Opinion

My father was a general surgeon in a very small town in West Virginia. He was very successful and his patients loved him. He loved them, too, and chose to practice well into his 70s. In retrospect, he should not have.

Perhaps brilliant in his day, he was less so at the end of his career. I realized his deficiencies when I was in residency. I wondered if, despite his undeniable experience, his age was compromising his clinical acumen.

There are data available that support my suspicions. Investigators from the Department of Health Policy and Management at Harvard T.H. Chan School of Public Health reviewed a random sample of Medicare beneficiaries admitted to a hospital between 2011 and 2014. They hypothesized that physician age may affect outcomes such as 30-day mortality, readmissions, and cost of care. Among the more than 700,000 admissions by more than 18,000 hospitalists, the 30-day mortality rates were significantly higher for physicians aged 60 years and older, compared with younger physicians. Importantly though, there was no difference in mortality for older, but high-volume, physicians, compared with younger ones.

These results were published in the BMJ (2017 May 16;357:j1797. doi: 10.1136/bmj.j1797) by the same group that described a similar reduction in mortality among female versus male internists (JAMA Intern Med. 2017 Feb 1;177[2]:206-13). Both studies attracted widespread media attention.

The BMJ study analyzed outcomes among hospitalists who exclusively manage inpatients. Hematologists, in contrast, are largely based in the outpatient setting or in a lab. Yet, hematologists are often called upon to cover inpatient units of very sick patients. We care for patients with acute leukemia, thrombotic thrombocytopenic purpura, and graft versus host disease, among other debilitating diseases. In that sense, I believe data generated from hospitalists probably apply to inpatient hematology as well.

Having just been the attending on one of these services, I am uncomfortably certain that they apply. I proudly boast that I once attended for 6 months in a year. I was good at it and enjoyed it. With time, though, we hired additional staff and I acquired administrative duties that decreased my attending service time. I now attend for 2 weeks, twice a year.

During the last one of these service times, I began to suspect that I was not as sharp as I once was. I don’t think I missed anything, I just didn’t seem to catch changes in clinical status as quickly as I once did. I was less comfortable with the new medications I was prescribing. I was depending more on the clinical pharmacist and the hematology fellow to keep track of side effects and dose adjustments. I was worried – more than ever – that I would make a mistake. The last thing I want to be is dangerous.


As department chairman, though, it is part of my job to ensure that no one else is dangerous either. The Joint Commission mandates Ongoing Professional Practice Evaluation (OPPE), which is intended to help assess a practitioner’s clinical competence. Yet, the commission recognizes that “Cognitive specialties (internal medicine, family practice, psychiatry, med specialties ...) are very difficult” in terms of identifying meaningful data that can be evaluated.

We do not have adequate tools to assess clinical competency. As a result, we are generally aware that physicians do a poor job of policing our own, in no small part because of a reluctance to identify and confront less competent physicians. Where police departments are accused of hiding behind a blue wall of silence, are physicians guilty of maintaining a white wall of silence?

Of course we are. How many clinically shaky fellows do we graduate into our profession every year? How many of us are aware of colleagues who are unskilled, but are reluctant to speak up about them? Our sins are documented in books such as “Wall of Silence: The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans” by Rosemary Gibson and Janardan Prasad Singh and “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care,” by Marty Makary.

Concern for my own competence notwithstanding, medicine as a profession requires reflection on its role in allowing substandard patient care to continue.

Punishment doesn’t seem to be the best way to right wrongs. The punished may not learn the lesson and the unpunished will be less forthcoming with their own errors.

Taking a lesson from highly reliable industries such as airlines, the medical profession is addressing medical errors better. For example, my institution has mandated thorough checklists before any and all invasive procedures, including bone marrow biopsies. Through a morbidity and mortality review of a case of hepatitis, we developed an automatic method of ordering hepatitis panels in every patient treated with monoclonal antibodies. Making systemic changes to prevent error avoids having to punish those who make errors, while holding accountable those who skirt the built-in safeguards.

We are less successful at applying similar error mitigation techniques to individual physicians who may not be clinically excellent. Examples abound of physicians who provide substandard care, but are allowed to continue. The repercussions continue at Wake Forest Baptist Medical Center, where a pathologist misdiagnosed some cancer cases over at least a 2-year period of time. Physicians, as a group, are not as good at certifying competency as are nurses, advanced practice providers, and pharmacists.

With many academic hematologists having relatively small practices, getting older, and getting burned out, the potential for patient harm as a result of medical error increases. Further, these physicians may not realize their increased risk and may be indignant when confronted.

I am interested in best practices that address this difficult and contentious issue. I hope our readers will offer their policies and procedures so that we can learn from each other. Patients should not have to worry about their doctors’ competency and doctors should be able to hold each other accountable by removing the white wall of silence.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

My father was a general surgeon in a very small town in West Virginia. He was very successful and his patients loved him. He loved them, too, and chose to practice well into his 70s. In retrospect, he should not have.

Perhaps brilliant in his day, he was less so at the end of his career. I realized his deficiencies when I was in residency. I wondered if, despite his undeniable experience, his age was compromising his clinical acumen.

There are data available that support my suspicions. Investigators from the Department of Health Policy and Management at Harvard T.H. Chan School of Public Health reviewed a random sample of Medicare beneficiaries admitted to a hospital between 2011 and 2014. They hypothesized that physician age may affect outcomes such as 30-day mortality, readmissions, and cost of care. Among the more than 700,000 admissions by more than 18,000 hospitalists, the 30-day mortality rates were significantly higher for physicians aged 60 years and older, compared with younger physicians. Importantly though, there was no difference in mortality for older, but high-volume, physicians, compared with younger ones.

These results were published in the BMJ (2017 May 16;357:j1797. doi: 10.1136/bmj.j1797) by the same group that described a similar reduction in mortality among female versus male internists (JAMA Intern Med. 2017 Feb 1;177[2]:206-13). Both studies attracted widespread media attention.

The BMJ study analyzed outcomes among hospitalists who exclusively manage inpatients. Hematologists, in contrast, are largely based in the outpatient setting or in a lab. Yet, hematologists are often called upon to cover inpatient units of very sick patients. We care for patients with acute leukemia, thrombotic thrombocytopenic purpura, and graft versus host disease, among other debilitating diseases. In that sense, I believe data generated from hospitalists probably apply to inpatient hematology as well.

Having just been the attending on one of these services, I am uncomfortably certain that they apply. I proudly boast that I once attended for 6 months in a year. I was good at it and enjoyed it. With time, though, we hired additional staff and I acquired administrative duties that decreased my attending service time. I now attend for 2 weeks, twice a year.

During the last one of these service times, I began to suspect that I was not as sharp as I once was. I don’t think I missed anything, I just didn’t seem to catch changes in clinical status as quickly as I once did. I was less comfortable with the new medications I was prescribing. I was depending more on the clinical pharmacist and the hematology fellow to keep track of side effects and dose adjustments. I was worried – more than ever – that I would make a mistake. The last thing I want to be is dangerous.


As department chairman, though, it is part of my job to ensure that no one else is dangerous either. The Joint Commission mandates Ongoing Professional Practice Evaluation (OPPE), which is intended to help assess a practitioner’s clinical competence. Yet, the commission recognizes that “Cognitive specialties (internal medicine, family practice, psychiatry, med specialties ...) are very difficult” in terms of identifying meaningful data that can be evaluated.

We do not have adequate tools to assess clinical competency. As a result, we are generally aware that physicians do a poor job of policing our own, in no small part because of a reluctance to identify and confront less competent physicians. Where police departments are accused of hiding behind a blue wall of silence, are physicians guilty of maintaining a white wall of silence?

Of course we are. How many clinically shaky fellows do we graduate into our profession every year? How many of us are aware of colleagues who are unskilled, but are reluctant to speak up about them? Our sins are documented in books such as “Wall of Silence: The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans” by Rosemary Gibson and Janardan Prasad Singh and “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care,” by Marty Makary.

Concern for my own competence notwithstanding, medicine as a profession requires reflection on its role in allowing substandard patient care to continue.

Punishment doesn’t seem to be the best way to right wrongs. The punished may not learn the lesson and the unpunished will be less forthcoming with their own errors.

Taking a lesson from highly reliable industries such as airlines, the medical profession is addressing medical errors better. For example, my institution has mandated thorough checklists before any and all invasive procedures, including bone marrow biopsies. Through a morbidity and mortality review of a case of hepatitis, we developed an automatic method of ordering hepatitis panels in every patient treated with monoclonal antibodies. Making systemic changes to prevent error avoids having to punish those who make errors, while holding accountable those who skirt the built-in safeguards.

We are less successful at applying similar error mitigation techniques to individual physicians who may not be clinically excellent. Examples abound of physicians who provide substandard care, but are allowed to continue. The repercussions continue at Wake Forest Baptist Medical Center, where a pathologist misdiagnosed some cancer cases over at least a 2-year period of time. Physicians, as a group, are not as good at certifying competency as are nurses, advanced practice providers, and pharmacists.

With many academic hematologists having relatively small practices, getting older, and getting burned out, the potential for patient harm as a result of medical error increases. Further, these physicians may not realize their increased risk and may be indignant when confronted.

I am interested in best practices that address this difficult and contentious issue. I hope our readers will offer their policies and procedures so that we can learn from each other. Patients should not have to worry about their doctors’ competency and doctors should be able to hold each other accountable by removing the white wall of silence.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

My father was a general surgeon in a very small town in West Virginia. He was very successful and his patients loved him. He loved them, too, and chose to practice well into his 70s. In retrospect, he should not have.

Perhaps brilliant in his day, he was less so at the end of his career. I realized his deficiencies when I was in residency. I wondered if, despite his undeniable experience, his age was compromising his clinical acumen.

There are data available that support my suspicions. Investigators from the Department of Health Policy and Management at Harvard T.H. Chan School of Public Health reviewed a random sample of Medicare beneficiaries admitted to a hospital between 2011 and 2014. They hypothesized that physician age may affect outcomes such as 30-day mortality, readmissions, and cost of care. Among the more than 700,000 admissions by more than 18,000 hospitalists, the 30-day mortality rates were significantly higher for physicians aged 60 years and older, compared with younger physicians. Importantly though, there was no difference in mortality for older, but high-volume, physicians, compared with younger ones.

These results were published in the BMJ (2017 May 16;357:j1797. doi: 10.1136/bmj.j1797) by the same group that described a similar reduction in mortality among female versus male internists (JAMA Intern Med. 2017 Feb 1;177[2]:206-13). Both studies attracted widespread media attention.

The BMJ study analyzed outcomes among hospitalists who exclusively manage inpatients. Hematologists, in contrast, are largely based in the outpatient setting or in a lab. Yet, hematologists are often called upon to cover inpatient units of very sick patients. We care for patients with acute leukemia, thrombotic thrombocytopenic purpura, and graft versus host disease, among other debilitating diseases. In that sense, I believe data generated from hospitalists probably apply to inpatient hematology as well.

Having just been the attending on one of these services, I am uncomfortably certain that they apply. I proudly boast that I once attended for 6 months in a year. I was good at it and enjoyed it. With time, though, we hired additional staff and I acquired administrative duties that decreased my attending service time. I now attend for 2 weeks, twice a year.

During the last one of these service times, I began to suspect that I was not as sharp as I once was. I don’t think I missed anything, I just didn’t seem to catch changes in clinical status as quickly as I once did. I was less comfortable with the new medications I was prescribing. I was depending more on the clinical pharmacist and the hematology fellow to keep track of side effects and dose adjustments. I was worried – more than ever – that I would make a mistake. The last thing I want to be is dangerous.


As department chairman, though, it is part of my job to ensure that no one else is dangerous either. The Joint Commission mandates Ongoing Professional Practice Evaluation (OPPE), which is intended to help assess a practitioner’s clinical competence. Yet, the commission recognizes that “Cognitive specialties (internal medicine, family practice, psychiatry, med specialties ...) are very difficult” in terms of identifying meaningful data that can be evaluated.

We do not have adequate tools to assess clinical competency. As a result, we are generally aware that physicians do a poor job of policing our own, in no small part because of a reluctance to identify and confront less competent physicians. Where police departments are accused of hiding behind a blue wall of silence, are physicians guilty of maintaining a white wall of silence?

Of course we are. How many clinically shaky fellows do we graduate into our profession every year? How many of us are aware of colleagues who are unskilled, but are reluctant to speak up about them? Our sins are documented in books such as “Wall of Silence: The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans” by Rosemary Gibson and Janardan Prasad Singh and “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care,” by Marty Makary.

Concern for my own competence notwithstanding, medicine as a profession requires reflection on its role in allowing substandard patient care to continue.

Punishment doesn’t seem to be the best way to right wrongs. The punished may not learn the lesson and the unpunished will be less forthcoming with their own errors.

Taking a lesson from highly reliable industries such as airlines, the medical profession is addressing medical errors better. For example, my institution has mandated thorough checklists before any and all invasive procedures, including bone marrow biopsies. Through a morbidity and mortality review of a case of hepatitis, we developed an automatic method of ordering hepatitis panels in every patient treated with monoclonal antibodies. Making systemic changes to prevent error avoids having to punish those who make errors, while holding accountable those who skirt the built-in safeguards.

We are less successful at applying similar error mitigation techniques to individual physicians who may not be clinically excellent. Examples abound of physicians who provide substandard care, but are allowed to continue. The repercussions continue at Wake Forest Baptist Medical Center, where a pathologist misdiagnosed some cancer cases over at least a 2-year period of time. Physicians, as a group, are not as good at certifying competency as are nurses, advanced practice providers, and pharmacists.

With many academic hematologists having relatively small practices, getting older, and getting burned out, the potential for patient harm as a result of medical error increases. Further, these physicians may not realize their increased risk and may be indignant when confronted.

I am interested in best practices that address this difficult and contentious issue. I hope our readers will offer their policies and procedures so that we can learn from each other. Patients should not have to worry about their doctors’ competency and doctors should be able to hold each other accountable by removing the white wall of silence.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

Primary intestinal lymphangiectasia

Histologic examination shows chronic inflammation of the ileum characterized by increased lymphoplasma cell infiltration of lamina propria without malignancy. Moreover, marked dilatation of lymphatic ducts that involved the mucosa was identified (Figure F, arrows; stain: hematoxylin and eosin; original magnification, ×100). On the basis of pathologic examinations, a diagnosis of primary intestinal lymphangiectasia (PIL) was made.

AGA Institute

PIL is an extremely rare cause of protein-losing enteropathy characterized by the presence of dilated lymphatic channels in the mucosa, submucosa, or subserosa leading to protein-losing enteropathy.¹ The true incidence and prevalence of this disease remains unclear. The disease affects males and females equally, and usually occurs in children and young adults. To date, less than 200 cases of PIL have been reported in the literature. The clinical manifestations of PIL may be asymptomatic or symptomatic such as abdominal pain, edema, diarrhea, and dyspnea. The diagnosis is based on the typical endoscopic findings of diffuse scattered mucosal white blebs with characteristic histologic findings of abnormal lymphatic dilatation. Double-balloon enteroscopy and capsule endoscopy are powerful modalities to evaluate the entire affected area of PIL.² Although diet modification is a major treatment of PIL, several medicines have been reported to be useful such as corticosteroids, octreotide, and antiplasmin.³ Moreover, in patients with segmental lesions, surgery with local bowel resection is a useful treatment.³ In addition, PIL had a 5% risk of malignant transformation into lymphoma.³
 

References

1. Waldmann TA, Steinfeld JL, Dutcher TF, et al. The role of the gastrointestinal system in “idiopathic hypoproteinemia.” Gastroenterology. 1961;41:197-207.

2. Oh TG, Chung JW, Kim HM, et al. Primary intestinal lymphangiectasia diagnosed by capsule endoscopy and double balloon enteroscopy. World J Gastrointest Endosc. 2011;3:235-40.

3. Wen J, Tang Q, Wu, J. Primary intestinal lymphangiectasia: four case reports and a review of the literature. Dig Dis Sci. 2010;55:3466-72.

Primary intestinal lymphangiectasia

Histologic examination shows chronic inflammation of the ileum characterized by increased lymphoplasma cell infiltration of lamina propria without malignancy. Moreover, marked dilatation of lymphatic ducts that involved the mucosa was identified (Figure F, arrows; stain: hematoxylin and eosin; original magnification, ×100). On the basis of pathologic examinations, a diagnosis of primary intestinal lymphangiectasia (PIL) was made.

AGA Institute

PIL is an extremely rare cause of protein-losing enteropathy characterized by the presence of dilated lymphatic channels in the mucosa, submucosa, or subserosa leading to protein-losing enteropathy.¹ The true incidence and prevalence of this disease remains unclear. The disease affects males and females equally, and usually occurs in children and young adults. To date, less than 200 cases of PIL have been reported in the literature. The clinical manifestations of PIL may be asymptomatic or symptomatic such as abdominal pain, edema, diarrhea, and dyspnea. The diagnosis is based on the typical endoscopic findings of diffuse scattered mucosal white blebs with characteristic histologic findings of abnormal lymphatic dilatation. Double-balloon enteroscopy and capsule endoscopy are powerful modalities to evaluate the entire affected area of PIL.² Although diet modification is a major treatment of PIL, several medicines have been reported to be useful such as corticosteroids, octreotide, and antiplasmin.³ Moreover, in patients with segmental lesions, surgery with local bowel resection is a useful treatment.³ In addition, PIL had a 5% risk of malignant transformation into lymphoma.³
 

References

1. Waldmann TA, Steinfeld JL, Dutcher TF, et al. The role of the gastrointestinal system in “idiopathic hypoproteinemia.” Gastroenterology. 1961;41:197-207.

2. Oh TG, Chung JW, Kim HM, et al. Primary intestinal lymphangiectasia diagnosed by capsule endoscopy and double balloon enteroscopy. World J Gastrointest Endosc. 2011;3:235-40.

3. Wen J, Tang Q, Wu, J. Primary intestinal lymphangiectasia: four case reports and a review of the literature. Dig Dis Sci. 2010;55:3466-72.

Primary intestinal lymphangiectasia

Histologic examination shows chronic inflammation of the ileum characterized by increased lymphoplasma cell infiltration of lamina propria without malignancy. Moreover, marked dilatation of lymphatic ducts that involved the mucosa was identified (Figure F, arrows; stain: hematoxylin and eosin; original magnification, ×100). On the basis of pathologic examinations, a diagnosis of primary intestinal lymphangiectasia (PIL) was made.

AGA Institute

PIL is an extremely rare cause of protein-losing enteropathy characterized by the presence of dilated lymphatic channels in the mucosa, submucosa, or subserosa leading to protein-losing enteropathy.¹ The true incidence and prevalence of this disease remains unclear. The disease affects males and females equally, and usually occurs in children and young adults. To date, less than 200 cases of PIL have been reported in the literature. The clinical manifestations of PIL may be asymptomatic or symptomatic such as abdominal pain, edema, diarrhea, and dyspnea. The diagnosis is based on the typical endoscopic findings of diffuse scattered mucosal white blebs with characteristic histologic findings of abnormal lymphatic dilatation. Double-balloon enteroscopy and capsule endoscopy are powerful modalities to evaluate the entire affected area of PIL.² Although diet modification is a major treatment of PIL, several medicines have been reported to be useful such as corticosteroids, octreotide, and antiplasmin.³ Moreover, in patients with segmental lesions, surgery with local bowel resection is a useful treatment.³ In addition, PIL had a 5% risk of malignant transformation into lymphoma.³
 

References

1. Waldmann TA, Steinfeld JL, Dutcher TF, et al. The role of the gastrointestinal system in “idiopathic hypoproteinemia.” Gastroenterology. 1961;41:197-207.

2. Oh TG, Chung JW, Kim HM, et al. Primary intestinal lymphangiectasia diagnosed by capsule endoscopy and double balloon enteroscopy. World J Gastrointest Endosc. 2011;3:235-40.

3. Wen J, Tang Q, Wu, J. Primary intestinal lymphangiectasia: four case reports and a review of the literature. Dig Dis Sci. 2010;55:3466-72.

Following a series of Vascular Specialist pieces highlighting the crisis of surgeon burnout and the unique challenges that face vascular surgeons, the SVS Wellness Task Force was formed in 2017. Recognizing that burnout may compromise recruitment and retention into our specialty, a particular threat at a time when our specialty faces projected increasing physician workforce needs, and that data suggests physician burnout compromises both patient quality of care and overall satisfaction, the task force was charged with proactively addressing vascular surgeon burnout. Our task force, comprising 21 engaged SVS members from across the country, has been working with strong support from leadership and administration to identify potential SVS targets for meaningful change.

The year 2018 was one of information gathering as we attempted clarify the severity of the problem and perceived member needs. We are grateful to our membership that have helped with this effort – for their time, for their insight, and for sharing their stories (some of which have been deeply personal). Two large-scale surveys were circulated to active SVS membership, both created with the assistance of the Mayo Clinic’s Division of Health Policy and Research.

The first survey was designed with a framework of validated wellness tools and well-described risk factors for burnout, then further “personalized” to incorporate unique challenges to the vascular surgeon. About 32% of our membership responded to this survey and alarmingly, when considering nonretired active SVS members, approximately one-third self-described depressive symptoms, 35% met criteria for burnout, and 8% self-reported suicidal thoughts in the last 12 months.

The second survey has only recently closed, focusing on the ergonomic challenges that we face across the spectrum of complex open and endovascular cases. Recognizing existing data that chronic pain and physical disability are associated with burnout, this data will be linked back to the original survey responses for association. Certainly there is more to come.

Concurrent with our survey initiatives, many of you participated in a Wellness Focus Group during VAM 2018. These focus groups intentionally considered the diversity of our membership across age, gender, practice setting, and region, revealing several important themes that threaten our wellness. It was no surprise that the EMR was identified as a clear threat to vascular surgery well-being and that this is not unique to our specialty. Importantly, our membership collectively feels “undervalued” at an institutional level. Specifically given the scope of comprehensive vascular care that we provide patients, a large part of our work includes both unpredictable acute vascular surgical care (such as intraoperative consultations for vascular trauma) and remedial salvage operations to manage vascular complications inflicted during care received from other physicians. This effort leaves us with little control over our time, often without perceived reciprocal clinical support, institutional support, or compensation.

Given this data, the Wellness Task Force is now strategizing efforts for change and supporting ongoing SVS initiatives. Our Task Force is currently:

• Collaborating with key EMR stakeholders with the goal of creating tools that can be shared across the specialty and addressing best practices for system-level support.
• Drafting a “public reply” to the Office of the National Coordinator for Health Information Technology’s “Strategy on Reducing Burden Relating to the Use of Health IT and EHRs” initiative.
• Collaborating with national experts to establish peer support tools and SVS networking opportunities that may help members cope with adverse outcomes and strategize the delivery of complex care.
• Identifying institutional best practices for surgeon wellness for broad dissemination.
• Supporting existing SVS initiatives that include the PAC/APM task force, branding initiatives through the PPO as we work to “own our space” and leverage our specialty and the community practice committee as the Society works proactively to optimize workload, fairness, and reward on a larger scale for membership.

We encourage everyone to stay tuned for periodic Vascular Specialist “Wellness Features” and to attend the Wellness Session at the 2019 VAM for interim progress that will feature the following discussions.

• (Re)Finding a meaningful career in vascular surgery.
• Ergonomic challenges to the vascular surgeon and strategies to mitigate the resulting threat of disability.
• EMR best practices to optimize efficiency.
• The role of peer support in vascular surgery, including the mitigation of second victim syndrome.

Surgeon burnout is a real threat to our workforce and the well-being of our colleagues and friends. Risk factors are multifactorial and will require broad, system-level change. The SVS remains fully committed to enhancing vascular surgeon wellness and this Task Force is grateful for your ongoing engagement and support.

Dr. Coleman is an associate professor of vascular surgery at the University of Michigan, Ann Arbor.

Following a series of Vascular Specialist pieces highlighting the crisis of surgeon burnout and the unique challenges that face vascular surgeons, the SVS Wellness Task Force was formed in 2017. Recognizing that burnout may compromise recruitment and retention into our specialty, a particular threat at a time when our specialty faces projected increasing physician workforce needs, and that data suggests physician burnout compromises both patient quality of care and overall satisfaction, the task force was charged with proactively addressing vascular surgeon burnout. Our task force, comprising 21 engaged SVS members from across the country, has been working with strong support from leadership and administration to identify potential SVS targets for meaningful change.

The year 2018 was one of information gathering as we attempted clarify the severity of the problem and perceived member needs. We are grateful to our membership that have helped with this effort – for their time, for their insight, and for sharing their stories (some of which have been deeply personal). Two large-scale surveys were circulated to active SVS membership, both created with the assistance of the Mayo Clinic’s Division of Health Policy and Research.

The first survey was designed with a framework of validated wellness tools and well-described risk factors for burnout, then further “personalized” to incorporate unique challenges to the vascular surgeon. About 32% of our membership responded to this survey and alarmingly, when considering nonretired active SVS members, approximately one-third self-described depressive symptoms, 35% met criteria for burnout, and 8% self-reported suicidal thoughts in the last 12 months.

The second survey has only recently closed, focusing on the ergonomic challenges that we face across the spectrum of complex open and endovascular cases. Recognizing existing data that chronic pain and physical disability are associated with burnout, this data will be linked back to the original survey responses for association. Certainly there is more to come.

Concurrent with our survey initiatives, many of you participated in a Wellness Focus Group during VAM 2018. These focus groups intentionally considered the diversity of our membership across age, gender, practice setting, and region, revealing several important themes that threaten our wellness. It was no surprise that the EMR was identified as a clear threat to vascular surgery well-being and that this is not unique to our specialty. Importantly, our membership collectively feels “undervalued” at an institutional level. Specifically given the scope of comprehensive vascular care that we provide patients, a large part of our work includes both unpredictable acute vascular surgical care (such as intraoperative consultations for vascular trauma) and remedial salvage operations to manage vascular complications inflicted during care received from other physicians. This effort leaves us with little control over our time, often without perceived reciprocal clinical support, institutional support, or compensation.

Given this data, the Wellness Task Force is now strategizing efforts for change and supporting ongoing SVS initiatives. Our Task Force is currently:

• Collaborating with key EMR stakeholders with the goal of creating tools that can be shared across the specialty and addressing best practices for system-level support.
• Drafting a “public reply” to the Office of the National Coordinator for Health Information Technology’s “Strategy on Reducing Burden Relating to the Use of Health IT and EHRs” initiative.
• Collaborating with national experts to establish peer support tools and SVS networking opportunities that may help members cope with adverse outcomes and strategize the delivery of complex care.
• Identifying institutional best practices for surgeon wellness for broad dissemination.
• Supporting existing SVS initiatives that include the PAC/APM task force, branding initiatives through the PPO as we work to “own our space” and leverage our specialty and the community practice committee as the Society works proactively to optimize workload, fairness, and reward on a larger scale for membership.

We encourage everyone to stay tuned for periodic Vascular Specialist “Wellness Features” and to attend the Wellness Session at the 2019 VAM for interim progress that will feature the following discussions.

• (Re)Finding a meaningful career in vascular surgery.
• Ergonomic challenges to the vascular surgeon and strategies to mitigate the resulting threat of disability.
• EMR best practices to optimize efficiency.
• The role of peer support in vascular surgery, including the mitigation of second victim syndrome.

Surgeon burnout is a real threat to our workforce and the well-being of our colleagues and friends. Risk factors are multifactorial and will require broad, system-level change. The SVS remains fully committed to enhancing vascular surgeon wellness and this Task Force is grateful for your ongoing engagement and support.

Dr. Coleman is an associate professor of vascular surgery at the University of Michigan, Ann Arbor.

Following a series of Vascular Specialist pieces highlighting the crisis of surgeon burnout and the unique challenges that face vascular surgeons, the SVS Wellness Task Force was formed in 2017. Recognizing that burnout may compromise recruitment and retention into our specialty, a particular threat at a time when our specialty faces projected increasing physician workforce needs, and that data suggests physician burnout compromises both patient quality of care and overall satisfaction, the task force was charged with proactively addressing vascular surgeon burnout. Our task force, comprising 21 engaged SVS members from across the country, has been working with strong support from leadership and administration to identify potential SVS targets for meaningful change.

The year 2018 was one of information gathering as we attempted clarify the severity of the problem and perceived member needs. We are grateful to our membership that have helped with this effort – for their time, for their insight, and for sharing their stories (some of which have been deeply personal). Two large-scale surveys were circulated to active SVS membership, both created with the assistance of the Mayo Clinic’s Division of Health Policy and Research.

The first survey was designed with a framework of validated wellness tools and well-described risk factors for burnout, then further “personalized” to incorporate unique challenges to the vascular surgeon. About 32% of our membership responded to this survey and alarmingly, when considering nonretired active SVS members, approximately one-third self-described depressive symptoms, 35% met criteria for burnout, and 8% self-reported suicidal thoughts in the last 12 months.

The second survey has only recently closed, focusing on the ergonomic challenges that we face across the spectrum of complex open and endovascular cases. Recognizing existing data that chronic pain and physical disability are associated with burnout, this data will be linked back to the original survey responses for association. Certainly there is more to come.

Concurrent with our survey initiatives, many of you participated in a Wellness Focus Group during VAM 2018. These focus groups intentionally considered the diversity of our membership across age, gender, practice setting, and region, revealing several important themes that threaten our wellness. It was no surprise that the EMR was identified as a clear threat to vascular surgery well-being and that this is not unique to our specialty. Importantly, our membership collectively feels “undervalued” at an institutional level. Specifically given the scope of comprehensive vascular care that we provide patients, a large part of our work includes both unpredictable acute vascular surgical care (such as intraoperative consultations for vascular trauma) and remedial salvage operations to manage vascular complications inflicted during care received from other physicians. This effort leaves us with little control over our time, often without perceived reciprocal clinical support, institutional support, or compensation.

Given this data, the Wellness Task Force is now strategizing efforts for change and supporting ongoing SVS initiatives. Our Task Force is currently:

• Collaborating with key EMR stakeholders with the goal of creating tools that can be shared across the specialty and addressing best practices for system-level support.
• Drafting a “public reply” to the Office of the National Coordinator for Health Information Technology’s “Strategy on Reducing Burden Relating to the Use of Health IT and EHRs” initiative.
• Collaborating with national experts to establish peer support tools and SVS networking opportunities that may help members cope with adverse outcomes and strategize the delivery of complex care.
• Identifying institutional best practices for surgeon wellness for broad dissemination.
• Supporting existing SVS initiatives that include the PAC/APM task force, branding initiatives through the PPO as we work to “own our space” and leverage our specialty and the community practice committee as the Society works proactively to optimize workload, fairness, and reward on a larger scale for membership.

We encourage everyone to stay tuned for periodic Vascular Specialist “Wellness Features” and to attend the Wellness Session at the 2019 VAM for interim progress that will feature the following discussions.

• (Re)Finding a meaningful career in vascular surgery.
• Ergonomic challenges to the vascular surgeon and strategies to mitigate the resulting threat of disability.
• EMR best practices to optimize efficiency.
• The role of peer support in vascular surgery, including the mitigation of second victim syndrome.

Surgeon burnout is a real threat to our workforce and the well-being of our colleagues and friends. Risk factors are multifactorial and will require broad, system-level change. The SVS remains fully committed to enhancing vascular surgeon wellness and this Task Force is grateful for your ongoing engagement and support.

Dr. Coleman is an associate professor of vascular surgery at the University of Michigan, Ann Arbor.

The Merriam-Webster dictionary defines value as “the regard that something is held to deserve; the importance, worth, or usefulness of something” and “relative worth, utility, or importance.” We usually assess our professional worth by how we are treated at work. In social valuing framework, we are given social status based on how others regard us for who we are, what we do, and what we are worth. This is described as “felt worth,” which encapsulates our feelings about how we are regarded by others, in contrast to self-esteem, which is more of an internally held belief.

Our power came from our relationship with our patients and our ability to communicate and influence our patients, peers and administrators. As owners of our practices and small businesses, our currency with hospitals and lawmakers was our ability to bring revenue to hospitals and patient concerns directly to legislators. Practicing in more than one hospital made us more valuable and hospitals battled with each other to provide us and our patients the latest tools and conveniences. In return, we gave our valuable time freely without compensation to hospitals as committee members, task force members, and sounding boards for the betterment of the community. If I were a conspiracy theorist, which I am not, and wanted to devalue physicians I would seek to weaken the physician-patient bond. The way to implement this would be for a single hospital employer to put us on a treadmill chasing work relative value units, give us hard-to-accomplish goals, and keep moving the goalpost. Like I said, I do not believe in conspiracies.

The tsunami of byzantine regulations, Stark laws, and complicated reimbursement formulas has sapped our energy to counter the devaluation. Some are glad to see physicians, particularly surgeons, get their comeuppance because we are perceived as having large egos. This may be true in some instances. Yet, it turns out that the top three job titles with the largest egos are: private household cooks, chief executives, and farm and ranch managers.¹

References

1. www.chicagotribune.com/business/ct-payscale-ego-survey-0830-biz-20160829-story.html

2. www.medpagetoday.com/primarycare/generalprimarycare/60446

3. https://nurse.org/articles/gallup-ethical-standards-poll-nurses-rank-highest/

4.https://news.gallup.com/poll/120890/healthcare-americans-trust-physicians-politicians.aspx

Bhagwan Satiani, MD, MBA, is professor of clinical surgery in the division of vascular diseases and surgery at Ohio State University, Columbus. He blogs at www.savvy-medicine.com . Reach him on Twitter @savvycutter.

The Merriam-Webster dictionary defines value as “the regard that something is held to deserve; the importance, worth, or usefulness of something” and “relative worth, utility, or importance.” We usually assess our professional worth by how we are treated at work. In social valuing framework, we are given social status based on how others regard us for who we are, what we do, and what we are worth. This is described as “felt worth,” which encapsulates our feelings about how we are regarded by others, in contrast to self-esteem, which is more of an internally held belief.

Our power came from our relationship with our patients and our ability to communicate and influence our patients, peers and administrators. As owners of our practices and small businesses, our currency with hospitals and lawmakers was our ability to bring revenue to hospitals and patient concerns directly to legislators. Practicing in more than one hospital made us more valuable and hospitals battled with each other to provide us and our patients the latest tools and conveniences. In return, we gave our valuable time freely without compensation to hospitals as committee members, task force members, and sounding boards for the betterment of the community. If I were a conspiracy theorist, which I am not, and wanted to devalue physicians I would seek to weaken the physician-patient bond. The way to implement this would be for a single hospital employer to put us on a treadmill chasing work relative value units, give us hard-to-accomplish goals, and keep moving the goalpost. Like I said, I do not believe in conspiracies.

The tsunami of byzantine regulations, Stark laws, and complicated reimbursement formulas has sapped our energy to counter the devaluation. Some are glad to see physicians, particularly surgeons, get their comeuppance because we are perceived as having large egos. This may be true in some instances. Yet, it turns out that the top three job titles with the largest egos are: private household cooks, chief executives, and farm and ranch managers.¹

References

1. www.chicagotribune.com/business/ct-payscale-ego-survey-0830-biz-20160829-story.html

2. www.medpagetoday.com/primarycare/generalprimarycare/60446

3. https://nurse.org/articles/gallup-ethical-standards-poll-nurses-rank-highest/

4.https://news.gallup.com/poll/120890/healthcare-americans-trust-physicians-politicians.aspx

Bhagwan Satiani, MD, MBA, is professor of clinical surgery in the division of vascular diseases and surgery at Ohio State University, Columbus. He blogs at www.savvy-medicine.com . Reach him on Twitter @savvycutter.

The Merriam-Webster dictionary defines value as “the regard that something is held to deserve; the importance, worth, or usefulness of something” and “relative worth, utility, or importance.” We usually assess our professional worth by how we are treated at work. In social valuing framework, we are given social status based on how others regard us for who we are, what we do, and what we are worth. This is described as “felt worth,” which encapsulates our feelings about how we are regarded by others, in contrast to self-esteem, which is more of an internally held belief.

Our power came from our relationship with our patients and our ability to communicate and influence our patients, peers and administrators. As owners of our practices and small businesses, our currency with hospitals and lawmakers was our ability to bring revenue to hospitals and patient concerns directly to legislators. Practicing in more than one hospital made us more valuable and hospitals battled with each other to provide us and our patients the latest tools and conveniences. In return, we gave our valuable time freely without compensation to hospitals as committee members, task force members, and sounding boards for the betterment of the community. If I were a conspiracy theorist, which I am not, and wanted to devalue physicians I would seek to weaken the physician-patient bond. The way to implement this would be for a single hospital employer to put us on a treadmill chasing work relative value units, give us hard-to-accomplish goals, and keep moving the goalpost. Like I said, I do not believe in conspiracies.

The tsunami of byzantine regulations, Stark laws, and complicated reimbursement formulas has sapped our energy to counter the devaluation. Some are glad to see physicians, particularly surgeons, get their comeuppance because we are perceived as having large egos. This may be true in some instances. Yet, it turns out that the top three job titles with the largest egos are: private household cooks, chief executives, and farm and ranch managers.¹

References

1. www.chicagotribune.com/business/ct-payscale-ego-survey-0830-biz-20160829-story.html

2. www.medpagetoday.com/primarycare/generalprimarycare/60446

3. https://nurse.org/articles/gallup-ethical-standards-poll-nurses-rank-highest/

4.https://news.gallup.com/poll/120890/healthcare-americans-trust-physicians-politicians.aspx

Bhagwan Satiani, MD, MBA, is professor of clinical surgery in the division of vascular diseases and surgery at Ohio State University, Columbus. He blogs at www.savvy-medicine.com . Reach him on Twitter @savvycutter.

There has been an increasing demand for achieving noninvasive skin lifting and tightening around aging knees and elbows. The cosmetic industry improves techniques for tightening faces, hands, necks, and decolletes; meanwhile, sagging elbows and knees, once ignored, also are a visible sign of aging. Modifying techniques commonly used for the face and neck can yield significant improvements in the elbows and knees. The elbows and knees naturally have looser skin to allow for joint movement; over time, the skin over these joints is exposed to sun damage, friction, and recurrent extension and flexion, which cause skin laxity and aging.

A combination approach addressing skin texture, collagen damage, rhytides, and fat deposition is the most effective method for knee and elbow rejuvenation.

For knees and elbows with loose skin and rhytides, in-office noninvasive and minimally invasive radio-frequency and light energy treatments are helpful in increasing collagen production and tissue tightening. Similarly, microfocused ultrasound has been shown to be a safe and effective skin tightening treatment for the knees. In comparison to the face, however, the skin around the elbows and knees can be thinner and has fewer sebaceous glands. Caution should be used particularly with minimally invasive radio-frequency techniques in order to protect the epidermal skin. Often, treatments have to be repeated to give optimal results, which are not apparent until 3-6 months after the initial procedure.

For knee skin with severe laxity, a comprehensive approach using polydioxanone (PDO) or poly-l-lactic acid (PLLA) threads in both the upper thighs and circumferentially around the knees provides collagen production and tightening of the loose skin. Treatment of the upper thighs is essential in providing a vector that lifts the skin of the knees. Treatments can be repeated, with results seen after 90 days. Thread lifts of the knees and thighs are highly effective, noninvasive procedures with little to no downtime and can be used for severe skin laxity, wrinkling, and thinning of the knee skin.

Lily Talakoub, MD

Loose, roughened knee and elbow skin can also be treated with nonablative factional resurfacing, radio-frequency microneedling, or a series of monthly treatments with PLLA and hyaluronic acid fillers injected in the superficial to mid-dermis. Both fractional resurfacing and dermal filler injections help stimulate collagen production and improve both fine rhytides and dermatoheliosis.

Adipose tissue around the knees can be treated with monthly deoxycholic acid injections (for a video of this procedure, go to https://drive.google.com/file/d/1rhw-nESy15AoDhKUrc25DDjKEun7RL4i/view). The volume of injection, however, is significantly higher than that recommended in the submental area. Two to four times the volume is needed per knee over a series of 3-6 treatments, depending on the amount of fat in the knees.

Cryolipolysis is also an effective option for fat pockets around the knees; however, in my experience, it can be difficult to fit the applicators onto the area of concern appropriately unless smaller applicators are applied.

With the increasing demand for body rejuvenation techniques, providers are adapting techniques used for the face and neck to lift, tighten, thin, and sculpt the knees and elbows. A combination approach using lasers, ultrasound, fillers, threads, and cryolipolysis can be effective for these areas. Results are obtainable when repeat treatments are performed; however, one must be patient because results are not seen for 6 months or more.

Dr. Lily Talakoub and Dr. Naissan Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.

References

Macedo O. et al. J Am Acad Dermatol. 2014;70(Suppl 1), Abstract P800, page AB193.
 

There has been an increasing demand for achieving noninvasive skin lifting and tightening around aging knees and elbows. The cosmetic industry improves techniques for tightening faces, hands, necks, and decolletes; meanwhile, sagging elbows and knees, once ignored, also are a visible sign of aging. Modifying techniques commonly used for the face and neck can yield significant improvements in the elbows and knees. The elbows and knees naturally have looser skin to allow for joint movement; over time, the skin over these joints is exposed to sun damage, friction, and recurrent extension and flexion, which cause skin laxity and aging.

A combination approach addressing skin texture, collagen damage, rhytides, and fat deposition is the most effective method for knee and elbow rejuvenation.

For knees and elbows with loose skin and rhytides, in-office noninvasive and minimally invasive radio-frequency and light energy treatments are helpful in increasing collagen production and tissue tightening. Similarly, microfocused ultrasound has been shown to be a safe and effective skin tightening treatment for the knees. In comparison to the face, however, the skin around the elbows and knees can be thinner and has fewer sebaceous glands. Caution should be used particularly with minimally invasive radio-frequency techniques in order to protect the epidermal skin. Often, treatments have to be repeated to give optimal results, which are not apparent until 3-6 months after the initial procedure.

For knee skin with severe laxity, a comprehensive approach using polydioxanone (PDO) or poly-l-lactic acid (PLLA) threads in both the upper thighs and circumferentially around the knees provides collagen production and tightening of the loose skin. Treatment of the upper thighs is essential in providing a vector that lifts the skin of the knees. Treatments can be repeated, with results seen after 90 days. Thread lifts of the knees and thighs are highly effective, noninvasive procedures with little to no downtime and can be used for severe skin laxity, wrinkling, and thinning of the knee skin.

Lily Talakoub, MD

Loose, roughened knee and elbow skin can also be treated with nonablative factional resurfacing, radio-frequency microneedling, or a series of monthly treatments with PLLA and hyaluronic acid fillers injected in the superficial to mid-dermis. Both fractional resurfacing and dermal filler injections help stimulate collagen production and improve both fine rhytides and dermatoheliosis.

Adipose tissue around the knees can be treated with monthly deoxycholic acid injections (for a video of this procedure, go to https://drive.google.com/file/d/1rhw-nESy15AoDhKUrc25DDjKEun7RL4i/view). The volume of injection, however, is significantly higher than that recommended in the submental area. Two to four times the volume is needed per knee over a series of 3-6 treatments, depending on the amount of fat in the knees.

Cryolipolysis is also an effective option for fat pockets around the knees; however, in my experience, it can be difficult to fit the applicators onto the area of concern appropriately unless smaller applicators are applied.

With the increasing demand for body rejuvenation techniques, providers are adapting techniques used for the face and neck to lift, tighten, thin, and sculpt the knees and elbows. A combination approach using lasers, ultrasound, fillers, threads, and cryolipolysis can be effective for these areas. Results are obtainable when repeat treatments are performed; however, one must be patient because results are not seen for 6 months or more.

Dr. Lily Talakoub and Dr. Naissan Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.

References

Macedo O. et al. J Am Acad Dermatol. 2014;70(Suppl 1), Abstract P800, page AB193.
 

There has been an increasing demand for achieving noninvasive skin lifting and tightening around aging knees and elbows. The cosmetic industry improves techniques for tightening faces, hands, necks, and decolletes; meanwhile, sagging elbows and knees, once ignored, also are a visible sign of aging. Modifying techniques commonly used for the face and neck can yield significant improvements in the elbows and knees. The elbows and knees naturally have looser skin to allow for joint movement; over time, the skin over these joints is exposed to sun damage, friction, and recurrent extension and flexion, which cause skin laxity and aging.

A combination approach addressing skin texture, collagen damage, rhytides, and fat deposition is the most effective method for knee and elbow rejuvenation.

For knees and elbows with loose skin and rhytides, in-office noninvasive and minimally invasive radio-frequency and light energy treatments are helpful in increasing collagen production and tissue tightening. Similarly, microfocused ultrasound has been shown to be a safe and effective skin tightening treatment for the knees. In comparison to the face, however, the skin around the elbows and knees can be thinner and has fewer sebaceous glands. Caution should be used particularly with minimally invasive radio-frequency techniques in order to protect the epidermal skin. Often, treatments have to be repeated to give optimal results, which are not apparent until 3-6 months after the initial procedure.

For knee skin with severe laxity, a comprehensive approach using polydioxanone (PDO) or poly-l-lactic acid (PLLA) threads in both the upper thighs and circumferentially around the knees provides collagen production and tightening of the loose skin. Treatment of the upper thighs is essential in providing a vector that lifts the skin of the knees. Treatments can be repeated, with results seen after 90 days. Thread lifts of the knees and thighs are highly effective, noninvasive procedures with little to no downtime and can be used for severe skin laxity, wrinkling, and thinning of the knee skin.

Lily Talakoub, MD

Loose, roughened knee and elbow skin can also be treated with nonablative factional resurfacing, radio-frequency microneedling, or a series of monthly treatments with PLLA and hyaluronic acid fillers injected in the superficial to mid-dermis. Both fractional resurfacing and dermal filler injections help stimulate collagen production and improve both fine rhytides and dermatoheliosis.

Adipose tissue around the knees can be treated with monthly deoxycholic acid injections (for a video of this procedure, go to https://drive.google.com/file/d/1rhw-nESy15AoDhKUrc25DDjKEun7RL4i/view). The volume of injection, however, is significantly higher than that recommended in the submental area. Two to four times the volume is needed per knee over a series of 3-6 treatments, depending on the amount of fat in the knees.

Cryolipolysis is also an effective option for fat pockets around the knees; however, in my experience, it can be difficult to fit the applicators onto the area of concern appropriately unless smaller applicators are applied.

With the increasing demand for body rejuvenation techniques, providers are adapting techniques used for the face and neck to lift, tighten, thin, and sculpt the knees and elbows. A combination approach using lasers, ultrasound, fillers, threads, and cryolipolysis can be effective for these areas. Results are obtainable when repeat treatments are performed; however, one must be patient because results are not seen for 6 months or more.

Dr. Lily Talakoub and Dr. Naissan Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.

References

Macedo O. et al. J Am Acad Dermatol. 2014;70(Suppl 1), Abstract P800, page AB193.
 

The suicide rate among veterans is almost double that of the general American population. It has been rising among those who served in the wars in Iraq and Afghanistan.

monkeybusinessimages/ThinkStock

“At a time when 20 veterans a day still die by suicide, [the Department of Veterans Affairs] should be doing everything in its power to inform the public about the resources available to veterans in crisis,” Rep. Tim Walz, the Minnesota Democrat who requested the investigation, reportedly said in a statement. “Unfortunately, VA failed to do that.”

Mr. Walz was referring to a failure in prevention efforts that was detailed in a Government Accountability Office report released recently and was the subject of an article in the New York Times. The report blames bureaucratic confusion and an absence of leadership – epitomized by several department vacancies.

“This is such an important issue; we need to be throwing everything we can at it,” said Caitin Thompson, PhD. She was director of the VA’s suicide prevention efforts but resigned in frustration in mid-2017. “It’s so ludicrous that money would be sitting on the table. Outreach is one of the first ways to engage with veterans and families about ways to get help. If we don’t have that, what do we have?”

Surviving the holidays with depression

The postcard image of the Christmas season is that of joyous celebration with family and friends. For many people, however, this image is false. Many complain about feelings of stress imposed by familial obligations, pressure to conform to those postcard myths, and the financial toll that all of that holiday largesse can exact.

Now add depression to this mix. How can those burdened by depression find some joy at this time of year? In a recent article in the Huffington Post, author Andrea Loewen advises staying away from social media and focusing on the positive.

“[Social media] is a double-edged sword: Either I see all the amazing things everyone else is doing and feel jealous/insignificant/left out, or I see that no one else is really posting and assume they must be too busy having incredible quality time with their families while I’m the unengaged loser scrolling Instagram,” Ms. Loewen wrote. “Either way, it’s bad news.”

One concrete practice that she engages in is taking a few minutes to think about and write down the positive things that happened each day.

“The list includes everything, big and small: from the thoughtful gift I wasn’t expecting to the simple observation that a friend seemed happy to see me,” Ms. Loewen wrote. “Depending on where I’m at in my depression, those seemingly tiny details can be vital reminders I hold a valuable place in the world.”

Artist perpetuates persistent myth

In some ways, Kanye West embraces his diagnosis of bipolar disorder. He calls the illness his “superpower,” and the art on his new album, “Ye,” includes the phrase: “I hate being Bi-Polar/it’s awesome.” But his decision to abandon his medications promotes a myth, Amanda Mull wrote in an opinion piece in the Atlantic.

“In apparently quitting his psychiatric medication for the sake of his creativity, Mr. West is promoting one of mental health’s most persistent and dangerous myths: that suffering is necessary for great art,” Ms. Mull wrote.

Philip R. Muskin, MD, who is affiliated with the department of psychiatry at Columbia University in New York, agreed that linking mental turmoil with creative genius is indeed problematic. “Creative people are not creative when they’re depressed, or so manic that no one can tolerate being with them and they start to merge into psychosis, or when they’re filled with numbing anxiety,” he said in the Atlantic article.

Esmé Weijun Wang concurred and offered a counterview to that of Mr. West. A novelist who has written about living with schizoaffective disorder, she said: “It may be true that mental illness has given me insights with which to work, creatively speaking, but it’s also made me too sick to use that creativity. The voice in my head that says, ‘Die, die, die’ is not a voice that encourages putting together a short story.”

For his part, Mr. West’s decision to stop taking his medicine threatens to undermine his own mental health. And his public musings could drive others away from treatment.

“Antiopioid backlash” causes pain

An article by Fox News has highlighted the daily toll that opioid addiction is exacting on Americans. Government efforts aimed at quelling the use of opioids by targeting availability have had the unintended consequence of the cut-off of prescriptions by many physicians. With that route turned off, many people are turning to other sources for pain relief – or are being left with no relief.

One person in the article related how his wife is unable to obtain pain relief for her neurologic and spinal diseases. “A welcome death has become a discussion,” he said.

Meanwhile, a 69-year-old veteran said the Department of Veterans Affairs ended his pain medication. “I now buy heroin on the street.”

Another person in the article, Herb Erne III, wrote: “As a nurse, I have seen addicts and the other end of opioid abuse. But there is another side to this crisis that people are not talking about, those that actually need pain medications but cannot get them because of the ‘fear factor’ of running afoul of the antiopioid – including legal ones taken safely under medical supervision – backlash.

“The chronically ill who do not abuse, who do not divert, have become the unintended victims of misguided and overzealous efforts by policy- and regulation-making bodies in the government,” he said.

Grandparents filling void

An article in the Detroit News reported on more carnage of the opioid crisis. In Michigan and elsewhere nationwide, increasing numbers of parents with opioid addiction are unable to safely care for their children or have died because of an overdose. Grandparents are stepping in to assume care.

Results of a national survey involving more than 1,000 grandparents found that 20% are the daily caregivers to their grandchildren. They can be on their own, without any financial aid from state or national programs. Other children without grandparents can be diverted to foster care.

It’s a role few grandparents anticipated. “Our system as a whole is messed up. It tears at my heart,” 47-year-old Christina Wasilewski said in the article. “Everyone keeps saying children are resilient, but only to a point.”

Ms. Wasilewski and her husband assumed care for their granddaughter when they discovered her in physical distress from lack of care.

In Michigan, the increase in the rate of opioid-related deaths slowed in 2017 but deaths still rose 9% from 2016 , according to the Michigan Department of Health & Human Services. The prior year the death rate was 35%. In Michigan, grandparents raising their grandchildren do not have legal parental rights for this care, including the right to seek medical care and to pursue educational options.

Ms. Wasilewski’s concern about these trends led her to launch the Caregiver Cafe, a support group for grandparents raising their grandchildren.

The suicide rate among veterans is almost double that of the general American population. It has been rising among those who served in the wars in Iraq and Afghanistan.

monkeybusinessimages/ThinkStock

“At a time when 20 veterans a day still die by suicide, [the Department of Veterans Affairs] should be doing everything in its power to inform the public about the resources available to veterans in crisis,” Rep. Tim Walz, the Minnesota Democrat who requested the investigation, reportedly said in a statement. “Unfortunately, VA failed to do that.”

Mr. Walz was referring to a failure in prevention efforts that was detailed in a Government Accountability Office report released recently and was the subject of an article in the New York Times. The report blames bureaucratic confusion and an absence of leadership – epitomized by several department vacancies.

“This is such an important issue; we need to be throwing everything we can at it,” said Caitin Thompson, PhD. She was director of the VA’s suicide prevention efforts but resigned in frustration in mid-2017. “It’s so ludicrous that money would be sitting on the table. Outreach is one of the first ways to engage with veterans and families about ways to get help. If we don’t have that, what do we have?”

Surviving the holidays with depression

The postcard image of the Christmas season is that of joyous celebration with family and friends. For many people, however, this image is false. Many complain about feelings of stress imposed by familial obligations, pressure to conform to those postcard myths, and the financial toll that all of that holiday largesse can exact.

Now add depression to this mix. How can those burdened by depression find some joy at this time of year? In a recent article in the Huffington Post, author Andrea Loewen advises staying away from social media and focusing on the positive.

“[Social media] is a double-edged sword: Either I see all the amazing things everyone else is doing and feel jealous/insignificant/left out, or I see that no one else is really posting and assume they must be too busy having incredible quality time with their families while I’m the unengaged loser scrolling Instagram,” Ms. Loewen wrote. “Either way, it’s bad news.”

One concrete practice that she engages in is taking a few minutes to think about and write down the positive things that happened each day.

“The list includes everything, big and small: from the thoughtful gift I wasn’t expecting to the simple observation that a friend seemed happy to see me,” Ms. Loewen wrote. “Depending on where I’m at in my depression, those seemingly tiny details can be vital reminders I hold a valuable place in the world.”

Artist perpetuates persistent myth

In some ways, Kanye West embraces his diagnosis of bipolar disorder. He calls the illness his “superpower,” and the art on his new album, “Ye,” includes the phrase: “I hate being Bi-Polar/it’s awesome.” But his decision to abandon his medications promotes a myth, Amanda Mull wrote in an opinion piece in the Atlantic.

“In apparently quitting his psychiatric medication for the sake of his creativity, Mr. West is promoting one of mental health’s most persistent and dangerous myths: that suffering is necessary for great art,” Ms. Mull wrote.

Philip R. Muskin, MD, who is affiliated with the department of psychiatry at Columbia University in New York, agreed that linking mental turmoil with creative genius is indeed problematic. “Creative people are not creative when they’re depressed, or so manic that no one can tolerate being with them and they start to merge into psychosis, or when they’re filled with numbing anxiety,” he said in the Atlantic article.

Esmé Weijun Wang concurred and offered a counterview to that of Mr. West. A novelist who has written about living with schizoaffective disorder, she said: “It may be true that mental illness has given me insights with which to work, creatively speaking, but it’s also made me too sick to use that creativity. The voice in my head that says, ‘Die, die, die’ is not a voice that encourages putting together a short story.”

For his part, Mr. West’s decision to stop taking his medicine threatens to undermine his own mental health. And his public musings could drive others away from treatment.

“Antiopioid backlash” causes pain

An article by Fox News has highlighted the daily toll that opioid addiction is exacting on Americans. Government efforts aimed at quelling the use of opioids by targeting availability have had the unintended consequence of the cut-off of prescriptions by many physicians. With that route turned off, many people are turning to other sources for pain relief – or are being left with no relief.

One person in the article related how his wife is unable to obtain pain relief for her neurologic and spinal diseases. “A welcome death has become a discussion,” he said.

Meanwhile, a 69-year-old veteran said the Department of Veterans Affairs ended his pain medication. “I now buy heroin on the street.”

Another person in the article, Herb Erne III, wrote: “As a nurse, I have seen addicts and the other end of opioid abuse. But there is another side to this crisis that people are not talking about, those that actually need pain medications but cannot get them because of the ‘fear factor’ of running afoul of the antiopioid – including legal ones taken safely under medical supervision – backlash.

“The chronically ill who do not abuse, who do not divert, have become the unintended victims of misguided and overzealous efforts by policy- and regulation-making bodies in the government,” he said.

Grandparents filling void

An article in the Detroit News reported on more carnage of the opioid crisis. In Michigan and elsewhere nationwide, increasing numbers of parents with opioid addiction are unable to safely care for their children or have died because of an overdose. Grandparents are stepping in to assume care.

Results of a national survey involving more than 1,000 grandparents found that 20% are the daily caregivers to their grandchildren. They can be on their own, without any financial aid from state or national programs. Other children without grandparents can be diverted to foster care.

It’s a role few grandparents anticipated. “Our system as a whole is messed up. It tears at my heart,” 47-year-old Christina Wasilewski said in the article. “Everyone keeps saying children are resilient, but only to a point.”

Ms. Wasilewski and her husband assumed care for their granddaughter when they discovered her in physical distress from lack of care.

In Michigan, the increase in the rate of opioid-related deaths slowed in 2017 but deaths still rose 9% from 2016 , according to the Michigan Department of Health & Human Services. The prior year the death rate was 35%. In Michigan, grandparents raising their grandchildren do not have legal parental rights for this care, including the right to seek medical care and to pursue educational options.

Ms. Wasilewski’s concern about these trends led her to launch the Caregiver Cafe, a support group for grandparents raising their grandchildren.

The suicide rate among veterans is almost double that of the general American population. It has been rising among those who served in the wars in Iraq and Afghanistan.

monkeybusinessimages/ThinkStock

“At a time when 20 veterans a day still die by suicide, [the Department of Veterans Affairs] should be doing everything in its power to inform the public about the resources available to veterans in crisis,” Rep. Tim Walz, the Minnesota Democrat who requested the investigation, reportedly said in a statement. “Unfortunately, VA failed to do that.”

Mr. Walz was referring to a failure in prevention efforts that was detailed in a Government Accountability Office report released recently and was the subject of an article in the New York Times. The report blames bureaucratic confusion and an absence of leadership – epitomized by several department vacancies.

“This is such an important issue; we need to be throwing everything we can at it,” said Caitin Thompson, PhD. She was director of the VA’s suicide prevention efforts but resigned in frustration in mid-2017. “It’s so ludicrous that money would be sitting on the table. Outreach is one of the first ways to engage with veterans and families about ways to get help. If we don’t have that, what do we have?”

Surviving the holidays with depression

The postcard image of the Christmas season is that of joyous celebration with family and friends. For many people, however, this image is false. Many complain about feelings of stress imposed by familial obligations, pressure to conform to those postcard myths, and the financial toll that all of that holiday largesse can exact.

Now add depression to this mix. How can those burdened by depression find some joy at this time of year? In a recent article in the Huffington Post, author Andrea Loewen advises staying away from social media and focusing on the positive.

“[Social media] is a double-edged sword: Either I see all the amazing things everyone else is doing and feel jealous/insignificant/left out, or I see that no one else is really posting and assume they must be too busy having incredible quality time with their families while I’m the unengaged loser scrolling Instagram,” Ms. Loewen wrote. “Either way, it’s bad news.”

One concrete practice that she engages in is taking a few minutes to think about and write down the positive things that happened each day.

“The list includes everything, big and small: from the thoughtful gift I wasn’t expecting to the simple observation that a friend seemed happy to see me,” Ms. Loewen wrote. “Depending on where I’m at in my depression, those seemingly tiny details can be vital reminders I hold a valuable place in the world.”

Artist perpetuates persistent myth

In some ways, Kanye West embraces his diagnosis of bipolar disorder. He calls the illness his “superpower,” and the art on his new album, “Ye,” includes the phrase: “I hate being Bi-Polar/it’s awesome.” But his decision to abandon his medications promotes a myth, Amanda Mull wrote in an opinion piece in the Atlantic.

“In apparently quitting his psychiatric medication for the sake of his creativity, Mr. West is promoting one of mental health’s most persistent and dangerous myths: that suffering is necessary for great art,” Ms. Mull wrote.

Philip R. Muskin, MD, who is affiliated with the department of psychiatry at Columbia University in New York, agreed that linking mental turmoil with creative genius is indeed problematic. “Creative people are not creative when they’re depressed, or so manic that no one can tolerate being with them and they start to merge into psychosis, or when they’re filled with numbing anxiety,” he said in the Atlantic article.

Esmé Weijun Wang concurred and offered a counterview to that of Mr. West. A novelist who has written about living with schizoaffective disorder, she said: “It may be true that mental illness has given me insights with which to work, creatively speaking, but it’s also made me too sick to use that creativity. The voice in my head that says, ‘Die, die, die’ is not a voice that encourages putting together a short story.”

For his part, Mr. West’s decision to stop taking his medicine threatens to undermine his own mental health. And his public musings could drive others away from treatment.

“Antiopioid backlash” causes pain

An article by Fox News has highlighted the daily toll that opioid addiction is exacting on Americans. Government efforts aimed at quelling the use of opioids by targeting availability have had the unintended consequence of the cut-off of prescriptions by many physicians. With that route turned off, many people are turning to other sources for pain relief – or are being left with no relief.

One person in the article related how his wife is unable to obtain pain relief for her neurologic and spinal diseases. “A welcome death has become a discussion,” he said.

Meanwhile, a 69-year-old veteran said the Department of Veterans Affairs ended his pain medication. “I now buy heroin on the street.”

Another person in the article, Herb Erne III, wrote: “As a nurse, I have seen addicts and the other end of opioid abuse. But there is another side to this crisis that people are not talking about, those that actually need pain medications but cannot get them because of the ‘fear factor’ of running afoul of the antiopioid – including legal ones taken safely under medical supervision – backlash.

“The chronically ill who do not abuse, who do not divert, have become the unintended victims of misguided and overzealous efforts by policy- and regulation-making bodies in the government,” he said.

Grandparents filling void

An article in the Detroit News reported on more carnage of the opioid crisis. In Michigan and elsewhere nationwide, increasing numbers of parents with opioid addiction are unable to safely care for their children or have died because of an overdose. Grandparents are stepping in to assume care.

Results of a national survey involving more than 1,000 grandparents found that 20% are the daily caregivers to their grandchildren. They can be on their own, without any financial aid from state or national programs. Other children without grandparents can be diverted to foster care.

It’s a role few grandparents anticipated. “Our system as a whole is messed up. It tears at my heart,” 47-year-old Christina Wasilewski said in the article. “Everyone keeps saying children are resilient, but only to a point.”

Ms. Wasilewski and her husband assumed care for their granddaughter when they discovered her in physical distress from lack of care.

In Michigan, the increase in the rate of opioid-related deaths slowed in 2017 but deaths still rose 9% from 2016 , according to the Michigan Department of Health & Human Services. The prior year the death rate was 35%. In Michigan, grandparents raising their grandchildren do not have legal parental rights for this care, including the right to seek medical care and to pursue educational options.

Ms. Wasilewski’s concern about these trends led her to launch the Caregiver Cafe, a support group for grandparents raising their grandchildren.

Responding to a police call can prove dangerous. In those kinds of high-pressure situations, agitation or other manifestations of mental illness might be mistaken for violent intent – with disastrous results.

Antonprado/iStock.com

In Kalamazoo, Mich., crime response training now includes subduing suspects without using violent force. “Through training and education, and scenarios that we use in the training, [the officers] start to detect the different cues or indicators where they start to see that this is really a crisis event. And we treat it as a medical issue and get that person the help that they need,” said Rafael Diaz, executive lieutenant with the Kalamazoo Department of Public Safety in an interview on Michigan NPR.

In the training, called the Crisis Intervention Team model, the goal is to slow down the pace of the interaction and keep some distance between themselves and the suspect after officers recognize signs of mental illness. Both responses can lower the chances of a lash-out response.

The result has been a drop in violent engagements between officers and suspects. “The number of injuries to officers goes down, the number of injuries to the person in crisis goes down, and there is a huge benefit to society there if you don’t have to use physical force,” Mr. Diaz said.

Animal neglect and mental health

Images of neglected and abused livestock on farms can inspire thoughts of how someone could mistreat the animals in their care. “Frankly, if you can’t understand that, it’s probably a good thing. It means you haven’t been in the depths of low, low mental health, depression, and anxiety,” Andria Jones-Bitton, DVM, PhD, said in an interview with the Western Producer.

Dr. Jones-Bitton is a veterinarian and epidemiologist at the Ontario Veterinary College in Guelph. She is studying the mental health and mental resilience of farmers and veterinarians.

“If farmers are struggling with their own well-being and motivation, they’re likely going to find it difficult to invest in improving animal welfare. When we’re mentally unwell, it’s hard to care for ourselves, let alone to care for others, even when those others are really important to us,” she said.

A national survey of Canadian farmers by Dr. Jones-Bitton showed high levels of stress and diminished ability to cope with the pressures that come with running a livestock farm. “What makes me the most upset is I have everything I’ve ever dreamed of – love, family, and a farm, and all I feel is overwhelmed out of control and sad,” one respondent said.

The problems are not unique to Canada. Studies from Ireland, for example, documented an association between animal neglect cases and the mental health, drug/alcohol addiction, and social problems of farmers.

“Even if you didn’t care about the humans that were struggling and you only cared about the animal welfare, you’d be wise to address the issue of farmer stress,” Dr. Jones-Britton said.

Depression and rural America

A recent “Farming in Tough Times” workshop that convened in Minnesota focused on the mental health of farmers. Making a living is challenging for many reasons. One is that prices for commodities are set by others.

“I realized that I can’t change the situation that we’re in. I can’t change milk prices. I can’t stop farms from going bankrupt. But I can change how we are. And we are together, and that really does matter,” said dairy farmer Brenda Rudolph during the workshop, according to a report from the St. Cloud Times, which is part of the USA Today network.

“There is a conversation you people have to have in America, rural America, that says, depression is part of your life. It is not a sign of weakness. It’s a sign of reality,” said Dennis Hoiberg, a farming consultant based in Australia who spoke at the workshop. He added that, from his perspective, the United States still tends to be more repressed about mental health issues than elsewhere in the world – with the focus on stress and not on resiliency.

“Most of you folk are proud folk, and most you folk are very proud of what you do,” Mr. Hoiberg said. “You’re also psychologically exposed because you are a true believer [in what you do].”

Advice offered to lessen the tough times included noticing the beauty in the world, breaking down problems into small chunks that are more easily dealt with and then moving on to the next, sleep, and a good diet.

People with mental illness languishing

Public defenders in Colorado are seeking to have dozens of people diagnosed with mental illness who are in jail awaiting trial set free until their court date. The usual scenario in Colorado for someone charged with a crime and jailed who is deemed mentally incompetent is treatment within 28 days. However, this system is broken and wait times are far longer – in one instance 270 days.

“Many of them are there for very, very low level offenses and they’re holding in jail for way longer than a person who did not suffer from mental illness would be in custody,” said Maureen Cain, policy liaison for the public defender’s office in an interview with the Denver Post. “They are being incarcerated for their mental illness, not really because of the crime they committed.” Responses from judges have ranged from immediate release to finding the incarcerated person guilty of contempt and sending them back to jail.

The Colorado Department of Human Services is in charge of people who have been jailed but have been found to be incompetent to stand trial. Officials there have say they do not have enough bed space or capacity to get people moved out of jail within 28 days.

“We are in a situation where [the human services department] is in breach, and I need to know what efforts are being made to bring it back into compliance,” said federal Judge Nina Y. Wang. “These individuals are not being served, and frankly, the state is not being served.”

“Cruel” practice confined youth

A federal class action lawsuit filed against the Departmental of Children and Family Services (DCFS) in the Chicago area alleges that, from 2015 to 2017, more than 800 youth were being confined to psychiatric hospitals even when they were cleared for discharge. The problem goes back decades and is getting worse, the lawsuit contends.

“I spent Thanksgiving, Christmas, New Year’s, Easter, and my 16th birthday in the hospital,” said Skylar, who’s now 19 years old. “I only got to go outside one time. I felt like a prisoner; I felt very depressed.”

As reported on Chicago’s WGN9 News, the delay between clearance for discharge and actual freedom is a month or more in many of the cases. Acting Cook County Public Guardian Charles Golbert said the practice is “cruel, unusual, and illegal. It’s a violation of the children’s civil and most basic human rights.”

Many of the youth had been incarcerated for setting fires and self-harm and had been rejected by foster parents and other providers, in some cases their own families, who were concerned with the possible behavior of the youth after their release.

“Blame the children is the wrong response from DCFS,” said attorney Russell Ainsworth. “DCFS should be apologizing for not addressing this issue and for violating the Constitution.”

Responding to a police call can prove dangerous. In those kinds of high-pressure situations, agitation or other manifestations of mental illness might be mistaken for violent intent – with disastrous results.

Antonprado/iStock.com

In Kalamazoo, Mich., crime response training now includes subduing suspects without using violent force. “Through training and education, and scenarios that we use in the training, [the officers] start to detect the different cues or indicators where they start to see that this is really a crisis event. And we treat it as a medical issue and get that person the help that they need,” said Rafael Diaz, executive lieutenant with the Kalamazoo Department of Public Safety in an interview on Michigan NPR.

In the training, called the Crisis Intervention Team model, the goal is to slow down the pace of the interaction and keep some distance between themselves and the suspect after officers recognize signs of mental illness. Both responses can lower the chances of a lash-out response.

The result has been a drop in violent engagements between officers and suspects. “The number of injuries to officers goes down, the number of injuries to the person in crisis goes down, and there is a huge benefit to society there if you don’t have to use physical force,” Mr. Diaz said.

Animal neglect and mental health

Images of neglected and abused livestock on farms can inspire thoughts of how someone could mistreat the animals in their care. “Frankly, if you can’t understand that, it’s probably a good thing. It means you haven’t been in the depths of low, low mental health, depression, and anxiety,” Andria Jones-Bitton, DVM, PhD, said in an interview with the Western Producer.

Dr. Jones-Bitton is a veterinarian and epidemiologist at the Ontario Veterinary College in Guelph. She is studying the mental health and mental resilience of farmers and veterinarians.

“If farmers are struggling with their own well-being and motivation, they’re likely going to find it difficult to invest in improving animal welfare. When we’re mentally unwell, it’s hard to care for ourselves, let alone to care for others, even when those others are really important to us,” she said.

A national survey of Canadian farmers by Dr. Jones-Bitton showed high levels of stress and diminished ability to cope with the pressures that come with running a livestock farm. “What makes me the most upset is I have everything I’ve ever dreamed of – love, family, and a farm, and all I feel is overwhelmed out of control and sad,” one respondent said.

The problems are not unique to Canada. Studies from Ireland, for example, documented an association between animal neglect cases and the mental health, drug/alcohol addiction, and social problems of farmers.

“Even if you didn’t care about the humans that were struggling and you only cared about the animal welfare, you’d be wise to address the issue of farmer stress,” Dr. Jones-Britton said.

Depression and rural America

A recent “Farming in Tough Times” workshop that convened in Minnesota focused on the mental health of farmers. Making a living is challenging for many reasons. One is that prices for commodities are set by others.

“I realized that I can’t change the situation that we’re in. I can’t change milk prices. I can’t stop farms from going bankrupt. But I can change how we are. And we are together, and that really does matter,” said dairy farmer Brenda Rudolph during the workshop, according to a report from the St. Cloud Times, which is part of the USA Today network.

“There is a conversation you people have to have in America, rural America, that says, depression is part of your life. It is not a sign of weakness. It’s a sign of reality,” said Dennis Hoiberg, a farming consultant based in Australia who spoke at the workshop. He added that, from his perspective, the United States still tends to be more repressed about mental health issues than elsewhere in the world – with the focus on stress and not on resiliency.

“Most of you folk are proud folk, and most you folk are very proud of what you do,” Mr. Hoiberg said. “You’re also psychologically exposed because you are a true believer [in what you do].”

Advice offered to lessen the tough times included noticing the beauty in the world, breaking down problems into small chunks that are more easily dealt with and then moving on to the next, sleep, and a good diet.

People with mental illness languishing

Public defenders in Colorado are seeking to have dozens of people diagnosed with mental illness who are in jail awaiting trial set free until their court date. The usual scenario in Colorado for someone charged with a crime and jailed who is deemed mentally incompetent is treatment within 28 days. However, this system is broken and wait times are far longer – in one instance 270 days.

“Many of them are there for very, very low level offenses and they’re holding in jail for way longer than a person who did not suffer from mental illness would be in custody,” said Maureen Cain, policy liaison for the public defender’s office in an interview with the Denver Post. “They are being incarcerated for their mental illness, not really because of the crime they committed.” Responses from judges have ranged from immediate release to finding the incarcerated person guilty of contempt and sending them back to jail.

The Colorado Department of Human Services is in charge of people who have been jailed but have been found to be incompetent to stand trial. Officials there have say they do not have enough bed space or capacity to get people moved out of jail within 28 days.

“We are in a situation where [the human services department] is in breach, and I need to know what efforts are being made to bring it back into compliance,” said federal Judge Nina Y. Wang. “These individuals are not being served, and frankly, the state is not being served.”

“Cruel” practice confined youth

A federal class action lawsuit filed against the Departmental of Children and Family Services (DCFS) in the Chicago area alleges that, from 2015 to 2017, more than 800 youth were being confined to psychiatric hospitals even when they were cleared for discharge. The problem goes back decades and is getting worse, the lawsuit contends.

“I spent Thanksgiving, Christmas, New Year’s, Easter, and my 16th birthday in the hospital,” said Skylar, who’s now 19 years old. “I only got to go outside one time. I felt like a prisoner; I felt very depressed.”

As reported on Chicago’s WGN9 News, the delay between clearance for discharge and actual freedom is a month or more in many of the cases. Acting Cook County Public Guardian Charles Golbert said the practice is “cruel, unusual, and illegal. It’s a violation of the children’s civil and most basic human rights.”

Many of the youth had been incarcerated for setting fires and self-harm and had been rejected by foster parents and other providers, in some cases their own families, who were concerned with the possible behavior of the youth after their release.

“Blame the children is the wrong response from DCFS,” said attorney Russell Ainsworth. “DCFS should be apologizing for not addressing this issue and for violating the Constitution.”

Responding to a police call can prove dangerous. In those kinds of high-pressure situations, agitation or other manifestations of mental illness might be mistaken for violent intent – with disastrous results.

Antonprado/iStock.com

In Kalamazoo, Mich., crime response training now includes subduing suspects without using violent force. “Through training and education, and scenarios that we use in the training, [the officers] start to detect the different cues or indicators where they start to see that this is really a crisis event. And we treat it as a medical issue and get that person the help that they need,” said Rafael Diaz, executive lieutenant with the Kalamazoo Department of Public Safety in an interview on Michigan NPR.

In the training, called the Crisis Intervention Team model, the goal is to slow down the pace of the interaction and keep some distance between themselves and the suspect after officers recognize signs of mental illness. Both responses can lower the chances of a lash-out response.

The result has been a drop in violent engagements between officers and suspects. “The number of injuries to officers goes down, the number of injuries to the person in crisis goes down, and there is a huge benefit to society there if you don’t have to use physical force,” Mr. Diaz said.

Animal neglect and mental health

Images of neglected and abused livestock on farms can inspire thoughts of how someone could mistreat the animals in their care. “Frankly, if you can’t understand that, it’s probably a good thing. It means you haven’t been in the depths of low, low mental health, depression, and anxiety,” Andria Jones-Bitton, DVM, PhD, said in an interview with the Western Producer.

Dr. Jones-Bitton is a veterinarian and epidemiologist at the Ontario Veterinary College in Guelph. She is studying the mental health and mental resilience of farmers and veterinarians.

“If farmers are struggling with their own well-being and motivation, they’re likely going to find it difficult to invest in improving animal welfare. When we’re mentally unwell, it’s hard to care for ourselves, let alone to care for others, even when those others are really important to us,” she said.

A national survey of Canadian farmers by Dr. Jones-Bitton showed high levels of stress and diminished ability to cope with the pressures that come with running a livestock farm. “What makes me the most upset is I have everything I’ve ever dreamed of – love, family, and a farm, and all I feel is overwhelmed out of control and sad,” one respondent said.

The problems are not unique to Canada. Studies from Ireland, for example, documented an association between animal neglect cases and the mental health, drug/alcohol addiction, and social problems of farmers.

“Even if you didn’t care about the humans that were struggling and you only cared about the animal welfare, you’d be wise to address the issue of farmer stress,” Dr. Jones-Britton said.

Depression and rural America

A recent “Farming in Tough Times” workshop that convened in Minnesota focused on the mental health of farmers. Making a living is challenging for many reasons. One is that prices for commodities are set by others.

“I realized that I can’t change the situation that we’re in. I can’t change milk prices. I can’t stop farms from going bankrupt. But I can change how we are. And we are together, and that really does matter,” said dairy farmer Brenda Rudolph during the workshop, according to a report from the St. Cloud Times, which is part of the USA Today network.

“There is a conversation you people have to have in America, rural America, that says, depression is part of your life. It is not a sign of weakness. It’s a sign of reality,” said Dennis Hoiberg, a farming consultant based in Australia who spoke at the workshop. He added that, from his perspective, the United States still tends to be more repressed about mental health issues than elsewhere in the world – with the focus on stress and not on resiliency.

“Most of you folk are proud folk, and most you folk are very proud of what you do,” Mr. Hoiberg said. “You’re also psychologically exposed because you are a true believer [in what you do].”

Advice offered to lessen the tough times included noticing the beauty in the world, breaking down problems into small chunks that are more easily dealt with and then moving on to the next, sleep, and a good diet.

People with mental illness languishing

Public defenders in Colorado are seeking to have dozens of people diagnosed with mental illness who are in jail awaiting trial set free until their court date. The usual scenario in Colorado for someone charged with a crime and jailed who is deemed mentally incompetent is treatment within 28 days. However, this system is broken and wait times are far longer – in one instance 270 days.

“Many of them are there for very, very low level offenses and they’re holding in jail for way longer than a person who did not suffer from mental illness would be in custody,” said Maureen Cain, policy liaison for the public defender’s office in an interview with the Denver Post. “They are being incarcerated for their mental illness, not really because of the crime they committed.” Responses from judges have ranged from immediate release to finding the incarcerated person guilty of contempt and sending them back to jail.

The Colorado Department of Human Services is in charge of people who have been jailed but have been found to be incompetent to stand trial. Officials there have say they do not have enough bed space or capacity to get people moved out of jail within 28 days.

“We are in a situation where [the human services department] is in breach, and I need to know what efforts are being made to bring it back into compliance,” said federal Judge Nina Y. Wang. “These individuals are not being served, and frankly, the state is not being served.”

“Cruel” practice confined youth

A federal class action lawsuit filed against the Departmental of Children and Family Services (DCFS) in the Chicago area alleges that, from 2015 to 2017, more than 800 youth were being confined to psychiatric hospitals even when they were cleared for discharge. The problem goes back decades and is getting worse, the lawsuit contends.

“I spent Thanksgiving, Christmas, New Year’s, Easter, and my 16th birthday in the hospital,” said Skylar, who’s now 19 years old. “I only got to go outside one time. I felt like a prisoner; I felt very depressed.”

As reported on Chicago’s WGN9 News, the delay between clearance for discharge and actual freedom is a month or more in many of the cases. Acting Cook County Public Guardian Charles Golbert said the practice is “cruel, unusual, and illegal. It’s a violation of the children’s civil and most basic human rights.”

Many of the youth had been incarcerated for setting fires and self-harm and had been rejected by foster parents and other providers, in some cases their own families, who were concerned with the possible behavior of the youth after their release.

“Blame the children is the wrong response from DCFS,” said attorney Russell Ainsworth. “DCFS should be apologizing for not addressing this issue and for violating the Constitution.”

As Dr. Melanie Schaffer neared the end of her family medicine residency in the spring of 2015, she found herself considering a hospital medicine fellowship. Unsure if she could get a hospitalist job in an urban market given the outpatient focus of her training, Dr. Schaffer began searching for fellowships on the Society of Hospital Medicine website.¹

Likewise, in 2014 Dr. Micah Prochaska was seriously contemplating a hospital medicine fellowship. He was about to graduate from internal medicine residency at the University of Chicago and was eager to gain skills and experience in clinical research.

In 2006, there were a total of 16 HM fellowship programs in the United States, catering to graduates of internal medicine, family medicine, and pediatric residencies.² Since that time, the number of hospital medicine fellowships has grown considerably, paralleling the explosive growth of hospital medicine as a specialty. For example, at one point in the summer of 2018, the SHM website listed 13 clinical family practice fellowships, 29 internal medicine fellowships, and 26 pediatric fellowships. Each fellowship emphasized different aspects of hospital medicine including clinical practice, research, quality improvement, and leadership.

Now more than ever, residents interested in hospital medicine may get overwhelmed by the multitude of options for fellowship training. And the question remains: why pursue fellowship training in the first place?

“I learned that as a family physician it is harder to get a job as a hospitalist outside of smaller communities, and I wanted to have extra training and credentials,” Dr. Schaffer said. “I pursued a fellowship in hospital medicine to hone my inpatient skills, obtain more ICU exposure, and work on procedures.”

Dr. Schaffer’s online search eventually led her to the Advanced Hospital Medicine Fellowship at Swedish Medical Center in Seattle. This 1-year hospital medicine fellowship started in 2008 with an intentional clinical focus, aiming to provide additional training opportunities in hospital medicine primarily to family medicine residency graduates.

“The goal of our program is to bridge the gap between the training of family medicine and internal medicine so our trainees can refine and develop their inpatient skills,” said Dr. David Wilson, program director of the Swedish Hospitalist Fellowship.

During her fellowship year, Dr. Schaffer was caring for hospitalized adult patients on a general medical ward, with supervision from a dedicated group of teaching hospitalists. She also completed rotations in the ICU, on subspecialty services, and received advanced training in point-of-care ultrasound.

Now in her second year of practice as a full time adult hospitalist at Swedish Medical Center, Dr. Schaffer believes her year of hospital medicine fellowship prepared her well for her current position.

“I am constantly using the tools and knowledge I acquired during my fellowship year,” she said. “I would encourage anyone who has an interest in working on procedural skills and gaining more ICU exposure to pursue a similar fellowship.”

In contrast to Dr. Schaffer, Dr. Prochaska was satisfied with his clinical training but chose to pursue a hospital medicine fellowship to develop research skills. Prior to starting the 2-year Hospitalist Scholars Training Program at the University of Chicago in 2014, Dr. Prochaska had a clear vision of becoming a hospital medicine health outcomes investigator, and believed this career would not be possible without the additional training offered by a research-focused fellowship program.

The Hospitalist Scholars Program at the University of Chicago, one of the first programs of its kind, offers a built-in master’s degree to all participants. At the conclusion of his fellowship training in 2016, Dr. Prochaska completed his Master’s in Health Sciences, which gives considerable attention to biostatistics and epidemiology. According to Dr. Prochaska, the key to becoming a successful academic researcher lies in one’s ability to write grants and receive funding, a skill he honed during this fellowship.

Now on faculty at the University of Chicago in the Section of Hospital Medicine, Dr. Prochaska devotes approximately 75% of his time to research and 25% to patient care.

Beyond the research training and experience he gained during his hospital medicine fellowship, Dr. Prochaska said he values the mentorship afforded to him. He noted that one of the most meaningful experiences during his 2 years of fellowship was having the opportunity to sit down with his program directors, Dr. Vineet Arora and Dr. David Meltzer, to discuss the trajectory of his career in academic medicine.

“It is hard to find senior mentors in hospital medicine,” Dr. Prochaska said. “You could get a master’s degree on your own, but with the fellowship program, your mentors can help you think about the next steps in your career.”

For Dr. Schaffer and Dr. Prochaska, fellowship provided training and experience well-matched to their individual goals and helped foster their careers in hospital medicine. For some, however, a fellowship may not be a necessary step on the path to becoming a hospitalist. Many leaders in the field of hospital medicine have advanced in their careers without further training. In addition, receiving little more than a resident’s salary for an additional year or more during fellowship may not be financially tenable for some. Given the ongoing demand for hospitalists across the country, the lack of a fellowship on your resume may not significantly diminish your chances of securing a position, especially in the community setting.

In the end, the decision of whether to pursue a hospital medicine fellowship is a personal one, and the programs available are as varied as the individuals completing them. “Any hospitalist interested in more than simply patient care – potentially QI, medical education, policy, or administration – should consider a fellowship,” Dr. Prochaska said. “Hospitalists have a unique opportunity to be involved in all these areas, but there are absolutely critical skills you need to develop beyond your clinical skills to succeed.” Fellowships are one way to enhance these nonclinical skills.

The best advice to those considering a hospital medicine fellowship? Dedicate some time to engage in self-assessment and goal setting, before jumping to SHM’s online list of programs.

Ask yourself: “Where do I see myself in 10 years? What do I wish to accomplish in my career as a hospitalist? What additional training (clinical, research, quality improvement, leadership) might I need to achieve these goals? Will completion of a hospital medicine fellowship help me make this vision a reality?”

For Dr. Schaffer, a clinical practice–focused hospital medicine fellowship served as a necessary bridge between her family medicine residency and her current position as an adult hospitalist. While for Dr. Prochaska, a research-intensive hospital medicine fellowship was a key step in launching his academic career.

Of course, for many trainees at the end of residency, your self-assessment may lead you in the opposite direction. In that case it is time to find your first “real job” as an attending physician. But if you feel you need more training to meet your personal goals you should rest assured – whether now or in the future, there is almost certainly a hospital medicine fellowship that is right for you.

Dr. Schouten is a hospitalist at Mayo Clinic in Rochester, Minn., and serves on the Society of Hospital Medicine Physicians in Training Committee. Dr. Sundar is a hospitalist at Emory Saint Joseph’s Hospital in Sandy Springs, Ga., and serves as the Site Assistant Director for Education.

References


1. www.hospitalmedicine.org/membership/hospitalist-fellowships/

2. Ranji et al. “Hospital medicine fellowships: Works in progress.” American J Med. 2006 Jan;119(1):72.e1-7. doi: 10.1016/j.amjmed.2005.07.061.
 

As Dr. Melanie Schaffer neared the end of her family medicine residency in the spring of 2015, she found herself considering a hospital medicine fellowship. Unsure if she could get a hospitalist job in an urban market given the outpatient focus of her training, Dr. Schaffer began searching for fellowships on the Society of Hospital Medicine website.¹

Likewise, in 2014 Dr. Micah Prochaska was seriously contemplating a hospital medicine fellowship. He was about to graduate from internal medicine residency at the University of Chicago and was eager to gain skills and experience in clinical research.

In 2006, there were a total of 16 HM fellowship programs in the United States, catering to graduates of internal medicine, family medicine, and pediatric residencies.² Since that time, the number of hospital medicine fellowships has grown considerably, paralleling the explosive growth of hospital medicine as a specialty. For example, at one point in the summer of 2018, the SHM website listed 13 clinical family practice fellowships, 29 internal medicine fellowships, and 26 pediatric fellowships. Each fellowship emphasized different aspects of hospital medicine including clinical practice, research, quality improvement, and leadership.

Now more than ever, residents interested in hospital medicine may get overwhelmed by the multitude of options for fellowship training. And the question remains: why pursue fellowship training in the first place?

“I learned that as a family physician it is harder to get a job as a hospitalist outside of smaller communities, and I wanted to have extra training and credentials,” Dr. Schaffer said. “I pursued a fellowship in hospital medicine to hone my inpatient skills, obtain more ICU exposure, and work on procedures.”

Dr. Schaffer’s online search eventually led her to the Advanced Hospital Medicine Fellowship at Swedish Medical Center in Seattle. This 1-year hospital medicine fellowship started in 2008 with an intentional clinical focus, aiming to provide additional training opportunities in hospital medicine primarily to family medicine residency graduates.

“The goal of our program is to bridge the gap between the training of family medicine and internal medicine so our trainees can refine and develop their inpatient skills,” said Dr. David Wilson, program director of the Swedish Hospitalist Fellowship.

During her fellowship year, Dr. Schaffer was caring for hospitalized adult patients on a general medical ward, with supervision from a dedicated group of teaching hospitalists. She also completed rotations in the ICU, on subspecialty services, and received advanced training in point-of-care ultrasound.

Now in her second year of practice as a full time adult hospitalist at Swedish Medical Center, Dr. Schaffer believes her year of hospital medicine fellowship prepared her well for her current position.

“I am constantly using the tools and knowledge I acquired during my fellowship year,” she said. “I would encourage anyone who has an interest in working on procedural skills and gaining more ICU exposure to pursue a similar fellowship.”

In contrast to Dr. Schaffer, Dr. Prochaska was satisfied with his clinical training but chose to pursue a hospital medicine fellowship to develop research skills. Prior to starting the 2-year Hospitalist Scholars Training Program at the University of Chicago in 2014, Dr. Prochaska had a clear vision of becoming a hospital medicine health outcomes investigator, and believed this career would not be possible without the additional training offered by a research-focused fellowship program.

The Hospitalist Scholars Program at the University of Chicago, one of the first programs of its kind, offers a built-in master’s degree to all participants. At the conclusion of his fellowship training in 2016, Dr. Prochaska completed his Master’s in Health Sciences, which gives considerable attention to biostatistics and epidemiology. According to Dr. Prochaska, the key to becoming a successful academic researcher lies in one’s ability to write grants and receive funding, a skill he honed during this fellowship.

Now on faculty at the University of Chicago in the Section of Hospital Medicine, Dr. Prochaska devotes approximately 75% of his time to research and 25% to patient care.

Beyond the research training and experience he gained during his hospital medicine fellowship, Dr. Prochaska said he values the mentorship afforded to him. He noted that one of the most meaningful experiences during his 2 years of fellowship was having the opportunity to sit down with his program directors, Dr. Vineet Arora and Dr. David Meltzer, to discuss the trajectory of his career in academic medicine.

“It is hard to find senior mentors in hospital medicine,” Dr. Prochaska said. “You could get a master’s degree on your own, but with the fellowship program, your mentors can help you think about the next steps in your career.”

For Dr. Schaffer and Dr. Prochaska, fellowship provided training and experience well-matched to their individual goals and helped foster their careers in hospital medicine. For some, however, a fellowship may not be a necessary step on the path to becoming a hospitalist. Many leaders in the field of hospital medicine have advanced in their careers without further training. In addition, receiving little more than a resident’s salary for an additional year or more during fellowship may not be financially tenable for some. Given the ongoing demand for hospitalists across the country, the lack of a fellowship on your resume may not significantly diminish your chances of securing a position, especially in the community setting.

In the end, the decision of whether to pursue a hospital medicine fellowship is a personal one, and the programs available are as varied as the individuals completing them. “Any hospitalist interested in more than simply patient care – potentially QI, medical education, policy, or administration – should consider a fellowship,” Dr. Prochaska said. “Hospitalists have a unique opportunity to be involved in all these areas, but there are absolutely critical skills you need to develop beyond your clinical skills to succeed.” Fellowships are one way to enhance these nonclinical skills.

The best advice to those considering a hospital medicine fellowship? Dedicate some time to engage in self-assessment and goal setting, before jumping to SHM’s online list of programs.

Ask yourself: “Where do I see myself in 10 years? What do I wish to accomplish in my career as a hospitalist? What additional training (clinical, research, quality improvement, leadership) might I need to achieve these goals? Will completion of a hospital medicine fellowship help me make this vision a reality?”

For Dr. Schaffer, a clinical practice–focused hospital medicine fellowship served as a necessary bridge between her family medicine residency and her current position as an adult hospitalist. While for Dr. Prochaska, a research-intensive hospital medicine fellowship was a key step in launching his academic career.

Of course, for many trainees at the end of residency, your self-assessment may lead you in the opposite direction. In that case it is time to find your first “real job” as an attending physician. But if you feel you need more training to meet your personal goals you should rest assured – whether now or in the future, there is almost certainly a hospital medicine fellowship that is right for you.

Dr. Schouten is a hospitalist at Mayo Clinic in Rochester, Minn., and serves on the Society of Hospital Medicine Physicians in Training Committee. Dr. Sundar is a hospitalist at Emory Saint Joseph’s Hospital in Sandy Springs, Ga., and serves as the Site Assistant Director for Education.

References


1. www.hospitalmedicine.org/membership/hospitalist-fellowships/

2. Ranji et al. “Hospital medicine fellowships: Works in progress.” American J Med. 2006 Jan;119(1):72.e1-7. doi: 10.1016/j.amjmed.2005.07.061.
 

As Dr. Melanie Schaffer neared the end of her family medicine residency in the spring of 2015, she found herself considering a hospital medicine fellowship. Unsure if she could get a hospitalist job in an urban market given the outpatient focus of her training, Dr. Schaffer began searching for fellowships on the Society of Hospital Medicine website.¹

Likewise, in 2014 Dr. Micah Prochaska was seriously contemplating a hospital medicine fellowship. He was about to graduate from internal medicine residency at the University of Chicago and was eager to gain skills and experience in clinical research.

In 2006, there were a total of 16 HM fellowship programs in the United States, catering to graduates of internal medicine, family medicine, and pediatric residencies.² Since that time, the number of hospital medicine fellowships has grown considerably, paralleling the explosive growth of hospital medicine as a specialty. For example, at one point in the summer of 2018, the SHM website listed 13 clinical family practice fellowships, 29 internal medicine fellowships, and 26 pediatric fellowships. Each fellowship emphasized different aspects of hospital medicine including clinical practice, research, quality improvement, and leadership.

Now more than ever, residents interested in hospital medicine may get overwhelmed by the multitude of options for fellowship training. And the question remains: why pursue fellowship training in the first place?

“I learned that as a family physician it is harder to get a job as a hospitalist outside of smaller communities, and I wanted to have extra training and credentials,” Dr. Schaffer said. “I pursued a fellowship in hospital medicine to hone my inpatient skills, obtain more ICU exposure, and work on procedures.”

Dr. Schaffer’s online search eventually led her to the Advanced Hospital Medicine Fellowship at Swedish Medical Center in Seattle. This 1-year hospital medicine fellowship started in 2008 with an intentional clinical focus, aiming to provide additional training opportunities in hospital medicine primarily to family medicine residency graduates.

“The goal of our program is to bridge the gap between the training of family medicine and internal medicine so our trainees can refine and develop their inpatient skills,” said Dr. David Wilson, program director of the Swedish Hospitalist Fellowship.

During her fellowship year, Dr. Schaffer was caring for hospitalized adult patients on a general medical ward, with supervision from a dedicated group of teaching hospitalists. She also completed rotations in the ICU, on subspecialty services, and received advanced training in point-of-care ultrasound.

Now in her second year of practice as a full time adult hospitalist at Swedish Medical Center, Dr. Schaffer believes her year of hospital medicine fellowship prepared her well for her current position.

“I am constantly using the tools and knowledge I acquired during my fellowship year,” she said. “I would encourage anyone who has an interest in working on procedural skills and gaining more ICU exposure to pursue a similar fellowship.”

In contrast to Dr. Schaffer, Dr. Prochaska was satisfied with his clinical training but chose to pursue a hospital medicine fellowship to develop research skills. Prior to starting the 2-year Hospitalist Scholars Training Program at the University of Chicago in 2014, Dr. Prochaska had a clear vision of becoming a hospital medicine health outcomes investigator, and believed this career would not be possible without the additional training offered by a research-focused fellowship program.

The Hospitalist Scholars Program at the University of Chicago, one of the first programs of its kind, offers a built-in master’s degree to all participants. At the conclusion of his fellowship training in 2016, Dr. Prochaska completed his Master’s in Health Sciences, which gives considerable attention to biostatistics and epidemiology. According to Dr. Prochaska, the key to becoming a successful academic researcher lies in one’s ability to write grants and receive funding, a skill he honed during this fellowship.

Now on faculty at the University of Chicago in the Section of Hospital Medicine, Dr. Prochaska devotes approximately 75% of his time to research and 25% to patient care.

Beyond the research training and experience he gained during his hospital medicine fellowship, Dr. Prochaska said he values the mentorship afforded to him. He noted that one of the most meaningful experiences during his 2 years of fellowship was having the opportunity to sit down with his program directors, Dr. Vineet Arora and Dr. David Meltzer, to discuss the trajectory of his career in academic medicine.

“It is hard to find senior mentors in hospital medicine,” Dr. Prochaska said. “You could get a master’s degree on your own, but with the fellowship program, your mentors can help you think about the next steps in your career.”

For Dr. Schaffer and Dr. Prochaska, fellowship provided training and experience well-matched to their individual goals and helped foster their careers in hospital medicine. For some, however, a fellowship may not be a necessary step on the path to becoming a hospitalist. Many leaders in the field of hospital medicine have advanced in their careers without further training. In addition, receiving little more than a resident’s salary for an additional year or more during fellowship may not be financially tenable for some. Given the ongoing demand for hospitalists across the country, the lack of a fellowship on your resume may not significantly diminish your chances of securing a position, especially in the community setting.

In the end, the decision of whether to pursue a hospital medicine fellowship is a personal one, and the programs available are as varied as the individuals completing them. “Any hospitalist interested in more than simply patient care – potentially QI, medical education, policy, or administration – should consider a fellowship,” Dr. Prochaska said. “Hospitalists have a unique opportunity to be involved in all these areas, but there are absolutely critical skills you need to develop beyond your clinical skills to succeed.” Fellowships are one way to enhance these nonclinical skills.

The best advice to those considering a hospital medicine fellowship? Dedicate some time to engage in self-assessment and goal setting, before jumping to SHM’s online list of programs.

Ask yourself: “Where do I see myself in 10 years? What do I wish to accomplish in my career as a hospitalist? What additional training (clinical, research, quality improvement, leadership) might I need to achieve these goals? Will completion of a hospital medicine fellowship help me make this vision a reality?”

For Dr. Schaffer, a clinical practice–focused hospital medicine fellowship served as a necessary bridge between her family medicine residency and her current position as an adult hospitalist. While for Dr. Prochaska, a research-intensive hospital medicine fellowship was a key step in launching his academic career.

Of course, for many trainees at the end of residency, your self-assessment may lead you in the opposite direction. In that case it is time to find your first “real job” as an attending physician. But if you feel you need more training to meet your personal goals you should rest assured – whether now or in the future, there is almost certainly a hospital medicine fellowship that is right for you.

Dr. Schouten is a hospitalist at Mayo Clinic in Rochester, Minn., and serves on the Society of Hospital Medicine Physicians in Training Committee. Dr. Sundar is a hospitalist at Emory Saint Joseph’s Hospital in Sandy Springs, Ga., and serves as the Site Assistant Director for Education.

References


1. www.hospitalmedicine.org/membership/hospitalist-fellowships/

2. Ranji et al. “Hospital medicine fellowships: Works in progress.” American J Med. 2006 Jan;119(1):72.e1-7. doi: 10.1016/j.amjmed.2005.07.061.
 

Five years after the legalization of marijuana in Colorado, anticipated legislation in 2019 could see home delivery of cannabis and cannabis-related products, and expanded medical availability.

skydie/ThinkStock

Governor-elect Jared Polis, who takes office in the new year, probably will take a different approach from outgoing Gov. John Hickenlooper, according to a recent article in the Denver Post. Mr. Hickenlooper vetoed previous legislation intended to increase drug’s accessibility.

“I think you’re going to start to see the new-age Budweisers and Coors Lights – the bigger companies that are going to be the name and the brand that we’re all going to know,” says Albert Gutierrez, CEO of MedPharm Holdings, a cannabis research and cultivation company.

“You’re going to probably have more variety from these companies, whether they’re offering drinks or chocolate bars. But these companies are going to be the household names that people are going to come to know over the next 30, 50, 100 years,” he says.

Not everyone is on board. “We should all be able to agree that Colorado’s increasingly potent marijuana products are harmful to youth and that we have a collective responsibility to protect Colorado kids,” writes Henny Lasley, the cofounder of Smart Colorado, which was formed in opposition to the legalization of marijuana in the state.

The availability of medical marijuana for people diagnosed with autism spectrum disorders is among the vetoed initiatives that are likely to reemerge in 2019. That bill reportedly was opposed by the Colorado Child and Adolescent Psychiatric Society, the Colorado Psychiatric Society, and by Larry Wolk, MD, who recently stepped down as chief medical officer of the state’s department of public health and environment.
 

Adjusting to life after fires

The latest wildfires have been vanquished in California. For those affected recently and in the past several years has come the reality that the draw of living on the edge of nature means living surrounded by tinder-dry terrain. It’s a great location – until it ignites.

A year ago, the Thomas Fire devastated Ventura and Santa Barbara counties, burning more than 440 square miles. Few people died, but more than 1,000 buildings were destroyed – and hundreds of people were left homeless. A year later, in the Clearpoint neighborhood of Ventura, residential lots sit empty, their owners having abandoned the effort to rebuild. Others, like Sandra and Ed Fuller, are choosing to begin again. The beauty of the area that pulled them there years ago remains strong.

They have come to terms with losing their home to the fire. “I think it was a sort of a breaking point where there was just a flood of peace that kind of went through. It’s like there is nothing we can do about this. We know what we have to do now. We’ll just get on with it,” Ed Fuller says in an interview with NPR.

Having the Christmas season looming has been a boost to their spirits and planning. “My wife is absolutely obsessed that she’s ready for Christmas. Last Christmas we sort of lost.”

The invisibility of asexuality

It can be hard for some to fathom that sex just isn’t important for some. “They are the friends and family members who don’t express any desire to pursue sexual intimacy, who don’t often or ever seem interested in conventional dating, and who get pushed to the sidelines in any conversation about sexual health,” Kate Sloan writes in a recent article in the Walrus.

“Much like same-sex attraction decades ago, this nonattraction was initially (and is sometimes still) conflated with a sexual-desire disorder, worthy of pathologization and medical treatment with pharmaceuticals or therapy. But scientists have confirmed asexuality isn’t a medical issue; it is a sexual orientation on the same plane as heterosexuality, homosexuality, and bisexuality,” Ms. Sloan writes.

“If someone is gay, as an example, it’s pretty easy to say, ‘Okay, well, I experience the same type of attraction that everyone else does, it’s just pointed at a different gender,’ ” says Brian Langevin, executive director of the nonprofit organization Asexual Outreach. “For asexual people ... they might not even know that sexual attraction exists, and to them, the whole world could seem very confusing.”

Meanwhile, a 2013 study in British Columbia showed that asexual individuals are more likely to be socially isolated, depressed, and anxious.

“True emotional intimacy is created, according to psychology, by honesty, empathy, and listening,” Ms. Sloan writes. “When we oversimplify relationships by insisting, on a sociocultural level, that sex is the ultimate key to and only sign of a profound connection, we deprive ourselves of the more holistic affinities available to us if we look for more.”

Fundamental churches face allegations

Joy Evans Ryder was 15 when she reportedly was raped by Dave Hyles, youth director at her Baptist church in Hammond, Ind. She was not the youth director’s only alleged victim. He never faced charges; in a scenario strikingly similar to that of hundreds of Roman Catholic priests, he escaped local prosecution by being moved on to other assignments.

An investigation by the Fort Worth (Tex.) Star-Telegram has unearthed a decades-old cover-up of more than 400 cases of sexual abuse at independent fundamental Baptist churches across the United States.

Former members of congregations point to the cultlike power of many independent fundamental Baptist churches and the constant pressure to never question pastors or leave the church.

“We didn’t have a compound ... but it may as well have been. Our mind was the compound,” says a former member. Some of the abused believed that if they disobeyed the pastor or left the church, God would kill them or their family.

Some independent fundamental Baptist churches preach separation from the world, nonbelievers, and Christians with other religious views. A natural outcome, according to Josh Elliott, a former member of Vineyard’s Oklahoma City church, is that for any issues, “even legal issues, you go to the pastor first, not the police. ... You don’t report to police because the pastor is the ultimate authority, not the government.”

“I see a culture where pastoral authority is taken to a level that’s beyond what the Scripture teaches,” says Tim Heck, who was a deacon at Faith Baptist Church in Wildomar, Calif., and whose daughter said she had been abused by the youth pastor there. “I think the independent fundamental Baptists have lost their way.”

Adam Lanza’s ‘separateness’ exposed

Written musings and other documents by Adam Lanza – who slaughtered 20 first-graders and six teachers at Sandy Hook Elementary School in Newtown, Conn., on Dec. 14, 2012 – have been reported by the Hartford Courant.

Adam Lanza was challenged by speech and sensory issues as a child but had a keen intellect. That potential was eclipsed in his teenage years by paranoia, disdain for relationships, and contempt for others, the documents show. Family, teachers, and counselors were aware of his isolation. And, with time, his obsessions and mental/physical deterioration grew. But the documents make clear that no one really had a full grasp of the person he was becoming.

“As a teenager, his sensory condition made him exceedingly sensitive to textures, sound, light, and movement. He shunned his classmates, bothered by their choice of clothes and the noises they made. He cultivated a set of ground rules that fed his separateness,” write reporters Josh Kovner and Dave Altimari. The critical addition to this toxic brew was an absence of empathy and social compassion, according to Harold I. Schwartz, MD, a psychiatrist and former member of the Sandy Hook Advisory Commission, which studied the shootings.

“In this mental state, known as solipsism, only the solipsist is real. Everyone else in the world is a cardboard cutout, placed there for your benefit and otherwise devoid of meaning or value. It is the most extreme end of one form of malignant narcissism. If the victims have no value, then there is nothing to constrain you from shooting them,” Dr. Schwartz says.

In a note accompanying the article, the editors write: “Understanding what a mass killer was thinking not only paints a clearer picture of the individual, it helps us identify and understand red flags that could be part of a prevention formula for future mass shootings.”

Five years after the legalization of marijuana in Colorado, anticipated legislation in 2019 could see home delivery of cannabis and cannabis-related products, and expanded medical availability.

skydie/ThinkStock

Governor-elect Jared Polis, who takes office in the new year, probably will take a different approach from outgoing Gov. John Hickenlooper, according to a recent article in the Denver Post. Mr. Hickenlooper vetoed previous legislation intended to increase drug’s accessibility.

“I think you’re going to start to see the new-age Budweisers and Coors Lights – the bigger companies that are going to be the name and the brand that we’re all going to know,” says Albert Gutierrez, CEO of MedPharm Holdings, a cannabis research and cultivation company.

“You’re going to probably have more variety from these companies, whether they’re offering drinks or chocolate bars. But these companies are going to be the household names that people are going to come to know over the next 30, 50, 100 years,” he says.

Not everyone is on board. “We should all be able to agree that Colorado’s increasingly potent marijuana products are harmful to youth and that we have a collective responsibility to protect Colorado kids,” writes Henny Lasley, the cofounder of Smart Colorado, which was formed in opposition to the legalization of marijuana in the state.

The availability of medical marijuana for people diagnosed with autism spectrum disorders is among the vetoed initiatives that are likely to reemerge in 2019. That bill reportedly was opposed by the Colorado Child and Adolescent Psychiatric Society, the Colorado Psychiatric Society, and by Larry Wolk, MD, who recently stepped down as chief medical officer of the state’s department of public health and environment.
 

Adjusting to life after fires

The latest wildfires have been vanquished in California. For those affected recently and in the past several years has come the reality that the draw of living on the edge of nature means living surrounded by tinder-dry terrain. It’s a great location – until it ignites.

A year ago, the Thomas Fire devastated Ventura and Santa Barbara counties, burning more than 440 square miles. Few people died, but more than 1,000 buildings were destroyed – and hundreds of people were left homeless. A year later, in the Clearpoint neighborhood of Ventura, residential lots sit empty, their owners having abandoned the effort to rebuild. Others, like Sandra and Ed Fuller, are choosing to begin again. The beauty of the area that pulled them there years ago remains strong.

They have come to terms with losing their home to the fire. “I think it was a sort of a breaking point where there was just a flood of peace that kind of went through. It’s like there is nothing we can do about this. We know what we have to do now. We’ll just get on with it,” Ed Fuller says in an interview with NPR.

Having the Christmas season looming has been a boost to their spirits and planning. “My wife is absolutely obsessed that she’s ready for Christmas. Last Christmas we sort of lost.”

The invisibility of asexuality

It can be hard for some to fathom that sex just isn’t important for some. “They are the friends and family members who don’t express any desire to pursue sexual intimacy, who don’t often or ever seem interested in conventional dating, and who get pushed to the sidelines in any conversation about sexual health,” Kate Sloan writes in a recent article in the Walrus.

“Much like same-sex attraction decades ago, this nonattraction was initially (and is sometimes still) conflated with a sexual-desire disorder, worthy of pathologization and medical treatment with pharmaceuticals or therapy. But scientists have confirmed asexuality isn’t a medical issue; it is a sexual orientation on the same plane as heterosexuality, homosexuality, and bisexuality,” Ms. Sloan writes.

“If someone is gay, as an example, it’s pretty easy to say, ‘Okay, well, I experience the same type of attraction that everyone else does, it’s just pointed at a different gender,’ ” says Brian Langevin, executive director of the nonprofit organization Asexual Outreach. “For asexual people ... they might not even know that sexual attraction exists, and to them, the whole world could seem very confusing.”

Meanwhile, a 2013 study in British Columbia showed that asexual individuals are more likely to be socially isolated, depressed, and anxious.

“True emotional intimacy is created, according to psychology, by honesty, empathy, and listening,” Ms. Sloan writes. “When we oversimplify relationships by insisting, on a sociocultural level, that sex is the ultimate key to and only sign of a profound connection, we deprive ourselves of the more holistic affinities available to us if we look for more.”

Fundamental churches face allegations

Joy Evans Ryder was 15 when she reportedly was raped by Dave Hyles, youth director at her Baptist church in Hammond, Ind. She was not the youth director’s only alleged victim. He never faced charges; in a scenario strikingly similar to that of hundreds of Roman Catholic priests, he escaped local prosecution by being moved on to other assignments.

An investigation by the Fort Worth (Tex.) Star-Telegram has unearthed a decades-old cover-up of more than 400 cases of sexual abuse at independent fundamental Baptist churches across the United States.

Former members of congregations point to the cultlike power of many independent fundamental Baptist churches and the constant pressure to never question pastors or leave the church.

“We didn’t have a compound ... but it may as well have been. Our mind was the compound,” says a former member. Some of the abused believed that if they disobeyed the pastor or left the church, God would kill them or their family.

Some independent fundamental Baptist churches preach separation from the world, nonbelievers, and Christians with other religious views. A natural outcome, according to Josh Elliott, a former member of Vineyard’s Oklahoma City church, is that for any issues, “even legal issues, you go to the pastor first, not the police. ... You don’t report to police because the pastor is the ultimate authority, not the government.”

“I see a culture where pastoral authority is taken to a level that’s beyond what the Scripture teaches,” says Tim Heck, who was a deacon at Faith Baptist Church in Wildomar, Calif., and whose daughter said she had been abused by the youth pastor there. “I think the independent fundamental Baptists have lost their way.”

Adam Lanza’s ‘separateness’ exposed

Written musings and other documents by Adam Lanza – who slaughtered 20 first-graders and six teachers at Sandy Hook Elementary School in Newtown, Conn., on Dec. 14, 2012 – have been reported by the Hartford Courant.

Adam Lanza was challenged by speech and sensory issues as a child but had a keen intellect. That potential was eclipsed in his teenage years by paranoia, disdain for relationships, and contempt for others, the documents show. Family, teachers, and counselors were aware of his isolation. And, with time, his obsessions and mental/physical deterioration grew. But the documents make clear that no one really had a full grasp of the person he was becoming.

“As a teenager, his sensory condition made him exceedingly sensitive to textures, sound, light, and movement. He shunned his classmates, bothered by their choice of clothes and the noises they made. He cultivated a set of ground rules that fed his separateness,” write reporters Josh Kovner and Dave Altimari. The critical addition to this toxic brew was an absence of empathy and social compassion, according to Harold I. Schwartz, MD, a psychiatrist and former member of the Sandy Hook Advisory Commission, which studied the shootings.

“In this mental state, known as solipsism, only the solipsist is real. Everyone else in the world is a cardboard cutout, placed there for your benefit and otherwise devoid of meaning or value. It is the most extreme end of one form of malignant narcissism. If the victims have no value, then there is nothing to constrain you from shooting them,” Dr. Schwartz says.

In a note accompanying the article, the editors write: “Understanding what a mass killer was thinking not only paints a clearer picture of the individual, it helps us identify and understand red flags that could be part of a prevention formula for future mass shootings.”

Five years after the legalization of marijuana in Colorado, anticipated legislation in 2019 could see home delivery of cannabis and cannabis-related products, and expanded medical availability.

skydie/ThinkStock

Governor-elect Jared Polis, who takes office in the new year, probably will take a different approach from outgoing Gov. John Hickenlooper, according to a recent article in the Denver Post. Mr. Hickenlooper vetoed previous legislation intended to increase drug’s accessibility.

“I think you’re going to start to see the new-age Budweisers and Coors Lights – the bigger companies that are going to be the name and the brand that we’re all going to know,” says Albert Gutierrez, CEO of MedPharm Holdings, a cannabis research and cultivation company.

“You’re going to probably have more variety from these companies, whether they’re offering drinks or chocolate bars. But these companies are going to be the household names that people are going to come to know over the next 30, 50, 100 years,” he says.

Not everyone is on board. “We should all be able to agree that Colorado’s increasingly potent marijuana products are harmful to youth and that we have a collective responsibility to protect Colorado kids,” writes Henny Lasley, the cofounder of Smart Colorado, which was formed in opposition to the legalization of marijuana in the state.

The availability of medical marijuana for people diagnosed with autism spectrum disorders is among the vetoed initiatives that are likely to reemerge in 2019. That bill reportedly was opposed by the Colorado Child and Adolescent Psychiatric Society, the Colorado Psychiatric Society, and by Larry Wolk, MD, who recently stepped down as chief medical officer of the state’s department of public health and environment.
 

Adjusting to life after fires

The latest wildfires have been vanquished in California. For those affected recently and in the past several years has come the reality that the draw of living on the edge of nature means living surrounded by tinder-dry terrain. It’s a great location – until it ignites.

A year ago, the Thomas Fire devastated Ventura and Santa Barbara counties, burning more than 440 square miles. Few people died, but more than 1,000 buildings were destroyed – and hundreds of people were left homeless. A year later, in the Clearpoint neighborhood of Ventura, residential lots sit empty, their owners having abandoned the effort to rebuild. Others, like Sandra and Ed Fuller, are choosing to begin again. The beauty of the area that pulled them there years ago remains strong.

They have come to terms with losing their home to the fire. “I think it was a sort of a breaking point where there was just a flood of peace that kind of went through. It’s like there is nothing we can do about this. We know what we have to do now. We’ll just get on with it,” Ed Fuller says in an interview with NPR.

Having the Christmas season looming has been a boost to their spirits and planning. “My wife is absolutely obsessed that she’s ready for Christmas. Last Christmas we sort of lost.”

The invisibility of asexuality

It can be hard for some to fathom that sex just isn’t important for some. “They are the friends and family members who don’t express any desire to pursue sexual intimacy, who don’t often or ever seem interested in conventional dating, and who get pushed to the sidelines in any conversation about sexual health,” Kate Sloan writes in a recent article in the Walrus.

“Much like same-sex attraction decades ago, this nonattraction was initially (and is sometimes still) conflated with a sexual-desire disorder, worthy of pathologization and medical treatment with pharmaceuticals or therapy. But scientists have confirmed asexuality isn’t a medical issue; it is a sexual orientation on the same plane as heterosexuality, homosexuality, and bisexuality,” Ms. Sloan writes.

“If someone is gay, as an example, it’s pretty easy to say, ‘Okay, well, I experience the same type of attraction that everyone else does, it’s just pointed at a different gender,’ ” says Brian Langevin, executive director of the nonprofit organization Asexual Outreach. “For asexual people ... they might not even know that sexual attraction exists, and to them, the whole world could seem very confusing.”

Meanwhile, a 2013 study in British Columbia showed that asexual individuals are more likely to be socially isolated, depressed, and anxious.

“True emotional intimacy is created, according to psychology, by honesty, empathy, and listening,” Ms. Sloan writes. “When we oversimplify relationships by insisting, on a sociocultural level, that sex is the ultimate key to and only sign of a profound connection, we deprive ourselves of the more holistic affinities available to us if we look for more.”

Fundamental churches face allegations

Joy Evans Ryder was 15 when she reportedly was raped by Dave Hyles, youth director at her Baptist church in Hammond, Ind. She was not the youth director’s only alleged victim. He never faced charges; in a scenario strikingly similar to that of hundreds of Roman Catholic priests, he escaped local prosecution by being moved on to other assignments.

An investigation by the Fort Worth (Tex.) Star-Telegram has unearthed a decades-old cover-up of more than 400 cases of sexual abuse at independent fundamental Baptist churches across the United States.

Former members of congregations point to the cultlike power of many independent fundamental Baptist churches and the constant pressure to never question pastors or leave the church.

“We didn’t have a compound ... but it may as well have been. Our mind was the compound,” says a former member. Some of the abused believed that if they disobeyed the pastor or left the church, God would kill them or their family.

Some independent fundamental Baptist churches preach separation from the world, nonbelievers, and Christians with other religious views. A natural outcome, according to Josh Elliott, a former member of Vineyard’s Oklahoma City church, is that for any issues, “even legal issues, you go to the pastor first, not the police. ... You don’t report to police because the pastor is the ultimate authority, not the government.”

“I see a culture where pastoral authority is taken to a level that’s beyond what the Scripture teaches,” says Tim Heck, who was a deacon at Faith Baptist Church in Wildomar, Calif., and whose daughter said she had been abused by the youth pastor there. “I think the independent fundamental Baptists have lost their way.”

Adam Lanza’s ‘separateness’ exposed

Written musings and other documents by Adam Lanza – who slaughtered 20 first-graders and six teachers at Sandy Hook Elementary School in Newtown, Conn., on Dec. 14, 2012 – have been reported by the Hartford Courant.

Adam Lanza was challenged by speech and sensory issues as a child but had a keen intellect. That potential was eclipsed in his teenage years by paranoia, disdain for relationships, and contempt for others, the documents show. Family, teachers, and counselors were aware of his isolation. And, with time, his obsessions and mental/physical deterioration grew. But the documents make clear that no one really had a full grasp of the person he was becoming.

“As a teenager, his sensory condition made him exceedingly sensitive to textures, sound, light, and movement. He shunned his classmates, bothered by their choice of clothes and the noises they made. He cultivated a set of ground rules that fed his separateness,” write reporters Josh Kovner and Dave Altimari. The critical addition to this toxic brew was an absence of empathy and social compassion, according to Harold I. Schwartz, MD, a psychiatrist and former member of the Sandy Hook Advisory Commission, which studied the shootings.

“In this mental state, known as solipsism, only the solipsist is real. Everyone else in the world is a cardboard cutout, placed there for your benefit and otherwise devoid of meaning or value. It is the most extreme end of one form of malignant narcissism. If the victims have no value, then there is nothing to constrain you from shooting them,” Dr. Schwartz says.

In a note accompanying the article, the editors write: “Understanding what a mass killer was thinking not only paints a clearer picture of the individual, it helps us identify and understand red flags that could be part of a prevention formula for future mass shootings.”

While many pediatric clinicians have not frequently managed newborns of mothers with reactive syphilis serology, increased adult syphilis may change that.¹

Diagnosing/managing congenital syphilis is not always clear cut. A positive rapid plasma reagin (RPR) titer in a newborn may not indicate congenital infection but merely may reflect transplacental, passively acquired maternal IgG from the mother’s current or previous infection rather than antibodies produced by the newborn. Because currently no IgM assay for syphilis is recommended by the Centers for Disease Control and Prevention for newborn testing, we must deal with IgG test results.

Often initial management decisions are needed while the infant’s status is evolving. The questions to answer to make final decisions include the following²:

• Was the mother actively infected with Treponema pallidum during pregnancy?
• If so, was the mother appropriately treated and when?
• Does the infant have any clinical, laboratory, or radiographic evidence of syphilis?
• How do the mother’s and infant’s nontreponemal serologic titers (NTT) compare at delivery using the same test?

Note: All infants assessed for congenital syphilis need a full evaluation for HIV.
 

Managing the infant of a mother with positive tests^3,4

All such neonates need an examination for evidence of congenital syphilis. The clinical signs of congenital syphilis in neonates include nonimmune hydrops, jaundice, hepatosplenomegaly, rhinitis, skin rash, and pseudoparalysis of extremity. Also, consider dark-field examination or polymerase chain reaction (PCR) of lesions (such as bullae) or secretions (nasal). If available, have the placenta examined histologically (silver stain) or by PCR (Clinical Laboratory Improvement Amendments–validated test). Skeletal radiographic surveys are more useful for stillborn than live born infants. (The complete algorithm can be found in Figure 3.10 of reference 4.)

Order a quantitative NTT, using the Venereal Disease Research Laboratory (VDRL) test or RPR test on neonatal serum. Umbilical cord blood is not appropriate because of potential maternal blood contamination, which could give a false-positive result, or Wharton’s jelly, which could give a false-negative result. Use of treponemal-specific tests that are used for maternal diagnosis – such as T. pallidum particle agglutination (TP-PA), T. pallidum enzyme-linked immunosorbent assay (TP-EIA), fluorescent treponemal antibody absorption (FTA-ABS) test, or T. pallidum chemiluminescence immunoassay (TP-CIA) – on neonatal serum is not recommended because of difficulties in interpretation.

Diagnostic results allow designation of an infant into one of four CDC categories: proven/highly probable syphilis; possible syphilis; syphilis less likely; and syphilis unlikely. Treatment recommendations are based on these categories.

Proven or highly probable syphilis

There are two alternative recommended 10-day treatment regimens.

A. Aqueous crystalline penicillin G 100,000-150,000 U/kg per day by IV at 50,000 U/kg per dose, given every 12 hours through 7 days of age or every 8 hours if greater than 7 days old.

B. Procaine penicillin G at 50,000 U/kg per dose intramuscularly in one dose each day.

More than 1 day of missed therapy requires restarting a new 10-day course. Use of other antimicrobial agents (such as ampicillin) is not validated, so any empiric ampicillin initially given for possible sepsis does not count toward the 10-day penicillin regimen. If nonpenicillin drugs must be used, close serologic follow-up must occur to ensure adequacy of response to therapy.
 

Possible syphilis

There are three alternative regimens, the same two as in proven/highly probable syphilis (above) plus a single-dose option

A. Aqueous crystalline penicillin G, as described above.

B. Procaine penicillin G, as described above.

C. Benzathine penicillin G at 50,000 U/kg per dose intramuscularly in a single dose.

Note: To be eligible for regimen C, an infant must have a complete evaluation that is normal (cerebrospinal fluid [CSF] examination, long-bone radiographs, and complete blood count with platelet count) and follow-up must be assured. Exception: Neonates born to mothers with untreated early syphilis at the time of delivery are at increased risk for congenital syphilis, and the 10-day course of penicillin G may be considered even if the complete evaluation is normal and follow-up is certain.
 

Less likely syphilis

One antibiotic regimen is available, but no treatment also may be an option.

A. Benzathine penicillin G as described above.

B. If mother’s NTT has decreased at least fourfold after appropriate early syphilis therapy or remained stably low, which indicates latent syphilis (VDRL less than 1:2; RPR less than 1:4), no treatment is an option but requires repeat serology every 2-3 months until infant is 6 months old.

Unlikely syphilis

No treatment is recommended unless follow-up is uncertain, in which case it is appropriate to give the infant benzathine penicillin G as described above.

Infant with positive NTT at birth

All neonates with reactive NTT need careful follow-up examinations and repeat NTT every 2-3 months until nonreactive. NTT in infants who are not treated because of less likely or unlikely syphilis status should drop by 3 months and be nonreactive by 6 months; this indicates NTT was passively transferred maternal IgG. If NTT remains reactive at 6 months, the infant is likely infected and needs treatment. Persistent NTT at 6-12 months in treated neonates should trigger repeat CSF examination and infectious diseases consultation about a possible repeat of the 10-day penicillin G regimen. If the mother was seroreactive, but the newborn’s NTT was negative at birth, testing of the infant’s NTT needs repeating at 3 months to exclude the possibility that the congenital syphilis was incubating when prior testing occurred at birth. Note: Treponemal-specific tests are not useful in assessing treatment because detectable maternal IgG treponemal antibody can persist at least 15 months.

Neonates with abnormal CSF at birth

Repeat cerebrospinal fluid evaluation every 6 months until results normalize. Persistently reactive CSF VDRL or abnormal CSF indexes not caused by another known cause requires retreatment for possible neurosyphilis, as well as consultation with an expert.

Summary

Decisions on managing infants of mothers with positive syphilis testing can be difficult. NTT are the essential test for newborns and some degree of laboratory or imaging work up often are needed. Consider consulting an expert in infectious diseases and/or perinatology if the gray areas do not readily become clear. Treatment of the correct patients with the right drug for the right duration remains the goal, as usual.

Dr. Harrison is a professor of pediatrics at University of Missouri-Kansas City and Director of Research Affairs in the pediatric infectious diseases division at Children’s Mercy Hospital – Kansas City. He said he had no relevant financial disclosures. Email him at [email protected].

References

1. MMWR. 2015 Nov 13;64(44);1241-5.

2. “Congenital Syphilis,” 2015 Sexually Transmitted Diseases Treatment Guidelines.

3. “Syphilis During Pregnancy,” 2015 Sexually Transmitted Diseases Treatment Guidelines.

4. Syphilis – Section 3: Summaries of Infectious Diseases. Red Book Online. 2018.
 

While many pediatric clinicians have not frequently managed newborns of mothers with reactive syphilis serology, increased adult syphilis may change that.¹

Diagnosing/managing congenital syphilis is not always clear cut. A positive rapid plasma reagin (RPR) titer in a newborn may not indicate congenital infection but merely may reflect transplacental, passively acquired maternal IgG from the mother’s current or previous infection rather than antibodies produced by the newborn. Because currently no IgM assay for syphilis is recommended by the Centers for Disease Control and Prevention for newborn testing, we must deal with IgG test results.

Often initial management decisions are needed while the infant’s status is evolving. The questions to answer to make final decisions include the following²:

• Was the mother actively infected with Treponema pallidum during pregnancy?
• If so, was the mother appropriately treated and when?
• Does the infant have any clinical, laboratory, or radiographic evidence of syphilis?
• How do the mother’s and infant’s nontreponemal serologic titers (NTT) compare at delivery using the same test?

Note: All infants assessed for congenital syphilis need a full evaluation for HIV.
 

Managing the infant of a mother with positive tests^3,4

All such neonates need an examination for evidence of congenital syphilis. The clinical signs of congenital syphilis in neonates include nonimmune hydrops, jaundice, hepatosplenomegaly, rhinitis, skin rash, and pseudoparalysis of extremity. Also, consider dark-field examination or polymerase chain reaction (PCR) of lesions (such as bullae) or secretions (nasal). If available, have the placenta examined histologically (silver stain) or by PCR (Clinical Laboratory Improvement Amendments–validated test). Skeletal radiographic surveys are more useful for stillborn than live born infants. (The complete algorithm can be found in Figure 3.10 of reference 4.)

Order a quantitative NTT, using the Venereal Disease Research Laboratory (VDRL) test or RPR test on neonatal serum. Umbilical cord blood is not appropriate because of potential maternal blood contamination, which could give a false-positive result, or Wharton’s jelly, which could give a false-negative result. Use of treponemal-specific tests that are used for maternal diagnosis – such as T. pallidum particle agglutination (TP-PA), T. pallidum enzyme-linked immunosorbent assay (TP-EIA), fluorescent treponemal antibody absorption (FTA-ABS) test, or T. pallidum chemiluminescence immunoassay (TP-CIA) – on neonatal serum is not recommended because of difficulties in interpretation.

Diagnostic results allow designation of an infant into one of four CDC categories: proven/highly probable syphilis; possible syphilis; syphilis less likely; and syphilis unlikely. Treatment recommendations are based on these categories.

Proven or highly probable syphilis

There are two alternative recommended 10-day treatment regimens.

A. Aqueous crystalline penicillin G 100,000-150,000 U/kg per day by IV at 50,000 U/kg per dose, given every 12 hours through 7 days of age or every 8 hours if greater than 7 days old.

B. Procaine penicillin G at 50,000 U/kg per dose intramuscularly in one dose each day.

More than 1 day of missed therapy requires restarting a new 10-day course. Use of other antimicrobial agents (such as ampicillin) is not validated, so any empiric ampicillin initially given for possible sepsis does not count toward the 10-day penicillin regimen. If nonpenicillin drugs must be used, close serologic follow-up must occur to ensure adequacy of response to therapy.
 

Possible syphilis

There are three alternative regimens, the same two as in proven/highly probable syphilis (above) plus a single-dose option

A. Aqueous crystalline penicillin G, as described above.

B. Procaine penicillin G, as described above.

C. Benzathine penicillin G at 50,000 U/kg per dose intramuscularly in a single dose.

Note: To be eligible for regimen C, an infant must have a complete evaluation that is normal (cerebrospinal fluid [CSF] examination, long-bone radiographs, and complete blood count with platelet count) and follow-up must be assured. Exception: Neonates born to mothers with untreated early syphilis at the time of delivery are at increased risk for congenital syphilis, and the 10-day course of penicillin G may be considered even if the complete evaluation is normal and follow-up is certain.
 

Less likely syphilis

One antibiotic regimen is available, but no treatment also may be an option.

A. Benzathine penicillin G as described above.

B. If mother’s NTT has decreased at least fourfold after appropriate early syphilis therapy or remained stably low, which indicates latent syphilis (VDRL less than 1:2; RPR less than 1:4), no treatment is an option but requires repeat serology every 2-3 months until infant is 6 months old.

Unlikely syphilis

No treatment is recommended unless follow-up is uncertain, in which case it is appropriate to give the infant benzathine penicillin G as described above.

Infant with positive NTT at birth

All neonates with reactive NTT need careful follow-up examinations and repeat NTT every 2-3 months until nonreactive. NTT in infants who are not treated because of less likely or unlikely syphilis status should drop by 3 months and be nonreactive by 6 months; this indicates NTT was passively transferred maternal IgG. If NTT remains reactive at 6 months, the infant is likely infected and needs treatment. Persistent NTT at 6-12 months in treated neonates should trigger repeat CSF examination and infectious diseases consultation about a possible repeat of the 10-day penicillin G regimen. If the mother was seroreactive, but the newborn’s NTT was negative at birth, testing of the infant’s NTT needs repeating at 3 months to exclude the possibility that the congenital syphilis was incubating when prior testing occurred at birth. Note: Treponemal-specific tests are not useful in assessing treatment because detectable maternal IgG treponemal antibody can persist at least 15 months.

Neonates with abnormal CSF at birth

Repeat cerebrospinal fluid evaluation every 6 months until results normalize. Persistently reactive CSF VDRL or abnormal CSF indexes not caused by another known cause requires retreatment for possible neurosyphilis, as well as consultation with an expert.

Summary

Decisions on managing infants of mothers with positive syphilis testing can be difficult. NTT are the essential test for newborns and some degree of laboratory or imaging work up often are needed. Consider consulting an expert in infectious diseases and/or perinatology if the gray areas do not readily become clear. Treatment of the correct patients with the right drug for the right duration remains the goal, as usual.

Dr. Harrison is a professor of pediatrics at University of Missouri-Kansas City and Director of Research Affairs in the pediatric infectious diseases division at Children’s Mercy Hospital – Kansas City. He said he had no relevant financial disclosures. Email him at [email protected].

References

1. MMWR. 2015 Nov 13;64(44);1241-5.

2. “Congenital Syphilis,” 2015 Sexually Transmitted Diseases Treatment Guidelines.

3. “Syphilis During Pregnancy,” 2015 Sexually Transmitted Diseases Treatment Guidelines.

4. Syphilis – Section 3: Summaries of Infectious Diseases. Red Book Online. 2018.
 

While many pediatric clinicians have not frequently managed newborns of mothers with reactive syphilis serology, increased adult syphilis may change that.¹

Diagnosing/managing congenital syphilis is not always clear cut. A positive rapid plasma reagin (RPR) titer in a newborn may not indicate congenital infection but merely may reflect transplacental, passively acquired maternal IgG from the mother’s current or previous infection rather than antibodies produced by the newborn. Because currently no IgM assay for syphilis is recommended by the Centers for Disease Control and Prevention for newborn testing, we must deal with IgG test results.

Often initial management decisions are needed while the infant’s status is evolving. The questions to answer to make final decisions include the following²:

• Was the mother actively infected with Treponema pallidum during pregnancy?
• If so, was the mother appropriately treated and when?
• Does the infant have any clinical, laboratory, or radiographic evidence of syphilis?
• How do the mother’s and infant’s nontreponemal serologic titers (NTT) compare at delivery using the same test?

Note: All infants assessed for congenital syphilis need a full evaluation for HIV.
 

Managing the infant of a mother with positive tests^3,4

All such neonates need an examination for evidence of congenital syphilis. The clinical signs of congenital syphilis in neonates include nonimmune hydrops, jaundice, hepatosplenomegaly, rhinitis, skin rash, and pseudoparalysis of extremity. Also, consider dark-field examination or polymerase chain reaction (PCR) of lesions (such as bullae) or secretions (nasal). If available, have the placenta examined histologically (silver stain) or by PCR (Clinical Laboratory Improvement Amendments–validated test). Skeletal radiographic surveys are more useful for stillborn than live born infants. (The complete algorithm can be found in Figure 3.10 of reference 4.)

Order a quantitative NTT, using the Venereal Disease Research Laboratory (VDRL) test or RPR test on neonatal serum. Umbilical cord blood is not appropriate because of potential maternal blood contamination, which could give a false-positive result, or Wharton’s jelly, which could give a false-negative result. Use of treponemal-specific tests that are used for maternal diagnosis – such as T. pallidum particle agglutination (TP-PA), T. pallidum enzyme-linked immunosorbent assay (TP-EIA), fluorescent treponemal antibody absorption (FTA-ABS) test, or T. pallidum chemiluminescence immunoassay (TP-CIA) – on neonatal serum is not recommended because of difficulties in interpretation.

Diagnostic results allow designation of an infant into one of four CDC categories: proven/highly probable syphilis; possible syphilis; syphilis less likely; and syphilis unlikely. Treatment recommendations are based on these categories.

Proven or highly probable syphilis

There are two alternative recommended 10-day treatment regimens.

A. Aqueous crystalline penicillin G 100,000-150,000 U/kg per day by IV at 50,000 U/kg per dose, given every 12 hours through 7 days of age or every 8 hours if greater than 7 days old.

B. Procaine penicillin G at 50,000 U/kg per dose intramuscularly in one dose each day.

More than 1 day of missed therapy requires restarting a new 10-day course. Use of other antimicrobial agents (such as ampicillin) is not validated, so any empiric ampicillin initially given for possible sepsis does not count toward the 10-day penicillin regimen. If nonpenicillin drugs must be used, close serologic follow-up must occur to ensure adequacy of response to therapy.
 

Possible syphilis

There are three alternative regimens, the same two as in proven/highly probable syphilis (above) plus a single-dose option

A. Aqueous crystalline penicillin G, as described above.

B. Procaine penicillin G, as described above.

C. Benzathine penicillin G at 50,000 U/kg per dose intramuscularly in a single dose.

Note: To be eligible for regimen C, an infant must have a complete evaluation that is normal (cerebrospinal fluid [CSF] examination, long-bone radiographs, and complete blood count with platelet count) and follow-up must be assured. Exception: Neonates born to mothers with untreated early syphilis at the time of delivery are at increased risk for congenital syphilis, and the 10-day course of penicillin G may be considered even if the complete evaluation is normal and follow-up is certain.
 

Less likely syphilis

One antibiotic regimen is available, but no treatment also may be an option.

A. Benzathine penicillin G as described above.

B. If mother’s NTT has decreased at least fourfold after appropriate early syphilis therapy or remained stably low, which indicates latent syphilis (VDRL less than 1:2; RPR less than 1:4), no treatment is an option but requires repeat serology every 2-3 months until infant is 6 months old.

Unlikely syphilis

No treatment is recommended unless follow-up is uncertain, in which case it is appropriate to give the infant benzathine penicillin G as described above.

Infant with positive NTT at birth

All neonates with reactive NTT need careful follow-up examinations and repeat NTT every 2-3 months until nonreactive. NTT in infants who are not treated because of less likely or unlikely syphilis status should drop by 3 months and be nonreactive by 6 months; this indicates NTT was passively transferred maternal IgG. If NTT remains reactive at 6 months, the infant is likely infected and needs treatment. Persistent NTT at 6-12 months in treated neonates should trigger repeat CSF examination and infectious diseases consultation about a possible repeat of the 10-day penicillin G regimen. If the mother was seroreactive, but the newborn’s NTT was negative at birth, testing of the infant’s NTT needs repeating at 3 months to exclude the possibility that the congenital syphilis was incubating when prior testing occurred at birth. Note: Treponemal-specific tests are not useful in assessing treatment because detectable maternal IgG treponemal antibody can persist at least 15 months.

Neonates with abnormal CSF at birth

Repeat cerebrospinal fluid evaluation every 6 months until results normalize. Persistently reactive CSF VDRL or abnormal CSF indexes not caused by another known cause requires retreatment for possible neurosyphilis, as well as consultation with an expert.

Summary

Decisions on managing infants of mothers with positive syphilis testing can be difficult. NTT are the essential test for newborns and some degree of laboratory or imaging work up often are needed. Consider consulting an expert in infectious diseases and/or perinatology if the gray areas do not readily become clear. Treatment of the correct patients with the right drug for the right duration remains the goal, as usual.

Dr. Harrison is a professor of pediatrics at University of Missouri-Kansas City and Director of Research Affairs in the pediatric infectious diseases division at Children’s Mercy Hospital – Kansas City. He said he had no relevant financial disclosures. Email him at [email protected].

References

1. MMWR. 2015 Nov 13;64(44);1241-5.

2. “Congenital Syphilis,” 2015 Sexually Transmitted Diseases Treatment Guidelines.

3. “Syphilis During Pregnancy,” 2015 Sexually Transmitted Diseases Treatment Guidelines.

4. Syphilis – Section 3: Summaries of Infectious Diseases. Red Book Online. 2018.