Opinion

“We’ll have one strawberry sugar cone, two chocolate swirls, and a mocha almond.”

iStock

“Dr. Wilkoff, I haven’t seen you in ... must be 5 years. You look great! How’s retirement going?”

“You look great too, Kim. The neighborhood has needed an ice cream parlor like yours for a long time. How’s the family?”

Alerted by the commotion of our catching up, Kim’s husband came outside to see what was going on. Looking at my wife, he said, “You know he saved our daughter’s life?”

Well, not exactly. A timely referral to a psychologist I knew was good with eating disorders had started the slow process of returning their anorectic daughter to health. I thanked him and tried to put a more historically correct spin on his story.

Most of my encounters with former patients and their parents aren’t as dramatic as this one at Kim’s Ice Cream Shack, but they always leave me with a warm, positive feeling that stays with me all day. Every now and then they include a compliment or a thank you, but most of the time the conversations are dominated by questions about how the other are doing and what our families are up to.

One of the perks of living in the town where you practice is that your patients also are your neighbors. Not every physician views this proximity as a positive, but for me, it was a gift that has kept on giving after I retired.

Our house phone number was always listed in the phone book, and I can count on the fingers of two hands how many times in 40 years that I received what I would consider an inappropriate or invasive call. Our office offered evening and weekend hours and a generous schedule of phone-in call times. But I’m convinced that it was the neighbor-to-neighbor relationship that kept the work/home balance intact. Even though I may have helped a plumber and his wife with their sick children, that professional arrangement didn’t include a free pass to call him after hours if I knew my leaking faucet could wait until the weekend was over.

By the same token, when a patient or a customer is also your neighbor there is an unspoken ethic that the service you provide must be your best effort. That’s not an admission that I was in the habit of offering substandard care to “folks from away,” but there is special motivation when your work is being scrutinized by people you’re likely to see next week at the grocery store checkout.

Office visits with neighbors often tended to take longer because there was a tendency to drift off topic and ask about a sibling’s baseball game I had read about in the paper or how the lobster catch was running that season. On the other hand, I must admit that I did my share of reporting (really it was bragging) on my own children’s accomplishments.

But now I’m reaping the benefits of those extra minutes invested in the office, because I suspect former patients and their families are more likely to want to reminisce when we meet in a restaurant or at the farmers’ market.

If you are a young physician and worrying about finding a good work/life balance, I urge you to consider living and working and then staying on in a place in which your patients also will be your neighbors. It will enrich your work experience and repay you many times over when it’s time to retire.

If you can’t find that place, at least treat your patients as though they were your neighbors.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

“We’ll have one strawberry sugar cone, two chocolate swirls, and a mocha almond.”

iStock

“Dr. Wilkoff, I haven’t seen you in ... must be 5 years. You look great! How’s retirement going?”

“You look great too, Kim. The neighborhood has needed an ice cream parlor like yours for a long time. How’s the family?”

Alerted by the commotion of our catching up, Kim’s husband came outside to see what was going on. Looking at my wife, he said, “You know he saved our daughter’s life?”

Well, not exactly. A timely referral to a psychologist I knew was good with eating disorders had started the slow process of returning their anorectic daughter to health. I thanked him and tried to put a more historically correct spin on his story.

Most of my encounters with former patients and their parents aren’t as dramatic as this one at Kim’s Ice Cream Shack, but they always leave me with a warm, positive feeling that stays with me all day. Every now and then they include a compliment or a thank you, but most of the time the conversations are dominated by questions about how the other are doing and what our families are up to.

One of the perks of living in the town where you practice is that your patients also are your neighbors. Not every physician views this proximity as a positive, but for me, it was a gift that has kept on giving after I retired.

Our house phone number was always listed in the phone book, and I can count on the fingers of two hands how many times in 40 years that I received what I would consider an inappropriate or invasive call. Our office offered evening and weekend hours and a generous schedule of phone-in call times. But I’m convinced that it was the neighbor-to-neighbor relationship that kept the work/home balance intact. Even though I may have helped a plumber and his wife with their sick children, that professional arrangement didn’t include a free pass to call him after hours if I knew my leaking faucet could wait until the weekend was over.

By the same token, when a patient or a customer is also your neighbor there is an unspoken ethic that the service you provide must be your best effort. That’s not an admission that I was in the habit of offering substandard care to “folks from away,” but there is special motivation when your work is being scrutinized by people you’re likely to see next week at the grocery store checkout.

Office visits with neighbors often tended to take longer because there was a tendency to drift off topic and ask about a sibling’s baseball game I had read about in the paper or how the lobster catch was running that season. On the other hand, I must admit that I did my share of reporting (really it was bragging) on my own children’s accomplishments.

But now I’m reaping the benefits of those extra minutes invested in the office, because I suspect former patients and their families are more likely to want to reminisce when we meet in a restaurant or at the farmers’ market.

If you are a young physician and worrying about finding a good work/life balance, I urge you to consider living and working and then staying on in a place in which your patients also will be your neighbors. It will enrich your work experience and repay you many times over when it’s time to retire.

If you can’t find that place, at least treat your patients as though they were your neighbors.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

“We’ll have one strawberry sugar cone, two chocolate swirls, and a mocha almond.”

iStock

“Dr. Wilkoff, I haven’t seen you in ... must be 5 years. You look great! How’s retirement going?”

“You look great too, Kim. The neighborhood has needed an ice cream parlor like yours for a long time. How’s the family?”

Alerted by the commotion of our catching up, Kim’s husband came outside to see what was going on. Looking at my wife, he said, “You know he saved our daughter’s life?”

Well, not exactly. A timely referral to a psychologist I knew was good with eating disorders had started the slow process of returning their anorectic daughter to health. I thanked him and tried to put a more historically correct spin on his story.

Most of my encounters with former patients and their parents aren’t as dramatic as this one at Kim’s Ice Cream Shack, but they always leave me with a warm, positive feeling that stays with me all day. Every now and then they include a compliment or a thank you, but most of the time the conversations are dominated by questions about how the other are doing and what our families are up to.

One of the perks of living in the town where you practice is that your patients also are your neighbors. Not every physician views this proximity as a positive, but for me, it was a gift that has kept on giving after I retired.

Our house phone number was always listed in the phone book, and I can count on the fingers of two hands how many times in 40 years that I received what I would consider an inappropriate or invasive call. Our office offered evening and weekend hours and a generous schedule of phone-in call times. But I’m convinced that it was the neighbor-to-neighbor relationship that kept the work/home balance intact. Even though I may have helped a plumber and his wife with their sick children, that professional arrangement didn’t include a free pass to call him after hours if I knew my leaking faucet could wait until the weekend was over.

By the same token, when a patient or a customer is also your neighbor there is an unspoken ethic that the service you provide must be your best effort. That’s not an admission that I was in the habit of offering substandard care to “folks from away,” but there is special motivation when your work is being scrutinized by people you’re likely to see next week at the grocery store checkout.

Office visits with neighbors often tended to take longer because there was a tendency to drift off topic and ask about a sibling’s baseball game I had read about in the paper or how the lobster catch was running that season. On the other hand, I must admit that I did my share of reporting (really it was bragging) on my own children’s accomplishments.

But now I’m reaping the benefits of those extra minutes invested in the office, because I suspect former patients and their families are more likely to want to reminisce when we meet in a restaurant or at the farmers’ market.

If you are a young physician and worrying about finding a good work/life balance, I urge you to consider living and working and then staying on in a place in which your patients also will be your neighbors. It will enrich your work experience and repay you many times over when it’s time to retire.

If you can’t find that place, at least treat your patients as though they were your neighbors.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Low-dose aspirin for the prevention of preeclampsia has been studied for more than 25 years, often with contradictory and confusing results. Studies have enrolled patients with varying levels of risk, assessed risk differently, and used different definitions of preeclampsia as well as a variety of aspirin dosages and treatment-initiation dates. Undoubtedly, this heterogeneity has made interpretation and comparisons difficult and frustrating.

Recently, systematic reviews and meta-analyses have improved our understanding of the role of low-dose aspirin, providing solid evidence that low-dose aspirin started after the first-trimester reduces the occurrence of preeclampsia in high-risk women. Data also suggest that low-dose aspirin reduces the incidence of fetal growth restriction and preterm birth in these women.

There is reasonable evidence, moreover, that low-dose aspirin provides similar benefit in women with modest levels of risk and that it’s best to begin aspirin use at 12-14 weeks’ gestation rather than later in the second trimester. Finally, there’s also good evidence that 81 mg of aspirin is a minimum dose for effectiveness and that higher doses – as much as 150 mg – are probably more effective.

Despite this evidence and current recommendations for low-dose aspirin use by the U.S. Preventive Services Task Force and the American College of Obstetricians and Gynecologists, its use in practice is varied. Obstetricians and other obstetrics providers are not consistently making the recommendation, and pharmacists are not consistently supporting it.

Without more consistent initiation of low-dose aspirin prophylaxis and more consistent adherence, we are losing an opportunity to reduce serious maternal morbidity and mortality. We also are underutilizing an important tool for the reduction of racial and other health disparities relating to preterm birth, maternal death, and other complications of preeclampsia.


 

Dr. Lockwood: Epidemiology, etiology, and clinical value of aspirin

The use of low-dose aspirin can have a high impact, considering that preeclampsia complicates 3.4% of pregnancies nationally and accounts for at least 9% of maternal deaths (BMJ. 2013 Nov;347:f6564).

Preeclampsia also has been shown in multiple long-term epidemiologic studies to be a strong risk factor for future cardiovascular disease and metabolic disorders in women – especially when it occurs in multiple pregnancies or develops preterm. Moreover, it is associated with stillbirth, intrauterine growth restriction (IUGR), and oligohydramnios in the fetus (BMJ. 2013 Nov;347:f6564).

It is important to remember that criteria for a diagnosis of preeclampsia changed in 2013 such that the detection of proteinuria is no longer required. Preeclampsia is defined today as the new onset of hypertension and proteinuria, or hypertension and end-organ dysfunction with or without proteinuria, after 20 weeks in a previously normotensive woman, according to the ACOG Task Force on Hypertension in Pregnancy.

The leading risk factor appears to be previous preeclampsia. In a systematic review and meta-analysis of 92 cohort studies that looked at the pooled relative risk of developing preeclampsia in the presence or absence of 14 commonly reported and accepted risk factors, prior preeclampsia topped the list, putting patients at an eightfold increased risk (relative risk 8.4) (BMJ. 2016 Apr 19;353:i1753).

Nulliparity (relative risk, 2.1) and multiple gestation (RR, 2.9) presented lesser risks but still were significant, and preexisting medical conditions increased risk as well. Notably, both chronic hypertension and a body mass index (BMI) greater than 30 had a fivefold increased risk (RR, 5.1), and preexisting diabetes presented more than a threefold increased risk (RR, 3.7). The review covered more than 25 million pregnancies in 27 countries.

The etiology of preeclampsia still is not completely understood. There is evidence that underlying decidual inflammation, including increased activated macrophages and decreased uterine natural killer cells (uNK), promotes shallow placentation leading to incomplete uterine spiral artery remodeling, relative placental hypoxia, and progressive release of placental antiangiogenic substances such as soluble fms-like tyrosine kinase 1 (sFlt1) and endoglin (Am J Pathol. 2013 Sep;183[3]:841-56; Reprod Sci. 2015 Nov;22[11]:1461-7). The latter result in systemic endothelial cell damage, reduced endothelial prostacyclin (PGI2), and increased platelet thromboxane A2, triggering vasospasm and increased platelet turnover that ultimately lead to the typical signs and symptoms of preeclampsia.

The research focus traditionally has been on the placenta, but more recently the uterine decidual contribution has received more attention. A recent study published in the Proceedings of the National Academy of Sciences offers evidence that affected women have defective decidualization during and after severe preeclampsia, suggesting that the defect could be detected prior to conception.

Investigators isolated endometrial cells from women at the end of a pregnancy complicated by preeclampsia and found a transcriptional signature that persisted for years. They then linked the defect to impaired cytotrophoblast invasion (Proc Natl Acad Sci. 2017;114[40]:E8468-77). This elegant and provocative study suggests that it might be possible in the future to evaluate the endometrium and try to enhance stromal cell decidualization before pregnancy.

Currently, the rationale for using aspirin to prevent preeclampsia lies with its ability to inhibit platelet production of thromboxane and block NF-kB, a protein complex that plays a role in systemic and/or decidual inflammation. There likely are numerous mechanisms of action, however, including some that improve placentation.

Among the most recent studies on timing and dosage is a systematic review and meta-analysis of 45 randomized controlled trials with 20,909 women randomized to 50-150 mg aspirin daily or to placebo or no treatment. The investigators stratified the results by gestational age at the time of aspirin initiation and found that timing matters. Women who began aspirin at or before 16 weeks had the most significant reductions in preeclampsia (RR, 0.57) and severe preeclampsia (RR, 0.47), as well as fetal growth restriction (RR, 0.56), with a dose-response effect up to 150 mg.

When aspirin was initiated after 16 weeks, there was a much smaller reduction of preeclampsia (RR, 0.81) and no effects for severe preeclampsia or IUGR. Nor was there any dose-response effect (Am J Obstet Gynecol. 2017; 216[2]:110-20.e6).

In contrast, another recent meta-analysis of individual participant data on 32,217 women recruited in 31 randomized controlled trials found no significant difference among women who were randomized before 16 weeks versus those who were randomized at 16 weeks or later (Am J Obstet Gynecol. 2017 Feb;216[2]:121-8.e2). It’s important to note that this analysis covered other antiplatelet agents as well and that it stratified outcomes by gestational age with a slightly later cutoff point.

What do official guidelines say? The USPSTF’s recommendation, issued in 2014, calls for low-dose aspirin at 81 mg/day after 12 weeks’ gestation in women who have one or more high-risk factors, and consideration of such treatment in patients with “several” moderate-risk factors (Ann Intern Med. 2014 Dec 2;161[11]:819-26). In July 2018, ACOG reaffirmed its earlier support for low-dose aspirin in a committee opinion that recommends 81 mg/day beginning at 12-28 weeks’ gestation, optimally before 16 weeks’, for women who have one or more high-risk factors or more than one moderate-risk factor (Obstet Gynecol. 2018 Jul;132[1]:e44-e52).

My own take, based on published literature, including my own research, is that low-dose aspirin reduces the frequency of preeclampsia, particularly cases occurring preterm, as well as related IUGR, by approximately 10%-20% in moderate- and high-risk women. Regarding dose and gestational age for initiation, I have split the difference of what’s reflected in the literature and in guidelines. I advise 122 mg (a tablet-and-a-half) a day, starting at 12-14 weeks’, for patients at high and moderate levels of risk. For patients who are not seen until later, low-dose aspirin can be started up to 28 weeks’ gestation.
 

Dr. Abbott: Messaging and education to reduce disparities

Black women are not only more likely to develop preeclampsia, but they’re also more likely to have more severe complications and worse outcomes. In one analysis, black women with preeclampsia experienced an almost threefold higher risk of maternal mortality and intrauterine fetal death than did white women with the disorder (Hypertens Pregnancy. 2015 Nov;34[4]:506-15).

At Boston Medical Center, 30% of pregnant women have a diagnosis of preeclampsia or hypertension at term. In addition to 68% identifying as Hispanic/black or black, half of the families we care for have incomes less than $20,000, and 30% are non–English speaking. Low-dose prenatal aspirin is therefore an important tool for reducing racial health disparities as well as disparities created by health literacy, economic status, and language and cultural barriers. At BMC, New England’s largest safety-net hospital, we’ve found that the factors driving health disparities often overlap.

To increase the use of low-dose aspirin for women at moderate to high risk, we marry education about aspirin’s effectiveness and safety with education about the potential severity of hypertension and preeclampsia. We counsel patients who are hospitalized at delivery with gestational or chronic hypertension, or fetal growth restriction, about how preeclampsia can be very serious – contrary to what they’ve experienced or what friends or family may have shared. We also counsel them about signs and symptoms of severe preeclampsia that warrant consulting their provider. And overall, we deliberately use the term “prenatal aspirin” so that, over time and in the broader community, it will become associated with good prenatal care and risk reduction.

To counter perceived risks and dangers that we identified through focus groups and interviews, our patient education materials state that low-dose aspirin in pregnancy will not cause increased bleeding, does not reach the baby’s blood, does not increase the risk of miscarriage, and has not been shown to have negative effects on the baby’s initial development (www.prenatalaspirin.com/education-materials). We try to engage family members whenever possible, and we recognize that the black population has historical reasons to be concerned or suspicious that aspirin might not be safe for them.

Especially for underserved patients who receive prescriptions for low-dose aspirin, we must ensure that pharmacists will dispense the medication. A national survey of pharmacists (not yet published) found that over two-thirds were unaware of the USPSTF guidelines, and that only a minority would feel comfortable dispensing low-dose aspirin during pregnancy. In our community, some pharmacists have told patients to return to their physician and inquire more. Until recently, one of the major pharmacy chains placed a warning label on aspirin bottles being dispensed to women who also had an active prescription for prenatal vitamins.

We are working both with pharmacies and with pharmacy schools to impact the education of current and future pharmacists on guidelines and recommendations for low-dose aspirin prophylaxis. In addition, when I write a prescription for prenatal aspirin, starting at 12 weeks’ whenever possible, I include the message “for the purpose of trying to reduce pregnancy complications.”

Dr. Lockwood is senior vice president at University of South Florida Health and dean of Morsani College of Medicine at the University of South Florida, Tampa. He said he had no relevant financial disclosures or conflicts of interest. Dr. Abbot is a specialist in maternal-fetal medicine, the director of obstetrics and gynecology, and assistant dean for patient safety and quality improvement education at Boston Medical Center. She also is an associate professor of obstetrics and gynecology at Boston University. She disclosed a grant from the March of Dimes. Email them at [email protected].

Low-dose aspirin for the prevention of preeclampsia has been studied for more than 25 years, often with contradictory and confusing results. Studies have enrolled patients with varying levels of risk, assessed risk differently, and used different definitions of preeclampsia as well as a variety of aspirin dosages and treatment-initiation dates. Undoubtedly, this heterogeneity has made interpretation and comparisons difficult and frustrating.

Recently, systematic reviews and meta-analyses have improved our understanding of the role of low-dose aspirin, providing solid evidence that low-dose aspirin started after the first-trimester reduces the occurrence of preeclampsia in high-risk women. Data also suggest that low-dose aspirin reduces the incidence of fetal growth restriction and preterm birth in these women.

There is reasonable evidence, moreover, that low-dose aspirin provides similar benefit in women with modest levels of risk and that it’s best to begin aspirin use at 12-14 weeks’ gestation rather than later in the second trimester. Finally, there’s also good evidence that 81 mg of aspirin is a minimum dose for effectiveness and that higher doses – as much as 150 mg – are probably more effective.

Despite this evidence and current recommendations for low-dose aspirin use by the U.S. Preventive Services Task Force and the American College of Obstetricians and Gynecologists, its use in practice is varied. Obstetricians and other obstetrics providers are not consistently making the recommendation, and pharmacists are not consistently supporting it.

Without more consistent initiation of low-dose aspirin prophylaxis and more consistent adherence, we are losing an opportunity to reduce serious maternal morbidity and mortality. We also are underutilizing an important tool for the reduction of racial and other health disparities relating to preterm birth, maternal death, and other complications of preeclampsia.


 

Dr. Lockwood: Epidemiology, etiology, and clinical value of aspirin

The use of low-dose aspirin can have a high impact, considering that preeclampsia complicates 3.4% of pregnancies nationally and accounts for at least 9% of maternal deaths (BMJ. 2013 Nov;347:f6564).

Preeclampsia also has been shown in multiple long-term epidemiologic studies to be a strong risk factor for future cardiovascular disease and metabolic disorders in women – especially when it occurs in multiple pregnancies or develops preterm. Moreover, it is associated with stillbirth, intrauterine growth restriction (IUGR), and oligohydramnios in the fetus (BMJ. 2013 Nov;347:f6564).

It is important to remember that criteria for a diagnosis of preeclampsia changed in 2013 such that the detection of proteinuria is no longer required. Preeclampsia is defined today as the new onset of hypertension and proteinuria, or hypertension and end-organ dysfunction with or without proteinuria, after 20 weeks in a previously normotensive woman, according to the ACOG Task Force on Hypertension in Pregnancy.

The leading risk factor appears to be previous preeclampsia. In a systematic review and meta-analysis of 92 cohort studies that looked at the pooled relative risk of developing preeclampsia in the presence or absence of 14 commonly reported and accepted risk factors, prior preeclampsia topped the list, putting patients at an eightfold increased risk (relative risk 8.4) (BMJ. 2016 Apr 19;353:i1753).

Nulliparity (relative risk, 2.1) and multiple gestation (RR, 2.9) presented lesser risks but still were significant, and preexisting medical conditions increased risk as well. Notably, both chronic hypertension and a body mass index (BMI) greater than 30 had a fivefold increased risk (RR, 5.1), and preexisting diabetes presented more than a threefold increased risk (RR, 3.7). The review covered more than 25 million pregnancies in 27 countries.

The etiology of preeclampsia still is not completely understood. There is evidence that underlying decidual inflammation, including increased activated macrophages and decreased uterine natural killer cells (uNK), promotes shallow placentation leading to incomplete uterine spiral artery remodeling, relative placental hypoxia, and progressive release of placental antiangiogenic substances such as soluble fms-like tyrosine kinase 1 (sFlt1) and endoglin (Am J Pathol. 2013 Sep;183[3]:841-56; Reprod Sci. 2015 Nov;22[11]:1461-7). The latter result in systemic endothelial cell damage, reduced endothelial prostacyclin (PGI2), and increased platelet thromboxane A2, triggering vasospasm and increased platelet turnover that ultimately lead to the typical signs and symptoms of preeclampsia.

The research focus traditionally has been on the placenta, but more recently the uterine decidual contribution has received more attention. A recent study published in the Proceedings of the National Academy of Sciences offers evidence that affected women have defective decidualization during and after severe preeclampsia, suggesting that the defect could be detected prior to conception.

Investigators isolated endometrial cells from women at the end of a pregnancy complicated by preeclampsia and found a transcriptional signature that persisted for years. They then linked the defect to impaired cytotrophoblast invasion (Proc Natl Acad Sci. 2017;114[40]:E8468-77). This elegant and provocative study suggests that it might be possible in the future to evaluate the endometrium and try to enhance stromal cell decidualization before pregnancy.

Currently, the rationale for using aspirin to prevent preeclampsia lies with its ability to inhibit platelet production of thromboxane and block NF-kB, a protein complex that plays a role in systemic and/or decidual inflammation. There likely are numerous mechanisms of action, however, including some that improve placentation.

Among the most recent studies on timing and dosage is a systematic review and meta-analysis of 45 randomized controlled trials with 20,909 women randomized to 50-150 mg aspirin daily or to placebo or no treatment. The investigators stratified the results by gestational age at the time of aspirin initiation and found that timing matters. Women who began aspirin at or before 16 weeks had the most significant reductions in preeclampsia (RR, 0.57) and severe preeclampsia (RR, 0.47), as well as fetal growth restriction (RR, 0.56), with a dose-response effect up to 150 mg.

When aspirin was initiated after 16 weeks, there was a much smaller reduction of preeclampsia (RR, 0.81) and no effects for severe preeclampsia or IUGR. Nor was there any dose-response effect (Am J Obstet Gynecol. 2017; 216[2]:110-20.e6).

In contrast, another recent meta-analysis of individual participant data on 32,217 women recruited in 31 randomized controlled trials found no significant difference among women who were randomized before 16 weeks versus those who were randomized at 16 weeks or later (Am J Obstet Gynecol. 2017 Feb;216[2]:121-8.e2). It’s important to note that this analysis covered other antiplatelet agents as well and that it stratified outcomes by gestational age with a slightly later cutoff point.

What do official guidelines say? The USPSTF’s recommendation, issued in 2014, calls for low-dose aspirin at 81 mg/day after 12 weeks’ gestation in women who have one or more high-risk factors, and consideration of such treatment in patients with “several” moderate-risk factors (Ann Intern Med. 2014 Dec 2;161[11]:819-26). In July 2018, ACOG reaffirmed its earlier support for low-dose aspirin in a committee opinion that recommends 81 mg/day beginning at 12-28 weeks’ gestation, optimally before 16 weeks’, for women who have one or more high-risk factors or more than one moderate-risk factor (Obstet Gynecol. 2018 Jul;132[1]:e44-e52).

My own take, based on published literature, including my own research, is that low-dose aspirin reduces the frequency of preeclampsia, particularly cases occurring preterm, as well as related IUGR, by approximately 10%-20% in moderate- and high-risk women. Regarding dose and gestational age for initiation, I have split the difference of what’s reflected in the literature and in guidelines. I advise 122 mg (a tablet-and-a-half) a day, starting at 12-14 weeks’, for patients at high and moderate levels of risk. For patients who are not seen until later, low-dose aspirin can be started up to 28 weeks’ gestation.
 

Dr. Abbott: Messaging and education to reduce disparities

Black women are not only more likely to develop preeclampsia, but they’re also more likely to have more severe complications and worse outcomes. In one analysis, black women with preeclampsia experienced an almost threefold higher risk of maternal mortality and intrauterine fetal death than did white women with the disorder (Hypertens Pregnancy. 2015 Nov;34[4]:506-15).

At Boston Medical Center, 30% of pregnant women have a diagnosis of preeclampsia or hypertension at term. In addition to 68% identifying as Hispanic/black or black, half of the families we care for have incomes less than $20,000, and 30% are non–English speaking. Low-dose prenatal aspirin is therefore an important tool for reducing racial health disparities as well as disparities created by health literacy, economic status, and language and cultural barriers. At BMC, New England’s largest safety-net hospital, we’ve found that the factors driving health disparities often overlap.

To increase the use of low-dose aspirin for women at moderate to high risk, we marry education about aspirin’s effectiveness and safety with education about the potential severity of hypertension and preeclampsia. We counsel patients who are hospitalized at delivery with gestational or chronic hypertension, or fetal growth restriction, about how preeclampsia can be very serious – contrary to what they’ve experienced or what friends or family may have shared. We also counsel them about signs and symptoms of severe preeclampsia that warrant consulting their provider. And overall, we deliberately use the term “prenatal aspirin” so that, over time and in the broader community, it will become associated with good prenatal care and risk reduction.

To counter perceived risks and dangers that we identified through focus groups and interviews, our patient education materials state that low-dose aspirin in pregnancy will not cause increased bleeding, does not reach the baby’s blood, does not increase the risk of miscarriage, and has not been shown to have negative effects on the baby’s initial development (www.prenatalaspirin.com/education-materials). We try to engage family members whenever possible, and we recognize that the black population has historical reasons to be concerned or suspicious that aspirin might not be safe for them.

Especially for underserved patients who receive prescriptions for low-dose aspirin, we must ensure that pharmacists will dispense the medication. A national survey of pharmacists (not yet published) found that over two-thirds were unaware of the USPSTF guidelines, and that only a minority would feel comfortable dispensing low-dose aspirin during pregnancy. In our community, some pharmacists have told patients to return to their physician and inquire more. Until recently, one of the major pharmacy chains placed a warning label on aspirin bottles being dispensed to women who also had an active prescription for prenatal vitamins.

We are working both with pharmacies and with pharmacy schools to impact the education of current and future pharmacists on guidelines and recommendations for low-dose aspirin prophylaxis. In addition, when I write a prescription for prenatal aspirin, starting at 12 weeks’ whenever possible, I include the message “for the purpose of trying to reduce pregnancy complications.”

Dr. Lockwood is senior vice president at University of South Florida Health and dean of Morsani College of Medicine at the University of South Florida, Tampa. He said he had no relevant financial disclosures or conflicts of interest. Dr. Abbot is a specialist in maternal-fetal medicine, the director of obstetrics and gynecology, and assistant dean for patient safety and quality improvement education at Boston Medical Center. She also is an associate professor of obstetrics and gynecology at Boston University. She disclosed a grant from the March of Dimes. Email them at [email protected].

Low-dose aspirin for the prevention of preeclampsia has been studied for more than 25 years, often with contradictory and confusing results. Studies have enrolled patients with varying levels of risk, assessed risk differently, and used different definitions of preeclampsia as well as a variety of aspirin dosages and treatment-initiation dates. Undoubtedly, this heterogeneity has made interpretation and comparisons difficult and frustrating.

Recently, systematic reviews and meta-analyses have improved our understanding of the role of low-dose aspirin, providing solid evidence that low-dose aspirin started after the first-trimester reduces the occurrence of preeclampsia in high-risk women. Data also suggest that low-dose aspirin reduces the incidence of fetal growth restriction and preterm birth in these women.

There is reasonable evidence, moreover, that low-dose aspirin provides similar benefit in women with modest levels of risk and that it’s best to begin aspirin use at 12-14 weeks’ gestation rather than later in the second trimester. Finally, there’s also good evidence that 81 mg of aspirin is a minimum dose for effectiveness and that higher doses – as much as 150 mg – are probably more effective.

Despite this evidence and current recommendations for low-dose aspirin use by the U.S. Preventive Services Task Force and the American College of Obstetricians and Gynecologists, its use in practice is varied. Obstetricians and other obstetrics providers are not consistently making the recommendation, and pharmacists are not consistently supporting it.

Without more consistent initiation of low-dose aspirin prophylaxis and more consistent adherence, we are losing an opportunity to reduce serious maternal morbidity and mortality. We also are underutilizing an important tool for the reduction of racial and other health disparities relating to preterm birth, maternal death, and other complications of preeclampsia.


 

Dr. Lockwood: Epidemiology, etiology, and clinical value of aspirin

The use of low-dose aspirin can have a high impact, considering that preeclampsia complicates 3.4% of pregnancies nationally and accounts for at least 9% of maternal deaths (BMJ. 2013 Nov;347:f6564).

Preeclampsia also has been shown in multiple long-term epidemiologic studies to be a strong risk factor for future cardiovascular disease and metabolic disorders in women – especially when it occurs in multiple pregnancies or develops preterm. Moreover, it is associated with stillbirth, intrauterine growth restriction (IUGR), and oligohydramnios in the fetus (BMJ. 2013 Nov;347:f6564).

It is important to remember that criteria for a diagnosis of preeclampsia changed in 2013 such that the detection of proteinuria is no longer required. Preeclampsia is defined today as the new onset of hypertension and proteinuria, or hypertension and end-organ dysfunction with or without proteinuria, after 20 weeks in a previously normotensive woman, according to the ACOG Task Force on Hypertension in Pregnancy.

The leading risk factor appears to be previous preeclampsia. In a systematic review and meta-analysis of 92 cohort studies that looked at the pooled relative risk of developing preeclampsia in the presence or absence of 14 commonly reported and accepted risk factors, prior preeclampsia topped the list, putting patients at an eightfold increased risk (relative risk 8.4) (BMJ. 2016 Apr 19;353:i1753).

Nulliparity (relative risk, 2.1) and multiple gestation (RR, 2.9) presented lesser risks but still were significant, and preexisting medical conditions increased risk as well. Notably, both chronic hypertension and a body mass index (BMI) greater than 30 had a fivefold increased risk (RR, 5.1), and preexisting diabetes presented more than a threefold increased risk (RR, 3.7). The review covered more than 25 million pregnancies in 27 countries.

The etiology of preeclampsia still is not completely understood. There is evidence that underlying decidual inflammation, including increased activated macrophages and decreased uterine natural killer cells (uNK), promotes shallow placentation leading to incomplete uterine spiral artery remodeling, relative placental hypoxia, and progressive release of placental antiangiogenic substances such as soluble fms-like tyrosine kinase 1 (sFlt1) and endoglin (Am J Pathol. 2013 Sep;183[3]:841-56; Reprod Sci. 2015 Nov;22[11]:1461-7). The latter result in systemic endothelial cell damage, reduced endothelial prostacyclin (PGI2), and increased platelet thromboxane A2, triggering vasospasm and increased platelet turnover that ultimately lead to the typical signs and symptoms of preeclampsia.

The research focus traditionally has been on the placenta, but more recently the uterine decidual contribution has received more attention. A recent study published in the Proceedings of the National Academy of Sciences offers evidence that affected women have defective decidualization during and after severe preeclampsia, suggesting that the defect could be detected prior to conception.

Investigators isolated endometrial cells from women at the end of a pregnancy complicated by preeclampsia and found a transcriptional signature that persisted for years. They then linked the defect to impaired cytotrophoblast invasion (Proc Natl Acad Sci. 2017;114[40]:E8468-77). This elegant and provocative study suggests that it might be possible in the future to evaluate the endometrium and try to enhance stromal cell decidualization before pregnancy.

Currently, the rationale for using aspirin to prevent preeclampsia lies with its ability to inhibit platelet production of thromboxane and block NF-kB, a protein complex that plays a role in systemic and/or decidual inflammation. There likely are numerous mechanisms of action, however, including some that improve placentation.

Among the most recent studies on timing and dosage is a systematic review and meta-analysis of 45 randomized controlled trials with 20,909 women randomized to 50-150 mg aspirin daily or to placebo or no treatment. The investigators stratified the results by gestational age at the time of aspirin initiation and found that timing matters. Women who began aspirin at or before 16 weeks had the most significant reductions in preeclampsia (RR, 0.57) and severe preeclampsia (RR, 0.47), as well as fetal growth restriction (RR, 0.56), with a dose-response effect up to 150 mg.

When aspirin was initiated after 16 weeks, there was a much smaller reduction of preeclampsia (RR, 0.81) and no effects for severe preeclampsia or IUGR. Nor was there any dose-response effect (Am J Obstet Gynecol. 2017; 216[2]:110-20.e6).

In contrast, another recent meta-analysis of individual participant data on 32,217 women recruited in 31 randomized controlled trials found no significant difference among women who were randomized before 16 weeks versus those who were randomized at 16 weeks or later (Am J Obstet Gynecol. 2017 Feb;216[2]:121-8.e2). It’s important to note that this analysis covered other antiplatelet agents as well and that it stratified outcomes by gestational age with a slightly later cutoff point.

What do official guidelines say? The USPSTF’s recommendation, issued in 2014, calls for low-dose aspirin at 81 mg/day after 12 weeks’ gestation in women who have one or more high-risk factors, and consideration of such treatment in patients with “several” moderate-risk factors (Ann Intern Med. 2014 Dec 2;161[11]:819-26). In July 2018, ACOG reaffirmed its earlier support for low-dose aspirin in a committee opinion that recommends 81 mg/day beginning at 12-28 weeks’ gestation, optimally before 16 weeks’, for women who have one or more high-risk factors or more than one moderate-risk factor (Obstet Gynecol. 2018 Jul;132[1]:e44-e52).

My own take, based on published literature, including my own research, is that low-dose aspirin reduces the frequency of preeclampsia, particularly cases occurring preterm, as well as related IUGR, by approximately 10%-20% in moderate- and high-risk women. Regarding dose and gestational age for initiation, I have split the difference of what’s reflected in the literature and in guidelines. I advise 122 mg (a tablet-and-a-half) a day, starting at 12-14 weeks’, for patients at high and moderate levels of risk. For patients who are not seen until later, low-dose aspirin can be started up to 28 weeks’ gestation.
 

Dr. Abbott: Messaging and education to reduce disparities

Black women are not only more likely to develop preeclampsia, but they’re also more likely to have more severe complications and worse outcomes. In one analysis, black women with preeclampsia experienced an almost threefold higher risk of maternal mortality and intrauterine fetal death than did white women with the disorder (Hypertens Pregnancy. 2015 Nov;34[4]:506-15).

At Boston Medical Center, 30% of pregnant women have a diagnosis of preeclampsia or hypertension at term. In addition to 68% identifying as Hispanic/black or black, half of the families we care for have incomes less than $20,000, and 30% are non–English speaking. Low-dose prenatal aspirin is therefore an important tool for reducing racial health disparities as well as disparities created by health literacy, economic status, and language and cultural barriers. At BMC, New England’s largest safety-net hospital, we’ve found that the factors driving health disparities often overlap.

To increase the use of low-dose aspirin for women at moderate to high risk, we marry education about aspirin’s effectiveness and safety with education about the potential severity of hypertension and preeclampsia. We counsel patients who are hospitalized at delivery with gestational or chronic hypertension, or fetal growth restriction, about how preeclampsia can be very serious – contrary to what they’ve experienced or what friends or family may have shared. We also counsel them about signs and symptoms of severe preeclampsia that warrant consulting their provider. And overall, we deliberately use the term “prenatal aspirin” so that, over time and in the broader community, it will become associated with good prenatal care and risk reduction.

To counter perceived risks and dangers that we identified through focus groups and interviews, our patient education materials state that low-dose aspirin in pregnancy will not cause increased bleeding, does not reach the baby’s blood, does not increase the risk of miscarriage, and has not been shown to have negative effects on the baby’s initial development (www.prenatalaspirin.com/education-materials). We try to engage family members whenever possible, and we recognize that the black population has historical reasons to be concerned or suspicious that aspirin might not be safe for them.

Especially for underserved patients who receive prescriptions for low-dose aspirin, we must ensure that pharmacists will dispense the medication. A national survey of pharmacists (not yet published) found that over two-thirds were unaware of the USPSTF guidelines, and that only a minority would feel comfortable dispensing low-dose aspirin during pregnancy. In our community, some pharmacists have told patients to return to their physician and inquire more. Until recently, one of the major pharmacy chains placed a warning label on aspirin bottles being dispensed to women who also had an active prescription for prenatal vitamins.

We are working both with pharmacies and with pharmacy schools to impact the education of current and future pharmacists on guidelines and recommendations for low-dose aspirin prophylaxis. In addition, when I write a prescription for prenatal aspirin, starting at 12 weeks’ whenever possible, I include the message “for the purpose of trying to reduce pregnancy complications.”

Dr. Lockwood is senior vice president at University of South Florida Health and dean of Morsani College of Medicine at the University of South Florida, Tampa. He said he had no relevant financial disclosures or conflicts of interest. Dr. Abbot is a specialist in maternal-fetal medicine, the director of obstetrics and gynecology, and assistant dean for patient safety and quality improvement education at Boston Medical Center. She also is an associate professor of obstetrics and gynecology at Boston University. She disclosed a grant from the March of Dimes. Email them at [email protected].

Some of our readers might remember the old saying, “Take two aspirin and call me in the morning,” as advice physicians gave to patients experiencing a minor malady. Aspirin often has been called a “wonder drug” as its uses continue to expand. From its first recorded use in the Ebers papyrus as an anti-inflammatory agent, to its first use in a clinical trial showing that it induces remission of fever and joint inflammation, to the discovery that it could prevent death from heart attack, to its anticancer properties, aspirin remains one of the most researched drugs in use today. According to ClinicalTrials.gov, there are over 465 active and nearly 1,000 completed aspirin-related clinical trials around the world.

Despite its myriad benefits, aspirin has been linked to bleeding, nausea, and gastrointestinal ulcers. Additionally, more research is needed to determine the risks/benefits of daily aspirin in younger adults (under age 50 years) or older adults (over age 70 years), although the ASPREE (Aspirin in Reducing Events in the Elderly) trial, expected to be completed in 2019, is working to determine the effects of daily low-dose aspirin (100 mg) on the health of people over age 65.

It is tempting to consider aspirin one of modern medicine’s so-called silver bullets, and, for women with a history of gestational hypertension and preeclampsia, it just might be. Aspirin use, especially daily aspirin, is typically not recommended during pregnancy, and most ob.gyns. will include aspirin on the “do not take” list they give to their patients during prenatal examinations. Women at risk for developing preeclampsia are the exceptions to this general rule, and a number of clinical studies have indicated that use of low-dose aspirin can help prevent disease as well as secondary outcomes for mother (i.e., placental abruption, antepartum hemorrhage) and baby (i.e., intrauterine growth restriction, stillbirth). In addition, aspirin is an easily obtainable, low-cost preventive measure for any patient at high risk.

To discuss the value of low-dose aspirin to prevent preeclampsia and how ob.gyns. can educate their patients and other health care professionals about its benefits, we have invited Charles J. Lockwood, MD, MHCM, senior vice president of University of South Florida Health and dean of Morsani College of Medicine at the University of South Florida, Tampa, and Jodi F. Abbott, MD, MSc, MHCM, director of obstetrics and gynecology at Boston Medical Center, and associate professor of obstetrics and gynecology at Boston University, to coauthor this month’s Master Class.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].

Some of our readers might remember the old saying, “Take two aspirin and call me in the morning,” as advice physicians gave to patients experiencing a minor malady. Aspirin often has been called a “wonder drug” as its uses continue to expand. From its first recorded use in the Ebers papyrus as an anti-inflammatory agent, to its first use in a clinical trial showing that it induces remission of fever and joint inflammation, to the discovery that it could prevent death from heart attack, to its anticancer properties, aspirin remains one of the most researched drugs in use today. According to ClinicalTrials.gov, there are over 465 active and nearly 1,000 completed aspirin-related clinical trials around the world.

Despite its myriad benefits, aspirin has been linked to bleeding, nausea, and gastrointestinal ulcers. Additionally, more research is needed to determine the risks/benefits of daily aspirin in younger adults (under age 50 years) or older adults (over age 70 years), although the ASPREE (Aspirin in Reducing Events in the Elderly) trial, expected to be completed in 2019, is working to determine the effects of daily low-dose aspirin (100 mg) on the health of people over age 65.

It is tempting to consider aspirin one of modern medicine’s so-called silver bullets, and, for women with a history of gestational hypertension and preeclampsia, it just might be. Aspirin use, especially daily aspirin, is typically not recommended during pregnancy, and most ob.gyns. will include aspirin on the “do not take” list they give to their patients during prenatal examinations. Women at risk for developing preeclampsia are the exceptions to this general rule, and a number of clinical studies have indicated that use of low-dose aspirin can help prevent disease as well as secondary outcomes for mother (i.e., placental abruption, antepartum hemorrhage) and baby (i.e., intrauterine growth restriction, stillbirth). In addition, aspirin is an easily obtainable, low-cost preventive measure for any patient at high risk.

To discuss the value of low-dose aspirin to prevent preeclampsia and how ob.gyns. can educate their patients and other health care professionals about its benefits, we have invited Charles J. Lockwood, MD, MHCM, senior vice president of University of South Florida Health and dean of Morsani College of Medicine at the University of South Florida, Tampa, and Jodi F. Abbott, MD, MSc, MHCM, director of obstetrics and gynecology at Boston Medical Center, and associate professor of obstetrics and gynecology at Boston University, to coauthor this month’s Master Class.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].

Some of our readers might remember the old saying, “Take two aspirin and call me in the morning,” as advice physicians gave to patients experiencing a minor malady. Aspirin often has been called a “wonder drug” as its uses continue to expand. From its first recorded use in the Ebers papyrus as an anti-inflammatory agent, to its first use in a clinical trial showing that it induces remission of fever and joint inflammation, to the discovery that it could prevent death from heart attack, to its anticancer properties, aspirin remains one of the most researched drugs in use today. According to ClinicalTrials.gov, there are over 465 active and nearly 1,000 completed aspirin-related clinical trials around the world.

Despite its myriad benefits, aspirin has been linked to bleeding, nausea, and gastrointestinal ulcers. Additionally, more research is needed to determine the risks/benefits of daily aspirin in younger adults (under age 50 years) or older adults (over age 70 years), although the ASPREE (Aspirin in Reducing Events in the Elderly) trial, expected to be completed in 2019, is working to determine the effects of daily low-dose aspirin (100 mg) on the health of people over age 65.

It is tempting to consider aspirin one of modern medicine’s so-called silver bullets, and, for women with a history of gestational hypertension and preeclampsia, it just might be. Aspirin use, especially daily aspirin, is typically not recommended during pregnancy, and most ob.gyns. will include aspirin on the “do not take” list they give to their patients during prenatal examinations. Women at risk for developing preeclampsia are the exceptions to this general rule, and a number of clinical studies have indicated that use of low-dose aspirin can help prevent disease as well as secondary outcomes for mother (i.e., placental abruption, antepartum hemorrhage) and baby (i.e., intrauterine growth restriction, stillbirth). In addition, aspirin is an easily obtainable, low-cost preventive measure for any patient at high risk.

To discuss the value of low-dose aspirin to prevent preeclampsia and how ob.gyns. can educate their patients and other health care professionals about its benefits, we have invited Charles J. Lockwood, MD, MHCM, senior vice president of University of South Florida Health and dean of Morsani College of Medicine at the University of South Florida, Tampa, and Jodi F. Abbott, MD, MSc, MHCM, director of obstetrics and gynecology at Boston Medical Center, and associate professor of obstetrics and gynecology at Boston University, to coauthor this month’s Master Class.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].

Some of us seem completely blank, but our minds are predisposed to constantly engage in various mental activities. Our minds can problem solve, fantasize, remember past events, get preoccupied with a book or movie, pay attention to social relationships and/or pay attention to our relationship with ourselves, focus on what we are doing in the moment, and more.

©Thinkstock

Many of us understand that our minds sometime operate on more than one level, for example, I can be talking or listening to someone in the “front of my mind” and be thinking something seemingly unrelated in the “back of my mind.” Accordingly, our minds are like a cornucopia of thoughts, feelings, and memories, to name a few, making them a very complex and intricate aspect of our lives. Sometimes we try to take a break from this never-ending mental activity by going to sleep or even taking drugs to “turn our minds off.”

Another important aspect of our minds is “will.” I like to think that most of us are familiar with the concept of “will” and put ours to good use. We intentionally or unintentionally use our wills in various ways – to improve ourselves; have fun; dawdle our lives away on imaginary activities; accomplish something tangible (for example, write a paper or wash the kitchen floor); pay attention to what we are doing in the moment; be healthy; and practice cultivating a “sound mind.”

Many of us would agree that to be of sound mind means having the ability to be comfortable with ourselves; to have some regulation of our emotions and affects; not to worry too much, but just enough to stay motivated; and to apply our minds toward accomplishing a goal we have chosen for ourselves. A sound mind also involves having a good memory, being aware and awake, being able to sort things out and adapt to various difficulties life throws at us, solving problems creatively and effectively, being able to relax, and being able to have a purpose in our lives that we have some success in fulfilling.

As a psychiatrist, I often have been curious about how people use their minds and how they direct their mental activities, or, if they do not direct their mental activities at all and simply meander through their mental lives not doing much thinking about thinking (many of us do both). Further, what is even more curious to me is how we psychiatrists use our minds; after all, we are supposed to be the experts. Certainly, with the advent of psychoanalysis, cognitive-behavioral therapy and other techniques, we are teaching our patients, and, hopefully, learning ourselves about how to manage our minds and what they preoccupy themselves with thinking. Of course, there were the methods of Abraham A. Low, MD, about “will training,” which I consider the first iteration of CBT. Prior to psychoanalysis and Low’s ideas, there have always been various forms of mindfulness.

Dr. Bell is staff psychiatrist at Jackson Park Hospital Surgical-Medical/Psychiatric Inpatient Unit; clinical professor emeritus, department of psychiatry, University of Illinois at Chicago; and former director of the Institute for Juvenile Research (the birthplace of child psychiatry), all in Chicago. He serves as chair of psychiatry at Windsor University, St. Kitts.

Some of us seem completely blank, but our minds are predisposed to constantly engage in various mental activities. Our minds can problem solve, fantasize, remember past events, get preoccupied with a book or movie, pay attention to social relationships and/or pay attention to our relationship with ourselves, focus on what we are doing in the moment, and more.

©Thinkstock

Many of us understand that our minds sometime operate on more than one level, for example, I can be talking or listening to someone in the “front of my mind” and be thinking something seemingly unrelated in the “back of my mind.” Accordingly, our minds are like a cornucopia of thoughts, feelings, and memories, to name a few, making them a very complex and intricate aspect of our lives. Sometimes we try to take a break from this never-ending mental activity by going to sleep or even taking drugs to “turn our minds off.”

Another important aspect of our minds is “will.” I like to think that most of us are familiar with the concept of “will” and put ours to good use. We intentionally or unintentionally use our wills in various ways – to improve ourselves; have fun; dawdle our lives away on imaginary activities; accomplish something tangible (for example, write a paper or wash the kitchen floor); pay attention to what we are doing in the moment; be healthy; and practice cultivating a “sound mind.”

Many of us would agree that to be of sound mind means having the ability to be comfortable with ourselves; to have some regulation of our emotions and affects; not to worry too much, but just enough to stay motivated; and to apply our minds toward accomplishing a goal we have chosen for ourselves. A sound mind also involves having a good memory, being aware and awake, being able to sort things out and adapt to various difficulties life throws at us, solving problems creatively and effectively, being able to relax, and being able to have a purpose in our lives that we have some success in fulfilling.

As a psychiatrist, I often have been curious about how people use their minds and how they direct their mental activities, or, if they do not direct their mental activities at all and simply meander through their mental lives not doing much thinking about thinking (many of us do both). Further, what is even more curious to me is how we psychiatrists use our minds; after all, we are supposed to be the experts. Certainly, with the advent of psychoanalysis, cognitive-behavioral therapy and other techniques, we are teaching our patients, and, hopefully, learning ourselves about how to manage our minds and what they preoccupy themselves with thinking. Of course, there were the methods of Abraham A. Low, MD, about “will training,” which I consider the first iteration of CBT. Prior to psychoanalysis and Low’s ideas, there have always been various forms of mindfulness.

Dr. Bell is staff psychiatrist at Jackson Park Hospital Surgical-Medical/Psychiatric Inpatient Unit; clinical professor emeritus, department of psychiatry, University of Illinois at Chicago; and former director of the Institute for Juvenile Research (the birthplace of child psychiatry), all in Chicago. He serves as chair of psychiatry at Windsor University, St. Kitts.

Some of us seem completely blank, but our minds are predisposed to constantly engage in various mental activities. Our minds can problem solve, fantasize, remember past events, get preoccupied with a book or movie, pay attention to social relationships and/or pay attention to our relationship with ourselves, focus on what we are doing in the moment, and more.

©Thinkstock

Many of us understand that our minds sometime operate on more than one level, for example, I can be talking or listening to someone in the “front of my mind” and be thinking something seemingly unrelated in the “back of my mind.” Accordingly, our minds are like a cornucopia of thoughts, feelings, and memories, to name a few, making them a very complex and intricate aspect of our lives. Sometimes we try to take a break from this never-ending mental activity by going to sleep or even taking drugs to “turn our minds off.”

Another important aspect of our minds is “will.” I like to think that most of us are familiar with the concept of “will” and put ours to good use. We intentionally or unintentionally use our wills in various ways – to improve ourselves; have fun; dawdle our lives away on imaginary activities; accomplish something tangible (for example, write a paper or wash the kitchen floor); pay attention to what we are doing in the moment; be healthy; and practice cultivating a “sound mind.”

Many of us would agree that to be of sound mind means having the ability to be comfortable with ourselves; to have some regulation of our emotions and affects; not to worry too much, but just enough to stay motivated; and to apply our minds toward accomplishing a goal we have chosen for ourselves. A sound mind also involves having a good memory, being aware and awake, being able to sort things out and adapt to various difficulties life throws at us, solving problems creatively and effectively, being able to relax, and being able to have a purpose in our lives that we have some success in fulfilling.

As a psychiatrist, I often have been curious about how people use their minds and how they direct their mental activities, or, if they do not direct their mental activities at all and simply meander through their mental lives not doing much thinking about thinking (many of us do both). Further, what is even more curious to me is how we psychiatrists use our minds; after all, we are supposed to be the experts. Certainly, with the advent of psychoanalysis, cognitive-behavioral therapy and other techniques, we are teaching our patients, and, hopefully, learning ourselves about how to manage our minds and what they preoccupy themselves with thinking. Of course, there were the methods of Abraham A. Low, MD, about “will training,” which I consider the first iteration of CBT. Prior to psychoanalysis and Low’s ideas, there have always been various forms of mindfulness.

Dr. Bell is staff psychiatrist at Jackson Park Hospital Surgical-Medical/Psychiatric Inpatient Unit; clinical professor emeritus, department of psychiatry, University of Illinois at Chicago; and former director of the Institute for Juvenile Research (the birthplace of child psychiatry), all in Chicago. He serves as chair of psychiatry at Windsor University, St. Kitts.

The optimist says the glass is half-full. The pessimist says it is half-empty. An engineer says the glass is twice as large as needed to contain the specified amount of fluid. To some people, that mindset makes engineers negative people. We focus on weaknesses and inefficiencies. A chain is only as strong as its weakest link. There is no partial credit when building a bridge. 98% right is still wrong.

When I worked as an engineer, critiquing ideas was a daily activity. I am used to conflicting opinions. Industry trains people to be professional and act appropriately when disagreeing with a colleague. Tact is the art of making a point without making an enemy. Engineering has a strong culture of focusing on a problem rather than on personalities. Upper management made it clear that in any turf war, both sides will lose. Academia has a different culture. Turf wars in academia are so bitter because the stakes are so small.

Pediatrics has less confrontation and competitiveness than do other subspecialties. That makes the work environment more pleasant, as long as every other group in the hospital isn’t walking all over you. Pediatricians often view themselves as dedicated to doing what is right for the children, even to the point of martyrdom. Some early pediatric hospitalist programs got into economic trouble because they adopted tasks that benefited the children but that weren’t being performed by other physicians precisely because those tasks were neither valued nor compensated. Learning to say “No” is hard but necessary.

As a clinical ethics consultant, I was consulted when conflict had developed between providers and patients/parents or between different specialties. Ethics consults are rarely about what philosophers would call ethics. They are mostly about miscommunication, empowering voices to be heard and clarifying values. Practical skills in de-escalation and mediation are more important than either law or philosophy degrees.

There are downsides to avoiding confrontation. Truth suffers. Integrity is lost. Goals become corrupted. I will give two examples. One ED had a five-level triage system. Level 1 was reserved for life-threatening situations such as gunshot wounds and resuscitations. So I was surprised to see a “bili” baby triaged at Level 1. He was a good baby with normal vitals. Admission for phototherapy was reasonable, but the urgency of a bilirubin of 19 did not match that of a gunshot wound. A colleague warned me not to even consider challenging the practice. A powerful physician at that institution had made it policy years earlier.

I witnessed a similar dynamic many times at that institution. Residents are even better than 4-year-olds at noticing hypocritical behavior. Once they perceive that the dynamic is political power and not science, they adapt quickly. A couple days later, I asked a resident if he really thought an IV was necessary for a toddler we were admitting. He replied no, but if he hadn’t put an IV in, the hospital wouldn’t get paid for the admission. To him, that was the unspoken policy. The action didn’t even cause him moral distress. I worry about that much cynicism so early in a career. Cognitive dissonance starts small and slowly creeps its way into everything.

The art of managing conflict is particularly important in pediatric hospital medicine because of its heavy investment in reducing overdiagnosis and overtreatment. Many pediatric hospitalists are located at academic institutions and more subject to its turf wars than outpatient colleagues practicing in small groups. The recent conference for pediatric hospital medicine was held in Atlanta, a few blocks from the Center for Civil and Human Rights. That museum evokes powerful images of struggles around the world. My two takeaway lessons: Silence is a form of collaboration. Tyrannical suppression of dissent magnifies suffering.

In poorly managed academic institutions, it can be harmful to one’s career to ask questions, challenge assumptions, and seek truth. A recent report found that the Department of Veterans Affairs health system also has a culture that punishes whistle-blowers. Nationally, politics has become polarized. Splitting, once considered a dysfunctional behavior, has become normalized. So I understand the reluctance to speak up. One must choose one’s battles.

Given the personal and career risks, why confront inaccurate research, wasteful practices, and unjust policies? I believe that there is a balance and a choice each person must make. Canadian engineers wear an iron ring to remind themselves of their professional responsibilities. Doctors wear white coats. Personally, I share a memory with other engineers of my generation. In January 1986, NASA engineers could not convince their managers about a risk. The space shuttle Challenger exploded. I heard about it in the medical school’s cafeteria. So for me, disputation is part of the vocation.

 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

The optimist says the glass is half-full. The pessimist says it is half-empty. An engineer says the glass is twice as large as needed to contain the specified amount of fluid. To some people, that mindset makes engineers negative people. We focus on weaknesses and inefficiencies. A chain is only as strong as its weakest link. There is no partial credit when building a bridge. 98% right is still wrong.

When I worked as an engineer, critiquing ideas was a daily activity. I am used to conflicting opinions. Industry trains people to be professional and act appropriately when disagreeing with a colleague. Tact is the art of making a point without making an enemy. Engineering has a strong culture of focusing on a problem rather than on personalities. Upper management made it clear that in any turf war, both sides will lose. Academia has a different culture. Turf wars in academia are so bitter because the stakes are so small.

Pediatrics has less confrontation and competitiveness than do other subspecialties. That makes the work environment more pleasant, as long as every other group in the hospital isn’t walking all over you. Pediatricians often view themselves as dedicated to doing what is right for the children, even to the point of martyrdom. Some early pediatric hospitalist programs got into economic trouble because they adopted tasks that benefited the children but that weren’t being performed by other physicians precisely because those tasks were neither valued nor compensated. Learning to say “No” is hard but necessary.

As a clinical ethics consultant, I was consulted when conflict had developed between providers and patients/parents or between different specialties. Ethics consults are rarely about what philosophers would call ethics. They are mostly about miscommunication, empowering voices to be heard and clarifying values. Practical skills in de-escalation and mediation are more important than either law or philosophy degrees.

There are downsides to avoiding confrontation. Truth suffers. Integrity is lost. Goals become corrupted. I will give two examples. One ED had a five-level triage system. Level 1 was reserved for life-threatening situations such as gunshot wounds and resuscitations. So I was surprised to see a “bili” baby triaged at Level 1. He was a good baby with normal vitals. Admission for phototherapy was reasonable, but the urgency of a bilirubin of 19 did not match that of a gunshot wound. A colleague warned me not to even consider challenging the practice. A powerful physician at that institution had made it policy years earlier.

I witnessed a similar dynamic many times at that institution. Residents are even better than 4-year-olds at noticing hypocritical behavior. Once they perceive that the dynamic is political power and not science, they adapt quickly. A couple days later, I asked a resident if he really thought an IV was necessary for a toddler we were admitting. He replied no, but if he hadn’t put an IV in, the hospital wouldn’t get paid for the admission. To him, that was the unspoken policy. The action didn’t even cause him moral distress. I worry about that much cynicism so early in a career. Cognitive dissonance starts small and slowly creeps its way into everything.

The art of managing conflict is particularly important in pediatric hospital medicine because of its heavy investment in reducing overdiagnosis and overtreatment. Many pediatric hospitalists are located at academic institutions and more subject to its turf wars than outpatient colleagues practicing in small groups. The recent conference for pediatric hospital medicine was held in Atlanta, a few blocks from the Center for Civil and Human Rights. That museum evokes powerful images of struggles around the world. My two takeaway lessons: Silence is a form of collaboration. Tyrannical suppression of dissent magnifies suffering.

In poorly managed academic institutions, it can be harmful to one’s career to ask questions, challenge assumptions, and seek truth. A recent report found that the Department of Veterans Affairs health system also has a culture that punishes whistle-blowers. Nationally, politics has become polarized. Splitting, once considered a dysfunctional behavior, has become normalized. So I understand the reluctance to speak up. One must choose one’s battles.

Given the personal and career risks, why confront inaccurate research, wasteful practices, and unjust policies? I believe that there is a balance and a choice each person must make. Canadian engineers wear an iron ring to remind themselves of their professional responsibilities. Doctors wear white coats. Personally, I share a memory with other engineers of my generation. In January 1986, NASA engineers could not convince their managers about a risk. The space shuttle Challenger exploded. I heard about it in the medical school’s cafeteria. So for me, disputation is part of the vocation.

 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

The optimist says the glass is half-full. The pessimist says it is half-empty. An engineer says the glass is twice as large as needed to contain the specified amount of fluid. To some people, that mindset makes engineers negative people. We focus on weaknesses and inefficiencies. A chain is only as strong as its weakest link. There is no partial credit when building a bridge. 98% right is still wrong.

When I worked as an engineer, critiquing ideas was a daily activity. I am used to conflicting opinions. Industry trains people to be professional and act appropriately when disagreeing with a colleague. Tact is the art of making a point without making an enemy. Engineering has a strong culture of focusing on a problem rather than on personalities. Upper management made it clear that in any turf war, both sides will lose. Academia has a different culture. Turf wars in academia are so bitter because the stakes are so small.

Pediatrics has less confrontation and competitiveness than do other subspecialties. That makes the work environment more pleasant, as long as every other group in the hospital isn’t walking all over you. Pediatricians often view themselves as dedicated to doing what is right for the children, even to the point of martyrdom. Some early pediatric hospitalist programs got into economic trouble because they adopted tasks that benefited the children but that weren’t being performed by other physicians precisely because those tasks were neither valued nor compensated. Learning to say “No” is hard but necessary.

As a clinical ethics consultant, I was consulted when conflict had developed between providers and patients/parents or between different specialties. Ethics consults are rarely about what philosophers would call ethics. They are mostly about miscommunication, empowering voices to be heard and clarifying values. Practical skills in de-escalation and mediation are more important than either law or philosophy degrees.

There are downsides to avoiding confrontation. Truth suffers. Integrity is lost. Goals become corrupted. I will give two examples. One ED had a five-level triage system. Level 1 was reserved for life-threatening situations such as gunshot wounds and resuscitations. So I was surprised to see a “bili” baby triaged at Level 1. He was a good baby with normal vitals. Admission for phototherapy was reasonable, but the urgency of a bilirubin of 19 did not match that of a gunshot wound. A colleague warned me not to even consider challenging the practice. A powerful physician at that institution had made it policy years earlier.

I witnessed a similar dynamic many times at that institution. Residents are even better than 4-year-olds at noticing hypocritical behavior. Once they perceive that the dynamic is political power and not science, they adapt quickly. A couple days later, I asked a resident if he really thought an IV was necessary for a toddler we were admitting. He replied no, but if he hadn’t put an IV in, the hospital wouldn’t get paid for the admission. To him, that was the unspoken policy. The action didn’t even cause him moral distress. I worry about that much cynicism so early in a career. Cognitive dissonance starts small and slowly creeps its way into everything.

The art of managing conflict is particularly important in pediatric hospital medicine because of its heavy investment in reducing overdiagnosis and overtreatment. Many pediatric hospitalists are located at academic institutions and more subject to its turf wars than outpatient colleagues practicing in small groups. The recent conference for pediatric hospital medicine was held in Atlanta, a few blocks from the Center for Civil and Human Rights. That museum evokes powerful images of struggles around the world. My two takeaway lessons: Silence is a form of collaboration. Tyrannical suppression of dissent magnifies suffering.

In poorly managed academic institutions, it can be harmful to one’s career to ask questions, challenge assumptions, and seek truth. A recent report found that the Department of Veterans Affairs health system also has a culture that punishes whistle-blowers. Nationally, politics has become polarized. Splitting, once considered a dysfunctional behavior, has become normalized. So I understand the reluctance to speak up. One must choose one’s battles.

Given the personal and career risks, why confront inaccurate research, wasteful practices, and unjust policies? I believe that there is a balance and a choice each person must make. Canadian engineers wear an iron ring to remind themselves of their professional responsibilities. Doctors wear white coats. Personally, I share a memory with other engineers of my generation. In January 1986, NASA engineers could not convince their managers about a risk. The space shuttle Challenger exploded. I heard about it in the medical school’s cafeteria. So for me, disputation is part of the vocation.

 

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

Defensive medicine exists. The question is how often it happens and how large a role it plays in making medical care in the United States so costly. When Dr. Tom Price was a congressman, he was quoted as saying that defensive medicine is responsible for more than 25% of every dollar this country spends on health care. (“A Fear of Lawsuits Really Does Seem to Result in Extra Medical Tests” Margot Sanger-Katz, New York Times, July 23, 2018). Neither I nor anyone else had any data to support or refute Dr. Price’s claim in 2010, but based on 50 years of practicing and observing medicine, I don’t find his claim completely unreasonable.

iStock

Defensive medicine has been going on for so many generations of physicians that most doctors practicing today don’t realize they are doing it. A physician may order a full battery of chemistries on a patient presenting with mild anemia when only a CBC is necessary because that’s the way he was trained.

However, the evidence to support my suspicion that defensive medicine is a significant financial drain on our economy has been difficult to tease out of the tangled web of confounders that is woven into our patchwork health care system. A recent study by two economists provides a glimpse into the role of defensive medicine in the cost of health care (“Defensive Medicine: Evidence from Military Immunity” Michael D. Frakes and Jonathan Gruber, National Bureau of Economic Research, July 2018). Using the unusual combination of circumstances in which military personnel and their dependents can or cannot sue depending on where they are receiving care, the investigators found that “liability immunity reduces inpatient spending by 5% with no measurable negative effect on patient outcomes.” While that may not be as high as Dr. Price or I think it may be, 5% of three trillion dollars is serious money.

The bigger problem is that defensive medicine is ugly, artless, and intellectually unsatisfying. While the patient may not view your diagnosis of his chronic debilitating or terminal illness as a work of art, there are such things as beautiful diagnoses. One may be beautiful in its simplicity and its ability to unify a variety of previously unexplained symptoms. Another diagnosis may be the intellectually stimulating result of a carefully thought out branching decision tree to solve a puzzling array of complaints using a minimum of costly studies.

Defensive medicine decisions are made primarily to avoid mistakes and omissions. Physicians often behave as though we believe our errors will always be fatal. That may be somewhat true for surgeons, but for the rest of us errors can be an important part of learning. The unfortunate outcome of an error, particularly one of omission, can usually be avoided by following the patient closely, remaining available ... and continuing to exude an aura of caring.

With close and thoughtful follow-up, you are going to discover pretty quickly when you have missed the target. Patients understand that we aren’t going to get the correct diagnosis or prescribe the best treatment on the first try every time. What patients don’t understand and what may prompt them to sue is feeling that they are being ignored.

While practicing defensive medicine isn’t usually listed as one of the cardinal symptoms of physician burnout, it probably deserves more attention. With some introspection and a bit of courage, recasting what you do in terms of its artistry and intellectual integrity could add a new and positive dimension to how you practice medicine. How many of your decisions are being made to avoid an error? Wouldn’t it be more fun to be making beautiful diagnoses you can be proud of?

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Is My Child Overtired?: The Sleep Solution for Raising Happier, Healthier Children.” Email him at [email protected].

Defensive medicine exists. The question is how often it happens and how large a role it plays in making medical care in the United States so costly. When Dr. Tom Price was a congressman, he was quoted as saying that defensive medicine is responsible for more than 25% of every dollar this country spends on health care. (“A Fear of Lawsuits Really Does Seem to Result in Extra Medical Tests” Margot Sanger-Katz, New York Times, July 23, 2018). Neither I nor anyone else had any data to support or refute Dr. Price’s claim in 2010, but based on 50 years of practicing and observing medicine, I don’t find his claim completely unreasonable.

iStock

Defensive medicine has been going on for so many generations of physicians that most doctors practicing today don’t realize they are doing it. A physician may order a full battery of chemistries on a patient presenting with mild anemia when only a CBC is necessary because that’s the way he was trained.

However, the evidence to support my suspicion that defensive medicine is a significant financial drain on our economy has been difficult to tease out of the tangled web of confounders that is woven into our patchwork health care system. A recent study by two economists provides a glimpse into the role of defensive medicine in the cost of health care (“Defensive Medicine: Evidence from Military Immunity” Michael D. Frakes and Jonathan Gruber, National Bureau of Economic Research, July 2018). Using the unusual combination of circumstances in which military personnel and their dependents can or cannot sue depending on where they are receiving care, the investigators found that “liability immunity reduces inpatient spending by 5% with no measurable negative effect on patient outcomes.” While that may not be as high as Dr. Price or I think it may be, 5% of three trillion dollars is serious money.

The bigger problem is that defensive medicine is ugly, artless, and intellectually unsatisfying. While the patient may not view your diagnosis of his chronic debilitating or terminal illness as a work of art, there are such things as beautiful diagnoses. One may be beautiful in its simplicity and its ability to unify a variety of previously unexplained symptoms. Another diagnosis may be the intellectually stimulating result of a carefully thought out branching decision tree to solve a puzzling array of complaints using a minimum of costly studies.

Defensive medicine decisions are made primarily to avoid mistakes and omissions. Physicians often behave as though we believe our errors will always be fatal. That may be somewhat true for surgeons, but for the rest of us errors can be an important part of learning. The unfortunate outcome of an error, particularly one of omission, can usually be avoided by following the patient closely, remaining available ... and continuing to exude an aura of caring.

With close and thoughtful follow-up, you are going to discover pretty quickly when you have missed the target. Patients understand that we aren’t going to get the correct diagnosis or prescribe the best treatment on the first try every time. What patients don’t understand and what may prompt them to sue is feeling that they are being ignored.

While practicing defensive medicine isn’t usually listed as one of the cardinal symptoms of physician burnout, it probably deserves more attention. With some introspection and a bit of courage, recasting what you do in terms of its artistry and intellectual integrity could add a new and positive dimension to how you practice medicine. How many of your decisions are being made to avoid an error? Wouldn’t it be more fun to be making beautiful diagnoses you can be proud of?

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Is My Child Overtired?: The Sleep Solution for Raising Happier, Healthier Children.” Email him at [email protected].

Defensive medicine exists. The question is how often it happens and how large a role it plays in making medical care in the United States so costly. When Dr. Tom Price was a congressman, he was quoted as saying that defensive medicine is responsible for more than 25% of every dollar this country spends on health care. (“A Fear of Lawsuits Really Does Seem to Result in Extra Medical Tests” Margot Sanger-Katz, New York Times, July 23, 2018). Neither I nor anyone else had any data to support or refute Dr. Price’s claim in 2010, but based on 50 years of practicing and observing medicine, I don’t find his claim completely unreasonable.

iStock

Defensive medicine has been going on for so many generations of physicians that most doctors practicing today don’t realize they are doing it. A physician may order a full battery of chemistries on a patient presenting with mild anemia when only a CBC is necessary because that’s the way he was trained.

However, the evidence to support my suspicion that defensive medicine is a significant financial drain on our economy has been difficult to tease out of the tangled web of confounders that is woven into our patchwork health care system. A recent study by two economists provides a glimpse into the role of defensive medicine in the cost of health care (“Defensive Medicine: Evidence from Military Immunity” Michael D. Frakes and Jonathan Gruber, National Bureau of Economic Research, July 2018). Using the unusual combination of circumstances in which military personnel and their dependents can or cannot sue depending on where they are receiving care, the investigators found that “liability immunity reduces inpatient spending by 5% with no measurable negative effect on patient outcomes.” While that may not be as high as Dr. Price or I think it may be, 5% of three trillion dollars is serious money.

The bigger problem is that defensive medicine is ugly, artless, and intellectually unsatisfying. While the patient may not view your diagnosis of his chronic debilitating or terminal illness as a work of art, there are such things as beautiful diagnoses. One may be beautiful in its simplicity and its ability to unify a variety of previously unexplained symptoms. Another diagnosis may be the intellectually stimulating result of a carefully thought out branching decision tree to solve a puzzling array of complaints using a minimum of costly studies.

Defensive medicine decisions are made primarily to avoid mistakes and omissions. Physicians often behave as though we believe our errors will always be fatal. That may be somewhat true for surgeons, but for the rest of us errors can be an important part of learning. The unfortunate outcome of an error, particularly one of omission, can usually be avoided by following the patient closely, remaining available ... and continuing to exude an aura of caring.

With close and thoughtful follow-up, you are going to discover pretty quickly when you have missed the target. Patients understand that we aren’t going to get the correct diagnosis or prescribe the best treatment on the first try every time. What patients don’t understand and what may prompt them to sue is feeling that they are being ignored.

While practicing defensive medicine isn’t usually listed as one of the cardinal symptoms of physician burnout, it probably deserves more attention. With some introspection and a bit of courage, recasting what you do in terms of its artistry and intellectual integrity could add a new and positive dimension to how you practice medicine. How many of your decisions are being made to avoid an error? Wouldn’t it be more fun to be making beautiful diagnoses you can be proud of?

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Is My Child Overtired?: The Sleep Solution for Raising Happier, Healthier Children.” Email him at [email protected].

When sitting through interminable meetings, endless reports, and unfocused discussions, I often feel a building pressure in my head that, if it continues, will surely result in my brain exploding. I used to carry in my pocket an elastic compression bandage, intending to wrap it around my head as a signal to the offending speakers, but never had the heart to use it. Still, that bandage in my pocket was the backup resource that gave me solace, gave me patience.

Yet, my emergency bandage was nowhere to be found while I was reading the 2019 Medicare proposed rule, which unexpectedly triggered the threat of a brain explosion.

I was prepared for the usual proposed rule of about 1,500 pages of dense, bureaucratic “Engfish,” proposing a cut here, a tuck there, an occasional evisceration, and several correctable errors. This time, though, the proposed rule is wide open, disruptive, uninformed, and disappointing to almost all medical practitioners.

For dermatology, it starts out promisingly, by collapsing the evaluation and management (E/M) codes into two levels, instead of five. That should benefit us slightly, because our coding usually falls at about level three. Also, it would simplify record keeping by only requiring level two documentation and not making docs repeatedly reenter data. Well, OK so far.

Keep reading, though, and then the hammer falls: a proposed 50% reduction in reimbursement for any procedure performed on the same day as the E/M code. What?! Implementation of this change would result in an estimated 20% reduction in reimbursement for dermatologists who, as a courtesy to their patients, do procedures on the same day as an evaluation visit. And this proposed change would likely hurt ophthalmologists, otolaryngologists, and even primary care physicians who do same-day procedures.

There are new extended-care codes that only primary care docs could use, and some other extended care codes for specialists (dermatology is not mentioned) that pay about $5 extra. There is a bone thrown to telemedicine, since telemedicine coverage is supported, including “store and forward,” but not if the patient is seen in person within a week, “or at the soonest available appointment.” Very strange.

The current reimbursement system is a carefully honed, carefully balanced, work of reasonable rational thought by the current procedural terminology committee, the American Medical Association’s RVS Update Committee (RUC) and the Centers for Medicare & Medicaid Services. CMS officials sit at the table at all these meetings, frequently comment, and the agency has the power of final approval. No one loves the final product, particularly the participants, but there are procedures and rules, an appeals process, and the process allows for a rough form of justice administered by your medical peers. Who better to decide what is fair to pay anyone out of a fixed reimbursement pool?

Unfortunately, there seems to be no institutional memory in this year’s final rule. For example, since it came out, various branches of organized medicine have held urgent meetings at which it was pointed out that a 50% reduction in procedures on the same day as an evaluation and management code is inappropriate, since the overlapping work and practice expense already had been removed for such codes by the relative value update committee. This observation reportedly came as a surprise to the CMS attendees – a most disturbing admission.

There was also discouraging news about the global period survey. Dermatology reported only 3% of the global visits possible.

It turns out that CMS did not look for additional 99024 visits beyond the 10- or 90-day global period in the surveyed states and did not look at practices of fewer than 10 dermatologists, even if they did report. Think about it, how many dermatology groups do you know of 10 or more dermatologists in Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island? How often do you delay suture removal beyond 10 days? How many times do you see a patient back for a triamcinolone injection or reassurance at no charge more than 10 days after procedures? Talk about a flawed process destined to fail!

The loss of global periods will hurt much, much more than the 50% cut in procedures on the same day as an E/M code. The premalignant and benign destruction codes could be cut by 75% – and good luck in charging for suture removal after surgery. We are talking about another 20% reimbursement cut if implemented.

The American Academy of Dermatology and other dermatology societies are actively involved in responding to the CMS regarding the shortcomings of the proposed rule. Be prepared to be called upon to submit your comments to CMS soon. I am hopeful that much of these misguided proposals can be corrected, but it will take a concerted effort of numerous individual dermatologists, including you.

Finally, I advise you to read the final rule for yourself. And, unlike me, do not forget to keep your emergency wrap handy!

Comments will be taken at www.regulations.gov through Sept. 10, 2018.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected] .

When sitting through interminable meetings, endless reports, and unfocused discussions, I often feel a building pressure in my head that, if it continues, will surely result in my brain exploding. I used to carry in my pocket an elastic compression bandage, intending to wrap it around my head as a signal to the offending speakers, but never had the heart to use it. Still, that bandage in my pocket was the backup resource that gave me solace, gave me patience.

Yet, my emergency bandage was nowhere to be found while I was reading the 2019 Medicare proposed rule, which unexpectedly triggered the threat of a brain explosion.

I was prepared for the usual proposed rule of about 1,500 pages of dense, bureaucratic “Engfish,” proposing a cut here, a tuck there, an occasional evisceration, and several correctable errors. This time, though, the proposed rule is wide open, disruptive, uninformed, and disappointing to almost all medical practitioners.

For dermatology, it starts out promisingly, by collapsing the evaluation and management (E/M) codes into two levels, instead of five. That should benefit us slightly, because our coding usually falls at about level three. Also, it would simplify record keeping by only requiring level two documentation and not making docs repeatedly reenter data. Well, OK so far.

Keep reading, though, and then the hammer falls: a proposed 50% reduction in reimbursement for any procedure performed on the same day as the E/M code. What?! Implementation of this change would result in an estimated 20% reduction in reimbursement for dermatologists who, as a courtesy to their patients, do procedures on the same day as an evaluation visit. And this proposed change would likely hurt ophthalmologists, otolaryngologists, and even primary care physicians who do same-day procedures.

There are new extended-care codes that only primary care docs could use, and some other extended care codes for specialists (dermatology is not mentioned) that pay about $5 extra. There is a bone thrown to telemedicine, since telemedicine coverage is supported, including “store and forward,” but not if the patient is seen in person within a week, “or at the soonest available appointment.” Very strange.

The current reimbursement system is a carefully honed, carefully balanced, work of reasonable rational thought by the current procedural terminology committee, the American Medical Association’s RVS Update Committee (RUC) and the Centers for Medicare & Medicaid Services. CMS officials sit at the table at all these meetings, frequently comment, and the agency has the power of final approval. No one loves the final product, particularly the participants, but there are procedures and rules, an appeals process, and the process allows for a rough form of justice administered by your medical peers. Who better to decide what is fair to pay anyone out of a fixed reimbursement pool?

Unfortunately, there seems to be no institutional memory in this year’s final rule. For example, since it came out, various branches of organized medicine have held urgent meetings at which it was pointed out that a 50% reduction in procedures on the same day as an evaluation and management code is inappropriate, since the overlapping work and practice expense already had been removed for such codes by the relative value update committee. This observation reportedly came as a surprise to the CMS attendees – a most disturbing admission.

There was also discouraging news about the global period survey. Dermatology reported only 3% of the global visits possible.

It turns out that CMS did not look for additional 99024 visits beyond the 10- or 90-day global period in the surveyed states and did not look at practices of fewer than 10 dermatologists, even if they did report. Think about it, how many dermatology groups do you know of 10 or more dermatologists in Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island? How often do you delay suture removal beyond 10 days? How many times do you see a patient back for a triamcinolone injection or reassurance at no charge more than 10 days after procedures? Talk about a flawed process destined to fail!

The loss of global periods will hurt much, much more than the 50% cut in procedures on the same day as an E/M code. The premalignant and benign destruction codes could be cut by 75% – and good luck in charging for suture removal after surgery. We are talking about another 20% reimbursement cut if implemented.

The American Academy of Dermatology and other dermatology societies are actively involved in responding to the CMS regarding the shortcomings of the proposed rule. Be prepared to be called upon to submit your comments to CMS soon. I am hopeful that much of these misguided proposals can be corrected, but it will take a concerted effort of numerous individual dermatologists, including you.

Finally, I advise you to read the final rule for yourself. And, unlike me, do not forget to keep your emergency wrap handy!

Comments will be taken at www.regulations.gov through Sept. 10, 2018.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected] .

When sitting through interminable meetings, endless reports, and unfocused discussions, I often feel a building pressure in my head that, if it continues, will surely result in my brain exploding. I used to carry in my pocket an elastic compression bandage, intending to wrap it around my head as a signal to the offending speakers, but never had the heart to use it. Still, that bandage in my pocket was the backup resource that gave me solace, gave me patience.

Yet, my emergency bandage was nowhere to be found while I was reading the 2019 Medicare proposed rule, which unexpectedly triggered the threat of a brain explosion.

I was prepared for the usual proposed rule of about 1,500 pages of dense, bureaucratic “Engfish,” proposing a cut here, a tuck there, an occasional evisceration, and several correctable errors. This time, though, the proposed rule is wide open, disruptive, uninformed, and disappointing to almost all medical practitioners.

For dermatology, it starts out promisingly, by collapsing the evaluation and management (E/M) codes into two levels, instead of five. That should benefit us slightly, because our coding usually falls at about level three. Also, it would simplify record keeping by only requiring level two documentation and not making docs repeatedly reenter data. Well, OK so far.

Keep reading, though, and then the hammer falls: a proposed 50% reduction in reimbursement for any procedure performed on the same day as the E/M code. What?! Implementation of this change would result in an estimated 20% reduction in reimbursement for dermatologists who, as a courtesy to their patients, do procedures on the same day as an evaluation visit. And this proposed change would likely hurt ophthalmologists, otolaryngologists, and even primary care physicians who do same-day procedures.

There are new extended-care codes that only primary care docs could use, and some other extended care codes for specialists (dermatology is not mentioned) that pay about $5 extra. There is a bone thrown to telemedicine, since telemedicine coverage is supported, including “store and forward,” but not if the patient is seen in person within a week, “or at the soonest available appointment.” Very strange.

The current reimbursement system is a carefully honed, carefully balanced, work of reasonable rational thought by the current procedural terminology committee, the American Medical Association’s RVS Update Committee (RUC) and the Centers for Medicare & Medicaid Services. CMS officials sit at the table at all these meetings, frequently comment, and the agency has the power of final approval. No one loves the final product, particularly the participants, but there are procedures and rules, an appeals process, and the process allows for a rough form of justice administered by your medical peers. Who better to decide what is fair to pay anyone out of a fixed reimbursement pool?

Unfortunately, there seems to be no institutional memory in this year’s final rule. For example, since it came out, various branches of organized medicine have held urgent meetings at which it was pointed out that a 50% reduction in procedures on the same day as an evaluation and management code is inappropriate, since the overlapping work and practice expense already had been removed for such codes by the relative value update committee. This observation reportedly came as a surprise to the CMS attendees – a most disturbing admission.

There was also discouraging news about the global period survey. Dermatology reported only 3% of the global visits possible.

It turns out that CMS did not look for additional 99024 visits beyond the 10- or 90-day global period in the surveyed states and did not look at practices of fewer than 10 dermatologists, even if they did report. Think about it, how many dermatology groups do you know of 10 or more dermatologists in Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island? How often do you delay suture removal beyond 10 days? How many times do you see a patient back for a triamcinolone injection or reassurance at no charge more than 10 days after procedures? Talk about a flawed process destined to fail!

The loss of global periods will hurt much, much more than the 50% cut in procedures on the same day as an E/M code. The premalignant and benign destruction codes could be cut by 75% – and good luck in charging for suture removal after surgery. We are talking about another 20% reimbursement cut if implemented.

The American Academy of Dermatology and other dermatology societies are actively involved in responding to the CMS regarding the shortcomings of the proposed rule. Be prepared to be called upon to submit your comments to CMS soon. I am hopeful that much of these misguided proposals can be corrected, but it will take a concerted effort of numerous individual dermatologists, including you.

Finally, I advise you to read the final rule for yourself. And, unlike me, do not forget to keep your emergency wrap handy!

Comments will be taken at www.regulations.gov through Sept. 10, 2018.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected] .

I want to start with a disclaimer: I don’t have a website for my private practice, and I have no formal education in marketing. My opinions on what should and should not be on physician practice websites are my own, and as you take my thoughts into account, remember that others have different opinions about what belongs on a website.

Periodically, I look at websites my colleagues have set up, and I have noted some interesting differences in how detailed they are, the photos that are chosen, the information that is listed, the editing, and how the doctor presents himself or herself. It seems like a wonderful way to both “advertise” and to have people know about the doctor in advance. Practice websites can save time for everyone: A patient can weed out psychiatrists who don’t treat the condition he or she has, and the doctor can refer to the website rather than having long phone conversations with someone who would not want to see them for any number of reasons. In theory, websites can include ways for patients to schedule their own appointments, but I have not yet seen this software on any psychiatry sites.

Psychiatrist websites often start with some biographical and training issues on either the home or Welcome page or in a specific About section. They may give helpful information, such as directions to the office, parking instructions, and what conditions the doctor treats. It’s important to have a clear link to the site’s menu, and I’m not sure that older users always know that the “hamburger” icon of three horizontal lines is a menu link. It’s nice if there is a picture of the doctor, and I’ve even seen a few sites where there is a photo of the doctor’s office; it seems like a nice touch and may allay some anxiety for new patients if the doctor and his or her space feel familiar and nonthreatening. As with everything on the website, the artwork and graphics reflect something about the doctor. Many psychotherapists will use nature photos; others feature stethoscopes and lab coats for a more medical feel. Some psychiatrists opt for more opaque graphics – geometric shapes, for example.

Dr. Miller is the coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).
 

I want to start with a disclaimer: I don’t have a website for my private practice, and I have no formal education in marketing. My opinions on what should and should not be on physician practice websites are my own, and as you take my thoughts into account, remember that others have different opinions about what belongs on a website.

Periodically, I look at websites my colleagues have set up, and I have noted some interesting differences in how detailed they are, the photos that are chosen, the information that is listed, the editing, and how the doctor presents himself or herself. It seems like a wonderful way to both “advertise” and to have people know about the doctor in advance. Practice websites can save time for everyone: A patient can weed out psychiatrists who don’t treat the condition he or she has, and the doctor can refer to the website rather than having long phone conversations with someone who would not want to see them for any number of reasons. In theory, websites can include ways for patients to schedule their own appointments, but I have not yet seen this software on any psychiatry sites.

Psychiatrist websites often start with some biographical and training issues on either the home or Welcome page or in a specific About section. They may give helpful information, such as directions to the office, parking instructions, and what conditions the doctor treats. It’s important to have a clear link to the site’s menu, and I’m not sure that older users always know that the “hamburger” icon of three horizontal lines is a menu link. It’s nice if there is a picture of the doctor, and I’ve even seen a few sites where there is a photo of the doctor’s office; it seems like a nice touch and may allay some anxiety for new patients if the doctor and his or her space feel familiar and nonthreatening. As with everything on the website, the artwork and graphics reflect something about the doctor. Many psychotherapists will use nature photos; others feature stethoscopes and lab coats for a more medical feel. Some psychiatrists opt for more opaque graphics – geometric shapes, for example.

Dr. Miller is the coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).
 

I want to start with a disclaimer: I don’t have a website for my private practice, and I have no formal education in marketing. My opinions on what should and should not be on physician practice websites are my own, and as you take my thoughts into account, remember that others have different opinions about what belongs on a website.

Periodically, I look at websites my colleagues have set up, and I have noted some interesting differences in how detailed they are, the photos that are chosen, the information that is listed, the editing, and how the doctor presents himself or herself. It seems like a wonderful way to both “advertise” and to have people know about the doctor in advance. Practice websites can save time for everyone: A patient can weed out psychiatrists who don’t treat the condition he or she has, and the doctor can refer to the website rather than having long phone conversations with someone who would not want to see them for any number of reasons. In theory, websites can include ways for patients to schedule their own appointments, but I have not yet seen this software on any psychiatry sites.

Psychiatrist websites often start with some biographical and training issues on either the home or Welcome page or in a specific About section. They may give helpful information, such as directions to the office, parking instructions, and what conditions the doctor treats. It’s important to have a clear link to the site’s menu, and I’m not sure that older users always know that the “hamburger” icon of three horizontal lines is a menu link. It’s nice if there is a picture of the doctor, and I’ve even seen a few sites where there is a photo of the doctor’s office; it seems like a nice touch and may allay some anxiety for new patients if the doctor and his or her space feel familiar and nonthreatening. As with everything on the website, the artwork and graphics reflect something about the doctor. Many psychotherapists will use nature photos; others feature stethoscopes and lab coats for a more medical feel. Some psychiatrists opt for more opaque graphics – geometric shapes, for example.

Dr. Miller is the coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).
 

For close to 6 decades, since the approval of imipramine in 1959, all Food and Drug Administration-approved medications for depression worked through the monoamine system, in some ways altering the concentration of serotonin, norepinephrine, or dopamine within synapses or binding to post synaptic receptors. A conservative estimate has at least a third of patients with depression not adequately responsive to these monoaminergic medications.

A host of medications in various stages of development might each offer unique additions to the current therapeutic paradigm. Compounds closest to market include N-methyl-D-aspartate (NMDA) blockers such as esketamine or rapastinel; opioid receptor partial agonists and antagonists, such as Alkermes 5461; and a GABA_A receptor modulator, brexanolone. A further off, more speculative intervention involves the use of psychedelic drugs like psilocybin.

NMDA antagonists have gained the highest visibility after some promising results in early studies looking at intravenous ketamine, an anesthetic agent approved by the FDA in 1970 for treatment-resistant depression. This has led to several companies trying to develop a patentable NMDA antagonist for depression. The most likely first candidate is one of the enantiomers of ketamine, esketamine, which, because of higher binding affinity, can be dosed intranasally rather than intravenously. Studies are completed to establish efficacy in TRD² [treatment-resistant depression] as well as acute suicidality³. Johnson & Johnson plans to submit these results for FDA approval this year.

Another promising NMDA antagonist, rapastinel, is wending its way through clinical trials – but should it be approved, its use might be limited by the requirement for intravenous delivery.

Despite only early evidence for efficacy in depression, the easy availability of ketamine for infusion has created a cadre of independent clinicians as well as some academic clinics offering intravenous ketamine infusions for those with difficult-to-treat depression and adequate finances to pay for off-label treatment (some insurance companies as well have supported its use). It is understandable to try to offer patients suffering with refractory illnesses anything the field has to offer, but the limitations on our knowledge, especially about the efficacy and safety of long-term use of ketamine for depression, need to be taken into account⁴. There is little to no regulation around providing intravenous ketamine, and clinicians and patients should be aware of the risks, take care in the administration of the drug, and watch for the potential of dissociation or substance abuse along with being clear about the likelihood of benefit being at best around 50%. As more evidence and experience are collected, NMDA antagonists might offer a unique efficacy profile within safe boundaries.

Opioid agonists have some antidepressant activity, but tolerance to it quickly develops – requiring users to take increasingly higher doses. Would a partial opioid agonist coupled with a pure opioid antagonist provide ongoing efficacy at a continuous dose with adequate safety? A combination medication containing buprenorphine, a partial* mu- and kappa-opioid partial agonist, and samidorphan, a mu-opioid antagonist, is currently being reviewed by the FDA. The phase 3 studies are not yet published. However, the phase 2 published trial demonstrated efficacy at low doses (2 mg of buprenorphine with 2 mg of samidorphan) as an adjunctive medication in treatment-resistant depression⁵. While offering a novel mechanism of action and a reasonable safety profile seen in several poster presentations, though not published articles, the drug – should it receive approval – will require an intensive effort to educate practitioners and the public about the critical differences (especially with regard to risk/benefits of long-term use, abuse potential, and safety) between opiate agonism and opiate modulation/antagonism.

Brexanolone, an intravenous formulation of allopregnanolone, a positive allosteric modulator of gamma-aminobutyric acid (GABA_A) receptors, has been studied for the treatment of postpartum depression⁶. Early development has focused on an intravenous delivery system and a unique target population of postpartum depression, but the novel concept of targeting GABA_A receptors might prove fruitful with a wider population of depressed patients with inadequate responses to existing antidepressants. An oral formulation, SAGE-217, is in early clinical trials.

While much earlier in the development for FDA approval, psychedelics, particularly psilocybin, have been investigated for use in treatment-resistant depression. A small double-blind trial in terminal cancer patients showed that psilocybin had a remarkable palliative effect on depression and anxiety⁷. An open label study of treatment-resistant depressed patients demonstrated lasting benefit over 6 months after two doses of psilocybin⁸. A neuroimaging study supported the idea that changes in resting state functional connectivity in specific brain regions from exposure to psilocybin might account for alleviation in depressive symptoms⁹. These findings are preliminary, but they have sparked the commencement of a few phase 2 randomized trials for psychedelic drugs. It should be noted that all these trial to date – and those planned – require dosing to be done in a very controlled and supervised psychologically supportive environment.

Which of these treatments will make it to market? That remains unclear, but it is reassuring that so many different novel paradigms for addressing treatment-resistant depression are in development.
 

Dr. Aaronson is the director of clinical research programs at the Sheppard Pratt Health System in Baltimore. He serves as a consultant to several companies, including Alkermes, Genomind, LivaNova, Neuronetics, and Sage Therapeutics. He has received honoraria for speaking from Neurocrine, Otsuka, and Sunovion. He has received research support from Neuronetics. Dr. Aaronson also serves as a clinical associate professor of psychiatry at the University of Maryland, Baltimore, and is a Distinguished Fellow of the American Psychiatric Association and a Fellow of the American College of Psychiatrists.
 

References

1. Am J Psychiatry. 2006;163(11):1905-17.

2. JAMA Psychiatry. 2018 Feb 1;75(2):139-48.

3. Am J Psychiatry. 2018 Jul 1;175(7):620-30.

4. JAMA Psychiatry. 2017;74(4):399-405.

5. Am J Psychiatry. 2016 May 1;173(5):499-508.

6. Lancet. 2017 Jul 29;390(10093):480-9.

7. J Psychopharmacol. 2016;30(12):1181-97.

8. Psychopharmacology (Berl). 2018 Feb;235(2):399-408.

9. Sci Rep. 2017 Oct 13;7(1):13187.

*Correction, 10/18/2019: An earlier version of this story misidentified buprenorphine.

For close to 6 decades, since the approval of imipramine in 1959, all Food and Drug Administration-approved medications for depression worked through the monoamine system, in some ways altering the concentration of serotonin, norepinephrine, or dopamine within synapses or binding to post synaptic receptors. A conservative estimate has at least a third of patients with depression not adequately responsive to these monoaminergic medications.

A host of medications in various stages of development might each offer unique additions to the current therapeutic paradigm. Compounds closest to market include N-methyl-D-aspartate (NMDA) blockers such as esketamine or rapastinel; opioid receptor partial agonists and antagonists, such as Alkermes 5461; and a GABA_A receptor modulator, brexanolone. A further off, more speculative intervention involves the use of psychedelic drugs like psilocybin.

NMDA antagonists have gained the highest visibility after some promising results in early studies looking at intravenous ketamine, an anesthetic agent approved by the FDA in 1970 for treatment-resistant depression. This has led to several companies trying to develop a patentable NMDA antagonist for depression. The most likely first candidate is one of the enantiomers of ketamine, esketamine, which, because of higher binding affinity, can be dosed intranasally rather than intravenously. Studies are completed to establish efficacy in TRD² [treatment-resistant depression] as well as acute suicidality³. Johnson & Johnson plans to submit these results for FDA approval this year.

Another promising NMDA antagonist, rapastinel, is wending its way through clinical trials – but should it be approved, its use might be limited by the requirement for intravenous delivery.

Despite only early evidence for efficacy in depression, the easy availability of ketamine for infusion has created a cadre of independent clinicians as well as some academic clinics offering intravenous ketamine infusions for those with difficult-to-treat depression and adequate finances to pay for off-label treatment (some insurance companies as well have supported its use). It is understandable to try to offer patients suffering with refractory illnesses anything the field has to offer, but the limitations on our knowledge, especially about the efficacy and safety of long-term use of ketamine for depression, need to be taken into account⁴. There is little to no regulation around providing intravenous ketamine, and clinicians and patients should be aware of the risks, take care in the administration of the drug, and watch for the potential of dissociation or substance abuse along with being clear about the likelihood of benefit being at best around 50%. As more evidence and experience are collected, NMDA antagonists might offer a unique efficacy profile within safe boundaries.

Opioid agonists have some antidepressant activity, but tolerance to it quickly develops – requiring users to take increasingly higher doses. Would a partial opioid agonist coupled with a pure opioid antagonist provide ongoing efficacy at a continuous dose with adequate safety? A combination medication containing buprenorphine, a partial* mu- and kappa-opioid partial agonist, and samidorphan, a mu-opioid antagonist, is currently being reviewed by the FDA. The phase 3 studies are not yet published. However, the phase 2 published trial demonstrated efficacy at low doses (2 mg of buprenorphine with 2 mg of samidorphan) as an adjunctive medication in treatment-resistant depression⁵. While offering a novel mechanism of action and a reasonable safety profile seen in several poster presentations, though not published articles, the drug – should it receive approval – will require an intensive effort to educate practitioners and the public about the critical differences (especially with regard to risk/benefits of long-term use, abuse potential, and safety) between opiate agonism and opiate modulation/antagonism.

Brexanolone, an intravenous formulation of allopregnanolone, a positive allosteric modulator of gamma-aminobutyric acid (GABA_A) receptors, has been studied for the treatment of postpartum depression⁶. Early development has focused on an intravenous delivery system and a unique target population of postpartum depression, but the novel concept of targeting GABA_A receptors might prove fruitful with a wider population of depressed patients with inadequate responses to existing antidepressants. An oral formulation, SAGE-217, is in early clinical trials.

While much earlier in the development for FDA approval, psychedelics, particularly psilocybin, have been investigated for use in treatment-resistant depression. A small double-blind trial in terminal cancer patients showed that psilocybin had a remarkable palliative effect on depression and anxiety⁷. An open label study of treatment-resistant depressed patients demonstrated lasting benefit over 6 months after two doses of psilocybin⁸. A neuroimaging study supported the idea that changes in resting state functional connectivity in specific brain regions from exposure to psilocybin might account for alleviation in depressive symptoms⁹. These findings are preliminary, but they have sparked the commencement of a few phase 2 randomized trials for psychedelic drugs. It should be noted that all these trial to date – and those planned – require dosing to be done in a very controlled and supervised psychologically supportive environment.

Which of these treatments will make it to market? That remains unclear, but it is reassuring that so many different novel paradigms for addressing treatment-resistant depression are in development.
 

Dr. Aaronson is the director of clinical research programs at the Sheppard Pratt Health System in Baltimore. He serves as a consultant to several companies, including Alkermes, Genomind, LivaNova, Neuronetics, and Sage Therapeutics. He has received honoraria for speaking from Neurocrine, Otsuka, and Sunovion. He has received research support from Neuronetics. Dr. Aaronson also serves as a clinical associate professor of psychiatry at the University of Maryland, Baltimore, and is a Distinguished Fellow of the American Psychiatric Association and a Fellow of the American College of Psychiatrists.
 

References

1. Am J Psychiatry. 2006;163(11):1905-17.

2. JAMA Psychiatry. 2018 Feb 1;75(2):139-48.

3. Am J Psychiatry. 2018 Jul 1;175(7):620-30.

4. JAMA Psychiatry. 2017;74(4):399-405.

5. Am J Psychiatry. 2016 May 1;173(5):499-508.

6. Lancet. 2017 Jul 29;390(10093):480-9.

7. J Psychopharmacol. 2016;30(12):1181-97.

8. Psychopharmacology (Berl). 2018 Feb;235(2):399-408.

9. Sci Rep. 2017 Oct 13;7(1):13187.

*Correction, 10/18/2019: An earlier version of this story misidentified buprenorphine.

For close to 6 decades, since the approval of imipramine in 1959, all Food and Drug Administration-approved medications for depression worked through the monoamine system, in some ways altering the concentration of serotonin, norepinephrine, or dopamine within synapses or binding to post synaptic receptors. A conservative estimate has at least a third of patients with depression not adequately responsive to these monoaminergic medications.

A host of medications in various stages of development might each offer unique additions to the current therapeutic paradigm. Compounds closest to market include N-methyl-D-aspartate (NMDA) blockers such as esketamine or rapastinel; opioid receptor partial agonists and antagonists, such as Alkermes 5461; and a GABA_A receptor modulator, brexanolone. A further off, more speculative intervention involves the use of psychedelic drugs like psilocybin.

NMDA antagonists have gained the highest visibility after some promising results in early studies looking at intravenous ketamine, an anesthetic agent approved by the FDA in 1970 for treatment-resistant depression. This has led to several companies trying to develop a patentable NMDA antagonist for depression. The most likely first candidate is one of the enantiomers of ketamine, esketamine, which, because of higher binding affinity, can be dosed intranasally rather than intravenously. Studies are completed to establish efficacy in TRD² [treatment-resistant depression] as well as acute suicidality³. Johnson & Johnson plans to submit these results for FDA approval this year.

Another promising NMDA antagonist, rapastinel, is wending its way through clinical trials – but should it be approved, its use might be limited by the requirement for intravenous delivery.

Despite only early evidence for efficacy in depression, the easy availability of ketamine for infusion has created a cadre of independent clinicians as well as some academic clinics offering intravenous ketamine infusions for those with difficult-to-treat depression and adequate finances to pay for off-label treatment (some insurance companies as well have supported its use). It is understandable to try to offer patients suffering with refractory illnesses anything the field has to offer, but the limitations on our knowledge, especially about the efficacy and safety of long-term use of ketamine for depression, need to be taken into account⁴. There is little to no regulation around providing intravenous ketamine, and clinicians and patients should be aware of the risks, take care in the administration of the drug, and watch for the potential of dissociation or substance abuse along with being clear about the likelihood of benefit being at best around 50%. As more evidence and experience are collected, NMDA antagonists might offer a unique efficacy profile within safe boundaries.

Opioid agonists have some antidepressant activity, but tolerance to it quickly develops – requiring users to take increasingly higher doses. Would a partial opioid agonist coupled with a pure opioid antagonist provide ongoing efficacy at a continuous dose with adequate safety? A combination medication containing buprenorphine, a partial* mu- and kappa-opioid partial agonist, and samidorphan, a mu-opioid antagonist, is currently being reviewed by the FDA. The phase 3 studies are not yet published. However, the phase 2 published trial demonstrated efficacy at low doses (2 mg of buprenorphine with 2 mg of samidorphan) as an adjunctive medication in treatment-resistant depression⁵. While offering a novel mechanism of action and a reasonable safety profile seen in several poster presentations, though not published articles, the drug – should it receive approval – will require an intensive effort to educate practitioners and the public about the critical differences (especially with regard to risk/benefits of long-term use, abuse potential, and safety) between opiate agonism and opiate modulation/antagonism.

Brexanolone, an intravenous formulation of allopregnanolone, a positive allosteric modulator of gamma-aminobutyric acid (GABA_A) receptors, has been studied for the treatment of postpartum depression⁶. Early development has focused on an intravenous delivery system and a unique target population of postpartum depression, but the novel concept of targeting GABA_A receptors might prove fruitful with a wider population of depressed patients with inadequate responses to existing antidepressants. An oral formulation, SAGE-217, is in early clinical trials.

While much earlier in the development for FDA approval, psychedelics, particularly psilocybin, have been investigated for use in treatment-resistant depression. A small double-blind trial in terminal cancer patients showed that psilocybin had a remarkable palliative effect on depression and anxiety⁷. An open label study of treatment-resistant depressed patients demonstrated lasting benefit over 6 months after two doses of psilocybin⁸. A neuroimaging study supported the idea that changes in resting state functional connectivity in specific brain regions from exposure to psilocybin might account for alleviation in depressive symptoms⁹. These findings are preliminary, but they have sparked the commencement of a few phase 2 randomized trials for psychedelic drugs. It should be noted that all these trial to date – and those planned – require dosing to be done in a very controlled and supervised psychologically supportive environment.

Which of these treatments will make it to market? That remains unclear, but it is reassuring that so many different novel paradigms for addressing treatment-resistant depression are in development.
 

Dr. Aaronson is the director of clinical research programs at the Sheppard Pratt Health System in Baltimore. He serves as a consultant to several companies, including Alkermes, Genomind, LivaNova, Neuronetics, and Sage Therapeutics. He has received honoraria for speaking from Neurocrine, Otsuka, and Sunovion. He has received research support from Neuronetics. Dr. Aaronson also serves as a clinical associate professor of psychiatry at the University of Maryland, Baltimore, and is a Distinguished Fellow of the American Psychiatric Association and a Fellow of the American College of Psychiatrists.
 

References

1. Am J Psychiatry. 2006;163(11):1905-17.

2. JAMA Psychiatry. 2018 Feb 1;75(2):139-48.

3. Am J Psychiatry. 2018 Jul 1;175(7):620-30.

4. JAMA Psychiatry. 2017;74(4):399-405.

5. Am J Psychiatry. 2016 May 1;173(5):499-508.

6. Lancet. 2017 Jul 29;390(10093):480-9.

7. J Psychopharmacol. 2016;30(12):1181-97.

8. Psychopharmacology (Berl). 2018 Feb;235(2):399-408.

9. Sci Rep. 2017 Oct 13;7(1):13187.

*Correction, 10/18/2019: An earlier version of this story misidentified buprenorphine.

Let’s start with an exercise, shall we? What was the last vacation you went on? How would you rate that vacation on a scale of 1-10?

How you came up with that score is likely not entirely reflective of your actual experience. Understanding how we remember experiences is critical for the work we do everyday. Health care is the ultimate service industry and understanding patients’ experiences will give you a significant advantage in your practice.

My last vacation was in Alaska. I’d rate it a 9 out of 10. How did I come up with that score? It is not the mean score of the entire trip as you might expect. Rather, I took a shortcut and thought only about the highlights to come up with a number. We remember, and evaluate, our experiences as a series of discrete events. In considering these events, it is only the highs, the lows, and the transitions that matter. Think about the score you gave your vacation. What specific moments did you remember?

This phenomenon is not specific to vacations. It applies to all service experiences. When your patients evaluate you, they will ignore most of what occurred and focus on only a few moments. Fair or not, it is from these bits only that they will rate their entire experience. This information helps us devise strategies to achieve high satisfaction scores: Focus on the high points, address the low points, if any, and be sure the transitions are pleasant.

For example, a patient might come to see you for a procedure. It could be something positive, such as injection of cosmetic filler or something negative like a colonoscopy. Either way, being finished with the procedure will likely be the best part for them. Don’t rush this time; instead of quickly moving on, take a moment to acknowledge you’re done, how well the patient did, or how much better they will now look or feel. Engaging with your patient at this moment can improve the salience of their experience and increase the likelihood that she or he will remember the appointment favorably and rate you accordingly, if given the opportunity.

In the same way, if you are aware your patient has experienced something negative, try to respond to it right away. Acknowledge if she or he expressed frustration, such as a long wait or pain, then take a minute to address or reframe it. Blunting the severity of the service failure can blunt their recall of it. This will make it less likely that it becomes a memorable part of their experience.

Last, transitions matter. These are the moments when your patient shifts from one setting to another, such as arriving at your office, moving from the waiting room to the exam room, and wrapping up the visit with the receptionist. Many of these moments will be managed by your staff. Therefore, invest time reminding them of their importance and teaching them tips and techniques to help patients transition smoothly and to feel well cared for. There will likely be a wonderful return on investment for them, you and, most importantly, your patients.


 

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

Let’s start with an exercise, shall we? What was the last vacation you went on? How would you rate that vacation on a scale of 1-10?

How you came up with that score is likely not entirely reflective of your actual experience. Understanding how we remember experiences is critical for the work we do everyday. Health care is the ultimate service industry and understanding patients’ experiences will give you a significant advantage in your practice.

My last vacation was in Alaska. I’d rate it a 9 out of 10. How did I come up with that score? It is not the mean score of the entire trip as you might expect. Rather, I took a shortcut and thought only about the highlights to come up with a number. We remember, and evaluate, our experiences as a series of discrete events. In considering these events, it is only the highs, the lows, and the transitions that matter. Think about the score you gave your vacation. What specific moments did you remember?

This phenomenon is not specific to vacations. It applies to all service experiences. When your patients evaluate you, they will ignore most of what occurred and focus on only a few moments. Fair or not, it is from these bits only that they will rate their entire experience. This information helps us devise strategies to achieve high satisfaction scores: Focus on the high points, address the low points, if any, and be sure the transitions are pleasant.

For example, a patient might come to see you for a procedure. It could be something positive, such as injection of cosmetic filler or something negative like a colonoscopy. Either way, being finished with the procedure will likely be the best part for them. Don’t rush this time; instead of quickly moving on, take a moment to acknowledge you’re done, how well the patient did, or how much better they will now look or feel. Engaging with your patient at this moment can improve the salience of their experience and increase the likelihood that she or he will remember the appointment favorably and rate you accordingly, if given the opportunity.

In the same way, if you are aware your patient has experienced something negative, try to respond to it right away. Acknowledge if she or he expressed frustration, such as a long wait or pain, then take a minute to address or reframe it. Blunting the severity of the service failure can blunt their recall of it. This will make it less likely that it becomes a memorable part of their experience.

Last, transitions matter. These are the moments when your patient shifts from one setting to another, such as arriving at your office, moving from the waiting room to the exam room, and wrapping up the visit with the receptionist. Many of these moments will be managed by your staff. Therefore, invest time reminding them of their importance and teaching them tips and techniques to help patients transition smoothly and to feel well cared for. There will likely be a wonderful return on investment for them, you and, most importantly, your patients.


 

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

Let’s start with an exercise, shall we? What was the last vacation you went on? How would you rate that vacation on a scale of 1-10?

How you came up with that score is likely not entirely reflective of your actual experience. Understanding how we remember experiences is critical for the work we do everyday. Health care is the ultimate service industry and understanding patients’ experiences will give you a significant advantage in your practice.

My last vacation was in Alaska. I’d rate it a 9 out of 10. How did I come up with that score? It is not the mean score of the entire trip as you might expect. Rather, I took a shortcut and thought only about the highlights to come up with a number. We remember, and evaluate, our experiences as a series of discrete events. In considering these events, it is only the highs, the lows, and the transitions that matter. Think about the score you gave your vacation. What specific moments did you remember?

This phenomenon is not specific to vacations. It applies to all service experiences. When your patients evaluate you, they will ignore most of what occurred and focus on only a few moments. Fair or not, it is from these bits only that they will rate their entire experience. This information helps us devise strategies to achieve high satisfaction scores: Focus on the high points, address the low points, if any, and be sure the transitions are pleasant.

For example, a patient might come to see you for a procedure. It could be something positive, such as injection of cosmetic filler or something negative like a colonoscopy. Either way, being finished with the procedure will likely be the best part for them. Don’t rush this time; instead of quickly moving on, take a moment to acknowledge you’re done, how well the patient did, or how much better they will now look or feel. Engaging with your patient at this moment can improve the salience of their experience and increase the likelihood that she or he will remember the appointment favorably and rate you accordingly, if given the opportunity.

In the same way, if you are aware your patient has experienced something negative, try to respond to it right away. Acknowledge if she or he expressed frustration, such as a long wait or pain, then take a minute to address or reframe it. Blunting the severity of the service failure can blunt their recall of it. This will make it less likely that it becomes a memorable part of their experience.

Last, transitions matter. These are the moments when your patient shifts from one setting to another, such as arriving at your office, moving from the waiting room to the exam room, and wrapping up the visit with the receptionist. Many of these moments will be managed by your staff. Therefore, invest time reminding them of their importance and teaching them tips and techniques to help patients transition smoothly and to feel well cared for. There will likely be a wonderful return on investment for them, you and, most importantly, your patients.


 

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].