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COVID-19: A guide to making telepsychiatry work
Changes prompted by social distancing could last beyond the pandemic
As the coronavirus pandemic persists, insurers and the federal government are making it easier for mental health professionals to deliver safe and effective psychiatric services to patients via Zoom, FaceTime, and other conferencing tools. Many psychiatrists, meanwhile, are embracing telepsychiatry for the first time – in some cases with urgency.
Jay H. Shore, MD, MPH, said in an interview that mental health providers at his medical center have gone entirely virtual in recent weeks.
“The genie is out of the bottle on this,” said Dr. Shore, director of telemedicine at the Helen and Arthur E. Johnson Depression Center and director of telemedicine programming for the department of psychiatry at the University of Colorado at Denver, Aurora. He thinks this is the beginning of a new era that will last beyond the pandemic. “There’s going to be a much wider and diffuse acceptance of telemedicine as we go forward,” he added.
Dr. Shore and several colleagues from across the country offered several tips about factors to consider while learning to use telepsychiatry as a treatment tool.
To start, Dr. Shore advised reviewing the American Psychiatric Association’s Telepsychiatry Practice Guidelines and its Telepsychiatry Toolkit, which include dozens of brief videos about topics such as room lighting and managing the content process.
Another resource is the joint APA–American Academy of Child and Adolescent Psychiatry Telepsychiatry Toolkit, said Shabana Khan, MD, an assistant professor and director of telemedicine for the department of child and adolescent psychiatry at New York University Langone Health.
One of the challenges is managing emergencies long distance. If a patient experiences a mental health emergency in a psychiatrist’s office, the clinician can call 911 or direct staff to seek help. “When they’re at their house,” said Dr. Shore, “it’s a little different.”
Staff members are not present at home offices, for example, and the patient might live in a different city and therefore have a different 911 system. “It’s important to know your protocol about how you plan to handle these emergencies before you start working with the patient,” Dr. Shore said.
Another tip is to ask staff to perform a test session to work out the technical kinks before the first patient appointment. “They can make the connection and make sure there’s a video signal with adequate quality,” Dr. Shore said. Failing to conduct a test run can lead to spending several minutes of a session trying to help patients figure out how to make video conferencing work properly.
“You can spend a lot of time acting as IT support,” he said.
It is important to ensure that virtual visits are not interrupted by technical glitches, Daniel Bristow, MD, said in an interview. If possible, hardwire your laptop or computer to an ethernet cable, said Dr. Bristow, president of the Oregon Psychiatric Physicians Association, the state’s branch of the APA. “This will lead to fewer fluctuations that you could see by using wifi,” said Dr. Bristow, who practices in Portland.
“Initially, I assumed that those with psychotic symptoms might struggle more. But I have been surprised at how well some patients have done,” said Andrew J. McLean, MD, MPH, clinical professor and chair of the department of psychiatry and behavioral science at the University of North Dakota, Grand Forks.
However, it might help to provide additional coaching to those patients, said Dr. Bristow. He offers a warning to these patients: “If you feel like you’re getting messages over the TV, my talking to you may make you feel worse.” However, “in every case, the patient was able to say, ‘I know you’re real.’ One patient even said: ‘I’ve heard these voices from my TV for years. But I know you’re a doctor, and you’re in an office trying to help me.’ ”
Dr. Shore thinks that video meetings have the potential to help psychiatrists and patients form better personal connections than in-person meetings. Patients with anxiety or PTSD, for example, “may feel safer since they’re in their own space, and they have a greater sense of control over the session than being in somebody’s office,” he said.
Dr. Khan agreed. “Some children, such as those with a significant trauma history or with significant anxiety, may feel more comfortable with this modality and may open up more during video sessions,” she said. In addition, “the distance that telepsychiatry provides may also enhance feelings of confidentiality and reduce potential stigma that may be associated with seeking mental health care.”
When it comes to using videoconferencing to treat children, take advantage of interactive features that are available, said Katherine Nguyen Williams, PhD. Zoom’s HIPAA-compliant health care software, for example, offers a “share screen” capability. “It allows for easy interactive activities,” said Dr. Nguyen Williams, director of strategic development and clinical innovation at Rady Children’s Hospital’s department of psychiatry at the University of California, San Diego. “Clinicians can play tic-tac-toe on the screen with the young patients, and they can work on cognitive-behavioral therapy worksheets together on the digital screen. Clinicians can even show a mindfulness video to the patient while actively coaching and giving feedback to the patient as they practice diaphragmatic breathing while viewing the video.
“There are so many more options for making virtual therapy as interactive as face-to-face therapy,” said Dr. Nguyen Williams, who also is an associate clinical professor at the university. “This is the key to getting and keeping the patient engaged in telepsychiatry.”
Despite the many positive aspects of using telepsychiatry as a treatment tool, some negative factors must be considered. “You lose some of the nuances, subtleties in terms of expression, movement, smell, etc.,” said Dr. McLean. “Also, there are rare instances where a part of a physical examination would be appropriate, which also is precluded.”
Videoconferencing software might allow the clinician to zoom in to take a closer look at a patient to look for subtle movements and tremors, Dr. McLean said. And, he added, he has asked nursing staff to check for particular signs and symptoms during visits and to describe them to him. “Still,” Dr. McLean said, “this does not take the place of being there.”
Dr. Shore suggested several other practical considerations. For example, while on a screen, keep the home environment as professional as the office would be, he said. Be clear with family members about the importance of not interrupting and make sure that privacy is maintained. The message should be: “I’m working from home, and I’m not available during these hours,” Dr. Shore said. “You need to be aware that, during this time, I need this for clinical work.”
Dr. Shore reported serving as chief medical officer of AccessCare Services, and receiving royalties from American Psychiatric Association Publishing and Springer. He also is coauthor with Peter Yellowlees, MD, of “Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals” (Arlington, Va.: American Psychiatric Association Publishing, 2018). Dr. Khan and Dr. McLean reported no relevant disclosures. Dr. Bristow reported relationships with MCG Health and Insight + Regroup Telehealth.
For more details about using telepsychiatry in the time of COVID-19, listen to the April 8 Psychcast Masterclass lecture by Dr. Shore.
Changes prompted by social distancing could last beyond the pandemic
Changes prompted by social distancing could last beyond the pandemic
As the coronavirus pandemic persists, insurers and the federal government are making it easier for mental health professionals to deliver safe and effective psychiatric services to patients via Zoom, FaceTime, and other conferencing tools. Many psychiatrists, meanwhile, are embracing telepsychiatry for the first time – in some cases with urgency.
Jay H. Shore, MD, MPH, said in an interview that mental health providers at his medical center have gone entirely virtual in recent weeks.
“The genie is out of the bottle on this,” said Dr. Shore, director of telemedicine at the Helen and Arthur E. Johnson Depression Center and director of telemedicine programming for the department of psychiatry at the University of Colorado at Denver, Aurora. He thinks this is the beginning of a new era that will last beyond the pandemic. “There’s going to be a much wider and diffuse acceptance of telemedicine as we go forward,” he added.
Dr. Shore and several colleagues from across the country offered several tips about factors to consider while learning to use telepsychiatry as a treatment tool.
To start, Dr. Shore advised reviewing the American Psychiatric Association’s Telepsychiatry Practice Guidelines and its Telepsychiatry Toolkit, which include dozens of brief videos about topics such as room lighting and managing the content process.
Another resource is the joint APA–American Academy of Child and Adolescent Psychiatry Telepsychiatry Toolkit, said Shabana Khan, MD, an assistant professor and director of telemedicine for the department of child and adolescent psychiatry at New York University Langone Health.
One of the challenges is managing emergencies long distance. If a patient experiences a mental health emergency in a psychiatrist’s office, the clinician can call 911 or direct staff to seek help. “When they’re at their house,” said Dr. Shore, “it’s a little different.”
Staff members are not present at home offices, for example, and the patient might live in a different city and therefore have a different 911 system. “It’s important to know your protocol about how you plan to handle these emergencies before you start working with the patient,” Dr. Shore said.
Another tip is to ask staff to perform a test session to work out the technical kinks before the first patient appointment. “They can make the connection and make sure there’s a video signal with adequate quality,” Dr. Shore said. Failing to conduct a test run can lead to spending several minutes of a session trying to help patients figure out how to make video conferencing work properly.
“You can spend a lot of time acting as IT support,” he said.
It is important to ensure that virtual visits are not interrupted by technical glitches, Daniel Bristow, MD, said in an interview. If possible, hardwire your laptop or computer to an ethernet cable, said Dr. Bristow, president of the Oregon Psychiatric Physicians Association, the state’s branch of the APA. “This will lead to fewer fluctuations that you could see by using wifi,” said Dr. Bristow, who practices in Portland.
“Initially, I assumed that those with psychotic symptoms might struggle more. But I have been surprised at how well some patients have done,” said Andrew J. McLean, MD, MPH, clinical professor and chair of the department of psychiatry and behavioral science at the University of North Dakota, Grand Forks.
However, it might help to provide additional coaching to those patients, said Dr. Bristow. He offers a warning to these patients: “If you feel like you’re getting messages over the TV, my talking to you may make you feel worse.” However, “in every case, the patient was able to say, ‘I know you’re real.’ One patient even said: ‘I’ve heard these voices from my TV for years. But I know you’re a doctor, and you’re in an office trying to help me.’ ”
Dr. Shore thinks that video meetings have the potential to help psychiatrists and patients form better personal connections than in-person meetings. Patients with anxiety or PTSD, for example, “may feel safer since they’re in their own space, and they have a greater sense of control over the session than being in somebody’s office,” he said.
Dr. Khan agreed. “Some children, such as those with a significant trauma history or with significant anxiety, may feel more comfortable with this modality and may open up more during video sessions,” she said. In addition, “the distance that telepsychiatry provides may also enhance feelings of confidentiality and reduce potential stigma that may be associated with seeking mental health care.”
When it comes to using videoconferencing to treat children, take advantage of interactive features that are available, said Katherine Nguyen Williams, PhD. Zoom’s HIPAA-compliant health care software, for example, offers a “share screen” capability. “It allows for easy interactive activities,” said Dr. Nguyen Williams, director of strategic development and clinical innovation at Rady Children’s Hospital’s department of psychiatry at the University of California, San Diego. “Clinicians can play tic-tac-toe on the screen with the young patients, and they can work on cognitive-behavioral therapy worksheets together on the digital screen. Clinicians can even show a mindfulness video to the patient while actively coaching and giving feedback to the patient as they practice diaphragmatic breathing while viewing the video.
“There are so many more options for making virtual therapy as interactive as face-to-face therapy,” said Dr. Nguyen Williams, who also is an associate clinical professor at the university. “This is the key to getting and keeping the patient engaged in telepsychiatry.”
Despite the many positive aspects of using telepsychiatry as a treatment tool, some negative factors must be considered. “You lose some of the nuances, subtleties in terms of expression, movement, smell, etc.,” said Dr. McLean. “Also, there are rare instances where a part of a physical examination would be appropriate, which also is precluded.”
Videoconferencing software might allow the clinician to zoom in to take a closer look at a patient to look for subtle movements and tremors, Dr. McLean said. And, he added, he has asked nursing staff to check for particular signs and symptoms during visits and to describe them to him. “Still,” Dr. McLean said, “this does not take the place of being there.”
Dr. Shore suggested several other practical considerations. For example, while on a screen, keep the home environment as professional as the office would be, he said. Be clear with family members about the importance of not interrupting and make sure that privacy is maintained. The message should be: “I’m working from home, and I’m not available during these hours,” Dr. Shore said. “You need to be aware that, during this time, I need this for clinical work.”
Dr. Shore reported serving as chief medical officer of AccessCare Services, and receiving royalties from American Psychiatric Association Publishing and Springer. He also is coauthor with Peter Yellowlees, MD, of “Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals” (Arlington, Va.: American Psychiatric Association Publishing, 2018). Dr. Khan and Dr. McLean reported no relevant disclosures. Dr. Bristow reported relationships with MCG Health and Insight + Regroup Telehealth.
For more details about using telepsychiatry in the time of COVID-19, listen to the April 8 Psychcast Masterclass lecture by Dr. Shore.
As the coronavirus pandemic persists, insurers and the federal government are making it easier for mental health professionals to deliver safe and effective psychiatric services to patients via Zoom, FaceTime, and other conferencing tools. Many psychiatrists, meanwhile, are embracing telepsychiatry for the first time – in some cases with urgency.
Jay H. Shore, MD, MPH, said in an interview that mental health providers at his medical center have gone entirely virtual in recent weeks.
“The genie is out of the bottle on this,” said Dr. Shore, director of telemedicine at the Helen and Arthur E. Johnson Depression Center and director of telemedicine programming for the department of psychiatry at the University of Colorado at Denver, Aurora. He thinks this is the beginning of a new era that will last beyond the pandemic. “There’s going to be a much wider and diffuse acceptance of telemedicine as we go forward,” he added.
Dr. Shore and several colleagues from across the country offered several tips about factors to consider while learning to use telepsychiatry as a treatment tool.
To start, Dr. Shore advised reviewing the American Psychiatric Association’s Telepsychiatry Practice Guidelines and its Telepsychiatry Toolkit, which include dozens of brief videos about topics such as room lighting and managing the content process.
Another resource is the joint APA–American Academy of Child and Adolescent Psychiatry Telepsychiatry Toolkit, said Shabana Khan, MD, an assistant professor and director of telemedicine for the department of child and adolescent psychiatry at New York University Langone Health.
One of the challenges is managing emergencies long distance. If a patient experiences a mental health emergency in a psychiatrist’s office, the clinician can call 911 or direct staff to seek help. “When they’re at their house,” said Dr. Shore, “it’s a little different.”
Staff members are not present at home offices, for example, and the patient might live in a different city and therefore have a different 911 system. “It’s important to know your protocol about how you plan to handle these emergencies before you start working with the patient,” Dr. Shore said.
Another tip is to ask staff to perform a test session to work out the technical kinks before the first patient appointment. “They can make the connection and make sure there’s a video signal with adequate quality,” Dr. Shore said. Failing to conduct a test run can lead to spending several minutes of a session trying to help patients figure out how to make video conferencing work properly.
“You can spend a lot of time acting as IT support,” he said.
It is important to ensure that virtual visits are not interrupted by technical glitches, Daniel Bristow, MD, said in an interview. If possible, hardwire your laptop or computer to an ethernet cable, said Dr. Bristow, president of the Oregon Psychiatric Physicians Association, the state’s branch of the APA. “This will lead to fewer fluctuations that you could see by using wifi,” said Dr. Bristow, who practices in Portland.
“Initially, I assumed that those with psychotic symptoms might struggle more. But I have been surprised at how well some patients have done,” said Andrew J. McLean, MD, MPH, clinical professor and chair of the department of psychiatry and behavioral science at the University of North Dakota, Grand Forks.
However, it might help to provide additional coaching to those patients, said Dr. Bristow. He offers a warning to these patients: “If you feel like you’re getting messages over the TV, my talking to you may make you feel worse.” However, “in every case, the patient was able to say, ‘I know you’re real.’ One patient even said: ‘I’ve heard these voices from my TV for years. But I know you’re a doctor, and you’re in an office trying to help me.’ ”
Dr. Shore thinks that video meetings have the potential to help psychiatrists and patients form better personal connections than in-person meetings. Patients with anxiety or PTSD, for example, “may feel safer since they’re in their own space, and they have a greater sense of control over the session than being in somebody’s office,” he said.
Dr. Khan agreed. “Some children, such as those with a significant trauma history or with significant anxiety, may feel more comfortable with this modality and may open up more during video sessions,” she said. In addition, “the distance that telepsychiatry provides may also enhance feelings of confidentiality and reduce potential stigma that may be associated with seeking mental health care.”
When it comes to using videoconferencing to treat children, take advantage of interactive features that are available, said Katherine Nguyen Williams, PhD. Zoom’s HIPAA-compliant health care software, for example, offers a “share screen” capability. “It allows for easy interactive activities,” said Dr. Nguyen Williams, director of strategic development and clinical innovation at Rady Children’s Hospital’s department of psychiatry at the University of California, San Diego. “Clinicians can play tic-tac-toe on the screen with the young patients, and they can work on cognitive-behavioral therapy worksheets together on the digital screen. Clinicians can even show a mindfulness video to the patient while actively coaching and giving feedback to the patient as they practice diaphragmatic breathing while viewing the video.
“There are so many more options for making virtual therapy as interactive as face-to-face therapy,” said Dr. Nguyen Williams, who also is an associate clinical professor at the university. “This is the key to getting and keeping the patient engaged in telepsychiatry.”
Despite the many positive aspects of using telepsychiatry as a treatment tool, some negative factors must be considered. “You lose some of the nuances, subtleties in terms of expression, movement, smell, etc.,” said Dr. McLean. “Also, there are rare instances where a part of a physical examination would be appropriate, which also is precluded.”
Videoconferencing software might allow the clinician to zoom in to take a closer look at a patient to look for subtle movements and tremors, Dr. McLean said. And, he added, he has asked nursing staff to check for particular signs and symptoms during visits and to describe them to him. “Still,” Dr. McLean said, “this does not take the place of being there.”
Dr. Shore suggested several other practical considerations. For example, while on a screen, keep the home environment as professional as the office would be, he said. Be clear with family members about the importance of not interrupting and make sure that privacy is maintained. The message should be: “I’m working from home, and I’m not available during these hours,” Dr. Shore said. “You need to be aware that, during this time, I need this for clinical work.”
Dr. Shore reported serving as chief medical officer of AccessCare Services, and receiving royalties from American Psychiatric Association Publishing and Springer. He also is coauthor with Peter Yellowlees, MD, of “Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals” (Arlington, Va.: American Psychiatric Association Publishing, 2018). Dr. Khan and Dr. McLean reported no relevant disclosures. Dr. Bristow reported relationships with MCG Health and Insight + Regroup Telehealth.
For more details about using telepsychiatry in the time of COVID-19, listen to the April 8 Psychcast Masterclass lecture by Dr. Shore.
Psychiatrists deemed ‘essential’ in time of COVID-19
New American Psychiatric Association poll shows depth of anxiety
The coronavirus pandemic weighs heavily on psychiatric patients with conditions such as anxiety, depression and PTSD. Meanwhile, a national poll released March 25 by the American Psychiatric Association shows that almost half of all Americans are anxious about contracting COVID-19 and 40% are anxious about becoming seriously ill or dying from the virus. In light of stressors on patients and nonpatients alike, mental health professionals have a key role in helping to alleviate suffering tied to the public health crisis, according to psychiatrists from across the country.
“There’s so much we can do to help people put order on this chaos,” said Shaili Jain, MD, section chief of outpatient mental health with the Veterans Affairs Palo Alto (Calif.) Health Care System, in an interview. “We are essential workers in this time.”
Dr. Jain, who specializes in treating PTSD, said those patients are especially vulnerable to the stress and disruptions spawned by the pandemic. “When you go to the grocery store and there’s no food, that can be triggering for people who survived situations with a feeling of calamity or panic,” she said. “People are reporting worsening of nightmares and spontaneous panic attacks after having been stable with symptoms for many months. These are the kinds of stories that are starting to filter through.”
To make things even more difficult, she said, shelter-in-place orders are preventing patients from taking advantage of healthy coping strategies, such as working out at the gym or going to support groups. “We have an invaluable role to play in trying to prevent long-term consequences by going into problem-solving modes with patients.” Dr. Jain offered several tips that might help patients who are suffering:
- Use technology to stay in touch with support communities and boost self-care. “How can you be flexible with FaceTime, Skype, or phone even if you might not be able to have that face-to-face time? What are you doing to double down on your efforts at self-care – listening to music, reading, daily meditation, or walks? Double down on what you can do to prevent anxiety and stress levels from building up.”
- Take breaks from the news, which can contribute to hypervigilance and disrupted sleep. “I’m seeing that people are going down these rabbit holes of having the news or social media on 24/7,” Dr. Jain said. “You have to stay informed. But you need to pick trusted news sources and have chunks of time that are free of coronavirus coverage.” Understand that life is going to be difficult for a while. “We’re doing a lot of reassurance and education,” she said, “helping people to know and accept that the next few days, weeks, and months are going to be stressful.”
Dr. Jain cautioned colleagues, however, that “there will be a tsunami” of mental illness when the coronavirus crisis lifts. She is especially concerned about patient populations that are socioeconomically disadvantaged already and how their lives with be affected by lost wages, unemployment, and business failures. “Medical professionals will see the consequences of this in the days and weeks and months after the pandemic has settled,” she predicted.
The APA poll shows that, early in the crisis, more than 60% of people are anxious about family and loved ones contracting COVID-19.
Maintaining ‘reflective space’ essential
At the Austen Riggs Center, a psychiatric residential treatment facility in Stockbridge, Mass., staff and patients are adjusting to new rules that aim to prevent transmission of the novel coronavirus. “Social distancing requirements are having a huge impact,” said Eric M. Plakun, MD, medical director and CEO of Austen Riggs, in an interview. “You can’t have groups in the same way; you can’t have families come in for a family meeting; you can’t have quite the same the freedom to come and go. A lot of management issues are being addressed, but it is crucial also to maintain the ‘reflective space’ essential to do the kind of clinical work we do.” One approach, he said, is virtual meetings with colleagues that address on-the-job management issues, but also leave a space for how staff members are feeling.
“It’s easy to get into crisis-response mode,” he said, “where you’re always managing but never leave a space to talk about vulnerability, helplessness, and fear.”
As the facility’s staff adjusts by embracing teleconference technology and adapting group meetings to the 6-feet-apart rule,
Dr. Plakun said he said, noting that patients have approached staff members to say they want to collaborate about changes. “That’s a credible offer we intend to accept.”
Still, communicating with patients as a whole about the coronavirus can be difficult. As Dr. Plakun noted, it’s now impossible to bring 75 people together into one room for a meeting. “If you have four to five smaller meetings, how do you maintain some congruence in the information that’s presented?”
Dr. Plakun suggested that colleagues find time to engage in the familiar, such as face-to-face clinical work. “That’s been the most reassuring and rewarding part of my day since it feels almost like normal,” he said.
Stocking up on medications
Jessica “Jessi” Gold, MD, MS, an assistant professor at Washington University in St. Louis, often treats college students. Asian students started to worry early in the pandemic, she said in an interview.
“At the beginning, there were a lot of concerns about the public’s view: ‘Did this come from China? Is it China’s fault?’ A lot of our students felt that if they coughed, and they were a white person, they’d be OK. But if they were Asian, everyone would wonder why they were in class and not at home. That got worse over time: the fear about – and anxiety from – stoking racism.”
Later, as classes began to be canceled, Dr. Gold started to see the psychological effects of disruption and uncertainty about the future. “This can lead people to feel like what they knew before is just not there anymore. This can obviously cause anxiety but also has the potential to cause depression.” Patients also might slip into overuse of alcohol and drugs, or they might engage in other kinds of harmful behavior. Eating disorders, for example, “are ways to have control when other things aren’t in control,” she said.
Dr. Gold pointed to research into the mental health after effects of quarantines, such as those imposed during the SARS outbreak. A review of 24 studies published this year found that most “reported negative psychological effects, including post-traumatic stress symptoms, confusion, and anger. Stressors included longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma. Some researchers have suggested long-lasting effects” (Lancet. 2020;395:912-20).
Dr. Gold is urging patients to recall the warning signs that alerted them to psychological downturns in the past: “Try to remember what those warning signs are and pay attention to whether you see them.” And, Dr. Gold said, she asks patients to think about what has helped them get better.
In some cases, she said, patients are already preparing themselves for experiencing mental distress by stocking up on medications. “Some people have a bottle of 10-20 pills that they only use in emergencies and keep as a kind of security blanket,” she said, and she’s seen some of them ask for refills. It seems they’ve either taken the pills recently or want to stash them just in case. This makes sense, since their anxiety is higher, she said.
Dr. Gold cautioned that psychiatrists need to be careful to not overextend themselves when they’re not treating patients. “It is easy to be therapist to friends, family, and colleagues,” she said, “but we need to take care of ourselves, too.”
Dr. Jain is author of “The Unspeakable Mind: Stories of Trauma and Healing From the Frontlines of PTSD Science” (New York: Harper, 2019). She has no other disclosures. Dr. Plakun and Dr. Gold reported no relevant disclosures.
New American Psychiatric Association poll shows depth of anxiety
New American Psychiatric Association poll shows depth of anxiety
The coronavirus pandemic weighs heavily on psychiatric patients with conditions such as anxiety, depression and PTSD. Meanwhile, a national poll released March 25 by the American Psychiatric Association shows that almost half of all Americans are anxious about contracting COVID-19 and 40% are anxious about becoming seriously ill or dying from the virus. In light of stressors on patients and nonpatients alike, mental health professionals have a key role in helping to alleviate suffering tied to the public health crisis, according to psychiatrists from across the country.
“There’s so much we can do to help people put order on this chaos,” said Shaili Jain, MD, section chief of outpatient mental health with the Veterans Affairs Palo Alto (Calif.) Health Care System, in an interview. “We are essential workers in this time.”
Dr. Jain, who specializes in treating PTSD, said those patients are especially vulnerable to the stress and disruptions spawned by the pandemic. “When you go to the grocery store and there’s no food, that can be triggering for people who survived situations with a feeling of calamity or panic,” she said. “People are reporting worsening of nightmares and spontaneous panic attacks after having been stable with symptoms for many months. These are the kinds of stories that are starting to filter through.”
To make things even more difficult, she said, shelter-in-place orders are preventing patients from taking advantage of healthy coping strategies, such as working out at the gym or going to support groups. “We have an invaluable role to play in trying to prevent long-term consequences by going into problem-solving modes with patients.” Dr. Jain offered several tips that might help patients who are suffering:
- Use technology to stay in touch with support communities and boost self-care. “How can you be flexible with FaceTime, Skype, or phone even if you might not be able to have that face-to-face time? What are you doing to double down on your efforts at self-care – listening to music, reading, daily meditation, or walks? Double down on what you can do to prevent anxiety and stress levels from building up.”
- Take breaks from the news, which can contribute to hypervigilance and disrupted sleep. “I’m seeing that people are going down these rabbit holes of having the news or social media on 24/7,” Dr. Jain said. “You have to stay informed. But you need to pick trusted news sources and have chunks of time that are free of coronavirus coverage.” Understand that life is going to be difficult for a while. “We’re doing a lot of reassurance and education,” she said, “helping people to know and accept that the next few days, weeks, and months are going to be stressful.”
Dr. Jain cautioned colleagues, however, that “there will be a tsunami” of mental illness when the coronavirus crisis lifts. She is especially concerned about patient populations that are socioeconomically disadvantaged already and how their lives with be affected by lost wages, unemployment, and business failures. “Medical professionals will see the consequences of this in the days and weeks and months after the pandemic has settled,” she predicted.
The APA poll shows that, early in the crisis, more than 60% of people are anxious about family and loved ones contracting COVID-19.
Maintaining ‘reflective space’ essential
At the Austen Riggs Center, a psychiatric residential treatment facility in Stockbridge, Mass., staff and patients are adjusting to new rules that aim to prevent transmission of the novel coronavirus. “Social distancing requirements are having a huge impact,” said Eric M. Plakun, MD, medical director and CEO of Austen Riggs, in an interview. “You can’t have groups in the same way; you can’t have families come in for a family meeting; you can’t have quite the same the freedom to come and go. A lot of management issues are being addressed, but it is crucial also to maintain the ‘reflective space’ essential to do the kind of clinical work we do.” One approach, he said, is virtual meetings with colleagues that address on-the-job management issues, but also leave a space for how staff members are feeling.
“It’s easy to get into crisis-response mode,” he said, “where you’re always managing but never leave a space to talk about vulnerability, helplessness, and fear.”
As the facility’s staff adjusts by embracing teleconference technology and adapting group meetings to the 6-feet-apart rule,
Dr. Plakun said he said, noting that patients have approached staff members to say they want to collaborate about changes. “That’s a credible offer we intend to accept.”
Still, communicating with patients as a whole about the coronavirus can be difficult. As Dr. Plakun noted, it’s now impossible to bring 75 people together into one room for a meeting. “If you have four to five smaller meetings, how do you maintain some congruence in the information that’s presented?”
Dr. Plakun suggested that colleagues find time to engage in the familiar, such as face-to-face clinical work. “That’s been the most reassuring and rewarding part of my day since it feels almost like normal,” he said.
Stocking up on medications
Jessica “Jessi” Gold, MD, MS, an assistant professor at Washington University in St. Louis, often treats college students. Asian students started to worry early in the pandemic, she said in an interview.
“At the beginning, there were a lot of concerns about the public’s view: ‘Did this come from China? Is it China’s fault?’ A lot of our students felt that if they coughed, and they were a white person, they’d be OK. But if they were Asian, everyone would wonder why they were in class and not at home. That got worse over time: the fear about – and anxiety from – stoking racism.”
Later, as classes began to be canceled, Dr. Gold started to see the psychological effects of disruption and uncertainty about the future. “This can lead people to feel like what they knew before is just not there anymore. This can obviously cause anxiety but also has the potential to cause depression.” Patients also might slip into overuse of alcohol and drugs, or they might engage in other kinds of harmful behavior. Eating disorders, for example, “are ways to have control when other things aren’t in control,” she said.
Dr. Gold pointed to research into the mental health after effects of quarantines, such as those imposed during the SARS outbreak. A review of 24 studies published this year found that most “reported negative psychological effects, including post-traumatic stress symptoms, confusion, and anger. Stressors included longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma. Some researchers have suggested long-lasting effects” (Lancet. 2020;395:912-20).
Dr. Gold is urging patients to recall the warning signs that alerted them to psychological downturns in the past: “Try to remember what those warning signs are and pay attention to whether you see them.” And, Dr. Gold said, she asks patients to think about what has helped them get better.
In some cases, she said, patients are already preparing themselves for experiencing mental distress by stocking up on medications. “Some people have a bottle of 10-20 pills that they only use in emergencies and keep as a kind of security blanket,” she said, and she’s seen some of them ask for refills. It seems they’ve either taken the pills recently or want to stash them just in case. This makes sense, since their anxiety is higher, she said.
Dr. Gold cautioned that psychiatrists need to be careful to not overextend themselves when they’re not treating patients. “It is easy to be therapist to friends, family, and colleagues,” she said, “but we need to take care of ourselves, too.”
Dr. Jain is author of “The Unspeakable Mind: Stories of Trauma and Healing From the Frontlines of PTSD Science” (New York: Harper, 2019). She has no other disclosures. Dr. Plakun and Dr. Gold reported no relevant disclosures.
The coronavirus pandemic weighs heavily on psychiatric patients with conditions such as anxiety, depression and PTSD. Meanwhile, a national poll released March 25 by the American Psychiatric Association shows that almost half of all Americans are anxious about contracting COVID-19 and 40% are anxious about becoming seriously ill or dying from the virus. In light of stressors on patients and nonpatients alike, mental health professionals have a key role in helping to alleviate suffering tied to the public health crisis, according to psychiatrists from across the country.
“There’s so much we can do to help people put order on this chaos,” said Shaili Jain, MD, section chief of outpatient mental health with the Veterans Affairs Palo Alto (Calif.) Health Care System, in an interview. “We are essential workers in this time.”
Dr. Jain, who specializes in treating PTSD, said those patients are especially vulnerable to the stress and disruptions spawned by the pandemic. “When you go to the grocery store and there’s no food, that can be triggering for people who survived situations with a feeling of calamity or panic,” she said. “People are reporting worsening of nightmares and spontaneous panic attacks after having been stable with symptoms for many months. These are the kinds of stories that are starting to filter through.”
To make things even more difficult, she said, shelter-in-place orders are preventing patients from taking advantage of healthy coping strategies, such as working out at the gym or going to support groups. “We have an invaluable role to play in trying to prevent long-term consequences by going into problem-solving modes with patients.” Dr. Jain offered several tips that might help patients who are suffering:
- Use technology to stay in touch with support communities and boost self-care. “How can you be flexible with FaceTime, Skype, or phone even if you might not be able to have that face-to-face time? What are you doing to double down on your efforts at self-care – listening to music, reading, daily meditation, or walks? Double down on what you can do to prevent anxiety and stress levels from building up.”
- Take breaks from the news, which can contribute to hypervigilance and disrupted sleep. “I’m seeing that people are going down these rabbit holes of having the news or social media on 24/7,” Dr. Jain said. “You have to stay informed. But you need to pick trusted news sources and have chunks of time that are free of coronavirus coverage.” Understand that life is going to be difficult for a while. “We’re doing a lot of reassurance and education,” she said, “helping people to know and accept that the next few days, weeks, and months are going to be stressful.”
Dr. Jain cautioned colleagues, however, that “there will be a tsunami” of mental illness when the coronavirus crisis lifts. She is especially concerned about patient populations that are socioeconomically disadvantaged already and how their lives with be affected by lost wages, unemployment, and business failures. “Medical professionals will see the consequences of this in the days and weeks and months after the pandemic has settled,” she predicted.
The APA poll shows that, early in the crisis, more than 60% of people are anxious about family and loved ones contracting COVID-19.
Maintaining ‘reflective space’ essential
At the Austen Riggs Center, a psychiatric residential treatment facility in Stockbridge, Mass., staff and patients are adjusting to new rules that aim to prevent transmission of the novel coronavirus. “Social distancing requirements are having a huge impact,” said Eric M. Plakun, MD, medical director and CEO of Austen Riggs, in an interview. “You can’t have groups in the same way; you can’t have families come in for a family meeting; you can’t have quite the same the freedom to come and go. A lot of management issues are being addressed, but it is crucial also to maintain the ‘reflective space’ essential to do the kind of clinical work we do.” One approach, he said, is virtual meetings with colleagues that address on-the-job management issues, but also leave a space for how staff members are feeling.
“It’s easy to get into crisis-response mode,” he said, “where you’re always managing but never leave a space to talk about vulnerability, helplessness, and fear.”
As the facility’s staff adjusts by embracing teleconference technology and adapting group meetings to the 6-feet-apart rule,
Dr. Plakun said he said, noting that patients have approached staff members to say they want to collaborate about changes. “That’s a credible offer we intend to accept.”
Still, communicating with patients as a whole about the coronavirus can be difficult. As Dr. Plakun noted, it’s now impossible to bring 75 people together into one room for a meeting. “If you have four to five smaller meetings, how do you maintain some congruence in the information that’s presented?”
Dr. Plakun suggested that colleagues find time to engage in the familiar, such as face-to-face clinical work. “That’s been the most reassuring and rewarding part of my day since it feels almost like normal,” he said.
Stocking up on medications
Jessica “Jessi” Gold, MD, MS, an assistant professor at Washington University in St. Louis, often treats college students. Asian students started to worry early in the pandemic, she said in an interview.
“At the beginning, there were a lot of concerns about the public’s view: ‘Did this come from China? Is it China’s fault?’ A lot of our students felt that if they coughed, and they were a white person, they’d be OK. But if they were Asian, everyone would wonder why they were in class and not at home. That got worse over time: the fear about – and anxiety from – stoking racism.”
Later, as classes began to be canceled, Dr. Gold started to see the psychological effects of disruption and uncertainty about the future. “This can lead people to feel like what they knew before is just not there anymore. This can obviously cause anxiety but also has the potential to cause depression.” Patients also might slip into overuse of alcohol and drugs, or they might engage in other kinds of harmful behavior. Eating disorders, for example, “are ways to have control when other things aren’t in control,” she said.
Dr. Gold pointed to research into the mental health after effects of quarantines, such as those imposed during the SARS outbreak. A review of 24 studies published this year found that most “reported negative psychological effects, including post-traumatic stress symptoms, confusion, and anger. Stressors included longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma. Some researchers have suggested long-lasting effects” (Lancet. 2020;395:912-20).
Dr. Gold is urging patients to recall the warning signs that alerted them to psychological downturns in the past: “Try to remember what those warning signs are and pay attention to whether you see them.” And, Dr. Gold said, she asks patients to think about what has helped them get better.
In some cases, she said, patients are already preparing themselves for experiencing mental distress by stocking up on medications. “Some people have a bottle of 10-20 pills that they only use in emergencies and keep as a kind of security blanket,” she said, and she’s seen some of them ask for refills. It seems they’ve either taken the pills recently or want to stash them just in case. This makes sense, since their anxiety is higher, she said.
Dr. Gold cautioned that psychiatrists need to be careful to not overextend themselves when they’re not treating patients. “It is easy to be therapist to friends, family, and colleagues,” she said, “but we need to take care of ourselves, too.”
Dr. Jain is author of “The Unspeakable Mind: Stories of Trauma and Healing From the Frontlines of PTSD Science” (New York: Harper, 2019). She has no other disclosures. Dr. Plakun and Dr. Gold reported no relevant disclosures.
Health professionals fight against COVID-19 myths and misinformation
Misinformation about the COVID-19 travels faster than the virus and complicates the job of doctors who are treating those infected and responding to concerns of their other patients.
An array of myths springing up around this disease can be found on the Internet. The main themes appear to be false narratives about the origin of the virus, the size of the outbreak in the United States and in other countries, the availability of cures and treatments, and ways to prevent infection. Widespread misinformation hampers public health efforts to control the disease outbreak, confuses the public, and requires medical professionals to spend time refuting myths and re-educating patients.
A group of infectious disease experts became so alarmed by the misinformation trend they published a statement in The Lancet decrying the spread of false statements being circulated by some media outlets. “The rapid, open, and transparent sharing of data on this outbreak is now being threatened by rumours and misinformation ... Conspiracy theories do nothing but create fear, rumours, and prejudice that jeopardise our global collaboration in the fight against this virus,” wrote Charles H. Calisher, PhD, of Colorado State University, Fort Collins, and colleagues.
What can physicians do to counter misinformation?
Pulmonologist and critical care physician Cedric “Jamie” Rutland, MD, who practices in Riverside, Calif., sees misinformation about the novel coronavirus every day at home and on the job. His patients worry that everyone who gets infected will die or end up in the ICU. His neighbors ask him to pilfer surgical masks to protect them from the false notion that Chinese people in their community posed some kind of COVID-19 risk.
As he pondered how to counter myths with facts, Dr. Rutland turned to an unusual resource: His 7-year-old daughter Amelia. He explained to her how COVID-19 works and found that she could easily understand the basics. Now, Dr. Rutland draws upon the lessons from chats with his daughter as he explains COVID-19 to his patient audience on his YouTube channel “Medicine Deconstructed.” Simplicity, but not too much simplicity, is key, he said. Dr. Rutland uses a visual aid – a rough drawing of a virus – and shows how inflammation and antibodies enter the picture after infection. “I just teach them that if you’re a healthy person, this is how the body works, and this is what the immune system will do,” he said. “For the most part, you can calm people down when you make time for education.”
What are best practices? In a series of interviews, specialists emphasized the importance of fact-finding, wide-ranging communication, and – perhaps most difficult of all – humility.
Dr. Rutland emphasizes thoughtful communication based on facts and humility when communicating to patients about this potential health risk. “A lot of people finish medical school and think, ‘Everyone should trust me because I’m the pulmonologist or the GI doc.’ That’s not how it works. You still have to earn people’s trust,” he said.
Make sure all staff get reliable information
Hospitals are scrambling to keep staff safe with up-to-date directives and debunk false narratives about the virus. Keeping all hospital staff informed with verified and authoritative facts about the coronavirus is a key objective of the Massachusetts General Hospital’s Center for Disaster Medicine. The Center’s coronavirus educational materials are distributed to all staffers from physicians to janitors. “These provide information that they need to understand the risks and keep themselves safe,” said Eileen Searle, PhD, the Biothreats Clinical Operations program manager in the CDM.
According to Dr. Searle, the hospital keeps a continually updated COVID-19 Frequently Asked Questions document in its internal computer system. All employees can access it, she said, and it’s updated to include questions as they come up.
Even valets and front-desk volunteers are encouraged to read the FAQ, she said, since “they’re the first people that family and patients are interacting with.” The document “gives them reassurance about delivering messages,” she said.
Use patience with your patients
Dr. Rutland urges colleagues to take the time to listen to patients and educate them. “Reduce the gap between you and them,” said Dr. Rutland, who treats patients in Orange and Riverside counties. “Take off your white coat, sit down, and talk to the person about their concerns.”
Boston cardiologist Haider Warraich, MD, of Brigham and Women’s Hospital, Boston, said it’s important to “put medical information into a greater human context.” For example, he has told patients that he’s still taking his daughter to school despite COVID-19 risks. “I take the information I provide and apply it to my own life,” he said.
The Washington State Department of Health offers this advice to physicians to counter false information and stigma: “Stay updated and informed on COVID-19 to avoid miscommunication or inaccurate information. Talk openly about the harm of stigma. View people directly impacted by stigma as people first. Be conscious of your language. Acknowledge access and language barriers.”
Speak out on social media – but don’t fight
Should medical professionals speak out about COVID-19 misinformation via social media? It’s an individual decision, Dr. Warraich said, “but my sense is that it’s never been more important for physicians to be part of the fray and help quell the epidemic of misinformation that almost always follows any type of medial calamity.”
Dr. Rutland, vice president and founding member of the Association for Healthcare Social Media, cautioned that effective communication via social media requires care. Avoid confrontation, he advised. “Don’t call people stupid or say things like, ‘I went to medical school and I’m smarter than you.’ ”
Instead, he said, “it’s important to just state the facts: These are the people who are dying, these are the people who are getting infected.”
And, he added, remember to push the most important message of all: Wash your hands!
Public health organizations fight the ‘infodemic’
In a trend that hearkens back to the days of snake oil cures for all maladies, advertisements for fake treatments are popping up on the Internet and on other media.
Facebook and Amazon have acted to remove these ads but these messages continue to flood social media such as Twitter, WhatsApp, and other sites. Discussion groups on platforms such as Reddit continue to pump out misinformation about COVID-19. Conspiracy theories that link the virus to espionage and bioweapons are making the rounds on the Internet and talk radio. Wrong information about the effectiveness of non-N95 face masks to protect wearers against infection is widespread, leading to shortages for medical personnel and price gouging. Pernicious rumors about the effectiveness of substances such a vinegar, silver, garlic, lemon juice, and even vodka to disinfect hands and surfaces abound on the Internet. An especially dangerous stream of misinformation stigmatizes ethnic groups and individuals as sources of the infection.
The World Health Organization identified early in the COVID-19 outbreak the global wave of misinformation about the virus and dubbed the problem the “infodemic.” The WHO “Q & A” page on COVID-19 is updated frequently and addresses myths and rumors currently circulating.
According to the WHO website, the agency has reached out to social media players such as Facebook, Twitter, Instagram, LinkedIn, Pinterest, TikTok, and Weibo, the microblogging site in China. WHO has worked with these sites to curb the “infodemic” of misinformation and has used these sites for public education outreach on COVID-19. “Myth busting” infographics posted on a WHO web page are also reposted on major social media sites.
The CDC has followed with its own “frequently asked questions” page to address questions and rumors. State health agencies have put up COVID-19 pages to address public concerns and offer advice on prevention. The Maryland Department of Health web page directly addresses dangerous misinformation: “Do not stigmatize people of any specific ethnicities or racial background. Viruses do not target people from specific populations, ethnicities or racial backgrounds. Stay informed and seek information from reliable, official sources. Be wary of myths, rumors and misinformation circulating online and elsewhere. Health information shared through social media is frequently inaccurate, unless coming from an official, reliable source such as the CDC, MDH or local health departments.”
The Washington State Department of Health has taken a more assertive stance on stigma. The COVID-19 web page recommends to the public: “Show compassion and support for individuals and communities more closely impacted. Avoid stigmatizing people who are in quarantine. They are making the right choice for their communities. Do not make assumptions about someone’s health status based on their ethnicity, race or national origin.”
Misinformation about the COVID-19 travels faster than the virus and complicates the job of doctors who are treating those infected and responding to concerns of their other patients.
An array of myths springing up around this disease can be found on the Internet. The main themes appear to be false narratives about the origin of the virus, the size of the outbreak in the United States and in other countries, the availability of cures and treatments, and ways to prevent infection. Widespread misinformation hampers public health efforts to control the disease outbreak, confuses the public, and requires medical professionals to spend time refuting myths and re-educating patients.
A group of infectious disease experts became so alarmed by the misinformation trend they published a statement in The Lancet decrying the spread of false statements being circulated by some media outlets. “The rapid, open, and transparent sharing of data on this outbreak is now being threatened by rumours and misinformation ... Conspiracy theories do nothing but create fear, rumours, and prejudice that jeopardise our global collaboration in the fight against this virus,” wrote Charles H. Calisher, PhD, of Colorado State University, Fort Collins, and colleagues.
What can physicians do to counter misinformation?
Pulmonologist and critical care physician Cedric “Jamie” Rutland, MD, who practices in Riverside, Calif., sees misinformation about the novel coronavirus every day at home and on the job. His patients worry that everyone who gets infected will die or end up in the ICU. His neighbors ask him to pilfer surgical masks to protect them from the false notion that Chinese people in their community posed some kind of COVID-19 risk.
As he pondered how to counter myths with facts, Dr. Rutland turned to an unusual resource: His 7-year-old daughter Amelia. He explained to her how COVID-19 works and found that she could easily understand the basics. Now, Dr. Rutland draws upon the lessons from chats with his daughter as he explains COVID-19 to his patient audience on his YouTube channel “Medicine Deconstructed.” Simplicity, but not too much simplicity, is key, he said. Dr. Rutland uses a visual aid – a rough drawing of a virus – and shows how inflammation and antibodies enter the picture after infection. “I just teach them that if you’re a healthy person, this is how the body works, and this is what the immune system will do,” he said. “For the most part, you can calm people down when you make time for education.”
What are best practices? In a series of interviews, specialists emphasized the importance of fact-finding, wide-ranging communication, and – perhaps most difficult of all – humility.
Dr. Rutland emphasizes thoughtful communication based on facts and humility when communicating to patients about this potential health risk. “A lot of people finish medical school and think, ‘Everyone should trust me because I’m the pulmonologist or the GI doc.’ That’s not how it works. You still have to earn people’s trust,” he said.
Make sure all staff get reliable information
Hospitals are scrambling to keep staff safe with up-to-date directives and debunk false narratives about the virus. Keeping all hospital staff informed with verified and authoritative facts about the coronavirus is a key objective of the Massachusetts General Hospital’s Center for Disaster Medicine. The Center’s coronavirus educational materials are distributed to all staffers from physicians to janitors. “These provide information that they need to understand the risks and keep themselves safe,” said Eileen Searle, PhD, the Biothreats Clinical Operations program manager in the CDM.
According to Dr. Searle, the hospital keeps a continually updated COVID-19 Frequently Asked Questions document in its internal computer system. All employees can access it, she said, and it’s updated to include questions as they come up.
Even valets and front-desk volunteers are encouraged to read the FAQ, she said, since “they’re the first people that family and patients are interacting with.” The document “gives them reassurance about delivering messages,” she said.
Use patience with your patients
Dr. Rutland urges colleagues to take the time to listen to patients and educate them. “Reduce the gap between you and them,” said Dr. Rutland, who treats patients in Orange and Riverside counties. “Take off your white coat, sit down, and talk to the person about their concerns.”
Boston cardiologist Haider Warraich, MD, of Brigham and Women’s Hospital, Boston, said it’s important to “put medical information into a greater human context.” For example, he has told patients that he’s still taking his daughter to school despite COVID-19 risks. “I take the information I provide and apply it to my own life,” he said.
The Washington State Department of Health offers this advice to physicians to counter false information and stigma: “Stay updated and informed on COVID-19 to avoid miscommunication or inaccurate information. Talk openly about the harm of stigma. View people directly impacted by stigma as people first. Be conscious of your language. Acknowledge access and language barriers.”
Speak out on social media – but don’t fight
Should medical professionals speak out about COVID-19 misinformation via social media? It’s an individual decision, Dr. Warraich said, “but my sense is that it’s never been more important for physicians to be part of the fray and help quell the epidemic of misinformation that almost always follows any type of medial calamity.”
Dr. Rutland, vice president and founding member of the Association for Healthcare Social Media, cautioned that effective communication via social media requires care. Avoid confrontation, he advised. “Don’t call people stupid or say things like, ‘I went to medical school and I’m smarter than you.’ ”
Instead, he said, “it’s important to just state the facts: These are the people who are dying, these are the people who are getting infected.”
And, he added, remember to push the most important message of all: Wash your hands!
Public health organizations fight the ‘infodemic’
In a trend that hearkens back to the days of snake oil cures for all maladies, advertisements for fake treatments are popping up on the Internet and on other media.
Facebook and Amazon have acted to remove these ads but these messages continue to flood social media such as Twitter, WhatsApp, and other sites. Discussion groups on platforms such as Reddit continue to pump out misinformation about COVID-19. Conspiracy theories that link the virus to espionage and bioweapons are making the rounds on the Internet and talk radio. Wrong information about the effectiveness of non-N95 face masks to protect wearers against infection is widespread, leading to shortages for medical personnel and price gouging. Pernicious rumors about the effectiveness of substances such a vinegar, silver, garlic, lemon juice, and even vodka to disinfect hands and surfaces abound on the Internet. An especially dangerous stream of misinformation stigmatizes ethnic groups and individuals as sources of the infection.
The World Health Organization identified early in the COVID-19 outbreak the global wave of misinformation about the virus and dubbed the problem the “infodemic.” The WHO “Q & A” page on COVID-19 is updated frequently and addresses myths and rumors currently circulating.
According to the WHO website, the agency has reached out to social media players such as Facebook, Twitter, Instagram, LinkedIn, Pinterest, TikTok, and Weibo, the microblogging site in China. WHO has worked with these sites to curb the “infodemic” of misinformation and has used these sites for public education outreach on COVID-19. “Myth busting” infographics posted on a WHO web page are also reposted on major social media sites.
The CDC has followed with its own “frequently asked questions” page to address questions and rumors. State health agencies have put up COVID-19 pages to address public concerns and offer advice on prevention. The Maryland Department of Health web page directly addresses dangerous misinformation: “Do not stigmatize people of any specific ethnicities or racial background. Viruses do not target people from specific populations, ethnicities or racial backgrounds. Stay informed and seek information from reliable, official sources. Be wary of myths, rumors and misinformation circulating online and elsewhere. Health information shared through social media is frequently inaccurate, unless coming from an official, reliable source such as the CDC, MDH or local health departments.”
The Washington State Department of Health has taken a more assertive stance on stigma. The COVID-19 web page recommends to the public: “Show compassion and support for individuals and communities more closely impacted. Avoid stigmatizing people who are in quarantine. They are making the right choice for their communities. Do not make assumptions about someone’s health status based on their ethnicity, race or national origin.”
Misinformation about the COVID-19 travels faster than the virus and complicates the job of doctors who are treating those infected and responding to concerns of their other patients.
An array of myths springing up around this disease can be found on the Internet. The main themes appear to be false narratives about the origin of the virus, the size of the outbreak in the United States and in other countries, the availability of cures and treatments, and ways to prevent infection. Widespread misinformation hampers public health efforts to control the disease outbreak, confuses the public, and requires medical professionals to spend time refuting myths and re-educating patients.
A group of infectious disease experts became so alarmed by the misinformation trend they published a statement in The Lancet decrying the spread of false statements being circulated by some media outlets. “The rapid, open, and transparent sharing of data on this outbreak is now being threatened by rumours and misinformation ... Conspiracy theories do nothing but create fear, rumours, and prejudice that jeopardise our global collaboration in the fight against this virus,” wrote Charles H. Calisher, PhD, of Colorado State University, Fort Collins, and colleagues.
What can physicians do to counter misinformation?
Pulmonologist and critical care physician Cedric “Jamie” Rutland, MD, who practices in Riverside, Calif., sees misinformation about the novel coronavirus every day at home and on the job. His patients worry that everyone who gets infected will die or end up in the ICU. His neighbors ask him to pilfer surgical masks to protect them from the false notion that Chinese people in their community posed some kind of COVID-19 risk.
As he pondered how to counter myths with facts, Dr. Rutland turned to an unusual resource: His 7-year-old daughter Amelia. He explained to her how COVID-19 works and found that she could easily understand the basics. Now, Dr. Rutland draws upon the lessons from chats with his daughter as he explains COVID-19 to his patient audience on his YouTube channel “Medicine Deconstructed.” Simplicity, but not too much simplicity, is key, he said. Dr. Rutland uses a visual aid – a rough drawing of a virus – and shows how inflammation and antibodies enter the picture after infection. “I just teach them that if you’re a healthy person, this is how the body works, and this is what the immune system will do,” he said. “For the most part, you can calm people down when you make time for education.”
What are best practices? In a series of interviews, specialists emphasized the importance of fact-finding, wide-ranging communication, and – perhaps most difficult of all – humility.
Dr. Rutland emphasizes thoughtful communication based on facts and humility when communicating to patients about this potential health risk. “A lot of people finish medical school and think, ‘Everyone should trust me because I’m the pulmonologist or the GI doc.’ That’s not how it works. You still have to earn people’s trust,” he said.
Make sure all staff get reliable information
Hospitals are scrambling to keep staff safe with up-to-date directives and debunk false narratives about the virus. Keeping all hospital staff informed with verified and authoritative facts about the coronavirus is a key objective of the Massachusetts General Hospital’s Center for Disaster Medicine. The Center’s coronavirus educational materials are distributed to all staffers from physicians to janitors. “These provide information that they need to understand the risks and keep themselves safe,” said Eileen Searle, PhD, the Biothreats Clinical Operations program manager in the CDM.
According to Dr. Searle, the hospital keeps a continually updated COVID-19 Frequently Asked Questions document in its internal computer system. All employees can access it, she said, and it’s updated to include questions as they come up.
Even valets and front-desk volunteers are encouraged to read the FAQ, she said, since “they’re the first people that family and patients are interacting with.” The document “gives them reassurance about delivering messages,” she said.
Use patience with your patients
Dr. Rutland urges colleagues to take the time to listen to patients and educate them. “Reduce the gap between you and them,” said Dr. Rutland, who treats patients in Orange and Riverside counties. “Take off your white coat, sit down, and talk to the person about their concerns.”
Boston cardiologist Haider Warraich, MD, of Brigham and Women’s Hospital, Boston, said it’s important to “put medical information into a greater human context.” For example, he has told patients that he’s still taking his daughter to school despite COVID-19 risks. “I take the information I provide and apply it to my own life,” he said.
The Washington State Department of Health offers this advice to physicians to counter false information and stigma: “Stay updated and informed on COVID-19 to avoid miscommunication or inaccurate information. Talk openly about the harm of stigma. View people directly impacted by stigma as people first. Be conscious of your language. Acknowledge access and language barriers.”
Speak out on social media – but don’t fight
Should medical professionals speak out about COVID-19 misinformation via social media? It’s an individual decision, Dr. Warraich said, “but my sense is that it’s never been more important for physicians to be part of the fray and help quell the epidemic of misinformation that almost always follows any type of medial calamity.”
Dr. Rutland, vice president and founding member of the Association for Healthcare Social Media, cautioned that effective communication via social media requires care. Avoid confrontation, he advised. “Don’t call people stupid or say things like, ‘I went to medical school and I’m smarter than you.’ ”
Instead, he said, “it’s important to just state the facts: These are the people who are dying, these are the people who are getting infected.”
And, he added, remember to push the most important message of all: Wash your hands!
Public health organizations fight the ‘infodemic’
In a trend that hearkens back to the days of snake oil cures for all maladies, advertisements for fake treatments are popping up on the Internet and on other media.
Facebook and Amazon have acted to remove these ads but these messages continue to flood social media such as Twitter, WhatsApp, and other sites. Discussion groups on platforms such as Reddit continue to pump out misinformation about COVID-19. Conspiracy theories that link the virus to espionage and bioweapons are making the rounds on the Internet and talk radio. Wrong information about the effectiveness of non-N95 face masks to protect wearers against infection is widespread, leading to shortages for medical personnel and price gouging. Pernicious rumors about the effectiveness of substances such a vinegar, silver, garlic, lemon juice, and even vodka to disinfect hands and surfaces abound on the Internet. An especially dangerous stream of misinformation stigmatizes ethnic groups and individuals as sources of the infection.
The World Health Organization identified early in the COVID-19 outbreak the global wave of misinformation about the virus and dubbed the problem the “infodemic.” The WHO “Q & A” page on COVID-19 is updated frequently and addresses myths and rumors currently circulating.
According to the WHO website, the agency has reached out to social media players such as Facebook, Twitter, Instagram, LinkedIn, Pinterest, TikTok, and Weibo, the microblogging site in China. WHO has worked with these sites to curb the “infodemic” of misinformation and has used these sites for public education outreach on COVID-19. “Myth busting” infographics posted on a WHO web page are also reposted on major social media sites.
The CDC has followed with its own “frequently asked questions” page to address questions and rumors. State health agencies have put up COVID-19 pages to address public concerns and offer advice on prevention. The Maryland Department of Health web page directly addresses dangerous misinformation: “Do not stigmatize people of any specific ethnicities or racial background. Viruses do not target people from specific populations, ethnicities or racial backgrounds. Stay informed and seek information from reliable, official sources. Be wary of myths, rumors and misinformation circulating online and elsewhere. Health information shared through social media is frequently inaccurate, unless coming from an official, reliable source such as the CDC, MDH or local health departments.”
The Washington State Department of Health has taken a more assertive stance on stigma. The COVID-19 web page recommends to the public: “Show compassion and support for individuals and communities more closely impacted. Avoid stigmatizing people who are in quarantine. They are making the right choice for their communities. Do not make assumptions about someone’s health status based on their ethnicity, race or national origin.”
In hysterectomy, consider wider risks of ovary removal
LAS VEGAS – While it’s fading in popularity, ovary removal in hysterectomy is still far from uncommon. A gynecologic surgeon urged colleagues to give deeper consideration to whether the ovaries can stay in place.
“Gynecologists should truly familiarize themselves with the data on cardiovascular, endocrine, bone, and sexual health implications of removing the ovaries when there isn’t a medical indication to do so,” Amanda Nickles Fader, MD, director of the Kelly gynecologic oncology service and the director of the center for rare gynecologic cancers at Johns Hopkins Hospital, Baltimore, said in an interview following her presentation at the Pelvic Anatomy and Gynecologic Surgery Symposium.
“Until I started giving this talk, I thought I knew this data. However, once I took a deeper dive into the studies of how hormonally active the postmenopausal ovaries are, as well as the population-based studies demonstrating worse all-cause mortality outcomes in low-risk women who have their ovaries surgically removed prior to their 60s, I was stunned at how compelling this data is,” she said.
The conventional wisdom about ovary removal in hysterectomy has changed dramatically over the decades. As Dr. Nickles Fader explained in the interview, “in the ’80s and early ’90s, the mantra was ‘just take everything out’ at hysterectomy surgery – tubes and ovaries should be removed – without understanding the implications. Then in the late ’90s and early 2000s, it was a more selective strategy of ‘wait until menopause to remove the ovaries.’ ”
Now, “more contemporary data suggests that the ovaries appear to be hormonally active to some degree well into the seventh decade of life, and even women in their early 60s who have their ovaries removed without a medical indication may be harmed.”
Still, ovary removal occurs in about 50%-60% of the 450,000-500,000 hysterectomies performed each year in the United States, Dr. Nickles Fader said at the meeting, which was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
These findings seem to suggest that messages about the potential benefits of ovary preservation are not getting through to surgeons and patients.
Indeed, a 2017 study of 57,776 benign premenopausal hysterectomies with ovary removal in California from 2005 to 2011 found that 38% had no documented sign of an appropriate diagnosis signaling a need for oophorectomy. These included “ovarian cyst, breast cancer susceptibility gene carrier status, and other diagnoses,” the study authors wrote (Menopause. 2017 Aug;24[8]:947-53).
Dr. Nickles Fader emphasized that ovary removal is appropriate in cases of gynecologic malignancy, while patients at high genetic risk of ovarian cancer may consider salpingo-oophorectomy or salpingectomy.
What about other situations? She offered these pearls in the presentation:
- Don’t remove ovaries before age 60 “without a good reason” because the procedure may lower lifespan and increase cardiovascular risk.
- Ovary removal is linked to cognitive decline, Parkinson’s disease, depression and anxiety, glaucoma, sexual dysfunction, and bone fractures.
- Ovary preservation, in contrast, is linked to improvement of menopausal symptoms, sleep quality, urogenital atrophy, skin conditions, and metabolism.
- Fallopian tubes may be the true trouble area. “The prevailing theory amongst scientists and clinicians is that ‘ovarian cancer’ is in most cases a misnomer, and most of these malignancies start in the fallopian tube,” Dr. Nickles Fader said in the interview.
“It’s a better time than ever to be thoughtful about removing a woman’s ovaries in someone who is at low risk for ovarian cancer. The new, universal guideline is that to best optimize cancer risk reduction and general health outcomes.”
Dr. Nickles Fader disclosed consulting work for Ethicon and Merck.
LAS VEGAS – While it’s fading in popularity, ovary removal in hysterectomy is still far from uncommon. A gynecologic surgeon urged colleagues to give deeper consideration to whether the ovaries can stay in place.
“Gynecologists should truly familiarize themselves with the data on cardiovascular, endocrine, bone, and sexual health implications of removing the ovaries when there isn’t a medical indication to do so,” Amanda Nickles Fader, MD, director of the Kelly gynecologic oncology service and the director of the center for rare gynecologic cancers at Johns Hopkins Hospital, Baltimore, said in an interview following her presentation at the Pelvic Anatomy and Gynecologic Surgery Symposium.
“Until I started giving this talk, I thought I knew this data. However, once I took a deeper dive into the studies of how hormonally active the postmenopausal ovaries are, as well as the population-based studies demonstrating worse all-cause mortality outcomes in low-risk women who have their ovaries surgically removed prior to their 60s, I was stunned at how compelling this data is,” she said.
The conventional wisdom about ovary removal in hysterectomy has changed dramatically over the decades. As Dr. Nickles Fader explained in the interview, “in the ’80s and early ’90s, the mantra was ‘just take everything out’ at hysterectomy surgery – tubes and ovaries should be removed – without understanding the implications. Then in the late ’90s and early 2000s, it was a more selective strategy of ‘wait until menopause to remove the ovaries.’ ”
Now, “more contemporary data suggests that the ovaries appear to be hormonally active to some degree well into the seventh decade of life, and even women in their early 60s who have their ovaries removed without a medical indication may be harmed.”
Still, ovary removal occurs in about 50%-60% of the 450,000-500,000 hysterectomies performed each year in the United States, Dr. Nickles Fader said at the meeting, which was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
These findings seem to suggest that messages about the potential benefits of ovary preservation are not getting through to surgeons and patients.
Indeed, a 2017 study of 57,776 benign premenopausal hysterectomies with ovary removal in California from 2005 to 2011 found that 38% had no documented sign of an appropriate diagnosis signaling a need for oophorectomy. These included “ovarian cyst, breast cancer susceptibility gene carrier status, and other diagnoses,” the study authors wrote (Menopause. 2017 Aug;24[8]:947-53).
Dr. Nickles Fader emphasized that ovary removal is appropriate in cases of gynecologic malignancy, while patients at high genetic risk of ovarian cancer may consider salpingo-oophorectomy or salpingectomy.
What about other situations? She offered these pearls in the presentation:
- Don’t remove ovaries before age 60 “without a good reason” because the procedure may lower lifespan and increase cardiovascular risk.
- Ovary removal is linked to cognitive decline, Parkinson’s disease, depression and anxiety, glaucoma, sexual dysfunction, and bone fractures.
- Ovary preservation, in contrast, is linked to improvement of menopausal symptoms, sleep quality, urogenital atrophy, skin conditions, and metabolism.
- Fallopian tubes may be the true trouble area. “The prevailing theory amongst scientists and clinicians is that ‘ovarian cancer’ is in most cases a misnomer, and most of these malignancies start in the fallopian tube,” Dr. Nickles Fader said in the interview.
“It’s a better time than ever to be thoughtful about removing a woman’s ovaries in someone who is at low risk for ovarian cancer. The new, universal guideline is that to best optimize cancer risk reduction and general health outcomes.”
Dr. Nickles Fader disclosed consulting work for Ethicon and Merck.
LAS VEGAS – While it’s fading in popularity, ovary removal in hysterectomy is still far from uncommon. A gynecologic surgeon urged colleagues to give deeper consideration to whether the ovaries can stay in place.
“Gynecologists should truly familiarize themselves with the data on cardiovascular, endocrine, bone, and sexual health implications of removing the ovaries when there isn’t a medical indication to do so,” Amanda Nickles Fader, MD, director of the Kelly gynecologic oncology service and the director of the center for rare gynecologic cancers at Johns Hopkins Hospital, Baltimore, said in an interview following her presentation at the Pelvic Anatomy and Gynecologic Surgery Symposium.
“Until I started giving this talk, I thought I knew this data. However, once I took a deeper dive into the studies of how hormonally active the postmenopausal ovaries are, as well as the population-based studies demonstrating worse all-cause mortality outcomes in low-risk women who have their ovaries surgically removed prior to their 60s, I was stunned at how compelling this data is,” she said.
The conventional wisdom about ovary removal in hysterectomy has changed dramatically over the decades. As Dr. Nickles Fader explained in the interview, “in the ’80s and early ’90s, the mantra was ‘just take everything out’ at hysterectomy surgery – tubes and ovaries should be removed – without understanding the implications. Then in the late ’90s and early 2000s, it was a more selective strategy of ‘wait until menopause to remove the ovaries.’ ”
Now, “more contemporary data suggests that the ovaries appear to be hormonally active to some degree well into the seventh decade of life, and even women in their early 60s who have their ovaries removed without a medical indication may be harmed.”
Still, ovary removal occurs in about 50%-60% of the 450,000-500,000 hysterectomies performed each year in the United States, Dr. Nickles Fader said at the meeting, which was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
These findings seem to suggest that messages about the potential benefits of ovary preservation are not getting through to surgeons and patients.
Indeed, a 2017 study of 57,776 benign premenopausal hysterectomies with ovary removal in California from 2005 to 2011 found that 38% had no documented sign of an appropriate diagnosis signaling a need for oophorectomy. These included “ovarian cyst, breast cancer susceptibility gene carrier status, and other diagnoses,” the study authors wrote (Menopause. 2017 Aug;24[8]:947-53).
Dr. Nickles Fader emphasized that ovary removal is appropriate in cases of gynecologic malignancy, while patients at high genetic risk of ovarian cancer may consider salpingo-oophorectomy or salpingectomy.
What about other situations? She offered these pearls in the presentation:
- Don’t remove ovaries before age 60 “without a good reason” because the procedure may lower lifespan and increase cardiovascular risk.
- Ovary removal is linked to cognitive decline, Parkinson’s disease, depression and anxiety, glaucoma, sexual dysfunction, and bone fractures.
- Ovary preservation, in contrast, is linked to improvement of menopausal symptoms, sleep quality, urogenital atrophy, skin conditions, and metabolism.
- Fallopian tubes may be the true trouble area. “The prevailing theory amongst scientists and clinicians is that ‘ovarian cancer’ is in most cases a misnomer, and most of these malignancies start in the fallopian tube,” Dr. Nickles Fader said in the interview.
“It’s a better time than ever to be thoughtful about removing a woman’s ovaries in someone who is at low risk for ovarian cancer. The new, universal guideline is that to best optimize cancer risk reduction and general health outcomes.”
Dr. Nickles Fader disclosed consulting work for Ethicon and Merck.
EXPERT ANALYSIS FROM PAGS 2019
Consider sparing the uterus in prolapse procedures
LAS VEGAS – A female pelvic medicine and reconstructive surgeon urged colleagues to consider uterus-sparing hysteropexies instead of hysterectomies in pelvic organ prolapse repairs.
said Beri M. Ridgeway, MD, of the Cleveland Clinic, at the Pelvic Anatomy and Gynecologic Surgery Symposium. Even so, “in the U.S., gynecologists rarely offer uterine preservation for women who desire repair of their uterovaginal prolapse.”
According to research compiled by Dr. Ridgeway, about 74,000 hysterectomies are performed each year in the United States to treat pelvic organ prolapse. The procedure became standard in the second half of the 20th century, in part to reduce cancer risk.
But attitudes evolved starting in the 1990s “as we have had better cancer screening and more focus on patient sexuality, patient autonomy, and quality of life,” Dr. Ridgeway said.
She offered these reasons to question hysterectomies to treat pelvic organ prolapse repairs:
- It’s not clear whether hysterectomies address the anatomic problems that produce prolapse in the first place. “Prolapse is caused by weakened or damaged tissue – connective tissue, muscles, etc.,” she said in an interview. “The problem is what is supporting the uterus, not the uterus itself.”
- Despite assumptions, women don’t necessarily prefer hysterectomy. Dr. Ridgeway pointed to a 2013 study in which researchers surveyed 213 women with prolapse symptoms about their preferred treatment, assuming that outcomes were the same. The results: 36% preferred uterine preservation, 20% preferred hysterectomy, and 44% reported no strong preference (Am J Obstet Gynecol. 2013 Nov;209[5]:470.e1-6.).
- Hysterectomies hasten menopause.
There has been a perception that uterus removal is appropriate in women who don’t wish to have any more children, Dr. Ridgeway said. “You had your babies, you’re done, you don’t need this anymore.” In fact, “that’s basically not true.”
As she explained, hysterectomy is linked to earlier menopause, and “even losing one ovary pushed patients into menopause significantly earlier.” She pointed to a 2016 Australian study, which found that “women who have a hysterectomy (with ovarian conservation) have a higher risk of hot flushes and night sweats that persist over an extended period” (Maturitas. 2016 Sep;91:1-7).
There’s no consensus on how hysterectomy affects sexual function. However, Dr. Ridgeway noted, it’s clear that pelvic floor disorders disrupt sexual function, and most women see improvement after surgical treatment.
The rate of uterine pathology is low in hysterectomy. Dr. Ridgeway highlighted a 2018 study of 24,076 women who underwent hysterectomy for benign indications. The study reported that “prevalence of occult corpus uteri, cervical, and ovarian malignancy was 1.44%, 0.60%, and 0.19%, respectively, among women undergoing hysterectomy and it varied by patient age and surgical route” (Obstet Gynecol. 2018 Apr;131[4]:642-51).
As an alternative, Dr. Ridgeway pointed to hysteropexy, which can be performed as a vaginal, laparoscopic, robot, or open procedure.
She highlighted a 2018 systematic review of pelvic organ prolapse surgeries that provided a meta-analysis and clinical practice guidelines. It found that “uterine-preserving prolapse surgeries improve operating time, blood loss, and risk of mesh exposure, compared with similar surgical routes with concomitant hysterectomy and do not significantly change short-term prolapse outcomes” (Am J Obstet Gynecol. 2018 Aug;219[2]:129-46.e2).
Dr. Ridgeway reported no relevant disclosures. This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
LAS VEGAS – A female pelvic medicine and reconstructive surgeon urged colleagues to consider uterus-sparing hysteropexies instead of hysterectomies in pelvic organ prolapse repairs.
said Beri M. Ridgeway, MD, of the Cleveland Clinic, at the Pelvic Anatomy and Gynecologic Surgery Symposium. Even so, “in the U.S., gynecologists rarely offer uterine preservation for women who desire repair of their uterovaginal prolapse.”
According to research compiled by Dr. Ridgeway, about 74,000 hysterectomies are performed each year in the United States to treat pelvic organ prolapse. The procedure became standard in the second half of the 20th century, in part to reduce cancer risk.
But attitudes evolved starting in the 1990s “as we have had better cancer screening and more focus on patient sexuality, patient autonomy, and quality of life,” Dr. Ridgeway said.
She offered these reasons to question hysterectomies to treat pelvic organ prolapse repairs:
- It’s not clear whether hysterectomies address the anatomic problems that produce prolapse in the first place. “Prolapse is caused by weakened or damaged tissue – connective tissue, muscles, etc.,” she said in an interview. “The problem is what is supporting the uterus, not the uterus itself.”
- Despite assumptions, women don’t necessarily prefer hysterectomy. Dr. Ridgeway pointed to a 2013 study in which researchers surveyed 213 women with prolapse symptoms about their preferred treatment, assuming that outcomes were the same. The results: 36% preferred uterine preservation, 20% preferred hysterectomy, and 44% reported no strong preference (Am J Obstet Gynecol. 2013 Nov;209[5]:470.e1-6.).
- Hysterectomies hasten menopause.
There has been a perception that uterus removal is appropriate in women who don’t wish to have any more children, Dr. Ridgeway said. “You had your babies, you’re done, you don’t need this anymore.” In fact, “that’s basically not true.”
As she explained, hysterectomy is linked to earlier menopause, and “even losing one ovary pushed patients into menopause significantly earlier.” She pointed to a 2016 Australian study, which found that “women who have a hysterectomy (with ovarian conservation) have a higher risk of hot flushes and night sweats that persist over an extended period” (Maturitas. 2016 Sep;91:1-7).
There’s no consensus on how hysterectomy affects sexual function. However, Dr. Ridgeway noted, it’s clear that pelvic floor disorders disrupt sexual function, and most women see improvement after surgical treatment.
The rate of uterine pathology is low in hysterectomy. Dr. Ridgeway highlighted a 2018 study of 24,076 women who underwent hysterectomy for benign indications. The study reported that “prevalence of occult corpus uteri, cervical, and ovarian malignancy was 1.44%, 0.60%, and 0.19%, respectively, among women undergoing hysterectomy and it varied by patient age and surgical route” (Obstet Gynecol. 2018 Apr;131[4]:642-51).
As an alternative, Dr. Ridgeway pointed to hysteropexy, which can be performed as a vaginal, laparoscopic, robot, or open procedure.
She highlighted a 2018 systematic review of pelvic organ prolapse surgeries that provided a meta-analysis and clinical practice guidelines. It found that “uterine-preserving prolapse surgeries improve operating time, blood loss, and risk of mesh exposure, compared with similar surgical routes with concomitant hysterectomy and do not significantly change short-term prolapse outcomes” (Am J Obstet Gynecol. 2018 Aug;219[2]:129-46.e2).
Dr. Ridgeway reported no relevant disclosures. This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
LAS VEGAS – A female pelvic medicine and reconstructive surgeon urged colleagues to consider uterus-sparing hysteropexies instead of hysterectomies in pelvic organ prolapse repairs.
said Beri M. Ridgeway, MD, of the Cleveland Clinic, at the Pelvic Anatomy and Gynecologic Surgery Symposium. Even so, “in the U.S., gynecologists rarely offer uterine preservation for women who desire repair of their uterovaginal prolapse.”
According to research compiled by Dr. Ridgeway, about 74,000 hysterectomies are performed each year in the United States to treat pelvic organ prolapse. The procedure became standard in the second half of the 20th century, in part to reduce cancer risk.
But attitudes evolved starting in the 1990s “as we have had better cancer screening and more focus on patient sexuality, patient autonomy, and quality of life,” Dr. Ridgeway said.
She offered these reasons to question hysterectomies to treat pelvic organ prolapse repairs:
- It’s not clear whether hysterectomies address the anatomic problems that produce prolapse in the first place. “Prolapse is caused by weakened or damaged tissue – connective tissue, muscles, etc.,” she said in an interview. “The problem is what is supporting the uterus, not the uterus itself.”
- Despite assumptions, women don’t necessarily prefer hysterectomy. Dr. Ridgeway pointed to a 2013 study in which researchers surveyed 213 women with prolapse symptoms about their preferred treatment, assuming that outcomes were the same. The results: 36% preferred uterine preservation, 20% preferred hysterectomy, and 44% reported no strong preference (Am J Obstet Gynecol. 2013 Nov;209[5]:470.e1-6.).
- Hysterectomies hasten menopause.
There has been a perception that uterus removal is appropriate in women who don’t wish to have any more children, Dr. Ridgeway said. “You had your babies, you’re done, you don’t need this anymore.” In fact, “that’s basically not true.”
As she explained, hysterectomy is linked to earlier menopause, and “even losing one ovary pushed patients into menopause significantly earlier.” She pointed to a 2016 Australian study, which found that “women who have a hysterectomy (with ovarian conservation) have a higher risk of hot flushes and night sweats that persist over an extended period” (Maturitas. 2016 Sep;91:1-7).
There’s no consensus on how hysterectomy affects sexual function. However, Dr. Ridgeway noted, it’s clear that pelvic floor disorders disrupt sexual function, and most women see improvement after surgical treatment.
The rate of uterine pathology is low in hysterectomy. Dr. Ridgeway highlighted a 2018 study of 24,076 women who underwent hysterectomy for benign indications. The study reported that “prevalence of occult corpus uteri, cervical, and ovarian malignancy was 1.44%, 0.60%, and 0.19%, respectively, among women undergoing hysterectomy and it varied by patient age and surgical route” (Obstet Gynecol. 2018 Apr;131[4]:642-51).
As an alternative, Dr. Ridgeway pointed to hysteropexy, which can be performed as a vaginal, laparoscopic, robot, or open procedure.
She highlighted a 2018 systematic review of pelvic organ prolapse surgeries that provided a meta-analysis and clinical practice guidelines. It found that “uterine-preserving prolapse surgeries improve operating time, blood loss, and risk of mesh exposure, compared with similar surgical routes with concomitant hysterectomy and do not significantly change short-term prolapse outcomes” (Am J Obstet Gynecol. 2018 Aug;219[2]:129-46.e2).
Dr. Ridgeway reported no relevant disclosures. This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
EXPERT ANALYSIS FROM PAGS 2019
Beware nerve injuries in laparoscopic surgery
LAS VEGAS – , and it’s not just nerves below the waist that are vulnerable.
But the risk can be lowered through careful positioning that avoids pressure and over-stretching, the two main causes of nerve injuries in these surgeries, Cleveland Clinic obstetrician-gynecologist and surgeon Tommaso Falcone, MD, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.
Dr. Falcone offered tips about avoiding injuries to these nerves:
Brachial plexus. To avoid injury to this nerve, arms should be tucked and pronated or kept at less than a 90-degree angle from the body. Hyperextension injuries can occur when the arm is outstretched too much, said Dr. Falcone, who recommends putting a cushion under the elbow and wrist.
How can you know if an injury has occurred? The patient will typically wake up with a dropped wrist and numbness in the arm, he said, signs suggesting a stretch injury to the brachial plexus.
Ulnar nerve: Improper tucking of the arms can injure the ulnar nerve and cause numbness and weakness in the fourth and fifth fingers. Dr. Falcone recommends keeping the arms pronated if they’re tucked and supinated if they’re on arm boards. Again, he emphasized placing a cushion under the elbow and wrist.
Femoral nerve: Hyperflexion or hyperextension can compress the femoral nerve under the inguinal ligament and cause it to become ischemic, Dr. Falcone said.
Femoral nerve injury can lead to numbness (in the anterior and medial thigh), decreased patellar reflex, weakness of the quadriceps, and loss of knee extension flexibility. Patients may need to use a wheelchair for a time and undergo physical therapy, he said.
Obdurator nerve: Excessive lateral thigh abduction – outward movement – can stretch this nerve, Dr. Falcone said. Avoid excessive abduction by keeping the thigh-to-thigh angle under 90 degrees, he recommended. (This rule also helps to prevent femoral nerve injury.)
Signs of injury can include numbness on the medial aspect of the thigh and weakness in the adductor muscles. Physical therapy can be helpful, he said.
Sciatic nerve: Beware of hyperflexion of the hips followed by sudden straightening of the knees, he said. According to him, this can occur when candy-cane stirrups are used. Signs of injury can include foot drop and numbness (calf, dorsum, sole, and lateral side of the foot).
Peroneal nerve: Prolonged pressure against the knee can injure this nerve and cause foot drop and numbness (over the lower anterior leg and dorsum of the foot).
Dr. Falcone reports honoraria (Journal of Minimally Invasive Gynecology and Up-To-Date) and federal research funds. This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
LAS VEGAS – , and it’s not just nerves below the waist that are vulnerable.
But the risk can be lowered through careful positioning that avoids pressure and over-stretching, the two main causes of nerve injuries in these surgeries, Cleveland Clinic obstetrician-gynecologist and surgeon Tommaso Falcone, MD, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.
Dr. Falcone offered tips about avoiding injuries to these nerves:
Brachial plexus. To avoid injury to this nerve, arms should be tucked and pronated or kept at less than a 90-degree angle from the body. Hyperextension injuries can occur when the arm is outstretched too much, said Dr. Falcone, who recommends putting a cushion under the elbow and wrist.
How can you know if an injury has occurred? The patient will typically wake up with a dropped wrist and numbness in the arm, he said, signs suggesting a stretch injury to the brachial plexus.
Ulnar nerve: Improper tucking of the arms can injure the ulnar nerve and cause numbness and weakness in the fourth and fifth fingers. Dr. Falcone recommends keeping the arms pronated if they’re tucked and supinated if they’re on arm boards. Again, he emphasized placing a cushion under the elbow and wrist.
Femoral nerve: Hyperflexion or hyperextension can compress the femoral nerve under the inguinal ligament and cause it to become ischemic, Dr. Falcone said.
Femoral nerve injury can lead to numbness (in the anterior and medial thigh), decreased patellar reflex, weakness of the quadriceps, and loss of knee extension flexibility. Patients may need to use a wheelchair for a time and undergo physical therapy, he said.
Obdurator nerve: Excessive lateral thigh abduction – outward movement – can stretch this nerve, Dr. Falcone said. Avoid excessive abduction by keeping the thigh-to-thigh angle under 90 degrees, he recommended. (This rule also helps to prevent femoral nerve injury.)
Signs of injury can include numbness on the medial aspect of the thigh and weakness in the adductor muscles. Physical therapy can be helpful, he said.
Sciatic nerve: Beware of hyperflexion of the hips followed by sudden straightening of the knees, he said. According to him, this can occur when candy-cane stirrups are used. Signs of injury can include foot drop and numbness (calf, dorsum, sole, and lateral side of the foot).
Peroneal nerve: Prolonged pressure against the knee can injure this nerve and cause foot drop and numbness (over the lower anterior leg and dorsum of the foot).
Dr. Falcone reports honoraria (Journal of Minimally Invasive Gynecology and Up-To-Date) and federal research funds. This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
LAS VEGAS – , and it’s not just nerves below the waist that are vulnerable.
But the risk can be lowered through careful positioning that avoids pressure and over-stretching, the two main causes of nerve injuries in these surgeries, Cleveland Clinic obstetrician-gynecologist and surgeon Tommaso Falcone, MD, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.
Dr. Falcone offered tips about avoiding injuries to these nerves:
Brachial plexus. To avoid injury to this nerve, arms should be tucked and pronated or kept at less than a 90-degree angle from the body. Hyperextension injuries can occur when the arm is outstretched too much, said Dr. Falcone, who recommends putting a cushion under the elbow and wrist.
How can you know if an injury has occurred? The patient will typically wake up with a dropped wrist and numbness in the arm, he said, signs suggesting a stretch injury to the brachial plexus.
Ulnar nerve: Improper tucking of the arms can injure the ulnar nerve and cause numbness and weakness in the fourth and fifth fingers. Dr. Falcone recommends keeping the arms pronated if they’re tucked and supinated if they’re on arm boards. Again, he emphasized placing a cushion under the elbow and wrist.
Femoral nerve: Hyperflexion or hyperextension can compress the femoral nerve under the inguinal ligament and cause it to become ischemic, Dr. Falcone said.
Femoral nerve injury can lead to numbness (in the anterior and medial thigh), decreased patellar reflex, weakness of the quadriceps, and loss of knee extension flexibility. Patients may need to use a wheelchair for a time and undergo physical therapy, he said.
Obdurator nerve: Excessive lateral thigh abduction – outward movement – can stretch this nerve, Dr. Falcone said. Avoid excessive abduction by keeping the thigh-to-thigh angle under 90 degrees, he recommended. (This rule also helps to prevent femoral nerve injury.)
Signs of injury can include numbness on the medial aspect of the thigh and weakness in the adductor muscles. Physical therapy can be helpful, he said.
Sciatic nerve: Beware of hyperflexion of the hips followed by sudden straightening of the knees, he said. According to him, this can occur when candy-cane stirrups are used. Signs of injury can include foot drop and numbness (calf, dorsum, sole, and lateral side of the foot).
Peroneal nerve: Prolonged pressure against the knee can injure this nerve and cause foot drop and numbness (over the lower anterior leg and dorsum of the foot).
Dr. Falcone reports honoraria (Journal of Minimally Invasive Gynecology and Up-To-Date) and federal research funds. This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
EXPERT ANALYSIS FROM PAGS 2019
Don’t neglect urinary tract in gynecologic procedures
LAS VEGAS – – but when the time is appropriate, John B. Gebhart, MD, MS, urged.
You don’t need to stop a procedure to fix a bladder injury. Rather, mark the spot with a suture, finish what you are doing, then come back and fix the bladder injury, he advised.
“We need to be thinking [of the]urinary tract all the time in the procedures that we’re doing,” Dr. Gebhart, a urogynecologist and reconstructive pelvic surgeon from the Mayo Clinic, Rochester, Minn, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.
“Can you look at the bladder and see that it’s intact, that ureters are functioning like they should? You don’t need to have the skill set to place stents, but you should be able to look in and know you’re okay leaving the operating room,” he said.
According to Dr. Gebhart, urethral injuries can occur in these procedures: anterior repair, cystoscopy, midurethral sling, and treatment of diverticulitis or Skene’s duct abscess.
He offered these tips about urethral injuries:
- Use catheters, dyes, and urethroscopy to reveal injuries. “Putting in a catheter is great because it helps you identify injury because you can visually see it,” he said. “We can squirt some dye in the urethra and see if it’s leaking out. We can put in a zero-degree scope and do urethroscopy.”
- Consider linking multiple holes in the urethra. “Don’t make individual repairs,” he said. “Connect the holes, making them into one hole that you can fix in one setting.”
- Check your repairs for leakage. “I might take a little indigo carmine or methylene blue in a little [angiocatheter], squirt it down the urethra, and see if I’ve got anything leaking out from my repair site,” he said. “If I do, then I want to go back and repair that so that I’ve got a watertight closure.”
- Consider a catheter after repair. “If you do a repair, you want to place a catheter at the end of the splint in the urethra for 7 to 10 to 14 days to help prevent stricture afterwards.”
Dr. Gebhart also discussed bladder injuries, which he said can occur in anterior repair, cystoscopy, hysterectomy, midurethral slings, sacrocolpopexy, and other procedures.
He offered these tips:
- Use bladder backfilling to detect injury. “We can backfill the bladder with the little methylene blue stain–normal saline to help identify whether you’ve got a leak or an injury,” he said. “[Cystogram] can also be very helpful as well.”
- Don’t stop a hysterectomy to fix a bladder injury. “Mark the hole with a suture, finish the hysterectomy and get it out of the way, then come back and fix the hole in the bladder,” Dr. Gebhart said.
- After repair, drain the bladder with a catheter for 10-14 days. “You’re always better draining through a catheter a little longer than pulling the catheter too soon, putting a stretch on the bladder, and maybe compromising your repair,” he said.
He recommended performing a quick cystogram before pulling the catheter to make sure there’s no leak.
Dr. Gebhart disclosed consultant (Hologic) and advisory board (UroCure) relationships and royalties (UpToDate, Elsevier).
This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
LAS VEGAS – – but when the time is appropriate, John B. Gebhart, MD, MS, urged.
You don’t need to stop a procedure to fix a bladder injury. Rather, mark the spot with a suture, finish what you are doing, then come back and fix the bladder injury, he advised.
“We need to be thinking [of the]urinary tract all the time in the procedures that we’re doing,” Dr. Gebhart, a urogynecologist and reconstructive pelvic surgeon from the Mayo Clinic, Rochester, Minn, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.
“Can you look at the bladder and see that it’s intact, that ureters are functioning like they should? You don’t need to have the skill set to place stents, but you should be able to look in and know you’re okay leaving the operating room,” he said.
According to Dr. Gebhart, urethral injuries can occur in these procedures: anterior repair, cystoscopy, midurethral sling, and treatment of diverticulitis or Skene’s duct abscess.
He offered these tips about urethral injuries:
- Use catheters, dyes, and urethroscopy to reveal injuries. “Putting in a catheter is great because it helps you identify injury because you can visually see it,” he said. “We can squirt some dye in the urethra and see if it’s leaking out. We can put in a zero-degree scope and do urethroscopy.”
- Consider linking multiple holes in the urethra. “Don’t make individual repairs,” he said. “Connect the holes, making them into one hole that you can fix in one setting.”
- Check your repairs for leakage. “I might take a little indigo carmine or methylene blue in a little [angiocatheter], squirt it down the urethra, and see if I’ve got anything leaking out from my repair site,” he said. “If I do, then I want to go back and repair that so that I’ve got a watertight closure.”
- Consider a catheter after repair. “If you do a repair, you want to place a catheter at the end of the splint in the urethra for 7 to 10 to 14 days to help prevent stricture afterwards.”
Dr. Gebhart also discussed bladder injuries, which he said can occur in anterior repair, cystoscopy, hysterectomy, midurethral slings, sacrocolpopexy, and other procedures.
He offered these tips:
- Use bladder backfilling to detect injury. “We can backfill the bladder with the little methylene blue stain–normal saline to help identify whether you’ve got a leak or an injury,” he said. “[Cystogram] can also be very helpful as well.”
- Don’t stop a hysterectomy to fix a bladder injury. “Mark the hole with a suture, finish the hysterectomy and get it out of the way, then come back and fix the hole in the bladder,” Dr. Gebhart said.
- After repair, drain the bladder with a catheter for 10-14 days. “You’re always better draining through a catheter a little longer than pulling the catheter too soon, putting a stretch on the bladder, and maybe compromising your repair,” he said.
He recommended performing a quick cystogram before pulling the catheter to make sure there’s no leak.
Dr. Gebhart disclosed consultant (Hologic) and advisory board (UroCure) relationships and royalties (UpToDate, Elsevier).
This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
LAS VEGAS – – but when the time is appropriate, John B. Gebhart, MD, MS, urged.
You don’t need to stop a procedure to fix a bladder injury. Rather, mark the spot with a suture, finish what you are doing, then come back and fix the bladder injury, he advised.
“We need to be thinking [of the]urinary tract all the time in the procedures that we’re doing,” Dr. Gebhart, a urogynecologist and reconstructive pelvic surgeon from the Mayo Clinic, Rochester, Minn, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.
“Can you look at the bladder and see that it’s intact, that ureters are functioning like they should? You don’t need to have the skill set to place stents, but you should be able to look in and know you’re okay leaving the operating room,” he said.
According to Dr. Gebhart, urethral injuries can occur in these procedures: anterior repair, cystoscopy, midurethral sling, and treatment of diverticulitis or Skene’s duct abscess.
He offered these tips about urethral injuries:
- Use catheters, dyes, and urethroscopy to reveal injuries. “Putting in a catheter is great because it helps you identify injury because you can visually see it,” he said. “We can squirt some dye in the urethra and see if it’s leaking out. We can put in a zero-degree scope and do urethroscopy.”
- Consider linking multiple holes in the urethra. “Don’t make individual repairs,” he said. “Connect the holes, making them into one hole that you can fix in one setting.”
- Check your repairs for leakage. “I might take a little indigo carmine or methylene blue in a little [angiocatheter], squirt it down the urethra, and see if I’ve got anything leaking out from my repair site,” he said. “If I do, then I want to go back and repair that so that I’ve got a watertight closure.”
- Consider a catheter after repair. “If you do a repair, you want to place a catheter at the end of the splint in the urethra for 7 to 10 to 14 days to help prevent stricture afterwards.”
Dr. Gebhart also discussed bladder injuries, which he said can occur in anterior repair, cystoscopy, hysterectomy, midurethral slings, sacrocolpopexy, and other procedures.
He offered these tips:
- Use bladder backfilling to detect injury. “We can backfill the bladder with the little methylene blue stain–normal saline to help identify whether you’ve got a leak or an injury,” he said. “[Cystogram] can also be very helpful as well.”
- Don’t stop a hysterectomy to fix a bladder injury. “Mark the hole with a suture, finish the hysterectomy and get it out of the way, then come back and fix the hole in the bladder,” Dr. Gebhart said.
- After repair, drain the bladder with a catheter for 10-14 days. “You’re always better draining through a catheter a little longer than pulling the catheter too soon, putting a stretch on the bladder, and maybe compromising your repair,” he said.
He recommended performing a quick cystogram before pulling the catheter to make sure there’s no leak.
Dr. Gebhart disclosed consultant (Hologic) and advisory board (UroCure) relationships and royalties (UpToDate, Elsevier).
This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
EXPERT ANALYSIS FROM PAGS 2019
Beware the dangers of nerve injury in vaginal surgery
LAS VEGAS – a pelvic surgeon urged colleagues.
“It’s a very high medical and legal risk. You have to think about the various nerves that can be influenced,” urogynecologist Mickey M. Karram, MD, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.
Dr. Karram, director of urogynecology and reconstructive surgery at the Christ Hospital in Cincinnati and clinical professor of obstetrics and gynecology at the University of Cincinnati, offered these pearls:
- Understand the anatomy of nerves at risk. These include the ilioinguinal nerve, obturator neurovascular bundle, and pudendal nerve.
- Position the patient correctly. The buttocks should be at edge of table, Dr. Karram said, and there should be slight extension and lateral rotation of the thigh. Beware of compression of the lateral knee.
- Avoid compression from stirrups. If you still use candy-cane stirrups, he said, you can get compression along the lateral aspect of the knee. “You can [get] common perineal nerve injuries. You can also get femoral nerve injuries that are stretch injuries and over-extension injuries as well. Just be careful about this.” Dr. Karram said he prefers fin-type stirrups such as the Allen Yellofin brand. Also, he said, avoid compression injuries that result when there are too many people between the patient’s legs and someone leans on the thighs, he said.
- Free the retractor in abdominal procedures. “If you’re operating abdominally and use retractors, free the retractor at times,” he said. Otherwise, “you can get injuries to the genitofemoral nerve and the femoral nerve itself.”
- Beware buttock pain after sacrospinous fixation. “About 15%-20% of the time, you’ll get extreme buttock pain,” Dr. Karram said. “Assuming the buttock pain doesn’t radiate anywhere and doesn’t go down the leg, it’s definitely not a problem. If it goes down the leg, then you have to think about things like deligating pretty quickly.”
Dr. Karram disclosed consulting (Coloplast and Cynosure/Hologic) and speaker (Allergan, Astellas, Coloplast, and Cynosure/Hologic) relationships. He has royalties from Fidelis Medical and LumeNXT.
This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
LAS VEGAS – a pelvic surgeon urged colleagues.
“It’s a very high medical and legal risk. You have to think about the various nerves that can be influenced,” urogynecologist Mickey M. Karram, MD, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.
Dr. Karram, director of urogynecology and reconstructive surgery at the Christ Hospital in Cincinnati and clinical professor of obstetrics and gynecology at the University of Cincinnati, offered these pearls:
- Understand the anatomy of nerves at risk. These include the ilioinguinal nerve, obturator neurovascular bundle, and pudendal nerve.
- Position the patient correctly. The buttocks should be at edge of table, Dr. Karram said, and there should be slight extension and lateral rotation of the thigh. Beware of compression of the lateral knee.
- Avoid compression from stirrups. If you still use candy-cane stirrups, he said, you can get compression along the lateral aspect of the knee. “You can [get] common perineal nerve injuries. You can also get femoral nerve injuries that are stretch injuries and over-extension injuries as well. Just be careful about this.” Dr. Karram said he prefers fin-type stirrups such as the Allen Yellofin brand. Also, he said, avoid compression injuries that result when there are too many people between the patient’s legs and someone leans on the thighs, he said.
- Free the retractor in abdominal procedures. “If you’re operating abdominally and use retractors, free the retractor at times,” he said. Otherwise, “you can get injuries to the genitofemoral nerve and the femoral nerve itself.”
- Beware buttock pain after sacrospinous fixation. “About 15%-20% of the time, you’ll get extreme buttock pain,” Dr. Karram said. “Assuming the buttock pain doesn’t radiate anywhere and doesn’t go down the leg, it’s definitely not a problem. If it goes down the leg, then you have to think about things like deligating pretty quickly.”
Dr. Karram disclosed consulting (Coloplast and Cynosure/Hologic) and speaker (Allergan, Astellas, Coloplast, and Cynosure/Hologic) relationships. He has royalties from Fidelis Medical and LumeNXT.
This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
LAS VEGAS – a pelvic surgeon urged colleagues.
“It’s a very high medical and legal risk. You have to think about the various nerves that can be influenced,” urogynecologist Mickey M. Karram, MD, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.
Dr. Karram, director of urogynecology and reconstructive surgery at the Christ Hospital in Cincinnati and clinical professor of obstetrics and gynecology at the University of Cincinnati, offered these pearls:
- Understand the anatomy of nerves at risk. These include the ilioinguinal nerve, obturator neurovascular bundle, and pudendal nerve.
- Position the patient correctly. The buttocks should be at edge of table, Dr. Karram said, and there should be slight extension and lateral rotation of the thigh. Beware of compression of the lateral knee.
- Avoid compression from stirrups. If you still use candy-cane stirrups, he said, you can get compression along the lateral aspect of the knee. “You can [get] common perineal nerve injuries. You can also get femoral nerve injuries that are stretch injuries and over-extension injuries as well. Just be careful about this.” Dr. Karram said he prefers fin-type stirrups such as the Allen Yellofin brand. Also, he said, avoid compression injuries that result when there are too many people between the patient’s legs and someone leans on the thighs, he said.
- Free the retractor in abdominal procedures. “If you’re operating abdominally and use retractors, free the retractor at times,” he said. Otherwise, “you can get injuries to the genitofemoral nerve and the femoral nerve itself.”
- Beware buttock pain after sacrospinous fixation. “About 15%-20% of the time, you’ll get extreme buttock pain,” Dr. Karram said. “Assuming the buttock pain doesn’t radiate anywhere and doesn’t go down the leg, it’s definitely not a problem. If it goes down the leg, then you have to think about things like deligating pretty quickly.”
Dr. Karram disclosed consulting (Coloplast and Cynosure/Hologic) and speaker (Allergan, Astellas, Coloplast, and Cynosure/Hologic) relationships. He has royalties from Fidelis Medical and LumeNXT.
This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
EXPERT ANALYSIS FROM PAGS 2019
Pelvic organ prolapse surgery isn’t as ‘simple’ as you think
LAS VEGAS – Surgical repair of pelvic organ prolapse often may seem like an uncomplicated procedure. But many factors play roles into decisions, and surgeons around the world vary widely in how they handle the operations, Mark D. Walters, MD, told colleagues at the Pelvic Anatomy and Gynecologic Surgery Symposium.
“These prolapse repairs seem relatively simple at first, but they’re not simple at all,” he said.
Questions to ask prior to surgery
It’s important to first answer a number of questions, said Dr. Walters, professor and vice-chair of gynecology at the Cleveland Clinic. “When you see a patient like this, you may not realize how many decisions you’re making.”
These questions include:
- Is the patient sexually active or planning to be?
- Has she had a hysterectomy, and or is one necessary? If so, how should it be done? What does the patient think about a hysterectomy?
- Should the prolapse procedure be performed vaginally, open, laparoscopically, or robotically?
- Is adding a graft advisable? What kind?
- Should there be a sling to prevent stress urinary incontinence?”
Worldwide differences in surgical technique choice
Dr. Walters talked to colleagues from several nations and learned about these variations in surgical techniques.
Chinese surgeons use a variety of techniques with transvaginal mesh (TVM). Their use is more common in more populated cities because of the effect of medical education; native tissue procedures are more common in less-populated regions that are considered “backward.”
TVM with hysteropexy (“apical sling”) also is common in Latin America, while Middle Eastern surgeons have little training in female pelvic medicine and reconstructive surgery.
In Europe, France embraces mesh surgery and laparoscopy, while the United Kingdom has “completely abandoned” mesh surgery, and the Netherlands rarely uses it in favor of vaginal procedures.
In the United States, he said, TVM is “discouraged” while a variety of other procedures are used.
What procedures should surgeons embrace? There are many topics of debate, Dr. Walters said, including type of transvaginal repair (native tissue or mesh-augmented or sacrocolpopexy?), repair of “defects” in the vagina (even if they’re nonsymptomatic?) and the removal of the uterus (yes or no?).
Dr. Walters pointed to several explanations for this variation, including lack of high-quality research, confirmation bias, economic conflicts – surgeons are in the business of surgery, after all – and lack of insight into what women prefer.
Consider patient choice
In a survey, Dr. Walters polled women in their 50s with this question: “How much do you value your uterus?” Three women, he said, had widely varied opinions on a scale of 1-10, with one at 10 and another at 0.
“A doctor doesn’t know this and doesn’t have a way to ask, and the doctor has [his/her] own opinion about the value of the uterus,” he said. “Shouldn’t we know what patients think?”
How to measure success
He offered these tips about measuring success:
- Focus on symptomatic cure more than clinical cure.
- Remember that perfect anatomic support isn’t linked to health-related quality of life, and some loss of anatomic support is normal.
- Understand that commonly used definitions of anatomic success often aren’t clinically relevant.
Dr. Walters’ disclosures: royalties (Elsevier, UpToDate), website/lecturer (International Academy of Pelvic Surgery), and website editor (Foundation for Female Health Awareness).
This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
LAS VEGAS – Surgical repair of pelvic organ prolapse often may seem like an uncomplicated procedure. But many factors play roles into decisions, and surgeons around the world vary widely in how they handle the operations, Mark D. Walters, MD, told colleagues at the Pelvic Anatomy and Gynecologic Surgery Symposium.
“These prolapse repairs seem relatively simple at first, but they’re not simple at all,” he said.
Questions to ask prior to surgery
It’s important to first answer a number of questions, said Dr. Walters, professor and vice-chair of gynecology at the Cleveland Clinic. “When you see a patient like this, you may not realize how many decisions you’re making.”
These questions include:
- Is the patient sexually active or planning to be?
- Has she had a hysterectomy, and or is one necessary? If so, how should it be done? What does the patient think about a hysterectomy?
- Should the prolapse procedure be performed vaginally, open, laparoscopically, or robotically?
- Is adding a graft advisable? What kind?
- Should there be a sling to prevent stress urinary incontinence?”
Worldwide differences in surgical technique choice
Dr. Walters talked to colleagues from several nations and learned about these variations in surgical techniques.
Chinese surgeons use a variety of techniques with transvaginal mesh (TVM). Their use is more common in more populated cities because of the effect of medical education; native tissue procedures are more common in less-populated regions that are considered “backward.”
TVM with hysteropexy (“apical sling”) also is common in Latin America, while Middle Eastern surgeons have little training in female pelvic medicine and reconstructive surgery.
In Europe, France embraces mesh surgery and laparoscopy, while the United Kingdom has “completely abandoned” mesh surgery, and the Netherlands rarely uses it in favor of vaginal procedures.
In the United States, he said, TVM is “discouraged” while a variety of other procedures are used.
What procedures should surgeons embrace? There are many topics of debate, Dr. Walters said, including type of transvaginal repair (native tissue or mesh-augmented or sacrocolpopexy?), repair of “defects” in the vagina (even if they’re nonsymptomatic?) and the removal of the uterus (yes or no?).
Dr. Walters pointed to several explanations for this variation, including lack of high-quality research, confirmation bias, economic conflicts – surgeons are in the business of surgery, after all – and lack of insight into what women prefer.
Consider patient choice
In a survey, Dr. Walters polled women in their 50s with this question: “How much do you value your uterus?” Three women, he said, had widely varied opinions on a scale of 1-10, with one at 10 and another at 0.
“A doctor doesn’t know this and doesn’t have a way to ask, and the doctor has [his/her] own opinion about the value of the uterus,” he said. “Shouldn’t we know what patients think?”
How to measure success
He offered these tips about measuring success:
- Focus on symptomatic cure more than clinical cure.
- Remember that perfect anatomic support isn’t linked to health-related quality of life, and some loss of anatomic support is normal.
- Understand that commonly used definitions of anatomic success often aren’t clinically relevant.
Dr. Walters’ disclosures: royalties (Elsevier, UpToDate), website/lecturer (International Academy of Pelvic Surgery), and website editor (Foundation for Female Health Awareness).
This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
LAS VEGAS – Surgical repair of pelvic organ prolapse often may seem like an uncomplicated procedure. But many factors play roles into decisions, and surgeons around the world vary widely in how they handle the operations, Mark D. Walters, MD, told colleagues at the Pelvic Anatomy and Gynecologic Surgery Symposium.
“These prolapse repairs seem relatively simple at first, but they’re not simple at all,” he said.
Questions to ask prior to surgery
It’s important to first answer a number of questions, said Dr. Walters, professor and vice-chair of gynecology at the Cleveland Clinic. “When you see a patient like this, you may not realize how many decisions you’re making.”
These questions include:
- Is the patient sexually active or planning to be?
- Has she had a hysterectomy, and or is one necessary? If so, how should it be done? What does the patient think about a hysterectomy?
- Should the prolapse procedure be performed vaginally, open, laparoscopically, or robotically?
- Is adding a graft advisable? What kind?
- Should there be a sling to prevent stress urinary incontinence?”
Worldwide differences in surgical technique choice
Dr. Walters talked to colleagues from several nations and learned about these variations in surgical techniques.
Chinese surgeons use a variety of techniques with transvaginal mesh (TVM). Their use is more common in more populated cities because of the effect of medical education; native tissue procedures are more common in less-populated regions that are considered “backward.”
TVM with hysteropexy (“apical sling”) also is common in Latin America, while Middle Eastern surgeons have little training in female pelvic medicine and reconstructive surgery.
In Europe, France embraces mesh surgery and laparoscopy, while the United Kingdom has “completely abandoned” mesh surgery, and the Netherlands rarely uses it in favor of vaginal procedures.
In the United States, he said, TVM is “discouraged” while a variety of other procedures are used.
What procedures should surgeons embrace? There are many topics of debate, Dr. Walters said, including type of transvaginal repair (native tissue or mesh-augmented or sacrocolpopexy?), repair of “defects” in the vagina (even if they’re nonsymptomatic?) and the removal of the uterus (yes or no?).
Dr. Walters pointed to several explanations for this variation, including lack of high-quality research, confirmation bias, economic conflicts – surgeons are in the business of surgery, after all – and lack of insight into what women prefer.
Consider patient choice
In a survey, Dr. Walters polled women in their 50s with this question: “How much do you value your uterus?” Three women, he said, had widely varied opinions on a scale of 1-10, with one at 10 and another at 0.
“A doctor doesn’t know this and doesn’t have a way to ask, and the doctor has [his/her] own opinion about the value of the uterus,” he said. “Shouldn’t we know what patients think?”
How to measure success
He offered these tips about measuring success:
- Focus on symptomatic cure more than clinical cure.
- Remember that perfect anatomic support isn’t linked to health-related quality of life, and some loss of anatomic support is normal.
- Understand that commonly used definitions of anatomic success often aren’t clinically relevant.
Dr. Walters’ disclosures: royalties (Elsevier, UpToDate), website/lecturer (International Academy of Pelvic Surgery), and website editor (Foundation for Female Health Awareness).
This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
EXPERT ANALYSIS FROM PAGS 2019
Emergency physicians not yet embracing buprenorphine for opioid users
SAN DIEGO – Emergency physicians can be persuaded to follow a recommended strategy to prescribe buprenorphine to patients with opioid addictions and to refer them to follow-up care, Kathryn F. Hawk, MD, said at the annual meeting of the American Academy of Addiction Psychiatry.
“People are willing to change their practices and evolve as long as they have the support to do so,” Dr. Hawk, assistant professor of emergency medicine at Yale University, New Haven, Conn., said at the meeting.
Dr. Hawk highlighted a landmark 2015 study led by Yale colleagues that compared three strategies to treating patients with opioid use disorder in the emergency department. Researchers randomly assigned 329 patients to 1) referral to treatment; 2) brief intervention and facilitated referral to community-based treatment services; and 3) emergency department-initiated treatment with buprenorphine/naloxone (Suboxone) plus referral to primary care for 10-week follow-up.
At 30 days, 78% of patients in the third group were in addiction treatment vs. 37% in the first group and 45% in the second group. (P less than .001). However, the percentage of patients in the groups who had negative urine screens for opioids were not statistically different (JAMA. 2015. Apr 28;313[16]:1636-44).
Both the American College of Emergency Physicians (ACEP) and the American College of Medical Toxicology have endorsed the use of buprenorphine in the ED “as a bridge to long-term addiction treatment,” said Dr. Hawk, who also is affiliated with Yale New Haven Hospital.
Emergency department physicians, however, have been reluctant to start prescribing buprenorphine and get more deeply involved in referrals to care, said E. Jennifer Edelman, MD, associate professor of general internal medicine at Yale. She described the results of a 2017-2019 survey of 268 medical professionals at urban emergency departments in Seattle, Cincinnati, New York City, and Baltimore. Only 20% of the survey respondents said they were “ready” to initiate the buprenorphine treatment protocol.
Researchers also held focus groups with 74 clinicians who offered insight into their hesitation. “That’s not something that we’re even really taught in medical school and certainly not in our training as emergency physicians,” one faculty member said. “It is this detox black box across the street, and that’s how it is in many places.”
Another faculty member expressed regret about the current system: “I feel like this is particularly vulnerable patient population [and] we’re just saying, ‘Here’s a sheet. Call some numbers. Good luck.’ That’s the way it feels when I discharge these folks.” And a resident said: “We can’t provide all of that care up front. It’s just too time-consuming, and there are other patients to see.”
But not all of the findings were grim.
Dr. Edelman said.
According to her, strategies aimed at boosting the Suboxone approach include establishing protocols, and providing leadership support and resources. Addiction psychiatrists also can be helpful, she said.
“Let’s think about partnering together to bridge that gap,” she said. One idea: Invite emergency physicians to observe a treatment initiation.
“Showing how you counsel patients to start medication at home would be really a wonderful way to facilitate practices in the emergency department,” she said.
Another idea, she said, is to “give them feedback on their patients.” If an emergency physician refers a patient and they walk in the door, “let them know how they did. That’s going to be really, really powerful.”
ACEP and the American Society of Addiction Medicine have created a tool aimed at helping facilitate the use of buprenorphine and naloxone in the emergency department.
Dr. Hawk and Dr. Edelman reported no relevant disclosures.
SAN DIEGO – Emergency physicians can be persuaded to follow a recommended strategy to prescribe buprenorphine to patients with opioid addictions and to refer them to follow-up care, Kathryn F. Hawk, MD, said at the annual meeting of the American Academy of Addiction Psychiatry.
“People are willing to change their practices and evolve as long as they have the support to do so,” Dr. Hawk, assistant professor of emergency medicine at Yale University, New Haven, Conn., said at the meeting.
Dr. Hawk highlighted a landmark 2015 study led by Yale colleagues that compared three strategies to treating patients with opioid use disorder in the emergency department. Researchers randomly assigned 329 patients to 1) referral to treatment; 2) brief intervention and facilitated referral to community-based treatment services; and 3) emergency department-initiated treatment with buprenorphine/naloxone (Suboxone) plus referral to primary care for 10-week follow-up.
At 30 days, 78% of patients in the third group were in addiction treatment vs. 37% in the first group and 45% in the second group. (P less than .001). However, the percentage of patients in the groups who had negative urine screens for opioids were not statistically different (JAMA. 2015. Apr 28;313[16]:1636-44).
Both the American College of Emergency Physicians (ACEP) and the American College of Medical Toxicology have endorsed the use of buprenorphine in the ED “as a bridge to long-term addiction treatment,” said Dr. Hawk, who also is affiliated with Yale New Haven Hospital.
Emergency department physicians, however, have been reluctant to start prescribing buprenorphine and get more deeply involved in referrals to care, said E. Jennifer Edelman, MD, associate professor of general internal medicine at Yale. She described the results of a 2017-2019 survey of 268 medical professionals at urban emergency departments in Seattle, Cincinnati, New York City, and Baltimore. Only 20% of the survey respondents said they were “ready” to initiate the buprenorphine treatment protocol.
Researchers also held focus groups with 74 clinicians who offered insight into their hesitation. “That’s not something that we’re even really taught in medical school and certainly not in our training as emergency physicians,” one faculty member said. “It is this detox black box across the street, and that’s how it is in many places.”
Another faculty member expressed regret about the current system: “I feel like this is particularly vulnerable patient population [and] we’re just saying, ‘Here’s a sheet. Call some numbers. Good luck.’ That’s the way it feels when I discharge these folks.” And a resident said: “We can’t provide all of that care up front. It’s just too time-consuming, and there are other patients to see.”
But not all of the findings were grim.
Dr. Edelman said.
According to her, strategies aimed at boosting the Suboxone approach include establishing protocols, and providing leadership support and resources. Addiction psychiatrists also can be helpful, she said.
“Let’s think about partnering together to bridge that gap,” she said. One idea: Invite emergency physicians to observe a treatment initiation.
“Showing how you counsel patients to start medication at home would be really a wonderful way to facilitate practices in the emergency department,” she said.
Another idea, she said, is to “give them feedback on their patients.” If an emergency physician refers a patient and they walk in the door, “let them know how they did. That’s going to be really, really powerful.”
ACEP and the American Society of Addiction Medicine have created a tool aimed at helping facilitate the use of buprenorphine and naloxone in the emergency department.
Dr. Hawk and Dr. Edelman reported no relevant disclosures.
SAN DIEGO – Emergency physicians can be persuaded to follow a recommended strategy to prescribe buprenorphine to patients with opioid addictions and to refer them to follow-up care, Kathryn F. Hawk, MD, said at the annual meeting of the American Academy of Addiction Psychiatry.
“People are willing to change their practices and evolve as long as they have the support to do so,” Dr. Hawk, assistant professor of emergency medicine at Yale University, New Haven, Conn., said at the meeting.
Dr. Hawk highlighted a landmark 2015 study led by Yale colleagues that compared three strategies to treating patients with opioid use disorder in the emergency department. Researchers randomly assigned 329 patients to 1) referral to treatment; 2) brief intervention and facilitated referral to community-based treatment services; and 3) emergency department-initiated treatment with buprenorphine/naloxone (Suboxone) plus referral to primary care for 10-week follow-up.
At 30 days, 78% of patients in the third group were in addiction treatment vs. 37% in the first group and 45% in the second group. (P less than .001). However, the percentage of patients in the groups who had negative urine screens for opioids were not statistically different (JAMA. 2015. Apr 28;313[16]:1636-44).
Both the American College of Emergency Physicians (ACEP) and the American College of Medical Toxicology have endorsed the use of buprenorphine in the ED “as a bridge to long-term addiction treatment,” said Dr. Hawk, who also is affiliated with Yale New Haven Hospital.
Emergency department physicians, however, have been reluctant to start prescribing buprenorphine and get more deeply involved in referrals to care, said E. Jennifer Edelman, MD, associate professor of general internal medicine at Yale. She described the results of a 2017-2019 survey of 268 medical professionals at urban emergency departments in Seattle, Cincinnati, New York City, and Baltimore. Only 20% of the survey respondents said they were “ready” to initiate the buprenorphine treatment protocol.
Researchers also held focus groups with 74 clinicians who offered insight into their hesitation. “That’s not something that we’re even really taught in medical school and certainly not in our training as emergency physicians,” one faculty member said. “It is this detox black box across the street, and that’s how it is in many places.”
Another faculty member expressed regret about the current system: “I feel like this is particularly vulnerable patient population [and] we’re just saying, ‘Here’s a sheet. Call some numbers. Good luck.’ That’s the way it feels when I discharge these folks.” And a resident said: “We can’t provide all of that care up front. It’s just too time-consuming, and there are other patients to see.”
But not all of the findings were grim.
Dr. Edelman said.
According to her, strategies aimed at boosting the Suboxone approach include establishing protocols, and providing leadership support and resources. Addiction psychiatrists also can be helpful, she said.
“Let’s think about partnering together to bridge that gap,” she said. One idea: Invite emergency physicians to observe a treatment initiation.
“Showing how you counsel patients to start medication at home would be really a wonderful way to facilitate practices in the emergency department,” she said.
Another idea, she said, is to “give them feedback on their patients.” If an emergency physician refers a patient and they walk in the door, “let them know how they did. That’s going to be really, really powerful.”
ACEP and the American Society of Addiction Medicine have created a tool aimed at helping facilitate the use of buprenorphine and naloxone in the emergency department.
Dr. Hawk and Dr. Edelman reported no relevant disclosures.
REPORTING FROM AAAP 2019