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Let’s learn from our experience
COVID-19 has revealed the worst and best of our country. Some have used it to validate their racism (my Korean-born son keeps me apprised of the Asian prejudice he has experienced) and a few leaders have made policy decisions based on ideology and not science, with disastrous consequences. That said, no world threat since those 13 days in October 1962 has demonstrated so decisively our interconnectedness. The best of our country has been demonstrated by our frontline health care workers, grocery clerks, people who deliver our packages, and volunteers who help feed our fellow citizens.
We are witnessing consequences of long-term health disparities that America continues to condone. Current hotspots are clustered in cities with high population density where people (usually minorities) lack ready access to health care and live with barriers to preventive care (poor nutritional options and a lack of sufficient primary care). We have underfunded our public health system and allowed politicians to ignore science. When testing was not prioritized initially, we lost the ability to isolate and trace index cases. If we want to honor those people who have died, let’s learn from our experience and change our priorities.
Private practices and health systems alike are being financially devastated. We are seeing massive numbers of people furloughed or laid off, as practices see drastic revenue loss. The transition to virtual health (video visits, remote patient monitoring) has been breath-taking with real implications about future needs for bricks and mortar. These changes in care delivery will be sustained in the future. Practice acquisitions have stopped, planned private equity exits are on hold, and the job market for graduating fellows will be challenging for the next 2 years. Now is a time for our GI societies to come together and find solutions for these problems so that our specialty can remain viable.
John I. Allen, MD, MBA, AGAF
Editor in Chief
COVID-19 has revealed the worst and best of our country. Some have used it to validate their racism (my Korean-born son keeps me apprised of the Asian prejudice he has experienced) and a few leaders have made policy decisions based on ideology and not science, with disastrous consequences. That said, no world threat since those 13 days in October 1962 has demonstrated so decisively our interconnectedness. The best of our country has been demonstrated by our frontline health care workers, grocery clerks, people who deliver our packages, and volunteers who help feed our fellow citizens.
We are witnessing consequences of long-term health disparities that America continues to condone. Current hotspots are clustered in cities with high population density where people (usually minorities) lack ready access to health care and live with barriers to preventive care (poor nutritional options and a lack of sufficient primary care). We have underfunded our public health system and allowed politicians to ignore science. When testing was not prioritized initially, we lost the ability to isolate and trace index cases. If we want to honor those people who have died, let’s learn from our experience and change our priorities.
Private practices and health systems alike are being financially devastated. We are seeing massive numbers of people furloughed or laid off, as practices see drastic revenue loss. The transition to virtual health (video visits, remote patient monitoring) has been breath-taking with real implications about future needs for bricks and mortar. These changes in care delivery will be sustained in the future. Practice acquisitions have stopped, planned private equity exits are on hold, and the job market for graduating fellows will be challenging for the next 2 years. Now is a time for our GI societies to come together and find solutions for these problems so that our specialty can remain viable.
John I. Allen, MD, MBA, AGAF
Editor in Chief
COVID-19 has revealed the worst and best of our country. Some have used it to validate their racism (my Korean-born son keeps me apprised of the Asian prejudice he has experienced) and a few leaders have made policy decisions based on ideology and not science, with disastrous consequences. That said, no world threat since those 13 days in October 1962 has demonstrated so decisively our interconnectedness. The best of our country has been demonstrated by our frontline health care workers, grocery clerks, people who deliver our packages, and volunteers who help feed our fellow citizens.
We are witnessing consequences of long-term health disparities that America continues to condone. Current hotspots are clustered in cities with high population density where people (usually minorities) lack ready access to health care and live with barriers to preventive care (poor nutritional options and a lack of sufficient primary care). We have underfunded our public health system and allowed politicians to ignore science. When testing was not prioritized initially, we lost the ability to isolate and trace index cases. If we want to honor those people who have died, let’s learn from our experience and change our priorities.
Private practices and health systems alike are being financially devastated. We are seeing massive numbers of people furloughed or laid off, as practices see drastic revenue loss. The transition to virtual health (video visits, remote patient monitoring) has been breath-taking with real implications about future needs for bricks and mortar. These changes in care delivery will be sustained in the future. Practice acquisitions have stopped, planned private equity exits are on hold, and the job market for graduating fellows will be challenging for the next 2 years. Now is a time for our GI societies to come together and find solutions for these problems so that our specialty can remain viable.
John I. Allen, MD, MBA, AGAF
Editor in Chief
Remaining connected
Dear colleagues,
We bring you the spring edition of The New Gastroenterologist amid a backdrop of uncertainty in the setting of the novel coronavirus disease 2019 (COVID-19) pandemic. As physicians, we are poised to view this unprecedented situation in modern medicine through a unique lens. At the time of this writing, we are experiencing significant interruptions to our work as gastroenterologists coupled with the possibility of reassignments in order to care for COVID-19 patients to meet the demand of the precipitous rise in cases. Weighing these responsibilities, along with the heightened concern about the threat of exposure to ourselves and our families, is a formidable challenge, but one that we can navigate together.
My sincere hope is that this quarter’s newsletter can provide, at the very least, a brief reprieve from some of these constant stressors. It is during times like this that remaining connected to our colleagues through digital platforms and publications such as The New Gastroenterologist remains of utmost importance.
That being said, I felt it was prudent to first address some common concerns regarding the COVID-19 pandemic, specifically, its implications within gastroenterology. In conjunction with Krishna Rao (University of Michigan), a specialist in infectious diseases, we attempt to shed some light on what is a rapidly evolving situation. For more resources from the American Gastroenterological Association (AGA) on up-to-date clinical guidance and research, you can also visit https://www.gastro.org/practice-guidance/practice-updates/covid-19.
Moving on to our “In Focus” feature, Thangam Ventakesan and Harrison Mooers (Medical College of Wisconsin) provide a comprehensive overview of cyclic vomiting syndrome. This is a valuable read as cyclic vomiting syndrome has been gaining increased recognition among adults, and Dr. Ventakesan and Dr. Mooers elucidate a thorough approach to the diagnosis and treatment of this disorder.
A facet of endoscopy that is extremely important, but frequently overlooked, is ergonomics. Manish Singla and Jared Magee (Walter Reed National Military Medical Center) compile a high-yield list of recommendations on the best practices to preserve our own safety and health as endoscopists.
We continue our medical ethics series with Jennifer Wang and Andrew Aronsohn (University of Chicago) who offer a thought-provoking discussion on the role of early liver transplantation for alcoholic hepatitis, including an analysis of the medical, psychosocial, and ethical considerations.
Also in this issue, Animesh Jain (University of North Carolina) gives us some excellent financial advice on student loan management, outlining a basic strategy of repayment with clear explanations of the available options including refinancing, public service loan forgiveness, and income-driven repayment.
Dilhana Badurdeen (Johns Hopkins), Aline Charabaty Pishvaian (Sibley Memorial Hospital), Miguel Malespin (University of South Florida), Ibironke Oduyebo (Midatlantic Permanente Medical Group), and Sandra Quezada (University of Maryland) give us an in-depth summary of the efforts of the AGA’s Diversity Committee, including publications, events, and future initiatives.
This quarter’s DHPA Private Practice Perspectives series features Paul Berggreen (Arizona Digestive Health), who reviews the advantages and disadvantages of pathology lab ownership as a gastroenterologist. Lastly, Sarah Ordway, Dawn Torres, Manish Singla, and Adam Tritsch (Walter Reed National Military Medical Center) broach the issue of fellowship burnout by providing guidance on how to identify signs and those at risk in addition to providing tangible solutions that any fellowship can incorporate.
Although the cancellation of the upcoming DDW meetings in Chicago is a disappointment, I hope that we can all take this time to prioritize the well-being of ourselves and our communities until we meet again.
As always, if you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]), or Ryan Farrell ([email protected]), managing editor of TNG.
Best wishes to stay safe and healthy.
Vijaya L. Rao, MD
Editor in Chief
Dr. Rao is assistant professor of medicine, University of Chicago, section of gastroenterology, hepatology & nutrition.
Dear colleagues,
We bring you the spring edition of The New Gastroenterologist amid a backdrop of uncertainty in the setting of the novel coronavirus disease 2019 (COVID-19) pandemic. As physicians, we are poised to view this unprecedented situation in modern medicine through a unique lens. At the time of this writing, we are experiencing significant interruptions to our work as gastroenterologists coupled with the possibility of reassignments in order to care for COVID-19 patients to meet the demand of the precipitous rise in cases. Weighing these responsibilities, along with the heightened concern about the threat of exposure to ourselves and our families, is a formidable challenge, but one that we can navigate together.
My sincere hope is that this quarter’s newsletter can provide, at the very least, a brief reprieve from some of these constant stressors. It is during times like this that remaining connected to our colleagues through digital platforms and publications such as The New Gastroenterologist remains of utmost importance.
That being said, I felt it was prudent to first address some common concerns regarding the COVID-19 pandemic, specifically, its implications within gastroenterology. In conjunction with Krishna Rao (University of Michigan), a specialist in infectious diseases, we attempt to shed some light on what is a rapidly evolving situation. For more resources from the American Gastroenterological Association (AGA) on up-to-date clinical guidance and research, you can also visit https://www.gastro.org/practice-guidance/practice-updates/covid-19.
Moving on to our “In Focus” feature, Thangam Ventakesan and Harrison Mooers (Medical College of Wisconsin) provide a comprehensive overview of cyclic vomiting syndrome. This is a valuable read as cyclic vomiting syndrome has been gaining increased recognition among adults, and Dr. Ventakesan and Dr. Mooers elucidate a thorough approach to the diagnosis and treatment of this disorder.
A facet of endoscopy that is extremely important, but frequently overlooked, is ergonomics. Manish Singla and Jared Magee (Walter Reed National Military Medical Center) compile a high-yield list of recommendations on the best practices to preserve our own safety and health as endoscopists.
We continue our medical ethics series with Jennifer Wang and Andrew Aronsohn (University of Chicago) who offer a thought-provoking discussion on the role of early liver transplantation for alcoholic hepatitis, including an analysis of the medical, psychosocial, and ethical considerations.
Also in this issue, Animesh Jain (University of North Carolina) gives us some excellent financial advice on student loan management, outlining a basic strategy of repayment with clear explanations of the available options including refinancing, public service loan forgiveness, and income-driven repayment.
Dilhana Badurdeen (Johns Hopkins), Aline Charabaty Pishvaian (Sibley Memorial Hospital), Miguel Malespin (University of South Florida), Ibironke Oduyebo (Midatlantic Permanente Medical Group), and Sandra Quezada (University of Maryland) give us an in-depth summary of the efforts of the AGA’s Diversity Committee, including publications, events, and future initiatives.
This quarter’s DHPA Private Practice Perspectives series features Paul Berggreen (Arizona Digestive Health), who reviews the advantages and disadvantages of pathology lab ownership as a gastroenterologist. Lastly, Sarah Ordway, Dawn Torres, Manish Singla, and Adam Tritsch (Walter Reed National Military Medical Center) broach the issue of fellowship burnout by providing guidance on how to identify signs and those at risk in addition to providing tangible solutions that any fellowship can incorporate.
Although the cancellation of the upcoming DDW meetings in Chicago is a disappointment, I hope that we can all take this time to prioritize the well-being of ourselves and our communities until we meet again.
As always, if you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]), or Ryan Farrell ([email protected]), managing editor of TNG.
Best wishes to stay safe and healthy.
Vijaya L. Rao, MD
Editor in Chief
Dr. Rao is assistant professor of medicine, University of Chicago, section of gastroenterology, hepatology & nutrition.
Dear colleagues,
We bring you the spring edition of The New Gastroenterologist amid a backdrop of uncertainty in the setting of the novel coronavirus disease 2019 (COVID-19) pandemic. As physicians, we are poised to view this unprecedented situation in modern medicine through a unique lens. At the time of this writing, we are experiencing significant interruptions to our work as gastroenterologists coupled with the possibility of reassignments in order to care for COVID-19 patients to meet the demand of the precipitous rise in cases. Weighing these responsibilities, along with the heightened concern about the threat of exposure to ourselves and our families, is a formidable challenge, but one that we can navigate together.
My sincere hope is that this quarter’s newsletter can provide, at the very least, a brief reprieve from some of these constant stressors. It is during times like this that remaining connected to our colleagues through digital platforms and publications such as The New Gastroenterologist remains of utmost importance.
That being said, I felt it was prudent to first address some common concerns regarding the COVID-19 pandemic, specifically, its implications within gastroenterology. In conjunction with Krishna Rao (University of Michigan), a specialist in infectious diseases, we attempt to shed some light on what is a rapidly evolving situation. For more resources from the American Gastroenterological Association (AGA) on up-to-date clinical guidance and research, you can also visit https://www.gastro.org/practice-guidance/practice-updates/covid-19.
Moving on to our “In Focus” feature, Thangam Ventakesan and Harrison Mooers (Medical College of Wisconsin) provide a comprehensive overview of cyclic vomiting syndrome. This is a valuable read as cyclic vomiting syndrome has been gaining increased recognition among adults, and Dr. Ventakesan and Dr. Mooers elucidate a thorough approach to the diagnosis and treatment of this disorder.
A facet of endoscopy that is extremely important, but frequently overlooked, is ergonomics. Manish Singla and Jared Magee (Walter Reed National Military Medical Center) compile a high-yield list of recommendations on the best practices to preserve our own safety and health as endoscopists.
We continue our medical ethics series with Jennifer Wang and Andrew Aronsohn (University of Chicago) who offer a thought-provoking discussion on the role of early liver transplantation for alcoholic hepatitis, including an analysis of the medical, psychosocial, and ethical considerations.
Also in this issue, Animesh Jain (University of North Carolina) gives us some excellent financial advice on student loan management, outlining a basic strategy of repayment with clear explanations of the available options including refinancing, public service loan forgiveness, and income-driven repayment.
Dilhana Badurdeen (Johns Hopkins), Aline Charabaty Pishvaian (Sibley Memorial Hospital), Miguel Malespin (University of South Florida), Ibironke Oduyebo (Midatlantic Permanente Medical Group), and Sandra Quezada (University of Maryland) give us an in-depth summary of the efforts of the AGA’s Diversity Committee, including publications, events, and future initiatives.
This quarter’s DHPA Private Practice Perspectives series features Paul Berggreen (Arizona Digestive Health), who reviews the advantages and disadvantages of pathology lab ownership as a gastroenterologist. Lastly, Sarah Ordway, Dawn Torres, Manish Singla, and Adam Tritsch (Walter Reed National Military Medical Center) broach the issue of fellowship burnout by providing guidance on how to identify signs and those at risk in addition to providing tangible solutions that any fellowship can incorporate.
Although the cancellation of the upcoming DDW meetings in Chicago is a disappointment, I hope that we can all take this time to prioritize the well-being of ourselves and our communities until we meet again.
As always, if you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]), or Ryan Farrell ([email protected]), managing editor of TNG.
Best wishes to stay safe and healthy.
Vijaya L. Rao, MD
Editor in Chief
Dr. Rao is assistant professor of medicine, University of Chicago, section of gastroenterology, hepatology & nutrition.
Reproductive psychiatry during the COVID-19 pandemic
When last I wrote this column, I was preparing for travel to professional meetings in the spring, planning a presentation for an upcoming grand rounds, and readying to host a scientific advisory board meeting as part of a large scientific project we conduct in Center for Women’s Mental Health. We were also awaiting the relocation of several junior faculty and research staff to Boston this spring and summer as we build our team.
It is now obvious that the COVID-19 pandemic is not a passing squall, but rather a persistent gale that has placed our collective sails in the water. It has not capsized the boat, however, thanks in part to the actions of courageous frontline caregivers and first responders who have mobilized in the wake of this recent public health crisis. From doctors, nurses, and hospital staff to grocery store clerks, home health aides, and neighbors checking in on the elderly – to name just a few – a whole crew of members across society have helped buoy our collective ship. Resilience also is required by all of us who are managing the array of feelings brought about by the day-in, day-out challenges of living life with restricted movement and freedom to engage in pre-COVID-19 activities we took for granted. What seemed like a temporary workaround is now becoming the “new normal” for an unknown amount of time looking forward.
For over 3 decades, my colleagues and I have worked with women who suffer from serious psychiatric disorders and whose treatment has required psychiatric medications such as antidepressants, mood stabilizers, and anxiolytics. The challenge of our work with women who are pregnant or planning pregnancy has been the configuration of the safest ways to navigate treatment on an individual basis for these women across pregnancy and post partum, with continual assessments of how to minimize the risk to fetus from in utero exposure to medications that have been instrumental in the treatment of psychiatric disorders on one hand versus the risks of untreated psychiatric disorder on the other. This work has been the essence of the clinical mission and the cornerstone of the research conducted at the Center for Women’s Mental Health since its inception.
While I have worked shoulder to shoulder with obstetricians for years, my respect for these colleagues during these past weeks has only grown as they have instituted the swiftest protocols to mitigate risk associated with COVID-19 for our pregnant patients, some of whom have tested positive for COVID-19, all in an effort to keep both mother, fetus, and newborn as safe as possible.
For those of us providing mental health services to pregnant women during this time, certain clinical situations have arisen in the context of the COVID-19 pandemic which require particular attention and discussion.
Planned pregnancy and contraception during the COVID-19 pandemic
Half of the pregnancies in this country are unplanned. Now more than ever, it is critical that decisions about moving forward with a plan to conceive be deliberate. These considerations range from the existential to the most concrete. For example, during these last weeks, we have consulted on cases where couples on the cusp of attempts to conceive face concerns about COVID-19, hence making more complicated their timeline with respect to actual plans to get pregnant. These are complicated decisions, particularly for women who may be slightly older and at the reproductive age where delaying pregnancy may have an adverse effect on fertility.
A concrete example of how the pandemic has affected fertility is evident as we encounter situations where women may defer starting a prescription oral contraceptive or lapse in its use because they have had difficulty coordinating visits with health care providers and may fear picking up prescriptions from pharmacies. We also have seen that procedures such as IUD placements have been deferred or canceled, or that some patients decline trips to the hospital or clinic to receive this type of service. These new barriers to access of contraception may require more planning at this time so that decisions about family planning are by design and not default during a time as complicated as the current public health crisis.
Telemedicine: telepsychiatry and obstetrics virtual visits
While wide-scale use of telemedicine platforms was not the standard day-to-day practice in either obstetrics or psychiatry prior to the pandemic, telepsychiatry has come up to speed within a short number of weeks. At our institution, 85% of outpatient visits are being conducted remotely, with in-person visits being reserved for only urgent or emergent visits. Our inpatient psychiatry service remains a setting where psychiatric patients, regardless of their COVID-19 status, can receive necessary care.
The use of telemedicine and specifically telepsychiatry is critical to mitigate the likelihood of exposure to SARS-CoV-2. On our reproductive psychiatry service, it has actually been an opportunity to engage with patients for comprehensive initial consults about reproductive safety of psychiatric medications currently being taken, or for ongoing consultation and direct patient care during follow-up visits during pregnancy to see that patients are sustaining emotional well-being or have changes for treatment implemented if they are not well. An increased frequency of visits allows us more opportunity to capture any signs of early clinical worsening of symptoms that might have been missed previously using the more traditional in-person setting.
Telepsychiatry and “virtual visits” have allowed us to do real-time, nimble modifications of treatment regimens with both pharmacologic and nonpharmacologic interventions to keep women well and to keep them out of the hospital for psychiatric care as often as possible. It also has facilitated a closer collaboration with our colleagues in obstetrics. In a way, the team of providers, including psychiatrists, obstetrical providers, social workers, and therapists can more easily communicate virtually than has sometimes been the case previously, when day-to-day use of telemedicine and virtual team meetings was less common.
Recognition and treatment of anxiety in perinatal patients
Even pregnant women without preexisting anxiety disorders may have heightened anxiety during usual times, and women and their partners cope with this typically in numerous ways including participation in peer-support opportunities, wellness and self-care activities, leveraging support from care providers, and engaging with family. But the previously “typical pregnancy experience” has shifted in the context of COVID-19. Specifically, added concerns of pregnant women about becoming infected, of potential separation from family if they do become ill, or of separation from partners or support systems during labor and delivery (an issue that has been largely resolved in many hospitals), as well as the possibility that a neonate might become ill with exposure to the coronavirus are obviously understandable and real. Such contingencies are unsettling, even for the most settled of our patients. Labor and delivery plans, and plans for outside help from family or others with the baby and older children in the postpartum period, have been upended for many patients.
These are anxious times. The number of nonpharmacologic virtual interventions available to mitigate anxiety are filling email inboxes daily. Curating these options can be a challenge, although several resources are worth noting, such as our department’s page on mental health resources.
During these past weeks, we have seen growing numbers of women for whom the normative anxiety of pregnancy is increasing to the point of causing distress to the level of functional impairment. Many patients for the first time meet criteria for frank anxiety disorders. These patients deserve prompt evaluation by mental health professionals and treatment with evidence-based therapies for anxiety disorders whether nonpharmacologic or pharmacologic so as to mitigate the risk of untreated anxiety on maternal and fetal well-being and also to limit risk for postpartum depression and postpartum anxiety disorders.
Miscarriage and infertility
A 36-year-old patient came to see me in clinic in late January following a miscarriage. She had a history of a previous miscarriage a year before and had an episode of major depression to follow for which she received treatment with an antidepressant and cognitive-behavioral therapy; she also attended a perinatal loss support group. She saw me in early March, anxious to try to conceive but extremely concerned about the risks associated with becoming pregnant at this point in time. Following a lengthy discussion with me and her obstetrician, the patient decided to wait until “the curve flattened” in Boston in terms of new cases of COVID-19, and then start trying to conceive. The case of another patient with a very similar history was presented at our rounds a few weeks ago; she also elected to defer attempts to conceive until life is more settled.
Perhaps one of the most dramatic examples of the impact of COVID-19 on fertility has been for those women with plans to pursue treatment with one of the assisted reproductive technologies. They have been told that professional societies have made recommendations regarding use of assisted reproductive technologies that are not entirely consistent across the country, but where in many places such interventions have been suspended during the COVID-19 pandemic. For many women near the end of their reproductive years, delays in trying to conceive either with or without the aid of fertility treatments may indelibly shape their plans to have children.
Sustaining emotional well-being across pregnancy
Because most psychiatric disorders are chronic in course, it is often the situation where women are treated to wellness for serious psychiatric disorders, with the goal of maintaining wellness across pregnancy and the post partum. One of the most critical takeaway points from 30 years of working with psychiatrically ill pregnant women is the maxim that keeping women well during pregnancy is simply imperative. Maternal psychiatric well-being during pregnancy is a strong predictor of obstetrical and neonatal outcomes, postpartum mental health, and longer-term neurobehavioral outcomes in children. Critically, in the context of the pandemic, keeping women out of psychiatric crises mitigates the necessity of visits to urgent clinical settings such as EDs and psychiatric inpatient units, which can increase the likelihood of exposure to the coronavirus.
Preservation of sleep
Disruption in sleep (duration and quality) can be seen in well over half of women during pregnancy with and without psychiatric disorders, and our experience has been that this has been exacerbated for many women during the COVID-19 crisis. Yet there are very rich data showing that sleep deprivation or sleep dysregulation in women, for example, who suffer from bipolar disorder or major depression can be a strong trigger for psychiatric relapse of underlying illness during pregnancy and the postpartum period.
During a time when normal rhythms of day-to-day life have been shifted – if not frankly disrupted – by swift transitions to remote work, cancellation of school and associated school activities across the country, complaints of insomnia and non-restorative sleep have been exceedingly common. Relevant to all but particularly for pregnant women with histories of psychiatric disorder, attention to sleep hygiene, moderation of caffeine use (if any), and use of any number of biobehavioral interventions to enhance relaxation and modulate stress may be of great value.
Cognitive-behavioral therapy for insomnia (CBT-I) has been demonstrated to be effective in pregnant women. Fortunately, there are user-friendly options on digital platforms that can be used during the pandemic that may play an important role in sustaining emotional well-being for pregnant women who have frank symptoms of insomnia.
Maintenance of ongoing antidepressant treatment during pregnancy among women with histories of mood disorder
Over a decade ago, my colleagues and I wrote about the comparison of outcomes for women with histories of recurrent major depression, demonstrating the value of maintenance treatment with antidepressants, compared with discontinuation of these medications during pregnancy (JAMA. 2006 Feb 1;295[5]:499-507). Recently, I was asked if maintenance antidepressant use in women with histories of recurrent depression was still our clinical recommendation. Over the last decade, we have noted that nearly half of women treated with antidepressants, regardless of illness severity, will discontinue their use of these medications prior to or early on in pregnancy given concerns about potential unknown effects of fetal exposure to medications, even medications for which there are robust data supporting reproductive safety regarding risk of congenital malformations. Routine discontinuation of antidepressants prior to or during pregnancy continues, despite the fact that we showed nearly 70% of those women with past histories of depression on maintenance antidepressant treatment relapsed shortly after discontinuing medication.
While we do not dictate the decisions women make about antidepressant use before, during, or after pregnancy, women with the same severity of illness will frequently make different decisions (a good thing) but we are now having very frank discussions about the particular need during a pandemic to avoid the relapse of serious psychiatric disorders. We typically endorse maintenance medication use with all but a very few number of psychotropic medications for which benefit may not outweigh risk to the fetus. However, for women who have decided nonetheless to discontinue antidepressants or other psychotropics during pregnancy despite the known risk of relapse, we strongly advise that they initiate treatment with evidence-based nonpharmacologic intervention such as CBT or mindfulness-based cognitive therapy (MBCT).
As in other areas of medicine, the pandemic is prompting we professionals in psychiatry, and specifically in perinatal psychiatry, to use all of our tools to keep pregnant and postpartum women well. The availability of digital tools to deliver MBCT and CBT has made the use of such interventions particularly viable at a time of social distancing. That being said, for patients with highly recurrent affective disorder with histories of previous recurrence when they stop their antidepressants, we are more strongly recommending serious consideration of maintenance medication treatment.
Virtual rounds in reproductive psychiatry and women’s mental health
The use of virtual platforms to connect with both patients and colleagues also has provided new opportunities for interaction with the reproductive psychiatry community as a whole. Peer teaching and peer support has been a critical part of our mission, and we decided 1 month ago to establish Virtual Rounds at the Center for Women’s Mental Health. This is a free digital platform, held on a weekly basis with our colleagues from across the country, where we discuss cases that come up in our own clinical rounds and also questions that get put forth by our colleagues in the area of reproductive psychiatry as they manage patients during the pandemic.
Changes in the postpartum experience
The last decade has brought a growing appreciation of postpartum depression and the need to screen and treat postpartum psychiatric disorders, such as postpartum mood and anxiety disorders. Yet in the era of this pandemic, the postpartum experience is itself is changing. Changes in carefully configured plans for the postpartum period – from family coming and going to mobilizing extra support at home and to now having new moms having to manage families and their other children at home – has been an enormous stressor for many women. Plans to have more elderly parents visit during the acute postpartum period, and the increased concerns about people traveling to and from a home where there is a newborn and the need to quarantine, has made the transition to motherhood much more complicated for all postpartum women, let alone for those postpartum women who have histories of psychiatric disorder.
There is a risk of social isolation for postpartum women even under normal circumstances, and this is profoundly more likely during this pandemic. We are actively working with our postpartum patients and optimizing treatment, brainstorming options in terms of using both virtual and real-time support to the extent that it is safe in order to keep women healthy during such a stressful and critical time.
I am heartened by the efforts on the part of organizations such as Postpartum Support International to make available virtually their resources with respect to community-based support and education for women who feel increasingly isolated during the postpartum period, a time where connectedness is so critical.
Summarily, these have been challenging times, but also times of opportunity. The COVID-19 pandemic has prompted us to get even more creative as we configure ways to optimize the emotional well-being of our patients who are planning to get pregnant, who are pregnant, or who are post partum.
The current time, while challenging in so many ways and a time of great pain, loss, and grief for far too many, has also provided an opportunity to work even more collaboratively with our colleagues, coming up with new paradigms of treatments as we weather this historic challenge.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email him at [email protected].
When last I wrote this column, I was preparing for travel to professional meetings in the spring, planning a presentation for an upcoming grand rounds, and readying to host a scientific advisory board meeting as part of a large scientific project we conduct in Center for Women’s Mental Health. We were also awaiting the relocation of several junior faculty and research staff to Boston this spring and summer as we build our team.
It is now obvious that the COVID-19 pandemic is not a passing squall, but rather a persistent gale that has placed our collective sails in the water. It has not capsized the boat, however, thanks in part to the actions of courageous frontline caregivers and first responders who have mobilized in the wake of this recent public health crisis. From doctors, nurses, and hospital staff to grocery store clerks, home health aides, and neighbors checking in on the elderly – to name just a few – a whole crew of members across society have helped buoy our collective ship. Resilience also is required by all of us who are managing the array of feelings brought about by the day-in, day-out challenges of living life with restricted movement and freedom to engage in pre-COVID-19 activities we took for granted. What seemed like a temporary workaround is now becoming the “new normal” for an unknown amount of time looking forward.
For over 3 decades, my colleagues and I have worked with women who suffer from serious psychiatric disorders and whose treatment has required psychiatric medications such as antidepressants, mood stabilizers, and anxiolytics. The challenge of our work with women who are pregnant or planning pregnancy has been the configuration of the safest ways to navigate treatment on an individual basis for these women across pregnancy and post partum, with continual assessments of how to minimize the risk to fetus from in utero exposure to medications that have been instrumental in the treatment of psychiatric disorders on one hand versus the risks of untreated psychiatric disorder on the other. This work has been the essence of the clinical mission and the cornerstone of the research conducted at the Center for Women’s Mental Health since its inception.
While I have worked shoulder to shoulder with obstetricians for years, my respect for these colleagues during these past weeks has only grown as they have instituted the swiftest protocols to mitigate risk associated with COVID-19 for our pregnant patients, some of whom have tested positive for COVID-19, all in an effort to keep both mother, fetus, and newborn as safe as possible.
For those of us providing mental health services to pregnant women during this time, certain clinical situations have arisen in the context of the COVID-19 pandemic which require particular attention and discussion.
Planned pregnancy and contraception during the COVID-19 pandemic
Half of the pregnancies in this country are unplanned. Now more than ever, it is critical that decisions about moving forward with a plan to conceive be deliberate. These considerations range from the existential to the most concrete. For example, during these last weeks, we have consulted on cases where couples on the cusp of attempts to conceive face concerns about COVID-19, hence making more complicated their timeline with respect to actual plans to get pregnant. These are complicated decisions, particularly for women who may be slightly older and at the reproductive age where delaying pregnancy may have an adverse effect on fertility.
A concrete example of how the pandemic has affected fertility is evident as we encounter situations where women may defer starting a prescription oral contraceptive or lapse in its use because they have had difficulty coordinating visits with health care providers and may fear picking up prescriptions from pharmacies. We also have seen that procedures such as IUD placements have been deferred or canceled, or that some patients decline trips to the hospital or clinic to receive this type of service. These new barriers to access of contraception may require more planning at this time so that decisions about family planning are by design and not default during a time as complicated as the current public health crisis.
Telemedicine: telepsychiatry and obstetrics virtual visits
While wide-scale use of telemedicine platforms was not the standard day-to-day practice in either obstetrics or psychiatry prior to the pandemic, telepsychiatry has come up to speed within a short number of weeks. At our institution, 85% of outpatient visits are being conducted remotely, with in-person visits being reserved for only urgent or emergent visits. Our inpatient psychiatry service remains a setting where psychiatric patients, regardless of their COVID-19 status, can receive necessary care.
The use of telemedicine and specifically telepsychiatry is critical to mitigate the likelihood of exposure to SARS-CoV-2. On our reproductive psychiatry service, it has actually been an opportunity to engage with patients for comprehensive initial consults about reproductive safety of psychiatric medications currently being taken, or for ongoing consultation and direct patient care during follow-up visits during pregnancy to see that patients are sustaining emotional well-being or have changes for treatment implemented if they are not well. An increased frequency of visits allows us more opportunity to capture any signs of early clinical worsening of symptoms that might have been missed previously using the more traditional in-person setting.
Telepsychiatry and “virtual visits” have allowed us to do real-time, nimble modifications of treatment regimens with both pharmacologic and nonpharmacologic interventions to keep women well and to keep them out of the hospital for psychiatric care as often as possible. It also has facilitated a closer collaboration with our colleagues in obstetrics. In a way, the team of providers, including psychiatrists, obstetrical providers, social workers, and therapists can more easily communicate virtually than has sometimes been the case previously, when day-to-day use of telemedicine and virtual team meetings was less common.
Recognition and treatment of anxiety in perinatal patients
Even pregnant women without preexisting anxiety disorders may have heightened anxiety during usual times, and women and their partners cope with this typically in numerous ways including participation in peer-support opportunities, wellness and self-care activities, leveraging support from care providers, and engaging with family. But the previously “typical pregnancy experience” has shifted in the context of COVID-19. Specifically, added concerns of pregnant women about becoming infected, of potential separation from family if they do become ill, or of separation from partners or support systems during labor and delivery (an issue that has been largely resolved in many hospitals), as well as the possibility that a neonate might become ill with exposure to the coronavirus are obviously understandable and real. Such contingencies are unsettling, even for the most settled of our patients. Labor and delivery plans, and plans for outside help from family or others with the baby and older children in the postpartum period, have been upended for many patients.
These are anxious times. The number of nonpharmacologic virtual interventions available to mitigate anxiety are filling email inboxes daily. Curating these options can be a challenge, although several resources are worth noting, such as our department’s page on mental health resources.
During these past weeks, we have seen growing numbers of women for whom the normative anxiety of pregnancy is increasing to the point of causing distress to the level of functional impairment. Many patients for the first time meet criteria for frank anxiety disorders. These patients deserve prompt evaluation by mental health professionals and treatment with evidence-based therapies for anxiety disorders whether nonpharmacologic or pharmacologic so as to mitigate the risk of untreated anxiety on maternal and fetal well-being and also to limit risk for postpartum depression and postpartum anxiety disorders.
Miscarriage and infertility
A 36-year-old patient came to see me in clinic in late January following a miscarriage. She had a history of a previous miscarriage a year before and had an episode of major depression to follow for which she received treatment with an antidepressant and cognitive-behavioral therapy; she also attended a perinatal loss support group. She saw me in early March, anxious to try to conceive but extremely concerned about the risks associated with becoming pregnant at this point in time. Following a lengthy discussion with me and her obstetrician, the patient decided to wait until “the curve flattened” in Boston in terms of new cases of COVID-19, and then start trying to conceive. The case of another patient with a very similar history was presented at our rounds a few weeks ago; she also elected to defer attempts to conceive until life is more settled.
Perhaps one of the most dramatic examples of the impact of COVID-19 on fertility has been for those women with plans to pursue treatment with one of the assisted reproductive technologies. They have been told that professional societies have made recommendations regarding use of assisted reproductive technologies that are not entirely consistent across the country, but where in many places such interventions have been suspended during the COVID-19 pandemic. For many women near the end of their reproductive years, delays in trying to conceive either with or without the aid of fertility treatments may indelibly shape their plans to have children.
Sustaining emotional well-being across pregnancy
Because most psychiatric disorders are chronic in course, it is often the situation where women are treated to wellness for serious psychiatric disorders, with the goal of maintaining wellness across pregnancy and the post partum. One of the most critical takeaway points from 30 years of working with psychiatrically ill pregnant women is the maxim that keeping women well during pregnancy is simply imperative. Maternal psychiatric well-being during pregnancy is a strong predictor of obstetrical and neonatal outcomes, postpartum mental health, and longer-term neurobehavioral outcomes in children. Critically, in the context of the pandemic, keeping women out of psychiatric crises mitigates the necessity of visits to urgent clinical settings such as EDs and psychiatric inpatient units, which can increase the likelihood of exposure to the coronavirus.
Preservation of sleep
Disruption in sleep (duration and quality) can be seen in well over half of women during pregnancy with and without psychiatric disorders, and our experience has been that this has been exacerbated for many women during the COVID-19 crisis. Yet there are very rich data showing that sleep deprivation or sleep dysregulation in women, for example, who suffer from bipolar disorder or major depression can be a strong trigger for psychiatric relapse of underlying illness during pregnancy and the postpartum period.
During a time when normal rhythms of day-to-day life have been shifted – if not frankly disrupted – by swift transitions to remote work, cancellation of school and associated school activities across the country, complaints of insomnia and non-restorative sleep have been exceedingly common. Relevant to all but particularly for pregnant women with histories of psychiatric disorder, attention to sleep hygiene, moderation of caffeine use (if any), and use of any number of biobehavioral interventions to enhance relaxation and modulate stress may be of great value.
Cognitive-behavioral therapy for insomnia (CBT-I) has been demonstrated to be effective in pregnant women. Fortunately, there are user-friendly options on digital platforms that can be used during the pandemic that may play an important role in sustaining emotional well-being for pregnant women who have frank symptoms of insomnia.
Maintenance of ongoing antidepressant treatment during pregnancy among women with histories of mood disorder
Over a decade ago, my colleagues and I wrote about the comparison of outcomes for women with histories of recurrent major depression, demonstrating the value of maintenance treatment with antidepressants, compared with discontinuation of these medications during pregnancy (JAMA. 2006 Feb 1;295[5]:499-507). Recently, I was asked if maintenance antidepressant use in women with histories of recurrent depression was still our clinical recommendation. Over the last decade, we have noted that nearly half of women treated with antidepressants, regardless of illness severity, will discontinue their use of these medications prior to or early on in pregnancy given concerns about potential unknown effects of fetal exposure to medications, even medications for which there are robust data supporting reproductive safety regarding risk of congenital malformations. Routine discontinuation of antidepressants prior to or during pregnancy continues, despite the fact that we showed nearly 70% of those women with past histories of depression on maintenance antidepressant treatment relapsed shortly after discontinuing medication.
While we do not dictate the decisions women make about antidepressant use before, during, or after pregnancy, women with the same severity of illness will frequently make different decisions (a good thing) but we are now having very frank discussions about the particular need during a pandemic to avoid the relapse of serious psychiatric disorders. We typically endorse maintenance medication use with all but a very few number of psychotropic medications for which benefit may not outweigh risk to the fetus. However, for women who have decided nonetheless to discontinue antidepressants or other psychotropics during pregnancy despite the known risk of relapse, we strongly advise that they initiate treatment with evidence-based nonpharmacologic intervention such as CBT or mindfulness-based cognitive therapy (MBCT).
As in other areas of medicine, the pandemic is prompting we professionals in psychiatry, and specifically in perinatal psychiatry, to use all of our tools to keep pregnant and postpartum women well. The availability of digital tools to deliver MBCT and CBT has made the use of such interventions particularly viable at a time of social distancing. That being said, for patients with highly recurrent affective disorder with histories of previous recurrence when they stop their antidepressants, we are more strongly recommending serious consideration of maintenance medication treatment.
Virtual rounds in reproductive psychiatry and women’s mental health
The use of virtual platforms to connect with both patients and colleagues also has provided new opportunities for interaction with the reproductive psychiatry community as a whole. Peer teaching and peer support has been a critical part of our mission, and we decided 1 month ago to establish Virtual Rounds at the Center for Women’s Mental Health. This is a free digital platform, held on a weekly basis with our colleagues from across the country, where we discuss cases that come up in our own clinical rounds and also questions that get put forth by our colleagues in the area of reproductive psychiatry as they manage patients during the pandemic.
Changes in the postpartum experience
The last decade has brought a growing appreciation of postpartum depression and the need to screen and treat postpartum psychiatric disorders, such as postpartum mood and anxiety disorders. Yet in the era of this pandemic, the postpartum experience is itself is changing. Changes in carefully configured plans for the postpartum period – from family coming and going to mobilizing extra support at home and to now having new moms having to manage families and their other children at home – has been an enormous stressor for many women. Plans to have more elderly parents visit during the acute postpartum period, and the increased concerns about people traveling to and from a home where there is a newborn and the need to quarantine, has made the transition to motherhood much more complicated for all postpartum women, let alone for those postpartum women who have histories of psychiatric disorder.
There is a risk of social isolation for postpartum women even under normal circumstances, and this is profoundly more likely during this pandemic. We are actively working with our postpartum patients and optimizing treatment, brainstorming options in terms of using both virtual and real-time support to the extent that it is safe in order to keep women healthy during such a stressful and critical time.
I am heartened by the efforts on the part of organizations such as Postpartum Support International to make available virtually their resources with respect to community-based support and education for women who feel increasingly isolated during the postpartum period, a time where connectedness is so critical.
Summarily, these have been challenging times, but also times of opportunity. The COVID-19 pandemic has prompted us to get even more creative as we configure ways to optimize the emotional well-being of our patients who are planning to get pregnant, who are pregnant, or who are post partum.
The current time, while challenging in so many ways and a time of great pain, loss, and grief for far too many, has also provided an opportunity to work even more collaboratively with our colleagues, coming up with new paradigms of treatments as we weather this historic challenge.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email him at [email protected].
When last I wrote this column, I was preparing for travel to professional meetings in the spring, planning a presentation for an upcoming grand rounds, and readying to host a scientific advisory board meeting as part of a large scientific project we conduct in Center for Women’s Mental Health. We were also awaiting the relocation of several junior faculty and research staff to Boston this spring and summer as we build our team.
It is now obvious that the COVID-19 pandemic is not a passing squall, but rather a persistent gale that has placed our collective sails in the water. It has not capsized the boat, however, thanks in part to the actions of courageous frontline caregivers and first responders who have mobilized in the wake of this recent public health crisis. From doctors, nurses, and hospital staff to grocery store clerks, home health aides, and neighbors checking in on the elderly – to name just a few – a whole crew of members across society have helped buoy our collective ship. Resilience also is required by all of us who are managing the array of feelings brought about by the day-in, day-out challenges of living life with restricted movement and freedom to engage in pre-COVID-19 activities we took for granted. What seemed like a temporary workaround is now becoming the “new normal” for an unknown amount of time looking forward.
For over 3 decades, my colleagues and I have worked with women who suffer from serious psychiatric disorders and whose treatment has required psychiatric medications such as antidepressants, mood stabilizers, and anxiolytics. The challenge of our work with women who are pregnant or planning pregnancy has been the configuration of the safest ways to navigate treatment on an individual basis for these women across pregnancy and post partum, with continual assessments of how to minimize the risk to fetus from in utero exposure to medications that have been instrumental in the treatment of psychiatric disorders on one hand versus the risks of untreated psychiatric disorder on the other. This work has been the essence of the clinical mission and the cornerstone of the research conducted at the Center for Women’s Mental Health since its inception.
While I have worked shoulder to shoulder with obstetricians for years, my respect for these colleagues during these past weeks has only grown as they have instituted the swiftest protocols to mitigate risk associated with COVID-19 for our pregnant patients, some of whom have tested positive for COVID-19, all in an effort to keep both mother, fetus, and newborn as safe as possible.
For those of us providing mental health services to pregnant women during this time, certain clinical situations have arisen in the context of the COVID-19 pandemic which require particular attention and discussion.
Planned pregnancy and contraception during the COVID-19 pandemic
Half of the pregnancies in this country are unplanned. Now more than ever, it is critical that decisions about moving forward with a plan to conceive be deliberate. These considerations range from the existential to the most concrete. For example, during these last weeks, we have consulted on cases where couples on the cusp of attempts to conceive face concerns about COVID-19, hence making more complicated their timeline with respect to actual plans to get pregnant. These are complicated decisions, particularly for women who may be slightly older and at the reproductive age where delaying pregnancy may have an adverse effect on fertility.
A concrete example of how the pandemic has affected fertility is evident as we encounter situations where women may defer starting a prescription oral contraceptive or lapse in its use because they have had difficulty coordinating visits with health care providers and may fear picking up prescriptions from pharmacies. We also have seen that procedures such as IUD placements have been deferred or canceled, or that some patients decline trips to the hospital or clinic to receive this type of service. These new barriers to access of contraception may require more planning at this time so that decisions about family planning are by design and not default during a time as complicated as the current public health crisis.
Telemedicine: telepsychiatry and obstetrics virtual visits
While wide-scale use of telemedicine platforms was not the standard day-to-day practice in either obstetrics or psychiatry prior to the pandemic, telepsychiatry has come up to speed within a short number of weeks. At our institution, 85% of outpatient visits are being conducted remotely, with in-person visits being reserved for only urgent or emergent visits. Our inpatient psychiatry service remains a setting where psychiatric patients, regardless of their COVID-19 status, can receive necessary care.
The use of telemedicine and specifically telepsychiatry is critical to mitigate the likelihood of exposure to SARS-CoV-2. On our reproductive psychiatry service, it has actually been an opportunity to engage with patients for comprehensive initial consults about reproductive safety of psychiatric medications currently being taken, or for ongoing consultation and direct patient care during follow-up visits during pregnancy to see that patients are sustaining emotional well-being or have changes for treatment implemented if they are not well. An increased frequency of visits allows us more opportunity to capture any signs of early clinical worsening of symptoms that might have been missed previously using the more traditional in-person setting.
Telepsychiatry and “virtual visits” have allowed us to do real-time, nimble modifications of treatment regimens with both pharmacologic and nonpharmacologic interventions to keep women well and to keep them out of the hospital for psychiatric care as often as possible. It also has facilitated a closer collaboration with our colleagues in obstetrics. In a way, the team of providers, including psychiatrists, obstetrical providers, social workers, and therapists can more easily communicate virtually than has sometimes been the case previously, when day-to-day use of telemedicine and virtual team meetings was less common.
Recognition and treatment of anxiety in perinatal patients
Even pregnant women without preexisting anxiety disorders may have heightened anxiety during usual times, and women and their partners cope with this typically in numerous ways including participation in peer-support opportunities, wellness and self-care activities, leveraging support from care providers, and engaging with family. But the previously “typical pregnancy experience” has shifted in the context of COVID-19. Specifically, added concerns of pregnant women about becoming infected, of potential separation from family if they do become ill, or of separation from partners or support systems during labor and delivery (an issue that has been largely resolved in many hospitals), as well as the possibility that a neonate might become ill with exposure to the coronavirus are obviously understandable and real. Such contingencies are unsettling, even for the most settled of our patients. Labor and delivery plans, and plans for outside help from family or others with the baby and older children in the postpartum period, have been upended for many patients.
These are anxious times. The number of nonpharmacologic virtual interventions available to mitigate anxiety are filling email inboxes daily. Curating these options can be a challenge, although several resources are worth noting, such as our department’s page on mental health resources.
During these past weeks, we have seen growing numbers of women for whom the normative anxiety of pregnancy is increasing to the point of causing distress to the level of functional impairment. Many patients for the first time meet criteria for frank anxiety disorders. These patients deserve prompt evaluation by mental health professionals and treatment with evidence-based therapies for anxiety disorders whether nonpharmacologic or pharmacologic so as to mitigate the risk of untreated anxiety on maternal and fetal well-being and also to limit risk for postpartum depression and postpartum anxiety disorders.
Miscarriage and infertility
A 36-year-old patient came to see me in clinic in late January following a miscarriage. She had a history of a previous miscarriage a year before and had an episode of major depression to follow for which she received treatment with an antidepressant and cognitive-behavioral therapy; she also attended a perinatal loss support group. She saw me in early March, anxious to try to conceive but extremely concerned about the risks associated with becoming pregnant at this point in time. Following a lengthy discussion with me and her obstetrician, the patient decided to wait until “the curve flattened” in Boston in terms of new cases of COVID-19, and then start trying to conceive. The case of another patient with a very similar history was presented at our rounds a few weeks ago; she also elected to defer attempts to conceive until life is more settled.
Perhaps one of the most dramatic examples of the impact of COVID-19 on fertility has been for those women with plans to pursue treatment with one of the assisted reproductive technologies. They have been told that professional societies have made recommendations regarding use of assisted reproductive technologies that are not entirely consistent across the country, but where in many places such interventions have been suspended during the COVID-19 pandemic. For many women near the end of their reproductive years, delays in trying to conceive either with or without the aid of fertility treatments may indelibly shape their plans to have children.
Sustaining emotional well-being across pregnancy
Because most psychiatric disorders are chronic in course, it is often the situation where women are treated to wellness for serious psychiatric disorders, with the goal of maintaining wellness across pregnancy and the post partum. One of the most critical takeaway points from 30 years of working with psychiatrically ill pregnant women is the maxim that keeping women well during pregnancy is simply imperative. Maternal psychiatric well-being during pregnancy is a strong predictor of obstetrical and neonatal outcomes, postpartum mental health, and longer-term neurobehavioral outcomes in children. Critically, in the context of the pandemic, keeping women out of psychiatric crises mitigates the necessity of visits to urgent clinical settings such as EDs and psychiatric inpatient units, which can increase the likelihood of exposure to the coronavirus.
Preservation of sleep
Disruption in sleep (duration and quality) can be seen in well over half of women during pregnancy with and without psychiatric disorders, and our experience has been that this has been exacerbated for many women during the COVID-19 crisis. Yet there are very rich data showing that sleep deprivation or sleep dysregulation in women, for example, who suffer from bipolar disorder or major depression can be a strong trigger for psychiatric relapse of underlying illness during pregnancy and the postpartum period.
During a time when normal rhythms of day-to-day life have been shifted – if not frankly disrupted – by swift transitions to remote work, cancellation of school and associated school activities across the country, complaints of insomnia and non-restorative sleep have been exceedingly common. Relevant to all but particularly for pregnant women with histories of psychiatric disorder, attention to sleep hygiene, moderation of caffeine use (if any), and use of any number of biobehavioral interventions to enhance relaxation and modulate stress may be of great value.
Cognitive-behavioral therapy for insomnia (CBT-I) has been demonstrated to be effective in pregnant women. Fortunately, there are user-friendly options on digital platforms that can be used during the pandemic that may play an important role in sustaining emotional well-being for pregnant women who have frank symptoms of insomnia.
Maintenance of ongoing antidepressant treatment during pregnancy among women with histories of mood disorder
Over a decade ago, my colleagues and I wrote about the comparison of outcomes for women with histories of recurrent major depression, demonstrating the value of maintenance treatment with antidepressants, compared with discontinuation of these medications during pregnancy (JAMA. 2006 Feb 1;295[5]:499-507). Recently, I was asked if maintenance antidepressant use in women with histories of recurrent depression was still our clinical recommendation. Over the last decade, we have noted that nearly half of women treated with antidepressants, regardless of illness severity, will discontinue their use of these medications prior to or early on in pregnancy given concerns about potential unknown effects of fetal exposure to medications, even medications for which there are robust data supporting reproductive safety regarding risk of congenital malformations. Routine discontinuation of antidepressants prior to or during pregnancy continues, despite the fact that we showed nearly 70% of those women with past histories of depression on maintenance antidepressant treatment relapsed shortly after discontinuing medication.
While we do not dictate the decisions women make about antidepressant use before, during, or after pregnancy, women with the same severity of illness will frequently make different decisions (a good thing) but we are now having very frank discussions about the particular need during a pandemic to avoid the relapse of serious psychiatric disorders. We typically endorse maintenance medication use with all but a very few number of psychotropic medications for which benefit may not outweigh risk to the fetus. However, for women who have decided nonetheless to discontinue antidepressants or other psychotropics during pregnancy despite the known risk of relapse, we strongly advise that they initiate treatment with evidence-based nonpharmacologic intervention such as CBT or mindfulness-based cognitive therapy (MBCT).
As in other areas of medicine, the pandemic is prompting we professionals in psychiatry, and specifically in perinatal psychiatry, to use all of our tools to keep pregnant and postpartum women well. The availability of digital tools to deliver MBCT and CBT has made the use of such interventions particularly viable at a time of social distancing. That being said, for patients with highly recurrent affective disorder with histories of previous recurrence when they stop their antidepressants, we are more strongly recommending serious consideration of maintenance medication treatment.
Virtual rounds in reproductive psychiatry and women’s mental health
The use of virtual platforms to connect with both patients and colleagues also has provided new opportunities for interaction with the reproductive psychiatry community as a whole. Peer teaching and peer support has been a critical part of our mission, and we decided 1 month ago to establish Virtual Rounds at the Center for Women’s Mental Health. This is a free digital platform, held on a weekly basis with our colleagues from across the country, where we discuss cases that come up in our own clinical rounds and also questions that get put forth by our colleagues in the area of reproductive psychiatry as they manage patients during the pandemic.
Changes in the postpartum experience
The last decade has brought a growing appreciation of postpartum depression and the need to screen and treat postpartum psychiatric disorders, such as postpartum mood and anxiety disorders. Yet in the era of this pandemic, the postpartum experience is itself is changing. Changes in carefully configured plans for the postpartum period – from family coming and going to mobilizing extra support at home and to now having new moms having to manage families and their other children at home – has been an enormous stressor for many women. Plans to have more elderly parents visit during the acute postpartum period, and the increased concerns about people traveling to and from a home where there is a newborn and the need to quarantine, has made the transition to motherhood much more complicated for all postpartum women, let alone for those postpartum women who have histories of psychiatric disorder.
There is a risk of social isolation for postpartum women even under normal circumstances, and this is profoundly more likely during this pandemic. We are actively working with our postpartum patients and optimizing treatment, brainstorming options in terms of using both virtual and real-time support to the extent that it is safe in order to keep women healthy during such a stressful and critical time.
I am heartened by the efforts on the part of organizations such as Postpartum Support International to make available virtually their resources with respect to community-based support and education for women who feel increasingly isolated during the postpartum period, a time where connectedness is so critical.
Summarily, these have been challenging times, but also times of opportunity. The COVID-19 pandemic has prompted us to get even more creative as we configure ways to optimize the emotional well-being of our patients who are planning to get pregnant, who are pregnant, or who are post partum.
The current time, while challenging in so many ways and a time of great pain, loss, and grief for far too many, has also provided an opportunity to work even more collaboratively with our colleagues, coming up with new paradigms of treatments as we weather this historic challenge.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email him at [email protected].
What is the significance of isolated tumor cells in endometrial cancer?
Over the past decade gynecologic oncology surgeons have increasingly adopted the technique of sentinel lymph node (SLN) biopsy to stage endometrial cancer. This is supported by evidence that selective removal of the few lymph nodes which are the first to drain the uterus can accurately detect metastatic disease, sparing the patient a complete lymphadenectomy and its associated risks, such as lymphedema.1 The proposed benefits of SLN biopsy are not just its ability to spare the patient removal of dozens of unnecessary lymph nodes, but also the ability to improve upon the detection of previously unrecognized nodal metastases in locations not routinely sampled by lymphadenectomy and by identifying very-low-volume metastatic disease. This is beneficial only, however, if that previously overlooked low-volume disease is clinically significant.
When pathologists evaluate lymph nodes as part of conventional lymphadenectomy, they typically bivalve the lymph node and evaluate with hematoxylin and eosin (H&E) stains. This technique is capable of detecting metastatic lesions greater than 2 mm, but can miss low-volume disease. In contrast, pathologists process SLNs with much finer sectioning (no greater than 2 mm), and, if the node is larger than 4 mm, they will section it perpendicular to the long axis in a bread-loaf fashion. It is not feasible to perform this ultrasectioning on the large numbers of lymph nodes of a complete lymphadenectomy specimen, but when applied to an SLN it allows pathologists to detect much smaller metastatic foci, the so-called “micrometastases” that are between 0.2 and 2 mm in size, and which typically arise in the subcapsular region of the node. The graphic depicts how a traditional longitudinal cut (a) might miss the micrometastasis that could be identified on the finer perpendicular cuts of ultra-sectioning (b). In addition to the ultrasectioning of the node into smaller slices, the pathologist performs additional immunohistochemistry stains for cytokeratin on sentinel nodes which appear negative on preliminary H&E stains. This allows the pathologist to identify even smaller clusters of malignant cells that are less than 0.2 mm, or individual cancer cells, so-called “isolated tumor cells” (ITCs) as shown in the photo. Most SLN series identify that approximately half of their “positive” lymph nodes are low-volume disease (micrometastases and ITCs). ITCs make up the majority of these cases, typically three-quarters.
Clinicians might be reassured by the discovery of low-volume metastatic disease, perceiving that the added attention afforded by the SLN approach helped them to identify metastases that might otherwise have been missed and therefore not treated. This is because node-positive (stage IIIC) disease is not cured by surgery or radiation alone and requires the addition of chemotherapy for survival benefit.2 Alternatively, there is no clear survival benefit derived from treating stage I high/intermediate cancers with chemotherapy, and therefore, the prescription of chemotherapy hinges upon reliable identification of extrauterine disease on pathology.3
It would make sense that if SLNs are more effective in identifying metastatic disease, clinicians who practice SLN biopsy would identify it more of the time. This appears to be the case with a trend towards upstaging in patients who undergo SLN biopsy, compared with those undergoing complete lymphadenectomy.4 It should also follow that if this increased detection of metastatic disease was clinically relevant, we would observe a corresponding improvement in survival outcomes. If not, then the additional identification of low-volume disease may not be value added: imparting toxicity of adjuvant therapy without survival benefit.
Micrometastases (foci sized 0.2-2 mm) are not a new phenomenon to the SLN era. Low-volume lesions were occasionally detected with routine nodal processing and H&E stains. Attention wasn’t paid to nodal volume categorization in pathology reports prior to the SLN era. These were usually reported collectively as stage IIIC disease. It would make sense to continue to approach micrometastases in a manner similar to what we have always done, recognizing that it may represent a continuum of nodal macrometastases. In contrast, ITCs are rarely detected with routine pathologic processing. Perhaps they are less within a continuum of nodal metastases, and more within the continuum of lymphovascular space invasion. We know that ITCs are significantly associated with the cofinding of this uterine phenomenon, which itself is considered a significant risk factor for local recurrence.5
Series have consistently shown the outcomes of women with ITCs to be favorable, compared with those with micrometastases or macrometastases.5,6 However, most retrospective series that evaluated the outcomes of patients with respect to volume of metastatic disease have high rates of treatment of ITCs with chemotherapy, radiotherapy, or both.6 This may mask and confuse whether there is any intrinsically favorable prognostic virtue of ITCs, compared with larger metastatic foci. When ITCs are untreated, it would appear that the rates and patterns of recurrence appear similar to those with negative SLNs, with the caveat that these series all include small numbers.5,7 This would suggest that women with ITCs do not need additional therapy beyond what would be prescribed for their uterine risk factors.
Further supporting the notion that ITCs have more favorable prognosis is that, while SLN biopsy is associated with a higher detection of nodal metastatic disease, it is not necessarily associated with improved survival when compared with complete lymphadenectomy in retrospective series.8 This suggests that finding and treating ITCs may not positively affect outcomes. Or possibly it is a result of inadequate statistical power to show a small benefit should one exist. It is especially difficult to differentiate micrometastases and ITCs with respect to treatment outcomes. Given that ITCs make up the majority of low-volume nodal disease detected through the SLN technique, any potential benefit of increased capture and treatment of the more substantial micrometastases is not likely to be captured. As a result, most series tend to lump patients with micrometastases with those with ITCs in their analysis of patient outcomes. This may be a mistake.
Clearly more research needs to be performed to definitively address the clinical significance of ITCs. While it would be ideal to conduct a prospective trial in which patients with ITCs are randomized to therapy or observation, in reality the scope of such a trial makes it impractical. ITCs are detected in only approximately 5% of all the patients with endometrial cancer, and given that outcomes for this group are, in general, good, it would require enrollment of tens of thousands of patients to establish a statistically satisfactory result. Therefore it is likely that we will need to rely on the results of large retrospective, population-based, observational series to determine if the identification and treatment of ITCs adds value and superior outcomes to patients. In addition, we are making leaps in better understanding the molecular profile of endometrial cancers and how we might incorporate this data with histology and staging results to create treatment algorithms, much like what has been developed for breast cancer. This is likely where the future lies in interpreting the results of staging. In the meantime, it seems reasonable to collect the data regarding volume of metastatic disease including the presence of ITCs, making shared treatment decisions with the patient regarding the addition of adjuvant therapy, recognizing that
Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She has no conflicts of interest to declare. Email her at [email protected].
References
1. Lancet Oncol. 2017 Mar;18(3):384-92.
2. J Clin Oncol. 2006 Jan 1;24(1):36-44.
3. J Clin Oncol. 2019 Jul 20;37(21):1810-8.
4. Clin Transl Oncol. 2019. doi: 10.1007/s12094-019-02249-x.
5. Gynecol Oncol. 2017 Aug;146(2):240-6.
6. Ann Surg Oncol. 2016 May;23(5):1653-9.
7. Gynecol Oncol. 2019 Jun;153(3):496-9.
8. Gynecol Oncol. 2018 Nov;151(2):235-42.
Over the past decade gynecologic oncology surgeons have increasingly adopted the technique of sentinel lymph node (SLN) biopsy to stage endometrial cancer. This is supported by evidence that selective removal of the few lymph nodes which are the first to drain the uterus can accurately detect metastatic disease, sparing the patient a complete lymphadenectomy and its associated risks, such as lymphedema.1 The proposed benefits of SLN biopsy are not just its ability to spare the patient removal of dozens of unnecessary lymph nodes, but also the ability to improve upon the detection of previously unrecognized nodal metastases in locations not routinely sampled by lymphadenectomy and by identifying very-low-volume metastatic disease. This is beneficial only, however, if that previously overlooked low-volume disease is clinically significant.
When pathologists evaluate lymph nodes as part of conventional lymphadenectomy, they typically bivalve the lymph node and evaluate with hematoxylin and eosin (H&E) stains. This technique is capable of detecting metastatic lesions greater than 2 mm, but can miss low-volume disease. In contrast, pathologists process SLNs with much finer sectioning (no greater than 2 mm), and, if the node is larger than 4 mm, they will section it perpendicular to the long axis in a bread-loaf fashion. It is not feasible to perform this ultrasectioning on the large numbers of lymph nodes of a complete lymphadenectomy specimen, but when applied to an SLN it allows pathologists to detect much smaller metastatic foci, the so-called “micrometastases” that are between 0.2 and 2 mm in size, and which typically arise in the subcapsular region of the node. The graphic depicts how a traditional longitudinal cut (a) might miss the micrometastasis that could be identified on the finer perpendicular cuts of ultra-sectioning (b). In addition to the ultrasectioning of the node into smaller slices, the pathologist performs additional immunohistochemistry stains for cytokeratin on sentinel nodes which appear negative on preliminary H&E stains. This allows the pathologist to identify even smaller clusters of malignant cells that are less than 0.2 mm, or individual cancer cells, so-called “isolated tumor cells” (ITCs) as shown in the photo. Most SLN series identify that approximately half of their “positive” lymph nodes are low-volume disease (micrometastases and ITCs). ITCs make up the majority of these cases, typically three-quarters.
Clinicians might be reassured by the discovery of low-volume metastatic disease, perceiving that the added attention afforded by the SLN approach helped them to identify metastases that might otherwise have been missed and therefore not treated. This is because node-positive (stage IIIC) disease is not cured by surgery or radiation alone and requires the addition of chemotherapy for survival benefit.2 Alternatively, there is no clear survival benefit derived from treating stage I high/intermediate cancers with chemotherapy, and therefore, the prescription of chemotherapy hinges upon reliable identification of extrauterine disease on pathology.3
It would make sense that if SLNs are more effective in identifying metastatic disease, clinicians who practice SLN biopsy would identify it more of the time. This appears to be the case with a trend towards upstaging in patients who undergo SLN biopsy, compared with those undergoing complete lymphadenectomy.4 It should also follow that if this increased detection of metastatic disease was clinically relevant, we would observe a corresponding improvement in survival outcomes. If not, then the additional identification of low-volume disease may not be value added: imparting toxicity of adjuvant therapy without survival benefit.
Micrometastases (foci sized 0.2-2 mm) are not a new phenomenon to the SLN era. Low-volume lesions were occasionally detected with routine nodal processing and H&E stains. Attention wasn’t paid to nodal volume categorization in pathology reports prior to the SLN era. These were usually reported collectively as stage IIIC disease. It would make sense to continue to approach micrometastases in a manner similar to what we have always done, recognizing that it may represent a continuum of nodal macrometastases. In contrast, ITCs are rarely detected with routine pathologic processing. Perhaps they are less within a continuum of nodal metastases, and more within the continuum of lymphovascular space invasion. We know that ITCs are significantly associated with the cofinding of this uterine phenomenon, which itself is considered a significant risk factor for local recurrence.5
Series have consistently shown the outcomes of women with ITCs to be favorable, compared with those with micrometastases or macrometastases.5,6 However, most retrospective series that evaluated the outcomes of patients with respect to volume of metastatic disease have high rates of treatment of ITCs with chemotherapy, radiotherapy, or both.6 This may mask and confuse whether there is any intrinsically favorable prognostic virtue of ITCs, compared with larger metastatic foci. When ITCs are untreated, it would appear that the rates and patterns of recurrence appear similar to those with negative SLNs, with the caveat that these series all include small numbers.5,7 This would suggest that women with ITCs do not need additional therapy beyond what would be prescribed for their uterine risk factors.
Further supporting the notion that ITCs have more favorable prognosis is that, while SLN biopsy is associated with a higher detection of nodal metastatic disease, it is not necessarily associated with improved survival when compared with complete lymphadenectomy in retrospective series.8 This suggests that finding and treating ITCs may not positively affect outcomes. Or possibly it is a result of inadequate statistical power to show a small benefit should one exist. It is especially difficult to differentiate micrometastases and ITCs with respect to treatment outcomes. Given that ITCs make up the majority of low-volume nodal disease detected through the SLN technique, any potential benefit of increased capture and treatment of the more substantial micrometastases is not likely to be captured. As a result, most series tend to lump patients with micrometastases with those with ITCs in their analysis of patient outcomes. This may be a mistake.
Clearly more research needs to be performed to definitively address the clinical significance of ITCs. While it would be ideal to conduct a prospective trial in which patients with ITCs are randomized to therapy or observation, in reality the scope of such a trial makes it impractical. ITCs are detected in only approximately 5% of all the patients with endometrial cancer, and given that outcomes for this group are, in general, good, it would require enrollment of tens of thousands of patients to establish a statistically satisfactory result. Therefore it is likely that we will need to rely on the results of large retrospective, population-based, observational series to determine if the identification and treatment of ITCs adds value and superior outcomes to patients. In addition, we are making leaps in better understanding the molecular profile of endometrial cancers and how we might incorporate this data with histology and staging results to create treatment algorithms, much like what has been developed for breast cancer. This is likely where the future lies in interpreting the results of staging. In the meantime, it seems reasonable to collect the data regarding volume of metastatic disease including the presence of ITCs, making shared treatment decisions with the patient regarding the addition of adjuvant therapy, recognizing that
Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She has no conflicts of interest to declare. Email her at [email protected].
References
1. Lancet Oncol. 2017 Mar;18(3):384-92.
2. J Clin Oncol. 2006 Jan 1;24(1):36-44.
3. J Clin Oncol. 2019 Jul 20;37(21):1810-8.
4. Clin Transl Oncol. 2019. doi: 10.1007/s12094-019-02249-x.
5. Gynecol Oncol. 2017 Aug;146(2):240-6.
6. Ann Surg Oncol. 2016 May;23(5):1653-9.
7. Gynecol Oncol. 2019 Jun;153(3):496-9.
8. Gynecol Oncol. 2018 Nov;151(2):235-42.
Over the past decade gynecologic oncology surgeons have increasingly adopted the technique of sentinel lymph node (SLN) biopsy to stage endometrial cancer. This is supported by evidence that selective removal of the few lymph nodes which are the first to drain the uterus can accurately detect metastatic disease, sparing the patient a complete lymphadenectomy and its associated risks, such as lymphedema.1 The proposed benefits of SLN biopsy are not just its ability to spare the patient removal of dozens of unnecessary lymph nodes, but also the ability to improve upon the detection of previously unrecognized nodal metastases in locations not routinely sampled by lymphadenectomy and by identifying very-low-volume metastatic disease. This is beneficial only, however, if that previously overlooked low-volume disease is clinically significant.
When pathologists evaluate lymph nodes as part of conventional lymphadenectomy, they typically bivalve the lymph node and evaluate with hematoxylin and eosin (H&E) stains. This technique is capable of detecting metastatic lesions greater than 2 mm, but can miss low-volume disease. In contrast, pathologists process SLNs with much finer sectioning (no greater than 2 mm), and, if the node is larger than 4 mm, they will section it perpendicular to the long axis in a bread-loaf fashion. It is not feasible to perform this ultrasectioning on the large numbers of lymph nodes of a complete lymphadenectomy specimen, but when applied to an SLN it allows pathologists to detect much smaller metastatic foci, the so-called “micrometastases” that are between 0.2 and 2 mm in size, and which typically arise in the subcapsular region of the node. The graphic depicts how a traditional longitudinal cut (a) might miss the micrometastasis that could be identified on the finer perpendicular cuts of ultra-sectioning (b). In addition to the ultrasectioning of the node into smaller slices, the pathologist performs additional immunohistochemistry stains for cytokeratin on sentinel nodes which appear negative on preliminary H&E stains. This allows the pathologist to identify even smaller clusters of malignant cells that are less than 0.2 mm, or individual cancer cells, so-called “isolated tumor cells” (ITCs) as shown in the photo. Most SLN series identify that approximately half of their “positive” lymph nodes are low-volume disease (micrometastases and ITCs). ITCs make up the majority of these cases, typically three-quarters.
Clinicians might be reassured by the discovery of low-volume metastatic disease, perceiving that the added attention afforded by the SLN approach helped them to identify metastases that might otherwise have been missed and therefore not treated. This is because node-positive (stage IIIC) disease is not cured by surgery or radiation alone and requires the addition of chemotherapy for survival benefit.2 Alternatively, there is no clear survival benefit derived from treating stage I high/intermediate cancers with chemotherapy, and therefore, the prescription of chemotherapy hinges upon reliable identification of extrauterine disease on pathology.3
It would make sense that if SLNs are more effective in identifying metastatic disease, clinicians who practice SLN biopsy would identify it more of the time. This appears to be the case with a trend towards upstaging in patients who undergo SLN biopsy, compared with those undergoing complete lymphadenectomy.4 It should also follow that if this increased detection of metastatic disease was clinically relevant, we would observe a corresponding improvement in survival outcomes. If not, then the additional identification of low-volume disease may not be value added: imparting toxicity of adjuvant therapy without survival benefit.
Micrometastases (foci sized 0.2-2 mm) are not a new phenomenon to the SLN era. Low-volume lesions were occasionally detected with routine nodal processing and H&E stains. Attention wasn’t paid to nodal volume categorization in pathology reports prior to the SLN era. These were usually reported collectively as stage IIIC disease. It would make sense to continue to approach micrometastases in a manner similar to what we have always done, recognizing that it may represent a continuum of nodal macrometastases. In contrast, ITCs are rarely detected with routine pathologic processing. Perhaps they are less within a continuum of nodal metastases, and more within the continuum of lymphovascular space invasion. We know that ITCs are significantly associated with the cofinding of this uterine phenomenon, which itself is considered a significant risk factor for local recurrence.5
Series have consistently shown the outcomes of women with ITCs to be favorable, compared with those with micrometastases or macrometastases.5,6 However, most retrospective series that evaluated the outcomes of patients with respect to volume of metastatic disease have high rates of treatment of ITCs with chemotherapy, radiotherapy, or both.6 This may mask and confuse whether there is any intrinsically favorable prognostic virtue of ITCs, compared with larger metastatic foci. When ITCs are untreated, it would appear that the rates and patterns of recurrence appear similar to those with negative SLNs, with the caveat that these series all include small numbers.5,7 This would suggest that women with ITCs do not need additional therapy beyond what would be prescribed for their uterine risk factors.
Further supporting the notion that ITCs have more favorable prognosis is that, while SLN biopsy is associated with a higher detection of nodal metastatic disease, it is not necessarily associated with improved survival when compared with complete lymphadenectomy in retrospective series.8 This suggests that finding and treating ITCs may not positively affect outcomes. Or possibly it is a result of inadequate statistical power to show a small benefit should one exist. It is especially difficult to differentiate micrometastases and ITCs with respect to treatment outcomes. Given that ITCs make up the majority of low-volume nodal disease detected through the SLN technique, any potential benefit of increased capture and treatment of the more substantial micrometastases is not likely to be captured. As a result, most series tend to lump patients with micrometastases with those with ITCs in their analysis of patient outcomes. This may be a mistake.
Clearly more research needs to be performed to definitively address the clinical significance of ITCs. While it would be ideal to conduct a prospective trial in which patients with ITCs are randomized to therapy or observation, in reality the scope of such a trial makes it impractical. ITCs are detected in only approximately 5% of all the patients with endometrial cancer, and given that outcomes for this group are, in general, good, it would require enrollment of tens of thousands of patients to establish a statistically satisfactory result. Therefore it is likely that we will need to rely on the results of large retrospective, population-based, observational series to determine if the identification and treatment of ITCs adds value and superior outcomes to patients. In addition, we are making leaps in better understanding the molecular profile of endometrial cancers and how we might incorporate this data with histology and staging results to create treatment algorithms, much like what has been developed for breast cancer. This is likely where the future lies in interpreting the results of staging. In the meantime, it seems reasonable to collect the data regarding volume of metastatic disease including the presence of ITCs, making shared treatment decisions with the patient regarding the addition of adjuvant therapy, recognizing that
Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She has no conflicts of interest to declare. Email her at [email protected].
References
1. Lancet Oncol. 2017 Mar;18(3):384-92.
2. J Clin Oncol. 2006 Jan 1;24(1):36-44.
3. J Clin Oncol. 2019 Jul 20;37(21):1810-8.
4. Clin Transl Oncol. 2019. doi: 10.1007/s12094-019-02249-x.
5. Gynecol Oncol. 2017 Aug;146(2):240-6.
6. Ann Surg Oncol. 2016 May;23(5):1653-9.
7. Gynecol Oncol. 2019 Jun;153(3):496-9.
8. Gynecol Oncol. 2018 Nov;151(2):235-42.
Decreased fetal movement: Time to educate patients and ourselves
We have all as providers experienced the tragic stillbirth of a term fetus for one of our patients. Too often no fetal movement was felt for days, but the patient never called. Or the patient did call, but the nonstress test (NST) was reactive or the ultrasound showed normal growth and fluid or the biophysical profile (BPP) was 8/8. Yet the patient still presented with a stillborn fetus a day later. Was the first patient simply so fearful of the likely deceased child within her that she did not call? Or did she simply not know to report it because she was not educated about what decreased fetal movement could mean? Could the second example have been prevented even though the testing was normal? I believe both scenarios could have been prevented with better education for both providers and patients.
The national stillbirth rate has remained relatively stagnant since 2000, despite many improvements in guidelines for the management of higher risk pregnancies.1 We follow the growth of these pregnancies, do NSTs, and often induce these patients prior to the due date. We do this in the hope of having a healthy mom and baby. However, an analysis of 614 stillbirth cases and 1,816 control deliveries found that 81% of patients presenting with a stillborn baby had no risks factors that required additional monitoring.2 Nearly 66% of 1,714 patients with a late stillbirth reported decreased fetal movement, no fetal movement, or a concerning increase in fetal movement in the days leading up to their baby’s death.3 Studies have suggested that persistent decreased fetal movement has an odds ratio for stillbirth of 4.51,4 which is higher than hypertensive disease and diabetes for this same outcome by nearly a factor of two. Yet there are no formal guidelines on education for patients or management of this chief complaint.
We assess fetal movement at every prenatal visit but patients who experienced stillbirth will say they didn’t know why. This is because as a culture and a profession we are afraid to talk about such a taboo subject as stillbirth. We are afraid we will scare our patients if we tell them that a decrease in fetal movement or no fetal movement may be because their baby is at risk for this dreaded complication. On one level this argument makes sense, but as soon as the baby is born we give parents plenty of education and advice to keep their children safe. Telling a parent to remove all bedding, put their baby on their back, and keep their baby from being too warm to prevent sudden infant death syndrome (SIDS) is very scary. However, this education is necessary. If moms simply know the reason why we ask about fetal movements, they may not wait 2 days before they call. We must have faith that pregnant women can handle this education about decreased fetal movement.
Next most important is our response to the complaint of decreased fetal movement. Often when the NST is reactive or the ultrasound is normal, we assume the baby is at no risk and we reassure the mother that everything is fine. We often tell moms the false myth that babies slow down at the end or advise kick counts after this complaint despite studies failing to show their utility. Because the education about kick count is frequency is what matters, a mother may not call if there is a change in pattern or strength – even if she is very worried about this. A baby may “pass” a kick count, but a mom still may be very worried, yet she will not call because the baby “passed.”
Protocols from the United Kingdom and Australia focus on the assumption that the complaint of decreased fetal movement may be the only warning sign of impending stillbirth. Harvey Kliman, MD, PhD, director of reproductive and placental research unit at Yale University, New Haven, Conn. said an analogy to this is a car driving 55 miles per hour despite only 10 miles of gas being left in the tank.* The car is running fine even when it is almost out of gas. That may be why we all have seen a fetus with recent reassuring tests in the last few days who presents stillborn. Perhaps the only warning sign is decreased fetal movement – not a nonreactive NST or low score BPP. Placental insufficiency is often the cause of initially unexplained stillbirth, far more common than “cord accidents.” If we liken the placenta to the “gas tank” for the pregnancy, then decreased fetal movement may be the “low gas” signal on the dashboard. After this patient has a reactive NST and/or reassuring ultrasound, we need to ask her if she is reassured. Data from a study of 380 women found that women who had a gut instinct that something was wrong were 23 times more likely to experience a stillbirth, according to the unadjusted odds ratio from the logistic regression model.5 We should follow up closely with moms who are not reassured and consider induction if they are over 39 weeks. We should tell every mom who presents with a concern about fetal movement that she did the right thing, and we want to hear from her again immediately if the movement is decreased again or persists. We cannot make women feel silly for calling. We should do an ultrasound for worried moms even if the NST is reactive to make sure we are not missing oligohydramnios or fetal growth restriction; the latter is the biggest known risk factor for stillbirth. We also should perform an ultrasound for moms with risk factors for stillbirth such as advanced maternal age or black race.
The education about and plan for management of decreased fetal movement are two components of the UK Saving Babies Lives Protocol; one study in the United Kingdom has shown a 20% decline in stillbirths from 2010 to 2017. The other two components are making sure to catch all fetal growth restricted babies and smoking cessation. We incorporated this protocol in my practice several months ago, and we have had very positive feedback from patients. We are not getting an increase in concerns/visits and have not had any patients call and say that they were upset about receiving this education. The Word Health Organization calls stillbirth a “neglected tragedy.” The United States has the lowest annual reduction of its stillbirth rate for all high-income nations in the Lancet 2015 series on stillbirth.6
Dr. Florescue is an ob.gyn. in private practice at Women Gynecology and Childbirth Associates in Rochester, N.Y. She delivers babies at Highland Hospital in Rochester. She has no relevant financial disclosures.
References
1. The Lancet. 2016, Jan 18;387(10018):587-603.
2. JAMA. 2011 Dec 14;306(22):2469-79.
3. BMC Pregnancy Childbirth. 2015 Aug 15;15:172.
4. BMJ Open. 2018 Jul 6;8(7):e020031.
5. Midwifery. 2018 Jul;62:171-6.
6. The Lancet. 2016, Jan 18;387(10019):691-702.
*This article was updated on 5/4/2020.
We have all as providers experienced the tragic stillbirth of a term fetus for one of our patients. Too often no fetal movement was felt for days, but the patient never called. Or the patient did call, but the nonstress test (NST) was reactive or the ultrasound showed normal growth and fluid or the biophysical profile (BPP) was 8/8. Yet the patient still presented with a stillborn fetus a day later. Was the first patient simply so fearful of the likely deceased child within her that she did not call? Or did she simply not know to report it because she was not educated about what decreased fetal movement could mean? Could the second example have been prevented even though the testing was normal? I believe both scenarios could have been prevented with better education for both providers and patients.
The national stillbirth rate has remained relatively stagnant since 2000, despite many improvements in guidelines for the management of higher risk pregnancies.1 We follow the growth of these pregnancies, do NSTs, and often induce these patients prior to the due date. We do this in the hope of having a healthy mom and baby. However, an analysis of 614 stillbirth cases and 1,816 control deliveries found that 81% of patients presenting with a stillborn baby had no risks factors that required additional monitoring.2 Nearly 66% of 1,714 patients with a late stillbirth reported decreased fetal movement, no fetal movement, or a concerning increase in fetal movement in the days leading up to their baby’s death.3 Studies have suggested that persistent decreased fetal movement has an odds ratio for stillbirth of 4.51,4 which is higher than hypertensive disease and diabetes for this same outcome by nearly a factor of two. Yet there are no formal guidelines on education for patients or management of this chief complaint.
We assess fetal movement at every prenatal visit but patients who experienced stillbirth will say they didn’t know why. This is because as a culture and a profession we are afraid to talk about such a taboo subject as stillbirth. We are afraid we will scare our patients if we tell them that a decrease in fetal movement or no fetal movement may be because their baby is at risk for this dreaded complication. On one level this argument makes sense, but as soon as the baby is born we give parents plenty of education and advice to keep their children safe. Telling a parent to remove all bedding, put their baby on their back, and keep their baby from being too warm to prevent sudden infant death syndrome (SIDS) is very scary. However, this education is necessary. If moms simply know the reason why we ask about fetal movements, they may not wait 2 days before they call. We must have faith that pregnant women can handle this education about decreased fetal movement.
Next most important is our response to the complaint of decreased fetal movement. Often when the NST is reactive or the ultrasound is normal, we assume the baby is at no risk and we reassure the mother that everything is fine. We often tell moms the false myth that babies slow down at the end or advise kick counts after this complaint despite studies failing to show their utility. Because the education about kick count is frequency is what matters, a mother may not call if there is a change in pattern or strength – even if she is very worried about this. A baby may “pass” a kick count, but a mom still may be very worried, yet she will not call because the baby “passed.”
Protocols from the United Kingdom and Australia focus on the assumption that the complaint of decreased fetal movement may be the only warning sign of impending stillbirth. Harvey Kliman, MD, PhD, director of reproductive and placental research unit at Yale University, New Haven, Conn. said an analogy to this is a car driving 55 miles per hour despite only 10 miles of gas being left in the tank.* The car is running fine even when it is almost out of gas. That may be why we all have seen a fetus with recent reassuring tests in the last few days who presents stillborn. Perhaps the only warning sign is decreased fetal movement – not a nonreactive NST or low score BPP. Placental insufficiency is often the cause of initially unexplained stillbirth, far more common than “cord accidents.” If we liken the placenta to the “gas tank” for the pregnancy, then decreased fetal movement may be the “low gas” signal on the dashboard. After this patient has a reactive NST and/or reassuring ultrasound, we need to ask her if she is reassured. Data from a study of 380 women found that women who had a gut instinct that something was wrong were 23 times more likely to experience a stillbirth, according to the unadjusted odds ratio from the logistic regression model.5 We should follow up closely with moms who are not reassured and consider induction if they are over 39 weeks. We should tell every mom who presents with a concern about fetal movement that she did the right thing, and we want to hear from her again immediately if the movement is decreased again or persists. We cannot make women feel silly for calling. We should do an ultrasound for worried moms even if the NST is reactive to make sure we are not missing oligohydramnios or fetal growth restriction; the latter is the biggest known risk factor for stillbirth. We also should perform an ultrasound for moms with risk factors for stillbirth such as advanced maternal age or black race.
The education about and plan for management of decreased fetal movement are two components of the UK Saving Babies Lives Protocol; one study in the United Kingdom has shown a 20% decline in stillbirths from 2010 to 2017. The other two components are making sure to catch all fetal growth restricted babies and smoking cessation. We incorporated this protocol in my practice several months ago, and we have had very positive feedback from patients. We are not getting an increase in concerns/visits and have not had any patients call and say that they were upset about receiving this education. The Word Health Organization calls stillbirth a “neglected tragedy.” The United States has the lowest annual reduction of its stillbirth rate for all high-income nations in the Lancet 2015 series on stillbirth.6
Dr. Florescue is an ob.gyn. in private practice at Women Gynecology and Childbirth Associates in Rochester, N.Y. She delivers babies at Highland Hospital in Rochester. She has no relevant financial disclosures.
References
1. The Lancet. 2016, Jan 18;387(10018):587-603.
2. JAMA. 2011 Dec 14;306(22):2469-79.
3. BMC Pregnancy Childbirth. 2015 Aug 15;15:172.
4. BMJ Open. 2018 Jul 6;8(7):e020031.
5. Midwifery. 2018 Jul;62:171-6.
6. The Lancet. 2016, Jan 18;387(10019):691-702.
*This article was updated on 5/4/2020.
We have all as providers experienced the tragic stillbirth of a term fetus for one of our patients. Too often no fetal movement was felt for days, but the patient never called. Or the patient did call, but the nonstress test (NST) was reactive or the ultrasound showed normal growth and fluid or the biophysical profile (BPP) was 8/8. Yet the patient still presented with a stillborn fetus a day later. Was the first patient simply so fearful of the likely deceased child within her that she did not call? Or did she simply not know to report it because she was not educated about what decreased fetal movement could mean? Could the second example have been prevented even though the testing was normal? I believe both scenarios could have been prevented with better education for both providers and patients.
The national stillbirth rate has remained relatively stagnant since 2000, despite many improvements in guidelines for the management of higher risk pregnancies.1 We follow the growth of these pregnancies, do NSTs, and often induce these patients prior to the due date. We do this in the hope of having a healthy mom and baby. However, an analysis of 614 stillbirth cases and 1,816 control deliveries found that 81% of patients presenting with a stillborn baby had no risks factors that required additional monitoring.2 Nearly 66% of 1,714 patients with a late stillbirth reported decreased fetal movement, no fetal movement, or a concerning increase in fetal movement in the days leading up to their baby’s death.3 Studies have suggested that persistent decreased fetal movement has an odds ratio for stillbirth of 4.51,4 which is higher than hypertensive disease and diabetes for this same outcome by nearly a factor of two. Yet there are no formal guidelines on education for patients or management of this chief complaint.
We assess fetal movement at every prenatal visit but patients who experienced stillbirth will say they didn’t know why. This is because as a culture and a profession we are afraid to talk about such a taboo subject as stillbirth. We are afraid we will scare our patients if we tell them that a decrease in fetal movement or no fetal movement may be because their baby is at risk for this dreaded complication. On one level this argument makes sense, but as soon as the baby is born we give parents plenty of education and advice to keep their children safe. Telling a parent to remove all bedding, put their baby on their back, and keep their baby from being too warm to prevent sudden infant death syndrome (SIDS) is very scary. However, this education is necessary. If moms simply know the reason why we ask about fetal movements, they may not wait 2 days before they call. We must have faith that pregnant women can handle this education about decreased fetal movement.
Next most important is our response to the complaint of decreased fetal movement. Often when the NST is reactive or the ultrasound is normal, we assume the baby is at no risk and we reassure the mother that everything is fine. We often tell moms the false myth that babies slow down at the end or advise kick counts after this complaint despite studies failing to show their utility. Because the education about kick count is frequency is what matters, a mother may not call if there is a change in pattern or strength – even if she is very worried about this. A baby may “pass” a kick count, but a mom still may be very worried, yet she will not call because the baby “passed.”
Protocols from the United Kingdom and Australia focus on the assumption that the complaint of decreased fetal movement may be the only warning sign of impending stillbirth. Harvey Kliman, MD, PhD, director of reproductive and placental research unit at Yale University, New Haven, Conn. said an analogy to this is a car driving 55 miles per hour despite only 10 miles of gas being left in the tank.* The car is running fine even when it is almost out of gas. That may be why we all have seen a fetus with recent reassuring tests in the last few days who presents stillborn. Perhaps the only warning sign is decreased fetal movement – not a nonreactive NST or low score BPP. Placental insufficiency is often the cause of initially unexplained stillbirth, far more common than “cord accidents.” If we liken the placenta to the “gas tank” for the pregnancy, then decreased fetal movement may be the “low gas” signal on the dashboard. After this patient has a reactive NST and/or reassuring ultrasound, we need to ask her if she is reassured. Data from a study of 380 women found that women who had a gut instinct that something was wrong were 23 times more likely to experience a stillbirth, according to the unadjusted odds ratio from the logistic regression model.5 We should follow up closely with moms who are not reassured and consider induction if they are over 39 weeks. We should tell every mom who presents with a concern about fetal movement that she did the right thing, and we want to hear from her again immediately if the movement is decreased again or persists. We cannot make women feel silly for calling. We should do an ultrasound for worried moms even if the NST is reactive to make sure we are not missing oligohydramnios or fetal growth restriction; the latter is the biggest known risk factor for stillbirth. We also should perform an ultrasound for moms with risk factors for stillbirth such as advanced maternal age or black race.
The education about and plan for management of decreased fetal movement are two components of the UK Saving Babies Lives Protocol; one study in the United Kingdom has shown a 20% decline in stillbirths from 2010 to 2017. The other two components are making sure to catch all fetal growth restricted babies and smoking cessation. We incorporated this protocol in my practice several months ago, and we have had very positive feedback from patients. We are not getting an increase in concerns/visits and have not had any patients call and say that they were upset about receiving this education. The Word Health Organization calls stillbirth a “neglected tragedy.” The United States has the lowest annual reduction of its stillbirth rate for all high-income nations in the Lancet 2015 series on stillbirth.6
Dr. Florescue is an ob.gyn. in private practice at Women Gynecology and Childbirth Associates in Rochester, N.Y. She delivers babies at Highland Hospital in Rochester. She has no relevant financial disclosures.
References
1. The Lancet. 2016, Jan 18;387(10018):587-603.
2. JAMA. 2011 Dec 14;306(22):2469-79.
3. BMC Pregnancy Childbirth. 2015 Aug 15;15:172.
4. BMJ Open. 2018 Jul 6;8(7):e020031.
5. Midwifery. 2018 Jul;62:171-6.
6. The Lancet. 2016, Jan 18;387(10019):691-702.
*This article was updated on 5/4/2020.
COVID-19: Loss and grief without an expiration date
We are all experiencing collective loss and grief because of COVID-19, but that doesn’t mean that we are experiencing the same loss or grieving the same way.
Losses can be unique to individuals, such as the death of a loved one or divorce from a spouse. They can also be more universal, such as the tragedy of Sept. 11, 2001. However, both of these types of losses are generally associated with a distinct event that has a known beginning and endpoint. What makes the losses related to the coronavirus so different is that there is not a known expiration date. This lack of certainty about when the losses caused by the pandemic will end makes it difficult to process and mourn appropriately.
The multitude of potential losses includes, of course, the death of thousands of people. Many of us have personally lost loved ones or know people who have had loss because of COVID-19-related illnesses. There have also been numerous illnesses caused by delayed medical care tied to fears of going to a hospital during the pandemic. Unfortunately, there is an anticipatory loss because of the invariable diseases that will be diagnosed because of the halt of routine and preventive medical care during this current restricted phase of social distancing.
There are also losses that are not related to health. These more intangible losses may include the loss of employment and stable income; loss of our children’s completion of their academic year; loss of socialization; loss of travel and visits to friends and family; loss of normal childbirth where a pregnant mother is accompanied by her partner; loss of visiting sick relatives and newborns; loss of dating, weddings, graduations, and milestone birthday celebrations; loss of visits to nursing homes of your loved ones; loss of the needed services and support to help with your young child’s disabilities; and loss of intimacy, connection and touch.
Such losses may seem inconsequential, compared with the death of an acquaintance or loved one. But we do not know the back story behind these other losses. For example, could a family member who is unable to meet the newest addition to the family have a terminal disease and his or her own expiration date? Could the lack of dating exacerbate a new divorcée’s feeling of loneliness and despair?
When we know the details associated with the individual’s loss due to COVID-19, we can understand and better empathize. Continued collective loss without an expiration date will lead to collective grief without an endpoint.
Stages of grief
The five distinct stages of grief experienced after a loss were initially developed by psychiatrist Elisabeth Kübler-Ross, in her 1969 book “On Death and Dying” and again explored in her book “On Grief and Grieving” in 2005. The stages of grief are denial, anger, bargaining, depression, and acceptance.
The grief process is unique to each individual and not necessarily a predictable process, with some moving through the stages at a slower pace while others can get stuck in one or more of the stages. This non-linear pattern of grief is evident in our grief response to the COVID-19 pandemic.
Some of us had experiences of denial back in early March, when initial thoughts crept up, such as “this can’t be as bad as what the medical officials are proposing” and “how is this any different from the flu?” Denial is used as a protective defense against feeling an abundance of emotions all at once, while allowing us time to adjust to the new situation.
Most of us have also had experiences with anger directed at our leaders for not adequately preparing us and intense rage at health care administrators for lack of proper protective gear for our first-line health care workers.
Bargaining tactics were noticeable with common thoughts such as “if we stay home and risk the demise of our economy, we will have the chance to protect our most vulnerable populations and therefore save lives.” Unfortunately, many of us have also experienced thoughts of despair and depression. Feelings of hopelessness and helplessness set in with many parents, who, overnight, were given dual roles as a parent and teacher. Many parents are attempting to simultaneously juggle a full-time workload.
Some of us already have begun to move to the last stage of grief, which is acceptance. Although most of us will experience all five of the stages of grief, we are not necessarily in the same stage at the same time. This can lead to contentious conversations among colleagues, friends, and family members. We might not necessarily be in the same mourning stage as our spouse, child, mother, father, sister, brother, aunt, uncle, cousins, or friend. The differences in how we mourn can result in your spouse remaining in the denial phase of grief and refusing to wear a mask to the grocery store. At the same time, you may have already entered the bargaining phase and are willing to forgo the niceties of grocery shopping to protect and promote the common good.
With loss inevitably comes change
This difference in these stages of loss can affect how we all return to a new sense of routine when we begin to reopen our communities.
Unfortunately, we will not have defined guidelines or cookbook steps and rules to abide by. The one thing we will have is our ability to accept each other’s differences, especially when it comes to grief.
Remember, we all will grieve in our way, and this isn’t a race to the finish line. What we do know is that none of us are coming out of this unscathed. This global loss will forever change us. Our new standard will take time for acclimation, but we will get there. With loss inevitably comes change, and this experience will allow us to redefine who we are and what we choose to prioritize and focus on post pandemic. There will be a post-pandemic period, whether it is 6 months, 1 year, or 2 years from now; we will eventually start to shake hands again, even hug and kiss hello. What we need to make sure of is that we don’t forget this time. Whatever meaning you find, and change for the better, will hopefully transcend to your post-pandemic life.
Dr. Abraham is a psychiatrist in private practice in Philadelphia. She has no disclosures.
We are all experiencing collective loss and grief because of COVID-19, but that doesn’t mean that we are experiencing the same loss or grieving the same way.
Losses can be unique to individuals, such as the death of a loved one or divorce from a spouse. They can also be more universal, such as the tragedy of Sept. 11, 2001. However, both of these types of losses are generally associated with a distinct event that has a known beginning and endpoint. What makes the losses related to the coronavirus so different is that there is not a known expiration date. This lack of certainty about when the losses caused by the pandemic will end makes it difficult to process and mourn appropriately.
The multitude of potential losses includes, of course, the death of thousands of people. Many of us have personally lost loved ones or know people who have had loss because of COVID-19-related illnesses. There have also been numerous illnesses caused by delayed medical care tied to fears of going to a hospital during the pandemic. Unfortunately, there is an anticipatory loss because of the invariable diseases that will be diagnosed because of the halt of routine and preventive medical care during this current restricted phase of social distancing.
There are also losses that are not related to health. These more intangible losses may include the loss of employment and stable income; loss of our children’s completion of their academic year; loss of socialization; loss of travel and visits to friends and family; loss of normal childbirth where a pregnant mother is accompanied by her partner; loss of visiting sick relatives and newborns; loss of dating, weddings, graduations, and milestone birthday celebrations; loss of visits to nursing homes of your loved ones; loss of the needed services and support to help with your young child’s disabilities; and loss of intimacy, connection and touch.
Such losses may seem inconsequential, compared with the death of an acquaintance or loved one. But we do not know the back story behind these other losses. For example, could a family member who is unable to meet the newest addition to the family have a terminal disease and his or her own expiration date? Could the lack of dating exacerbate a new divorcée’s feeling of loneliness and despair?
When we know the details associated with the individual’s loss due to COVID-19, we can understand and better empathize. Continued collective loss without an expiration date will lead to collective grief without an endpoint.
Stages of grief
The five distinct stages of grief experienced after a loss were initially developed by psychiatrist Elisabeth Kübler-Ross, in her 1969 book “On Death and Dying” and again explored in her book “On Grief and Grieving” in 2005. The stages of grief are denial, anger, bargaining, depression, and acceptance.
The grief process is unique to each individual and not necessarily a predictable process, with some moving through the stages at a slower pace while others can get stuck in one or more of the stages. This non-linear pattern of grief is evident in our grief response to the COVID-19 pandemic.
Some of us had experiences of denial back in early March, when initial thoughts crept up, such as “this can’t be as bad as what the medical officials are proposing” and “how is this any different from the flu?” Denial is used as a protective defense against feeling an abundance of emotions all at once, while allowing us time to adjust to the new situation.
Most of us have also had experiences with anger directed at our leaders for not adequately preparing us and intense rage at health care administrators for lack of proper protective gear for our first-line health care workers.
Bargaining tactics were noticeable with common thoughts such as “if we stay home and risk the demise of our economy, we will have the chance to protect our most vulnerable populations and therefore save lives.” Unfortunately, many of us have also experienced thoughts of despair and depression. Feelings of hopelessness and helplessness set in with many parents, who, overnight, were given dual roles as a parent and teacher. Many parents are attempting to simultaneously juggle a full-time workload.
Some of us already have begun to move to the last stage of grief, which is acceptance. Although most of us will experience all five of the stages of grief, we are not necessarily in the same stage at the same time. This can lead to contentious conversations among colleagues, friends, and family members. We might not necessarily be in the same mourning stage as our spouse, child, mother, father, sister, brother, aunt, uncle, cousins, or friend. The differences in how we mourn can result in your spouse remaining in the denial phase of grief and refusing to wear a mask to the grocery store. At the same time, you may have already entered the bargaining phase and are willing to forgo the niceties of grocery shopping to protect and promote the common good.
With loss inevitably comes change
This difference in these stages of loss can affect how we all return to a new sense of routine when we begin to reopen our communities.
Unfortunately, we will not have defined guidelines or cookbook steps and rules to abide by. The one thing we will have is our ability to accept each other’s differences, especially when it comes to grief.
Remember, we all will grieve in our way, and this isn’t a race to the finish line. What we do know is that none of us are coming out of this unscathed. This global loss will forever change us. Our new standard will take time for acclimation, but we will get there. With loss inevitably comes change, and this experience will allow us to redefine who we are and what we choose to prioritize and focus on post pandemic. There will be a post-pandemic period, whether it is 6 months, 1 year, or 2 years from now; we will eventually start to shake hands again, even hug and kiss hello. What we need to make sure of is that we don’t forget this time. Whatever meaning you find, and change for the better, will hopefully transcend to your post-pandemic life.
Dr. Abraham is a psychiatrist in private practice in Philadelphia. She has no disclosures.
We are all experiencing collective loss and grief because of COVID-19, but that doesn’t mean that we are experiencing the same loss or grieving the same way.
Losses can be unique to individuals, such as the death of a loved one or divorce from a spouse. They can also be more universal, such as the tragedy of Sept. 11, 2001. However, both of these types of losses are generally associated with a distinct event that has a known beginning and endpoint. What makes the losses related to the coronavirus so different is that there is not a known expiration date. This lack of certainty about when the losses caused by the pandemic will end makes it difficult to process and mourn appropriately.
The multitude of potential losses includes, of course, the death of thousands of people. Many of us have personally lost loved ones or know people who have had loss because of COVID-19-related illnesses. There have also been numerous illnesses caused by delayed medical care tied to fears of going to a hospital during the pandemic. Unfortunately, there is an anticipatory loss because of the invariable diseases that will be diagnosed because of the halt of routine and preventive medical care during this current restricted phase of social distancing.
There are also losses that are not related to health. These more intangible losses may include the loss of employment and stable income; loss of our children’s completion of their academic year; loss of socialization; loss of travel and visits to friends and family; loss of normal childbirth where a pregnant mother is accompanied by her partner; loss of visiting sick relatives and newborns; loss of dating, weddings, graduations, and milestone birthday celebrations; loss of visits to nursing homes of your loved ones; loss of the needed services and support to help with your young child’s disabilities; and loss of intimacy, connection and touch.
Such losses may seem inconsequential, compared with the death of an acquaintance or loved one. But we do not know the back story behind these other losses. For example, could a family member who is unable to meet the newest addition to the family have a terminal disease and his or her own expiration date? Could the lack of dating exacerbate a new divorcée’s feeling of loneliness and despair?
When we know the details associated with the individual’s loss due to COVID-19, we can understand and better empathize. Continued collective loss without an expiration date will lead to collective grief without an endpoint.
Stages of grief
The five distinct stages of grief experienced after a loss were initially developed by psychiatrist Elisabeth Kübler-Ross, in her 1969 book “On Death and Dying” and again explored in her book “On Grief and Grieving” in 2005. The stages of grief are denial, anger, bargaining, depression, and acceptance.
The grief process is unique to each individual and not necessarily a predictable process, with some moving through the stages at a slower pace while others can get stuck in one or more of the stages. This non-linear pattern of grief is evident in our grief response to the COVID-19 pandemic.
Some of us had experiences of denial back in early March, when initial thoughts crept up, such as “this can’t be as bad as what the medical officials are proposing” and “how is this any different from the flu?” Denial is used as a protective defense against feeling an abundance of emotions all at once, while allowing us time to adjust to the new situation.
Most of us have also had experiences with anger directed at our leaders for not adequately preparing us and intense rage at health care administrators for lack of proper protective gear for our first-line health care workers.
Bargaining tactics were noticeable with common thoughts such as “if we stay home and risk the demise of our economy, we will have the chance to protect our most vulnerable populations and therefore save lives.” Unfortunately, many of us have also experienced thoughts of despair and depression. Feelings of hopelessness and helplessness set in with many parents, who, overnight, were given dual roles as a parent and teacher. Many parents are attempting to simultaneously juggle a full-time workload.
Some of us already have begun to move to the last stage of grief, which is acceptance. Although most of us will experience all five of the stages of grief, we are not necessarily in the same stage at the same time. This can lead to contentious conversations among colleagues, friends, and family members. We might not necessarily be in the same mourning stage as our spouse, child, mother, father, sister, brother, aunt, uncle, cousins, or friend. The differences in how we mourn can result in your spouse remaining in the denial phase of grief and refusing to wear a mask to the grocery store. At the same time, you may have already entered the bargaining phase and are willing to forgo the niceties of grocery shopping to protect and promote the common good.
With loss inevitably comes change
This difference in these stages of loss can affect how we all return to a new sense of routine when we begin to reopen our communities.
Unfortunately, we will not have defined guidelines or cookbook steps and rules to abide by. The one thing we will have is our ability to accept each other’s differences, especially when it comes to grief.
Remember, we all will grieve in our way, and this isn’t a race to the finish line. What we do know is that none of us are coming out of this unscathed. This global loss will forever change us. Our new standard will take time for acclimation, but we will get there. With loss inevitably comes change, and this experience will allow us to redefine who we are and what we choose to prioritize and focus on post pandemic. There will be a post-pandemic period, whether it is 6 months, 1 year, or 2 years from now; we will eventually start to shake hands again, even hug and kiss hello. What we need to make sure of is that we don’t forget this time. Whatever meaning you find, and change for the better, will hopefully transcend to your post-pandemic life.
Dr. Abraham is a psychiatrist in private practice in Philadelphia. She has no disclosures.
What will pediatrics look like in 2022?
In 1966 I was struggling with the decision of whether to become an art historian or go to medical school. I decided corporate ladder climbs and tenure chases were not for me. I wanted to be my own boss. I reckoned that medicine would offer me rock-solid job security and a comfortable income that I could adjust to my needs simply by working harder. In my Norman Rockwell–influenced view of the world, there would always be sick children. There would never be a quiet week or even a day when I would have to worry about not having an income.
So it was an idyllic existence for decades, tarnished only slightly when corporate entities began gobbling up owner-operator practices. But I never envisioned a pandemic that would turn the world – including its pediatricians – upside down. For the last several weeks as I pedal past my old office, I am dumbstruck by the empty parking lot. For the present I appear to be buffered by my retirement, but know that many of you are under serious financial pressure as a result of the pandemic.
We are all yearning to return to business as usual, but we know that it isn’t going to happen because everything has changed. The usual has yet to be defined. When you finally reopen your offices, you will be walking into a strange and eerie new normal. Initially you may struggle to make it feel like nothing has changed, but very quickly the full force of the postpandemic tsunami will hit us all broadside. In 2 years, the ship may still be rocking but what will clinical pediatrics look like in the late spring of 2022?
Will the patient mix have shifted even more toward behavioral and mental health complaints as a ripple effect of the pandemic’s emotional turmoil? Will your waiting room have become a maze of plexiglass barriers to separate the sick from the well? Has the hospital invested hundreds of thousands of dollars in a ventilation system in hopes of minimizing contagion in your exam rooms? Maybe you will have instituted an appointment schedule with sick visits in the morning and well checks in the afternoon. Or you may no longer have a waiting room because patients are queuing in their cars in the parking lot. Your support staff may be rollerskating around like carhops at a drive-in recording histories and taking vital signs.
Telemedicine will hopefully have gone mainstream with more robust guidelines for billing and quality control. Medical schools may be devoting more attention to teaching student how to assess remotely. Parents may now be equipped with a tool kit of remote sensors so that you can assess their child’s tympanic membranes, pulse rate, oxygen saturation, and blood pressure on your office computer screen.
Will the EHR finally have begun to emerge from its awkward and at times painful adolescence into an easily accessible and transportable nationwide data bank that includes immunization records for all ages? Patients may have been asked or ordered to allow their cell phones to be used as tracking devices for serious communicable diseases. How many vaccine-resistant people will have responded to the pandemic by deciding that immunizations are worth the minimal risks? I fear not many.
How many of your colleagues will have left pediatrics and heeded the call for more epidemiologists? Will you be required to take a CME course in ventilation management? The good news may be that to keep the pediatric workforce robust the government has decided to forgive your student loans.
None of these changes may have come to pass because we have notoriously short memories. But I am sure that we will all still bear the deep scars of this world changing event.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
In 1966 I was struggling with the decision of whether to become an art historian or go to medical school. I decided corporate ladder climbs and tenure chases were not for me. I wanted to be my own boss. I reckoned that medicine would offer me rock-solid job security and a comfortable income that I could adjust to my needs simply by working harder. In my Norman Rockwell–influenced view of the world, there would always be sick children. There would never be a quiet week or even a day when I would have to worry about not having an income.
So it was an idyllic existence for decades, tarnished only slightly when corporate entities began gobbling up owner-operator practices. But I never envisioned a pandemic that would turn the world – including its pediatricians – upside down. For the last several weeks as I pedal past my old office, I am dumbstruck by the empty parking lot. For the present I appear to be buffered by my retirement, but know that many of you are under serious financial pressure as a result of the pandemic.
We are all yearning to return to business as usual, but we know that it isn’t going to happen because everything has changed. The usual has yet to be defined. When you finally reopen your offices, you will be walking into a strange and eerie new normal. Initially you may struggle to make it feel like nothing has changed, but very quickly the full force of the postpandemic tsunami will hit us all broadside. In 2 years, the ship may still be rocking but what will clinical pediatrics look like in the late spring of 2022?
Will the patient mix have shifted even more toward behavioral and mental health complaints as a ripple effect of the pandemic’s emotional turmoil? Will your waiting room have become a maze of plexiglass barriers to separate the sick from the well? Has the hospital invested hundreds of thousands of dollars in a ventilation system in hopes of minimizing contagion in your exam rooms? Maybe you will have instituted an appointment schedule with sick visits in the morning and well checks in the afternoon. Or you may no longer have a waiting room because patients are queuing in their cars in the parking lot. Your support staff may be rollerskating around like carhops at a drive-in recording histories and taking vital signs.
Telemedicine will hopefully have gone mainstream with more robust guidelines for billing and quality control. Medical schools may be devoting more attention to teaching student how to assess remotely. Parents may now be equipped with a tool kit of remote sensors so that you can assess their child’s tympanic membranes, pulse rate, oxygen saturation, and blood pressure on your office computer screen.
Will the EHR finally have begun to emerge from its awkward and at times painful adolescence into an easily accessible and transportable nationwide data bank that includes immunization records for all ages? Patients may have been asked or ordered to allow their cell phones to be used as tracking devices for serious communicable diseases. How many vaccine-resistant people will have responded to the pandemic by deciding that immunizations are worth the minimal risks? I fear not many.
How many of your colleagues will have left pediatrics and heeded the call for more epidemiologists? Will you be required to take a CME course in ventilation management? The good news may be that to keep the pediatric workforce robust the government has decided to forgive your student loans.
None of these changes may have come to pass because we have notoriously short memories. But I am sure that we will all still bear the deep scars of this world changing event.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
In 1966 I was struggling with the decision of whether to become an art historian or go to medical school. I decided corporate ladder climbs and tenure chases were not for me. I wanted to be my own boss. I reckoned that medicine would offer me rock-solid job security and a comfortable income that I could adjust to my needs simply by working harder. In my Norman Rockwell–influenced view of the world, there would always be sick children. There would never be a quiet week or even a day when I would have to worry about not having an income.
So it was an idyllic existence for decades, tarnished only slightly when corporate entities began gobbling up owner-operator practices. But I never envisioned a pandemic that would turn the world – including its pediatricians – upside down. For the last several weeks as I pedal past my old office, I am dumbstruck by the empty parking lot. For the present I appear to be buffered by my retirement, but know that many of you are under serious financial pressure as a result of the pandemic.
We are all yearning to return to business as usual, but we know that it isn’t going to happen because everything has changed. The usual has yet to be defined. When you finally reopen your offices, you will be walking into a strange and eerie new normal. Initially you may struggle to make it feel like nothing has changed, but very quickly the full force of the postpandemic tsunami will hit us all broadside. In 2 years, the ship may still be rocking but what will clinical pediatrics look like in the late spring of 2022?
Will the patient mix have shifted even more toward behavioral and mental health complaints as a ripple effect of the pandemic’s emotional turmoil? Will your waiting room have become a maze of plexiglass barriers to separate the sick from the well? Has the hospital invested hundreds of thousands of dollars in a ventilation system in hopes of minimizing contagion in your exam rooms? Maybe you will have instituted an appointment schedule with sick visits in the morning and well checks in the afternoon. Or you may no longer have a waiting room because patients are queuing in their cars in the parking lot. Your support staff may be rollerskating around like carhops at a drive-in recording histories and taking vital signs.
Telemedicine will hopefully have gone mainstream with more robust guidelines for billing and quality control. Medical schools may be devoting more attention to teaching student how to assess remotely. Parents may now be equipped with a tool kit of remote sensors so that you can assess their child’s tympanic membranes, pulse rate, oxygen saturation, and blood pressure on your office computer screen.
Will the EHR finally have begun to emerge from its awkward and at times painful adolescence into an easily accessible and transportable nationwide data bank that includes immunization records for all ages? Patients may have been asked or ordered to allow their cell phones to be used as tracking devices for serious communicable diseases. How many vaccine-resistant people will have responded to the pandemic by deciding that immunizations are worth the minimal risks? I fear not many.
How many of your colleagues will have left pediatrics and heeded the call for more epidemiologists? Will you be required to take a CME course in ventilation management? The good news may be that to keep the pediatric workforce robust the government has decided to forgive your student loans.
None of these changes may have come to pass because we have notoriously short memories. But I am sure that we will all still bear the deep scars of this world changing event.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
New guidelines for testosterone treatment in adult men with age-related low testosterone
Testosterone normally decreases with age in men beginning in their mid-30s, with a rate of decline averaging approximately 1.6% per year. Using a cutoff of a total testosterone less than 325 ng/dL, the incidence of low testosterone is approximately 20% after age 60 years, and 30% after age 70. While the change in labs values has been reasonably validated,
Additional potential symptoms of testosterone deficiency include changes in bone mineral density, decreased libido, depression, erectile dysfunction, loss of hair, and general weakness. Since the symptoms are nonspecific, it is often unclear if someone should be tested or treated for testosterone deficiency. To address this issue, the American College of Physicians commissioned a systematic review of the evidence on testosterone-replacement therapy for age-related testosterone deficiency.1
The evidence review of testosterone replacement in men with age-related low testosterone found the following.
- Low-certainty evidence of improvement in quality of life
- Moderate-certainty evidence of a small improvement in sexual function
- Low-certainty evidence of a small improvement in erectile function
- Low-certainty evidence showing little to no improvement in physical function
- Low-certainty evidence of a small increase to no difference in adverse cardiovascular events
- Moderate-certainty evidence of no increase in the risk for serious adverse events
The trials were not powered to assess mortality, but pool analysis showed fewer deaths among patients treated with testosterone than those who received placebo (odds ratio, 0.47; 95% confidence interval, 0.25-0.89). There were no differences in cognitive function, and the improvement in vitality and fatigue was “less than a small amount.” Evidence from an observational trial showed no increased risk for mortality, cardiovascular events, prostate cancer, or pulmonary embolus or deep vein thrombosis. Of note, most studies excluded men with recent cardiovascular disease.
This evidence review led to the following recommendations.2
Recommendation 1a
Clinicians should have a discussion regarding the potential risk and benefits of treatment with the patients who have documented age-related low testosterone (testosterone levels less than 10.4 nmol/L or 300 ng/dL) and are suffering from sexual dysfunction or have a desire to enhance their sexual function.
This recommendation was based on evidence showing small improvement in sexual function and erectile dysfunction.
Recommendation 1b
For patients who opt for treatment based on recommendation 1a, clinicians should reevaluate the benefit of treatment within 12 months. If a patient is not receiving any benefit in sexual function by 12 months, it is recommended that treatment be stopped at that time.
The ACP recommendation to stop treatment if a patient lacks improvement of sexual function within 12 months stems from low or insufficient evidence regarding potential harm of treatment. If the treatment is not helping the target symptom then the benefit no longer outweighs the potential harm.
Recommendation 1c
For patients who opt for treatment based on recommendation 1a, intramuscular replacement therapy rather than transdermal replacement therapy is recommended because of substantial differences in the cost.
It is important to note that both intramuscular and transdermal testosterone applications have been associated with improvements in sexual function, without any significant differences noted in benefit or harm for the patients. This recommendation is based on a per-person per-year average cost of the intramuscular formulation – $156.32, compared with the transdermal formulation – $2,135.32.
Recommendation 2
The ACP does not endorse the use of testosterone treatment for age-related low testosterone in patients desiring improvement in physical function, mood, energy, or cognitive function.
This clear recommendation is critical, as this might be the most common reason for prescriptions of testosterone – a misplaced belief that testosterone will help general quality of life. The evidence simply does not support this effect of testosterone replacement for age-related testosterone deficiency.
The bottom line
Testosterone levels in men decrease steadily with age, with a great deal of variability. Testosterone replacement therapy may be considered for men with age-related testosterone deficiency and sexual dysfunction. Testosterone replacement therapy is not recommended as a treatment for general fatigue, weakness or with an expectation that it will improve physical function, mood, energy, or cognitive function.
Dr. Hansen is a third-year resident in the family medicine residency program at Abington (Pa.) Hospital–Jefferson Health. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Hospital–Jefferson Health.
References
1. Diem SJ et al. Efficacy and safety of testosterone treatment in men: An evidence report for a clinical practice guideline by the American College of Physicians. Ann Intern Med. 2020 Jan 21. doi: 10.7326/M19-0830.
2. Qaseem A et al. Testosterone treatment in adult men with age-related low testosterone: A clinical guideline from the American College of Physicians. Ann Intern Med. 2020 Jan 21. doi: 10.7326/M19-0882.
Testosterone normally decreases with age in men beginning in their mid-30s, with a rate of decline averaging approximately 1.6% per year. Using a cutoff of a total testosterone less than 325 ng/dL, the incidence of low testosterone is approximately 20% after age 60 years, and 30% after age 70. While the change in labs values has been reasonably validated,
Additional potential symptoms of testosterone deficiency include changes in bone mineral density, decreased libido, depression, erectile dysfunction, loss of hair, and general weakness. Since the symptoms are nonspecific, it is often unclear if someone should be tested or treated for testosterone deficiency. To address this issue, the American College of Physicians commissioned a systematic review of the evidence on testosterone-replacement therapy for age-related testosterone deficiency.1
The evidence review of testosterone replacement in men with age-related low testosterone found the following.
- Low-certainty evidence of improvement in quality of life
- Moderate-certainty evidence of a small improvement in sexual function
- Low-certainty evidence of a small improvement in erectile function
- Low-certainty evidence showing little to no improvement in physical function
- Low-certainty evidence of a small increase to no difference in adverse cardiovascular events
- Moderate-certainty evidence of no increase in the risk for serious adverse events
The trials were not powered to assess mortality, but pool analysis showed fewer deaths among patients treated with testosterone than those who received placebo (odds ratio, 0.47; 95% confidence interval, 0.25-0.89). There were no differences in cognitive function, and the improvement in vitality and fatigue was “less than a small amount.” Evidence from an observational trial showed no increased risk for mortality, cardiovascular events, prostate cancer, or pulmonary embolus or deep vein thrombosis. Of note, most studies excluded men with recent cardiovascular disease.
This evidence review led to the following recommendations.2
Recommendation 1a
Clinicians should have a discussion regarding the potential risk and benefits of treatment with the patients who have documented age-related low testosterone (testosterone levels less than 10.4 nmol/L or 300 ng/dL) and are suffering from sexual dysfunction or have a desire to enhance their sexual function.
This recommendation was based on evidence showing small improvement in sexual function and erectile dysfunction.
Recommendation 1b
For patients who opt for treatment based on recommendation 1a, clinicians should reevaluate the benefit of treatment within 12 months. If a patient is not receiving any benefit in sexual function by 12 months, it is recommended that treatment be stopped at that time.
The ACP recommendation to stop treatment if a patient lacks improvement of sexual function within 12 months stems from low or insufficient evidence regarding potential harm of treatment. If the treatment is not helping the target symptom then the benefit no longer outweighs the potential harm.
Recommendation 1c
For patients who opt for treatment based on recommendation 1a, intramuscular replacement therapy rather than transdermal replacement therapy is recommended because of substantial differences in the cost.
It is important to note that both intramuscular and transdermal testosterone applications have been associated with improvements in sexual function, without any significant differences noted in benefit or harm for the patients. This recommendation is based on a per-person per-year average cost of the intramuscular formulation – $156.32, compared with the transdermal formulation – $2,135.32.
Recommendation 2
The ACP does not endorse the use of testosterone treatment for age-related low testosterone in patients desiring improvement in physical function, mood, energy, or cognitive function.
This clear recommendation is critical, as this might be the most common reason for prescriptions of testosterone – a misplaced belief that testosterone will help general quality of life. The evidence simply does not support this effect of testosterone replacement for age-related testosterone deficiency.
The bottom line
Testosterone levels in men decrease steadily with age, with a great deal of variability. Testosterone replacement therapy may be considered for men with age-related testosterone deficiency and sexual dysfunction. Testosterone replacement therapy is not recommended as a treatment for general fatigue, weakness or with an expectation that it will improve physical function, mood, energy, or cognitive function.
Dr. Hansen is a third-year resident in the family medicine residency program at Abington (Pa.) Hospital–Jefferson Health. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Hospital–Jefferson Health.
References
1. Diem SJ et al. Efficacy and safety of testosterone treatment in men: An evidence report for a clinical practice guideline by the American College of Physicians. Ann Intern Med. 2020 Jan 21. doi: 10.7326/M19-0830.
2. Qaseem A et al. Testosterone treatment in adult men with age-related low testosterone: A clinical guideline from the American College of Physicians. Ann Intern Med. 2020 Jan 21. doi: 10.7326/M19-0882.
Testosterone normally decreases with age in men beginning in their mid-30s, with a rate of decline averaging approximately 1.6% per year. Using a cutoff of a total testosterone less than 325 ng/dL, the incidence of low testosterone is approximately 20% after age 60 years, and 30% after age 70. While the change in labs values has been reasonably validated,
Additional potential symptoms of testosterone deficiency include changes in bone mineral density, decreased libido, depression, erectile dysfunction, loss of hair, and general weakness. Since the symptoms are nonspecific, it is often unclear if someone should be tested or treated for testosterone deficiency. To address this issue, the American College of Physicians commissioned a systematic review of the evidence on testosterone-replacement therapy for age-related testosterone deficiency.1
The evidence review of testosterone replacement in men with age-related low testosterone found the following.
- Low-certainty evidence of improvement in quality of life
- Moderate-certainty evidence of a small improvement in sexual function
- Low-certainty evidence of a small improvement in erectile function
- Low-certainty evidence showing little to no improvement in physical function
- Low-certainty evidence of a small increase to no difference in adverse cardiovascular events
- Moderate-certainty evidence of no increase in the risk for serious adverse events
The trials were not powered to assess mortality, but pool analysis showed fewer deaths among patients treated with testosterone than those who received placebo (odds ratio, 0.47; 95% confidence interval, 0.25-0.89). There were no differences in cognitive function, and the improvement in vitality and fatigue was “less than a small amount.” Evidence from an observational trial showed no increased risk for mortality, cardiovascular events, prostate cancer, or pulmonary embolus or deep vein thrombosis. Of note, most studies excluded men with recent cardiovascular disease.
This evidence review led to the following recommendations.2
Recommendation 1a
Clinicians should have a discussion regarding the potential risk and benefits of treatment with the patients who have documented age-related low testosterone (testosterone levels less than 10.4 nmol/L or 300 ng/dL) and are suffering from sexual dysfunction or have a desire to enhance their sexual function.
This recommendation was based on evidence showing small improvement in sexual function and erectile dysfunction.
Recommendation 1b
For patients who opt for treatment based on recommendation 1a, clinicians should reevaluate the benefit of treatment within 12 months. If a patient is not receiving any benefit in sexual function by 12 months, it is recommended that treatment be stopped at that time.
The ACP recommendation to stop treatment if a patient lacks improvement of sexual function within 12 months stems from low or insufficient evidence regarding potential harm of treatment. If the treatment is not helping the target symptom then the benefit no longer outweighs the potential harm.
Recommendation 1c
For patients who opt for treatment based on recommendation 1a, intramuscular replacement therapy rather than transdermal replacement therapy is recommended because of substantial differences in the cost.
It is important to note that both intramuscular and transdermal testosterone applications have been associated with improvements in sexual function, without any significant differences noted in benefit or harm for the patients. This recommendation is based on a per-person per-year average cost of the intramuscular formulation – $156.32, compared with the transdermal formulation – $2,135.32.
Recommendation 2
The ACP does not endorse the use of testosterone treatment for age-related low testosterone in patients desiring improvement in physical function, mood, energy, or cognitive function.
This clear recommendation is critical, as this might be the most common reason for prescriptions of testosterone – a misplaced belief that testosterone will help general quality of life. The evidence simply does not support this effect of testosterone replacement for age-related testosterone deficiency.
The bottom line
Testosterone levels in men decrease steadily with age, with a great deal of variability. Testosterone replacement therapy may be considered for men with age-related testosterone deficiency and sexual dysfunction. Testosterone replacement therapy is not recommended as a treatment for general fatigue, weakness or with an expectation that it will improve physical function, mood, energy, or cognitive function.
Dr. Hansen is a third-year resident in the family medicine residency program at Abington (Pa.) Hospital–Jefferson Health. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Hospital–Jefferson Health.
References
1. Diem SJ et al. Efficacy and safety of testosterone treatment in men: An evidence report for a clinical practice guideline by the American College of Physicians. Ann Intern Med. 2020 Jan 21. doi: 10.7326/M19-0830.
2. Qaseem A et al. Testosterone treatment in adult men with age-related low testosterone: A clinical guideline from the American College of Physicians. Ann Intern Med. 2020 Jan 21. doi: 10.7326/M19-0882.
Climate changes are leading to ‘eco-anxiety,’ trauma
It is difficult right now to contemplate issues other than battling COVID-19. However, we must not lose sight of another worldwide crisis that, unless we confront it head-on, will be with us long after the pandemic is behind us. That crisis is climate change. Increased susceptibility to pandemics is likely to be a consequence of it. Unlike pandemics, climate change poses an even more long-term and pervasive existential threat to both our mental and physical health, and our existences. Many more of us who live in Australia now fear that climate change is upon us and here to stay.
Droughts, no stranger to Australians, often are punctuated by dramatic floods, and we are now dealing with extended summer seasons filled with bushfires. We are experienced in managing them. These fires are usually limited to a few different states, so fire crews typically help one another out as they are controlled and extinguished. Australians pull together with great community spirit and resilience under these circumstances.
But the last two fire seasons have been different. They have become unseasonably long, more severe, and often uncontrollable and overwhelming. We have experienced two uncharacteristically prolonged droughts, more recently creeping across most of our continent. Last spring, wild fires took hold very early and were ubiquitous, increasing during the unusually high summer heat. Climate change already had worsened our accustomed pattern of droughts, fires, and floods.
Meanwhile, the Australian federal government repeatedly ignored advice from highly respected meteorological, environmental, scientific, and economic experts.1
Warnings from experts
The state fire commissioners had formally warned our government of increasing vulnerability via climate change to bushfires. This occurred in the context of government inaction, lack of national investment (for example, insufficient water bombing equipment), and the absence of national preparation for the predicted catastrophic fire season. Prime Minister Scott Morrison declined to meet with them, minimizing the role of climate change. He provided no extra resources, emphatically leaving the responsibility to state governments.2
Distinguished economist Ross Garnaut concluded that Australia could lead the world in renewable energy production and harness it for industries and employment, if only the government chose to invest in our ample renewable sources. Sadly, our conservative government and its corporate sponsors maintain an addiction to fossil fuels, arguing that they protect employment. Meanwhile, the economic “trickle-down” benefit from massive coal and gas exports has been illusory. Socioeconomic inequities have widened, with profits favoring the mega-rich, while mining automation takes jobs.
With the fire emergency crisis at its height, Mr. Morrison sent his energy minister to the U.N. Madrid Climate Change Conference with the goal of preventing meaningful CO2 reductions, in collaboration with Brazil, Saudi Arabia, and the United States.
The sustained drought and desiccated vegetation, the escalating fuel load growth, and early hot weather led to super-hot fires, with catapulted ember attacks and fireballs falling from the sky, which burned down thousands of homes and incinerated livestock. The fires led to numerous human fatalities and overloaded hospital burn units. The unprecedented fire season duration and uncontrollable fires exhausted voluntary fire crews. There have even been fires in cool damp rain forests – the usual refuge/reservoir of endangered flora and fauna species.
The simultaneous droughts, unusual heat, and pervasive smoke also badly affect major cities, and intense fires terrorized the entire nation. Consequently, regional firefighting teams were unable to help other regions. Huge, unquenchable fires created spiraling micro-weather systems, with thunderstorms spitting dry lightning, sparking new fires and twisters, tornadoes, and updrafts hurtling heavy fire trucks into the air, which caused terrible injuries and death to fire crews. Ultimately, the federal government had to supply large-scale sea and air evacuations, and call up military reservists for civic duties.
Mental health implications
In 2007, Australian Glenn Albrecht defined “solastalgia” as the emotional pain, existential distress, loss, and grieving derived from rapid and severe changes in one’s geophysical environment or familiar habitat.3 Studies now support its existence worldwide in communities suffering great environmental change, indicating its contribution to climate change’s psychosocial impacts.4 Mental health studies also recognize the reality of “eco-anxiety,” defined as “a chronic fear of ecological doom” for self, family, community, future generations, and our planet.5
Other climate-derived psychiatric consequences include trauma, which leads to lifelong consequences for survivors of fires; grief associated with lost lives, homes, and livelihoods; posttraumatic hyperarousal; hypervigilance, re-experiencing, and rekindling; anxiety; depression; substance misuse; and long-term cognitive impacts of poor air quality. These effects are all borne from anticipated and actual loss, uncertainty about the future, and distrust in the capacity of leadership to aid recovery or prevent future recurrences. The Australian government has announced commendable, but long overdue, funds for psychological first aid, counseling, telepsychiatry, and support for developing community cohesion and resilience for first responders, young people, and badly affected rural families and communities. However, those efforts do nothing to prevent the ongoing shift of resources away from rural community mental health services, which results in severe depletion of community mental health teams, often in the very locations and communities that are suffering most from bushfires. This forces affected communities to rely on less reliable and time-limited telehealth assessments and other online services conducted by strangers, rather than more familiar and engaging in-person services – thus betraying community expectations of continuity of care and support.
While we observe our country’s path to a fateful rendezvous with an rapidly accelerating climate emergency, we can only hope that Australia and the world beyond can awaken to its reality, immediacy, extremity, and persistence and to the compelling need for serious constructive responses. It is finally dawning on the easy-going and complacent Australian public that climate change is here to stay, fully formed, as a runaway, spiraling vicious cycle – unpredictable and uncontrolled. This is not “the new normal”: It can only get worse, unless and until the nations of the world move collaboratively beyond their denial to ensure the survival of the planet and our species.
So, rather than just exemplifying a tragic casualty of rampant climate change for the world, maybe we can transform this catastrophe into an opportunity to collectively wake us up. Only then, can Australia ultimately become a positive example of developing a full national awareness of the reality and severity of the threat. Hopefully, we Australians will then commit ourselves to a full share of the global effort needed to effectively address our climate’s dire last-ditch warnings to us all.
References
1. Easton S. “ ‘Ignored and trivialized’: Experts warned Australian government before catastrophic blazes.” NBCnews.com. 2020 Feb 9.
2. Rouse A. “Scott Morrison defends why he refused to meet former fire chiefs who warned him about horror season – as he defends his handling of bushfire crisis.” Daily Mail Australia. 2020 Jan 3.
3. Albrecht G et al. Australas Psychiatry. 2007;15 Supp1:S95-8.
4. Prescott SL et al. Int J Environ Res Public Health. 2019 Nov 5;16(21).
5. Usher K et al. Int J Ment Health Nurs. 2019. Dec;28(6):1233-4.
Dr. Rosen, an officer of the Order of Australia and a Fellow of the Royal Australian and New Zealand College of Psychiatrists, is affiliated with the Brain & Mind Centre, University of Sydney, and the Institute of Mental Health at the University of Wollongong, Australia. He also is a community psychiatrist in a remote region of New South Wales, Australia. Dr. Rosen has no conflicts of interest. In Part 2, he discusses the impact of the fires on Australia’s indigenous population.
It is difficult right now to contemplate issues other than battling COVID-19. However, we must not lose sight of another worldwide crisis that, unless we confront it head-on, will be with us long after the pandemic is behind us. That crisis is climate change. Increased susceptibility to pandemics is likely to be a consequence of it. Unlike pandemics, climate change poses an even more long-term and pervasive existential threat to both our mental and physical health, and our existences. Many more of us who live in Australia now fear that climate change is upon us and here to stay.
Droughts, no stranger to Australians, often are punctuated by dramatic floods, and we are now dealing with extended summer seasons filled with bushfires. We are experienced in managing them. These fires are usually limited to a few different states, so fire crews typically help one another out as they are controlled and extinguished. Australians pull together with great community spirit and resilience under these circumstances.
But the last two fire seasons have been different. They have become unseasonably long, more severe, and often uncontrollable and overwhelming. We have experienced two uncharacteristically prolonged droughts, more recently creeping across most of our continent. Last spring, wild fires took hold very early and were ubiquitous, increasing during the unusually high summer heat. Climate change already had worsened our accustomed pattern of droughts, fires, and floods.
Meanwhile, the Australian federal government repeatedly ignored advice from highly respected meteorological, environmental, scientific, and economic experts.1
Warnings from experts
The state fire commissioners had formally warned our government of increasing vulnerability via climate change to bushfires. This occurred in the context of government inaction, lack of national investment (for example, insufficient water bombing equipment), and the absence of national preparation for the predicted catastrophic fire season. Prime Minister Scott Morrison declined to meet with them, minimizing the role of climate change. He provided no extra resources, emphatically leaving the responsibility to state governments.2
Distinguished economist Ross Garnaut concluded that Australia could lead the world in renewable energy production and harness it for industries and employment, if only the government chose to invest in our ample renewable sources. Sadly, our conservative government and its corporate sponsors maintain an addiction to fossil fuels, arguing that they protect employment. Meanwhile, the economic “trickle-down” benefit from massive coal and gas exports has been illusory. Socioeconomic inequities have widened, with profits favoring the mega-rich, while mining automation takes jobs.
With the fire emergency crisis at its height, Mr. Morrison sent his energy minister to the U.N. Madrid Climate Change Conference with the goal of preventing meaningful CO2 reductions, in collaboration with Brazil, Saudi Arabia, and the United States.
The sustained drought and desiccated vegetation, the escalating fuel load growth, and early hot weather led to super-hot fires, with catapulted ember attacks and fireballs falling from the sky, which burned down thousands of homes and incinerated livestock. The fires led to numerous human fatalities and overloaded hospital burn units. The unprecedented fire season duration and uncontrollable fires exhausted voluntary fire crews. There have even been fires in cool damp rain forests – the usual refuge/reservoir of endangered flora and fauna species.
The simultaneous droughts, unusual heat, and pervasive smoke also badly affect major cities, and intense fires terrorized the entire nation. Consequently, regional firefighting teams were unable to help other regions. Huge, unquenchable fires created spiraling micro-weather systems, with thunderstorms spitting dry lightning, sparking new fires and twisters, tornadoes, and updrafts hurtling heavy fire trucks into the air, which caused terrible injuries and death to fire crews. Ultimately, the federal government had to supply large-scale sea and air evacuations, and call up military reservists for civic duties.
Mental health implications
In 2007, Australian Glenn Albrecht defined “solastalgia” as the emotional pain, existential distress, loss, and grieving derived from rapid and severe changes in one’s geophysical environment or familiar habitat.3 Studies now support its existence worldwide in communities suffering great environmental change, indicating its contribution to climate change’s psychosocial impacts.4 Mental health studies also recognize the reality of “eco-anxiety,” defined as “a chronic fear of ecological doom” for self, family, community, future generations, and our planet.5
Other climate-derived psychiatric consequences include trauma, which leads to lifelong consequences for survivors of fires; grief associated with lost lives, homes, and livelihoods; posttraumatic hyperarousal; hypervigilance, re-experiencing, and rekindling; anxiety; depression; substance misuse; and long-term cognitive impacts of poor air quality. These effects are all borne from anticipated and actual loss, uncertainty about the future, and distrust in the capacity of leadership to aid recovery or prevent future recurrences. The Australian government has announced commendable, but long overdue, funds for psychological first aid, counseling, telepsychiatry, and support for developing community cohesion and resilience for first responders, young people, and badly affected rural families and communities. However, those efforts do nothing to prevent the ongoing shift of resources away from rural community mental health services, which results in severe depletion of community mental health teams, often in the very locations and communities that are suffering most from bushfires. This forces affected communities to rely on less reliable and time-limited telehealth assessments and other online services conducted by strangers, rather than more familiar and engaging in-person services – thus betraying community expectations of continuity of care and support.
While we observe our country’s path to a fateful rendezvous with an rapidly accelerating climate emergency, we can only hope that Australia and the world beyond can awaken to its reality, immediacy, extremity, and persistence and to the compelling need for serious constructive responses. It is finally dawning on the easy-going and complacent Australian public that climate change is here to stay, fully formed, as a runaway, spiraling vicious cycle – unpredictable and uncontrolled. This is not “the new normal”: It can only get worse, unless and until the nations of the world move collaboratively beyond their denial to ensure the survival of the planet and our species.
So, rather than just exemplifying a tragic casualty of rampant climate change for the world, maybe we can transform this catastrophe into an opportunity to collectively wake us up. Only then, can Australia ultimately become a positive example of developing a full national awareness of the reality and severity of the threat. Hopefully, we Australians will then commit ourselves to a full share of the global effort needed to effectively address our climate’s dire last-ditch warnings to us all.
References
1. Easton S. “ ‘Ignored and trivialized’: Experts warned Australian government before catastrophic blazes.” NBCnews.com. 2020 Feb 9.
2. Rouse A. “Scott Morrison defends why he refused to meet former fire chiefs who warned him about horror season – as he defends his handling of bushfire crisis.” Daily Mail Australia. 2020 Jan 3.
3. Albrecht G et al. Australas Psychiatry. 2007;15 Supp1:S95-8.
4. Prescott SL et al. Int J Environ Res Public Health. 2019 Nov 5;16(21).
5. Usher K et al. Int J Ment Health Nurs. 2019. Dec;28(6):1233-4.
Dr. Rosen, an officer of the Order of Australia and a Fellow of the Royal Australian and New Zealand College of Psychiatrists, is affiliated with the Brain & Mind Centre, University of Sydney, and the Institute of Mental Health at the University of Wollongong, Australia. He also is a community psychiatrist in a remote region of New South Wales, Australia. Dr. Rosen has no conflicts of interest. In Part 2, he discusses the impact of the fires on Australia’s indigenous population.
It is difficult right now to contemplate issues other than battling COVID-19. However, we must not lose sight of another worldwide crisis that, unless we confront it head-on, will be with us long after the pandemic is behind us. That crisis is climate change. Increased susceptibility to pandemics is likely to be a consequence of it. Unlike pandemics, climate change poses an even more long-term and pervasive existential threat to both our mental and physical health, and our existences. Many more of us who live in Australia now fear that climate change is upon us and here to stay.
Droughts, no stranger to Australians, often are punctuated by dramatic floods, and we are now dealing with extended summer seasons filled with bushfires. We are experienced in managing them. These fires are usually limited to a few different states, so fire crews typically help one another out as they are controlled and extinguished. Australians pull together with great community spirit and resilience under these circumstances.
But the last two fire seasons have been different. They have become unseasonably long, more severe, and often uncontrollable and overwhelming. We have experienced two uncharacteristically prolonged droughts, more recently creeping across most of our continent. Last spring, wild fires took hold very early and were ubiquitous, increasing during the unusually high summer heat. Climate change already had worsened our accustomed pattern of droughts, fires, and floods.
Meanwhile, the Australian federal government repeatedly ignored advice from highly respected meteorological, environmental, scientific, and economic experts.1
Warnings from experts
The state fire commissioners had formally warned our government of increasing vulnerability via climate change to bushfires. This occurred in the context of government inaction, lack of national investment (for example, insufficient water bombing equipment), and the absence of national preparation for the predicted catastrophic fire season. Prime Minister Scott Morrison declined to meet with them, minimizing the role of climate change. He provided no extra resources, emphatically leaving the responsibility to state governments.2
Distinguished economist Ross Garnaut concluded that Australia could lead the world in renewable energy production and harness it for industries and employment, if only the government chose to invest in our ample renewable sources. Sadly, our conservative government and its corporate sponsors maintain an addiction to fossil fuels, arguing that they protect employment. Meanwhile, the economic “trickle-down” benefit from massive coal and gas exports has been illusory. Socioeconomic inequities have widened, with profits favoring the mega-rich, while mining automation takes jobs.
With the fire emergency crisis at its height, Mr. Morrison sent his energy minister to the U.N. Madrid Climate Change Conference with the goal of preventing meaningful CO2 reductions, in collaboration with Brazil, Saudi Arabia, and the United States.
The sustained drought and desiccated vegetation, the escalating fuel load growth, and early hot weather led to super-hot fires, with catapulted ember attacks and fireballs falling from the sky, which burned down thousands of homes and incinerated livestock. The fires led to numerous human fatalities and overloaded hospital burn units. The unprecedented fire season duration and uncontrollable fires exhausted voluntary fire crews. There have even been fires in cool damp rain forests – the usual refuge/reservoir of endangered flora and fauna species.
The simultaneous droughts, unusual heat, and pervasive smoke also badly affect major cities, and intense fires terrorized the entire nation. Consequently, regional firefighting teams were unable to help other regions. Huge, unquenchable fires created spiraling micro-weather systems, with thunderstorms spitting dry lightning, sparking new fires and twisters, tornadoes, and updrafts hurtling heavy fire trucks into the air, which caused terrible injuries and death to fire crews. Ultimately, the federal government had to supply large-scale sea and air evacuations, and call up military reservists for civic duties.
Mental health implications
In 2007, Australian Glenn Albrecht defined “solastalgia” as the emotional pain, existential distress, loss, and grieving derived from rapid and severe changes in one’s geophysical environment or familiar habitat.3 Studies now support its existence worldwide in communities suffering great environmental change, indicating its contribution to climate change’s psychosocial impacts.4 Mental health studies also recognize the reality of “eco-anxiety,” defined as “a chronic fear of ecological doom” for self, family, community, future generations, and our planet.5
Other climate-derived psychiatric consequences include trauma, which leads to lifelong consequences for survivors of fires; grief associated with lost lives, homes, and livelihoods; posttraumatic hyperarousal; hypervigilance, re-experiencing, and rekindling; anxiety; depression; substance misuse; and long-term cognitive impacts of poor air quality. These effects are all borne from anticipated and actual loss, uncertainty about the future, and distrust in the capacity of leadership to aid recovery or prevent future recurrences. The Australian government has announced commendable, but long overdue, funds for psychological first aid, counseling, telepsychiatry, and support for developing community cohesion and resilience for first responders, young people, and badly affected rural families and communities. However, those efforts do nothing to prevent the ongoing shift of resources away from rural community mental health services, which results in severe depletion of community mental health teams, often in the very locations and communities that are suffering most from bushfires. This forces affected communities to rely on less reliable and time-limited telehealth assessments and other online services conducted by strangers, rather than more familiar and engaging in-person services – thus betraying community expectations of continuity of care and support.
While we observe our country’s path to a fateful rendezvous with an rapidly accelerating climate emergency, we can only hope that Australia and the world beyond can awaken to its reality, immediacy, extremity, and persistence and to the compelling need for serious constructive responses. It is finally dawning on the easy-going and complacent Australian public that climate change is here to stay, fully formed, as a runaway, spiraling vicious cycle – unpredictable and uncontrolled. This is not “the new normal”: It can only get worse, unless and until the nations of the world move collaboratively beyond their denial to ensure the survival of the planet and our species.
So, rather than just exemplifying a tragic casualty of rampant climate change for the world, maybe we can transform this catastrophe into an opportunity to collectively wake us up. Only then, can Australia ultimately become a positive example of developing a full national awareness of the reality and severity of the threat. Hopefully, we Australians will then commit ourselves to a full share of the global effort needed to effectively address our climate’s dire last-ditch warnings to us all.
References
1. Easton S. “ ‘Ignored and trivialized’: Experts warned Australian government before catastrophic blazes.” NBCnews.com. 2020 Feb 9.
2. Rouse A. “Scott Morrison defends why he refused to meet former fire chiefs who warned him about horror season – as he defends his handling of bushfire crisis.” Daily Mail Australia. 2020 Jan 3.
3. Albrecht G et al. Australas Psychiatry. 2007;15 Supp1:S95-8.
4. Prescott SL et al. Int J Environ Res Public Health. 2019 Nov 5;16(21).
5. Usher K et al. Int J Ment Health Nurs. 2019. Dec;28(6):1233-4.
Dr. Rosen, an officer of the Order of Australia and a Fellow of the Royal Australian and New Zealand College of Psychiatrists, is affiliated with the Brain & Mind Centre, University of Sydney, and the Institute of Mental Health at the University of Wollongong, Australia. He also is a community psychiatrist in a remote region of New South Wales, Australia. Dr. Rosen has no conflicts of interest. In Part 2, he discusses the impact of the fires on Australia’s indigenous population.
Coping with COVID-19: Things may never be the same
The last few weeks have been confusing and a little overwhelming. A hodgepodge of rapid-fire publications of potential treatments and multiple, sometimes confusing government mandates and initiatives have inundated us. The overriding theme is clear, though: Let’s first concentrate on keeping our civilization intact. State governments have been largely focused on “flattening the curve” of new infections. And the longer we slow this disease down, the better we learn how to treat it.
Multiple existing medications, repurposed from all walks of the pharmacologic world, have been screened and shown to have potential therapeutic benefit, and they are being tested even as I write this column. The nasty form of this disease is a unique form of adult respiratory distress syndrome, and the terminal event appears to be a form of disseminated intravascular coagulation, which may respond to unexpected therapies, such as clot busters (J Thromb Haemost. 2020 Apr 8. doi: 10.1111/jth.14828).
Now, let’s consider the more mundane issue of keeping your medical practice alive.
Some state medical boards have relaxed the rules on licensing, and the federal government on HIPAA compliance, so that telemedicine has finally become practical. Some EHR vendors have even rushed out modules to make it easier to conduct visits with patients through their patient portals. This has all made it almost practical to see, monitor, and treat existing patients with chronic conditions, and even new ones who do not require a biopsy.
But it has also become clear that telemedicine is not a long-term means of keeping your practice viable, at least not in your practice’s current form. It can be difficult to enroll new patients and the process of collecting copays and deductibles can be frustrating and slow. There may also resistance from our patients, who may be used to having this sort of service performed by us free-of-charge. Those selfies that in the past you may have viewed, called the patient to discuss, and then called their medication into the pharmacy – all as a convenience – are coming back to haunt you. It was free before, they say, what has changed?
Another obstacle, as always, is reimbursement. There is an inconsistent patchwork of private insurance coverage that may or may not pay you. The American Academy of Dermatology has put together an excellent resource on its web site on all matters regarding COVID-19 to help you.
But the underlying undeniable reality is that you cannot support your current practice model long term with telemedicine because only about 30% of dermatology reimbursement comes from evaluation and management codes, according to a recently published study – and the rest, procedures, obviously requires patient contact (JAMA Surg. 2020 Apr 15. doi: 10.1001/jamasurg.2020.0422).
The federal government has been economically responsive by injecting money into businesses with less than 500 employees. Most of you will be eligible and probably already have applied for the Paycheck Protection Program. These are small business “loans” that your bank puts the paperwork in for, which can total up to 2.5 times one month’s average payroll. These “loans” may be 100% forgivable (75% must come from two months payroll, another 25% rent and expenses) if you do not lay anyone off.
Employees can be kept busy doing other tasks besides directly helping with patients. Like many of you with state-mandated lockdowns, my office has never been so clean, the cabinets so well stocked, and the files so organized. The stock room has been cleaned out, and any extra personal protective gear has been donated to the hospital and emergency medical services. We have landscaped the front of our building and if it warms up, we will seal and remark the parking lot. You get my drift. I have also applied for and received an advance of three months of Medicare payments, which will be automatically paid back as practice resumes. This is in effect an interest-free loan. A few days ago, my business checking account received a deposit from the Department of Health & Human Services for 6.1% of last year’s Medicare billings. This is unexpected, no obligation support to help keep your medical office open in the time of COVID-19. It appears that the office and practice will be able to weather the fire.
Assuming our practices survive more or less intact, there are major social consequences to consider. Society is a conglomeration of individuals, and individuals act on their Maslow’s hierarchy of needs (a concept introduced by psychologist Abraham Maslow, PhD, over 75 years ago). Our society has already slid down several of Maslow’s levels. We have reset to about level two, which is safety, one level above physiologic needs. Recall the grocery store fights. Look at the gun sales. The toilet paper roll has been reset from wheel of fortune spin to safe cracking mode.
This reset of the societal mindset has many ramifications you may not normally consider. For example, who will risk buying up to that dream home or purchasing a second home, if you are being told to shelter in place? Fewer may gamble $300,000 on a college education at a less-than-top-50 school. Who even knows when college will start next year. Who is going to take that promotion to New York City, or even New Jersey, and ride the train and subway to work every day? Who wants to commute through the crowded airport on the jam packed “plane train”?
It is easy to predict we will see a severe recession followed by higher taxes and inflation (stagflation). There is a financial writer I like to read who has been predicting a “great reset” of American society for several years. COVID-19 may have precipitated that reset, and things may never be the same.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected]. He has no disclosures.
The last few weeks have been confusing and a little overwhelming. A hodgepodge of rapid-fire publications of potential treatments and multiple, sometimes confusing government mandates and initiatives have inundated us. The overriding theme is clear, though: Let’s first concentrate on keeping our civilization intact. State governments have been largely focused on “flattening the curve” of new infections. And the longer we slow this disease down, the better we learn how to treat it.
Multiple existing medications, repurposed from all walks of the pharmacologic world, have been screened and shown to have potential therapeutic benefit, and they are being tested even as I write this column. The nasty form of this disease is a unique form of adult respiratory distress syndrome, and the terminal event appears to be a form of disseminated intravascular coagulation, which may respond to unexpected therapies, such as clot busters (J Thromb Haemost. 2020 Apr 8. doi: 10.1111/jth.14828).
Now, let’s consider the more mundane issue of keeping your medical practice alive.
Some state medical boards have relaxed the rules on licensing, and the federal government on HIPAA compliance, so that telemedicine has finally become practical. Some EHR vendors have even rushed out modules to make it easier to conduct visits with patients through their patient portals. This has all made it almost practical to see, monitor, and treat existing patients with chronic conditions, and even new ones who do not require a biopsy.
But it has also become clear that telemedicine is not a long-term means of keeping your practice viable, at least not in your practice’s current form. It can be difficult to enroll new patients and the process of collecting copays and deductibles can be frustrating and slow. There may also resistance from our patients, who may be used to having this sort of service performed by us free-of-charge. Those selfies that in the past you may have viewed, called the patient to discuss, and then called their medication into the pharmacy – all as a convenience – are coming back to haunt you. It was free before, they say, what has changed?
Another obstacle, as always, is reimbursement. There is an inconsistent patchwork of private insurance coverage that may or may not pay you. The American Academy of Dermatology has put together an excellent resource on its web site on all matters regarding COVID-19 to help you.
But the underlying undeniable reality is that you cannot support your current practice model long term with telemedicine because only about 30% of dermatology reimbursement comes from evaluation and management codes, according to a recently published study – and the rest, procedures, obviously requires patient contact (JAMA Surg. 2020 Apr 15. doi: 10.1001/jamasurg.2020.0422).
The federal government has been economically responsive by injecting money into businesses with less than 500 employees. Most of you will be eligible and probably already have applied for the Paycheck Protection Program. These are small business “loans” that your bank puts the paperwork in for, which can total up to 2.5 times one month’s average payroll. These “loans” may be 100% forgivable (75% must come from two months payroll, another 25% rent and expenses) if you do not lay anyone off.
Employees can be kept busy doing other tasks besides directly helping with patients. Like many of you with state-mandated lockdowns, my office has never been so clean, the cabinets so well stocked, and the files so organized. The stock room has been cleaned out, and any extra personal protective gear has been donated to the hospital and emergency medical services. We have landscaped the front of our building and if it warms up, we will seal and remark the parking lot. You get my drift. I have also applied for and received an advance of three months of Medicare payments, which will be automatically paid back as practice resumes. This is in effect an interest-free loan. A few days ago, my business checking account received a deposit from the Department of Health & Human Services for 6.1% of last year’s Medicare billings. This is unexpected, no obligation support to help keep your medical office open in the time of COVID-19. It appears that the office and practice will be able to weather the fire.
Assuming our practices survive more or less intact, there are major social consequences to consider. Society is a conglomeration of individuals, and individuals act on their Maslow’s hierarchy of needs (a concept introduced by psychologist Abraham Maslow, PhD, over 75 years ago). Our society has already slid down several of Maslow’s levels. We have reset to about level two, which is safety, one level above physiologic needs. Recall the grocery store fights. Look at the gun sales. The toilet paper roll has been reset from wheel of fortune spin to safe cracking mode.
This reset of the societal mindset has many ramifications you may not normally consider. For example, who will risk buying up to that dream home or purchasing a second home, if you are being told to shelter in place? Fewer may gamble $300,000 on a college education at a less-than-top-50 school. Who even knows when college will start next year. Who is going to take that promotion to New York City, or even New Jersey, and ride the train and subway to work every day? Who wants to commute through the crowded airport on the jam packed “plane train”?
It is easy to predict we will see a severe recession followed by higher taxes and inflation (stagflation). There is a financial writer I like to read who has been predicting a “great reset” of American society for several years. COVID-19 may have precipitated that reset, and things may never be the same.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected]. He has no disclosures.
The last few weeks have been confusing and a little overwhelming. A hodgepodge of rapid-fire publications of potential treatments and multiple, sometimes confusing government mandates and initiatives have inundated us. The overriding theme is clear, though: Let’s first concentrate on keeping our civilization intact. State governments have been largely focused on “flattening the curve” of new infections. And the longer we slow this disease down, the better we learn how to treat it.
Multiple existing medications, repurposed from all walks of the pharmacologic world, have been screened and shown to have potential therapeutic benefit, and they are being tested even as I write this column. The nasty form of this disease is a unique form of adult respiratory distress syndrome, and the terminal event appears to be a form of disseminated intravascular coagulation, which may respond to unexpected therapies, such as clot busters (J Thromb Haemost. 2020 Apr 8. doi: 10.1111/jth.14828).
Now, let’s consider the more mundane issue of keeping your medical practice alive.
Some state medical boards have relaxed the rules on licensing, and the federal government on HIPAA compliance, so that telemedicine has finally become practical. Some EHR vendors have even rushed out modules to make it easier to conduct visits with patients through their patient portals. This has all made it almost practical to see, monitor, and treat existing patients with chronic conditions, and even new ones who do not require a biopsy.
But it has also become clear that telemedicine is not a long-term means of keeping your practice viable, at least not in your practice’s current form. It can be difficult to enroll new patients and the process of collecting copays and deductibles can be frustrating and slow. There may also resistance from our patients, who may be used to having this sort of service performed by us free-of-charge. Those selfies that in the past you may have viewed, called the patient to discuss, and then called their medication into the pharmacy – all as a convenience – are coming back to haunt you. It was free before, they say, what has changed?
Another obstacle, as always, is reimbursement. There is an inconsistent patchwork of private insurance coverage that may or may not pay you. The American Academy of Dermatology has put together an excellent resource on its web site on all matters regarding COVID-19 to help you.
But the underlying undeniable reality is that you cannot support your current practice model long term with telemedicine because only about 30% of dermatology reimbursement comes from evaluation and management codes, according to a recently published study – and the rest, procedures, obviously requires patient contact (JAMA Surg. 2020 Apr 15. doi: 10.1001/jamasurg.2020.0422).
The federal government has been economically responsive by injecting money into businesses with less than 500 employees. Most of you will be eligible and probably already have applied for the Paycheck Protection Program. These are small business “loans” that your bank puts the paperwork in for, which can total up to 2.5 times one month’s average payroll. These “loans” may be 100% forgivable (75% must come from two months payroll, another 25% rent and expenses) if you do not lay anyone off.
Employees can be kept busy doing other tasks besides directly helping with patients. Like many of you with state-mandated lockdowns, my office has never been so clean, the cabinets so well stocked, and the files so organized. The stock room has been cleaned out, and any extra personal protective gear has been donated to the hospital and emergency medical services. We have landscaped the front of our building and if it warms up, we will seal and remark the parking lot. You get my drift. I have also applied for and received an advance of three months of Medicare payments, which will be automatically paid back as practice resumes. This is in effect an interest-free loan. A few days ago, my business checking account received a deposit from the Department of Health & Human Services for 6.1% of last year’s Medicare billings. This is unexpected, no obligation support to help keep your medical office open in the time of COVID-19. It appears that the office and practice will be able to weather the fire.
Assuming our practices survive more or less intact, there are major social consequences to consider. Society is a conglomeration of individuals, and individuals act on their Maslow’s hierarchy of needs (a concept introduced by psychologist Abraham Maslow, PhD, over 75 years ago). Our society has already slid down several of Maslow’s levels. We have reset to about level two, which is safety, one level above physiologic needs. Recall the grocery store fights. Look at the gun sales. The toilet paper roll has been reset from wheel of fortune spin to safe cracking mode.
This reset of the societal mindset has many ramifications you may not normally consider. For example, who will risk buying up to that dream home or purchasing a second home, if you are being told to shelter in place? Fewer may gamble $300,000 on a college education at a less-than-top-50 school. Who even knows when college will start next year. Who is going to take that promotion to New York City, or even New Jersey, and ride the train and subway to work every day? Who wants to commute through the crowded airport on the jam packed “plane train”?
It is easy to predict we will see a severe recession followed by higher taxes and inflation (stagflation). There is a financial writer I like to read who has been predicting a “great reset” of American society for several years. COVID-19 may have precipitated that reset, and things may never be the same.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected]. He has no disclosures.