CASE Sleepless, hallucinating

Mr. F, age 30, is brought to the emergency department (ED) by his brother, with whom he has been living for the last 2 days; his brother says that Mr. F’s wife is afraid of her husband and concerned about her children’s safety. Mr. F has been talking to himself, saying “odd things,” and has an unpredictable temper. He claims that his long-deceased father is alive and telling him “to move to a land that he brought [sic] for him.” In order to follow his father’s instructions, Mr. F says he wants to “see the ambassador so he can get his passport ready.” He also believes his wife and children are intruders in his home. Although he had never smoked before, Mr. F has started smoking ≥2 packs of cigarettes per day, sometimes smoking a pack in 30 minutes. He has not eaten or slept for the last 2 days and lies awake in bed all night staring at the ceiling and smiling to himself.

On examination, Mr. F is short with a slight build and has large, dark eyes, disheveled, short, brown hair, and a scraggly beard. English is not his first language, and he speaks with a thick Eastern European accent. His speech is latent, monotonous, tangential, and illogical. He is alert, oriented only to his person, and says he is 21 or 27 years old and at the hospital for “smoking medication and that’s it.” Despite immigrating to the United States 8 years ago, Mr. F claims he has spent his whole life “here,” although he is unsure of exactly where that is. Cognition and memory are impaired. Regarding his wife and 5 children, he says, “I am a virgin. How then can I have children? That woman is abusing me by forcefully entering my house with 5 kids.” He is fidgety, appears anxious, and does not make eye contact with the examiner during the interview. He is suspicious and irritable. Initial medical workup in the ED is negative.

[polldaddy:9813268]

EVALUATION Labs and observation

Because Mr. F had delusions and hallucinations for the past 2 days and the initial medical workup was negative, brief psychotic disorder is suspected.¹ He is admitted to a secure psychiatric floor for further evaluation. He has no documented medical history. A thorough medical workup for a cause of his hallucinations and delusions, including EEG and brain MRI, is negative. Additional collateral interviews with Mr. F’s wife and brother at a family meeting indicate Mr. F had a slow onset of symptoms that began 4 to 5 years ago. Initially, he became isolated, withdrawn, inactive, and had poor sleep. Recently, he also had become suspicious, irritable, delusional, and hallucinatory. Mr. F used to work full-time in construction, then began working intermittently in a warehouse as a day laborer, but has not worked for the last few months. He used to be an involved father and reliable partner, helping with household chores and caring for the children. However, for the last few months, he had become increasingly apathetic and isolated.

During the comprehensive workup for psychosis, Mr. F’s symptoms continue. He is disoriented; although it is 2015, he states it is “2007… I carry a cell phone so I don’t need to know.” On July 31, he is told the date, and for several days after that, he states that it is July 31. When asked his birth date, he looks at his hospital wrist ID. His affect is flat, but he states he feels “fine” and smiles at inappropriate times. He answers open-ended questions briefly, with irrelevant or illogical answers after long pauses, or not at all. His eye contact is poor; he seems preoccupied with internal stimuli, and it is difficult to keep his attention.
 

Mr. F says he is a “natural-born Bosnian gypsy translator,” and that he needs to finish “building the warehouse” with his father and grandfather (both are deceased). The nurses note that he is withdrawn, inactive, and suspicious; he spends most of the day lying in bed awake, and in the evening he paces in the hallway. Mr. F does not interact with other patients, is guarded when questioned, and does not eat much. He has minimal insight into his condition and says that he is at the hospital for “fevers and a cold,” “ESL treatment,” or because his “right side is thicker” than his left. It is unclear what Mr. F means by “ESL.” It may refer to English as a Second Language, given his apparent perseveration regarding his immigration status and language ability, but this is speculation.

[polldaddy:9813271]

TREATMENT Residual symptoms

With the additional collateral history and a negative medical workup, Mr. F meets DSM-5 criteria for acute, first-episode schizophrenia¹ and is started on risperidone, 2 mg/d, titrated up to 2 mg twice daily, and trazodone, 50 mg, as needed, as a sleep aid. He shows significant improvement in his symptoms early in his treatment course. During visiting hours and at family meetings, he recognizes his wife, and during interviews he denies any continuing hallucinations. He initially says that he never failed to recognize his wife and kids, but later explains that he “woke up different…from a dream, and she was a different woman.” When asked specifically about hearing his father’s voice, he is uncertain, saying “No,” “I don’t know,” “I didn’t hear,” or “Not anymore.”

Despite his improvement, Mr. F continues to be disoriented and suspicious, and has minimal insight into his illness. He also continues to exhibit significant negative symptoms and cognitive impairment. Mr. F is withdrawn and has a flat affect, poverty of speech, delayed processing, and poor focus and attention.

On hospital Day 6, Mr. F reports feeling depressed. He misses his children and wants to go home. He has lost several pounds because he had a poor appetite and is now underweight. He is apathetic; interactions with staff and patients are minimal, he declines to attend group therapy sessions, and he still spends most of his time lying in bed awake or pacing the hallway. He also expresses a desire to quit smoking.

[polldaddy:9813273]

The authors’ observations

Despite its lack of specific inclusion in the DSM-5 criteria,¹ cognitive impairment is a distinct, core, and nearly universal feature of schizophrenia. As demonstrated by Mr. F’s case, the severity of cognitive impairment in schizophrenia has no association with the positive symptoms of schizophrenia; it is a patient’s neuro­cognitive abilities—not the severity of his (her) psychotic symptoms—that most strongly predict functional outcomes.²

Neurocognitive impairment is a strong contributor to and predictor of disability in schizophrenia.^3,4 Treatment of the cognitive symptoms of schizophrenia with antipsychotics has been largely ineffective.² Effective drug therapy regimens are still being developed, and although there are some promising novel targets, no drug is FDA-approved to treat the cognitive symptoms of schizophrenia.^2,4 However, it is known that additional treatment modalities, including social skills training and/or vocational rehabilitation, as well as treatment of comorbid conditions, may lead to improved cognitive status and, as a result, improved functional outcomes in schizophrenia.^2-4

It is well documented that persons with schizophrenia in households with high expressed emotion (EE) have higher rates of relapse, independent of demographics and pharmacotherapy.⁵ EE is a measure of the family environment that evaluates how the relatives of a psychiatric patient spontaneously talk about the patient. Relatives are considered to have high EE if they show hostility or marked emotional overinvolvement, or if they make a certain number of critical comments. The tool used to measure EE is the Camberwell Family Interview Schedule.^6,7 Rates of first-year relapse in high EE homes when family treatment is employed drop significantly, especially when combined with social skills training.⁸ The patient’s family members are educated about EE and its potential negative effects on the patient.

Cognitive remediation therapy (CRT) uses therapist-led, computer-based techniques to preserve intact neuroplasticity and has been shown to improve cognition and functional status, especially when paired with vocational rehabilitation or social skills training.^2,3 Many trials confirm that CRT produces meaningful, durable improvements in cognition and functioning.³ One systematic review that focused on trials in early schizophrenia found that CRT had a significant effect on functioning and symptoms, and that these effects were larger when CRT was combined with adjunctive psychiatric rehabilitation and small group interventions.³

OUTCOME Gradual improvement

Mr. F is started on nicotine gum, 2 mg/d, for smoking cessation and fluoxetine, 20 mg/d, for depression, and a dietary consult is made for his poor appetite and weight loss. His psychotic symptoms continue to improve, and by hospital Day 10, his depressive symptoms begin to improve as well: his affect brightens, he has increased appetite, and he wants to shave. He also exhibits mildly increased insight into his illness.

The authors’ observations

A major goal of the National Institute of Mental Health’s Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative was to develop a consensus cognitive battery for clinical trials of cognition-enhancing treatments for schizophrenia. The MATRICS Consensus Cognitive Battery (MCCB) is a comprehensive cognitive assessment designed for use in patients with schizophrenia (Table 3⁹). Although the MCCB was developed to be the standard tool for assessing cognitive change in clinical trials of cognition-enhancing drugs for schizophrenia, it also may aid evaluation of cognitive remediation strategies.⁹

In Mr. F’s case, such testing was not performed, in part because of his improvement. The MoCA was chosen because it is a universally accepted brief cognitive assessment tool used for screening. More robust testing can be administered by the neuropsychiatry team if indicated and if resources are available.

CASE Sleepless, hallucinating

Mr. F, age 30, is brought to the emergency department (ED) by his brother, with whom he has been living for the last 2 days; his brother says that Mr. F’s wife is afraid of her husband and concerned about her children’s safety. Mr. F has been talking to himself, saying “odd things,” and has an unpredictable temper. He claims that his long-deceased father is alive and telling him “to move to a land that he brought [sic] for him.” In order to follow his father’s instructions, Mr. F says he wants to “see the ambassador so he can get his passport ready.” He also believes his wife and children are intruders in his home. Although he had never smoked before, Mr. F has started smoking ≥2 packs of cigarettes per day, sometimes smoking a pack in 30 minutes. He has not eaten or slept for the last 2 days and lies awake in bed all night staring at the ceiling and smiling to himself.

On examination, Mr. F is short with a slight build and has large, dark eyes, disheveled, short, brown hair, and a scraggly beard. English is not his first language, and he speaks with a thick Eastern European accent. His speech is latent, monotonous, tangential, and illogical. He is alert, oriented only to his person, and says he is 21 or 27 years old and at the hospital for “smoking medication and that’s it.” Despite immigrating to the United States 8 years ago, Mr. F claims he has spent his whole life “here,” although he is unsure of exactly where that is. Cognition and memory are impaired. Regarding his wife and 5 children, he says, “I am a virgin. How then can I have children? That woman is abusing me by forcefully entering my house with 5 kids.” He is fidgety, appears anxious, and does not make eye contact with the examiner during the interview. He is suspicious and irritable. Initial medical workup in the ED is negative.

[polldaddy:9813268]

EVALUATION Labs and observation

Because Mr. F had delusions and hallucinations for the past 2 days and the initial medical workup was negative, brief psychotic disorder is suspected.¹ He is admitted to a secure psychiatric floor for further evaluation. He has no documented medical history. A thorough medical workup for a cause of his hallucinations and delusions, including EEG and brain MRI, is negative. Additional collateral interviews with Mr. F’s wife and brother at a family meeting indicate Mr. F had a slow onset of symptoms that began 4 to 5 years ago. Initially, he became isolated, withdrawn, inactive, and had poor sleep. Recently, he also had become suspicious, irritable, delusional, and hallucinatory. Mr. F used to work full-time in construction, then began working intermittently in a warehouse as a day laborer, but has not worked for the last few months. He used to be an involved father and reliable partner, helping with household chores and caring for the children. However, for the last few months, he had become increasingly apathetic and isolated.

During the comprehensive workup for psychosis, Mr. F’s symptoms continue. He is disoriented; although it is 2015, he states it is “2007… I carry a cell phone so I don’t need to know.” On July 31, he is told the date, and for several days after that, he states that it is July 31. When asked his birth date, he looks at his hospital wrist ID. His affect is flat, but he states he feels “fine” and smiles at inappropriate times. He answers open-ended questions briefly, with irrelevant or illogical answers after long pauses, or not at all. His eye contact is poor; he seems preoccupied with internal stimuli, and it is difficult to keep his attention.
 

Mr. F says he is a “natural-born Bosnian gypsy translator,” and that he needs to finish “building the warehouse” with his father and grandfather (both are deceased). The nurses note that he is withdrawn, inactive, and suspicious; he spends most of the day lying in bed awake, and in the evening he paces in the hallway. Mr. F does not interact with other patients, is guarded when questioned, and does not eat much. He has minimal insight into his condition and says that he is at the hospital for “fevers and a cold,” “ESL treatment,” or because his “right side is thicker” than his left. It is unclear what Mr. F means by “ESL.” It may refer to English as a Second Language, given his apparent perseveration regarding his immigration status and language ability, but this is speculation.

[polldaddy:9813271]

TREATMENT Residual symptoms

With the additional collateral history and a negative medical workup, Mr. F meets DSM-5 criteria for acute, first-episode schizophrenia¹ and is started on risperidone, 2 mg/d, titrated up to 2 mg twice daily, and trazodone, 50 mg, as needed, as a sleep aid. He shows significant improvement in his symptoms early in his treatment course. During visiting hours and at family meetings, he recognizes his wife, and during interviews he denies any continuing hallucinations. He initially says that he never failed to recognize his wife and kids, but later explains that he “woke up different…from a dream, and she was a different woman.” When asked specifically about hearing his father’s voice, he is uncertain, saying “No,” “I don’t know,” “I didn’t hear,” or “Not anymore.”

Despite his improvement, Mr. F continues to be disoriented and suspicious, and has minimal insight into his illness. He also continues to exhibit significant negative symptoms and cognitive impairment. Mr. F is withdrawn and has a flat affect, poverty of speech, delayed processing, and poor focus and attention.

On hospital Day 6, Mr. F reports feeling depressed. He misses his children and wants to go home. He has lost several pounds because he had a poor appetite and is now underweight. He is apathetic; interactions with staff and patients are minimal, he declines to attend group therapy sessions, and he still spends most of his time lying in bed awake or pacing the hallway. He also expresses a desire to quit smoking.

[polldaddy:9813273]

The authors’ observations

Despite its lack of specific inclusion in the DSM-5 criteria,¹ cognitive impairment is a distinct, core, and nearly universal feature of schizophrenia. As demonstrated by Mr. F’s case, the severity of cognitive impairment in schizophrenia has no association with the positive symptoms of schizophrenia; it is a patient’s neuro­cognitive abilities—not the severity of his (her) psychotic symptoms—that most strongly predict functional outcomes.²

Neurocognitive impairment is a strong contributor to and predictor of disability in schizophrenia.^3,4 Treatment of the cognitive symptoms of schizophrenia with antipsychotics has been largely ineffective.² Effective drug therapy regimens are still being developed, and although there are some promising novel targets, no drug is FDA-approved to treat the cognitive symptoms of schizophrenia.^2,4 However, it is known that additional treatment modalities, including social skills training and/or vocational rehabilitation, as well as treatment of comorbid conditions, may lead to improved cognitive status and, as a result, improved functional outcomes in schizophrenia.^2-4

It is well documented that persons with schizophrenia in households with high expressed emotion (EE) have higher rates of relapse, independent of demographics and pharmacotherapy.⁵ EE is a measure of the family environment that evaluates how the relatives of a psychiatric patient spontaneously talk about the patient. Relatives are considered to have high EE if they show hostility or marked emotional overinvolvement, or if they make a certain number of critical comments. The tool used to measure EE is the Camberwell Family Interview Schedule.^6,7 Rates of first-year relapse in high EE homes when family treatment is employed drop significantly, especially when combined with social skills training.⁸ The patient’s family members are educated about EE and its potential negative effects on the patient.

Cognitive remediation therapy (CRT) uses therapist-led, computer-based techniques to preserve intact neuroplasticity and has been shown to improve cognition and functional status, especially when paired with vocational rehabilitation or social skills training.^2,3 Many trials confirm that CRT produces meaningful, durable improvements in cognition and functioning.³ One systematic review that focused on trials in early schizophrenia found that CRT had a significant effect on functioning and symptoms, and that these effects were larger when CRT was combined with adjunctive psychiatric rehabilitation and small group interventions.³

OUTCOME Gradual improvement

Mr. F is started on nicotine gum, 2 mg/d, for smoking cessation and fluoxetine, 20 mg/d, for depression, and a dietary consult is made for his poor appetite and weight loss. His psychotic symptoms continue to improve, and by hospital Day 10, his depressive symptoms begin to improve as well: his affect brightens, he has increased appetite, and he wants to shave. He also exhibits mildly increased insight into his illness.

The authors’ observations

A major goal of the National Institute of Mental Health’s Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative was to develop a consensus cognitive battery for clinical trials of cognition-enhancing treatments for schizophrenia. The MATRICS Consensus Cognitive Battery (MCCB) is a comprehensive cognitive assessment designed for use in patients with schizophrenia (Table 3⁹). Although the MCCB was developed to be the standard tool for assessing cognitive change in clinical trials of cognition-enhancing drugs for schizophrenia, it also may aid evaluation of cognitive remediation strategies.⁹

In Mr. F’s case, such testing was not performed, in part because of his improvement. The MoCA was chosen because it is a universally accepted brief cognitive assessment tool used for screening. More robust testing can be administered by the neuropsychiatry team if indicated and if resources are available.

CASE Sleepless, hallucinating

Mr. F, age 30, is brought to the emergency department (ED) by his brother, with whom he has been living for the last 2 days; his brother says that Mr. F’s wife is afraid of her husband and concerned about her children’s safety. Mr. F has been talking to himself, saying “odd things,” and has an unpredictable temper. He claims that his long-deceased father is alive and telling him “to move to a land that he brought [sic] for him.” In order to follow his father’s instructions, Mr. F says he wants to “see the ambassador so he can get his passport ready.” He also believes his wife and children are intruders in his home. Although he had never smoked before, Mr. F has started smoking ≥2 packs of cigarettes per day, sometimes smoking a pack in 30 minutes. He has not eaten or slept for the last 2 days and lies awake in bed all night staring at the ceiling and smiling to himself.

On examination, Mr. F is short with a slight build and has large, dark eyes, disheveled, short, brown hair, and a scraggly beard. English is not his first language, and he speaks with a thick Eastern European accent. His speech is latent, monotonous, tangential, and illogical. He is alert, oriented only to his person, and says he is 21 or 27 years old and at the hospital for “smoking medication and that’s it.” Despite immigrating to the United States 8 years ago, Mr. F claims he has spent his whole life “here,” although he is unsure of exactly where that is. Cognition and memory are impaired. Regarding his wife and 5 children, he says, “I am a virgin. How then can I have children? That woman is abusing me by forcefully entering my house with 5 kids.” He is fidgety, appears anxious, and does not make eye contact with the examiner during the interview. He is suspicious and irritable. Initial medical workup in the ED is negative.

[polldaddy:9813268]

EVALUATION Labs and observation

Because Mr. F had delusions and hallucinations for the past 2 days and the initial medical workup was negative, brief psychotic disorder is suspected.¹ He is admitted to a secure psychiatric floor for further evaluation. He has no documented medical history. A thorough medical workup for a cause of his hallucinations and delusions, including EEG and brain MRI, is negative. Additional collateral interviews with Mr. F’s wife and brother at a family meeting indicate Mr. F had a slow onset of symptoms that began 4 to 5 years ago. Initially, he became isolated, withdrawn, inactive, and had poor sleep. Recently, he also had become suspicious, irritable, delusional, and hallucinatory. Mr. F used to work full-time in construction, then began working intermittently in a warehouse as a day laborer, but has not worked for the last few months. He used to be an involved father and reliable partner, helping with household chores and caring for the children. However, for the last few months, he had become increasingly apathetic and isolated.

During the comprehensive workup for psychosis, Mr. F’s symptoms continue. He is disoriented; although it is 2015, he states it is “2007… I carry a cell phone so I don’t need to know.” On July 31, he is told the date, and for several days after that, he states that it is July 31. When asked his birth date, he looks at his hospital wrist ID. His affect is flat, but he states he feels “fine” and smiles at inappropriate times. He answers open-ended questions briefly, with irrelevant or illogical answers after long pauses, or not at all. His eye contact is poor; he seems preoccupied with internal stimuli, and it is difficult to keep his attention.
 

Mr. F says he is a “natural-born Bosnian gypsy translator,” and that he needs to finish “building the warehouse” with his father and grandfather (both are deceased). The nurses note that he is withdrawn, inactive, and suspicious; he spends most of the day lying in bed awake, and in the evening he paces in the hallway. Mr. F does not interact with other patients, is guarded when questioned, and does not eat much. He has minimal insight into his condition and says that he is at the hospital for “fevers and a cold,” “ESL treatment,” or because his “right side is thicker” than his left. It is unclear what Mr. F means by “ESL.” It may refer to English as a Second Language, given his apparent perseveration regarding his immigration status and language ability, but this is speculation.

[polldaddy:9813271]

TREATMENT Residual symptoms

With the additional collateral history and a negative medical workup, Mr. F meets DSM-5 criteria for acute, first-episode schizophrenia¹ and is started on risperidone, 2 mg/d, titrated up to 2 mg twice daily, and trazodone, 50 mg, as needed, as a sleep aid. He shows significant improvement in his symptoms early in his treatment course. During visiting hours and at family meetings, he recognizes his wife, and during interviews he denies any continuing hallucinations. He initially says that he never failed to recognize his wife and kids, but later explains that he “woke up different…from a dream, and she was a different woman.” When asked specifically about hearing his father’s voice, he is uncertain, saying “No,” “I don’t know,” “I didn’t hear,” or “Not anymore.”

Despite his improvement, Mr. F continues to be disoriented and suspicious, and has minimal insight into his illness. He also continues to exhibit significant negative symptoms and cognitive impairment. Mr. F is withdrawn and has a flat affect, poverty of speech, delayed processing, and poor focus and attention.

On hospital Day 6, Mr. F reports feeling depressed. He misses his children and wants to go home. He has lost several pounds because he had a poor appetite and is now underweight. He is apathetic; interactions with staff and patients are minimal, he declines to attend group therapy sessions, and he still spends most of his time lying in bed awake or pacing the hallway. He also expresses a desire to quit smoking.

[polldaddy:9813273]

The authors’ observations

Despite its lack of specific inclusion in the DSM-5 criteria,¹ cognitive impairment is a distinct, core, and nearly universal feature of schizophrenia. As demonstrated by Mr. F’s case, the severity of cognitive impairment in schizophrenia has no association with the positive symptoms of schizophrenia; it is a patient’s neuro­cognitive abilities—not the severity of his (her) psychotic symptoms—that most strongly predict functional outcomes.²

Neurocognitive impairment is a strong contributor to and predictor of disability in schizophrenia.^3,4 Treatment of the cognitive symptoms of schizophrenia with antipsychotics has been largely ineffective.² Effective drug therapy regimens are still being developed, and although there are some promising novel targets, no drug is FDA-approved to treat the cognitive symptoms of schizophrenia.^2,4 However, it is known that additional treatment modalities, including social skills training and/or vocational rehabilitation, as well as treatment of comorbid conditions, may lead to improved cognitive status and, as a result, improved functional outcomes in schizophrenia.^2-4

It is well documented that persons with schizophrenia in households with high expressed emotion (EE) have higher rates of relapse, independent of demographics and pharmacotherapy.⁵ EE is a measure of the family environment that evaluates how the relatives of a psychiatric patient spontaneously talk about the patient. Relatives are considered to have high EE if they show hostility or marked emotional overinvolvement, or if they make a certain number of critical comments. The tool used to measure EE is the Camberwell Family Interview Schedule.^6,7 Rates of first-year relapse in high EE homes when family treatment is employed drop significantly, especially when combined with social skills training.⁸ The patient’s family members are educated about EE and its potential negative effects on the patient.

Cognitive remediation therapy (CRT) uses therapist-led, computer-based techniques to preserve intact neuroplasticity and has been shown to improve cognition and functional status, especially when paired with vocational rehabilitation or social skills training.^2,3 Many trials confirm that CRT produces meaningful, durable improvements in cognition and functioning.³ One systematic review that focused on trials in early schizophrenia found that CRT had a significant effect on functioning and symptoms, and that these effects were larger when CRT was combined with adjunctive psychiatric rehabilitation and small group interventions.³

OUTCOME Gradual improvement

Mr. F is started on nicotine gum, 2 mg/d, for smoking cessation and fluoxetine, 20 mg/d, for depression, and a dietary consult is made for his poor appetite and weight loss. His psychotic symptoms continue to improve, and by hospital Day 10, his depressive symptoms begin to improve as well: his affect brightens, he has increased appetite, and he wants to shave. He also exhibits mildly increased insight into his illness.

The authors’ observations

A major goal of the National Institute of Mental Health’s Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative was to develop a consensus cognitive battery for clinical trials of cognition-enhancing treatments for schizophrenia. The MATRICS Consensus Cognitive Battery (MCCB) is a comprehensive cognitive assessment designed for use in patients with schizophrenia (Table 3⁹). Although the MCCB was developed to be the standard tool for assessing cognitive change in clinical trials of cognition-enhancing drugs for schizophrenia, it also may aid evaluation of cognitive remediation strategies.⁹

In Mr. F’s case, such testing was not performed, in part because of his improvement. The MoCA was chosen because it is a universally accepted brief cognitive assessment tool used for screening. More robust testing can be administered by the neuropsychiatry team if indicated and if resources are available.

In response to Dr. Nasrallah’s editorial “Prescribing is the culmination of extensive medical training and psychologists don’t qualify” (From the Editor, Current Psychiatry. June 2017, p. 11-12,14-16): I have mixed feelings about prescription privileges for psychologists, and I am not pursuing them. But Dr. Nasrallah’s manner of arguing with anecdotes and unsubstantiated opinion is undeserving of publication. He notes that psychologists with further training now have prescription privileges in several states and warns of the possible dangers of such practices. However, he did not bother to describe the training psychologists receive or report on the psychiatrists who helped develop that curriculum. Dr. Nasrallah did not present any empirical evidence to indicate that any actual harm has resulted from psychologists having prescription privileges or compare that with the harm from the prescription privileges of psychiatrists, other physicians, physician assistants, nurse practitioners, naturopaths, etc. He implies that only psychiatrists can properly prescribe psychiatric medications, which would certainly be a minority opinion. He offers no alternative solution to the current public health problems.

Tedd Judd, PhD, ABPP-CN
Diplomate in Clinical Neuropsychology
Certified Hispanic Mental Health Specialist
Cross-Cultural Specialist
Bellingham, Washington

I read Dr. Nasrallah’s editorial with a critical eye. As a psychologist in private clinical and forensic practice for more than 30 years, it is disheartening that you toe the politico-economic line proffered over the decades that establishes and buoys a clash between our helping professions in the hoary guise of protecting the consuming public.

It is disingenuous and misleading for you to cite “28,000 hours of training… 8 years of medical school” as a prerequisite for having adequate “psycho­pharmacological skills.”

Psychologists and psychiatrists can learn the same necessary and comprehensive skills to perform competent and equivalent prescription duties in succinct, operational ways.

It is about time the welfare of the consuming public be served instead of territorial profiteering. Perhaps you should focus more on the dwindling numbers of psychiatrists who perform psychotherapy in conjunction with psychopharmacology than on limiting the pool of providers who are qualified by training to do both. How many of those 28,000 hours are dedicated to training your psychiatrists in psychotherapy?

Norman R. Klein, PhD
Licensed Psychologist
Westport, Connecticut

Dr. Nasrallah wrote an unsurprisingly eloquent and passionate editorial and argues a cogent case for restricting prescription privileges to medically trained professionals. I wonder, though, if public health statistics of outcomes among mental health patients in states where clinical psychologists have been licensed to prescribe, such as New Mexico and Hawaii, bear out any of Dr. Nasrallah’s concerns.

Ole J. Thienhaus, MD, MBA
Department Head and Professor of Psychiatry
University of Arizona
College of Medicine-Tucson
Tucson, Arizona
 

Dr. Nasrallah responds

I am not surprised by Dr. Judd’s or Dr. Klein’s disagreement with my editorial asserting that psycho­logists do not receive the medical training that qualifies them to prescribe. They side with their fellow psychologists, just as psychiatrists agree with me. After all, those of us who have had the extensive training of psychiatric physicians know the abundance of medical skills needed for competent prescribing and find it preposterous that psychologists, who have a PhD and are acknowledged for their psychotherapy and psychometric skills, can take a drastic shortcut by getting politicians to give them the right to prescribe. Dr. Klein has no idea how much training it takes to become a competent prescriber, so his comments that both psychiatrists and psych­ologists can be similarly trained cannot be taken seriously. Even after 4 years of psychiatric residency with daily psychopharmacology teaching and training psychiatrists still feel they have much more to learn. It is dangerous hubris to think that even without the vital medical school foundation prior to psychiatric training that psychologists can enroll in a course and practicum and become psychopharmacologists.

Here, I provide a description of one state’s proposed the training that psycho­logists would receive. I hope that Drs. Judd and Klein will recognize the dangerously inadequate training recently proposed for psychologists to become “prescribers.”

Proposed curriculum for psychologists

1. Online instruction, not face-to-face classroom experience

2. Many courses are prerecorded

3. Instructors are psychologists, not psychiatrists

4. Psychologists can complete the program at their own pace, which can be done in a few weeks

5. Hours of instruction range between 306 to 468 hours, compared with 500 hours required for massage therapists

6. A minimum of 40 hours of “basic training on clinical assessment” is required, compared with 60 hours for electrologists

7. The “graduate” must pass a test prepared by the American Psychological Association, which advocates for prescriptive authority and is not an independent testing organization

8. There is no minimum of requirements of an undergraduate biomedical prerequisite course—the work that is required for all medical students, physician assistants, and nursing students—which includes chemistry or biochemistry (with laboratory experience), human anatomy, physiology, general biology, microbiology (with laboratory experience), cell biology, and molecular biology

9. Recommended number of patient encounters is anemic: 600 encounters, which can be 10 encounters with 60 patients or 15 encounters with 40 patients. This is far below what is required of psychiatric residents

10. The proposed training requires treating a minimum of 75 patients over 2 years. A typical third-year psychiatric resident sees 75 patients every month. Each first- and second-year resident works up and treats >600 inpatients in <1 year

11. At the end of the practicum, applicants must demonstrate competency in 9 milestones, but competency is not defined. In contrast, psychiatric residency programs have mandates from the Accreditation Council for Graduate Medical Education requiring that residents be graded every 6 months on 23 milestones, with specific anchor points provided

12. Only 25% of the practicum occurs on psychiatric inpatient wards or outpatient clinics. One wonders where the patients who need psychopharmacology would be

13. Supervision is inadequate. There is no requirement for supervision by psychiatrists, whose training and experience make them qualified psychopharmacologists

14. There is no guidance on the frequency or intensity of supervision. In psychiatry, residents are supervised with each patient encounter over 4 years. Should psychologists without medical training be held to a lesser standard?

15. There are no specifications of continuing medical education, ongoing supervision, or outcomes

16. The potential dangers of psycho­tropics are not emphasized. For example:

• permanent or life-threatening adverse effects, such as tardive dyskinesia or agranulocytosis
• addiction potential, such as with stimulants or benzodiazepines
• potentially fatal drug interactions with monoamine oxidase inhibitors and meperidine or serotonin syndrome, or cardiac arrests with overdoses of tricyclic antidepressants

17. Many medications require on­going monitoring. Some involve physical examination (extrapyramidal side effects, metabolic syndrome) or laboratory tests (lithium, carbamazepine, clozapine, valproate, renal and hepatic functions, metabolic profile for all antipsychotics). Failure to monitor may lead to fatal outcomes. Some medications are considered unsafe during pregnancy or breast-feeding.

Psychologists do a great service for patients with mental illness by providing evidence-based psycho­therapies, such as cognitive-behavioral, dialectical-behavioral, interpersonal, and behavioral therapy. They complement what psychiatrists and nurse practitioners do with pharmaco­therapy. Many patients with mild or moderate psychiatric disorders improve significantly with psychotherapy without the use of psychotropics. Psychologists should focus on what they were trained to do because they can benefit numerous patients. That is much better than trying to become prescribers and practice mediocre psychopharmacology without the requisite medical training. Patients with mental illness deserve no less.
 

Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri

In response to Dr. Nasrallah’s editorial “Prescribing is the culmination of extensive medical training and psychologists don’t qualify” (From the Editor, Current Psychiatry. June 2017, p. 11-12,14-16): I have mixed feelings about prescription privileges for psychologists, and I am not pursuing them. But Dr. Nasrallah’s manner of arguing with anecdotes and unsubstantiated opinion is undeserving of publication. He notes that psychologists with further training now have prescription privileges in several states and warns of the possible dangers of such practices. However, he did not bother to describe the training psychologists receive or report on the psychiatrists who helped develop that curriculum. Dr. Nasrallah did not present any empirical evidence to indicate that any actual harm has resulted from psychologists having prescription privileges or compare that with the harm from the prescription privileges of psychiatrists, other physicians, physician assistants, nurse practitioners, naturopaths, etc. He implies that only psychiatrists can properly prescribe psychiatric medications, which would certainly be a minority opinion. He offers no alternative solution to the current public health problems.

Tedd Judd, PhD, ABPP-CN
Diplomate in Clinical Neuropsychology
Certified Hispanic Mental Health Specialist
Cross-Cultural Specialist
Bellingham, Washington

I read Dr. Nasrallah’s editorial with a critical eye. As a psychologist in private clinical and forensic practice for more than 30 years, it is disheartening that you toe the politico-economic line proffered over the decades that establishes and buoys a clash between our helping professions in the hoary guise of protecting the consuming public.

It is disingenuous and misleading for you to cite “28,000 hours of training… 8 years of medical school” as a prerequisite for having adequate “psycho­pharmacological skills.”

Psychologists and psychiatrists can learn the same necessary and comprehensive skills to perform competent and equivalent prescription duties in succinct, operational ways.

It is about time the welfare of the consuming public be served instead of territorial profiteering. Perhaps you should focus more on the dwindling numbers of psychiatrists who perform psychotherapy in conjunction with psychopharmacology than on limiting the pool of providers who are qualified by training to do both. How many of those 28,000 hours are dedicated to training your psychiatrists in psychotherapy?

Norman R. Klein, PhD
Licensed Psychologist
Westport, Connecticut

Dr. Nasrallah wrote an unsurprisingly eloquent and passionate editorial and argues a cogent case for restricting prescription privileges to medically trained professionals. I wonder, though, if public health statistics of outcomes among mental health patients in states where clinical psychologists have been licensed to prescribe, such as New Mexico and Hawaii, bear out any of Dr. Nasrallah’s concerns.

Ole J. Thienhaus, MD, MBA
Department Head and Professor of Psychiatry
University of Arizona
College of Medicine-Tucson
Tucson, Arizona
 

Dr. Nasrallah responds

I am not surprised by Dr. Judd’s or Dr. Klein’s disagreement with my editorial asserting that psycho­logists do not receive the medical training that qualifies them to prescribe. They side with their fellow psychologists, just as psychiatrists agree with me. After all, those of us who have had the extensive training of psychiatric physicians know the abundance of medical skills needed for competent prescribing and find it preposterous that psychologists, who have a PhD and are acknowledged for their psychotherapy and psychometric skills, can take a drastic shortcut by getting politicians to give them the right to prescribe. Dr. Klein has no idea how much training it takes to become a competent prescriber, so his comments that both psychiatrists and psych­ologists can be similarly trained cannot be taken seriously. Even after 4 years of psychiatric residency with daily psychopharmacology teaching and training psychiatrists still feel they have much more to learn. It is dangerous hubris to think that even without the vital medical school foundation prior to psychiatric training that psychologists can enroll in a course and practicum and become psychopharmacologists.

Here, I provide a description of one state’s proposed the training that psycho­logists would receive. I hope that Drs. Judd and Klein will recognize the dangerously inadequate training recently proposed for psychologists to become “prescribers.”

Proposed curriculum for psychologists

1. Online instruction, not face-to-face classroom experience

2. Many courses are prerecorded

3. Instructors are psychologists, not psychiatrists

4. Psychologists can complete the program at their own pace, which can be done in a few weeks

5. Hours of instruction range between 306 to 468 hours, compared with 500 hours required for massage therapists

6. A minimum of 40 hours of “basic training on clinical assessment” is required, compared with 60 hours for electrologists

7. The “graduate” must pass a test prepared by the American Psychological Association, which advocates for prescriptive authority and is not an independent testing organization

8. There is no minimum of requirements of an undergraduate biomedical prerequisite course—the work that is required for all medical students, physician assistants, and nursing students—which includes chemistry or biochemistry (with laboratory experience), human anatomy, physiology, general biology, microbiology (with laboratory experience), cell biology, and molecular biology

9. Recommended number of patient encounters is anemic: 600 encounters, which can be 10 encounters with 60 patients or 15 encounters with 40 patients. This is far below what is required of psychiatric residents

10. The proposed training requires treating a minimum of 75 patients over 2 years. A typical third-year psychiatric resident sees 75 patients every month. Each first- and second-year resident works up and treats >600 inpatients in <1 year

11. At the end of the practicum, applicants must demonstrate competency in 9 milestones, but competency is not defined. In contrast, psychiatric residency programs have mandates from the Accreditation Council for Graduate Medical Education requiring that residents be graded every 6 months on 23 milestones, with specific anchor points provided

12. Only 25% of the practicum occurs on psychiatric inpatient wards or outpatient clinics. One wonders where the patients who need psychopharmacology would be

13. Supervision is inadequate. There is no requirement for supervision by psychiatrists, whose training and experience make them qualified psychopharmacologists

14. There is no guidance on the frequency or intensity of supervision. In psychiatry, residents are supervised with each patient encounter over 4 years. Should psychologists without medical training be held to a lesser standard?

15. There are no specifications of continuing medical education, ongoing supervision, or outcomes

16. The potential dangers of psycho­tropics are not emphasized. For example:

• permanent or life-threatening adverse effects, such as tardive dyskinesia or agranulocytosis
• addiction potential, such as with stimulants or benzodiazepines
• potentially fatal drug interactions with monoamine oxidase inhibitors and meperidine or serotonin syndrome, or cardiac arrests with overdoses of tricyclic antidepressants

17. Many medications require on­going monitoring. Some involve physical examination (extrapyramidal side effects, metabolic syndrome) or laboratory tests (lithium, carbamazepine, clozapine, valproate, renal and hepatic functions, metabolic profile for all antipsychotics). Failure to monitor may lead to fatal outcomes. Some medications are considered unsafe during pregnancy or breast-feeding.

Psychologists do a great service for patients with mental illness by providing evidence-based psycho­therapies, such as cognitive-behavioral, dialectical-behavioral, interpersonal, and behavioral therapy. They complement what psychiatrists and nurse practitioners do with pharmaco­therapy. Many patients with mild or moderate psychiatric disorders improve significantly with psychotherapy without the use of psychotropics. Psychologists should focus on what they were trained to do because they can benefit numerous patients. That is much better than trying to become prescribers and practice mediocre psychopharmacology without the requisite medical training. Patients with mental illness deserve no less.
 

Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri

In response to Dr. Nasrallah’s editorial “Prescribing is the culmination of extensive medical training and psychologists don’t qualify” (From the Editor, Current Psychiatry. June 2017, p. 11-12,14-16): I have mixed feelings about prescription privileges for psychologists, and I am not pursuing them. But Dr. Nasrallah’s manner of arguing with anecdotes and unsubstantiated opinion is undeserving of publication. He notes that psychologists with further training now have prescription privileges in several states and warns of the possible dangers of such practices. However, he did not bother to describe the training psychologists receive or report on the psychiatrists who helped develop that curriculum. Dr. Nasrallah did not present any empirical evidence to indicate that any actual harm has resulted from psychologists having prescription privileges or compare that with the harm from the prescription privileges of psychiatrists, other physicians, physician assistants, nurse practitioners, naturopaths, etc. He implies that only psychiatrists can properly prescribe psychiatric medications, which would certainly be a minority opinion. He offers no alternative solution to the current public health problems.

Tedd Judd, PhD, ABPP-CN
Diplomate in Clinical Neuropsychology
Certified Hispanic Mental Health Specialist
Cross-Cultural Specialist
Bellingham, Washington

I read Dr. Nasrallah’s editorial with a critical eye. As a psychologist in private clinical and forensic practice for more than 30 years, it is disheartening that you toe the politico-economic line proffered over the decades that establishes and buoys a clash between our helping professions in the hoary guise of protecting the consuming public.

It is disingenuous and misleading for you to cite “28,000 hours of training… 8 years of medical school” as a prerequisite for having adequate “psycho­pharmacological skills.”

Psychologists and psychiatrists can learn the same necessary and comprehensive skills to perform competent and equivalent prescription duties in succinct, operational ways.

It is about time the welfare of the consuming public be served instead of territorial profiteering. Perhaps you should focus more on the dwindling numbers of psychiatrists who perform psychotherapy in conjunction with psychopharmacology than on limiting the pool of providers who are qualified by training to do both. How many of those 28,000 hours are dedicated to training your psychiatrists in psychotherapy?

Norman R. Klein, PhD
Licensed Psychologist
Westport, Connecticut

Dr. Nasrallah wrote an unsurprisingly eloquent and passionate editorial and argues a cogent case for restricting prescription privileges to medically trained professionals. I wonder, though, if public health statistics of outcomes among mental health patients in states where clinical psychologists have been licensed to prescribe, such as New Mexico and Hawaii, bear out any of Dr. Nasrallah’s concerns.

Ole J. Thienhaus, MD, MBA
Department Head and Professor of Psychiatry
University of Arizona
College of Medicine-Tucson
Tucson, Arizona
 

Dr. Nasrallah responds

I am not surprised by Dr. Judd’s or Dr. Klein’s disagreement with my editorial asserting that psycho­logists do not receive the medical training that qualifies them to prescribe. They side with their fellow psychologists, just as psychiatrists agree with me. After all, those of us who have had the extensive training of psychiatric physicians know the abundance of medical skills needed for competent prescribing and find it preposterous that psychologists, who have a PhD and are acknowledged for their psychotherapy and psychometric skills, can take a drastic shortcut by getting politicians to give them the right to prescribe. Dr. Klein has no idea how much training it takes to become a competent prescriber, so his comments that both psychiatrists and psych­ologists can be similarly trained cannot be taken seriously. Even after 4 years of psychiatric residency with daily psychopharmacology teaching and training psychiatrists still feel they have much more to learn. It is dangerous hubris to think that even without the vital medical school foundation prior to psychiatric training that psychologists can enroll in a course and practicum and become psychopharmacologists.

Here, I provide a description of one state’s proposed the training that psycho­logists would receive. I hope that Drs. Judd and Klein will recognize the dangerously inadequate training recently proposed for psychologists to become “prescribers.”

Proposed curriculum for psychologists

1. Online instruction, not face-to-face classroom experience

2. Many courses are prerecorded

3. Instructors are psychologists, not psychiatrists

4. Psychologists can complete the program at their own pace, which can be done in a few weeks

5. Hours of instruction range between 306 to 468 hours, compared with 500 hours required for massage therapists

6. A minimum of 40 hours of “basic training on clinical assessment” is required, compared with 60 hours for electrologists

7. The “graduate” must pass a test prepared by the American Psychological Association, which advocates for prescriptive authority and is not an independent testing organization

8. There is no minimum of requirements of an undergraduate biomedical prerequisite course—the work that is required for all medical students, physician assistants, and nursing students—which includes chemistry or biochemistry (with laboratory experience), human anatomy, physiology, general biology, microbiology (with laboratory experience), cell biology, and molecular biology

9. Recommended number of patient encounters is anemic: 600 encounters, which can be 10 encounters with 60 patients or 15 encounters with 40 patients. This is far below what is required of psychiatric residents

10. The proposed training requires treating a minimum of 75 patients over 2 years. A typical third-year psychiatric resident sees 75 patients every month. Each first- and second-year resident works up and treats >600 inpatients in <1 year

11. At the end of the practicum, applicants must demonstrate competency in 9 milestones, but competency is not defined. In contrast, psychiatric residency programs have mandates from the Accreditation Council for Graduate Medical Education requiring that residents be graded every 6 months on 23 milestones, with specific anchor points provided

12. Only 25% of the practicum occurs on psychiatric inpatient wards or outpatient clinics. One wonders where the patients who need psychopharmacology would be

13. Supervision is inadequate. There is no requirement for supervision by psychiatrists, whose training and experience make them qualified psychopharmacologists

14. There is no guidance on the frequency or intensity of supervision. In psychiatry, residents are supervised with each patient encounter over 4 years. Should psychologists without medical training be held to a lesser standard?

15. There are no specifications of continuing medical education, ongoing supervision, or outcomes

16. The potential dangers of psycho­tropics are not emphasized. For example:

• permanent or life-threatening adverse effects, such as tardive dyskinesia or agranulocytosis
• addiction potential, such as with stimulants or benzodiazepines
• potentially fatal drug interactions with monoamine oxidase inhibitors and meperidine or serotonin syndrome, or cardiac arrests with overdoses of tricyclic antidepressants

17. Many medications require on­going monitoring. Some involve physical examination (extrapyramidal side effects, metabolic syndrome) or laboratory tests (lithium, carbamazepine, clozapine, valproate, renal and hepatic functions, metabolic profile for all antipsychotics). Failure to monitor may lead to fatal outcomes. Some medications are considered unsafe during pregnancy or breast-feeding.

Psychologists do a great service for patients with mental illness by providing evidence-based psycho­therapies, such as cognitive-behavioral, dialectical-behavioral, interpersonal, and behavioral therapy. They complement what psychiatrists and nurse practitioners do with pharmaco­therapy. Many patients with mild or moderate psychiatric disorders improve significantly with psychotherapy without the use of psychotropics. Psychologists should focus on what they were trained to do because they can benefit numerous patients. That is much better than trying to become prescribers and practice mediocre psychopharmacology without the requisite medical training. Patients with mental illness deserve no less.
 

Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri

Second-generation antipsychotics (SGAs) have been a remarkably effective innovation in psychotropic therapy. Unfortunately, the metabolic effects of these medications—primarily weight gain—present an obstacle to medication adherence. Preliminary studies have suggested that melatonin, a hormone most commonly used as a sleep aid, may help minimize weight gain among patients receiving SGAs.

Modabbernia et al¹ demonstrated positive results from melatonin augmentation in an 8-week, randomized, double-blind, placebo-controlled study of 48 patients with first-episode schizophrenia. Compared with patients who received olanzapine and placebo, those taking olanzapine and melatonin, 3 mg/d, had significantly less weight gain, smaller increases in abdominal obesity, and lower triglycerides. Patients who were given melatonin also had a significantly greater reduction on the Positive and Negative Symptom Scale score.¹

Romo-Nava et al² had similar findings in an 8-week, randomized, double-blind, placebo-controlled trial. Forty-four patients (24 with schizophrenia, 20 with bipolar disorder) who were taking clozapine, quetiapine, risperidone, or olanzapine received adjunctive melatonin, 5 mg/d, or placebo. Patients receiving melatonin had significantly less weight gain (P = .04) and significantly reduced diastolic blood pressure (5.1 vs 1.1 mm Hg; P = .03).

In both studies, researchers hypo­thesized that melatonin exerted its effect through the suprachiasmatic nucleus—the part of the hypothalamus that regulates body weight, energy balance, and meta­bolism. Exogenous melatonin suppresses intra-abdominal fat and restores serum leptin and insulin levels in middle-aged rats, partly due to correcting the age-related decline in melatonin production.³

Wang et al⁴ conducted a systematic review of using melatonin in patients taking SGAs. In addition to preventing metabolic adverse effects of antipsychotics, melatonin also reduced weight gain from lithium.

Early evidence suggests that this in­expensive and relatively safe augmenting agent can minimize metabolic effects of SGAs. It is surprising that scheduled melatonin has eluded popular use in psychiatry.

Second-generation antipsychotics (SGAs) have been a remarkably effective innovation in psychotropic therapy. Unfortunately, the metabolic effects of these medications—primarily weight gain—present an obstacle to medication adherence. Preliminary studies have suggested that melatonin, a hormone most commonly used as a sleep aid, may help minimize weight gain among patients receiving SGAs.

Modabbernia et al¹ demonstrated positive results from melatonin augmentation in an 8-week, randomized, double-blind, placebo-controlled study of 48 patients with first-episode schizophrenia. Compared with patients who received olanzapine and placebo, those taking olanzapine and melatonin, 3 mg/d, had significantly less weight gain, smaller increases in abdominal obesity, and lower triglycerides. Patients who were given melatonin also had a significantly greater reduction on the Positive and Negative Symptom Scale score.¹

Romo-Nava et al² had similar findings in an 8-week, randomized, double-blind, placebo-controlled trial. Forty-four patients (24 with schizophrenia, 20 with bipolar disorder) who were taking clozapine, quetiapine, risperidone, or olanzapine received adjunctive melatonin, 5 mg/d, or placebo. Patients receiving melatonin had significantly less weight gain (P = .04) and significantly reduced diastolic blood pressure (5.1 vs 1.1 mm Hg; P = .03).

In both studies, researchers hypo­thesized that melatonin exerted its effect through the suprachiasmatic nucleus—the part of the hypothalamus that regulates body weight, energy balance, and meta­bolism. Exogenous melatonin suppresses intra-abdominal fat and restores serum leptin and insulin levels in middle-aged rats, partly due to correcting the age-related decline in melatonin production.³

Wang et al⁴ conducted a systematic review of using melatonin in patients taking SGAs. In addition to preventing metabolic adverse effects of antipsychotics, melatonin also reduced weight gain from lithium.

Early evidence suggests that this in­expensive and relatively safe augmenting agent can minimize metabolic effects of SGAs. It is surprising that scheduled melatonin has eluded popular use in psychiatry.

Second-generation antipsychotics (SGAs) have been a remarkably effective innovation in psychotropic therapy. Unfortunately, the metabolic effects of these medications—primarily weight gain—present an obstacle to medication adherence. Preliminary studies have suggested that melatonin, a hormone most commonly used as a sleep aid, may help minimize weight gain among patients receiving SGAs.

Modabbernia et al¹ demonstrated positive results from melatonin augmentation in an 8-week, randomized, double-blind, placebo-controlled study of 48 patients with first-episode schizophrenia. Compared with patients who received olanzapine and placebo, those taking olanzapine and melatonin, 3 mg/d, had significantly less weight gain, smaller increases in abdominal obesity, and lower triglycerides. Patients who were given melatonin also had a significantly greater reduction on the Positive and Negative Symptom Scale score.¹

Romo-Nava et al² had similar findings in an 8-week, randomized, double-blind, placebo-controlled trial. Forty-four patients (24 with schizophrenia, 20 with bipolar disorder) who were taking clozapine, quetiapine, risperidone, or olanzapine received adjunctive melatonin, 5 mg/d, or placebo. Patients receiving melatonin had significantly less weight gain (P = .04) and significantly reduced diastolic blood pressure (5.1 vs 1.1 mm Hg; P = .03).

In both studies, researchers hypo­thesized that melatonin exerted its effect through the suprachiasmatic nucleus—the part of the hypothalamus that regulates body weight, energy balance, and meta­bolism. Exogenous melatonin suppresses intra-abdominal fat and restores serum leptin and insulin levels in middle-aged rats, partly due to correcting the age-related decline in melatonin production.³

Wang et al⁴ conducted a systematic review of using melatonin in patients taking SGAs. In addition to preventing metabolic adverse effects of antipsychotics, melatonin also reduced weight gain from lithium.

Early evidence suggests that this in­expensive and relatively safe augmenting agent can minimize metabolic effects of SGAs. It is surprising that scheduled melatonin has eluded popular use in psychiatry.

Gone are the days when social media was primarily used by millennials and those early adopters on the diffusion-of-innovation curve. Now, baby boomers and laggards alike are using social media to communicate with the world around them. Furthermore, health and healthcare issues are common topics in the social media universe. Eight in 10 Internet users seek health information online and 74% of these health information seekers use social media.^1,2 Additionally, when they look online, they are more likely to trust information from doctors (61%) than from hospitals (55%), insurers (42%), or pharmaceutical companies (37%).³ Therefore, there is tremendous opportunity for physicians to engage patients, policy makers, advocacy groups, and other health care influencers in order to share reliable information. Yet, we must do so responsibly. There is a considerable degree of misinformation circulated in social media and we believe that physicians should help combat this by providing accurate information.

SonerCdem/Thinkstock

3. Share reliable/vetted information in your area of expertise and interest. Do not try to be all things to all people. Focus on content that distinguishes you and meets your goals. On the other hand, this should not be all about you; this can be boring, difficult, and give the impression that all you care about is self-promotion. No more than a quarter to a third of the content should be about you and the rest should be curated content from other reliable sources. Sharing with attribution helps you build your community. Also, people appreciate vetted content in the great web of misinformation available. You can facilitate audience engagement by including graphics, photos, and videos and by engaging and responding to other posts. Importantly, having a disclaimer on your account (e.g., retweets are not endorsements, posts are not medical advice) is never a substitute for knowing/vetting what you are sharing.

4. Exercise caution when responding to medical questions on social media and/or sharing patient information. While we encourage engagement, you should never answer specific medical questions. This develops a doctor-patient relationship and creates legal “duty.” It could even constitute practicing without a license, if the person asking the question lives in another state. Instead, provide general information about a condition, especially as a link to a reliable site (www.gastro.org/patient-care/patientinfo-center) and suggest seeking care from their local medical professional. Along these lines, do not share any potentially identifiable patient information without documented permission. In addition to the obvious (e.g., patient name, photos, medical documents with identifiers), avoid stories of care, complications, rare conditions, or identifiable specimens. With an approximate date and the location of your practice, it may be very easy for someone to determine the patient’s identity.

6. Know and adhere to the social media policies of your practice, institution, organization, or employer. Most academic institutions have social media policies and they are becoming more widely adapted to other settings. While you may just get a metaphorical slap on the wrist for not following the rules, I think we all would agree that it would be a tragedy to get fired over a social media post.

However, none of the above best practices are a substitute for being intentional and mindful when sharing information on social media, whether it be Facebook, Twitter, Instagram, Youtube, or another platform. What does being intentional and mindful on social media mean? Absolutely avoid commenting/posting about patients, colleagues, or your workplace in any way that could be perceived to be negative. Declare conflicts of interest where applicable (i.e., if you’re a consultant for a pharma company, avoid endorsing a drug without declaring your conflict). Above all else, don’t post anything that you wouldn’t mind being on a billboard or mainstream news.

Participation is an investment of your most valuable resource: time. Therefore, know your goals and revisit these goals and your success in reaching them regularly. Start small and expand as your time and interest allows. Finally, minimize your exposure to risk by keeping our guidance and your institutional policies in mind and always pause before you post.

You can find out more about the AGA, its programs, and publications via our social media outlets, including:
 

Twitter:

@amergastroassn

@AGA_CGH

@AGA_CMGH

@AGA_Gastro


Facebook:

@AmerGastroAssn

@cghjournal

@cmghjournal

@gastrojournal

Dr. Fisher is associate professor in the department of medicine, division of gastroenterology, Duke University, Durham, N.C. VA Medical Center. Twitter: @DrDeborahFisher. Dr. Gray is assistant professor, department of medicine, division of gastroenterology, hepatology and nutrition, Ohio State University College of Medicine. Twitter: @DMGrayMD.

This information was presented at a Meet-the-Professor Luncheon at DDW® 2017. More for in-depth details than are described in this article, refer to this session on DDW on Demand (http://www.ddw.org/education/session-recordings).

References

1 Von Muhlen M., Ohno-Machado L. J Am Med Inform Assoc. 2012;19(5):777-81.

2 Childs L.M., Martin C.Y. Am J Health System Pharm. 2012;69(23):2044-50.

3. Social media “likes” healthcare. From marketing to social business – 2012 Report

https://www.pwc.com/us/en/health-industries/health-research-institute/publications/health-care-social-media.html.

4. www.martinsights.com/social-media-marketing/social-media-strategy/new-global-social-media-research/.

5. Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 2013;158(8):620-7.

Gone are the days when social media was primarily used by millennials and those early adopters on the diffusion-of-innovation curve. Now, baby boomers and laggards alike are using social media to communicate with the world around them. Furthermore, health and healthcare issues are common topics in the social media universe. Eight in 10 Internet users seek health information online and 74% of these health information seekers use social media.^1,2 Additionally, when they look online, they are more likely to trust information from doctors (61%) than from hospitals (55%), insurers (42%), or pharmaceutical companies (37%).³ Therefore, there is tremendous opportunity for physicians to engage patients, policy makers, advocacy groups, and other health care influencers in order to share reliable information. Yet, we must do so responsibly. There is a considerable degree of misinformation circulated in social media and we believe that physicians should help combat this by providing accurate information.

SonerCdem/Thinkstock

3. Share reliable/vetted information in your area of expertise and interest. Do not try to be all things to all people. Focus on content that distinguishes you and meets your goals. On the other hand, this should not be all about you; this can be boring, difficult, and give the impression that all you care about is self-promotion. No more than a quarter to a third of the content should be about you and the rest should be curated content from other reliable sources. Sharing with attribution helps you build your community. Also, people appreciate vetted content in the great web of misinformation available. You can facilitate audience engagement by including graphics, photos, and videos and by engaging and responding to other posts. Importantly, having a disclaimer on your account (e.g., retweets are not endorsements, posts are not medical advice) is never a substitute for knowing/vetting what you are sharing.

4. Exercise caution when responding to medical questions on social media and/or sharing patient information. While we encourage engagement, you should never answer specific medical questions. This develops a doctor-patient relationship and creates legal “duty.” It could even constitute practicing without a license, if the person asking the question lives in another state. Instead, provide general information about a condition, especially as a link to a reliable site (www.gastro.org/patient-care/patientinfo-center) and suggest seeking care from their local medical professional. Along these lines, do not share any potentially identifiable patient information without documented permission. In addition to the obvious (e.g., patient name, photos, medical documents with identifiers), avoid stories of care, complications, rare conditions, or identifiable specimens. With an approximate date and the location of your practice, it may be very easy for someone to determine the patient’s identity.

6. Know and adhere to the social media policies of your practice, institution, organization, or employer. Most academic institutions have social media policies and they are becoming more widely adapted to other settings. While you may just get a metaphorical slap on the wrist for not following the rules, I think we all would agree that it would be a tragedy to get fired over a social media post.

However, none of the above best practices are a substitute for being intentional and mindful when sharing information on social media, whether it be Facebook, Twitter, Instagram, Youtube, or another platform. What does being intentional and mindful on social media mean? Absolutely avoid commenting/posting about patients, colleagues, or your workplace in any way that could be perceived to be negative. Declare conflicts of interest where applicable (i.e., if you’re a consultant for a pharma company, avoid endorsing a drug without declaring your conflict). Above all else, don’t post anything that you wouldn’t mind being on a billboard or mainstream news.

Participation is an investment of your most valuable resource: time. Therefore, know your goals and revisit these goals and your success in reaching them regularly. Start small and expand as your time and interest allows. Finally, minimize your exposure to risk by keeping our guidance and your institutional policies in mind and always pause before you post.

You can find out more about the AGA, its programs, and publications via our social media outlets, including:
 

Twitter:

@amergastroassn

@AGA_CGH

@AGA_CMGH

@AGA_Gastro


Facebook:

@AmerGastroAssn

@cghjournal

@cmghjournal

@gastrojournal

Dr. Fisher is associate professor in the department of medicine, division of gastroenterology, Duke University, Durham, N.C. VA Medical Center. Twitter: @DrDeborahFisher. Dr. Gray is assistant professor, department of medicine, division of gastroenterology, hepatology and nutrition, Ohio State University College of Medicine. Twitter: @DMGrayMD.

This information was presented at a Meet-the-Professor Luncheon at DDW® 2017. More for in-depth details than are described in this article, refer to this session on DDW on Demand (http://www.ddw.org/education/session-recordings).

References

1 Von Muhlen M., Ohno-Machado L. J Am Med Inform Assoc. 2012;19(5):777-81.

2 Childs L.M., Martin C.Y. Am J Health System Pharm. 2012;69(23):2044-50.

3. Social media “likes” healthcare. From marketing to social business – 2012 Report

https://www.pwc.com/us/en/health-industries/health-research-institute/publications/health-care-social-media.html.

4. www.martinsights.com/social-media-marketing/social-media-strategy/new-global-social-media-research/.

5. Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 2013;158(8):620-7.

Gone are the days when social media was primarily used by millennials and those early adopters on the diffusion-of-innovation curve. Now, baby boomers and laggards alike are using social media to communicate with the world around them. Furthermore, health and healthcare issues are common topics in the social media universe. Eight in 10 Internet users seek health information online and 74% of these health information seekers use social media.^1,2 Additionally, when they look online, they are more likely to trust information from doctors (61%) than from hospitals (55%), insurers (42%), or pharmaceutical companies (37%).³ Therefore, there is tremendous opportunity for physicians to engage patients, policy makers, advocacy groups, and other health care influencers in order to share reliable information. Yet, we must do so responsibly. There is a considerable degree of misinformation circulated in social media and we believe that physicians should help combat this by providing accurate information.

SonerCdem/Thinkstock

3. Share reliable/vetted information in your area of expertise and interest. Do not try to be all things to all people. Focus on content that distinguishes you and meets your goals. On the other hand, this should not be all about you; this can be boring, difficult, and give the impression that all you care about is self-promotion. No more than a quarter to a third of the content should be about you and the rest should be curated content from other reliable sources. Sharing with attribution helps you build your community. Also, people appreciate vetted content in the great web of misinformation available. You can facilitate audience engagement by including graphics, photos, and videos and by engaging and responding to other posts. Importantly, having a disclaimer on your account (e.g., retweets are not endorsements, posts are not medical advice) is never a substitute for knowing/vetting what you are sharing.

4. Exercise caution when responding to medical questions on social media and/or sharing patient information. While we encourage engagement, you should never answer specific medical questions. This develops a doctor-patient relationship and creates legal “duty.” It could even constitute practicing without a license, if the person asking the question lives in another state. Instead, provide general information about a condition, especially as a link to a reliable site (www.gastro.org/patient-care/patientinfo-center) and suggest seeking care from their local medical professional. Along these lines, do not share any potentially identifiable patient information without documented permission. In addition to the obvious (e.g., patient name, photos, medical documents with identifiers), avoid stories of care, complications, rare conditions, or identifiable specimens. With an approximate date and the location of your practice, it may be very easy for someone to determine the patient’s identity.

6. Know and adhere to the social media policies of your practice, institution, organization, or employer. Most academic institutions have social media policies and they are becoming more widely adapted to other settings. While you may just get a metaphorical slap on the wrist for not following the rules, I think we all would agree that it would be a tragedy to get fired over a social media post.

However, none of the above best practices are a substitute for being intentional and mindful when sharing information on social media, whether it be Facebook, Twitter, Instagram, Youtube, or another platform. What does being intentional and mindful on social media mean? Absolutely avoid commenting/posting about patients, colleagues, or your workplace in any way that could be perceived to be negative. Declare conflicts of interest where applicable (i.e., if you’re a consultant for a pharma company, avoid endorsing a drug without declaring your conflict). Above all else, don’t post anything that you wouldn’t mind being on a billboard or mainstream news.

Participation is an investment of your most valuable resource: time. Therefore, know your goals and revisit these goals and your success in reaching them regularly. Start small and expand as your time and interest allows. Finally, minimize your exposure to risk by keeping our guidance and your institutional policies in mind and always pause before you post.

You can find out more about the AGA, its programs, and publications via our social media outlets, including:
 

Twitter:

@amergastroassn

@AGA_CGH

@AGA_CMGH

@AGA_Gastro


Facebook:

@AmerGastroAssn

@cghjournal

@cmghjournal

@gastrojournal

Dr. Fisher is associate professor in the department of medicine, division of gastroenterology, Duke University, Durham, N.C. VA Medical Center. Twitter: @DrDeborahFisher. Dr. Gray is assistant professor, department of medicine, division of gastroenterology, hepatology and nutrition, Ohio State University College of Medicine. Twitter: @DMGrayMD.

This information was presented at a Meet-the-Professor Luncheon at DDW® 2017. More for in-depth details than are described in this article, refer to this session on DDW on Demand (http://www.ddw.org/education/session-recordings).

References

1 Von Muhlen M., Ohno-Machado L. J Am Med Inform Assoc. 2012;19(5):777-81.

2 Childs L.M., Martin C.Y. Am J Health System Pharm. 2012;69(23):2044-50.

3. Social media “likes” healthcare. From marketing to social business – 2012 Report

https://www.pwc.com/us/en/health-industries/health-research-institute/publications/health-care-social-media.html.

4. www.martinsights.com/social-media-marketing/social-media-strategy/new-global-social-media-research/.

5. Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 2013;158(8):620-7.

The hospital is often the intersection between a patient’s medical illness and their social and financial issues. As physicians, it is important to recognize that patient care encompasses not only prescribing medications and performing procedures but also practicing systems-based medicine; ensuring social and financial barriers do not impede access to, and delivery of, care. Some of these barriers cannot be eliminated by one individual practitioner; they can only be improved by working with government representatives and policy makers to make systemic changes. For gastroenterologists, advocacy involves educating patients, practitioners, and our government representatives about issues related to GI illnesses and the importance of ensuring access to GI specialty care and treatment for all patients who require it.

AGA Institute

Dr. Natarajan is assistant professor, Dr. Shukla is assistant professor, and Dr. Shapiro is a second-year fellow; all are in the section of gastroenterology and hepatology, Baylor College of Medicine, Houston.

References

1. Ehrlich E. (2017). NIH’S Role in Sustaining the U.S. Economy. United for Medical Research. Accessed at http://www.unitedformedicalresearch.com/wp-content/uploads/2017/03/NIH-Role-in-the-Economy-FY2016.

2. AGA Position Statement on Research Funding. Accessed at http://www.gastro.org/take-action/top-issues/research-funding.

3. El-Serag H.B., Kanwal F., Davila J.A., Kramer J., Richardson P. A new laboratory-based algorithm to predict development of hepatocellular carcinoma in patients with hepatitis C and cirrhosis. Gastroenterology. 2014;May146(5):1249-55.

4. White D.L., Richardson P., Tayoub N., Davila J.A., Kanwal F., El-Serag H.B. The updated model: An adjusted serum alpha-fetoprotein-based algorithm for hepatocellular carcinoma detection with hepatitis C virus-related cirrhosis. Gastroenterology. 2015;Dec 149(7):1986-7.

5. AGA Position Statement on Patient Cost-Sharing for Screening Colonoscopy. Accessed a: http://www.gastro.org/take-action/top-issues/patient-cost-sharing-for-screening-colonoscopy.
 

The hospital is often the intersection between a patient’s medical illness and their social and financial issues. As physicians, it is important to recognize that patient care encompasses not only prescribing medications and performing procedures but also practicing systems-based medicine; ensuring social and financial barriers do not impede access to, and delivery of, care. Some of these barriers cannot be eliminated by one individual practitioner; they can only be improved by working with government representatives and policy makers to make systemic changes. For gastroenterologists, advocacy involves educating patients, practitioners, and our government representatives about issues related to GI illnesses and the importance of ensuring access to GI specialty care and treatment for all patients who require it.

AGA Institute

Dr. Natarajan is assistant professor, Dr. Shukla is assistant professor, and Dr. Shapiro is a second-year fellow; all are in the section of gastroenterology and hepatology, Baylor College of Medicine, Houston.

References

1. Ehrlich E. (2017). NIH’S Role in Sustaining the U.S. Economy. United for Medical Research. Accessed at http://www.unitedformedicalresearch.com/wp-content/uploads/2017/03/NIH-Role-in-the-Economy-FY2016.

2. AGA Position Statement on Research Funding. Accessed at http://www.gastro.org/take-action/top-issues/research-funding.

3. El-Serag H.B., Kanwal F., Davila J.A., Kramer J., Richardson P. A new laboratory-based algorithm to predict development of hepatocellular carcinoma in patients with hepatitis C and cirrhosis. Gastroenterology. 2014;May146(5):1249-55.

4. White D.L., Richardson P., Tayoub N., Davila J.A., Kanwal F., El-Serag H.B. The updated model: An adjusted serum alpha-fetoprotein-based algorithm for hepatocellular carcinoma detection with hepatitis C virus-related cirrhosis. Gastroenterology. 2015;Dec 149(7):1986-7.

5. AGA Position Statement on Patient Cost-Sharing for Screening Colonoscopy. Accessed a: http://www.gastro.org/take-action/top-issues/patient-cost-sharing-for-screening-colonoscopy.
 

The hospital is often the intersection between a patient’s medical illness and their social and financial issues. As physicians, it is important to recognize that patient care encompasses not only prescribing medications and performing procedures but also practicing systems-based medicine; ensuring social and financial barriers do not impede access to, and delivery of, care. Some of these barriers cannot be eliminated by one individual practitioner; they can only be improved by working with government representatives and policy makers to make systemic changes. For gastroenterologists, advocacy involves educating patients, practitioners, and our government representatives about issues related to GI illnesses and the importance of ensuring access to GI specialty care and treatment for all patients who require it.

AGA Institute

Dr. Natarajan is assistant professor, Dr. Shukla is assistant professor, and Dr. Shapiro is a second-year fellow; all are in the section of gastroenterology and hepatology, Baylor College of Medicine, Houston.

References

1. Ehrlich E. (2017). NIH’S Role in Sustaining the U.S. Economy. United for Medical Research. Accessed at http://www.unitedformedicalresearch.com/wp-content/uploads/2017/03/NIH-Role-in-the-Economy-FY2016.

2. AGA Position Statement on Research Funding. Accessed at http://www.gastro.org/take-action/top-issues/research-funding.

3. El-Serag H.B., Kanwal F., Davila J.A., Kramer J., Richardson P. A new laboratory-based algorithm to predict development of hepatocellular carcinoma in patients with hepatitis C and cirrhosis. Gastroenterology. 2014;May146(5):1249-55.

4. White D.L., Richardson P., Tayoub N., Davila J.A., Kanwal F., El-Serag H.B. The updated model: An adjusted serum alpha-fetoprotein-based algorithm for hepatocellular carcinoma detection with hepatitis C virus-related cirrhosis. Gastroenterology. 2015;Dec 149(7):1986-7.

5. AGA Position Statement on Patient Cost-Sharing for Screening Colonoscopy. Accessed a: http://www.gastro.org/take-action/top-issues/patient-cost-sharing-for-screening-colonoscopy.
 

In the previous issue of The New Gastroenterologist, we discussed statistics and the basis on which most gastroenterologists are sued as well as what you can do to minimize this risk. In this second article, we discuss steps to assist in your defense in the event you have been sued. The following suggestions are based on our experience as defense attorneys who practice in the arena of medical malpractice.

Your deposition

At some point during the lawsuit, the plaintiff’s attorney will take your deposition. The plaintiff’s attorney will strive to obtain concessions that establish the standard of care, breach of the standard, causation, and damages. Your deposition is not the time for you to provide explanations. It is the time for you to concisely answer specific questions posed by counsel without volunteering any additional information. Ultimately, trials build on what occurs during depositions. Preparation is key. Be open to advice or criticisms from your lawyer. Try to eliminate any quirks or habits that interfere with the substance of your testimony or perceived credibility. A deposition is not a casual conversation, nor is it a test of your memory. Limit your answers to personal knowledge; never guess or speculate. If you do not know the answer to a question, or do not remember something, it is perfectly acceptable for you to say so. Only answer questions that you understand. You are allowed to ask the plaintiff’s counsel to repeat or rephrase questions.

Preparing for trial

Conclusion

In summary, remember that there are things you can do both before and after you are sued to minimize litigation and its impact. As mentioned previously, before a lawsuit, and as a regular part of your practice, it is important that you stay current with medical advances, that you take the time to create a relationship with your patients involving quality communication, and that you thoroughly and legibly document all aspects of care provided. After a suit is filed against you, make sure you notify your insurer immediately, do not alter any records or discuss the case with anyone other than your lawyer or spouse, and do all you can to create a productive and honest relationship with your lawyer. This relationship will be invaluable as you do the difficult and time-consuming work of preparing for your deposition and trial, and it can help you endure and successfully navigate the litigation process.

The Importance of Follow-Up: Further Advice on How to Decrease the Risk of Being Sued

A common basis for establishing a malpractice liability claim against a physician is the failure to follow-up or track a patient’s test results. In today’s world, there is an increasing number of moving parts involved in any given patient’s care. A particular patient may treat with numerous physicians, all of whom use different record systems. Electronic medical record systems have made records more accessible and easier to track, but they also present a new set of challenges.

Every physician needs to determine how they plan to track test results. The ideal system would allow a physician to quickly get back any lab or diagnostic test that he or she orders. All staff members should know how the physician’s system works. Otherwise, test results might accidentally be filed before the physician reviews them or a miscommunication could prevent test results from being delivered. Whatever choice of system, it is key to follow and effectively use the program every time.

Additionally, it can be beneficial to let the patient know when he or she can expect to hear about their results, as failure to keep the patient reasonably informed can create a new set of patient concerns and anxiety. Ultimately, establishing a well-defined system for record-tracking can help physicians avoid malpractice liability claims because of a failure to follow-up.

In the previous issue of The New Gastroenterologist, we discussed statistics and the basis on which most gastroenterologists are sued as well as what you can do to minimize this risk. In this second article, we discuss steps to assist in your defense in the event you have been sued. The following suggestions are based on our experience as defense attorneys who practice in the arena of medical malpractice.

Your deposition

At some point during the lawsuit, the plaintiff’s attorney will take your deposition. The plaintiff’s attorney will strive to obtain concessions that establish the standard of care, breach of the standard, causation, and damages. Your deposition is not the time for you to provide explanations. It is the time for you to concisely answer specific questions posed by counsel without volunteering any additional information. Ultimately, trials build on what occurs during depositions. Preparation is key. Be open to advice or criticisms from your lawyer. Try to eliminate any quirks or habits that interfere with the substance of your testimony or perceived credibility. A deposition is not a casual conversation, nor is it a test of your memory. Limit your answers to personal knowledge; never guess or speculate. If you do not know the answer to a question, or do not remember something, it is perfectly acceptable for you to say so. Only answer questions that you understand. You are allowed to ask the plaintiff’s counsel to repeat or rephrase questions.

Preparing for trial

Conclusion

In summary, remember that there are things you can do both before and after you are sued to minimize litigation and its impact. As mentioned previously, before a lawsuit, and as a regular part of your practice, it is important that you stay current with medical advances, that you take the time to create a relationship with your patients involving quality communication, and that you thoroughly and legibly document all aspects of care provided. After a suit is filed against you, make sure you notify your insurer immediately, do not alter any records or discuss the case with anyone other than your lawyer or spouse, and do all you can to create a productive and honest relationship with your lawyer. This relationship will be invaluable as you do the difficult and time-consuming work of preparing for your deposition and trial, and it can help you endure and successfully navigate the litigation process.

The Importance of Follow-Up: Further Advice on How to Decrease the Risk of Being Sued

A common basis for establishing a malpractice liability claim against a physician is the failure to follow-up or track a patient’s test results. In today’s world, there is an increasing number of moving parts involved in any given patient’s care. A particular patient may treat with numerous physicians, all of whom use different record systems. Electronic medical record systems have made records more accessible and easier to track, but they also present a new set of challenges.

Every physician needs to determine how they plan to track test results. The ideal system would allow a physician to quickly get back any lab or diagnostic test that he or she orders. All staff members should know how the physician’s system works. Otherwise, test results might accidentally be filed before the physician reviews them or a miscommunication could prevent test results from being delivered. Whatever choice of system, it is key to follow and effectively use the program every time.

Additionally, it can be beneficial to let the patient know when he or she can expect to hear about their results, as failure to keep the patient reasonably informed can create a new set of patient concerns and anxiety. Ultimately, establishing a well-defined system for record-tracking can help physicians avoid malpractice liability claims because of a failure to follow-up.

In the previous issue of The New Gastroenterologist, we discussed statistics and the basis on which most gastroenterologists are sued as well as what you can do to minimize this risk. In this second article, we discuss steps to assist in your defense in the event you have been sued. The following suggestions are based on our experience as defense attorneys who practice in the arena of medical malpractice.

Your deposition

At some point during the lawsuit, the plaintiff’s attorney will take your deposition. The plaintiff’s attorney will strive to obtain concessions that establish the standard of care, breach of the standard, causation, and damages. Your deposition is not the time for you to provide explanations. It is the time for you to concisely answer specific questions posed by counsel without volunteering any additional information. Ultimately, trials build on what occurs during depositions. Preparation is key. Be open to advice or criticisms from your lawyer. Try to eliminate any quirks or habits that interfere with the substance of your testimony or perceived credibility. A deposition is not a casual conversation, nor is it a test of your memory. Limit your answers to personal knowledge; never guess or speculate. If you do not know the answer to a question, or do not remember something, it is perfectly acceptable for you to say so. Only answer questions that you understand. You are allowed to ask the plaintiff’s counsel to repeat or rephrase questions.

Preparing for trial

Conclusion

In summary, remember that there are things you can do both before and after you are sued to minimize litigation and its impact. As mentioned previously, before a lawsuit, and as a regular part of your practice, it is important that you stay current with medical advances, that you take the time to create a relationship with your patients involving quality communication, and that you thoroughly and legibly document all aspects of care provided. After a suit is filed against you, make sure you notify your insurer immediately, do not alter any records or discuss the case with anyone other than your lawyer or spouse, and do all you can to create a productive and honest relationship with your lawyer. This relationship will be invaluable as you do the difficult and time-consuming work of preparing for your deposition and trial, and it can help you endure and successfully navigate the litigation process.

The Importance of Follow-Up: Further Advice on How to Decrease the Risk of Being Sued

A common basis for establishing a malpractice liability claim against a physician is the failure to follow-up or track a patient’s test results. In today’s world, there is an increasing number of moving parts involved in any given patient’s care. A particular patient may treat with numerous physicians, all of whom use different record systems. Electronic medical record systems have made records more accessible and easier to track, but they also present a new set of challenges.

Every physician needs to determine how they plan to track test results. The ideal system would allow a physician to quickly get back any lab or diagnostic test that he or she orders. All staff members should know how the physician’s system works. Otherwise, test results might accidentally be filed before the physician reviews them or a miscommunication could prevent test results from being delivered. Whatever choice of system, it is key to follow and effectively use the program every time.

Additionally, it can be beneficial to let the patient know when he or she can expect to hear about their results, as failure to keep the patient reasonably informed can create a new set of patient concerns and anxiety. Ultimately, establishing a well-defined system for record-tracking can help physicians avoid malpractice liability claims because of a failure to follow-up.

Introduction

Direct visualization of the biliary ductal system is quickly gaining importance among gastroenterologists. Since the inception of cholangioscopy in the 1970s, the technology has progressed, allowing for ease of use, better visualization, and a growing number of indications. Conventional endoscopic retrograde cholangiopancreatography (ERCP) is successful for removal of bile duct stones (with success rates over 90%);¹ however, its use in the evaluation of potential biliary neoplasia has been somewhat disappointing. The diagnostic yield of ERCP-guided biliary brushings can range from 30% to 40%.^2-4 An alternative to ERCP-guided biliary brushings for biliary strictures is endoscopic ultrasound (EUS)-directed fine needle aspiration (FNA), but the reported sensitivity remains poor, ranging from 43% to 77% with negative predictive values of less than 30%.^5-7 These results leave much to be desired for diagnostic yield.

Clinical indications

Dr. Sonnier, Dr. Mizrahi, and Dr. Pleskow

Dr. Sonnier, Dr. Mizrahi, and Dr. Pleskow

Risks and complications

Conclusions

Direct visualization of the biliary and pancreatic ductal system with fiber-optic and now digital-based platforms have greatly expanded the diagnostic and therapeutic capabilities available to gastroenterologists in the diagnosis and management of biliary and pancreatic disorders. The digital single-operator cholangiopancreatascope system offers greater diagnostic yield of pancreaticobiliary disorders over conventional diagnostic sampling techniques. In addition, direct visualization has expanded our therapeutic ability in complex stone disease allowing laser-based therapies that are not available with traditional fluoroscopic based techniques. Cholangiopancreatoscopic techniques and indications are rapidly expanding and will continue to expand the diagnostic and therapeutic armamentarium available to gastroenterologists.

Dr. Sonnier is a general gastroenterology fellow, division of gastroenterology, University of South Alabama. Dr. Mizrahi is director of advanced endoscopy, division of gastroenterology, University of South Alabama. Dr. Pleskow, is clinical chief, department of gastroenterology, Beth Israel Deaconess Medical Center, and associate professor of medicine, Harvard Medical School, Boston. Dr. Sonnier and Dr. Mizrahi have no conflicts of interest. Dr. Pleskow serves as a consultant to Boston Scientific.

References

1. Cohen S., et al. Gastrointest Endosc. 2002;56:803–9

2. Lee J.G., et al. Am J Gastroenterol. 1995;90:722-6.

3. De Bellis M., et al. Gastrointest Endosc. 2003;58:176-82

4. Fritcher E.G., et al. Gastroenterology. 2009;136:2180-6.

5. Rosch T., et al. Gastrointest Endosc. 2004;60:390-6.

6. Byrne M.F., et al. Endoscopy. 2004;36:715-9.

7. DeWitt J., et al. Gastrointest Endosc. 2006;64:325-33.

8. Rosch W., Endoscopy. 1976;8:172-5.

9. Takekoshi T., Takagi K. Gastrointest Endosc. 1975;17:678-83.

10. Chen Y.K. Gastrointest Endosc 2007;65:303-11.

11. Navaneethan U., et al. Gastrointest Endosc 2016;84:649-55.

12. Navaneethan U., et al. Gastrointest Endosc 2015;82: 608-14.

13. Chen Y.K., Pleskow DK. Gastrointest Endosc. 2007;65:832-41.

14. Draganov P.V., et al. Gastrointest Endosc. 2011;73:971-9.

15. Ramchandani M., et al. Gastrointest Endosc. 2011;74:511-9.

16. Chen Y.K., et al. Gastrointest Endosc. 2011;74:805-14.

17. Draganov P.V., et al. Gastrointest Endosc. 2012;75:347-53.

18. Classen M., et al. Endoscopy 1988;20:21-6.

19. Parsi M.A., et al. Gastrointest Endosc 2008;67:AB102.

20. Fishman D.S., et al. World J Gastroenterol. 2009;15:1353-8.

21. Maydeo A., et al. Gastrointest Endosc. 2011;74:1308-14.

22. Yamao K., et al. Gastrointest Endosc 2003;57:205-9.

23. Hara T., et al. Gastroenterology 2002;122:34-43.

24. Rösch T., et al. Endoscopy. 2002;34:765–71.

25. Bekkali N.L., et al. Pancreas. 2017;46:528-30.

26. Adwan H., et al. Dig Endosc. 2011;23:199-200.

27. Ransibrahmanakul K., et al. Clin Gastroenterol Hepatol. 2010;8:e9.

28. Pereira P., et al. J Gastrointestin Liver Dis, June 2017;Vol. 26(No 2):165-70.

29. Kawakubo K., et al. Endoscopy 2011;43:E241-2.

Introduction

Direct visualization of the biliary ductal system is quickly gaining importance among gastroenterologists. Since the inception of cholangioscopy in the 1970s, the technology has progressed, allowing for ease of use, better visualization, and a growing number of indications. Conventional endoscopic retrograde cholangiopancreatography (ERCP) is successful for removal of bile duct stones (with success rates over 90%);¹ however, its use in the evaluation of potential biliary neoplasia has been somewhat disappointing. The diagnostic yield of ERCP-guided biliary brushings can range from 30% to 40%.^2-4 An alternative to ERCP-guided biliary brushings for biliary strictures is endoscopic ultrasound (EUS)-directed fine needle aspiration (FNA), but the reported sensitivity remains poor, ranging from 43% to 77% with negative predictive values of less than 30%.^5-7 These results leave much to be desired for diagnostic yield.

Clinical indications

Dr. Sonnier, Dr. Mizrahi, and Dr. Pleskow

Dr. Sonnier, Dr. Mizrahi, and Dr. Pleskow

Risks and complications

Conclusions

Direct visualization of the biliary and pancreatic ductal system with fiber-optic and now digital-based platforms have greatly expanded the diagnostic and therapeutic capabilities available to gastroenterologists in the diagnosis and management of biliary and pancreatic disorders. The digital single-operator cholangiopancreatascope system offers greater diagnostic yield of pancreaticobiliary disorders over conventional diagnostic sampling techniques. In addition, direct visualization has expanded our therapeutic ability in complex stone disease allowing laser-based therapies that are not available with traditional fluoroscopic based techniques. Cholangiopancreatoscopic techniques and indications are rapidly expanding and will continue to expand the diagnostic and therapeutic armamentarium available to gastroenterologists.

Dr. Sonnier is a general gastroenterology fellow, division of gastroenterology, University of South Alabama. Dr. Mizrahi is director of advanced endoscopy, division of gastroenterology, University of South Alabama. Dr. Pleskow, is clinical chief, department of gastroenterology, Beth Israel Deaconess Medical Center, and associate professor of medicine, Harvard Medical School, Boston. Dr. Sonnier and Dr. Mizrahi have no conflicts of interest. Dr. Pleskow serves as a consultant to Boston Scientific.

References

1. Cohen S., et al. Gastrointest Endosc. 2002;56:803–9

2. Lee J.G., et al. Am J Gastroenterol. 1995;90:722-6.

3. De Bellis M., et al. Gastrointest Endosc. 2003;58:176-82

4. Fritcher E.G., et al. Gastroenterology. 2009;136:2180-6.

5. Rosch T., et al. Gastrointest Endosc. 2004;60:390-6.

6. Byrne M.F., et al. Endoscopy. 2004;36:715-9.

7. DeWitt J., et al. Gastrointest Endosc. 2006;64:325-33.

8. Rosch W., Endoscopy. 1976;8:172-5.

9. Takekoshi T., Takagi K. Gastrointest Endosc. 1975;17:678-83.

10. Chen Y.K. Gastrointest Endosc 2007;65:303-11.

11. Navaneethan U., et al. Gastrointest Endosc 2016;84:649-55.

12. Navaneethan U., et al. Gastrointest Endosc 2015;82: 608-14.

13. Chen Y.K., Pleskow DK. Gastrointest Endosc. 2007;65:832-41.

14. Draganov P.V., et al. Gastrointest Endosc. 2011;73:971-9.

15. Ramchandani M., et al. Gastrointest Endosc. 2011;74:511-9.

16. Chen Y.K., et al. Gastrointest Endosc. 2011;74:805-14.

17. Draganov P.V., et al. Gastrointest Endosc. 2012;75:347-53.

18. Classen M., et al. Endoscopy 1988;20:21-6.

19. Parsi M.A., et al. Gastrointest Endosc 2008;67:AB102.

20. Fishman D.S., et al. World J Gastroenterol. 2009;15:1353-8.

21. Maydeo A., et al. Gastrointest Endosc. 2011;74:1308-14.

22. Yamao K., et al. Gastrointest Endosc 2003;57:205-9.

23. Hara T., et al. Gastroenterology 2002;122:34-43.

24. Rösch T., et al. Endoscopy. 2002;34:765–71.

25. Bekkali N.L., et al. Pancreas. 2017;46:528-30.

26. Adwan H., et al. Dig Endosc. 2011;23:199-200.

27. Ransibrahmanakul K., et al. Clin Gastroenterol Hepatol. 2010;8:e9.

28. Pereira P., et al. J Gastrointestin Liver Dis, June 2017;Vol. 26(No 2):165-70.

29. Kawakubo K., et al. Endoscopy 2011;43:E241-2.

Introduction

Direct visualization of the biliary ductal system is quickly gaining importance among gastroenterologists. Since the inception of cholangioscopy in the 1970s, the technology has progressed, allowing for ease of use, better visualization, and a growing number of indications. Conventional endoscopic retrograde cholangiopancreatography (ERCP) is successful for removal of bile duct stones (with success rates over 90%);¹ however, its use in the evaluation of potential biliary neoplasia has been somewhat disappointing. The diagnostic yield of ERCP-guided biliary brushings can range from 30% to 40%.^2-4 An alternative to ERCP-guided biliary brushings for biliary strictures is endoscopic ultrasound (EUS)-directed fine needle aspiration (FNA), but the reported sensitivity remains poor, ranging from 43% to 77% with negative predictive values of less than 30%.^5-7 These results leave much to be desired for diagnostic yield.

Clinical indications

Dr. Sonnier, Dr. Mizrahi, and Dr. Pleskow

Dr. Sonnier, Dr. Mizrahi, and Dr. Pleskow

Risks and complications

Conclusions

Direct visualization of the biliary and pancreatic ductal system with fiber-optic and now digital-based platforms have greatly expanded the diagnostic and therapeutic capabilities available to gastroenterologists in the diagnosis and management of biliary and pancreatic disorders. The digital single-operator cholangiopancreatascope system offers greater diagnostic yield of pancreaticobiliary disorders over conventional diagnostic sampling techniques. In addition, direct visualization has expanded our therapeutic ability in complex stone disease allowing laser-based therapies that are not available with traditional fluoroscopic based techniques. Cholangiopancreatoscopic techniques and indications are rapidly expanding and will continue to expand the diagnostic and therapeutic armamentarium available to gastroenterologists.

Dr. Sonnier is a general gastroenterology fellow, division of gastroenterology, University of South Alabama. Dr. Mizrahi is director of advanced endoscopy, division of gastroenterology, University of South Alabama. Dr. Pleskow, is clinical chief, department of gastroenterology, Beth Israel Deaconess Medical Center, and associate professor of medicine, Harvard Medical School, Boston. Dr. Sonnier and Dr. Mizrahi have no conflicts of interest. Dr. Pleskow serves as a consultant to Boston Scientific.

References

1. Cohen S., et al. Gastrointest Endosc. 2002;56:803–9

2. Lee J.G., et al. Am J Gastroenterol. 1995;90:722-6.

3. De Bellis M., et al. Gastrointest Endosc. 2003;58:176-82

4. Fritcher E.G., et al. Gastroenterology. 2009;136:2180-6.

5. Rosch T., et al. Gastrointest Endosc. 2004;60:390-6.

6. Byrne M.F., et al. Endoscopy. 2004;36:715-9.

7. DeWitt J., et al. Gastrointest Endosc. 2006;64:325-33.

8. Rosch W., Endoscopy. 1976;8:172-5.

9. Takekoshi T., Takagi K. Gastrointest Endosc. 1975;17:678-83.

10. Chen Y.K. Gastrointest Endosc 2007;65:303-11.

11. Navaneethan U., et al. Gastrointest Endosc 2016;84:649-55.

12. Navaneethan U., et al. Gastrointest Endosc 2015;82: 608-14.

13. Chen Y.K., Pleskow DK. Gastrointest Endosc. 2007;65:832-41.

14. Draganov P.V., et al. Gastrointest Endosc. 2011;73:971-9.

15. Ramchandani M., et al. Gastrointest Endosc. 2011;74:511-9.

16. Chen Y.K., et al. Gastrointest Endosc. 2011;74:805-14.

17. Draganov P.V., et al. Gastrointest Endosc. 2012;75:347-53.

18. Classen M., et al. Endoscopy 1988;20:21-6.

19. Parsi M.A., et al. Gastrointest Endosc 2008;67:AB102.

20. Fishman D.S., et al. World J Gastroenterol. 2009;15:1353-8.

21. Maydeo A., et al. Gastrointest Endosc. 2011;74:1308-14.

22. Yamao K., et al. Gastrointest Endosc 2003;57:205-9.

23. Hara T., et al. Gastroenterology 2002;122:34-43.

24. Rösch T., et al. Endoscopy. 2002;34:765–71.

25. Bekkali N.L., et al. Pancreas. 2017;46:528-30.

26. Adwan H., et al. Dig Endosc. 2011;23:199-200.

27. Ransibrahmanakul K., et al. Clin Gastroenterol Hepatol. 2010;8:e9.

28. Pereira P., et al. J Gastrointestin Liver Dis, June 2017;Vol. 26(No 2):165-70.

29. Kawakubo K., et al. Endoscopy 2011;43:E241-2.

AGA Institute

We carefully reviewed the patient’s history and found that he had been using jineijin, a traditional Chinese medicine (TCM) drug, which is made with dried endothelium corneum gigeriae galli (Figure E), at about 500 g/month and squama mantis (a TCM drug, at less than 5 g/month) as dietary supplements for 3 years.

AGA Institute

AGA Institute

Acknowledgments

We thank Linshen Xie, MD, department of environmental health and occupational diseases, No. 4 West China Teaching Hospital, Sichuan University, for offering some clinical data. We thank the patient for giving permission to share his information.

References

1. National Research Council (US). Safe Drinking Water Committee. Drinking water and health. National Academy Press. Washington, D.C. 1977;1:309.

2. State Administration of Traditional Chinese Medicine. Advanced Textbook on Traditional Chinese Medicine and Pharmacology. New World Press, Beijing. 1995. (vol. 2).

3. Hui Hu, Q.J., Kavan, P. A study of heavy metal pollution in China: Current status, pollution-control policies and countermeasures. Sustainability. 2014;6:5820-38.
 

This article has an accompanying continuing medical education activity, also eligible for MOC credit, Learning objective: Upon completion of this examination, successful learners will be able to identify the features of lead poisoning.
 

AGA Institute

We carefully reviewed the patient’s history and found that he had been using jineijin, a traditional Chinese medicine (TCM) drug, which is made with dried endothelium corneum gigeriae galli (Figure E), at about 500 g/month and squama mantis (a TCM drug, at less than 5 g/month) as dietary supplements for 3 years.

AGA Institute

AGA Institute

Acknowledgments

We thank Linshen Xie, MD, department of environmental health and occupational diseases, No. 4 West China Teaching Hospital, Sichuan University, for offering some clinical data. We thank the patient for giving permission to share his information.

References

1. National Research Council (US). Safe Drinking Water Committee. Drinking water and health. National Academy Press. Washington, D.C. 1977;1:309.

2. State Administration of Traditional Chinese Medicine. Advanced Textbook on Traditional Chinese Medicine and Pharmacology. New World Press, Beijing. 1995. (vol. 2).

3. Hui Hu, Q.J., Kavan, P. A study of heavy metal pollution in China: Current status, pollution-control policies and countermeasures. Sustainability. 2014;6:5820-38.
 

This article has an accompanying continuing medical education activity, also eligible for MOC credit, Learning objective: Upon completion of this examination, successful learners will be able to identify the features of lead poisoning.
 

AGA Institute

We carefully reviewed the patient’s history and found that he had been using jineijin, a traditional Chinese medicine (TCM) drug, which is made with dried endothelium corneum gigeriae galli (Figure E), at about 500 g/month and squama mantis (a TCM drug, at less than 5 g/month) as dietary supplements for 3 years.

AGA Institute

AGA Institute

Acknowledgments

We thank Linshen Xie, MD, department of environmental health and occupational diseases, No. 4 West China Teaching Hospital, Sichuan University, for offering some clinical data. We thank the patient for giving permission to share his information.

References

1. National Research Council (US). Safe Drinking Water Committee. Drinking water and health. National Academy Press. Washington, D.C. 1977;1:309.

2. State Administration of Traditional Chinese Medicine. Advanced Textbook on Traditional Chinese Medicine and Pharmacology. New World Press, Beijing. 1995. (vol. 2).

3. Hui Hu, Q.J., Kavan, P. A study of heavy metal pollution in China: Current status, pollution-control policies and countermeasures. Sustainability. 2014;6:5820-38.
 

This article has an accompanying continuing medical education activity, also eligible for MOC credit, Learning objective: Upon completion of this examination, successful learners will be able to identify the features of lead poisoning.
 

Advice on Achieving Work-Life Balance

Successfully maintaining a balance between your personal and professional lives is a difficult concept to grasp and practice to enforce. Is this thing called “work-life balance” within reach or just some elusive circumstance people talk about? The AGA Community Early Career Group was the hub for discussions on ways early-career gastroenterologists can modify their day-to-day approach to help prevent burnout.

We consolidated the advice and tips shared into a series of articles and resources to help students, trainees, and early career members get a little closer to balancing their work and professional lives. Here are some highlights:
 

Choose work-life “integration”

If your career and your personal life were a successful relationship, remember that it’s not always 50/50, and be sure to allow forgiveness and reparation when needed.

Maternity leave

When it comes to starting a family, think about your current training or career climate and how you can make it work. Be transparent with your supervisor so there aren’t any surprises, and plans can be made in advance to cover for your time away. Prepare to be flexible from the beginning.

Learn when to say “no”

Saying “yes” to too many things not only leads to overextending yourself beyond your capabilities, but you could also be losing time on what is important to you. Choose one night a week when you can work late – pack a snack, and give yourself a hard stop the rest of the week. Keep patient documentation as a daytime/work task.

Communication is key

When your partner or spouse is just as busy, it’s important to keep a joint calendar up to date and make plans far in advance. Also, create a routine: Try making time once a month to discuss calendars and anticipated events, face-to-face. When life throws a divot in your path, don’t lose sight of your priorities.

Make time for family and friends

Your career can take over as much of your life as you will allow. Making time for family and friends is rewarding and vacations, staycations, long weekends or even day trips can be great “resets.”
 

View the tip sheet and other work-life balance resources in the AGA Community Early Career Group library at http://community.gastro.org/WorkLife.
 

New Clinical Guidelines and Practice Updates

The latest AGA Clinical Practice Guideline, published in Gastroenterology, is on the role of therapeutic drug monitoring (TDM) in the management of IBD. It focuses on the application of TDM for biologic therapy, specifically anti-tumor necrosis factor-α (TNF) agents, and for thiopurines, and addresses questions on the risks and benefits of reactive TDM, routine proactive TDM, or no TDM in guiding treatment changes.

View the full guideline, technical review, and patient guide at www.gastro.org/guidelines.

In addition to guidelines, please check out the most recent Clinical Practice Updates (CPU) in Gastroenterology and Clinical Gastroenterology and Hepatology (CGH), which are often accompanied by a practice quiz from one of the authors, via the AGA Community. Visit http://community.gastro.org/guidelinecpu to test your knowledge. The most recent CPU, published in the September issue of CGH, focuses on GI side effects related to opioid medications.
 

Be Part of the Meeting to Transform IBD

If you treat patients with inflammatory bowel disease, conduct IBD research, or plan to pursue a career in IBD, join us for the inaugural Crohn’s & Colitis Congress™, taking place Jan. 18-20, 2018, in Las Vegas, NV. The Crohn’s & Colitis Foundation (formerly CCFA) and AGA have joined together to develop a must-attend program for the entire IBD care team. Expand your knowledge, network with your peers as well as IBD leaders across multiple disciplines, and get inspired to improve care for patients with Crohn’s disease and ulcerative colitis.

You may also be interested in the free precongress workshop – The Lloyd Mayer, MD, Young IBD Investigators Clinical, Basic, and Translational Research Workshop. This half-day precongress workshop is targeted to early-career clinical, basic, and translational researchers as well as senior researchers and will feature a mix of research presentations by young investigator colleagues, keynote presentations, and panel discussion, featuring established IBD researchers. The theme this year is focused around grant proposals and will include two mock grant review sessions.

Learn more about the Crohn’s & Colitis Congress and register: http://crohnscolitiscongress.org.
 

Advice on Achieving Work-Life Balance

Successfully maintaining a balance between your personal and professional lives is a difficult concept to grasp and practice to enforce. Is this thing called “work-life balance” within reach or just some elusive circumstance people talk about? The AGA Community Early Career Group was the hub for discussions on ways early-career gastroenterologists can modify their day-to-day approach to help prevent burnout.

We consolidated the advice and tips shared into a series of articles and resources to help students, trainees, and early career members get a little closer to balancing their work and professional lives. Here are some highlights:
 

Choose work-life “integration”

If your career and your personal life were a successful relationship, remember that it’s not always 50/50, and be sure to allow forgiveness and reparation when needed.

Maternity leave

When it comes to starting a family, think about your current training or career climate and how you can make it work. Be transparent with your supervisor so there aren’t any surprises, and plans can be made in advance to cover for your time away. Prepare to be flexible from the beginning.

Learn when to say “no”

Saying “yes” to too many things not only leads to overextending yourself beyond your capabilities, but you could also be losing time on what is important to you. Choose one night a week when you can work late – pack a snack, and give yourself a hard stop the rest of the week. Keep patient documentation as a daytime/work task.

Communication is key

When your partner or spouse is just as busy, it’s important to keep a joint calendar up to date and make plans far in advance. Also, create a routine: Try making time once a month to discuss calendars and anticipated events, face-to-face. When life throws a divot in your path, don’t lose sight of your priorities.

Make time for family and friends

Your career can take over as much of your life as you will allow. Making time for family and friends is rewarding and vacations, staycations, long weekends or even day trips can be great “resets.”
 

View the tip sheet and other work-life balance resources in the AGA Community Early Career Group library at http://community.gastro.org/WorkLife.
 

New Clinical Guidelines and Practice Updates

The latest AGA Clinical Practice Guideline, published in Gastroenterology, is on the role of therapeutic drug monitoring (TDM) in the management of IBD. It focuses on the application of TDM for biologic therapy, specifically anti-tumor necrosis factor-α (TNF) agents, and for thiopurines, and addresses questions on the risks and benefits of reactive TDM, routine proactive TDM, or no TDM in guiding treatment changes.

View the full guideline, technical review, and patient guide at www.gastro.org/guidelines.

In addition to guidelines, please check out the most recent Clinical Practice Updates (CPU) in Gastroenterology and Clinical Gastroenterology and Hepatology (CGH), which are often accompanied by a practice quiz from one of the authors, via the AGA Community. Visit http://community.gastro.org/guidelinecpu to test your knowledge. The most recent CPU, published in the September issue of CGH, focuses on GI side effects related to opioid medications.
 

Be Part of the Meeting to Transform IBD

If you treat patients with inflammatory bowel disease, conduct IBD research, or plan to pursue a career in IBD, join us for the inaugural Crohn’s & Colitis Congress™, taking place Jan. 18-20, 2018, in Las Vegas, NV. The Crohn’s & Colitis Foundation (formerly CCFA) and AGA have joined together to develop a must-attend program for the entire IBD care team. Expand your knowledge, network with your peers as well as IBD leaders across multiple disciplines, and get inspired to improve care for patients with Crohn’s disease and ulcerative colitis.

You may also be interested in the free precongress workshop – The Lloyd Mayer, MD, Young IBD Investigators Clinical, Basic, and Translational Research Workshop. This half-day precongress workshop is targeted to early-career clinical, basic, and translational researchers as well as senior researchers and will feature a mix of research presentations by young investigator colleagues, keynote presentations, and panel discussion, featuring established IBD researchers. The theme this year is focused around grant proposals and will include two mock grant review sessions.

Learn more about the Crohn’s & Colitis Congress and register: http://crohnscolitiscongress.org.
 

Advice on Achieving Work-Life Balance

Successfully maintaining a balance between your personal and professional lives is a difficult concept to grasp and practice to enforce. Is this thing called “work-life balance” within reach or just some elusive circumstance people talk about? The AGA Community Early Career Group was the hub for discussions on ways early-career gastroenterologists can modify their day-to-day approach to help prevent burnout.

We consolidated the advice and tips shared into a series of articles and resources to help students, trainees, and early career members get a little closer to balancing their work and professional lives. Here are some highlights:
 

Choose work-life “integration”

If your career and your personal life were a successful relationship, remember that it’s not always 50/50, and be sure to allow forgiveness and reparation when needed.

Maternity leave

When it comes to starting a family, think about your current training or career climate and how you can make it work. Be transparent with your supervisor so there aren’t any surprises, and plans can be made in advance to cover for your time away. Prepare to be flexible from the beginning.

Learn when to say “no”

Saying “yes” to too many things not only leads to overextending yourself beyond your capabilities, but you could also be losing time on what is important to you. Choose one night a week when you can work late – pack a snack, and give yourself a hard stop the rest of the week. Keep patient documentation as a daytime/work task.

Communication is key

When your partner or spouse is just as busy, it’s important to keep a joint calendar up to date and make plans far in advance. Also, create a routine: Try making time once a month to discuss calendars and anticipated events, face-to-face. When life throws a divot in your path, don’t lose sight of your priorities.

Make time for family and friends

Your career can take over as much of your life as you will allow. Making time for family and friends is rewarding and vacations, staycations, long weekends or even day trips can be great “resets.”
 

View the tip sheet and other work-life balance resources in the AGA Community Early Career Group library at http://community.gastro.org/WorkLife.
 

New Clinical Guidelines and Practice Updates

The latest AGA Clinical Practice Guideline, published in Gastroenterology, is on the role of therapeutic drug monitoring (TDM) in the management of IBD. It focuses on the application of TDM for biologic therapy, specifically anti-tumor necrosis factor-α (TNF) agents, and for thiopurines, and addresses questions on the risks and benefits of reactive TDM, routine proactive TDM, or no TDM in guiding treatment changes.

View the full guideline, technical review, and patient guide at www.gastro.org/guidelines.

In addition to guidelines, please check out the most recent Clinical Practice Updates (CPU) in Gastroenterology and Clinical Gastroenterology and Hepatology (CGH), which are often accompanied by a practice quiz from one of the authors, via the AGA Community. Visit http://community.gastro.org/guidelinecpu to test your knowledge. The most recent CPU, published in the September issue of CGH, focuses on GI side effects related to opioid medications.
 

Be Part of the Meeting to Transform IBD

If you treat patients with inflammatory bowel disease, conduct IBD research, or plan to pursue a career in IBD, join us for the inaugural Crohn’s & Colitis Congress™, taking place Jan. 18-20, 2018, in Las Vegas, NV. The Crohn’s & Colitis Foundation (formerly CCFA) and AGA have joined together to develop a must-attend program for the entire IBD care team. Expand your knowledge, network with your peers as well as IBD leaders across multiple disciplines, and get inspired to improve care for patients with Crohn’s disease and ulcerative colitis.

You may also be interested in the free precongress workshop – The Lloyd Mayer, MD, Young IBD Investigators Clinical, Basic, and Translational Research Workshop. This half-day precongress workshop is targeted to early-career clinical, basic, and translational researchers as well as senior researchers and will feature a mix of research presentations by young investigator colleagues, keynote presentations, and panel discussion, featuring established IBD researchers. The theme this year is focused around grant proposals and will include two mock grant review sessions.

Learn more about the Crohn’s & Colitis Congress and register: http://crohnscolitiscongress.org.
 

Dear Colleagues,

In this issue of The New Gastroenterologist, the feature article examines recent advances in the field of cholangiopancreatoscopy. In this article, William Sonnier, Meir Mizrahi (University of South Alabama), and Douglas Pleskow (Beth Israel Deaconess) provide a fantastic overview of the technologic advances in the field of cholangiopancreatoscopy as well as the clinical indications for this procedure and the risks involved. Also in this issue, Deborah Fisher (Duke University) and Darrell Gray (Ohio State University) provide advice about how to appropriately and responsibly handle social media. This is an incredibly important topic, given the increasing pervasiveness of social media in many aspects of our personal and professional lives.

Sincerely,

Bryson W. Katona, MD, PhD

Editor in Chief

Bryson W. Katona is an instructor of medicine in the division of gastroenterology at the University of Pennsylvania.

Dear Colleagues,

In this issue of The New Gastroenterologist, the feature article examines recent advances in the field of cholangiopancreatoscopy. In this article, William Sonnier, Meir Mizrahi (University of South Alabama), and Douglas Pleskow (Beth Israel Deaconess) provide a fantastic overview of the technologic advances in the field of cholangiopancreatoscopy as well as the clinical indications for this procedure and the risks involved. Also in this issue, Deborah Fisher (Duke University) and Darrell Gray (Ohio State University) provide advice about how to appropriately and responsibly handle social media. This is an incredibly important topic, given the increasing pervasiveness of social media in many aspects of our personal and professional lives.

Sincerely,

Bryson W. Katona, MD, PhD

Editor in Chief

Bryson W. Katona is an instructor of medicine in the division of gastroenterology at the University of Pennsylvania.

Dear Colleagues,

In this issue of The New Gastroenterologist, the feature article examines recent advances in the field of cholangiopancreatoscopy. In this article, William Sonnier, Meir Mizrahi (University of South Alabama), and Douglas Pleskow (Beth Israel Deaconess) provide a fantastic overview of the technologic advances in the field of cholangiopancreatoscopy as well as the clinical indications for this procedure and the risks involved. Also in this issue, Deborah Fisher (Duke University) and Darrell Gray (Ohio State University) provide advice about how to appropriately and responsibly handle social media. This is an incredibly important topic, given the increasing pervasiveness of social media in many aspects of our personal and professional lives.

Sincerely,

Bryson W. Katona, MD, PhD

Editor in Chief

Bryson W. Katona is an instructor of medicine in the division of gastroenterology at the University of Pennsylvania.