If your practice sees adolescent patients and you’re not identifying intimate partner violence or coercion on a regular basis, it’s time to ask, "Why not?"

It’s there, it’s more common than you may suspect, and it often produces lifelong health consequences. Not enough teenagers are reporting it – and not enough physicians are asking about it – for a slew of reasons.

Increased attention to these problems in recent years has generated some handy resources for physicians to improve prevention, detection, and responses to intimate partner violence and sexual or reproductive coercion.

Sherry Boschert/IMNG Medical Media

More than half (53%) of 1,278 women aged 16-29 years who were seen at family planning clinics reported physical or sexual violence by intimate partners, 19% reported pregnancy coercion, and 15% reported birth control sabotage in one study (Contraception 2010;81:316-22).

Some 40% of 448 females aged 14-20 years who were seen at five urban adolescent clinics said they had experienced intimate partner violence in a separate study (Matern. Child Health J. 2010;14:910-7). A survey of 10th and 11th graders found that more than half of the girls and 13% of boys reported sexual coercion, defined as sexual behaviors involving verbal coercion, threats of force, or use of drugs or alcohol (Violence Vict. 1995;10:299-313).

In a survey of 1,430 seventh graders in three states that was conducted by the Robert Wood Johnson Foundation, 37% said they had witnessed physical dating violence against a peer, 37% reported experiencing psychological dating abuse, and – during the prior 6 month – 15% experienced physical dating abuse and 31% experienced electronic dating aggression.

In a survey of 305 school counselors, the majority (71%) had not received formal training on adolescent dating violence (ADV). Eighty-one percent said their school did not have a protocol to respond to incidents of ADV, and 83% said the school did not conduct periodic student surveys that included questions that mentioned ADV (Pediatrics 2012;130:202-10).

Adolescents overwhelmingly want health care providers to ask about intimate partner violence and coercion, other studies have shown. So, why aren’t they telling you about it, even if you ask?

You may not be asking in the right way, nor asking often enough, Dr. Harise Stein said at Stanford (Calif.) University’s annual pediatric update and preconference.

Teens aged 15-19 years have the highest rates of intimate partner violence and stalking of any age group, yet they report only an estimated 1 in 11 episodes of dating-related violence, said Dr. Stein, an ob.gyn at the university. She is a member of the Santa Clara County (Calif.) Domestic Violence Council.

One in six U.S. women experience rape – "which I think is a national disgrace," she said – and 32% of first rapes occur in female victims aged 12-17-years. In that age group, 36% of rapists are intimate partners, and 33% are acquaintances, according to a 2006 U.S. Department of Justice report.

Abuse during adolescence interferes with emotional development and has been associated with mental and physical illness both during the teen years and carried forward into adulthood, she said. It can exacerbate asthma, headaches, or other chronic illnesses. Consider abuse in the diagnostic differential when you see an adolescent who has developed school problems, increased isolation, personality changes, mental health issues, an eating disorder, substance abuse, cutting and other forms of self-harm, or suicidal ideology, Dr. Stein said.

Vague physical symptoms or symptoms that don’t make sense are red flags for possible abuse, as are chronic pain symptoms (especially headaches), or unexplained worsening of chronic illness. New sexually transmitted infections, an unplanned pregnancy, or a request for emergency contraception open a window to ask about abuse.

Suspicious injuries may result from abuse. Slap marks, scratches, bruises, welts, cuts, or muscle sprains are typical signs in adolescents, but most common are soft tissue injuries of the forearms (held up to defend against blows), face, head, and neck, Dr. Stein said.

Sherry Boschert/IMNG Medical Media

The prevalence of being choked to unconsciousness is "very underappreciated by health care workers" because half the time choking leaves no immediate external signs on the neck, she said. The teenager may wake up on the floor and not remember what happened. Only 10 seconds of strangulation can induce unconsciousness, and every second after that causes brain damage. Laryngeal edema over the following 24-48 hours can create airway emergencies. Brain cell death from the choking may cause problems in memory, reasoning, and concentration for several weeks. At least 10% of adult abused women who obtain restraining orders are estimated to have been choked to unconsciousness. Data are lacking for teens.

Teens in abusive relationships are four to six times more likely to get pregnant than are other teens, and 25% of pregnant teens are in abusive relationships, compared with 4%-8% of pregnant adults, Dr. Stein said.

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (ACOG) recommend screening for dating abuse (Pediatrics 2009;124:393-402; Obstet. Gynecol. 2012;119:412-7) – perhaps starting as early at age 11, according to AAP’s Bright Futures – and educating preteens and teens about healthy relationships, she said.

Remember a key lesson from Adolescence 101: Teens are more likely to open up if you start with open-ended questions like "How’s school?" instead of pointed questions, or if you approach the topic obliquely by bringing up bullying as something a lot of people are talking about, and use that as a lead-in to talking about relationships. Focus on behaviors, not "abuse," Dr. Stein said.

Adolescents get most of their advice on health topics from peers, so use that to your advantage by giving your patients materials about healthy relationships and resources for abused teens, and telling them it’s "for a friend," if you suspect the patient or a friend is at risk.

To detect intimate partner violence and coercion, watch for it– but also make your office a place where teens will feel comfortable talking about it. Make informational materials available in nonconspicuous places. Explain confidentiality up front in teen visits.

Sherry Boschert/IMNG Medical Media

Dr. Eve Espey learned some of these lessons in a vivid way. A patient and her boyfriend came to the emergency department, and an HCG test suggested that she had an ectopic pregnancy. She refused emergency treatment. Once the boyfriend left the room, she admitted that she’d just had an abortion, and didn’t want him to know because she feared he’d be violent. A nurse had screened her and asked specifically about domestic violence, but with the boyfriend in the room, she couldn’t discuss it.

"We made changes after that," said Dr. Espey, professor of ob.gyn. at the University of New Mexico, Albuquerque, and chair of ACOG’s Working Group on Long-Acting Reversible Contraception. "We talk to every woman by herself. We tell them it’s part of our protocol," she said at ACOG’s annual meeting.

A February 2012 opinion published by ACOG’s Committee on Health Care for Underserved Women calls on physicians to screen all women for intimate partner violence at periodic intervals, to offer ongoing support, and to review prevention and referral options with patients. Intimate partner violence is most common during the reproductive years, so it’s important to screen several times during obstetric care, including at the first prenatal visit, at least once per trimester, and at the postpartum checkup, the committee recommended. The opinion paper includes sample questions (Obstet. Gynecol. 2012;119:412-7).

Dr. Espey recommends that ob.gyns. screen patients for intimate partner violence and reproductive coercion at most contraceptive visits, again not by immediate blunt questions like, "Are you safe at home?" but in a more circuitous, conversational way.

"The goal is not disclosure. Just engaging in the conversation is a great first step," she said.

When a patient does reveal intimate partner violence but is not ready to make changes, help the patient avoid unintended pregnancy by separating out the issue of reproductive coercion (in which a partner sabotages birth control or coerces the person to have or terminate a pregnancy), Dr. Espey said.

Talk about contraceptive methods that are less detectable by partners, for example. Long-acting reversible contraceptive methods are less vulnerable to tampering, but hormonal methods that eliminate periods may not work for women whose cycles are being closely monitored by a partner. The string on an IUD can be cut before insertion so that a partner cannot pull it out. If the IUD already is inserted, you’ll need to remove it and cut the string and reinsert it, because cutting the string just at the cervix leaves it potentially detectable, she said. Pills for emergency contraception can be stored in a vitamin bottle to avoid detection.

Her practice keeps laminated copies handy of a color-coded chart from the Centers for Disease Control and Prevention that helps clinicians quickly identify which forms of contraception are medically appropriate for particular patients – and showing that long-active contraceptives usually are an option. The "Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use" is free.

She also lets patients who get an abortion know that they can say they’ve had a miscarriage, if they need to. "Women don’t realize that abortion cannot be detected. Tell them," she said.

These discussions plant the seeds for women to grow into readiness to leave abusive relationships, Dr. Espey said. Of course, keep in mind any legal requirements in your state to report abuse.

Adolescents often feel more comfortable being asked initially about abuse and coercion if it’s asked electronically, Virginia A. Duplessis said at ACOG’s annual meeting. In live conversations, "We’re moving from ‘Have you ever been punched, slapped, or kicked?’ to more nuanced conversation," said Ms. Duplessis, a program manager for Futures Without Violence, a nonprofit organization formerly known as the Family Violence Prevention Fund, headquartered in San Francisco.

Teens may not understand that violence and coercion are not acceptable ways to show love, she said.

Dr. Stein also pointed to a segment of the Tyra Banks television talk show that’s posted online, in which adolescents in the audience had trouble identifying types of abuse other than physical abuse.

Other times, the patient may have the knowledge, but feel unable to act on it. Ms. Duplessis described her frustration in a previous job as a community educator when teens who had condoms or birth control pills and knew how to use them kept reporting that they weren’t used. It’s not that they were dumb or apathetic, she finally learned; reproductive coercion often was the problem. The girls feared the consequences of negotiating condom use more than they feared pregnancy, or their partners threw away their pills.

That frustration with patients who do not follow a plan of care is one reason that clinicians don’t screen for intimate partner violence, she said. They also may not be comfortable starting conversations on this topic, or don’t ask because they don’t know what to do if a patient discloses intimate partner violence or coercion.

Futures Without Violence offers free materials to clinicians to simplify screening, such as folding wallet-size "safety cards" to give patients that list screening questions and resources.

Ms. Duplessis manages Project Connect, a national public health initiative to prevent violence against women through efforts focused on adolescent health, reproductive health, and home visiting programs. Funded by the U.S. Office on Women’s Health, Project Connect’s 10 geographically and ethnically diverse sites explore new ways to prevent, identify, and respond to domestic and sexual violence.

In a randomized, controlled pilot trial, a community-based intervention achieved some success (Contraception 2011;83:274-80). Clinicians asked 906 women at four family planning clinics questions about intimate partner violence and sexual and reproductive coercion, and reviewed the "safety cards" they gave to patients. The intervention took less than a minute of time in some cases, or longer if a positive screen led to more discussion.

Among women who had experienced recent partner violence, those in the intervention group were 71% less likely to report pregnancy coercion and 63% more likely to end an unhealthy or unsafe relationship, compared with a control group who got usual care.

Data suggest that reducing adolescent relationship abuse should reduce rates of substance abuse, teen pregnancy, depression, eating disorders, suicide, school dropouts, and adult intimate partner violence, Dr. Stein said.

For the past 4 years, she has reviewed the literature on the effects of abuse and has sent out monthly updates to interested parties. During that time, her monthly summary has grown from three to six pages. Attention to intimate partner violence and coercion is increasing, and every clinician plays a role, she said.

Dr. Stein, Dr. Espey and Ms. Duplessis recommended the following resources:

• ACOG and Futures Without Violence cobranded a guide for clinicians, "Addressing Intimate Partner Violence, Reproductive and Sexual Coercion." The 56-page pamphlet includes sample scripts for talking with patients, advice on managing someone who screens positive, quality assessment tools for clinical practices, and links to resources including a clinician training kit, "safety cards" for patients, and more.

• The "Healthcare Education, Assessment and Response Tool for Teen Relationships (HEART) Primer" is another free comprehensive toolkit to help clinicians recognize and decrease adolescent relationship abuse and sexual and reproductive coercion, offered by the California Adolescent Health Collaborative.

• The National Center for Youth Law created legal guides for Arizona, California, Maine, Michigan, and Ohio for "When Teens Disclose Dating Violence to Health Care Providers: A Guide to Confidentiality and Reporting Laws."

• Dr. Stein sends monthly e-mail updates about the literature on the effects of abuse. To get on her list, e-mail [email protected].

Dr. Stein, Dr. Espey, and Ms. Duplessis reported having no financial disclosures.

If your practice sees adolescent patients and you’re not identifying intimate partner violence or coercion on a regular basis, it’s time to ask, "Why not?"

It’s there, it’s more common than you may suspect, and it often produces lifelong health consequences. Not enough teenagers are reporting it – and not enough physicians are asking about it – for a slew of reasons.

Increased attention to these problems in recent years has generated some handy resources for physicians to improve prevention, detection, and responses to intimate partner violence and sexual or reproductive coercion.

Sherry Boschert/IMNG Medical Media

More than half (53%) of 1,278 women aged 16-29 years who were seen at family planning clinics reported physical or sexual violence by intimate partners, 19% reported pregnancy coercion, and 15% reported birth control sabotage in one study (Contraception 2010;81:316-22).

Some 40% of 448 females aged 14-20 years who were seen at five urban adolescent clinics said they had experienced intimate partner violence in a separate study (Matern. Child Health J. 2010;14:910-7). A survey of 10th and 11th graders found that more than half of the girls and 13% of boys reported sexual coercion, defined as sexual behaviors involving verbal coercion, threats of force, or use of drugs or alcohol (Violence Vict. 1995;10:299-313).

In a survey of 1,430 seventh graders in three states that was conducted by the Robert Wood Johnson Foundation, 37% said they had witnessed physical dating violence against a peer, 37% reported experiencing psychological dating abuse, and – during the prior 6 month – 15% experienced physical dating abuse and 31% experienced electronic dating aggression.

In a survey of 305 school counselors, the majority (71%) had not received formal training on adolescent dating violence (ADV). Eighty-one percent said their school did not have a protocol to respond to incidents of ADV, and 83% said the school did not conduct periodic student surveys that included questions that mentioned ADV (Pediatrics 2012;130:202-10).

Adolescents overwhelmingly want health care providers to ask about intimate partner violence and coercion, other studies have shown. So, why aren’t they telling you about it, even if you ask?

You may not be asking in the right way, nor asking often enough, Dr. Harise Stein said at Stanford (Calif.) University’s annual pediatric update and preconference.

Teens aged 15-19 years have the highest rates of intimate partner violence and stalking of any age group, yet they report only an estimated 1 in 11 episodes of dating-related violence, said Dr. Stein, an ob.gyn at the university. She is a member of the Santa Clara County (Calif.) Domestic Violence Council.

One in six U.S. women experience rape – "which I think is a national disgrace," she said – and 32% of first rapes occur in female victims aged 12-17-years. In that age group, 36% of rapists are intimate partners, and 33% are acquaintances, according to a 2006 U.S. Department of Justice report.

Abuse during adolescence interferes with emotional development and has been associated with mental and physical illness both during the teen years and carried forward into adulthood, she said. It can exacerbate asthma, headaches, or other chronic illnesses. Consider abuse in the diagnostic differential when you see an adolescent who has developed school problems, increased isolation, personality changes, mental health issues, an eating disorder, substance abuse, cutting and other forms of self-harm, or suicidal ideology, Dr. Stein said.

Vague physical symptoms or symptoms that don’t make sense are red flags for possible abuse, as are chronic pain symptoms (especially headaches), or unexplained worsening of chronic illness. New sexually transmitted infections, an unplanned pregnancy, or a request for emergency contraception open a window to ask about abuse.

Suspicious injuries may result from abuse. Slap marks, scratches, bruises, welts, cuts, or muscle sprains are typical signs in adolescents, but most common are soft tissue injuries of the forearms (held up to defend against blows), face, head, and neck, Dr. Stein said.

Sherry Boschert/IMNG Medical Media

The prevalence of being choked to unconsciousness is "very underappreciated by health care workers" because half the time choking leaves no immediate external signs on the neck, she said. The teenager may wake up on the floor and not remember what happened. Only 10 seconds of strangulation can induce unconsciousness, and every second after that causes brain damage. Laryngeal edema over the following 24-48 hours can create airway emergencies. Brain cell death from the choking may cause problems in memory, reasoning, and concentration for several weeks. At least 10% of adult abused women who obtain restraining orders are estimated to have been choked to unconsciousness. Data are lacking for teens.

Teens in abusive relationships are four to six times more likely to get pregnant than are other teens, and 25% of pregnant teens are in abusive relationships, compared with 4%-8% of pregnant adults, Dr. Stein said.

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (ACOG) recommend screening for dating abuse (Pediatrics 2009;124:393-402; Obstet. Gynecol. 2012;119:412-7) – perhaps starting as early at age 11, according to AAP’s Bright Futures – and educating preteens and teens about healthy relationships, she said.

Remember a key lesson from Adolescence 101: Teens are more likely to open up if you start with open-ended questions like "How’s school?" instead of pointed questions, or if you approach the topic obliquely by bringing up bullying as something a lot of people are talking about, and use that as a lead-in to talking about relationships. Focus on behaviors, not "abuse," Dr. Stein said.

Adolescents get most of their advice on health topics from peers, so use that to your advantage by giving your patients materials about healthy relationships and resources for abused teens, and telling them it’s "for a friend," if you suspect the patient or a friend is at risk.

To detect intimate partner violence and coercion, watch for it– but also make your office a place where teens will feel comfortable talking about it. Make informational materials available in nonconspicuous places. Explain confidentiality up front in teen visits.

Sherry Boschert/IMNG Medical Media

Dr. Eve Espey learned some of these lessons in a vivid way. A patient and her boyfriend came to the emergency department, and an HCG test suggested that she had an ectopic pregnancy. She refused emergency treatment. Once the boyfriend left the room, she admitted that she’d just had an abortion, and didn’t want him to know because she feared he’d be violent. A nurse had screened her and asked specifically about domestic violence, but with the boyfriend in the room, she couldn’t discuss it.

"We made changes after that," said Dr. Espey, professor of ob.gyn. at the University of New Mexico, Albuquerque, and chair of ACOG’s Working Group on Long-Acting Reversible Contraception. "We talk to every woman by herself. We tell them it’s part of our protocol," she said at ACOG’s annual meeting.

A February 2012 opinion published by ACOG’s Committee on Health Care for Underserved Women calls on physicians to screen all women for intimate partner violence at periodic intervals, to offer ongoing support, and to review prevention and referral options with patients. Intimate partner violence is most common during the reproductive years, so it’s important to screen several times during obstetric care, including at the first prenatal visit, at least once per trimester, and at the postpartum checkup, the committee recommended. The opinion paper includes sample questions (Obstet. Gynecol. 2012;119:412-7).

Dr. Espey recommends that ob.gyns. screen patients for intimate partner violence and reproductive coercion at most contraceptive visits, again not by immediate blunt questions like, "Are you safe at home?" but in a more circuitous, conversational way.

"The goal is not disclosure. Just engaging in the conversation is a great first step," she said.

When a patient does reveal intimate partner violence but is not ready to make changes, help the patient avoid unintended pregnancy by separating out the issue of reproductive coercion (in which a partner sabotages birth control or coerces the person to have or terminate a pregnancy), Dr. Espey said.

Talk about contraceptive methods that are less detectable by partners, for example. Long-acting reversible contraceptive methods are less vulnerable to tampering, but hormonal methods that eliminate periods may not work for women whose cycles are being closely monitored by a partner. The string on an IUD can be cut before insertion so that a partner cannot pull it out. If the IUD already is inserted, you’ll need to remove it and cut the string and reinsert it, because cutting the string just at the cervix leaves it potentially detectable, she said. Pills for emergency contraception can be stored in a vitamin bottle to avoid detection.

Her practice keeps laminated copies handy of a color-coded chart from the Centers for Disease Control and Prevention that helps clinicians quickly identify which forms of contraception are medically appropriate for particular patients – and showing that long-active contraceptives usually are an option. The "Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use" is free.

She also lets patients who get an abortion know that they can say they’ve had a miscarriage, if they need to. "Women don’t realize that abortion cannot be detected. Tell them," she said.

These discussions plant the seeds for women to grow into readiness to leave abusive relationships, Dr. Espey said. Of course, keep in mind any legal requirements in your state to report abuse.

Adolescents often feel more comfortable being asked initially about abuse and coercion if it’s asked electronically, Virginia A. Duplessis said at ACOG’s annual meeting. In live conversations, "We’re moving from ‘Have you ever been punched, slapped, or kicked?’ to more nuanced conversation," said Ms. Duplessis, a program manager for Futures Without Violence, a nonprofit organization formerly known as the Family Violence Prevention Fund, headquartered in San Francisco.

Teens may not understand that violence and coercion are not acceptable ways to show love, she said.

Dr. Stein also pointed to a segment of the Tyra Banks television talk show that’s posted online, in which adolescents in the audience had trouble identifying types of abuse other than physical abuse.

Other times, the patient may have the knowledge, but feel unable to act on it. Ms. Duplessis described her frustration in a previous job as a community educator when teens who had condoms or birth control pills and knew how to use them kept reporting that they weren’t used. It’s not that they were dumb or apathetic, she finally learned; reproductive coercion often was the problem. The girls feared the consequences of negotiating condom use more than they feared pregnancy, or their partners threw away their pills.

That frustration with patients who do not follow a plan of care is one reason that clinicians don’t screen for intimate partner violence, she said. They also may not be comfortable starting conversations on this topic, or don’t ask because they don’t know what to do if a patient discloses intimate partner violence or coercion.

Futures Without Violence offers free materials to clinicians to simplify screening, such as folding wallet-size "safety cards" to give patients that list screening questions and resources.

Ms. Duplessis manages Project Connect, a national public health initiative to prevent violence against women through efforts focused on adolescent health, reproductive health, and home visiting programs. Funded by the U.S. Office on Women’s Health, Project Connect’s 10 geographically and ethnically diverse sites explore new ways to prevent, identify, and respond to domestic and sexual violence.

In a randomized, controlled pilot trial, a community-based intervention achieved some success (Contraception 2011;83:274-80). Clinicians asked 906 women at four family planning clinics questions about intimate partner violence and sexual and reproductive coercion, and reviewed the "safety cards" they gave to patients. The intervention took less than a minute of time in some cases, or longer if a positive screen led to more discussion.

Among women who had experienced recent partner violence, those in the intervention group were 71% less likely to report pregnancy coercion and 63% more likely to end an unhealthy or unsafe relationship, compared with a control group who got usual care.

Data suggest that reducing adolescent relationship abuse should reduce rates of substance abuse, teen pregnancy, depression, eating disorders, suicide, school dropouts, and adult intimate partner violence, Dr. Stein said.

For the past 4 years, she has reviewed the literature on the effects of abuse and has sent out monthly updates to interested parties. During that time, her monthly summary has grown from three to six pages. Attention to intimate partner violence and coercion is increasing, and every clinician plays a role, she said.

Dr. Stein, Dr. Espey and Ms. Duplessis recommended the following resources:

• ACOG and Futures Without Violence cobranded a guide for clinicians, "Addressing Intimate Partner Violence, Reproductive and Sexual Coercion." The 56-page pamphlet includes sample scripts for talking with patients, advice on managing someone who screens positive, quality assessment tools for clinical practices, and links to resources including a clinician training kit, "safety cards" for patients, and more.

• The "Healthcare Education, Assessment and Response Tool for Teen Relationships (HEART) Primer" is another free comprehensive toolkit to help clinicians recognize and decrease adolescent relationship abuse and sexual and reproductive coercion, offered by the California Adolescent Health Collaborative.

• The National Center for Youth Law created legal guides for Arizona, California, Maine, Michigan, and Ohio for "When Teens Disclose Dating Violence to Health Care Providers: A Guide to Confidentiality and Reporting Laws."

• Dr. Stein sends monthly e-mail updates about the literature on the effects of abuse. To get on her list, e-mail [email protected].

Dr. Stein, Dr. Espey, and Ms. Duplessis reported having no financial disclosures.

If your practice sees adolescent patients and you’re not identifying intimate partner violence or coercion on a regular basis, it’s time to ask, "Why not?"

It’s there, it’s more common than you may suspect, and it often produces lifelong health consequences. Not enough teenagers are reporting it – and not enough physicians are asking about it – for a slew of reasons.

Increased attention to these problems in recent years has generated some handy resources for physicians to improve prevention, detection, and responses to intimate partner violence and sexual or reproductive coercion.

Sherry Boschert/IMNG Medical Media

More than half (53%) of 1,278 women aged 16-29 years who were seen at family planning clinics reported physical or sexual violence by intimate partners, 19% reported pregnancy coercion, and 15% reported birth control sabotage in one study (Contraception 2010;81:316-22).

Some 40% of 448 females aged 14-20 years who were seen at five urban adolescent clinics said they had experienced intimate partner violence in a separate study (Matern. Child Health J. 2010;14:910-7). A survey of 10th and 11th graders found that more than half of the girls and 13% of boys reported sexual coercion, defined as sexual behaviors involving verbal coercion, threats of force, or use of drugs or alcohol (Violence Vict. 1995;10:299-313).

In a survey of 1,430 seventh graders in three states that was conducted by the Robert Wood Johnson Foundation, 37% said they had witnessed physical dating violence against a peer, 37% reported experiencing psychological dating abuse, and – during the prior 6 month – 15% experienced physical dating abuse and 31% experienced electronic dating aggression.

In a survey of 305 school counselors, the majority (71%) had not received formal training on adolescent dating violence (ADV). Eighty-one percent said their school did not have a protocol to respond to incidents of ADV, and 83% said the school did not conduct periodic student surveys that included questions that mentioned ADV (Pediatrics 2012;130:202-10).

Adolescents overwhelmingly want health care providers to ask about intimate partner violence and coercion, other studies have shown. So, why aren’t they telling you about it, even if you ask?

You may not be asking in the right way, nor asking often enough, Dr. Harise Stein said at Stanford (Calif.) University’s annual pediatric update and preconference.

Teens aged 15-19 years have the highest rates of intimate partner violence and stalking of any age group, yet they report only an estimated 1 in 11 episodes of dating-related violence, said Dr. Stein, an ob.gyn at the university. She is a member of the Santa Clara County (Calif.) Domestic Violence Council.

One in six U.S. women experience rape – "which I think is a national disgrace," she said – and 32% of first rapes occur in female victims aged 12-17-years. In that age group, 36% of rapists are intimate partners, and 33% are acquaintances, according to a 2006 U.S. Department of Justice report.

Abuse during adolescence interferes with emotional development and has been associated with mental and physical illness both during the teen years and carried forward into adulthood, she said. It can exacerbate asthma, headaches, or other chronic illnesses. Consider abuse in the diagnostic differential when you see an adolescent who has developed school problems, increased isolation, personality changes, mental health issues, an eating disorder, substance abuse, cutting and other forms of self-harm, or suicidal ideology, Dr. Stein said.

Vague physical symptoms or symptoms that don’t make sense are red flags for possible abuse, as are chronic pain symptoms (especially headaches), or unexplained worsening of chronic illness. New sexually transmitted infections, an unplanned pregnancy, or a request for emergency contraception open a window to ask about abuse.

Suspicious injuries may result from abuse. Slap marks, scratches, bruises, welts, cuts, or muscle sprains are typical signs in adolescents, but most common are soft tissue injuries of the forearms (held up to defend against blows), face, head, and neck, Dr. Stein said.

Sherry Boschert/IMNG Medical Media

The prevalence of being choked to unconsciousness is "very underappreciated by health care workers" because half the time choking leaves no immediate external signs on the neck, she said. The teenager may wake up on the floor and not remember what happened. Only 10 seconds of strangulation can induce unconsciousness, and every second after that causes brain damage. Laryngeal edema over the following 24-48 hours can create airway emergencies. Brain cell death from the choking may cause problems in memory, reasoning, and concentration for several weeks. At least 10% of adult abused women who obtain restraining orders are estimated to have been choked to unconsciousness. Data are lacking for teens.

Teens in abusive relationships are four to six times more likely to get pregnant than are other teens, and 25% of pregnant teens are in abusive relationships, compared with 4%-8% of pregnant adults, Dr. Stein said.

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (ACOG) recommend screening for dating abuse (Pediatrics 2009;124:393-402; Obstet. Gynecol. 2012;119:412-7) – perhaps starting as early at age 11, according to AAP’s Bright Futures – and educating preteens and teens about healthy relationships, she said.

Remember a key lesson from Adolescence 101: Teens are more likely to open up if you start with open-ended questions like "How’s school?" instead of pointed questions, or if you approach the topic obliquely by bringing up bullying as something a lot of people are talking about, and use that as a lead-in to talking about relationships. Focus on behaviors, not "abuse," Dr. Stein said.

Adolescents get most of their advice on health topics from peers, so use that to your advantage by giving your patients materials about healthy relationships and resources for abused teens, and telling them it’s "for a friend," if you suspect the patient or a friend is at risk.

To detect intimate partner violence and coercion, watch for it– but also make your office a place where teens will feel comfortable talking about it. Make informational materials available in nonconspicuous places. Explain confidentiality up front in teen visits.

Sherry Boschert/IMNG Medical Media

Dr. Eve Espey learned some of these lessons in a vivid way. A patient and her boyfriend came to the emergency department, and an HCG test suggested that she had an ectopic pregnancy. She refused emergency treatment. Once the boyfriend left the room, she admitted that she’d just had an abortion, and didn’t want him to know because she feared he’d be violent. A nurse had screened her and asked specifically about domestic violence, but with the boyfriend in the room, she couldn’t discuss it.

"We made changes after that," said Dr. Espey, professor of ob.gyn. at the University of New Mexico, Albuquerque, and chair of ACOG’s Working Group on Long-Acting Reversible Contraception. "We talk to every woman by herself. We tell them it’s part of our protocol," she said at ACOG’s annual meeting.

A February 2012 opinion published by ACOG’s Committee on Health Care for Underserved Women calls on physicians to screen all women for intimate partner violence at periodic intervals, to offer ongoing support, and to review prevention and referral options with patients. Intimate partner violence is most common during the reproductive years, so it’s important to screen several times during obstetric care, including at the first prenatal visit, at least once per trimester, and at the postpartum checkup, the committee recommended. The opinion paper includes sample questions (Obstet. Gynecol. 2012;119:412-7).

Dr. Espey recommends that ob.gyns. screen patients for intimate partner violence and reproductive coercion at most contraceptive visits, again not by immediate blunt questions like, "Are you safe at home?" but in a more circuitous, conversational way.

"The goal is not disclosure. Just engaging in the conversation is a great first step," she said.

When a patient does reveal intimate partner violence but is not ready to make changes, help the patient avoid unintended pregnancy by separating out the issue of reproductive coercion (in which a partner sabotages birth control or coerces the person to have or terminate a pregnancy), Dr. Espey said.

Talk about contraceptive methods that are less detectable by partners, for example. Long-acting reversible contraceptive methods are less vulnerable to tampering, but hormonal methods that eliminate periods may not work for women whose cycles are being closely monitored by a partner. The string on an IUD can be cut before insertion so that a partner cannot pull it out. If the IUD already is inserted, you’ll need to remove it and cut the string and reinsert it, because cutting the string just at the cervix leaves it potentially detectable, she said. Pills for emergency contraception can be stored in a vitamin bottle to avoid detection.

Her practice keeps laminated copies handy of a color-coded chart from the Centers for Disease Control and Prevention that helps clinicians quickly identify which forms of contraception are medically appropriate for particular patients – and showing that long-active contraceptives usually are an option. The "Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use" is free.

She also lets patients who get an abortion know that they can say they’ve had a miscarriage, if they need to. "Women don’t realize that abortion cannot be detected. Tell them," she said.

These discussions plant the seeds for women to grow into readiness to leave abusive relationships, Dr. Espey said. Of course, keep in mind any legal requirements in your state to report abuse.

Adolescents often feel more comfortable being asked initially about abuse and coercion if it’s asked electronically, Virginia A. Duplessis said at ACOG’s annual meeting. In live conversations, "We’re moving from ‘Have you ever been punched, slapped, or kicked?’ to more nuanced conversation," said Ms. Duplessis, a program manager for Futures Without Violence, a nonprofit organization formerly known as the Family Violence Prevention Fund, headquartered in San Francisco.

Teens may not understand that violence and coercion are not acceptable ways to show love, she said.

Dr. Stein also pointed to a segment of the Tyra Banks television talk show that’s posted online, in which adolescents in the audience had trouble identifying types of abuse other than physical abuse.

Other times, the patient may have the knowledge, but feel unable to act on it. Ms. Duplessis described her frustration in a previous job as a community educator when teens who had condoms or birth control pills and knew how to use them kept reporting that they weren’t used. It’s not that they were dumb or apathetic, she finally learned; reproductive coercion often was the problem. The girls feared the consequences of negotiating condom use more than they feared pregnancy, or their partners threw away their pills.

That frustration with patients who do not follow a plan of care is one reason that clinicians don’t screen for intimate partner violence, she said. They also may not be comfortable starting conversations on this topic, or don’t ask because they don’t know what to do if a patient discloses intimate partner violence or coercion.

Futures Without Violence offers free materials to clinicians to simplify screening, such as folding wallet-size "safety cards" to give patients that list screening questions and resources.

Ms. Duplessis manages Project Connect, a national public health initiative to prevent violence against women through efforts focused on adolescent health, reproductive health, and home visiting programs. Funded by the U.S. Office on Women’s Health, Project Connect’s 10 geographically and ethnically diverse sites explore new ways to prevent, identify, and respond to domestic and sexual violence.

In a randomized, controlled pilot trial, a community-based intervention achieved some success (Contraception 2011;83:274-80). Clinicians asked 906 women at four family planning clinics questions about intimate partner violence and sexual and reproductive coercion, and reviewed the "safety cards" they gave to patients. The intervention took less than a minute of time in some cases, or longer if a positive screen led to more discussion.

Among women who had experienced recent partner violence, those in the intervention group were 71% less likely to report pregnancy coercion and 63% more likely to end an unhealthy or unsafe relationship, compared with a control group who got usual care.

Data suggest that reducing adolescent relationship abuse should reduce rates of substance abuse, teen pregnancy, depression, eating disorders, suicide, school dropouts, and adult intimate partner violence, Dr. Stein said.

For the past 4 years, she has reviewed the literature on the effects of abuse and has sent out monthly updates to interested parties. During that time, her monthly summary has grown from three to six pages. Attention to intimate partner violence and coercion is increasing, and every clinician plays a role, she said.

Dr. Stein, Dr. Espey and Ms. Duplessis recommended the following resources:

• ACOG and Futures Without Violence cobranded a guide for clinicians, "Addressing Intimate Partner Violence, Reproductive and Sexual Coercion." The 56-page pamphlet includes sample scripts for talking with patients, advice on managing someone who screens positive, quality assessment tools for clinical practices, and links to resources including a clinician training kit, "safety cards" for patients, and more.

• The "Healthcare Education, Assessment and Response Tool for Teen Relationships (HEART) Primer" is another free comprehensive toolkit to help clinicians recognize and decrease adolescent relationship abuse and sexual and reproductive coercion, offered by the California Adolescent Health Collaborative.

• The National Center for Youth Law created legal guides for Arizona, California, Maine, Michigan, and Ohio for "When Teens Disclose Dating Violence to Health Care Providers: A Guide to Confidentiality and Reporting Laws."

• Dr. Stein sends monthly e-mail updates about the literature on the effects of abuse. To get on her list, e-mail [email protected].

Dr. Stein, Dr. Espey, and Ms. Duplessis reported having no financial disclosures.

A new implementation date for the 10th revision of the International Statistical Classification of Diseases coding system (ICD-10) isn't expected to be known until after the November election, says a coding specialist. But hospitalists and others should not take that as a sign to just sit around and wait for a date.

"We're probably not going to hear anything until after the election is finished," says Brenda Edwards, CPC, CPMA, a coding and compliance specialist with Kansas Medical Mutual Insurance Co. and a trainer with AAPC. "The thing that's worrisome, though, is people think this delay we have encountered is a time to sit back and do nothing, but really we’re almost burning money by not doing anything."

An outcry from many physicians led the U.S. Department of Health and Human Services to delay the planned October 2013 implementation date. No new date has been announced.

Edwards urges physicians, billing specialists, and group leaders to use the delay as an opportunity to better prepare for the implementation. She suggests checking with vendors and preparing training programs to help adjust to the new coding initiative, which will quadruple the number of billing codes to 68,000.

"Everyone at this point should still be moving forward," she says.

At the same time, the Centers for Medicare & Medicaid Services (CMS) is seeking public comment on a new version of its ICD-10 readiness assessment. Those interested in weighing in can learn more here.

A new implementation date for the 10th revision of the International Statistical Classification of Diseases coding system (ICD-10) isn't expected to be known until after the November election, says a coding specialist. But hospitalists and others should not take that as a sign to just sit around and wait for a date.

"We're probably not going to hear anything until after the election is finished," says Brenda Edwards, CPC, CPMA, a coding and compliance specialist with Kansas Medical Mutual Insurance Co. and a trainer with AAPC. "The thing that's worrisome, though, is people think this delay we have encountered is a time to sit back and do nothing, but really we’re almost burning money by not doing anything."

An outcry from many physicians led the U.S. Department of Health and Human Services to delay the planned October 2013 implementation date. No new date has been announced.

Edwards urges physicians, billing specialists, and group leaders to use the delay as an opportunity to better prepare for the implementation. She suggests checking with vendors and preparing training programs to help adjust to the new coding initiative, which will quadruple the number of billing codes to 68,000.

"Everyone at this point should still be moving forward," she says.

At the same time, the Centers for Medicare & Medicaid Services (CMS) is seeking public comment on a new version of its ICD-10 readiness assessment. Those interested in weighing in can learn more here.

A new implementation date for the 10th revision of the International Statistical Classification of Diseases coding system (ICD-10) isn't expected to be known until after the November election, says a coding specialist. But hospitalists and others should not take that as a sign to just sit around and wait for a date.

"We're probably not going to hear anything until after the election is finished," says Brenda Edwards, CPC, CPMA, a coding and compliance specialist with Kansas Medical Mutual Insurance Co. and a trainer with AAPC. "The thing that's worrisome, though, is people think this delay we have encountered is a time to sit back and do nothing, but really we’re almost burning money by not doing anything."

An outcry from many physicians led the U.S. Department of Health and Human Services to delay the planned October 2013 implementation date. No new date has been announced.

Edwards urges physicians, billing specialists, and group leaders to use the delay as an opportunity to better prepare for the implementation. She suggests checking with vendors and preparing training programs to help adjust to the new coding initiative, which will quadruple the number of billing codes to 68,000.

"Everyone at this point should still be moving forward," she says.

At the same time, the Centers for Medicare & Medicaid Services (CMS) is seeking public comment on a new version of its ICD-10 readiness assessment. Those interested in weighing in can learn more here.

Six out of 7 respondents to an unscientific survey at the-hospitalist.org correctly answered the question "Which patient being discharged DOES NOT require VTE prophylaxis?" while 14% of respondents answered incorrectly, according to veteran hospitalists who reviewed survey results.

Nearly 200 people responded to the survey, which provided the following answers:

• Hip/knee replacement patients;

• Hip-fracture surgery patients;

• Patients with advanced solid tumors;

• Patients with congestive heart failure; and

• Immobile or bed-bound patients.

The survey ran from June 29 to July 27 and was not limited to physicians. Sixty-six percent of respondents chose "patients with congestive heart failure" as their answer; 20% of respondents chose "patients with advanced solid tumors." Both types of discharged patients do not require VTE prophylaxis, according to the new American College of Chest Physicians (ACCP) guidelines, says Joseph Ming Wah Li, MD, SFHM, FACP, past president of SHM, associate professor of medicine at Harvard Medical School, and hospitalist at Beth Israel Deaconess Medical Center in Boston.

"Hospitalists are familiar with the fact that patients with advanced solid tumors without additional risk factors do not need extended prophylaxis, as per the guidelines put out by ACCP," Dr. Li says. "And patients with congestive heart failure being discharged from the hospital do not need extended thromboprophylaxis, either."

As for the 14% of respondents who chose incorrectly, Gregory Maynard, MD, MSc, SFHM, health sciences professor of medicine at the University of California at San Diego, says extended prophylaxis "may not be on their radar."

"Hospitalists are still struggling to get a consistent approach to inpatient VTE prophylaxis, especially since the ACCP 9 guidelines changed methodologies and provided weaker support for prophylaxis," says Dr. Maynard, senior vice president of SHM's Center for Hospital Innovation and Improvement.

For more information, check out our "Key Clinical Question" outlining VTE prophylaxis guidelines.

Six out of 7 respondents to an unscientific survey at the-hospitalist.org correctly answered the question "Which patient being discharged DOES NOT require VTE prophylaxis?" while 14% of respondents answered incorrectly, according to veteran hospitalists who reviewed survey results.

Nearly 200 people responded to the survey, which provided the following answers:

• Hip/knee replacement patients;

• Hip-fracture surgery patients;

• Patients with advanced solid tumors;

• Patients with congestive heart failure; and

• Immobile or bed-bound patients.

The survey ran from June 29 to July 27 and was not limited to physicians. Sixty-six percent of respondents chose "patients with congestive heart failure" as their answer; 20% of respondents chose "patients with advanced solid tumors." Both types of discharged patients do not require VTE prophylaxis, according to the new American College of Chest Physicians (ACCP) guidelines, says Joseph Ming Wah Li, MD, SFHM, FACP, past president of SHM, associate professor of medicine at Harvard Medical School, and hospitalist at Beth Israel Deaconess Medical Center in Boston.

"Hospitalists are familiar with the fact that patients with advanced solid tumors without additional risk factors do not need extended prophylaxis, as per the guidelines put out by ACCP," Dr. Li says. "And patients with congestive heart failure being discharged from the hospital do not need extended thromboprophylaxis, either."

As for the 14% of respondents who chose incorrectly, Gregory Maynard, MD, MSc, SFHM, health sciences professor of medicine at the University of California at San Diego, says extended prophylaxis "may not be on their radar."

"Hospitalists are still struggling to get a consistent approach to inpatient VTE prophylaxis, especially since the ACCP 9 guidelines changed methodologies and provided weaker support for prophylaxis," says Dr. Maynard, senior vice president of SHM's Center for Hospital Innovation and Improvement.

For more information, check out our "Key Clinical Question" outlining VTE prophylaxis guidelines.

Six out of 7 respondents to an unscientific survey at the-hospitalist.org correctly answered the question "Which patient being discharged DOES NOT require VTE prophylaxis?" while 14% of respondents answered incorrectly, according to veteran hospitalists who reviewed survey results.

Nearly 200 people responded to the survey, which provided the following answers:

• Hip/knee replacement patients;

• Hip-fracture surgery patients;

• Patients with advanced solid tumors;

• Patients with congestive heart failure; and

• Immobile or bed-bound patients.

The survey ran from June 29 to July 27 and was not limited to physicians. Sixty-six percent of respondents chose "patients with congestive heart failure" as their answer; 20% of respondents chose "patients with advanced solid tumors." Both types of discharged patients do not require VTE prophylaxis, according to the new American College of Chest Physicians (ACCP) guidelines, says Joseph Ming Wah Li, MD, SFHM, FACP, past president of SHM, associate professor of medicine at Harvard Medical School, and hospitalist at Beth Israel Deaconess Medical Center in Boston.

"Hospitalists are familiar with the fact that patients with advanced solid tumors without additional risk factors do not need extended prophylaxis, as per the guidelines put out by ACCP," Dr. Li says. "And patients with congestive heart failure being discharged from the hospital do not need extended thromboprophylaxis, either."

As for the 14% of respondents who chose incorrectly, Gregory Maynard, MD, MSc, SFHM, health sciences professor of medicine at the University of California at San Diego, says extended prophylaxis "may not be on their radar."

"Hospitalists are still struggling to get a consistent approach to inpatient VTE prophylaxis, especially since the ACCP 9 guidelines changed methodologies and provided weaker support for prophylaxis," says Dr. Maynard, senior vice president of SHM's Center for Hospital Innovation and Improvement.

For more information, check out our "Key Clinical Question" outlining VTE prophylaxis guidelines.

When the Society for Vascular Surgery (SVS) was approached to become involved in assessing vascular out-patient centers (OEC) the Clinical Practices Committee (CPC) convened to examine this topic that was arousing so much interest and concern among providers and patients.

After reviewing the preliminary CPC assessment, the SVS leadership asked two of the committee to develop an editorial for publication in Vascular Specialist. The intent is to survey the SVS membership on this increasingly relevant issue.

So click on the editorial. Read it. And take the easy online, interactive survey at the bottom.

Your views ARE important. They will help shape how SVS deals with this important issue going forward. Let us know your opinions about OECs. There is room for comment after each survey question, but if you have a lengthier opinion, please take the survey and then e-mail us your in-depth comments at [email protected].

When the Society for Vascular Surgery (SVS) was approached to become involved in assessing vascular out-patient centers (OEC) the Clinical Practices Committee (CPC) convened to examine this topic that was arousing so much interest and concern among providers and patients.

After reviewing the preliminary CPC assessment, the SVS leadership asked two of the committee to develop an editorial for publication in Vascular Specialist. The intent is to survey the SVS membership on this increasingly relevant issue.

So click on the editorial. Read it. And take the easy online, interactive survey at the bottom.

Your views ARE important. They will help shape how SVS deals with this important issue going forward. Let us know your opinions about OECs. There is room for comment after each survey question, but if you have a lengthier opinion, please take the survey and then e-mail us your in-depth comments at [email protected].

When the Society for Vascular Surgery (SVS) was approached to become involved in assessing vascular out-patient centers (OEC) the Clinical Practices Committee (CPC) convened to examine this topic that was arousing so much interest and concern among providers and patients.

After reviewing the preliminary CPC assessment, the SVS leadership asked two of the committee to develop an editorial for publication in Vascular Specialist. The intent is to survey the SVS membership on this increasingly relevant issue.

So click on the editorial. Read it. And take the easy online, interactive survey at the bottom.

Your views ARE important. They will help shape how SVS deals with this important issue going forward. Let us know your opinions about OECs. There is room for comment after each survey question, but if you have a lengthier opinion, please take the survey and then e-mail us your in-depth comments at [email protected].

Recovery includes having a good social support system – family members and friends who believe in the patient’s recovery. The health care system fiercely guards the patient’s personal information. How do we as mental health providers best communicate with the patient’s family?

There are differing attitudes about talking with families. In a study by Phyllis Solomon, Ph.D., most providers interpreted confidentiality policies conservatively, and 54 percent were confused about the types of information that are confidential (Psychiatric Serv. 2003;54:1622-8).

The need to ensure that communication is optimal is further demonstrated by the findings of a recently devised instrument called the Confidentiality Issues Test, or CIT. The CIT, as outlined by Tina Marshall, Ph.D., and Dr. Solomon, contains scenarios, descriptions, and questions about confidentiality issues and family members (Am J. Psychiatric Rehab. 2012;15:97-115). The following two questions come from the CIT, and the answer in bold is the correct one.

First Situation

A woman calls you about a patient on your caseload and identifies herself as your patient’s mother. You have no release, but the patient has mentioned that he visits his mother frequently, and you have no reason to believe that the caller is a danger to the patient. The caller says she wants to make sure that her son’s case manager gets certain very important information about his financial and legal situation –information that he often does not mention to staff.

Which answer is correct?

1a. All you can say is that you cannot give out any information about patients without a release, including whether any particular person receives services at your agency.

1b. You are only allowed to take the caller’s name and contact information and tell her that if any information can be released, someone will get back to her.

1c. While stating that you cannot give out any information, you are allowed to ask the caller about the information she is concerned about conveying and say that if it turns out that her son is a patient there, you will make sure the information gets to the right person.

1d. Since the caller is an immediate family member and has important information, you are allowed to confirm that the son is a patient at your agency, but not to release any other information.

Second Situation

A patient has told you (or someone at your agency) that she plans to take an overdose tonight, and has a large number of pills saved up at her apartment. You know that she has a roommate, and you have the roommate’s contact information, but you have no signed release to talk to the roommate.

Which answer is correct?

5a. Even in this situation, you must get a signed release from the patient to be able to call and talk to the roommate about the patient’s safety.

5b. You do not need to have a release to talk to the roommate if there is a question of imminent death or serious injury to the patient, as long as the information you share is restricted to the issue of the consumer’s safety.

5c. Neither of the above choices is correct.

5d. Not sure

Almost 50% of behavioral health providers who completed this test believed that even without revealing any information about a client, they could not listen to a family member or a significant support person without a release from the patient, or were unsure whether they could, according to Dr. Marshall and Dr. Solomon. Staff also indicated that they would attempt to avoid being in a situation where they had to implement a policy that seemed too fraught with difficulties.

Most patients, and especially those with chronic mental illness, need assistance in monitoring and managing symptoms as an important part of recovery. Families are the first to notice symptoms; families bring the patients to the emergency room; and families are most affected by their relative’s disability. Family conflict can arise when the family member does not understand the illness or the symptoms – and does not understand how best to respond to an ill relative. Families want to offer support but need some information about their relative’s illness and treatment. What can you divulge to families?

First, the patient needs to understand the role of the family in managing the illness. When patients understand that their family/friends can be helpful and agree to give the family members ways to be helpful, they usually are willing to have their family members come for a visit. A family consultation clarifies where the boundaries are between the patient, the mental health providers, and the family members. The family member does not need to know "specifics," but does need to know how to respond when difficulties arise so that the family member does not get overly anxious and then does things that are unhelpful.

A conversation with a patient about sharing information with family members might go something like this:

Doctor: "Suzi, if you have a side effect from your medication, what should your husband do? Is the side effect life-threatening, or can you call in the morning to get advice? We have talked about if you have a side effect you call me, and we can discuss it. If your husband gets too worried because your side effect is frightening, then there is conflict about how to manage the symptom. So, if your husband knows what we discuss about side effects, then things at home will be calm. What do you think?"

Patient: "Okay, I understand. That sounds good. The less worried he is, the more he will let me alone."

D: "Are there other situations where you think that if your husband had more information, he might be less anxious and therefore less on your back about things?"

P: "Maybe if he understood my depression more – that I get forgetful or too tired or feeling hopeless ..."

D: "How would it help if he had more information?"

P: "He would not start to talk to me in that angry voice, then get on the phone and complain to his mother."

D: "Do you think he would agree to come in so that we could talk about ways to manage your symptoms?"

P: "Yes, but you have to promise not to talk about other things."

D: "What other things do you not want me to talk to her about?"

P: "I don’t want you telling him that I feel suicidal."

D: "Do you think he knows?"

P: "Yes, but I don’t want him talking about it with me."

D: "Don’t you think he would be more settled if he knew you could successfully use your safety plan? Your plan is for you to do something to distract your thoughts and to counteract the feelings, then to call me or the emergency number if you are needing further help. Remember the plan you have? You have used it a couple of times."

P: "Maybe, yes, perhaps."

D: "Put yourself in his shoes. Wouldn’t you be more comfortable knowing that there is a good safety plan in place?"

P: "I guess so."

D: "Okay, think about it, talk to him, and let’s schedule a meeting. Also, if you want, you can both go to the family support group we have."

P: "Okay, I’ll talk to him."

Staff also can offer nonconfidential information to family members and friends. We make it clear that we are not authorized to acknowledge whether the person is receiving treatment at the agency but can still answer general questions such as those dealing with diagnosis and treatment. We can provide written educational material and information about community resources. We can say that family involvement is important and that with the patient’s agreement, family members and friends can be involved in treatment; and we can listen to whatever they want to tell us.

Here is a quick summary of points to remember when it comes to confidentiality issues:

1. Discuss goals of family involvement with patients.

2. Educate staff about the benefits of involving family.

3. Provide guidance to staff on what to discuss with families and how to talk to families.

4. Ensure that your staff understands what is and what is not confidential information.

5. Remember that you can always listen to what a family member or friend has to say.

6. Keep in mind that serious risk trumps the need for a release of information to family or friends.

Confidentiality is vital. It safeguards patients’ trust and allows patients to work toward their own recovery. There are consent procedures for releasing confidential information, and some agencies have forms specifically designed for families. These forms specify the types of information to be released to a designated family member or significant person, and have a longer time frame of 1 year. These forms allow information to be communicated verbally rather than in writing.

When staff members understand the rationale and goals of involving family and friends, and if they receive training in how to approach patients and their families, willingness will be greater to implement a family-friendly approach to recovery.

Dr. Heru is with the department of psychiatry at the University of Colorado Medical School. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

Recovery includes having a good social support system – family members and friends who believe in the patient’s recovery. The health care system fiercely guards the patient’s personal information. How do we as mental health providers best communicate with the patient’s family?

There are differing attitudes about talking with families. In a study by Phyllis Solomon, Ph.D., most providers interpreted confidentiality policies conservatively, and 54 percent were confused about the types of information that are confidential (Psychiatric Serv. 2003;54:1622-8).

The need to ensure that communication is optimal is further demonstrated by the findings of a recently devised instrument called the Confidentiality Issues Test, or CIT. The CIT, as outlined by Tina Marshall, Ph.D., and Dr. Solomon, contains scenarios, descriptions, and questions about confidentiality issues and family members (Am J. Psychiatric Rehab. 2012;15:97-115). The following two questions come from the CIT, and the answer in bold is the correct one.

First Situation

A woman calls you about a patient on your caseload and identifies herself as your patient’s mother. You have no release, but the patient has mentioned that he visits his mother frequently, and you have no reason to believe that the caller is a danger to the patient. The caller says she wants to make sure that her son’s case manager gets certain very important information about his financial and legal situation –information that he often does not mention to staff.

Which answer is correct?

1a. All you can say is that you cannot give out any information about patients without a release, including whether any particular person receives services at your agency.

1b. You are only allowed to take the caller’s name and contact information and tell her that if any information can be released, someone will get back to her.

1c. While stating that you cannot give out any information, you are allowed to ask the caller about the information she is concerned about conveying and say that if it turns out that her son is a patient there, you will make sure the information gets to the right person.

1d. Since the caller is an immediate family member and has important information, you are allowed to confirm that the son is a patient at your agency, but not to release any other information.

Second Situation

A patient has told you (or someone at your agency) that she plans to take an overdose tonight, and has a large number of pills saved up at her apartment. You know that she has a roommate, and you have the roommate’s contact information, but you have no signed release to talk to the roommate.

Which answer is correct?

5a. Even in this situation, you must get a signed release from the patient to be able to call and talk to the roommate about the patient’s safety.

5b. You do not need to have a release to talk to the roommate if there is a question of imminent death or serious injury to the patient, as long as the information you share is restricted to the issue of the consumer’s safety.

5c. Neither of the above choices is correct.

5d. Not sure

Almost 50% of behavioral health providers who completed this test believed that even without revealing any information about a client, they could not listen to a family member or a significant support person without a release from the patient, or were unsure whether they could, according to Dr. Marshall and Dr. Solomon. Staff also indicated that they would attempt to avoid being in a situation where they had to implement a policy that seemed too fraught with difficulties.

Most patients, and especially those with chronic mental illness, need assistance in monitoring and managing symptoms as an important part of recovery. Families are the first to notice symptoms; families bring the patients to the emergency room; and families are most affected by their relative’s disability. Family conflict can arise when the family member does not understand the illness or the symptoms – and does not understand how best to respond to an ill relative. Families want to offer support but need some information about their relative’s illness and treatment. What can you divulge to families?

First, the patient needs to understand the role of the family in managing the illness. When patients understand that their family/friends can be helpful and agree to give the family members ways to be helpful, they usually are willing to have their family members come for a visit. A family consultation clarifies where the boundaries are between the patient, the mental health providers, and the family members. The family member does not need to know "specifics," but does need to know how to respond when difficulties arise so that the family member does not get overly anxious and then does things that are unhelpful.

A conversation with a patient about sharing information with family members might go something like this:

Doctor: "Suzi, if you have a side effect from your medication, what should your husband do? Is the side effect life-threatening, or can you call in the morning to get advice? We have talked about if you have a side effect you call me, and we can discuss it. If your husband gets too worried because your side effect is frightening, then there is conflict about how to manage the symptom. So, if your husband knows what we discuss about side effects, then things at home will be calm. What do you think?"

Patient: "Okay, I understand. That sounds good. The less worried he is, the more he will let me alone."

D: "Are there other situations where you think that if your husband had more information, he might be less anxious and therefore less on your back about things?"

P: "Maybe if he understood my depression more – that I get forgetful or too tired or feeling hopeless ..."

D: "How would it help if he had more information?"

P: "He would not start to talk to me in that angry voice, then get on the phone and complain to his mother."

D: "Do you think he would agree to come in so that we could talk about ways to manage your symptoms?"

P: "Yes, but you have to promise not to talk about other things."

D: "What other things do you not want me to talk to her about?"

P: "I don’t want you telling him that I feel suicidal."

D: "Do you think he knows?"

P: "Yes, but I don’t want him talking about it with me."

D: "Don’t you think he would be more settled if he knew you could successfully use your safety plan? Your plan is for you to do something to distract your thoughts and to counteract the feelings, then to call me or the emergency number if you are needing further help. Remember the plan you have? You have used it a couple of times."

P: "Maybe, yes, perhaps."

D: "Put yourself in his shoes. Wouldn’t you be more comfortable knowing that there is a good safety plan in place?"

P: "I guess so."

D: "Okay, think about it, talk to him, and let’s schedule a meeting. Also, if you want, you can both go to the family support group we have."

P: "Okay, I’ll talk to him."

Staff also can offer nonconfidential information to family members and friends. We make it clear that we are not authorized to acknowledge whether the person is receiving treatment at the agency but can still answer general questions such as those dealing with diagnosis and treatment. We can provide written educational material and information about community resources. We can say that family involvement is important and that with the patient’s agreement, family members and friends can be involved in treatment; and we can listen to whatever they want to tell us.

Here is a quick summary of points to remember when it comes to confidentiality issues:

1. Discuss goals of family involvement with patients.

2. Educate staff about the benefits of involving family.

3. Provide guidance to staff on what to discuss with families and how to talk to families.

4. Ensure that your staff understands what is and what is not confidential information.

5. Remember that you can always listen to what a family member or friend has to say.

6. Keep in mind that serious risk trumps the need for a release of information to family or friends.

Confidentiality is vital. It safeguards patients’ trust and allows patients to work toward their own recovery. There are consent procedures for releasing confidential information, and some agencies have forms specifically designed for families. These forms specify the types of information to be released to a designated family member or significant person, and have a longer time frame of 1 year. These forms allow information to be communicated verbally rather than in writing.

When staff members understand the rationale and goals of involving family and friends, and if they receive training in how to approach patients and their families, willingness will be greater to implement a family-friendly approach to recovery.

Dr. Heru is with the department of psychiatry at the University of Colorado Medical School. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

Recovery includes having a good social support system – family members and friends who believe in the patient’s recovery. The health care system fiercely guards the patient’s personal information. How do we as mental health providers best communicate with the patient’s family?

There are differing attitudes about talking with families. In a study by Phyllis Solomon, Ph.D., most providers interpreted confidentiality policies conservatively, and 54 percent were confused about the types of information that are confidential (Psychiatric Serv. 2003;54:1622-8).

The need to ensure that communication is optimal is further demonstrated by the findings of a recently devised instrument called the Confidentiality Issues Test, or CIT. The CIT, as outlined by Tina Marshall, Ph.D., and Dr. Solomon, contains scenarios, descriptions, and questions about confidentiality issues and family members (Am J. Psychiatric Rehab. 2012;15:97-115). The following two questions come from the CIT, and the answer in bold is the correct one.

First Situation

A woman calls you about a patient on your caseload and identifies herself as your patient’s mother. You have no release, but the patient has mentioned that he visits his mother frequently, and you have no reason to believe that the caller is a danger to the patient. The caller says she wants to make sure that her son’s case manager gets certain very important information about his financial and legal situation –information that he often does not mention to staff.

Which answer is correct?

1a. All you can say is that you cannot give out any information about patients without a release, including whether any particular person receives services at your agency.

1b. You are only allowed to take the caller’s name and contact information and tell her that if any information can be released, someone will get back to her.

1c. While stating that you cannot give out any information, you are allowed to ask the caller about the information she is concerned about conveying and say that if it turns out that her son is a patient there, you will make sure the information gets to the right person.

1d. Since the caller is an immediate family member and has important information, you are allowed to confirm that the son is a patient at your agency, but not to release any other information.

Second Situation

A patient has told you (or someone at your agency) that she plans to take an overdose tonight, and has a large number of pills saved up at her apartment. You know that she has a roommate, and you have the roommate’s contact information, but you have no signed release to talk to the roommate.

Which answer is correct?

5a. Even in this situation, you must get a signed release from the patient to be able to call and talk to the roommate about the patient’s safety.

5b. You do not need to have a release to talk to the roommate if there is a question of imminent death or serious injury to the patient, as long as the information you share is restricted to the issue of the consumer’s safety.

5c. Neither of the above choices is correct.

5d. Not sure

Almost 50% of behavioral health providers who completed this test believed that even without revealing any information about a client, they could not listen to a family member or a significant support person without a release from the patient, or were unsure whether they could, according to Dr. Marshall and Dr. Solomon. Staff also indicated that they would attempt to avoid being in a situation where they had to implement a policy that seemed too fraught with difficulties.

Most patients, and especially those with chronic mental illness, need assistance in monitoring and managing symptoms as an important part of recovery. Families are the first to notice symptoms; families bring the patients to the emergency room; and families are most affected by their relative’s disability. Family conflict can arise when the family member does not understand the illness or the symptoms – and does not understand how best to respond to an ill relative. Families want to offer support but need some information about their relative’s illness and treatment. What can you divulge to families?

First, the patient needs to understand the role of the family in managing the illness. When patients understand that their family/friends can be helpful and agree to give the family members ways to be helpful, they usually are willing to have their family members come for a visit. A family consultation clarifies where the boundaries are between the patient, the mental health providers, and the family members. The family member does not need to know "specifics," but does need to know how to respond when difficulties arise so that the family member does not get overly anxious and then does things that are unhelpful.

A conversation with a patient about sharing information with family members might go something like this:

Doctor: "Suzi, if you have a side effect from your medication, what should your husband do? Is the side effect life-threatening, or can you call in the morning to get advice? We have talked about if you have a side effect you call me, and we can discuss it. If your husband gets too worried because your side effect is frightening, then there is conflict about how to manage the symptom. So, if your husband knows what we discuss about side effects, then things at home will be calm. What do you think?"

Patient: "Okay, I understand. That sounds good. The less worried he is, the more he will let me alone."

D: "Are there other situations where you think that if your husband had more information, he might be less anxious and therefore less on your back about things?"

P: "Maybe if he understood my depression more – that I get forgetful or too tired or feeling hopeless ..."

D: "How would it help if he had more information?"

P: "He would not start to talk to me in that angry voice, then get on the phone and complain to his mother."

D: "Do you think he would agree to come in so that we could talk about ways to manage your symptoms?"

P: "Yes, but you have to promise not to talk about other things."

D: "What other things do you not want me to talk to her about?"

P: "I don’t want you telling him that I feel suicidal."

D: "Do you think he knows?"

P: "Yes, but I don’t want him talking about it with me."

D: "Don’t you think he would be more settled if he knew you could successfully use your safety plan? Your plan is for you to do something to distract your thoughts and to counteract the feelings, then to call me or the emergency number if you are needing further help. Remember the plan you have? You have used it a couple of times."

P: "Maybe, yes, perhaps."

D: "Put yourself in his shoes. Wouldn’t you be more comfortable knowing that there is a good safety plan in place?"

P: "I guess so."

D: "Okay, think about it, talk to him, and let’s schedule a meeting. Also, if you want, you can both go to the family support group we have."

P: "Okay, I’ll talk to him."

Staff also can offer nonconfidential information to family members and friends. We make it clear that we are not authorized to acknowledge whether the person is receiving treatment at the agency but can still answer general questions such as those dealing with diagnosis and treatment. We can provide written educational material and information about community resources. We can say that family involvement is important and that with the patient’s agreement, family members and friends can be involved in treatment; and we can listen to whatever they want to tell us.

Here is a quick summary of points to remember when it comes to confidentiality issues:

1. Discuss goals of family involvement with patients.

2. Educate staff about the benefits of involving family.

3. Provide guidance to staff on what to discuss with families and how to talk to families.

4. Ensure that your staff understands what is and what is not confidential information.

5. Remember that you can always listen to what a family member or friend has to say.

6. Keep in mind that serious risk trumps the need for a release of information to family or friends.

Confidentiality is vital. It safeguards patients’ trust and allows patients to work toward their own recovery. There are consent procedures for releasing confidential information, and some agencies have forms specifically designed for families. These forms specify the types of information to be released to a designated family member or significant person, and have a longer time frame of 1 year. These forms allow information to be communicated verbally rather than in writing.

When staff members understand the rationale and goals of involving family and friends, and if they receive training in how to approach patients and their families, willingness will be greater to implement a family-friendly approach to recovery.

Dr. Heru is with the department of psychiatry at the University of Colorado Medical School. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

The Centers for Disease Control and Prevention recommends that all Americans aged 47-67 years should be tested once for hepatitis C infection, according to a CDC statement published Aug. 16 online. The CDC proposed the recommendation in May 2012.

Data from previous studies suggest that the baby boomers, defined by the CDC as individuals born between 1945 and 1965, are at increased risk for hepatitis C for many reasons, including blood transfusions, hospital exposures, and a possible history of risky behaviors in their younger years. However, many people in this age group are amenable to hepatitis C testing if it is available to them.

Photo courtesy US Veterans Admin.

According to the CDC statement, "1 in 30 baby boomers has been infected with hepatitis C, and most don’t know it." This life-threatening infection has few symptoms and affects approximately 3.2 million U.S. adults, most of whom are baby boomers, according to the CDC. Hepatitis C is the leading cause of liver transplantation in the United States, and the virus causes serious liver diseases including cirrhosis and liver cancer.

The CDC said in the statement that a one-time hepatitis C test for all baby boomers could potentially identify more than 800,000 additional cases. If treated early, up to 75% of these individuals could be cured, avoiding the costs and serious complications associated with untreated hepatitis C infections. New therapies have recently improved the cure rate significantly.

The CDC encourages clinicians to promote hepatitis C testing to their baby boomer patients.

"Identifying these hidden infections early will allow more baby boomers to receive care and treatment, before they develop life-threatening liver disease," Dr. Kevin Fenton, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, said in the CDC statement. One-time hepatitis C testing for baby boomers "could potentially save tens of thousands of lives," he said.

The Centers for Disease Control and Prevention recommends that all Americans aged 47-67 years should be tested once for hepatitis C infection, according to a CDC statement published Aug. 16 online. The CDC proposed the recommendation in May 2012.

Data from previous studies suggest that the baby boomers, defined by the CDC as individuals born between 1945 and 1965, are at increased risk for hepatitis C for many reasons, including blood transfusions, hospital exposures, and a possible history of risky behaviors in their younger years. However, many people in this age group are amenable to hepatitis C testing if it is available to them.

Photo courtesy US Veterans Admin.

According to the CDC statement, "1 in 30 baby boomers has been infected with hepatitis C, and most don’t know it." This life-threatening infection has few symptoms and affects approximately 3.2 million U.S. adults, most of whom are baby boomers, according to the CDC. Hepatitis C is the leading cause of liver transplantation in the United States, and the virus causes serious liver diseases including cirrhosis and liver cancer.

The CDC said in the statement that a one-time hepatitis C test for all baby boomers could potentially identify more than 800,000 additional cases. If treated early, up to 75% of these individuals could be cured, avoiding the costs and serious complications associated with untreated hepatitis C infections. New therapies have recently improved the cure rate significantly.

The CDC encourages clinicians to promote hepatitis C testing to their baby boomer patients.

"Identifying these hidden infections early will allow more baby boomers to receive care and treatment, before they develop life-threatening liver disease," Dr. Kevin Fenton, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, said in the CDC statement. One-time hepatitis C testing for baby boomers "could potentially save tens of thousands of lives," he said.

The Centers for Disease Control and Prevention recommends that all Americans aged 47-67 years should be tested once for hepatitis C infection, according to a CDC statement published Aug. 16 online. The CDC proposed the recommendation in May 2012.

Data from previous studies suggest that the baby boomers, defined by the CDC as individuals born between 1945 and 1965, are at increased risk for hepatitis C for many reasons, including blood transfusions, hospital exposures, and a possible history of risky behaviors in their younger years. However, many people in this age group are amenable to hepatitis C testing if it is available to them.

Photo courtesy US Veterans Admin.

According to the CDC statement, "1 in 30 baby boomers has been infected with hepatitis C, and most don’t know it." This life-threatening infection has few symptoms and affects approximately 3.2 million U.S. adults, most of whom are baby boomers, according to the CDC. Hepatitis C is the leading cause of liver transplantation in the United States, and the virus causes serious liver diseases including cirrhosis and liver cancer.

The CDC said in the statement that a one-time hepatitis C test for all baby boomers could potentially identify more than 800,000 additional cases. If treated early, up to 75% of these individuals could be cured, avoiding the costs and serious complications associated with untreated hepatitis C infections. New therapies have recently improved the cure rate significantly.

The CDC encourages clinicians to promote hepatitis C testing to their baby boomer patients.

"Identifying these hidden infections early will allow more baby boomers to receive care and treatment, before they develop life-threatening liver disease," Dr. Kevin Fenton, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, said in the CDC statement. One-time hepatitis C testing for baby boomers "could potentially save tens of thousands of lives," he said.

My recent column on good hiring practices, which stressed the importance of replacing marginal employees with excellent ones, triggered an interesting round of discussion. "Isn’t it true," asked a colleague, "that most physicians tolerate marginal employees because it’s less painful than firing them?"

Indeed it is. Firing someone is never easy, and it is particularly tough on physicians. But sometimes it is unavoidable to preserve the efficiency and morale of yourself and your other employees.

Before you do it, however, be sure that you have legitimate grounds, and assemble as much documentation as possible. Record all terminatable transgressions in the employee’s permanent record, and document all verbal and written warnings. This is essential; you must be prepared to prove that your reasons for termination were legal.

Former employees will sometimes charge that their civil rights were violated. For example, federal law prohibits you from firing anyone because of race, gender, national origin, disability, religion, or age. You cannot fire a woman because she is pregnant, or recently gave birth. Other illegal reasons include assertion of antidiscrimination rights, refusing to take a lie detector test, and reporting OSHA (Occupational Safety and Health Administration) violations.

You also can’t terminate someone for refusing to commit an illegal act, such as filing false insurance claims; or for exercising a legal right, such as voting or participating in a political demonstration.

And you cannot fire an alcohol abuser unless he or she is caught drinking at work; but many forms of illegal drug use are legitimate cause for termination. Other laws may apply, depending on where you live. When in doubt, contact your state labor department or fair employment office.

If a fired employee alleges that he or she was fired for any of these illegal reasons, and you do not have convincing documentation to counter the charge, you may find yourself defending your actions in court.

As I’ve mentioned in the past, consider adding employment practices liability insurance (EPLI) to your umbrella policy, since a wrongful termination lawsuit is always a possibility despite your best efforts to prevent it.

Once you have all your legal ducks in a row, don’t procrastinate. Get it over with, first thing on Monday morning. If you wait until Friday afternoon you will worry about the dreaded task all week long, and the fired employee will stew about it all weekend.

Explain the performance you have expected, the steps you have taken to help correct the problems you have seen, and the fact that the problems persist. Try to limit the conversation to a minute or two, have the final paycheck ready, and make it clear that the decision has already been made, so begging and pleading will not change anything.

I’ve been asked to share exactly what I say; so for what it’s worth, here it is: "I have called you in to discuss a difficult issue. You know that we have not been happy with your performance. We are still not happy with it, despite all the discussions we have had, and we feel that you can do better elsewhere. So today we will part company, and I wish you the best of luck in your future endeavors. Here is your severance check. I hope there are no hard feelings."

There will, of course be hard feelings, but that cannot be helped. The point is to be quick, firm, and decisive. Get it over with and allow everyone to move on.

Be sure to get all your office keys back – or change the locks if you cannot. Back up all important computer files, and change all your passwords. Most employees know more of them than you would ever suspect.

Finally, call the staff together and explain what you have done. They should hear the story from you, not a distorted version through the rumor mill. You don’t have to explain your reasoning or divulge every detail, but do explain how the termination will affect everyone else. Responsibilities will need to be shifted until a replacement can be hired, and all employees should understand that.

If you are asked in the future to give a reference or write a letter of recommendation for the terminated employee, be sure that everything you say is truthful and well documented.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. 

My recent column on good hiring practices, which stressed the importance of replacing marginal employees with excellent ones, triggered an interesting round of discussion. "Isn’t it true," asked a colleague, "that most physicians tolerate marginal employees because it’s less painful than firing them?"

Indeed it is. Firing someone is never easy, and it is particularly tough on physicians. But sometimes it is unavoidable to preserve the efficiency and morale of yourself and your other employees.

Before you do it, however, be sure that you have legitimate grounds, and assemble as much documentation as possible. Record all terminatable transgressions in the employee’s permanent record, and document all verbal and written warnings. This is essential; you must be prepared to prove that your reasons for termination were legal.

Former employees will sometimes charge that their civil rights were violated. For example, federal law prohibits you from firing anyone because of race, gender, national origin, disability, religion, or age. You cannot fire a woman because she is pregnant, or recently gave birth. Other illegal reasons include assertion of antidiscrimination rights, refusing to take a lie detector test, and reporting OSHA (Occupational Safety and Health Administration) violations.

You also can’t terminate someone for refusing to commit an illegal act, such as filing false insurance claims; or for exercising a legal right, such as voting or participating in a political demonstration.

And you cannot fire an alcohol abuser unless he or she is caught drinking at work; but many forms of illegal drug use are legitimate cause for termination. Other laws may apply, depending on where you live. When in doubt, contact your state labor department or fair employment office.

If a fired employee alleges that he or she was fired for any of these illegal reasons, and you do not have convincing documentation to counter the charge, you may find yourself defending your actions in court.

As I’ve mentioned in the past, consider adding employment practices liability insurance (EPLI) to your umbrella policy, since a wrongful termination lawsuit is always a possibility despite your best efforts to prevent it.

Once you have all your legal ducks in a row, don’t procrastinate. Get it over with, first thing on Monday morning. If you wait until Friday afternoon you will worry about the dreaded task all week long, and the fired employee will stew about it all weekend.

Explain the performance you have expected, the steps you have taken to help correct the problems you have seen, and the fact that the problems persist. Try to limit the conversation to a minute or two, have the final paycheck ready, and make it clear that the decision has already been made, so begging and pleading will not change anything.

I’ve been asked to share exactly what I say; so for what it’s worth, here it is: "I have called you in to discuss a difficult issue. You know that we have not been happy with your performance. We are still not happy with it, despite all the discussions we have had, and we feel that you can do better elsewhere. So today we will part company, and I wish you the best of luck in your future endeavors. Here is your severance check. I hope there are no hard feelings."

There will, of course be hard feelings, but that cannot be helped. The point is to be quick, firm, and decisive. Get it over with and allow everyone to move on.

Be sure to get all your office keys back – or change the locks if you cannot. Back up all important computer files, and change all your passwords. Most employees know more of them than you would ever suspect.

Finally, call the staff together and explain what you have done. They should hear the story from you, not a distorted version through the rumor mill. You don’t have to explain your reasoning or divulge every detail, but do explain how the termination will affect everyone else. Responsibilities will need to be shifted until a replacement can be hired, and all employees should understand that.

If you are asked in the future to give a reference or write a letter of recommendation for the terminated employee, be sure that everything you say is truthful and well documented.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. 

My recent column on good hiring practices, which stressed the importance of replacing marginal employees with excellent ones, triggered an interesting round of discussion. "Isn’t it true," asked a colleague, "that most physicians tolerate marginal employees because it’s less painful than firing them?"

Indeed it is. Firing someone is never easy, and it is particularly tough on physicians. But sometimes it is unavoidable to preserve the efficiency and morale of yourself and your other employees.

Before you do it, however, be sure that you have legitimate grounds, and assemble as much documentation as possible. Record all terminatable transgressions in the employee’s permanent record, and document all verbal and written warnings. This is essential; you must be prepared to prove that your reasons for termination were legal.

Former employees will sometimes charge that their civil rights were violated. For example, federal law prohibits you from firing anyone because of race, gender, national origin, disability, religion, or age. You cannot fire a woman because she is pregnant, or recently gave birth. Other illegal reasons include assertion of antidiscrimination rights, refusing to take a lie detector test, and reporting OSHA (Occupational Safety and Health Administration) violations.

You also can’t terminate someone for refusing to commit an illegal act, such as filing false insurance claims; or for exercising a legal right, such as voting or participating in a political demonstration.

And you cannot fire an alcohol abuser unless he or she is caught drinking at work; but many forms of illegal drug use are legitimate cause for termination. Other laws may apply, depending on where you live. When in doubt, contact your state labor department or fair employment office.

If a fired employee alleges that he or she was fired for any of these illegal reasons, and you do not have convincing documentation to counter the charge, you may find yourself defending your actions in court.

As I’ve mentioned in the past, consider adding employment practices liability insurance (EPLI) to your umbrella policy, since a wrongful termination lawsuit is always a possibility despite your best efforts to prevent it.

Once you have all your legal ducks in a row, don’t procrastinate. Get it over with, first thing on Monday morning. If you wait until Friday afternoon you will worry about the dreaded task all week long, and the fired employee will stew about it all weekend.

Explain the performance you have expected, the steps you have taken to help correct the problems you have seen, and the fact that the problems persist. Try to limit the conversation to a minute or two, have the final paycheck ready, and make it clear that the decision has already been made, so begging and pleading will not change anything.

I’ve been asked to share exactly what I say; so for what it’s worth, here it is: "I have called you in to discuss a difficult issue. You know that we have not been happy with your performance. We are still not happy with it, despite all the discussions we have had, and we feel that you can do better elsewhere. So today we will part company, and I wish you the best of luck in your future endeavors. Here is your severance check. I hope there are no hard feelings."

There will, of course be hard feelings, but that cannot be helped. The point is to be quick, firm, and decisive. Get it over with and allow everyone to move on.

Be sure to get all your office keys back – or change the locks if you cannot. Back up all important computer files, and change all your passwords. Most employees know more of them than you would ever suspect.

Finally, call the staff together and explain what you have done. They should hear the story from you, not a distorted version through the rumor mill. You don’t have to explain your reasoning or divulge every detail, but do explain how the termination will affect everyone else. Responsibilities will need to be shifted until a replacement can be hired, and all employees should understand that.

If you are asked in the future to give a reference or write a letter of recommendation for the terminated employee, be sure that everything you say is truthful and well documented.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. 

Tofacitinib was associated with greater clinical response and remission rates than was placebo in a double-blind, phase II trial of patients with moderately or severely active ulcerative colitis.

Current treatment of ulcerative colitis with mesalamine, glucocorticoids, azathioprine, and anti–tumor necrosis factor (anti-TNF) agents such as infliximab and adalimumab is not always effective, and may be associated with serious toxic effects (Gastroenterology 2006;130:940-87). Thus, "additional treatments are needed," said Dr. William J. Sandborn, chief of the division of gastroenterology and professor of medicine at the University of California, San Diego and his associates (N. Engl. J. Med. 2012;367:616-24).

Tofacitinib is a selective oral inhibitor of the Janus kinase (JAK) family of enzymes that includes JAK1 and JAK3, which mediate signal-transduction activity for multiple cytokines, including several that are integral to lymphocyte activation, function, and proliferation. Although the importance of the JAK family in the pathogenesis of ulcerative colitis is unclear, tofacitinib has shown efficacy against other immune-mediated conditions, including organ allograft rejection, rheumatoid arthritis, and psoriasis.

The 8-week trial was conducted at 51 centers in 17 countries from January 2009 through September 2010 with funding from Pfizer. Subjects had to be at least 18 years of age, with a confirmed diagnosis of ulcerative colitis of 3 months’ duration or longer, a score of 6-12 on the Mayo risk calculator for ulcerative colitis,and evidence on sigmoidoscopic examination of moderately or severely active disease. In most of the patients, the use of conventional therapy (mesalamine, glucocorticoids, immunosuppressants, or anti-TNF agents used as monotherapy or in some combination) had failed, according to the investigators.

During the study, patients could receive oral mesalamine or oral prednisone at a stable dosage of 30 mg or less per day. However, patients receiving azathioprine, 6-mercaptopurine, and methotrexate discontinued them immediately before initiating therapy with tofacitinib, and patients who had previously received anti-TNF therapy were required to discontinue it for at least 8 weeks before study entry.

Patients were randomly assigned to receive twice-daily oral tofacitinib doses of 0.5 mg, 3 mg, 10 mg, or 15 mg or placebo for 8 weeks, and were then followed for 4 weeks through 12 weeks. Of the 195 patients randomized, 194 received at least one dose of the study drug or placebo and 157 completed the full 8 weeks of treatment. Across all treatment groups, 131 patients (67.5%) received concomitant aminosalicylates, and 85 (43.8%) received concomitant glucocorticoids at some point during the study, they noted.

Clinical response was defined as a decrease from baseline in the total Mayo score (defined as an absolute decrease by at least 3 points and a relative decrease by at least 30%) with an accompanying decrease in the rectal bleeding subscore of at least 1 point or an absolute rectal bleeding subscore of 0 or 1.

The primary end point, clinical response at 8 weeks, occurred in 42% (20) of the patients who received placebo. The response was significantly greater than that seen only among the patients who received the highest doses of tofacitinib, 78% of those receiving 15 mg (P less than .001). For the lower doses, the clinical response rates were not significantly different from those with placebo (61%, 48% and 32%, respectively, for 10 mg, 3 mg and 0.5 mg).

Clinical remission, a secondary end point, was defined as a total Mayo score of 0-2, with no individual subscore exceeding 1. Clinical remission at 8 weeks occurred in 10% (5) of the placebo patients. Here, the difference from placebo with tofacitinib was significant for doses of 3 mg (33%; P = .01), 10 mg (48%; P less than .001), and 15 mg (41%; P less than .001).

Another secondary end point, endoscopic response, was defined as a decrease from baseline in the endoscopy subscore by at least 1.The secondary end point of endoscopic remission was defined as an endoscopy subscore of 0.

An endoscopic response at 8 weeks occurred in 46% with placebo, significantly lower than the responses with tofacitinib doses of 10 mg (67%; P = .07) and 15mg (78%; P = .001). Endoscopic remission at 8 weeks occurred in just 2% of the placebo group, vs. significantly greater proportions of 18% with 3 mg (P = .01), 30% with 10 mg (P less than .001), and 27% with 15 mg (P less than .001).

Rates of overall and serious adverse events, as well as adverse events from infection, were similar among the groups. Two patients receiving 10 mg of tofacitinib twice daily had serious adverse events from infection (a postoperative abscess in one and anal abscess in the other). There was a dose-dependent increase in both LDL and HDL cholesterol concentrations at 8 weeks with tofacitinib, which reversed after discontinuation of the study drug . During the study period, the absolute neutrophil count was less than 1,500 cells per cubic millimeter in three patients receiving tofacitinib, but was not less than 1,000 cells per cubic millimeter in any patient, Dr. Sandborn and his associates reported.

In previous studies of patients with rheumatoid arthritis, tofacitinib has been associated with increases in LDL cholesterol and serum creatinine, and decreases in absolute neutrophil count, whereas increased infection risk has been seen with the 15-mg, twice-daily dose. The small size and short duration of the current trial did not allow for a comprehensive assessment of the safety and tolerability of the drug in patients with ulcerative colitis, they noted.

This study was funded by Pfizer, from whom Dr. Sandborn has received grants and consulting fees. He has also served as a consultant and has additional ties to numerous other companies.

Tofacitinib was associated with greater clinical response and remission rates than was placebo in a double-blind, phase II trial of patients with moderately or severely active ulcerative colitis.

Current treatment of ulcerative colitis with mesalamine, glucocorticoids, azathioprine, and anti–tumor necrosis factor (anti-TNF) agents such as infliximab and adalimumab is not always effective, and may be associated with serious toxic effects (Gastroenterology 2006;130:940-87). Thus, "additional treatments are needed," said Dr. William J. Sandborn, chief of the division of gastroenterology and professor of medicine at the University of California, San Diego and his associates (N. Engl. J. Med. 2012;367:616-24).

Tofacitinib is a selective oral inhibitor of the Janus kinase (JAK) family of enzymes that includes JAK1 and JAK3, which mediate signal-transduction activity for multiple cytokines, including several that are integral to lymphocyte activation, function, and proliferation. Although the importance of the JAK family in the pathogenesis of ulcerative colitis is unclear, tofacitinib has shown efficacy against other immune-mediated conditions, including organ allograft rejection, rheumatoid arthritis, and psoriasis.

The 8-week trial was conducted at 51 centers in 17 countries from January 2009 through September 2010 with funding from Pfizer. Subjects had to be at least 18 years of age, with a confirmed diagnosis of ulcerative colitis of 3 months’ duration or longer, a score of 6-12 on the Mayo risk calculator for ulcerative colitis,and evidence on sigmoidoscopic examination of moderately or severely active disease. In most of the patients, the use of conventional therapy (mesalamine, glucocorticoids, immunosuppressants, or anti-TNF agents used as monotherapy or in some combination) had failed, according to the investigators.

During the study, patients could receive oral mesalamine or oral prednisone at a stable dosage of 30 mg or less per day. However, patients receiving azathioprine, 6-mercaptopurine, and methotrexate discontinued them immediately before initiating therapy with tofacitinib, and patients who had previously received anti-TNF therapy were required to discontinue it for at least 8 weeks before study entry.

Patients were randomly assigned to receive twice-daily oral tofacitinib doses of 0.5 mg, 3 mg, 10 mg, or 15 mg or placebo for 8 weeks, and were then followed for 4 weeks through 12 weeks. Of the 195 patients randomized, 194 received at least one dose of the study drug or placebo and 157 completed the full 8 weeks of treatment. Across all treatment groups, 131 patients (67.5%) received concomitant aminosalicylates, and 85 (43.8%) received concomitant glucocorticoids at some point during the study, they noted.

Clinical response was defined as a decrease from baseline in the total Mayo score (defined as an absolute decrease by at least 3 points and a relative decrease by at least 30%) with an accompanying decrease in the rectal bleeding subscore of at least 1 point or an absolute rectal bleeding subscore of 0 or 1.

The primary end point, clinical response at 8 weeks, occurred in 42% (20) of the patients who received placebo. The response was significantly greater than that seen only among the patients who received the highest doses of tofacitinib, 78% of those receiving 15 mg (P less than .001). For the lower doses, the clinical response rates were not significantly different from those with placebo (61%, 48% and 32%, respectively, for 10 mg, 3 mg and 0.5 mg).

Clinical remission, a secondary end point, was defined as a total Mayo score of 0-2, with no individual subscore exceeding 1. Clinical remission at 8 weeks occurred in 10% (5) of the placebo patients. Here, the difference from placebo with tofacitinib was significant for doses of 3 mg (33%; P = .01), 10 mg (48%; P less than .001), and 15 mg (41%; P less than .001).

Another secondary end point, endoscopic response, was defined as a decrease from baseline in the endoscopy subscore by at least 1.The secondary end point of endoscopic remission was defined as an endoscopy subscore of 0.

An endoscopic response at 8 weeks occurred in 46% with placebo, significantly lower than the responses with tofacitinib doses of 10 mg (67%; P = .07) and 15mg (78%; P = .001). Endoscopic remission at 8 weeks occurred in just 2% of the placebo group, vs. significantly greater proportions of 18% with 3 mg (P = .01), 30% with 10 mg (P less than .001), and 27% with 15 mg (P less than .001).

Rates of overall and serious adverse events, as well as adverse events from infection, were similar among the groups. Two patients receiving 10 mg of tofacitinib twice daily had serious adverse events from infection (a postoperative abscess in one and anal abscess in the other). There was a dose-dependent increase in both LDL and HDL cholesterol concentrations at 8 weeks with tofacitinib, which reversed after discontinuation of the study drug . During the study period, the absolute neutrophil count was less than 1,500 cells per cubic millimeter in three patients receiving tofacitinib, but was not less than 1,000 cells per cubic millimeter in any patient, Dr. Sandborn and his associates reported.

In previous studies of patients with rheumatoid arthritis, tofacitinib has been associated with increases in LDL cholesterol and serum creatinine, and decreases in absolute neutrophil count, whereas increased infection risk has been seen with the 15-mg, twice-daily dose. The small size and short duration of the current trial did not allow for a comprehensive assessment of the safety and tolerability of the drug in patients with ulcerative colitis, they noted.

This study was funded by Pfizer, from whom Dr. Sandborn has received grants and consulting fees. He has also served as a consultant and has additional ties to numerous other companies.

Tofacitinib was associated with greater clinical response and remission rates than was placebo in a double-blind, phase II trial of patients with moderately or severely active ulcerative colitis.

Current treatment of ulcerative colitis with mesalamine, glucocorticoids, azathioprine, and anti–tumor necrosis factor (anti-TNF) agents such as infliximab and adalimumab is not always effective, and may be associated with serious toxic effects (Gastroenterology 2006;130:940-87). Thus, "additional treatments are needed," said Dr. William J. Sandborn, chief of the division of gastroenterology and professor of medicine at the University of California, San Diego and his associates (N. Engl. J. Med. 2012;367:616-24).

Tofacitinib is a selective oral inhibitor of the Janus kinase (JAK) family of enzymes that includes JAK1 and JAK3, which mediate signal-transduction activity for multiple cytokines, including several that are integral to lymphocyte activation, function, and proliferation. Although the importance of the JAK family in the pathogenesis of ulcerative colitis is unclear, tofacitinib has shown efficacy against other immune-mediated conditions, including organ allograft rejection, rheumatoid arthritis, and psoriasis.

The 8-week trial was conducted at 51 centers in 17 countries from January 2009 through September 2010 with funding from Pfizer. Subjects had to be at least 18 years of age, with a confirmed diagnosis of ulcerative colitis of 3 months’ duration or longer, a score of 6-12 on the Mayo risk calculator for ulcerative colitis,and evidence on sigmoidoscopic examination of moderately or severely active disease. In most of the patients, the use of conventional therapy (mesalamine, glucocorticoids, immunosuppressants, or anti-TNF agents used as monotherapy or in some combination) had failed, according to the investigators.

During the study, patients could receive oral mesalamine or oral prednisone at a stable dosage of 30 mg or less per day. However, patients receiving azathioprine, 6-mercaptopurine, and methotrexate discontinued them immediately before initiating therapy with tofacitinib, and patients who had previously received anti-TNF therapy were required to discontinue it for at least 8 weeks before study entry.

Patients were randomly assigned to receive twice-daily oral tofacitinib doses of 0.5 mg, 3 mg, 10 mg, or 15 mg or placebo for 8 weeks, and were then followed for 4 weeks through 12 weeks. Of the 195 patients randomized, 194 received at least one dose of the study drug or placebo and 157 completed the full 8 weeks of treatment. Across all treatment groups, 131 patients (67.5%) received concomitant aminosalicylates, and 85 (43.8%) received concomitant glucocorticoids at some point during the study, they noted.

Clinical response was defined as a decrease from baseline in the total Mayo score (defined as an absolute decrease by at least 3 points and a relative decrease by at least 30%) with an accompanying decrease in the rectal bleeding subscore of at least 1 point or an absolute rectal bleeding subscore of 0 or 1.

The primary end point, clinical response at 8 weeks, occurred in 42% (20) of the patients who received placebo. The response was significantly greater than that seen only among the patients who received the highest doses of tofacitinib, 78% of those receiving 15 mg (P less than .001). For the lower doses, the clinical response rates were not significantly different from those with placebo (61%, 48% and 32%, respectively, for 10 mg, 3 mg and 0.5 mg).

Clinical remission, a secondary end point, was defined as a total Mayo score of 0-2, with no individual subscore exceeding 1. Clinical remission at 8 weeks occurred in 10% (5) of the placebo patients. Here, the difference from placebo with tofacitinib was significant for doses of 3 mg (33%; P = .01), 10 mg (48%; P less than .001), and 15 mg (41%; P less than .001).

Another secondary end point, endoscopic response, was defined as a decrease from baseline in the endoscopy subscore by at least 1.The secondary end point of endoscopic remission was defined as an endoscopy subscore of 0.

An endoscopic response at 8 weeks occurred in 46% with placebo, significantly lower than the responses with tofacitinib doses of 10 mg (67%; P = .07) and 15mg (78%; P = .001). Endoscopic remission at 8 weeks occurred in just 2% of the placebo group, vs. significantly greater proportions of 18% with 3 mg (P = .01), 30% with 10 mg (P less than .001), and 27% with 15 mg (P less than .001).

Rates of overall and serious adverse events, as well as adverse events from infection, were similar among the groups. Two patients receiving 10 mg of tofacitinib twice daily had serious adverse events from infection (a postoperative abscess in one and anal abscess in the other). There was a dose-dependent increase in both LDL and HDL cholesterol concentrations at 8 weeks with tofacitinib, which reversed after discontinuation of the study drug . During the study period, the absolute neutrophil count was less than 1,500 cells per cubic millimeter in three patients receiving tofacitinib, but was not less than 1,000 cells per cubic millimeter in any patient, Dr. Sandborn and his associates reported.

In previous studies of patients with rheumatoid arthritis, tofacitinib has been associated with increases in LDL cholesterol and serum creatinine, and decreases in absolute neutrophil count, whereas increased infection risk has been seen with the 15-mg, twice-daily dose. The small size and short duration of the current trial did not allow for a comprehensive assessment of the safety and tolerability of the drug in patients with ulcerative colitis, they noted.

This study was funded by Pfizer, from whom Dr. Sandborn has received grants and consulting fees. He has also served as a consultant and has additional ties to numerous other companies.

The Food and Drug Administration issued a warning on Aug. 15 about the risk of death in children who receive codeine for postoperative pain, particularly after tonsillectomy and/or adenoidectomy, based on three deaths and a nonfatal case of life-threatening respiratory depression.

The three children who died had evidence of being ultrarapid metabolizers of codeine, and the fourth case was in a child with evidence of being an "extensive" metabolizer, the FDA said in a statement announcing the warning. All four children, aged 2-5 years, underwent a tonsillectomy and/or adenoidectomy for treating obstructive sleep apnea syndrome, and received codeine within the typical dose range.

"The FDA is currently conducting a review of adverse event reports and other information to determine if there are additional cases of inadvertent overdose or death in children taking codeine, and if these adverse events occur during treatment of other kinds of pain, such as postoperative pain following other types of surgery or procedures," Dr. Bob Rappaport, director of the Division of Anesthesia, Analgesia, and Addiction Products in the FDA’s Center for Drug Evaluation and Research, said in the statement.

For now, the FDA is advising health care professionals and parents to be aware of the risks of codeine in children, "particularly in those who have undergone tonsillectomy and/or adenoidectomy for obstructive sleep apnea syndrome," and – when they prescribe medications that contain codeine to children – to use "the lowest effective dose for the shortest time on an as-needed basis." Parents and caregivers should stop codeine and get immediate medical attention if a child who has been receiving codeine after surgery has any symptoms of an overdose.

CYP2D6 (cytochrome P450 2D6) metabolizes codeine to morphine. Ultrametabolizers of codeine have a genetic variation in this enzyme and are more likely to have abnormally high levels of morphine after taking codeine, and therefore are at greater risk of related adverse events and death.

The four children started to show signs of morphine toxicity within 1-2 days of starting the codeine, and in the three children who died, postmortem morphine levels were "substantially higher" than the normal therapeutic range, according to the FDA. The four cases were also described in Pediatrics (2012;129:e1343-7).

An estimated 1%-7% of the general population are ultrarapid metabolizers, but the rate is much higher in certain ethnic groups, with the highest prevalence (29%) reported for people of Ethiopian descent. The reported prevalence is 6% in the Greek population, 3.4%-6.5% among the African American population, 3.6% in whites, and 1%-2% in northern Europeans.

When the FDA review is completed, the agency plans to provide an update.

The risk of morphine overdose in nursing infants whose mothers are taking codeine and who are ultrarapid metabolizers was recognized several years ago. In 2007, a year after the first case report was described in the Lancet (2006;368:704), the FDA issued a warning about this risk.

The FDA has also posted a consumer update on its website.

The full alert is available, and possible cases should be reported to the FDA’s MedWatch program at 800-332-1088 or www.fda.gov/medwatch.

The Food and Drug Administration issued a warning on Aug. 15 about the risk of death in children who receive codeine for postoperative pain, particularly after tonsillectomy and/or adenoidectomy, based on three deaths and a nonfatal case of life-threatening respiratory depression.

The three children who died had evidence of being ultrarapid metabolizers of codeine, and the fourth case was in a child with evidence of being an "extensive" metabolizer, the FDA said in a statement announcing the warning. All four children, aged 2-5 years, underwent a tonsillectomy and/or adenoidectomy for treating obstructive sleep apnea syndrome, and received codeine within the typical dose range.

"The FDA is currently conducting a review of adverse event reports and other information to determine if there are additional cases of inadvertent overdose or death in children taking codeine, and if these adverse events occur during treatment of other kinds of pain, such as postoperative pain following other types of surgery or procedures," Dr. Bob Rappaport, director of the Division of Anesthesia, Analgesia, and Addiction Products in the FDA’s Center for Drug Evaluation and Research, said in the statement.

For now, the FDA is advising health care professionals and parents to be aware of the risks of codeine in children, "particularly in those who have undergone tonsillectomy and/or adenoidectomy for obstructive sleep apnea syndrome," and – when they prescribe medications that contain codeine to children – to use "the lowest effective dose for the shortest time on an as-needed basis." Parents and caregivers should stop codeine and get immediate medical attention if a child who has been receiving codeine after surgery has any symptoms of an overdose.

CYP2D6 (cytochrome P450 2D6) metabolizes codeine to morphine. Ultrametabolizers of codeine have a genetic variation in this enzyme and are more likely to have abnormally high levels of morphine after taking codeine, and therefore are at greater risk of related adverse events and death.

The four children started to show signs of morphine toxicity within 1-2 days of starting the codeine, and in the three children who died, postmortem morphine levels were "substantially higher" than the normal therapeutic range, according to the FDA. The four cases were also described in Pediatrics (2012;129:e1343-7).

An estimated 1%-7% of the general population are ultrarapid metabolizers, but the rate is much higher in certain ethnic groups, with the highest prevalence (29%) reported for people of Ethiopian descent. The reported prevalence is 6% in the Greek population, 3.4%-6.5% among the African American population, 3.6% in whites, and 1%-2% in northern Europeans.

When the FDA review is completed, the agency plans to provide an update.

The risk of morphine overdose in nursing infants whose mothers are taking codeine and who are ultrarapid metabolizers was recognized several years ago. In 2007, a year after the first case report was described in the Lancet (2006;368:704), the FDA issued a warning about this risk.

The FDA has also posted a consumer update on its website.

The full alert is available, and possible cases should be reported to the FDA’s MedWatch program at 800-332-1088 or www.fda.gov/medwatch.

The Food and Drug Administration issued a warning on Aug. 15 about the risk of death in children who receive codeine for postoperative pain, particularly after tonsillectomy and/or adenoidectomy, based on three deaths and a nonfatal case of life-threatening respiratory depression.

The three children who died had evidence of being ultrarapid metabolizers of codeine, and the fourth case was in a child with evidence of being an "extensive" metabolizer, the FDA said in a statement announcing the warning. All four children, aged 2-5 years, underwent a tonsillectomy and/or adenoidectomy for treating obstructive sleep apnea syndrome, and received codeine within the typical dose range.

"The FDA is currently conducting a review of adverse event reports and other information to determine if there are additional cases of inadvertent overdose or death in children taking codeine, and if these adverse events occur during treatment of other kinds of pain, such as postoperative pain following other types of surgery or procedures," Dr. Bob Rappaport, director of the Division of Anesthesia, Analgesia, and Addiction Products in the FDA’s Center for Drug Evaluation and Research, said in the statement.

For now, the FDA is advising health care professionals and parents to be aware of the risks of codeine in children, "particularly in those who have undergone tonsillectomy and/or adenoidectomy for obstructive sleep apnea syndrome," and – when they prescribe medications that contain codeine to children – to use "the lowest effective dose for the shortest time on an as-needed basis." Parents and caregivers should stop codeine and get immediate medical attention if a child who has been receiving codeine after surgery has any symptoms of an overdose.

CYP2D6 (cytochrome P450 2D6) metabolizes codeine to morphine. Ultrametabolizers of codeine have a genetic variation in this enzyme and are more likely to have abnormally high levels of morphine after taking codeine, and therefore are at greater risk of related adverse events and death.

The four children started to show signs of morphine toxicity within 1-2 days of starting the codeine, and in the three children who died, postmortem morphine levels were "substantially higher" than the normal therapeutic range, according to the FDA. The four cases were also described in Pediatrics (2012;129:e1343-7).

An estimated 1%-7% of the general population are ultrarapid metabolizers, but the rate is much higher in certain ethnic groups, with the highest prevalence (29%) reported for people of Ethiopian descent. The reported prevalence is 6% in the Greek population, 3.4%-6.5% among the African American population, 3.6% in whites, and 1%-2% in northern Europeans.

When the FDA review is completed, the agency plans to provide an update.

The risk of morphine overdose in nursing infants whose mothers are taking codeine and who are ultrarapid metabolizers was recognized several years ago. In 2007, a year after the first case report was described in the Lancet (2006;368:704), the FDA issued a warning about this risk.

The FDA has also posted a consumer update on its website.

The full alert is available, and possible cases should be reported to the FDA’s MedWatch program at 800-332-1088 or www.fda.gov/medwatch.

Medical Education Library

A Best Practices Supplement to Skin & Allergy News^®. This supplement was sponsored by Valeant Dermatology.

• Introduction
• CL/BPO 2.5%
• CL/BPO 2.5% In Clinical Practice
• Conclusion

Faculty/Faculty Disclosure

Julie Harper, MD

Physician/Speaker

The Dermatology and Skin Care Center of Birmingham, PC

Birmingham, AL

Dr Harper received an honorarium for writing this article.

Copyright © 2012 Elsevier Inc.

Medical Education Library

A Best Practices Supplement to Skin & Allergy News^®. This supplement was sponsored by Valeant Dermatology.

• Introduction
• CL/BPO 2.5%
• CL/BPO 2.5% In Clinical Practice
• Conclusion

Faculty/Faculty Disclosure

Julie Harper, MD

Physician/Speaker

The Dermatology and Skin Care Center of Birmingham, PC

Birmingham, AL

Dr Harper received an honorarium for writing this article.

Copyright © 2012 Elsevier Inc.

Medical Education Library

A Best Practices Supplement to Skin & Allergy News^®. This supplement was sponsored by Valeant Dermatology.

• Introduction
• CL/BPO 2.5%
• CL/BPO 2.5% In Clinical Practice
• Conclusion

Faculty/Faculty Disclosure

Julie Harper, MD

Physician/Speaker

The Dermatology and Skin Care Center of Birmingham, PC

Birmingham, AL

Dr Harper received an honorarium for writing this article.

Copyright © 2012 Elsevier Inc.