knowledge gaps in transgender health care because of insufficient education and exposure.
For medical students, the Association of American Medical Colleges (AAMC) launched a guide for medical schools in 2014 regarding the integration of LGBT-related curricula. Still, in a survey of 4,262 medical students from 170 medical schools in Canada and the United States, 67% of students rated their LGBT-related curriculum as “very poor,” “poor,” or “fair.”6
Data that are transgender specific are scarce. In a transgender medicine education–specific survey done among 365 Canadian medical students attending English-language medical schools, only 24% of them reported that transgender health was proficiently taught and only 6% reported feeling sufficiently knowledgeable to care for transgender individuals.7 Additionally, a survey among 341 United States medical students at a single institution reported that knowledge of transgender health lagged behind knowledge of other LGB health.8
Park et al. reported on the expanded Boston University School of Medicine (BUSM) transgender medical education model which supplemented the AAMC framework with evidence based, transgender-specific medical–education integrated throughout the medical curriculum.9 Beyond the AAMC-suggested program, first-year BUSM students in physiology learn about the biologic evidence for gender identity.10 In the following year, BUSM students are taught both the classic treatment regimens and monitoring requirements for transgender hormone therapy as part of the standard endocrinology curriculum.11 Following the first 2 years, students reported a significant increase in willingness to care for transgender patients and a 67% decrease in discomfort with providing care to transgender patients.
However, the relative comfort with transgender-specific care still lagged behind the comfort for LGB care in general. In 2014, BUSM expanded its transgender programming further to include an experiential component with a clinical elective for 4th-year medical students.9 The transgender medicine elective included direct patient care experiences with transgender individuals in adult primary care, pediatrics, endocrinology, and surgery. Direct patient contact has been demonstrated to facilitate greater confidence in providing transgender medical care for other medical trainees.12
A mechanism for the national adoption of the BUSM approach should be instituted for all medical schools. Such a move could easily result in a significant improvement in reported comfort among students. After that, the goal should be to leverage opportunities to mandate experiential components in transgender medical education.
While aspects of health care for transgender individuals have improved significantly, education among healthcare providers still lags and remains the largest barrier to care for transgender individuals. With the identified transgender population continuing to expand, the gap remains large in the production and training of sufficient numbers of providers proficient in transgender care. Although data for effectiveness are only short term, several interventions among medical students have been shown to be effective and seem logical to adopt universally.
Dr. Safer is executive director, Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine, New York.
References
1. Coleman E et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. Int J Transgend. 2012;13:165.
2. Hembree WC et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102:3869-903.
3. Safer JD et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016;23:168-71.
4. Flores AR et al. How many adults identify as transgender in the United States? The Williams Institute. 2017 Jun. Los Angeles, Calif. (Accessed on Oct. 30, 2018).
5. Irwig MS. Transgender care by endocrinologists in the United States. Endocr Pract. 2016 Jul;22:832-6.
6. White W et al. Lesbian, gay, bisexual, and transgender patient care: Medical students’ preparedness and comfort. Teach Learn Med. 2015 Jul 9;27:254-63.
7. Chan B et al. Gaps in transgender medicine content identified among Canadian medical school curricula. Transgend Health. 2016 Jul 1;1:142-50.
8. Liang JJ et al. Observed deficiencies in medical student knowledge of transgender and intersex health. Endocr Pract. 2017 Aug;23:897-906.
9. Park JA et al. Clinical exposure to transgender medicine improves students’ preparedness above levels seen with didactic teaching alone: A key addition to the Boston University model for teaching transgender healthcare. Transgend Health. 2018 Jan 1;3:10-6.
10. Eriksson SE et al. Evidence-based curricular content improves student knowledge and changes attitudes towards transgender medicine. Endocr Pract. 2016 Jul;22:837-41.
11. Safer JD et al. A simple curriculum content change increased medical student comfort with transgender medicine. Endocr Pract. 2013 Jul-Aug;19:633-7.
12. Morrison SD et al. Transgender-related education in plastic surgery and urology residency programs. J Grad Med Educ. 2017 Apr;9:178-83.
Despite clinical practice guidelines,1,2 the lack of informed providers remains the greatest barrier to optimal transgender medical care, notable even with improvement with regard to other barriers to care.3 Barriers accessing appropriate care play a significant role in the persistent health disparities experienced by transgender individuals, such as increased rates of certain cancers, substance abuse, mental health concerns, infections, and chronic diseases.
In the United States, transgender people make up an estimated 0.6% of the population.4 Transgender individuals have unique health needs. However, when surveyed, most members of the medical community report that they are not adequately trained to address those needs.5 There is a need for health care providers to be comfortable treating, as well as versed in the health needs of, transgender patients. Physicians and medical students report having knowledge gaps in transgender health care because of insufficient education and exposure.
For medical students, the Association of American Medical Colleges (AAMC) launched a guide for medical schools in 2014 regarding the integration of LGBT-related curricula. Still, in a survey of 4,262 medical students from 170 medical schools in Canada and the United States, 67% of students rated their LGBT-related curriculum as “very poor,” “poor,” or “fair.”6
Data that are transgender specific are scarce. In a transgender medicine education–specific survey done among 365 Canadian medical students attending English-language medical schools, only 24% of them reported that transgender health was proficiently taught and only 6% reported feeling sufficiently knowledgeable to care for transgender individuals.7 Additionally, a survey among 341 United States medical students at a single institution reported that knowledge of transgender health lagged behind knowledge of other LGB health.8
Park et al. reported on the expanded Boston University School of Medicine (BUSM) transgender medical education model which supplemented the AAMC framework with evidence based, transgender-specific medical–education integrated throughout the medical curriculum.9 Beyond the AAMC-suggested program, first-year BUSM students in physiology learn about the biologic evidence for gender identity.10 In the following year, BUSM students are taught both the classic treatment regimens and monitoring requirements for transgender hormone therapy as part of the standard endocrinology curriculum.11 Following the first 2 years, students reported a significant increase in willingness to care for transgender patients and a 67% decrease in discomfort with providing care to transgender patients.
However, the relative comfort with transgender-specific care still lagged behind the comfort for LGB care in general. In 2014, BUSM expanded its transgender programming further to include an experiential component with a clinical elective for 4th-year medical students.9 The transgender medicine elective included direct patient care experiences with transgender individuals in adult primary care, pediatrics, endocrinology, and surgery. Direct patient contact has been demonstrated to facilitate greater confidence in providing transgender medical care for other medical trainees.12
A mechanism for the national adoption of the BUSM approach should be instituted for all medical schools. Such a move could easily result in a significant improvement in reported comfort among students. After that, the goal should be to leverage opportunities to mandate experiential components in transgender medical education.
While aspects of health care for transgender individuals have improved significantly, education among healthcare providers still lags and remains the largest barrier to care for transgender individuals. With the identified transgender population continuing to expand, the gap remains large in the production and training of sufficient numbers of providers proficient in transgender care. Although data for effectiveness are only short term, several interventions among medical students have been shown to be effective and seem logical to adopt universally.
Dr. Safer is executive director, Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine, New York.
References
1. Coleman E et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. Int J Transgend. 2012;13:165.
2. Hembree WC et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102:3869-903.
3. Safer JD et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016;23:168-71.
4. Flores AR et al. How many adults identify as transgender in the United States? The Williams Institute. 2017 Jun. Los Angeles, Calif. (Accessed on Oct. 30, 2018).
5. Irwig MS. Transgender care by endocrinologists in the United States. Endocr Pract. 2016 Jul;22:832-6.
6. White W et al. Lesbian, gay, bisexual, and transgender patient care: Medical students’ preparedness and comfort. Teach Learn Med. 2015 Jul 9;27:254-63.
7. Chan B et al. Gaps in transgender medicine content identified among Canadian medical school curricula. Transgend Health. 2016 Jul 1;1:142-50.
8. Liang JJ et al. Observed deficiencies in medical student knowledge of transgender and intersex health. Endocr Pract. 2017 Aug;23:897-906.
9. Park JA et al. Clinical exposure to transgender medicine improves students’ preparedness above levels seen with didactic teaching alone: A key addition to the Boston University model for teaching transgender healthcare. Transgend Health. 2018 Jan 1;3:10-6.
10. Eriksson SE et al. Evidence-based curricular content improves student knowledge and changes attitudes towards transgender medicine. Endocr Pract. 2016 Jul;22:837-41.
11. Safer JD et al. A simple curriculum content change increased medical student comfort with transgender medicine. Endocr Pract. 2013 Jul-Aug;19:633-7.
12. Morrison SD et al. Transgender-related education in plastic surgery and urology residency programs. J Grad Med Educ. 2017 Apr;9:178-83.
Liquid nicotine in e-cigarettes could prove more addictive; gratitude tied to less anxiety, depression
The image of inhaling the vapor from electronic cigarettes – vaping – is presented by some as an innocuous substitute to smoking traditional cigarettes. It is true that vaping might pose less danger than cigarettes and can wean people off smoking,
“Oh man, [withdrawal] was hell,” said Andrea “Nick” Tattanelli, a 39-year-old mortgage banker who reported engaging in vaping for more than 20 years, in a USA Today article. Mr. Tattanelli said quitting left him depressed.
Malissa M. Barbosa, DO, an addiction medicine specialist, wonders whether vaping is the best way to get patients to stop smoking. “The thing is, the studies aren’t fully available around vaping, and I’m very conservative. This is new, and I say, ‘Why aren’t we thinking of traditional means of quitting?’ ”
Vaping is more addictive than smoking traditional cigarettes “because the concentrated liquid form is more quickly metabolized,” said Dr. Barbosa, area medical director of CleanSlate Outpatient Addiction Medicine in Orlando.
And as the number of vapers grows, evidence is mounting that, rather than using it as a stepping stone to becoming nicotine-free, vaping is increasingly being used by adolescents as a form of delivering nicotine.
“We know how hard it is to quit smoking,” said Michael J. Blaha, MD, MPH, a cardiologist who serves as director of clinical research at the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins University, Baltimore. “[With vaping], we’re really dealing with much of the same problem. Early on, there were some reports vaping was less addictive, but that’s still something that can be debated.”
In the United States, vapers include nearly 4 million middle and high school students. Surgeon General Jerome M. Adams, MD, MPH, has suggested raising prices as a strategy aimed at curbing adolescent use.
Impact of gratitude on the brain
The beginning of a new year can be a time for reflection that can include a sense of gratitude for a relatively happy and secure life. And, according to an article at theconversation.com, the ability to have a sense of gratitude is good for well-being.
“Not only does gratitude go along with more optimism, less anxiety and depression, and greater goal attainment, but it’s also associated with fewer symptoms of illness and other physical benefits;” wrote Christina Karns, PhD, research associate in psychology at the University of Oregon, Portland.
A feeling of gratitude stimulates a part of the brain that controls the release of neurochemicals that confer pleasure. The benefits of gratitude aren’t just between the ears. Feeling gratitude can motivate people to pay it forward as altruistic behavior that helps others. Put another way, feeling good about life can trigger kindness.
Research by Dr. Karns and her colleagues also has demonstrated that this link between personal good feeling and altruism can be learned and accentuated. “So in terms of the brain’s reward response, it really can be true that giving is better than receiving,” wrote Dr. Karns, who also is affiliated with the Center for Brain Injury Research and Training at the university.
Imagine if the recipients of such goodwill, in turn, did some good for others, and they for others, and so on.
Did talk radio host save a life?
Talk radio can be filled with acrimony and argument – but it also can save lives. As reported in the Guardian, a show hosted by British TV and radio personality Iain Lee is different in that Mr. Lee sometimes connects with his audience by riffing on his own struggles with depression. A recent show extended the audience connection in a lifesaving way.
Mr. Lee received a call from a listener who reported overdosing on drugs with the intent of suicide. In hearing of that intent, Mr. Lee kept the caller on the line for 30 minutes. At one point, he responded: “Shut up, man, I know you want to die, brother, but I love you. I love you. You may want to die, but we can talk about that tomorrow.”
The response got through to the caller, who reportedly lay on the pavement outside a nightclub. Meanwhile, the call was being traced, and emergency medical personnel responded.
When Mr. Lee learned that the caller had been located and was still alive, he broke down on air. Later, he tweeted: “Tonight we took a call from a man who had taken an overdose … Long periods of silence where I thought he’d died. That was intense and upsetting. Thanks for your kind words. I really hope he makes it.”
A trip to Walmart can include therapy
A Walmart in Carrollton, Tex., is trying out a new service for customers: It is including an on-site mental health clinic. As reported by the Dallas Morning News, the idea is to make mental health care convenient and bring people who otherwise might forgo help through the clinic door.
“Twenty years ago, we would never imagine going to a retail location for a flu shot. You’d make an appointment with your primary care,” said Russell Petrella, chief executive of Beacon Health Options, which runs the in-store clinic. “The idea of bringing these services to places where consumers – potential patients – are more comfortable is getting more and more accepted.”
Initially, therapy was $25 for a 45-minute session with an individual or family. Prices will rise to $110 for an individual and $125 for a family early in this year. Lower prices are available for people who demonstrate a financial need.
The location for this trial run was deliberate. Texas has a disproportionately large number of residents without mental health care, ranking 49th in the nation, according to a 2018 report by Mental Health America.
Greg Hansch, public policy director of the National Alliance on Mental Illness in Texas, said he is encouraged by novel types of care like the Walmart clinic. He would like to see further integration of mental health care into schools, workplaces, and other retailers. “You remove some of that stigma if you can make services part of a person’s everyday routine,” he said.
Smartphones and the teenage brain
The explosion in smartphone use since 2012 has coincided with increased rates of depression in adolescents. Reduced sleep might be one reason. Teenagers in the United States routinely rack up 6 hours a day on social media, which includes texting and other online activities. “For teens in particular, it’s catnip,” said Jean M. Twenge, PhD, professor of psychology at San Diego State University and author of “I-Gen: Why Today’s Super-Connected Kids Are Growing Up Less Rebellious, More Tolerant, Less Happy – and Completely Unprepared for Adulthood” (Atria Books, 2017).
A smartphone is no substitute for face-to-face interactions, and offers little training in verbal communication and problem solving. A consequence of a smartphone-connected youth, according to Dr. Twenge, could be worsened mental health.
But there is some good news. Some teens are working to curb their smartphone use. Stopping the use of a smartphone as a relief for boredom, setting self-imposed time limits of phone use, and not succumbing to the wired world’s tendency to ratchet up anxiety are helpful strategies that can make smartphone use more productive.
The image of inhaling the vapor from electronic cigarettes – vaping – is presented by some as an innocuous substitute to smoking traditional cigarettes. It is true that vaping might pose less danger than cigarettes and can wean people off smoking,
“Oh man, [withdrawal] was hell,” said Andrea “Nick” Tattanelli, a 39-year-old mortgage banker who reported engaging in vaping for more than 20 years, in a USA Today article. Mr. Tattanelli said quitting left him depressed.
Malissa M. Barbosa, DO, an addiction medicine specialist, wonders whether vaping is the best way to get patients to stop smoking. “The thing is, the studies aren’t fully available around vaping, and I’m very conservative. This is new, and I say, ‘Why aren’t we thinking of traditional means of quitting?’ ”
Vaping is more addictive than smoking traditional cigarettes “because the concentrated liquid form is more quickly metabolized,” said Dr. Barbosa, area medical director of CleanSlate Outpatient Addiction Medicine in Orlando.
And as the number of vapers grows, evidence is mounting that, rather than using it as a stepping stone to becoming nicotine-free, vaping is increasingly being used by adolescents as a form of delivering nicotine.
“We know how hard it is to quit smoking,” said Michael J. Blaha, MD, MPH, a cardiologist who serves as director of clinical research at the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins University, Baltimore. “[With vaping], we’re really dealing with much of the same problem. Early on, there were some reports vaping was less addictive, but that’s still something that can be debated.”
In the United States, vapers include nearly 4 million middle and high school students. Surgeon General Jerome M. Adams, MD, MPH, has suggested raising prices as a strategy aimed at curbing adolescent use.
Impact of gratitude on the brain
The beginning of a new year can be a time for reflection that can include a sense of gratitude for a relatively happy and secure life. And, according to an article at theconversation.com, the ability to have a sense of gratitude is good for well-being.
“Not only does gratitude go along with more optimism, less anxiety and depression, and greater goal attainment, but it’s also associated with fewer symptoms of illness and other physical benefits;” wrote Christina Karns, PhD, research associate in psychology at the University of Oregon, Portland.
A feeling of gratitude stimulates a part of the brain that controls the release of neurochemicals that confer pleasure. The benefits of gratitude aren’t just between the ears. Feeling gratitude can motivate people to pay it forward as altruistic behavior that helps others. Put another way, feeling good about life can trigger kindness.
Research by Dr. Karns and her colleagues also has demonstrated that this link between personal good feeling and altruism can be learned and accentuated. “So in terms of the brain’s reward response, it really can be true that giving is better than receiving,” wrote Dr. Karns, who also is affiliated with the Center for Brain Injury Research and Training at the university.
Imagine if the recipients of such goodwill, in turn, did some good for others, and they for others, and so on.
Did talk radio host save a life?
Talk radio can be filled with acrimony and argument – but it also can save lives. As reported in the Guardian, a show hosted by British TV and radio personality Iain Lee is different in that Mr. Lee sometimes connects with his audience by riffing on his own struggles with depression. A recent show extended the audience connection in a lifesaving way.
Mr. Lee received a call from a listener who reported overdosing on drugs with the intent of suicide. In hearing of that intent, Mr. Lee kept the caller on the line for 30 minutes. At one point, he responded: “Shut up, man, I know you want to die, brother, but I love you. I love you. You may want to die, but we can talk about that tomorrow.”
The response got through to the caller, who reportedly lay on the pavement outside a nightclub. Meanwhile, the call was being traced, and emergency medical personnel responded.
When Mr. Lee learned that the caller had been located and was still alive, he broke down on air. Later, he tweeted: “Tonight we took a call from a man who had taken an overdose … Long periods of silence where I thought he’d died. That was intense and upsetting. Thanks for your kind words. I really hope he makes it.”
A trip to Walmart can include therapy
A Walmart in Carrollton, Tex., is trying out a new service for customers: It is including an on-site mental health clinic. As reported by the Dallas Morning News, the idea is to make mental health care convenient and bring people who otherwise might forgo help through the clinic door.
“Twenty years ago, we would never imagine going to a retail location for a flu shot. You’d make an appointment with your primary care,” said Russell Petrella, chief executive of Beacon Health Options, which runs the in-store clinic. “The idea of bringing these services to places where consumers – potential patients – are more comfortable is getting more and more accepted.”
Initially, therapy was $25 for a 45-minute session with an individual or family. Prices will rise to $110 for an individual and $125 for a family early in this year. Lower prices are available for people who demonstrate a financial need.
The location for this trial run was deliberate. Texas has a disproportionately large number of residents without mental health care, ranking 49th in the nation, according to a 2018 report by Mental Health America.
Greg Hansch, public policy director of the National Alliance on Mental Illness in Texas, said he is encouraged by novel types of care like the Walmart clinic. He would like to see further integration of mental health care into schools, workplaces, and other retailers. “You remove some of that stigma if you can make services part of a person’s everyday routine,” he said.
Smartphones and the teenage brain
The explosion in smartphone use since 2012 has coincided with increased rates of depression in adolescents. Reduced sleep might be one reason. Teenagers in the United States routinely rack up 6 hours a day on social media, which includes texting and other online activities. “For teens in particular, it’s catnip,” said Jean M. Twenge, PhD, professor of psychology at San Diego State University and author of “I-Gen: Why Today’s Super-Connected Kids Are Growing Up Less Rebellious, More Tolerant, Less Happy – and Completely Unprepared for Adulthood” (Atria Books, 2017).
A smartphone is no substitute for face-to-face interactions, and offers little training in verbal communication and problem solving. A consequence of a smartphone-connected youth, according to Dr. Twenge, could be worsened mental health.
But there is some good news. Some teens are working to curb their smartphone use. Stopping the use of a smartphone as a relief for boredom, setting self-imposed time limits of phone use, and not succumbing to the wired world’s tendency to ratchet up anxiety are helpful strategies that can make smartphone use more productive.
The image of inhaling the vapor from electronic cigarettes – vaping – is presented by some as an innocuous substitute to smoking traditional cigarettes. It is true that vaping might pose less danger than cigarettes and can wean people off smoking,
“Oh man, [withdrawal] was hell,” said Andrea “Nick” Tattanelli, a 39-year-old mortgage banker who reported engaging in vaping for more than 20 years, in a USA Today article. Mr. Tattanelli said quitting left him depressed.
Malissa M. Barbosa, DO, an addiction medicine specialist, wonders whether vaping is the best way to get patients to stop smoking. “The thing is, the studies aren’t fully available around vaping, and I’m very conservative. This is new, and I say, ‘Why aren’t we thinking of traditional means of quitting?’ ”
Vaping is more addictive than smoking traditional cigarettes “because the concentrated liquid form is more quickly metabolized,” said Dr. Barbosa, area medical director of CleanSlate Outpatient Addiction Medicine in Orlando.
And as the number of vapers grows, evidence is mounting that, rather than using it as a stepping stone to becoming nicotine-free, vaping is increasingly being used by adolescents as a form of delivering nicotine.
“We know how hard it is to quit smoking,” said Michael J. Blaha, MD, MPH, a cardiologist who serves as director of clinical research at the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins University, Baltimore. “[With vaping], we’re really dealing with much of the same problem. Early on, there were some reports vaping was less addictive, but that’s still something that can be debated.”
In the United States, vapers include nearly 4 million middle and high school students. Surgeon General Jerome M. Adams, MD, MPH, has suggested raising prices as a strategy aimed at curbing adolescent use.
Impact of gratitude on the brain
The beginning of a new year can be a time for reflection that can include a sense of gratitude for a relatively happy and secure life. And, according to an article at theconversation.com, the ability to have a sense of gratitude is good for well-being.
“Not only does gratitude go along with more optimism, less anxiety and depression, and greater goal attainment, but it’s also associated with fewer symptoms of illness and other physical benefits;” wrote Christina Karns, PhD, research associate in psychology at the University of Oregon, Portland.
A feeling of gratitude stimulates a part of the brain that controls the release of neurochemicals that confer pleasure. The benefits of gratitude aren’t just between the ears. Feeling gratitude can motivate people to pay it forward as altruistic behavior that helps others. Put another way, feeling good about life can trigger kindness.
Research by Dr. Karns and her colleagues also has demonstrated that this link between personal good feeling and altruism can be learned and accentuated. “So in terms of the brain’s reward response, it really can be true that giving is better than receiving,” wrote Dr. Karns, who also is affiliated with the Center for Brain Injury Research and Training at the university.
Imagine if the recipients of such goodwill, in turn, did some good for others, and they for others, and so on.
Did talk radio host save a life?
Talk radio can be filled with acrimony and argument – but it also can save lives. As reported in the Guardian, a show hosted by British TV and radio personality Iain Lee is different in that Mr. Lee sometimes connects with his audience by riffing on his own struggles with depression. A recent show extended the audience connection in a lifesaving way.
Mr. Lee received a call from a listener who reported overdosing on drugs with the intent of suicide. In hearing of that intent, Mr. Lee kept the caller on the line for 30 minutes. At one point, he responded: “Shut up, man, I know you want to die, brother, but I love you. I love you. You may want to die, but we can talk about that tomorrow.”
The response got through to the caller, who reportedly lay on the pavement outside a nightclub. Meanwhile, the call was being traced, and emergency medical personnel responded.
When Mr. Lee learned that the caller had been located and was still alive, he broke down on air. Later, he tweeted: “Tonight we took a call from a man who had taken an overdose … Long periods of silence where I thought he’d died. That was intense and upsetting. Thanks for your kind words. I really hope he makes it.”
A trip to Walmart can include therapy
A Walmart in Carrollton, Tex., is trying out a new service for customers: It is including an on-site mental health clinic. As reported by the Dallas Morning News, the idea is to make mental health care convenient and bring people who otherwise might forgo help through the clinic door.
“Twenty years ago, we would never imagine going to a retail location for a flu shot. You’d make an appointment with your primary care,” said Russell Petrella, chief executive of Beacon Health Options, which runs the in-store clinic. “The idea of bringing these services to places where consumers – potential patients – are more comfortable is getting more and more accepted.”
Initially, therapy was $25 for a 45-minute session with an individual or family. Prices will rise to $110 for an individual and $125 for a family early in this year. Lower prices are available for people who demonstrate a financial need.
The location for this trial run was deliberate. Texas has a disproportionately large number of residents without mental health care, ranking 49th in the nation, according to a 2018 report by Mental Health America.
Greg Hansch, public policy director of the National Alliance on Mental Illness in Texas, said he is encouraged by novel types of care like the Walmart clinic. He would like to see further integration of mental health care into schools, workplaces, and other retailers. “You remove some of that stigma if you can make services part of a person’s everyday routine,” he said.
Smartphones and the teenage brain
The explosion in smartphone use since 2012 has coincided with increased rates of depression in adolescents. Reduced sleep might be one reason. Teenagers in the United States routinely rack up 6 hours a day on social media, which includes texting and other online activities. “For teens in particular, it’s catnip,” said Jean M. Twenge, PhD, professor of psychology at San Diego State University and author of “I-Gen: Why Today’s Super-Connected Kids Are Growing Up Less Rebellious, More Tolerant, Less Happy – and Completely Unprepared for Adulthood” (Atria Books, 2017).
A smartphone is no substitute for face-to-face interactions, and offers little training in verbal communication and problem solving. A consequence of a smartphone-connected youth, according to Dr. Twenge, could be worsened mental health.
But there is some good news. Some teens are working to curb their smartphone use. Stopping the use of a smartphone as a relief for boredom, setting self-imposed time limits of phone use, and not succumbing to the wired world’s tendency to ratchet up anxiety are helpful strategies that can make smartphone use more productive.
Martin Buber, deep learning, and the still soft voice beyond the screen
Life is short, art long, opportunity fleeting. – Hippocrates
The new year provides an opportunity to reflect on old things: to decide what to keep and what to toss out, to contemplate the habits to which we choose to rededicate ourselves, and those we choose to let wane. Over the last few years, while some older physicians have expressed a yearning for the comfort of paper charts, most of us have come to embrace the benefits of the electronic health record. That is a good thing. The EHR offers many advantages over paper, and, like it or not, it’s here to stay.
The other day I was working with a resident, admitting a patient to a nursing home. I handed her the inch-thick stack of papers that came from the hospital, and she immediately asked what we were supposed to do with it. When I explained that it was the hospital chart, she wondered aloud how she was supposed to navigate to the different sections in order to review the information. I was stupefied but understood the reason behind her question. The way we document has changed so dramatically over just the past decade. Unfortunately, without intention, the way that we chart has affected the way we relate to patients.
In 1923, the German philosopher Martin Buber published the book for which he is best known, “I and Thou.” In that book Buber says that there are two ways we can approach relationships: “I-Thou” or “I-It.” In I-It relationships, we view the other person as an “it” to be used to accomplish a purpose or to be experienced without his or her full involvement. In an I-Thou relationship, we appreciate the other person for all their complexity, in their full humanness. We acknowledge and approach the person as a unique individual who has dreams, goals, fears, and wishes that may be different than ours but to which we can still relate.
While the importance and benefits of the electronic record are clear, we must constantly remind ourselves that the EHR is a tool of care and not the goal of care. While the people we see have health needs that must be diagnosed, treated, and recorded, and their illnesses are an important part of their being, they do not define their being. Nor should they define our relationship with them. Patients agree; when surveyed about the attributes of a good physician, they regularly respond that they want their physicians to have a sense of them as people, not just patients.
Recently, I was reminded of the challenge of keeping this simple task in the forefront of care while on hospital service. I had occasion to sit and talk with one of my patients without a computer in the room. This was unusual for me, as I typically fill out the EHR as I am seeing the patient. As I listened to the individual in his gown, lying on his hospital bed and describing the symptoms that brought him to the hospital, I was reminded of the subtle pauses and nuances that occur during focused conversations, during deep listening.
We have written in previous columns about exciting applications of technology that are in the pipeline. Artificial intelligence with “deep learning” is predicted to change the way we diagnose and treat disease. Deep learning is a term that has been used to describe a type of machine analysis where data are interpreted and analyzed in layers, allowing the computer to detect patterns. In the first layer of learning, the computer may identify the way pixels of the same color form a line or a curve. In the next layer it might detect the way that curve resembles a face. Peeling away layer after layer, the computer might eventually recognize whose face is being represented. This is the type of programing that has allowed computers to interpret mammograms and retina scans, detecting patterns that represent cancer or small retinal hemorrhages. While deep learning will be the subject of much excitement over the next few years, at the start of this new year we think it is equally important be reminded of an essential quality of the excellent physician – deep listening.
Deep listening requires a lifetime of practice. We have all experienced it, both as listeners and as those being listened to. When we are in the presence of someone who is truly interested in what we are saying – in our story and in our life – we feel reaffirmed and refreshed. Regardless of the topic of our discussion, we feel a sense of trust, for we believe that the person with whom we are speaking understands us, and, in that understanding, cares about us. We have a sense that we could trust the listener with our lives.
A lifetime of practice – that is the promise of our jobs as physicians. Every time we enter the exam room we have the opportunity to carry out the sacred skill of hearing others, while trying in some way to improve their lives. With each visit we have the opportunity to perfect our craft. Chaucer, the medieval English poet, observed, “the life so short, the craft so long to learn.” It seems he borrowed that idea from a physician, Hippocrates.
Hippocrates opened his medical text with the words, “Vita brevis, ars longa, occasio praeceps,” which means, “Life is short, the art long, opportunity fleeting.” Hippocrates recognized the challenge involved in learning all that is necessary to take care of our fellow man. This challenge has only become more difficult as the quantity of information required to practice competent medicine has increased. In addition, we now need to record data into the EHR to be used for record keeping, billing, and the further advancement of knowledge. Hippocrates’ medical text continued, “The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.”
On the occasion of this New Year, it is a perfect time to reflect and rededicate ourselves to listening to our patients, to being interested in them and their stories. We just may find that in deep listening, and in the trust that comes from that singular focus, lie solutions to many of the largest problems we face in medicine today: burnout, poor adherence, and regaining the moral authority that comes with truly caring for those in need.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington Jefferson Health. Follow him on twitter (@doctornotte).
Life is short, art long, opportunity fleeting. – Hippocrates
The new year provides an opportunity to reflect on old things: to decide what to keep and what to toss out, to contemplate the habits to which we choose to rededicate ourselves, and those we choose to let wane. Over the last few years, while some older physicians have expressed a yearning for the comfort of paper charts, most of us have come to embrace the benefits of the electronic health record. That is a good thing. The EHR offers many advantages over paper, and, like it or not, it’s here to stay.
The other day I was working with a resident, admitting a patient to a nursing home. I handed her the inch-thick stack of papers that came from the hospital, and she immediately asked what we were supposed to do with it. When I explained that it was the hospital chart, she wondered aloud how she was supposed to navigate to the different sections in order to review the information. I was stupefied but understood the reason behind her question. The way we document has changed so dramatically over just the past decade. Unfortunately, without intention, the way that we chart has affected the way we relate to patients.
In 1923, the German philosopher Martin Buber published the book for which he is best known, “I and Thou.” In that book Buber says that there are two ways we can approach relationships: “I-Thou” or “I-It.” In I-It relationships, we view the other person as an “it” to be used to accomplish a purpose or to be experienced without his or her full involvement. In an I-Thou relationship, we appreciate the other person for all their complexity, in their full humanness. We acknowledge and approach the person as a unique individual who has dreams, goals, fears, and wishes that may be different than ours but to which we can still relate.
While the importance and benefits of the electronic record are clear, we must constantly remind ourselves that the EHR is a tool of care and not the goal of care. While the people we see have health needs that must be diagnosed, treated, and recorded, and their illnesses are an important part of their being, they do not define their being. Nor should they define our relationship with them. Patients agree; when surveyed about the attributes of a good physician, they regularly respond that they want their physicians to have a sense of them as people, not just patients.
Recently, I was reminded of the challenge of keeping this simple task in the forefront of care while on hospital service. I had occasion to sit and talk with one of my patients without a computer in the room. This was unusual for me, as I typically fill out the EHR as I am seeing the patient. As I listened to the individual in his gown, lying on his hospital bed and describing the symptoms that brought him to the hospital, I was reminded of the subtle pauses and nuances that occur during focused conversations, during deep listening.
We have written in previous columns about exciting applications of technology that are in the pipeline. Artificial intelligence with “deep learning” is predicted to change the way we diagnose and treat disease. Deep learning is a term that has been used to describe a type of machine analysis where data are interpreted and analyzed in layers, allowing the computer to detect patterns. In the first layer of learning, the computer may identify the way pixels of the same color form a line or a curve. In the next layer it might detect the way that curve resembles a face. Peeling away layer after layer, the computer might eventually recognize whose face is being represented. This is the type of programing that has allowed computers to interpret mammograms and retina scans, detecting patterns that represent cancer or small retinal hemorrhages. While deep learning will be the subject of much excitement over the next few years, at the start of this new year we think it is equally important be reminded of an essential quality of the excellent physician – deep listening.
Deep listening requires a lifetime of practice. We have all experienced it, both as listeners and as those being listened to. When we are in the presence of someone who is truly interested in what we are saying – in our story and in our life – we feel reaffirmed and refreshed. Regardless of the topic of our discussion, we feel a sense of trust, for we believe that the person with whom we are speaking understands us, and, in that understanding, cares about us. We have a sense that we could trust the listener with our lives.
A lifetime of practice – that is the promise of our jobs as physicians. Every time we enter the exam room we have the opportunity to carry out the sacred skill of hearing others, while trying in some way to improve their lives. With each visit we have the opportunity to perfect our craft. Chaucer, the medieval English poet, observed, “the life so short, the craft so long to learn.” It seems he borrowed that idea from a physician, Hippocrates.
Hippocrates opened his medical text with the words, “Vita brevis, ars longa, occasio praeceps,” which means, “Life is short, the art long, opportunity fleeting.” Hippocrates recognized the challenge involved in learning all that is necessary to take care of our fellow man. This challenge has only become more difficult as the quantity of information required to practice competent medicine has increased. In addition, we now need to record data into the EHR to be used for record keeping, billing, and the further advancement of knowledge. Hippocrates’ medical text continued, “The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.”
On the occasion of this New Year, it is a perfect time to reflect and rededicate ourselves to listening to our patients, to being interested in them and their stories. We just may find that in deep listening, and in the trust that comes from that singular focus, lie solutions to many of the largest problems we face in medicine today: burnout, poor adherence, and regaining the moral authority that comes with truly caring for those in need.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington Jefferson Health. Follow him on twitter (@doctornotte).
Life is short, art long, opportunity fleeting. – Hippocrates
The new year provides an opportunity to reflect on old things: to decide what to keep and what to toss out, to contemplate the habits to which we choose to rededicate ourselves, and those we choose to let wane. Over the last few years, while some older physicians have expressed a yearning for the comfort of paper charts, most of us have come to embrace the benefits of the electronic health record. That is a good thing. The EHR offers many advantages over paper, and, like it or not, it’s here to stay.
The other day I was working with a resident, admitting a patient to a nursing home. I handed her the inch-thick stack of papers that came from the hospital, and she immediately asked what we were supposed to do with it. When I explained that it was the hospital chart, she wondered aloud how she was supposed to navigate to the different sections in order to review the information. I was stupefied but understood the reason behind her question. The way we document has changed so dramatically over just the past decade. Unfortunately, without intention, the way that we chart has affected the way we relate to patients.
In 1923, the German philosopher Martin Buber published the book for which he is best known, “I and Thou.” In that book Buber says that there are two ways we can approach relationships: “I-Thou” or “I-It.” In I-It relationships, we view the other person as an “it” to be used to accomplish a purpose or to be experienced without his or her full involvement. In an I-Thou relationship, we appreciate the other person for all their complexity, in their full humanness. We acknowledge and approach the person as a unique individual who has dreams, goals, fears, and wishes that may be different than ours but to which we can still relate.
While the importance and benefits of the electronic record are clear, we must constantly remind ourselves that the EHR is a tool of care and not the goal of care. While the people we see have health needs that must be diagnosed, treated, and recorded, and their illnesses are an important part of their being, they do not define their being. Nor should they define our relationship with them. Patients agree; when surveyed about the attributes of a good physician, they regularly respond that they want their physicians to have a sense of them as people, not just patients.
Recently, I was reminded of the challenge of keeping this simple task in the forefront of care while on hospital service. I had occasion to sit and talk with one of my patients without a computer in the room. This was unusual for me, as I typically fill out the EHR as I am seeing the patient. As I listened to the individual in his gown, lying on his hospital bed and describing the symptoms that brought him to the hospital, I was reminded of the subtle pauses and nuances that occur during focused conversations, during deep listening.
We have written in previous columns about exciting applications of technology that are in the pipeline. Artificial intelligence with “deep learning” is predicted to change the way we diagnose and treat disease. Deep learning is a term that has been used to describe a type of machine analysis where data are interpreted and analyzed in layers, allowing the computer to detect patterns. In the first layer of learning, the computer may identify the way pixels of the same color form a line or a curve. In the next layer it might detect the way that curve resembles a face. Peeling away layer after layer, the computer might eventually recognize whose face is being represented. This is the type of programing that has allowed computers to interpret mammograms and retina scans, detecting patterns that represent cancer or small retinal hemorrhages. While deep learning will be the subject of much excitement over the next few years, at the start of this new year we think it is equally important be reminded of an essential quality of the excellent physician – deep listening.
Deep listening requires a lifetime of practice. We have all experienced it, both as listeners and as those being listened to. When we are in the presence of someone who is truly interested in what we are saying – in our story and in our life – we feel reaffirmed and refreshed. Regardless of the topic of our discussion, we feel a sense of trust, for we believe that the person with whom we are speaking understands us, and, in that understanding, cares about us. We have a sense that we could trust the listener with our lives.
A lifetime of practice – that is the promise of our jobs as physicians. Every time we enter the exam room we have the opportunity to carry out the sacred skill of hearing others, while trying in some way to improve their lives. With each visit we have the opportunity to perfect our craft. Chaucer, the medieval English poet, observed, “the life so short, the craft so long to learn.” It seems he borrowed that idea from a physician, Hippocrates.
Hippocrates opened his medical text with the words, “Vita brevis, ars longa, occasio praeceps,” which means, “Life is short, the art long, opportunity fleeting.” Hippocrates recognized the challenge involved in learning all that is necessary to take care of our fellow man. This challenge has only become more difficult as the quantity of information required to practice competent medicine has increased. In addition, we now need to record data into the EHR to be used for record keeping, billing, and the further advancement of knowledge. Hippocrates’ medical text continued, “The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.”
On the occasion of this New Year, it is a perfect time to reflect and rededicate ourselves to listening to our patients, to being interested in them and their stories. We just may find that in deep listening, and in the trust that comes from that singular focus, lie solutions to many of the largest problems we face in medicine today: burnout, poor adherence, and regaining the moral authority that comes with truly caring for those in need.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington Jefferson Health. Follow him on twitter (@doctornotte).
Packed with science
This month’s issue is packed with important science – nice to get back to medicine and not focus on politics. On page one, we highlight important new clinical guidance on the use of thiopurines in inflammatory bowel disease. This clinical practice update has some very specific and clear recommendations about thiopurines, especially in combination with biologic agents. As any clinician knowns, treatment of IBD has become complex from both a biologic standpoint and because we now recognize the importance of social determinants of health in our management of chronic diseases. We have seen an enormous outpouring of work that helps gastroenterologists develop multidisciplinary “homes” for IBD patients. These programs are now becoming best practice standards. Such approaches are practical for both academic and community GI practices. Best practice for our IBD patients now involves following clinical guidelines, understanding the impact of IBD on patients’ social and behavioral health and the incorporation of support services (or referral), and outcomes measurement. This clinical practice update will help us enhance our medical therapy for patients with both Crohn’s disease and ulcerative colitis.
Other stories include a review of the new AGA clinical practice update on endoscopic submucosal dissection for early stage cancers with important information about technique, indications, and management of complications. Questions about our approach to prevention of GI bleeding for patients in the ICU are raised by a new multicentered trial of PPI use in over 3,500 patients. Essentially, PPI prophylaxis should be reserved for seriously ill patients at high risk for bleeding – prophylaxis may not be needed in other ICU patients. Finally, another study does not support use of probiotics (at least in the current formulation) in children with gastroenteritis.
I hope you enjoy the issue and that you had a wonderful year’s end. We look forward to more excitement in 2019.
John I. Allen, MD, MBA, AGAF
Editor in Chief
This month’s issue is packed with important science – nice to get back to medicine and not focus on politics. On page one, we highlight important new clinical guidance on the use of thiopurines in inflammatory bowel disease. This clinical practice update has some very specific and clear recommendations about thiopurines, especially in combination with biologic agents. As any clinician knowns, treatment of IBD has become complex from both a biologic standpoint and because we now recognize the importance of social determinants of health in our management of chronic diseases. We have seen an enormous outpouring of work that helps gastroenterologists develop multidisciplinary “homes” for IBD patients. These programs are now becoming best practice standards. Such approaches are practical for both academic and community GI practices. Best practice for our IBD patients now involves following clinical guidelines, understanding the impact of IBD on patients’ social and behavioral health and the incorporation of support services (or referral), and outcomes measurement. This clinical practice update will help us enhance our medical therapy for patients with both Crohn’s disease and ulcerative colitis.
Other stories include a review of the new AGA clinical practice update on endoscopic submucosal dissection for early stage cancers with important information about technique, indications, and management of complications. Questions about our approach to prevention of GI bleeding for patients in the ICU are raised by a new multicentered trial of PPI use in over 3,500 patients. Essentially, PPI prophylaxis should be reserved for seriously ill patients at high risk for bleeding – prophylaxis may not be needed in other ICU patients. Finally, another study does not support use of probiotics (at least in the current formulation) in children with gastroenteritis.
I hope you enjoy the issue and that you had a wonderful year’s end. We look forward to more excitement in 2019.
John I. Allen, MD, MBA, AGAF
Editor in Chief
This month’s issue is packed with important science – nice to get back to medicine and not focus on politics. On page one, we highlight important new clinical guidance on the use of thiopurines in inflammatory bowel disease. This clinical practice update has some very specific and clear recommendations about thiopurines, especially in combination with biologic agents. As any clinician knowns, treatment of IBD has become complex from both a biologic standpoint and because we now recognize the importance of social determinants of health in our management of chronic diseases. We have seen an enormous outpouring of work that helps gastroenterologists develop multidisciplinary “homes” for IBD patients. These programs are now becoming best practice standards. Such approaches are practical for both academic and community GI practices. Best practice for our IBD patients now involves following clinical guidelines, understanding the impact of IBD on patients’ social and behavioral health and the incorporation of support services (or referral), and outcomes measurement. This clinical practice update will help us enhance our medical therapy for patients with both Crohn’s disease and ulcerative colitis.
Other stories include a review of the new AGA clinical practice update on endoscopic submucosal dissection for early stage cancers with important information about technique, indications, and management of complications. Questions about our approach to prevention of GI bleeding for patients in the ICU are raised by a new multicentered trial of PPI use in over 3,500 patients. Essentially, PPI prophylaxis should be reserved for seriously ill patients at high risk for bleeding – prophylaxis may not be needed in other ICU patients. Finally, another study does not support use of probiotics (at least in the current formulation) in children with gastroenteritis.
I hope you enjoy the issue and that you had a wonderful year’s end. We look forward to more excitement in 2019.
John I. Allen, MD, MBA, AGAF
Editor in Chief
Should doctors disclose preliminary results?
Outside the clinic room, I paced the hallway and pressed the phone to my ear, waiting for the resident to pick up.
“I have patient SB in clinic for her appointment now. I’m hoping to get preliminary results of her bone marrow biopsy.”
I had known SB well from her month-long inpatient stay on our leukemia service. She had come in with a white blood cell count through the roof – a relapse of her leukemia, 4 years out from her bone marrow transplant. It was devastating. After a few cycles of chemotherapy and a bone marrow biopsy yesterday to see if it had worked, she was here now to get her results and decide next steps.
“Hello!” I said and we hugged. Her mother and father accompanied her, sitting still with their hands folded nervously. SB had multiple complications during her hospitalization, and we went through how each was doing. Did she get her new heart medication? Did she do okay on the antibiotics? Was the rash improving? With each question, she and her parents seemed more nervous.
There was an elephant in that exam room. Asking a cancer patient in limbo if she refilled her heart medications becomes as trivial as asking her about the weather. SB and her parents were here for one thing, from which everything else was a distraction. The only question that mattered was the one splitting their world in two: Is their daughter in remission or not?
“She’s here with her parents now,” I said outside the door. “What do you think?” The resident told me he had looked at the case this morning, and it looked like 3% blasts. I smiled – anything under 5% is good, considered a remission. But the pathology resident still hadn’t reviewed the sample with his attending.
Inside the room, after exhausting all other conversation, I hesitated. Should I tell SB the preliminary results? Or should I wait for the final diagnosis?
I’d been burned before. Once, I told a patient with a new diagnosis of esophageal cancer that it was early stage. It was not. Upon additional radiology review, the surrounding lymph nodes were enlarged, and they were ultimately found to be metastases. That initial conversation – and the subsequent one, in which I had to walk back my reassurance that the cancer was contained – was seared into my mind.
I learned from it. Giving preliminary results can be dangerous. What if we say all clear and then learn days later it isn’t so? Or what if we reveal the cancer is progressing, causing despair and re-evaluation of life’s priorities, only to find out it was a false alarm? False alarms are terrifying, and false reassurance is cruel, yet all the while, excessive waiting can feel excruciating for the person whose very existence is suspended.
As hematologists and oncologists, we scroll through CT scans, and we look at slides ourselves. But we also value and depend on the expertise of our colleagues in other departments like pathology and radiology who have their own workflow. It’s a process; it’s for quality assurance that we don’t get immediate results, and that’s a good thing.
It depends on the patient, but often I find the most straightforward solution is to say exactly what is true. For some, the combination of incredibly high stakes coupled with extended wait times becomes agonizing. They might incorrectly read into unrelated, benign actions – if my pager goes off or I look at the computer screen a moment too long – as clues into something I know and am not sharing. They might be so distracted we cannot address anything else.
So I’ve walked back from my initial “do not share anything” reaction to “it’s sometimes okay” – as long as the patient understands the nuances of what preliminary results do and do not mean. The problem with my esophageal cancer patient was not that I had shared preliminary results; it was that I hadn’t framed them as such. I had simply stated the findings, portraying them as certain.
Now, I tend to break the fourth wall. I explain that it’s the resident’s read, that it isn’t final, and that it can be amended. Do you still want to know?
Most people say yes.
SB and her parents were in that boat. They had driven 3 hours to make this appointment. They didn’t want to drive home empty handed.
“It’s preliminary,” I carefully qualified.
“Okay.”
“The final results may be different.”
“Okay, yes. We understand.”
The three of them held hands. They were holding their breath.
“It looks like remission.”
SB cried. Her mother threw her arms around my neck. “You know, she broke down when you stepped out,” her father whispered to me. “She was sure it meant bad news.”
I tried to be happy for them and with them, but now I was the one holding my breath. I hoped I wouldn’t have to take it all away.
For the next 24 hours, I compulsively checked SB’s chart, hoping final results would populate that would be consistent with what I had shared.
The next day, the pathologist called me, and I called SB.
“I have the final results,” I said, followed by my favorite phrase in hematology and oncology. “I have good news.”
Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.
Outside the clinic room, I paced the hallway and pressed the phone to my ear, waiting for the resident to pick up.
“I have patient SB in clinic for her appointment now. I’m hoping to get preliminary results of her bone marrow biopsy.”
I had known SB well from her month-long inpatient stay on our leukemia service. She had come in with a white blood cell count through the roof – a relapse of her leukemia, 4 years out from her bone marrow transplant. It was devastating. After a few cycles of chemotherapy and a bone marrow biopsy yesterday to see if it had worked, she was here now to get her results and decide next steps.
“Hello!” I said and we hugged. Her mother and father accompanied her, sitting still with their hands folded nervously. SB had multiple complications during her hospitalization, and we went through how each was doing. Did she get her new heart medication? Did she do okay on the antibiotics? Was the rash improving? With each question, she and her parents seemed more nervous.
There was an elephant in that exam room. Asking a cancer patient in limbo if she refilled her heart medications becomes as trivial as asking her about the weather. SB and her parents were here for one thing, from which everything else was a distraction. The only question that mattered was the one splitting their world in two: Is their daughter in remission or not?
“She’s here with her parents now,” I said outside the door. “What do you think?” The resident told me he had looked at the case this morning, and it looked like 3% blasts. I smiled – anything under 5% is good, considered a remission. But the pathology resident still hadn’t reviewed the sample with his attending.
Inside the room, after exhausting all other conversation, I hesitated. Should I tell SB the preliminary results? Or should I wait for the final diagnosis?
I’d been burned before. Once, I told a patient with a new diagnosis of esophageal cancer that it was early stage. It was not. Upon additional radiology review, the surrounding lymph nodes were enlarged, and they were ultimately found to be metastases. That initial conversation – and the subsequent one, in which I had to walk back my reassurance that the cancer was contained – was seared into my mind.
I learned from it. Giving preliminary results can be dangerous. What if we say all clear and then learn days later it isn’t so? Or what if we reveal the cancer is progressing, causing despair and re-evaluation of life’s priorities, only to find out it was a false alarm? False alarms are terrifying, and false reassurance is cruel, yet all the while, excessive waiting can feel excruciating for the person whose very existence is suspended.
As hematologists and oncologists, we scroll through CT scans, and we look at slides ourselves. But we also value and depend on the expertise of our colleagues in other departments like pathology and radiology who have their own workflow. It’s a process; it’s for quality assurance that we don’t get immediate results, and that’s a good thing.
It depends on the patient, but often I find the most straightforward solution is to say exactly what is true. For some, the combination of incredibly high stakes coupled with extended wait times becomes agonizing. They might incorrectly read into unrelated, benign actions – if my pager goes off or I look at the computer screen a moment too long – as clues into something I know and am not sharing. They might be so distracted we cannot address anything else.
So I’ve walked back from my initial “do not share anything” reaction to “it’s sometimes okay” – as long as the patient understands the nuances of what preliminary results do and do not mean. The problem with my esophageal cancer patient was not that I had shared preliminary results; it was that I hadn’t framed them as such. I had simply stated the findings, portraying them as certain.
Now, I tend to break the fourth wall. I explain that it’s the resident’s read, that it isn’t final, and that it can be amended. Do you still want to know?
Most people say yes.
SB and her parents were in that boat. They had driven 3 hours to make this appointment. They didn’t want to drive home empty handed.
“It’s preliminary,” I carefully qualified.
“Okay.”
“The final results may be different.”
“Okay, yes. We understand.”
The three of them held hands. They were holding their breath.
“It looks like remission.”
SB cried. Her mother threw her arms around my neck. “You know, she broke down when you stepped out,” her father whispered to me. “She was sure it meant bad news.”
I tried to be happy for them and with them, but now I was the one holding my breath. I hoped I wouldn’t have to take it all away.
For the next 24 hours, I compulsively checked SB’s chart, hoping final results would populate that would be consistent with what I had shared.
The next day, the pathologist called me, and I called SB.
“I have the final results,” I said, followed by my favorite phrase in hematology and oncology. “I have good news.”
Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.
Outside the clinic room, I paced the hallway and pressed the phone to my ear, waiting for the resident to pick up.
“I have patient SB in clinic for her appointment now. I’m hoping to get preliminary results of her bone marrow biopsy.”
I had known SB well from her month-long inpatient stay on our leukemia service. She had come in with a white blood cell count through the roof – a relapse of her leukemia, 4 years out from her bone marrow transplant. It was devastating. After a few cycles of chemotherapy and a bone marrow biopsy yesterday to see if it had worked, she was here now to get her results and decide next steps.
“Hello!” I said and we hugged. Her mother and father accompanied her, sitting still with their hands folded nervously. SB had multiple complications during her hospitalization, and we went through how each was doing. Did she get her new heart medication? Did she do okay on the antibiotics? Was the rash improving? With each question, she and her parents seemed more nervous.
There was an elephant in that exam room. Asking a cancer patient in limbo if she refilled her heart medications becomes as trivial as asking her about the weather. SB and her parents were here for one thing, from which everything else was a distraction. The only question that mattered was the one splitting their world in two: Is their daughter in remission or not?
“She’s here with her parents now,” I said outside the door. “What do you think?” The resident told me he had looked at the case this morning, and it looked like 3% blasts. I smiled – anything under 5% is good, considered a remission. But the pathology resident still hadn’t reviewed the sample with his attending.
Inside the room, after exhausting all other conversation, I hesitated. Should I tell SB the preliminary results? Or should I wait for the final diagnosis?
I’d been burned before. Once, I told a patient with a new diagnosis of esophageal cancer that it was early stage. It was not. Upon additional radiology review, the surrounding lymph nodes were enlarged, and they were ultimately found to be metastases. That initial conversation – and the subsequent one, in which I had to walk back my reassurance that the cancer was contained – was seared into my mind.
I learned from it. Giving preliminary results can be dangerous. What if we say all clear and then learn days later it isn’t so? Or what if we reveal the cancer is progressing, causing despair and re-evaluation of life’s priorities, only to find out it was a false alarm? False alarms are terrifying, and false reassurance is cruel, yet all the while, excessive waiting can feel excruciating for the person whose very existence is suspended.
As hematologists and oncologists, we scroll through CT scans, and we look at slides ourselves. But we also value and depend on the expertise of our colleagues in other departments like pathology and radiology who have their own workflow. It’s a process; it’s for quality assurance that we don’t get immediate results, and that’s a good thing.
It depends on the patient, but often I find the most straightforward solution is to say exactly what is true. For some, the combination of incredibly high stakes coupled with extended wait times becomes agonizing. They might incorrectly read into unrelated, benign actions – if my pager goes off or I look at the computer screen a moment too long – as clues into something I know and am not sharing. They might be so distracted we cannot address anything else.
So I’ve walked back from my initial “do not share anything” reaction to “it’s sometimes okay” – as long as the patient understands the nuances of what preliminary results do and do not mean. The problem with my esophageal cancer patient was not that I had shared preliminary results; it was that I hadn’t framed them as such. I had simply stated the findings, portraying them as certain.
Now, I tend to break the fourth wall. I explain that it’s the resident’s read, that it isn’t final, and that it can be amended. Do you still want to know?
Most people say yes.
SB and her parents were in that boat. They had driven 3 hours to make this appointment. They didn’t want to drive home empty handed.
“It’s preliminary,” I carefully qualified.
“Okay.”
“The final results may be different.”
“Okay, yes. We understand.”
The three of them held hands. They were holding their breath.
“It looks like remission.”
SB cried. Her mother threw her arms around my neck. “You know, she broke down when you stepped out,” her father whispered to me. “She was sure it meant bad news.”
I tried to be happy for them and with them, but now I was the one holding my breath. I hoped I wouldn’t have to take it all away.
For the next 24 hours, I compulsively checked SB’s chart, hoping final results would populate that would be consistent with what I had shared.
The next day, the pathologist called me, and I called SB.
“I have the final results,” I said, followed by my favorite phrase in hematology and oncology. “I have good news.”
Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.