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Letters: Reframing Clinician Distress: Moral Injury Not Burnout
To the Editor: In the September 2019 guest editorial “Reframing Clinician Distress: Moral Injury Not Burnout,” the authors have advanced a thoughtful and provocative hypothesis addressing a salient issue.1 Their argument is that burnout does not accurately capture physician distress. Furthermore, they posit the term burnout focuses remediation strategies at the individual provider level, thereby discounting the contribution of the larger health care system. This is not the first effort to argue that burnout is not a syndrome of mental illness (eg, depression) located within the person but rather a disrupted physician-work relationship.2
As the authors cite, population and practice changes have contributed significantly to physician distress and dissatisfaction. Indeed, recent findings indicate that female physicians may suffer increased prevalence of burnout, which represents a challenge given the growing numbers of women in medicine.3 Unfortunately, by shifting focus almost exclusively to the system level to address burnout, the authors discount a large body of literature examining associations and contributors at the individual and clinic level.
Burnout is conceptualized as consisting of 3 domains: depersonalization, emotional exhaustion, and personal accomplishment.4 While this conceptualization may not capture the totality of physician distress, it has provided a body of literature focused on decreasing symptoms of burnout. Successful interventions have been targeted at the individual provider level (ie, stress management, small group discussion, mindfulness) as well as the organizational level (ie, reduction in duty hours, scribes).5,6 Recent studies have also suggested that increasing the occurrence of social encounters that are civil and respectful decreases reported physician burnout.7
Frustration, the annoyance or anger at being unable to change or achieve something, also can be a leading cause of burnout and moral injury. The inability to deal with unresolvable issues due to a lack of skills or inability to create a positive reframe can lead to a constellation of symptoms that are detrimental to the individual provider. Nevertheless, system rigidity, inability to recognitize pain and pressure, and goals perceived as unachievable can also lead to frustration. Physicians may experience growing frustration if they are unable to influence their systems. Thus, experiencing personal frustration, combined with an inability or lack of energy or time to influence a system can snowball.
Just as we counsel our patients that good medical care involves not only engagement with the medical system, but also individual engagement in their care (eg, nutrition, exercise), this problem requires a multicomponent solution. While advocating and working for a system that induces less moral injury, frustration, and burnout, physicians need to examine the resources available to them and their colleagues in a more immediate way.
Physician distress is a serious problem with both personal, patient, occupational, and public health costs. Thus, it is important that we grapple with the complexity of a multiconstruct definition amenable to multilevel interventions. The concept of moral injury is an important component and opens additional lines of both clinical inquiry and intervention. However, in our view, to subsume all burnout under this construct is overly reductive.
In closing, this topic is too important not to discuss. Let the conversations continue!
Lynne Padgett, PhD; and Joao L. Ascensao, MD, PhD
Author affiliations: Departments of Medicine and Mental Health, Washington DC VA Medical Center and Department of Medicine, George Washington University School of Medicine
Correspondence: Lynne Padgett ([email protected])
Disclosures: The authors report no conflict of interest with regard to this article.
References
1. Dean W, Talbot S, Dean A. Reframing clinical distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.
2. Epstein RM, Privitera MR. Doing something about physician burnout. Lancet. 2016;388(10057):2216-2217.
3. Templeton K, Bernstein CA, Sukhera J, et al. Gender-based differences in burnout: issues faced by women physicians. NAM Perspectives. Discussion Paper. Washington, DC: National Academy of Medicine; 2019. https://nam.edu/wp-content/uploads/2019/05/Gender-Based-Differences-in-Burnout.pdf. Published May 28, 2019. Accessed October 10, 2019.
4. Eckleberry-Hunt J Kirkpatrick H, Barbera T. The problems with burnout research. Acad Med. 2018;93(3):367-370.
5. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281.
6. Squiers JJ, Lobdell KW, Fann JI, DiMaio JM. Physician burnout: are we treating the symptom instead of the disease? Ann Thorac Surg. 2017;104(4):1117-1122.
7. Maslach C, Leiter MP. New insights into burnout and health care: strategies for improving civility and alleviating burnout. Med Teach. 2017;39(2):160-163.
To the Editor: We applaud Dean and her colleagues for their thought-provoking commentary on clinicians’ distress, a problem that has surged in recent years and has now reached epidemic proportions.1 Their argument focuses on the language used to define and frame clinical distress. Do we label this distress as burnout, as moral injury, or as something else? Moral injury occurs any time clinicians are impeded from doing the right thing at the right time in the right way; or even worse, doing the wrong thing to serve the needs of health system stakeholders other than the patient. These other stakeholders may include administrators, corporations, insurance adjusters, and others.
Naming the problem correctly is crucial to finding the solution. The name frames the discussion and impacts the solution. Burnout implies difficulty coping with the many stresses of health care and of personal responsibility for the problem. The solution would therefore be to help individuals to cope with their stresses. Moral injury on the other hand implies a corrupt system; thereby, reframing the discussion to systems issues and suggesting solutions by changing the business of health care delivery.
These authors state that current clinical distress is due to moral injury and not to burnout. Therefore, the business in which health care is performed needs to change.
The authors define the drivers of moral injury in our current system, mostly as (1) a massive information technology overload that has largely overtaken the patient as center of attention; and (2) the profit motive of the health care corporation and its shareholders. A focus on making profits has increased in the wake of falling reimbursements; the result is pressure on clinicians to see more patients more quickly and to do more even when not necessary. This has diverted the focus on healing patients to a focus on making profits. These major drivers of clinician distress—the electronic health record and the pressure to bill more—are fundamentally driven by the corporatization of American medicine in which profit is the measured outcome.
Thus rather than having their highest loyalty to patients and their families, clinicians now have other loyalties—the electronic health record, insurers, the hospital, the health care system, and even their own salaries.
Therein lies the moral injury felt by increasing numbers of clinicians, leading to soaring rates of clinical distress. Many physicians are now recognizing moral injury as the basis of their pain. For example, Gawande has described unceasing computer data entry as a cause of physician distress and physician loneliness in the interesting essay, “Why Doctors Hate Their Computers.”2 Topol has suggested that corporate interference and attention away from patient care is a reason doctors should unite and organize for a more healthful environment.3 Ofri has gone so far as to suggest that the health care system is surviving because it can exploit its physicians for every drop of energy, diverting the focus of clinical encounters on billing rather than healing.4 However, it may be simplistic to imply or state that all clinical distress is related to moral injury. Other factors in caring for the sick and dying also can cause distress to health care providers. Physicians work long, hard hours and listen to many stories of distress and suffering from patients. Some of this is internalized and processed as one’s own suffering. Clinicians also have enormous amounts of information to absorb and assimilate, keep long hours, and are often sleep deprived, all of which may harm their well-being. In addition, clinicians may have work/life imbalances, be hesitant to reveal their weaknesses, and have perfectionist personalities. Still other factors may also be involved, such as a hostile environment in which managers can overuse their power; racism that can limit opportunities for advancement; and/or a family-unfriendly environment.
Just as the treatment of cancer depends on good surgery, radiation and/or chemotherapy as well as reducing underlying predisposing cause (ie, smoking, drinking, obesity, antiviral therapy) and leading a healthy lifestyle, so too treatment of clinical distress needs a multipronged approach. Fixing the business framework is an important step forward but may not always be enough. We agree with the authors’ suggestions for improvement: bringing administrators and clinicians into conversation with each other, making clinician satisfaction a financial priority, assuring that physician leaders have cell phone numbers of their legislators, and reestablishing a sense of community among clinicians. However, none of these goals will be easy to accomplish and some may be impossible to realize in some settings.
A necessary corollary to the suggestions by Dean and colleagues is research. Much research is needed to discover all of the factors of clinician distress, whatever we name the problem. We need to know vulnerabilities of different populations of clinicians and differences in prevalence in different types of health care systems.
It is likely that physicians in a government-owned health care system, such as the US Department of Veterans Affairs (VA) hospitals, have lower distress since there are no corporate interests or profit motives. In our experience, we have noted that many VA providers are expatriates of private health care systems due to their moral distress. If profit making and corporatization are important factors in distress, then clinicians in the VA system should have much lower distress; however, this is not known.
We also need research in pilot projects that relieve clinician distress. These could relate to collegial activities to bring physicians—and administrators—together in community, allowing more time with patients than the usual 15-minute allotments, allowing more time for creative, narrative experiences in medicine, developing forums for discussion and resolution of distress-inducing situations, etc.
An important yet overlooked issue in this discussion is that clinician distress, regardless of its name or cause, is a public health crisis. Clinician distress not only affects the clinician most directly and most crucially, but also affects every person in his/her community. Physicians who are distressed for whatever reason deliver less adequate care, make more medical errors, and are less invested in their patients. Patients of distressed clinicians have less favorable outcomes and suffer more. Medical errors are now the third leading cause of death in the US. Much of this is due to inadequate care by focusing attention on profit-making over health improvement and to clinician distress. Clinician distress due to moral injury or any other factor is a public health crisis and needs much more attention, research, and prioritization of clinician satisfaction.
Paulette Mehta, MD, MPH; and Jay Mehta, PhD
Author Affiliations: Central Arkansas Veterans Health Care System; University of Arkansas for Medical Sciences
Correspondence: Paulette Mehta ([email protected])
Disclosures: The authors report no conflict of interest with regard to this article.
References
1. Dean W, Talbot S, Dean A. Reframing clinical distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.
2. Gawande A. Why doctors hate their computers. New Yorker. November 12, 2018. https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers. Accessed October 16, 2019.
3. Topol E. Why doctors should organize. New Yorker. August 5, 2019. https://www.newyorker.com/culture/annals-of-inquiry/why-doctors-should-organize. Accessed October 16, 2019.
4. Ofri D. The business of healthcare depends on exploiting doctors and nurses. The New York Times. June 8, 2019. https://www.nytimes.com/2019/06/08/opinion/sunday/hospitals-doctors-nurses-burnout.html. Accessed October 16, 2019.
To the Editor: The September 2019 editorial “Reframing clinician distress: moral injury not burnout” argues for a renaming of what has been called burnout to moral injury.1 The article by Dean, Talbot, and Dean compares the experience of health care providers to soldiers and other service members who have served in combat and suffer as a result of their experiences. I would like to comment on 2 areas: Whether the term burnout should be replaced with moral injury; and the adequacy of the recommendations made by Dean, Talbot, and Dean.
Briefly, my own credentials to opine on the topic include being both a physician and a soldier. I served in the US Army as a psychiatrist from 1986 to 2010 and deployed to various hazardous locations, including South Korea, Somalia, Iraq, and Guantanamo Bay, Cuba. Since my retirement from the Army I have worked as a psychiatrist on different front lines, with both veterans and the chronically mentally ill and often homeless population.
Moral injury is a term that was popularized by Johnathan Shay after the Vietnam War, especially in his masterful book Achilles in Vietnam.1 Most authors who have written on the subject of moral injury, including myself, think of it as feelings of guilt and shame related to (1) killing civilians (especially children or innocents); (2) surviving while other comrades did not; and/or (3) feeling betrayed by the government they served.2,3
While also arising in combat settings, moral injury is related but separate from posttraumatic stress disorder (PTSD). It comes from an affront to our morals rather than our physical well-being. It is not considered a medical diagnosis, treatments are experimental, and the literature is anecdotal.
I have mixed feelings about equating the moral injury from combat to working as a physician or other health care provider. On the one hand, certainly health care providers may sacrifice health and safety to taking care of patients. They may feel guilty when they cannot do enough for their patients. But does it rise to the same level as actually combat and having numerous comrades killed or maimed?
On the other hand, working on an inpatient psychiatry ward with an inner-city population who generally have severe mental illness and are often on phencyclidine and related drugs, has its own share of risks. Unfortunately, physical attacks on staff are way too common.
The term burnout also has a robust background of research into both causes and possible solutions. Indeed, there was even a journal devoted to it: Burnout Research.4 Moral injury research is on different populations, and generally the remedies are focused more on spiritual and existential support.
Which brings me to the recommendations and solutions part of the editorial. I agree that yoga and meditation, while beneficial, do not curb the feelings of frustration and betrayal that often arise when you cannot treat patients the way you feel they deserve. The recommendations listed in the editorial are a start, but much more should be done.
Now comes the hard part. Specifically, what more should be done? All the easy solutions have already been tried. Ones that would really make a difference, such as making an electronic health record that allows you to still look at and connect to the patient, seem to elude us. Many of us in the health care industry would love to have a single payer system across the board, to avoid all the inequities cited in the article. But health care, like climate change, is mired in our political deadlocks.
Therefore, I will finish by focusing on one of their recommendations, which is achievable: tie the incentives for the executive leadership to the satisfaction of health care providers, as is done for patient satisfaction. That is both doable and will benefit various institutions in the long run. Health care providers will be more likely to stay in a health care system and thus patient satisfaction improves. Win-win.
COL (Ret) Elspeth Cameron Ritchie, MD, MPH, USA
Author Affiliation: Uniformed Services University of the Health Sciences
Correspondence: Elspeth Cameron Ritchie ([email protected])
Disclosures: The author reports no conflict of interest with regard to this article.
References
1. Shay J. Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York: Atheneum; 1994.
2. Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin. Psychol Rev. 2009;29(8):695-706.
3. Ritchie EC. Moral injury: a profound sense of alienation and abject shame. Time. April 17, 2013. http://nation.time.com/2013/04/17/moral-injury-a-profound-sense-of-alienation-and-abject-shame.
4. Burnout Research. 2014;1(1):1-56. https://www.sciencedirect.com/journal/burnout-research/vol/1/issue/1. Accessed October 17, 2019.
Response: We appreciate the very thoughtful and thorough responses of Mehta. Mehta, Padgett, Ascensao, and Ritchie. Common themes in the responses were the suggestion that supplanting the term burnout with moral injury may not be appropriate and that changing the underlying drivers of distress requires a multifaceted approach, which is likely to require prolonged effort. We agree with both of these themes, believing the concept of moral injury and mitigation strategies do not benefit from reductionism.
Burnout is a nonspecific symptom constellation of emotional exhaustion, depersonalization, and a lack of a sense of accomplishment.1 Because it is nonspecific, the symptoms can arise from any number of situations, not only moral injury. However, from our conversations over the past 15 months, moral injury fuels a large percentage of burnout in health care. In a recent informal survey conducted at the ORExcellence meeting, almost all respondents believed they were experiencing moral injury rather than burnout when both terms were explained. When clinicians are physically and emotionally exhausted with battling a broken system in their efforts to provide good care—when they have incurred innumerable moral insults, amassing to a moral injury—many give up. This is the end stage of moral injury, or burnout.We absolutely agree research is necessary to validate this concept, which has been applied only to health care since July 2018. We are pursuing various avenues of inquiry and are validating a new assessment tool. But we do not believe that intervention must wait until there are data to support what resonates so profoundly with so many and, as we have heard dozens of times, “finally gives language to my experience.”Finally, we would not suggest that civilian physician experience is equivalent to combat experience. But just as there are multiple etiologies for posttraumatic stress disorder (PTSD), such as combat exposure, physical abuse, sexual assault, there are likely multiple ways one can incur moral injury. Witnessing or participating in a situation that transgresses deeply held moral beliefs is the prerequisite for moral injury rather than physical danger. In different contexts, physicians and service members may ultimately face similar accumulated risk to their moral integrity, though of widely disparate intensity, frequency, and duration. Physicians face low-intensity, high-frequency threats over years; service members more often face high-intensity, less frequent threats during time-limited deployments. Just because moral injury was first applied to combat veterans—as was PTSD—does not mean we should limit the use of a powerfully resonant concept to a military population any more than we limited the use of Letterman’s ambulances or Morel’s tourniquets to the battlefield.2,3
Wendy Dean, MD; and Simon Talbot, MD
Author affiliations: Wendy Dean is President and co-founder of Moral Injury of Healthcare. Simon Talbot is a reconstructive plastic surgeon at Brigham and Women’s Hospital and associate professor of surgery at Harvard Medical School, Boston, Massachusetts.
Correspondence: Wendy Dean (wdean@moralinjury. Healthcare,@WDeanMD)
Disclosures: Wendy Dean and Simon Talbot founded Moral Injury of Healthcare, a nonprofit organization; they report no other actual or potential conflicts of interest with regard to this article.
References
1. Freudenberger HJ. The staff burn-out syndrome in alternative institutions. Psychother Theory Res Pract. 1975;12(1):73-82.
2. Place RJ. The strategic genius of Jonathan Letterman: the relevancy of the American Civil War to current health care policy makers. Mil Med. 2015;180(3):259-262.
3. Welling DR, McKay PL, Rasmussen TE, Rich NM. A brief history of the tourniquet. J Vasc Surg. 2012;55(1):286-290.
To the Editor: In the September 2019 guest editorial “Reframing Clinician Distress: Moral Injury Not Burnout,” the authors have advanced a thoughtful and provocative hypothesis addressing a salient issue.1 Their argument is that burnout does not accurately capture physician distress. Furthermore, they posit the term burnout focuses remediation strategies at the individual provider level, thereby discounting the contribution of the larger health care system. This is not the first effort to argue that burnout is not a syndrome of mental illness (eg, depression) located within the person but rather a disrupted physician-work relationship.2
As the authors cite, population and practice changes have contributed significantly to physician distress and dissatisfaction. Indeed, recent findings indicate that female physicians may suffer increased prevalence of burnout, which represents a challenge given the growing numbers of women in medicine.3 Unfortunately, by shifting focus almost exclusively to the system level to address burnout, the authors discount a large body of literature examining associations and contributors at the individual and clinic level.
Burnout is conceptualized as consisting of 3 domains: depersonalization, emotional exhaustion, and personal accomplishment.4 While this conceptualization may not capture the totality of physician distress, it has provided a body of literature focused on decreasing symptoms of burnout. Successful interventions have been targeted at the individual provider level (ie, stress management, small group discussion, mindfulness) as well as the organizational level (ie, reduction in duty hours, scribes).5,6 Recent studies have also suggested that increasing the occurrence of social encounters that are civil and respectful decreases reported physician burnout.7
Frustration, the annoyance or anger at being unable to change or achieve something, also can be a leading cause of burnout and moral injury. The inability to deal with unresolvable issues due to a lack of skills or inability to create a positive reframe can lead to a constellation of symptoms that are detrimental to the individual provider. Nevertheless, system rigidity, inability to recognitize pain and pressure, and goals perceived as unachievable can also lead to frustration. Physicians may experience growing frustration if they are unable to influence their systems. Thus, experiencing personal frustration, combined with an inability or lack of energy or time to influence a system can snowball.
Just as we counsel our patients that good medical care involves not only engagement with the medical system, but also individual engagement in their care (eg, nutrition, exercise), this problem requires a multicomponent solution. While advocating and working for a system that induces less moral injury, frustration, and burnout, physicians need to examine the resources available to them and their colleagues in a more immediate way.
Physician distress is a serious problem with both personal, patient, occupational, and public health costs. Thus, it is important that we grapple with the complexity of a multiconstruct definition amenable to multilevel interventions. The concept of moral injury is an important component and opens additional lines of both clinical inquiry and intervention. However, in our view, to subsume all burnout under this construct is overly reductive.
In closing, this topic is too important not to discuss. Let the conversations continue!
Lynne Padgett, PhD; and Joao L. Ascensao, MD, PhD
Author affiliations: Departments of Medicine and Mental Health, Washington DC VA Medical Center and Department of Medicine, George Washington University School of Medicine
Correspondence: Lynne Padgett ([email protected])
Disclosures: The authors report no conflict of interest with regard to this article.
References
1. Dean W, Talbot S, Dean A. Reframing clinical distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.
2. Epstein RM, Privitera MR. Doing something about physician burnout. Lancet. 2016;388(10057):2216-2217.
3. Templeton K, Bernstein CA, Sukhera J, et al. Gender-based differences in burnout: issues faced by women physicians. NAM Perspectives. Discussion Paper. Washington, DC: National Academy of Medicine; 2019. https://nam.edu/wp-content/uploads/2019/05/Gender-Based-Differences-in-Burnout.pdf. Published May 28, 2019. Accessed October 10, 2019.
4. Eckleberry-Hunt J Kirkpatrick H, Barbera T. The problems with burnout research. Acad Med. 2018;93(3):367-370.
5. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281.
6. Squiers JJ, Lobdell KW, Fann JI, DiMaio JM. Physician burnout: are we treating the symptom instead of the disease? Ann Thorac Surg. 2017;104(4):1117-1122.
7. Maslach C, Leiter MP. New insights into burnout and health care: strategies for improving civility and alleviating burnout. Med Teach. 2017;39(2):160-163.
To the Editor: We applaud Dean and her colleagues for their thought-provoking commentary on clinicians’ distress, a problem that has surged in recent years and has now reached epidemic proportions.1 Their argument focuses on the language used to define and frame clinical distress. Do we label this distress as burnout, as moral injury, or as something else? Moral injury occurs any time clinicians are impeded from doing the right thing at the right time in the right way; or even worse, doing the wrong thing to serve the needs of health system stakeholders other than the patient. These other stakeholders may include administrators, corporations, insurance adjusters, and others.
Naming the problem correctly is crucial to finding the solution. The name frames the discussion and impacts the solution. Burnout implies difficulty coping with the many stresses of health care and of personal responsibility for the problem. The solution would therefore be to help individuals to cope with their stresses. Moral injury on the other hand implies a corrupt system; thereby, reframing the discussion to systems issues and suggesting solutions by changing the business of health care delivery.
These authors state that current clinical distress is due to moral injury and not to burnout. Therefore, the business in which health care is performed needs to change.
The authors define the drivers of moral injury in our current system, mostly as (1) a massive information technology overload that has largely overtaken the patient as center of attention; and (2) the profit motive of the health care corporation and its shareholders. A focus on making profits has increased in the wake of falling reimbursements; the result is pressure on clinicians to see more patients more quickly and to do more even when not necessary. This has diverted the focus on healing patients to a focus on making profits. These major drivers of clinician distress—the electronic health record and the pressure to bill more—are fundamentally driven by the corporatization of American medicine in which profit is the measured outcome.
Thus rather than having their highest loyalty to patients and their families, clinicians now have other loyalties—the electronic health record, insurers, the hospital, the health care system, and even their own salaries.
Therein lies the moral injury felt by increasing numbers of clinicians, leading to soaring rates of clinical distress. Many physicians are now recognizing moral injury as the basis of their pain. For example, Gawande has described unceasing computer data entry as a cause of physician distress and physician loneliness in the interesting essay, “Why Doctors Hate Their Computers.”2 Topol has suggested that corporate interference and attention away from patient care is a reason doctors should unite and organize for a more healthful environment.3 Ofri has gone so far as to suggest that the health care system is surviving because it can exploit its physicians for every drop of energy, diverting the focus of clinical encounters on billing rather than healing.4 However, it may be simplistic to imply or state that all clinical distress is related to moral injury. Other factors in caring for the sick and dying also can cause distress to health care providers. Physicians work long, hard hours and listen to many stories of distress and suffering from patients. Some of this is internalized and processed as one’s own suffering. Clinicians also have enormous amounts of information to absorb and assimilate, keep long hours, and are often sleep deprived, all of which may harm their well-being. In addition, clinicians may have work/life imbalances, be hesitant to reveal their weaknesses, and have perfectionist personalities. Still other factors may also be involved, such as a hostile environment in which managers can overuse their power; racism that can limit opportunities for advancement; and/or a family-unfriendly environment.
Just as the treatment of cancer depends on good surgery, radiation and/or chemotherapy as well as reducing underlying predisposing cause (ie, smoking, drinking, obesity, antiviral therapy) and leading a healthy lifestyle, so too treatment of clinical distress needs a multipronged approach. Fixing the business framework is an important step forward but may not always be enough. We agree with the authors’ suggestions for improvement: bringing administrators and clinicians into conversation with each other, making clinician satisfaction a financial priority, assuring that physician leaders have cell phone numbers of their legislators, and reestablishing a sense of community among clinicians. However, none of these goals will be easy to accomplish and some may be impossible to realize in some settings.
A necessary corollary to the suggestions by Dean and colleagues is research. Much research is needed to discover all of the factors of clinician distress, whatever we name the problem. We need to know vulnerabilities of different populations of clinicians and differences in prevalence in different types of health care systems.
It is likely that physicians in a government-owned health care system, such as the US Department of Veterans Affairs (VA) hospitals, have lower distress since there are no corporate interests or profit motives. In our experience, we have noted that many VA providers are expatriates of private health care systems due to their moral distress. If profit making and corporatization are important factors in distress, then clinicians in the VA system should have much lower distress; however, this is not known.
We also need research in pilot projects that relieve clinician distress. These could relate to collegial activities to bring physicians—and administrators—together in community, allowing more time with patients than the usual 15-minute allotments, allowing more time for creative, narrative experiences in medicine, developing forums for discussion and resolution of distress-inducing situations, etc.
An important yet overlooked issue in this discussion is that clinician distress, regardless of its name or cause, is a public health crisis. Clinician distress not only affects the clinician most directly and most crucially, but also affects every person in his/her community. Physicians who are distressed for whatever reason deliver less adequate care, make more medical errors, and are less invested in their patients. Patients of distressed clinicians have less favorable outcomes and suffer more. Medical errors are now the third leading cause of death in the US. Much of this is due to inadequate care by focusing attention on profit-making over health improvement and to clinician distress. Clinician distress due to moral injury or any other factor is a public health crisis and needs much more attention, research, and prioritization of clinician satisfaction.
Paulette Mehta, MD, MPH; and Jay Mehta, PhD
Author Affiliations: Central Arkansas Veterans Health Care System; University of Arkansas for Medical Sciences
Correspondence: Paulette Mehta ([email protected])
Disclosures: The authors report no conflict of interest with regard to this article.
References
1. Dean W, Talbot S, Dean A. Reframing clinical distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.
2. Gawande A. Why doctors hate their computers. New Yorker. November 12, 2018. https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers. Accessed October 16, 2019.
3. Topol E. Why doctors should organize. New Yorker. August 5, 2019. https://www.newyorker.com/culture/annals-of-inquiry/why-doctors-should-organize. Accessed October 16, 2019.
4. Ofri D. The business of healthcare depends on exploiting doctors and nurses. The New York Times. June 8, 2019. https://www.nytimes.com/2019/06/08/opinion/sunday/hospitals-doctors-nurses-burnout.html. Accessed October 16, 2019.
To the Editor: The September 2019 editorial “Reframing clinician distress: moral injury not burnout” argues for a renaming of what has been called burnout to moral injury.1 The article by Dean, Talbot, and Dean compares the experience of health care providers to soldiers and other service members who have served in combat and suffer as a result of their experiences. I would like to comment on 2 areas: Whether the term burnout should be replaced with moral injury; and the adequacy of the recommendations made by Dean, Talbot, and Dean.
Briefly, my own credentials to opine on the topic include being both a physician and a soldier. I served in the US Army as a psychiatrist from 1986 to 2010 and deployed to various hazardous locations, including South Korea, Somalia, Iraq, and Guantanamo Bay, Cuba. Since my retirement from the Army I have worked as a psychiatrist on different front lines, with both veterans and the chronically mentally ill and often homeless population.
Moral injury is a term that was popularized by Johnathan Shay after the Vietnam War, especially in his masterful book Achilles in Vietnam.1 Most authors who have written on the subject of moral injury, including myself, think of it as feelings of guilt and shame related to (1) killing civilians (especially children or innocents); (2) surviving while other comrades did not; and/or (3) feeling betrayed by the government they served.2,3
While also arising in combat settings, moral injury is related but separate from posttraumatic stress disorder (PTSD). It comes from an affront to our morals rather than our physical well-being. It is not considered a medical diagnosis, treatments are experimental, and the literature is anecdotal.
I have mixed feelings about equating the moral injury from combat to working as a physician or other health care provider. On the one hand, certainly health care providers may sacrifice health and safety to taking care of patients. They may feel guilty when they cannot do enough for their patients. But does it rise to the same level as actually combat and having numerous comrades killed or maimed?
On the other hand, working on an inpatient psychiatry ward with an inner-city population who generally have severe mental illness and are often on phencyclidine and related drugs, has its own share of risks. Unfortunately, physical attacks on staff are way too common.
The term burnout also has a robust background of research into both causes and possible solutions. Indeed, there was even a journal devoted to it: Burnout Research.4 Moral injury research is on different populations, and generally the remedies are focused more on spiritual and existential support.
Which brings me to the recommendations and solutions part of the editorial. I agree that yoga and meditation, while beneficial, do not curb the feelings of frustration and betrayal that often arise when you cannot treat patients the way you feel they deserve. The recommendations listed in the editorial are a start, but much more should be done.
Now comes the hard part. Specifically, what more should be done? All the easy solutions have already been tried. Ones that would really make a difference, such as making an electronic health record that allows you to still look at and connect to the patient, seem to elude us. Many of us in the health care industry would love to have a single payer system across the board, to avoid all the inequities cited in the article. But health care, like climate change, is mired in our political deadlocks.
Therefore, I will finish by focusing on one of their recommendations, which is achievable: tie the incentives for the executive leadership to the satisfaction of health care providers, as is done for patient satisfaction. That is both doable and will benefit various institutions in the long run. Health care providers will be more likely to stay in a health care system and thus patient satisfaction improves. Win-win.
COL (Ret) Elspeth Cameron Ritchie, MD, MPH, USA
Author Affiliation: Uniformed Services University of the Health Sciences
Correspondence: Elspeth Cameron Ritchie ([email protected])
Disclosures: The author reports no conflict of interest with regard to this article.
References
1. Shay J. Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York: Atheneum; 1994.
2. Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin. Psychol Rev. 2009;29(8):695-706.
3. Ritchie EC. Moral injury: a profound sense of alienation and abject shame. Time. April 17, 2013. http://nation.time.com/2013/04/17/moral-injury-a-profound-sense-of-alienation-and-abject-shame.
4. Burnout Research. 2014;1(1):1-56. https://www.sciencedirect.com/journal/burnout-research/vol/1/issue/1. Accessed October 17, 2019.
Response: We appreciate the very thoughtful and thorough responses of Mehta. Mehta, Padgett, Ascensao, and Ritchie. Common themes in the responses were the suggestion that supplanting the term burnout with moral injury may not be appropriate and that changing the underlying drivers of distress requires a multifaceted approach, which is likely to require prolonged effort. We agree with both of these themes, believing the concept of moral injury and mitigation strategies do not benefit from reductionism.
Burnout is a nonspecific symptom constellation of emotional exhaustion, depersonalization, and a lack of a sense of accomplishment.1 Because it is nonspecific, the symptoms can arise from any number of situations, not only moral injury. However, from our conversations over the past 15 months, moral injury fuels a large percentage of burnout in health care. In a recent informal survey conducted at the ORExcellence meeting, almost all respondents believed they were experiencing moral injury rather than burnout when both terms were explained. When clinicians are physically and emotionally exhausted with battling a broken system in their efforts to provide good care—when they have incurred innumerable moral insults, amassing to a moral injury—many give up. This is the end stage of moral injury, or burnout.We absolutely agree research is necessary to validate this concept, which has been applied only to health care since July 2018. We are pursuing various avenues of inquiry and are validating a new assessment tool. But we do not believe that intervention must wait until there are data to support what resonates so profoundly with so many and, as we have heard dozens of times, “finally gives language to my experience.”Finally, we would not suggest that civilian physician experience is equivalent to combat experience. But just as there are multiple etiologies for posttraumatic stress disorder (PTSD), such as combat exposure, physical abuse, sexual assault, there are likely multiple ways one can incur moral injury. Witnessing or participating in a situation that transgresses deeply held moral beliefs is the prerequisite for moral injury rather than physical danger. In different contexts, physicians and service members may ultimately face similar accumulated risk to their moral integrity, though of widely disparate intensity, frequency, and duration. Physicians face low-intensity, high-frequency threats over years; service members more often face high-intensity, less frequent threats during time-limited deployments. Just because moral injury was first applied to combat veterans—as was PTSD—does not mean we should limit the use of a powerfully resonant concept to a military population any more than we limited the use of Letterman’s ambulances or Morel’s tourniquets to the battlefield.2,3
Wendy Dean, MD; and Simon Talbot, MD
Author affiliations: Wendy Dean is President and co-founder of Moral Injury of Healthcare. Simon Talbot is a reconstructive plastic surgeon at Brigham and Women’s Hospital and associate professor of surgery at Harvard Medical School, Boston, Massachusetts.
Correspondence: Wendy Dean (wdean@moralinjury. Healthcare,@WDeanMD)
Disclosures: Wendy Dean and Simon Talbot founded Moral Injury of Healthcare, a nonprofit organization; they report no other actual or potential conflicts of interest with regard to this article.
References
1. Freudenberger HJ. The staff burn-out syndrome in alternative institutions. Psychother Theory Res Pract. 1975;12(1):73-82.
2. Place RJ. The strategic genius of Jonathan Letterman: the relevancy of the American Civil War to current health care policy makers. Mil Med. 2015;180(3):259-262.
3. Welling DR, McKay PL, Rasmussen TE, Rich NM. A brief history of the tourniquet. J Vasc Surg. 2012;55(1):286-290.
To the Editor: In the September 2019 guest editorial “Reframing Clinician Distress: Moral Injury Not Burnout,” the authors have advanced a thoughtful and provocative hypothesis addressing a salient issue.1 Their argument is that burnout does not accurately capture physician distress. Furthermore, they posit the term burnout focuses remediation strategies at the individual provider level, thereby discounting the contribution of the larger health care system. This is not the first effort to argue that burnout is not a syndrome of mental illness (eg, depression) located within the person but rather a disrupted physician-work relationship.2
As the authors cite, population and practice changes have contributed significantly to physician distress and dissatisfaction. Indeed, recent findings indicate that female physicians may suffer increased prevalence of burnout, which represents a challenge given the growing numbers of women in medicine.3 Unfortunately, by shifting focus almost exclusively to the system level to address burnout, the authors discount a large body of literature examining associations and contributors at the individual and clinic level.
Burnout is conceptualized as consisting of 3 domains: depersonalization, emotional exhaustion, and personal accomplishment.4 While this conceptualization may not capture the totality of physician distress, it has provided a body of literature focused on decreasing symptoms of burnout. Successful interventions have been targeted at the individual provider level (ie, stress management, small group discussion, mindfulness) as well as the organizational level (ie, reduction in duty hours, scribes).5,6 Recent studies have also suggested that increasing the occurrence of social encounters that are civil and respectful decreases reported physician burnout.7
Frustration, the annoyance or anger at being unable to change or achieve something, also can be a leading cause of burnout and moral injury. The inability to deal with unresolvable issues due to a lack of skills or inability to create a positive reframe can lead to a constellation of symptoms that are detrimental to the individual provider. Nevertheless, system rigidity, inability to recognitize pain and pressure, and goals perceived as unachievable can also lead to frustration. Physicians may experience growing frustration if they are unable to influence their systems. Thus, experiencing personal frustration, combined with an inability or lack of energy or time to influence a system can snowball.
Just as we counsel our patients that good medical care involves not only engagement with the medical system, but also individual engagement in their care (eg, nutrition, exercise), this problem requires a multicomponent solution. While advocating and working for a system that induces less moral injury, frustration, and burnout, physicians need to examine the resources available to them and their colleagues in a more immediate way.
Physician distress is a serious problem with both personal, patient, occupational, and public health costs. Thus, it is important that we grapple with the complexity of a multiconstruct definition amenable to multilevel interventions. The concept of moral injury is an important component and opens additional lines of both clinical inquiry and intervention. However, in our view, to subsume all burnout under this construct is overly reductive.
In closing, this topic is too important not to discuss. Let the conversations continue!
Lynne Padgett, PhD; and Joao L. Ascensao, MD, PhD
Author affiliations: Departments of Medicine and Mental Health, Washington DC VA Medical Center and Department of Medicine, George Washington University School of Medicine
Correspondence: Lynne Padgett ([email protected])
Disclosures: The authors report no conflict of interest with regard to this article.
References
1. Dean W, Talbot S, Dean A. Reframing clinical distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.
2. Epstein RM, Privitera MR. Doing something about physician burnout. Lancet. 2016;388(10057):2216-2217.
3. Templeton K, Bernstein CA, Sukhera J, et al. Gender-based differences in burnout: issues faced by women physicians. NAM Perspectives. Discussion Paper. Washington, DC: National Academy of Medicine; 2019. https://nam.edu/wp-content/uploads/2019/05/Gender-Based-Differences-in-Burnout.pdf. Published May 28, 2019. Accessed October 10, 2019.
4. Eckleberry-Hunt J Kirkpatrick H, Barbera T. The problems with burnout research. Acad Med. 2018;93(3):367-370.
5. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281.
6. Squiers JJ, Lobdell KW, Fann JI, DiMaio JM. Physician burnout: are we treating the symptom instead of the disease? Ann Thorac Surg. 2017;104(4):1117-1122.
7. Maslach C, Leiter MP. New insights into burnout and health care: strategies for improving civility and alleviating burnout. Med Teach. 2017;39(2):160-163.
To the Editor: We applaud Dean and her colleagues for their thought-provoking commentary on clinicians’ distress, a problem that has surged in recent years and has now reached epidemic proportions.1 Their argument focuses on the language used to define and frame clinical distress. Do we label this distress as burnout, as moral injury, or as something else? Moral injury occurs any time clinicians are impeded from doing the right thing at the right time in the right way; or even worse, doing the wrong thing to serve the needs of health system stakeholders other than the patient. These other stakeholders may include administrators, corporations, insurance adjusters, and others.
Naming the problem correctly is crucial to finding the solution. The name frames the discussion and impacts the solution. Burnout implies difficulty coping with the many stresses of health care and of personal responsibility for the problem. The solution would therefore be to help individuals to cope with their stresses. Moral injury on the other hand implies a corrupt system; thereby, reframing the discussion to systems issues and suggesting solutions by changing the business of health care delivery.
These authors state that current clinical distress is due to moral injury and not to burnout. Therefore, the business in which health care is performed needs to change.
The authors define the drivers of moral injury in our current system, mostly as (1) a massive information technology overload that has largely overtaken the patient as center of attention; and (2) the profit motive of the health care corporation and its shareholders. A focus on making profits has increased in the wake of falling reimbursements; the result is pressure on clinicians to see more patients more quickly and to do more even when not necessary. This has diverted the focus on healing patients to a focus on making profits. These major drivers of clinician distress—the electronic health record and the pressure to bill more—are fundamentally driven by the corporatization of American medicine in which profit is the measured outcome.
Thus rather than having their highest loyalty to patients and their families, clinicians now have other loyalties—the electronic health record, insurers, the hospital, the health care system, and even their own salaries.
Therein lies the moral injury felt by increasing numbers of clinicians, leading to soaring rates of clinical distress. Many physicians are now recognizing moral injury as the basis of their pain. For example, Gawande has described unceasing computer data entry as a cause of physician distress and physician loneliness in the interesting essay, “Why Doctors Hate Their Computers.”2 Topol has suggested that corporate interference and attention away from patient care is a reason doctors should unite and organize for a more healthful environment.3 Ofri has gone so far as to suggest that the health care system is surviving because it can exploit its physicians for every drop of energy, diverting the focus of clinical encounters on billing rather than healing.4 However, it may be simplistic to imply or state that all clinical distress is related to moral injury. Other factors in caring for the sick and dying also can cause distress to health care providers. Physicians work long, hard hours and listen to many stories of distress and suffering from patients. Some of this is internalized and processed as one’s own suffering. Clinicians also have enormous amounts of information to absorb and assimilate, keep long hours, and are often sleep deprived, all of which may harm their well-being. In addition, clinicians may have work/life imbalances, be hesitant to reveal their weaknesses, and have perfectionist personalities. Still other factors may also be involved, such as a hostile environment in which managers can overuse their power; racism that can limit opportunities for advancement; and/or a family-unfriendly environment.
Just as the treatment of cancer depends on good surgery, radiation and/or chemotherapy as well as reducing underlying predisposing cause (ie, smoking, drinking, obesity, antiviral therapy) and leading a healthy lifestyle, so too treatment of clinical distress needs a multipronged approach. Fixing the business framework is an important step forward but may not always be enough. We agree with the authors’ suggestions for improvement: bringing administrators and clinicians into conversation with each other, making clinician satisfaction a financial priority, assuring that physician leaders have cell phone numbers of their legislators, and reestablishing a sense of community among clinicians. However, none of these goals will be easy to accomplish and some may be impossible to realize in some settings.
A necessary corollary to the suggestions by Dean and colleagues is research. Much research is needed to discover all of the factors of clinician distress, whatever we name the problem. We need to know vulnerabilities of different populations of clinicians and differences in prevalence in different types of health care systems.
It is likely that physicians in a government-owned health care system, such as the US Department of Veterans Affairs (VA) hospitals, have lower distress since there are no corporate interests or profit motives. In our experience, we have noted that many VA providers are expatriates of private health care systems due to their moral distress. If profit making and corporatization are important factors in distress, then clinicians in the VA system should have much lower distress; however, this is not known.
We also need research in pilot projects that relieve clinician distress. These could relate to collegial activities to bring physicians—and administrators—together in community, allowing more time with patients than the usual 15-minute allotments, allowing more time for creative, narrative experiences in medicine, developing forums for discussion and resolution of distress-inducing situations, etc.
An important yet overlooked issue in this discussion is that clinician distress, regardless of its name or cause, is a public health crisis. Clinician distress not only affects the clinician most directly and most crucially, but also affects every person in his/her community. Physicians who are distressed for whatever reason deliver less adequate care, make more medical errors, and are less invested in their patients. Patients of distressed clinicians have less favorable outcomes and suffer more. Medical errors are now the third leading cause of death in the US. Much of this is due to inadequate care by focusing attention on profit-making over health improvement and to clinician distress. Clinician distress due to moral injury or any other factor is a public health crisis and needs much more attention, research, and prioritization of clinician satisfaction.
Paulette Mehta, MD, MPH; and Jay Mehta, PhD
Author Affiliations: Central Arkansas Veterans Health Care System; University of Arkansas for Medical Sciences
Correspondence: Paulette Mehta ([email protected])
Disclosures: The authors report no conflict of interest with regard to this article.
References
1. Dean W, Talbot S, Dean A. Reframing clinical distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.
2. Gawande A. Why doctors hate their computers. New Yorker. November 12, 2018. https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers. Accessed October 16, 2019.
3. Topol E. Why doctors should organize. New Yorker. August 5, 2019. https://www.newyorker.com/culture/annals-of-inquiry/why-doctors-should-organize. Accessed October 16, 2019.
4. Ofri D. The business of healthcare depends on exploiting doctors and nurses. The New York Times. June 8, 2019. https://www.nytimes.com/2019/06/08/opinion/sunday/hospitals-doctors-nurses-burnout.html. Accessed October 16, 2019.
To the Editor: The September 2019 editorial “Reframing clinician distress: moral injury not burnout” argues for a renaming of what has been called burnout to moral injury.1 The article by Dean, Talbot, and Dean compares the experience of health care providers to soldiers and other service members who have served in combat and suffer as a result of their experiences. I would like to comment on 2 areas: Whether the term burnout should be replaced with moral injury; and the adequacy of the recommendations made by Dean, Talbot, and Dean.
Briefly, my own credentials to opine on the topic include being both a physician and a soldier. I served in the US Army as a psychiatrist from 1986 to 2010 and deployed to various hazardous locations, including South Korea, Somalia, Iraq, and Guantanamo Bay, Cuba. Since my retirement from the Army I have worked as a psychiatrist on different front lines, with both veterans and the chronically mentally ill and often homeless population.
Moral injury is a term that was popularized by Johnathan Shay after the Vietnam War, especially in his masterful book Achilles in Vietnam.1 Most authors who have written on the subject of moral injury, including myself, think of it as feelings of guilt and shame related to (1) killing civilians (especially children or innocents); (2) surviving while other comrades did not; and/or (3) feeling betrayed by the government they served.2,3
While also arising in combat settings, moral injury is related but separate from posttraumatic stress disorder (PTSD). It comes from an affront to our morals rather than our physical well-being. It is not considered a medical diagnosis, treatments are experimental, and the literature is anecdotal.
I have mixed feelings about equating the moral injury from combat to working as a physician or other health care provider. On the one hand, certainly health care providers may sacrifice health and safety to taking care of patients. They may feel guilty when they cannot do enough for their patients. But does it rise to the same level as actually combat and having numerous comrades killed or maimed?
On the other hand, working on an inpatient psychiatry ward with an inner-city population who generally have severe mental illness and are often on phencyclidine and related drugs, has its own share of risks. Unfortunately, physical attacks on staff are way too common.
The term burnout also has a robust background of research into both causes and possible solutions. Indeed, there was even a journal devoted to it: Burnout Research.4 Moral injury research is on different populations, and generally the remedies are focused more on spiritual and existential support.
Which brings me to the recommendations and solutions part of the editorial. I agree that yoga and meditation, while beneficial, do not curb the feelings of frustration and betrayal that often arise when you cannot treat patients the way you feel they deserve. The recommendations listed in the editorial are a start, but much more should be done.
Now comes the hard part. Specifically, what more should be done? All the easy solutions have already been tried. Ones that would really make a difference, such as making an electronic health record that allows you to still look at and connect to the patient, seem to elude us. Many of us in the health care industry would love to have a single payer system across the board, to avoid all the inequities cited in the article. But health care, like climate change, is mired in our political deadlocks.
Therefore, I will finish by focusing on one of their recommendations, which is achievable: tie the incentives for the executive leadership to the satisfaction of health care providers, as is done for patient satisfaction. That is both doable and will benefit various institutions in the long run. Health care providers will be more likely to stay in a health care system and thus patient satisfaction improves. Win-win.
COL (Ret) Elspeth Cameron Ritchie, MD, MPH, USA
Author Affiliation: Uniformed Services University of the Health Sciences
Correspondence: Elspeth Cameron Ritchie ([email protected])
Disclosures: The author reports no conflict of interest with regard to this article.
References
1. Shay J. Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York: Atheneum; 1994.
2. Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin. Psychol Rev. 2009;29(8):695-706.
3. Ritchie EC. Moral injury: a profound sense of alienation and abject shame. Time. April 17, 2013. http://nation.time.com/2013/04/17/moral-injury-a-profound-sense-of-alienation-and-abject-shame.
4. Burnout Research. 2014;1(1):1-56. https://www.sciencedirect.com/journal/burnout-research/vol/1/issue/1. Accessed October 17, 2019.
Response: We appreciate the very thoughtful and thorough responses of Mehta. Mehta, Padgett, Ascensao, and Ritchie. Common themes in the responses were the suggestion that supplanting the term burnout with moral injury may not be appropriate and that changing the underlying drivers of distress requires a multifaceted approach, which is likely to require prolonged effort. We agree with both of these themes, believing the concept of moral injury and mitigation strategies do not benefit from reductionism.
Burnout is a nonspecific symptom constellation of emotional exhaustion, depersonalization, and a lack of a sense of accomplishment.1 Because it is nonspecific, the symptoms can arise from any number of situations, not only moral injury. However, from our conversations over the past 15 months, moral injury fuels a large percentage of burnout in health care. In a recent informal survey conducted at the ORExcellence meeting, almost all respondents believed they were experiencing moral injury rather than burnout when both terms were explained. When clinicians are physically and emotionally exhausted with battling a broken system in their efforts to provide good care—when they have incurred innumerable moral insults, amassing to a moral injury—many give up. This is the end stage of moral injury, or burnout.We absolutely agree research is necessary to validate this concept, which has been applied only to health care since July 2018. We are pursuing various avenues of inquiry and are validating a new assessment tool. But we do not believe that intervention must wait until there are data to support what resonates so profoundly with so many and, as we have heard dozens of times, “finally gives language to my experience.”Finally, we would not suggest that civilian physician experience is equivalent to combat experience. But just as there are multiple etiologies for posttraumatic stress disorder (PTSD), such as combat exposure, physical abuse, sexual assault, there are likely multiple ways one can incur moral injury. Witnessing or participating in a situation that transgresses deeply held moral beliefs is the prerequisite for moral injury rather than physical danger. In different contexts, physicians and service members may ultimately face similar accumulated risk to their moral integrity, though of widely disparate intensity, frequency, and duration. Physicians face low-intensity, high-frequency threats over years; service members more often face high-intensity, less frequent threats during time-limited deployments. Just because moral injury was first applied to combat veterans—as was PTSD—does not mean we should limit the use of a powerfully resonant concept to a military population any more than we limited the use of Letterman’s ambulances or Morel’s tourniquets to the battlefield.2,3
Wendy Dean, MD; and Simon Talbot, MD
Author affiliations: Wendy Dean is President and co-founder of Moral Injury of Healthcare. Simon Talbot is a reconstructive plastic surgeon at Brigham and Women’s Hospital and associate professor of surgery at Harvard Medical School, Boston, Massachusetts.
Correspondence: Wendy Dean (wdean@moralinjury. Healthcare,@WDeanMD)
Disclosures: Wendy Dean and Simon Talbot founded Moral Injury of Healthcare, a nonprofit organization; they report no other actual or potential conflicts of interest with regard to this article.
References
1. Freudenberger HJ. The staff burn-out syndrome in alternative institutions. Psychother Theory Res Pract. 1975;12(1):73-82.
2. Place RJ. The strategic genius of Jonathan Letterman: the relevancy of the American Civil War to current health care policy makers. Mil Med. 2015;180(3):259-262.
3. Welling DR, McKay PL, Rasmussen TE, Rich NM. A brief history of the tourniquet. J Vasc Surg. 2012;55(1):286-290.
Ask about vaping and e-cigarette use
When we studied the knowledge and practice of e-cigarette use among pregnant women in one of our outpatient practices, we found that 43% of more than 300 survey participants believed e-cigarettes are less harmful to a fetus than traditional cigarettes. Just over half – 57% – believed that e-cigarettes contain nicotine.
This study from 5 years ago demonstrated the need for more patient education.1 Today, we have even more clarity that, while there may be health benefits of switching to noncombustible forms of nicotine consumption outside of pregnancy, these potential benefits do not extend to pregnancy. Both human and animal studies have demonstrated that nicotine itself is harmful to the developing fetus; the Centers for Disease Control and Prevention warns against the use of e-cigarettes in pregnancy for this reason.
A 2018 literature review on the use of e-cigarettes in pregnancy and the effects on perinatal/neonatal outcomes reported that the amount of nicotine consumed by e-cigarette users is similar to that of cigarette smokers and that most animal studies suggest a potential danger to the fetus, primarily because of the nicotine.2 Effects on the immune system, neural development, lung function, and cardiac function were all noted in the review. Other research has shown that e-cigarette fluid can contain formaldehyde and other harmful substances.
A new analysis of data from the 2014-2017 National Health Interview Survey shows a significantly lower prevalence of conventional cigarette use among pregnant women than in nonpregnant women, and an almost identical prevalence of e-cigarette use among pregnant and nonpregnant women of reproductive age.3 This discrepancy again suggests that women may not be aware of the potential harms of e-cigarettes in pregnancy, which is not surprising considering that prenatal care clinicians often are not appropriately screening or counseling regarding e-cigarette use.4
and counsel women that the use of e-cigarettes is not a safer alternative to cigarette smoking. I urge patients who have switched to e-cigarettes as a means of smoking cessation or as a choice they perceive to be safer to work together with me to find another way to reduce potential harm to their baby.
References
1. J Addict Med. 2015 Jul-Aug;9(4):266-72.
2. Obstet Gynecol Surv. 2018 Sep;73(9):544-9.
3. JAMA Pediatr. 2019 Jun 1;173(6):600-2.
4. Am J Obstet Gynecol. 2014 Dec;211(6):695.e1-7.
When we studied the knowledge and practice of e-cigarette use among pregnant women in one of our outpatient practices, we found that 43% of more than 300 survey participants believed e-cigarettes are less harmful to a fetus than traditional cigarettes. Just over half – 57% – believed that e-cigarettes contain nicotine.
This study from 5 years ago demonstrated the need for more patient education.1 Today, we have even more clarity that, while there may be health benefits of switching to noncombustible forms of nicotine consumption outside of pregnancy, these potential benefits do not extend to pregnancy. Both human and animal studies have demonstrated that nicotine itself is harmful to the developing fetus; the Centers for Disease Control and Prevention warns against the use of e-cigarettes in pregnancy for this reason.
A 2018 literature review on the use of e-cigarettes in pregnancy and the effects on perinatal/neonatal outcomes reported that the amount of nicotine consumed by e-cigarette users is similar to that of cigarette smokers and that most animal studies suggest a potential danger to the fetus, primarily because of the nicotine.2 Effects on the immune system, neural development, lung function, and cardiac function were all noted in the review. Other research has shown that e-cigarette fluid can contain formaldehyde and other harmful substances.
A new analysis of data from the 2014-2017 National Health Interview Survey shows a significantly lower prevalence of conventional cigarette use among pregnant women than in nonpregnant women, and an almost identical prevalence of e-cigarette use among pregnant and nonpregnant women of reproductive age.3 This discrepancy again suggests that women may not be aware of the potential harms of e-cigarettes in pregnancy, which is not surprising considering that prenatal care clinicians often are not appropriately screening or counseling regarding e-cigarette use.4
and counsel women that the use of e-cigarettes is not a safer alternative to cigarette smoking. I urge patients who have switched to e-cigarettes as a means of smoking cessation or as a choice they perceive to be safer to work together with me to find another way to reduce potential harm to their baby.
References
1. J Addict Med. 2015 Jul-Aug;9(4):266-72.
2. Obstet Gynecol Surv. 2018 Sep;73(9):544-9.
3. JAMA Pediatr. 2019 Jun 1;173(6):600-2.
4. Am J Obstet Gynecol. 2014 Dec;211(6):695.e1-7.
When we studied the knowledge and practice of e-cigarette use among pregnant women in one of our outpatient practices, we found that 43% of more than 300 survey participants believed e-cigarettes are less harmful to a fetus than traditional cigarettes. Just over half – 57% – believed that e-cigarettes contain nicotine.
This study from 5 years ago demonstrated the need for more patient education.1 Today, we have even more clarity that, while there may be health benefits of switching to noncombustible forms of nicotine consumption outside of pregnancy, these potential benefits do not extend to pregnancy. Both human and animal studies have demonstrated that nicotine itself is harmful to the developing fetus; the Centers for Disease Control and Prevention warns against the use of e-cigarettes in pregnancy for this reason.
A 2018 literature review on the use of e-cigarettes in pregnancy and the effects on perinatal/neonatal outcomes reported that the amount of nicotine consumed by e-cigarette users is similar to that of cigarette smokers and that most animal studies suggest a potential danger to the fetus, primarily because of the nicotine.2 Effects on the immune system, neural development, lung function, and cardiac function were all noted in the review. Other research has shown that e-cigarette fluid can contain formaldehyde and other harmful substances.
A new analysis of data from the 2014-2017 National Health Interview Survey shows a significantly lower prevalence of conventional cigarette use among pregnant women than in nonpregnant women, and an almost identical prevalence of e-cigarette use among pregnant and nonpregnant women of reproductive age.3 This discrepancy again suggests that women may not be aware of the potential harms of e-cigarettes in pregnancy, which is not surprising considering that prenatal care clinicians often are not appropriately screening or counseling regarding e-cigarette use.4
and counsel women that the use of e-cigarettes is not a safer alternative to cigarette smoking. I urge patients who have switched to e-cigarettes as a means of smoking cessation or as a choice they perceive to be safer to work together with me to find another way to reduce potential harm to their baby.
References
1. J Addict Med. 2015 Jul-Aug;9(4):266-72.
2. Obstet Gynecol Surv. 2018 Sep;73(9):544-9.
3. JAMA Pediatr. 2019 Jun 1;173(6):600-2.
4. Am J Obstet Gynecol. 2014 Dec;211(6):695.e1-7.
Cannabis and prenatal care
We know that the environment significantly impacts our health. People who live in areas prone to industrial waste, poor air or water quality, and crime have higher risks for cardiovascular disease, severe asthma, and stress-induced illnesses. Children who grow up under these conditions can experience a failure to thrive.
As ob.gyns., we also recognize that the intrauterine environment plays a key role in influencing embryonic and fetal development. For this reason, we counsel our pregnant patients to eat well-balanced diets, drink healthy amounts of water, get plenty of rest, and incorporate physical activity into their daily routines. Indeed, the seminal work by Sir David Barker demonstrated that the roots of chronic diseases – including hypertension, stroke, and type 2 diabetes – begin in utero. We truly are where we live – from before birth up through adulthood.
Because the womb environment, where we spend the first critical 9 months of life, dramatically affects our lifelong health, we advise against the use of certain medications and other substances during pregnancy. Some of these recommendations seem clear-cut: Don’t smoke and significantly reduce or abstain from alcohol consumption; illicit drugs – such as cocaine or heroin – should never be used. However, gray areas exist. For example, although anticonvulsants carry higher risks for congenital malformations, patients who experience seizures may need to continue taking antiepileptic drugs during pregnancy, especially those with long safety records.
One of the newer challenges the medical community in general must face is the broadened use and wider societal acceptance of cannabis. Currently legal in 33 U.S. states and Washington, D.C., medical marijuana now is viewed as another legitimate tool in the health care arsenal, rather than the off-limits, off-label substance it was less than a generation ago.
Although proponents may tout the health benefits of cannabis and related products like cannabidiol, it remains unclear what the long-term effects of routine use may have on development, especially fetal development. However, how we as ob.gyns. navigate conversations with our patients around substance use remains crucial to our delivery of the best possible prenatal care.
We have invited Katrina S. Mark, MD, associate professor of obstetrics, gynecology, and reproductive sciences at the University of Maryland School of Medicine, to examine use of cannabis in pregnancy and the need for maintaining trust in the patient-practitioner relationship when discussing substance use during prenatal counseling.
Dr. Reece, who specializes in maternal-fetal medicine, is executive vice president for medical affairs at the University of Maryland School of Medicine as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. He is the medical editor of this column. He said he had no relevant financial disclosures. Contact him at [email protected].
We know that the environment significantly impacts our health. People who live in areas prone to industrial waste, poor air or water quality, and crime have higher risks for cardiovascular disease, severe asthma, and stress-induced illnesses. Children who grow up under these conditions can experience a failure to thrive.
As ob.gyns., we also recognize that the intrauterine environment plays a key role in influencing embryonic and fetal development. For this reason, we counsel our pregnant patients to eat well-balanced diets, drink healthy amounts of water, get plenty of rest, and incorporate physical activity into their daily routines. Indeed, the seminal work by Sir David Barker demonstrated that the roots of chronic diseases – including hypertension, stroke, and type 2 diabetes – begin in utero. We truly are where we live – from before birth up through adulthood.
Because the womb environment, where we spend the first critical 9 months of life, dramatically affects our lifelong health, we advise against the use of certain medications and other substances during pregnancy. Some of these recommendations seem clear-cut: Don’t smoke and significantly reduce or abstain from alcohol consumption; illicit drugs – such as cocaine or heroin – should never be used. However, gray areas exist. For example, although anticonvulsants carry higher risks for congenital malformations, patients who experience seizures may need to continue taking antiepileptic drugs during pregnancy, especially those with long safety records.
One of the newer challenges the medical community in general must face is the broadened use and wider societal acceptance of cannabis. Currently legal in 33 U.S. states and Washington, D.C., medical marijuana now is viewed as another legitimate tool in the health care arsenal, rather than the off-limits, off-label substance it was less than a generation ago.
Although proponents may tout the health benefits of cannabis and related products like cannabidiol, it remains unclear what the long-term effects of routine use may have on development, especially fetal development. However, how we as ob.gyns. navigate conversations with our patients around substance use remains crucial to our delivery of the best possible prenatal care.
We have invited Katrina S. Mark, MD, associate professor of obstetrics, gynecology, and reproductive sciences at the University of Maryland School of Medicine, to examine use of cannabis in pregnancy and the need for maintaining trust in the patient-practitioner relationship when discussing substance use during prenatal counseling.
Dr. Reece, who specializes in maternal-fetal medicine, is executive vice president for medical affairs at the University of Maryland School of Medicine as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. He is the medical editor of this column. He said he had no relevant financial disclosures. Contact him at [email protected].
We know that the environment significantly impacts our health. People who live in areas prone to industrial waste, poor air or water quality, and crime have higher risks for cardiovascular disease, severe asthma, and stress-induced illnesses. Children who grow up under these conditions can experience a failure to thrive.
As ob.gyns., we also recognize that the intrauterine environment plays a key role in influencing embryonic and fetal development. For this reason, we counsel our pregnant patients to eat well-balanced diets, drink healthy amounts of water, get plenty of rest, and incorporate physical activity into their daily routines. Indeed, the seminal work by Sir David Barker demonstrated that the roots of chronic diseases – including hypertension, stroke, and type 2 diabetes – begin in utero. We truly are where we live – from before birth up through adulthood.
Because the womb environment, where we spend the first critical 9 months of life, dramatically affects our lifelong health, we advise against the use of certain medications and other substances during pregnancy. Some of these recommendations seem clear-cut: Don’t smoke and significantly reduce or abstain from alcohol consumption; illicit drugs – such as cocaine or heroin – should never be used. However, gray areas exist. For example, although anticonvulsants carry higher risks for congenital malformations, patients who experience seizures may need to continue taking antiepileptic drugs during pregnancy, especially those with long safety records.
One of the newer challenges the medical community in general must face is the broadened use and wider societal acceptance of cannabis. Currently legal in 33 U.S. states and Washington, D.C., medical marijuana now is viewed as another legitimate tool in the health care arsenal, rather than the off-limits, off-label substance it was less than a generation ago.
Although proponents may tout the health benefits of cannabis and related products like cannabidiol, it remains unclear what the long-term effects of routine use may have on development, especially fetal development. However, how we as ob.gyns. navigate conversations with our patients around substance use remains crucial to our delivery of the best possible prenatal care.
We have invited Katrina S. Mark, MD, associate professor of obstetrics, gynecology, and reproductive sciences at the University of Maryland School of Medicine, to examine use of cannabis in pregnancy and the need for maintaining trust in the patient-practitioner relationship when discussing substance use during prenatal counseling.
Dr. Reece, who specializes in maternal-fetal medicine, is executive vice president for medical affairs at the University of Maryland School of Medicine as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. He is the medical editor of this column. He said he had no relevant financial disclosures. Contact him at [email protected].
Counseling on cannabis use in pregnancy
A flurry of research papers published this year has simultaneously documented a rise in the use of cannabis during pregnancy and offered more data about its potential harms. This confluence of findings is concerning and highlights the importance of screening our patients for cannabis use and engaging with them in a way in which we can maintain their trust and their commitment to prenatal care.
A retrospective cohort study involving 661,617 women in Ontario found a significant association between self-reported cannabis use in pregnancy and an increased risk of preterm birth (relative risk, 1.41), as well as a greater likelihood of small-for-gestational-age babies (RR, 1.53), placental abruption (RR, 1.72), and transfer to neonatal intensive care (RR, 1.40).1 The study, reported in JAMA in July 2019, carefully matched users with nonusers who had the same characteristics – for example, tobacco use or not.
This new information builds upon other meta-analyses that have demonstrated a decrease in birth weight and greater admittance to the neonatal ICU associated with cannabis use in pregnancy – and it supplements what some research suggests about long-term neurologic development and a potentially increased risk of attention and behavioral problems. Other outcomes that have been noted in long-term neurologic studies of children who were exposed to cannabis in utero include impaired visual acuity, verbal reasoning and comprehension, and short-term memory.2
Increases in use were recently documented in two studies. One, an analysis of data from the National Survey on Drug Use and Health (NSDUH) published in JAMA in June 2019, showed that, between 2002-2003 and 2016-2017, the use of cannabis “in the past month” increased from 3.4% to 7.0% among pregnant women overall, and from 6% to 12% during the first trimester.3
The use of cannabis on a daily or near-daily basis, moreover, increased from 0.9% to 3% among pregnant women overall and from 2% to 5% during the first trimester. The data were collected during face-to-face interviews and were adjusted for age, race/ethnicity, and family income.
In the second study – a cross-sectional study of 367,403 pregnancies among women who filled out a questionnaire on cannabis use during standard prenatal care at Kaiser Permanente Northern California – the adjusted prevalence of use in the year before pregnancy increased from 7% in 2009 to 13% in 2017, and the adjusted prevalence during pregnancy increased from 2% to 3%.4
As in the NSDUH analysis, daily use increased most rapidly (compared with weekly or monthly) such that, by 2017, 25% of those who reported using cannabis in the year before pregnancy – and 21% of those who used cannabis during pregnancy – were daily users. It is notable that Kaiser’s population is diverse in all respects, and that the annual relative rates of increase in cannabis use before and during pregnancy (at each level of frequency) were consistent across racial/ethnic and household income groups.
It’s also worth noting that, in earlier research covering a similar time period (2009-2016), the investigators found significant increases in use via urine toxicology testing that occurs at the first prenatal visit at Kaiser. The increase found through questionnaires, therefore, reflects more than a greater willingness to self-report.
Choosing a screening tool
Universal prenatal substance use screening is recommended by the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention, but we don’t have any specific recommendations on what this means. Who should be screening, and what should that screening look like? Should we use a biologic screen, a standardized screening tool, or simply ask patients whether they use illicit substances?
Screening tools seem advantageous in that they are low cost, noninvasive, potentially comprehensive, and not subject to false-positive results as biologic screens can be – but which tool or tools are best? There are several validated screening tools that can be used outside of pregnancy to determine an individual’s use of illicit substances and whether or not that use is problematic, but previous studies have not used biologic markers to validate substance use screeners in pregnancy. Nor have studies compared screeners in pregnancy.
In our prenatal population in Baltimore, we have not been getting the answers we want using various nonvalidated screening tools. Approximately 30% of patients are positive for cannabis by urine screen, but only half tell us about their use.
Through research in our two prenatal care practices (one serving mostly privately insured and the other serving primarily Medicaid-eligible patients), we assessed both the accuracy and the acceptability of three substance use screening tools that are brief and that have been validated (for the general population) by the World Health Organization for screening of multiple substances: the 4P’s Plus (Parents, Partner, Past, and Pregnancy), the National Institute on Drug Abuse Quick Screen–ASSIST (Modified Alcohol, Smoking and Substance Involvement Screening Test), and the SURP-P (Substance Use Risk Profile–Pregnancy) scale.
In one study, published in May 2019 in Obstetrics & Gynecology, we recruited 500 pregnant women and administered these three tests to each of them.5 We then compared results with those of urine and hair drug testing, and checked the test-retest reliability of each test by readministering them (albeit by telephone) a week later. Although hair testing is not an indicator of current substance use, we used it to validate the screening tools on less-recent use.
The tests with the highest sensitivity and negative predictive values – the qualities we most want for screening – were the SURP-P and the 4P’s Plus (sensitivity of 92.4% and 90.2%, respectively). Overall they were highly sensitive screening tools across all trimesters, races, and age groups, making them more ideal screening tests than the NIDA Quick Screen–ASSIST.
Of the two tests, the 4P’s Plus screening tool was the one preferred by staff from both practices. In a companion qualitative study, we conducted focus-group discussions with 40 practice staff who were responsible for administering or overseeing patient screening.6 The staff, who were unaware of the sensitivity findings, were asked what they thought about the acceptability to patients of each of the three tools and their usability in practice.
Most of the participating staff preferred the 4P’s Plus screening tool for several reasons: It is easy to understand, is brief and to the point, and it has nonjudgmental language and tone. The screener first asks the patient about her parents’ and her partner’s use of alcohol and drugs, and then asks the patient about her own use of alcohol and tobacco. Affirmative responses to these questions lead to additional questions.
The premise is that one’s genetics, history, and current exposures – as well as one’s own use of tobacco and alcohol – are significantly associated with the use of illicit substances. If the patient reports no parental history or partner usage, and has never drank or smoked before, it’s extremely unlikely that she is using other drugs. The progression of questions does indeed seem less judgmental than immediately asking: “Do you use drugs?”
For us, the insight from this staff perception study combined with the findings on accuracy mean that the 4P’s Plus may be the most useful and acceptable screening tool for routine use in prenatal care.
Talking with our patients
The increase in the use of cannabis before and after pregnancy parallels the movement toward state legalization and decriminalization. Historically, clinicians often have relied on illegality as their main focus of counseling when giving recommendations for cessation and abstinence in pregnancy.2 This approach not only leads to punitive counseling, which can fracture the doctor-patient relationship, but increasingly it is no longer valid. In our changing legal climate, we need to provide medically based counseling and be very clear with our patients that legalization does not equate to safety.
It is important that we neither minimize nor overstate the risks. The evidence base for adverse birth outcomes of cannabis use in pregnancy is quite robust, but the associations can be subtle and are moderated by other behaviors and environmental factors that continue to challenge researchers.
As with alcohol, there likely are dose-or trimester-dependent differences in perinatal outcomes, and it’s quite possible that different cannabis products and routes of consumption have different effects. At this point, however, we don’t know the full story, nor do we know the extent to which the literature is biased toward positive correlations – the reporting of adverse effects – compared with negative findings. It is our job as medical care providers to be comfortable in that gray area and to still counsel patients on what we do know, providing the best-possible medical advice based on the information available to us.
In talking with patients, I explain that cannabis may cause a spectrum of problems and that there certainly are risks. I also tell them that we’re uncertain about the conditions and magnitude of that risk and that some babies who are exposed to cannabis in utero may have no perceivable consequences. Such honesty is important for maintaining trust, especially as some patients may see friends and relatives who also are cannabis users have normal pregnancy outcomes.
Much of my concern about cannabis in pregnancy centers on its effect on the developing brain and on long-term neurologic development. I share this with patients – I tell them that cannabis crosses the placenta and may well affect their baby’s brain as it is developing. I explain that I do not know whether this effect would be big or small, but that it’s not a chance I’m willing to take for their baby.
It is also important to educate patients that cannabis products are untested and unregulated and that they may be contaminated with heavy metals, pesticides, and other toxins that may be harmful to themselves and their babies. Patients also should know that the potency of cannabis has been dramatically increasing; research shows that the tetrahydrocannabinol – the psychoactive component – concentration has tripled over the past 2 decades.7
Research tells us that women who use illicit drugs and alcohol categorically engage in some form of harm reduction once they learn they are pregnant, and the same is true for cannabis. This is seen in dramatically different rates of first- and third-trimester use in the new analysis of NSDUH data; third-trimester use is approximately halved.
Some women will not be able to discontinue use, however, or they may try to quit and fail in their attempts. As we should with substance use more broadly, we must meet patients where they are, view cannabis use as a chronic medical problem, offer our assistance in helping them reduce harms of their use, and understand that quitting is a process.
Screening for mental health disorders and trauma is, of course, especially important in patients who use cannabis and other substances recreationally. In cases of medical marijuana usage, I recommend, as ACOG and other have done, that we discuss the risks and benefits of continuing cannabis versus shifting to alternative medications if options exist.
All patients should be welcomed, congratulated on their pregnancy and on coming for prenatal care, and engaged in the overall process of optimizing their health and the health of their baby. Like any other health issue during pregnancy, cannabis use needs to be screened for and treated in an evidence-based manner, but it does not define the trajectory or success of a woman’s pregnancy or her ability to be a successful parent.
Dr. Mark is associate professor of obstetrics, gynecology, and reproductive sciences at the University of Maryland School of Medicine.
References
1. JAMA. 2019 Jul 9;322(2):145-52.
2. Preventive Medicine 2017 May 18;104:46-9.
3. JAMA. 2019 Jul 9;322(2):167-9.
4. JAMA Netw Open. 2019 Jul 3;2(7):e196471.
5. Obstet Gynecol. 2019 May;133(5):952-61.
6. J. Addict Med. 2019 May 10. doi: 10.1097/ADM.0000000000000543.
7. Biol Psychiatry. 2016 Apr 1;79(7):613-9.
A flurry of research papers published this year has simultaneously documented a rise in the use of cannabis during pregnancy and offered more data about its potential harms. This confluence of findings is concerning and highlights the importance of screening our patients for cannabis use and engaging with them in a way in which we can maintain their trust and their commitment to prenatal care.
A retrospective cohort study involving 661,617 women in Ontario found a significant association between self-reported cannabis use in pregnancy and an increased risk of preterm birth (relative risk, 1.41), as well as a greater likelihood of small-for-gestational-age babies (RR, 1.53), placental abruption (RR, 1.72), and transfer to neonatal intensive care (RR, 1.40).1 The study, reported in JAMA in July 2019, carefully matched users with nonusers who had the same characteristics – for example, tobacco use or not.
This new information builds upon other meta-analyses that have demonstrated a decrease in birth weight and greater admittance to the neonatal ICU associated with cannabis use in pregnancy – and it supplements what some research suggests about long-term neurologic development and a potentially increased risk of attention and behavioral problems. Other outcomes that have been noted in long-term neurologic studies of children who were exposed to cannabis in utero include impaired visual acuity, verbal reasoning and comprehension, and short-term memory.2
Increases in use were recently documented in two studies. One, an analysis of data from the National Survey on Drug Use and Health (NSDUH) published in JAMA in June 2019, showed that, between 2002-2003 and 2016-2017, the use of cannabis “in the past month” increased from 3.4% to 7.0% among pregnant women overall, and from 6% to 12% during the first trimester.3
The use of cannabis on a daily or near-daily basis, moreover, increased from 0.9% to 3% among pregnant women overall and from 2% to 5% during the first trimester. The data were collected during face-to-face interviews and were adjusted for age, race/ethnicity, and family income.
In the second study – a cross-sectional study of 367,403 pregnancies among women who filled out a questionnaire on cannabis use during standard prenatal care at Kaiser Permanente Northern California – the adjusted prevalence of use in the year before pregnancy increased from 7% in 2009 to 13% in 2017, and the adjusted prevalence during pregnancy increased from 2% to 3%.4
As in the NSDUH analysis, daily use increased most rapidly (compared with weekly or monthly) such that, by 2017, 25% of those who reported using cannabis in the year before pregnancy – and 21% of those who used cannabis during pregnancy – were daily users. It is notable that Kaiser’s population is diverse in all respects, and that the annual relative rates of increase in cannabis use before and during pregnancy (at each level of frequency) were consistent across racial/ethnic and household income groups.
It’s also worth noting that, in earlier research covering a similar time period (2009-2016), the investigators found significant increases in use via urine toxicology testing that occurs at the first prenatal visit at Kaiser. The increase found through questionnaires, therefore, reflects more than a greater willingness to self-report.
Choosing a screening tool
Universal prenatal substance use screening is recommended by the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention, but we don’t have any specific recommendations on what this means. Who should be screening, and what should that screening look like? Should we use a biologic screen, a standardized screening tool, or simply ask patients whether they use illicit substances?
Screening tools seem advantageous in that they are low cost, noninvasive, potentially comprehensive, and not subject to false-positive results as biologic screens can be – but which tool or tools are best? There are several validated screening tools that can be used outside of pregnancy to determine an individual’s use of illicit substances and whether or not that use is problematic, but previous studies have not used biologic markers to validate substance use screeners in pregnancy. Nor have studies compared screeners in pregnancy.
In our prenatal population in Baltimore, we have not been getting the answers we want using various nonvalidated screening tools. Approximately 30% of patients are positive for cannabis by urine screen, but only half tell us about their use.
Through research in our two prenatal care practices (one serving mostly privately insured and the other serving primarily Medicaid-eligible patients), we assessed both the accuracy and the acceptability of three substance use screening tools that are brief and that have been validated (for the general population) by the World Health Organization for screening of multiple substances: the 4P’s Plus (Parents, Partner, Past, and Pregnancy), the National Institute on Drug Abuse Quick Screen–ASSIST (Modified Alcohol, Smoking and Substance Involvement Screening Test), and the SURP-P (Substance Use Risk Profile–Pregnancy) scale.
In one study, published in May 2019 in Obstetrics & Gynecology, we recruited 500 pregnant women and administered these three tests to each of them.5 We then compared results with those of urine and hair drug testing, and checked the test-retest reliability of each test by readministering them (albeit by telephone) a week later. Although hair testing is not an indicator of current substance use, we used it to validate the screening tools on less-recent use.
The tests with the highest sensitivity and negative predictive values – the qualities we most want for screening – were the SURP-P and the 4P’s Plus (sensitivity of 92.4% and 90.2%, respectively). Overall they were highly sensitive screening tools across all trimesters, races, and age groups, making them more ideal screening tests than the NIDA Quick Screen–ASSIST.
Of the two tests, the 4P’s Plus screening tool was the one preferred by staff from both practices. In a companion qualitative study, we conducted focus-group discussions with 40 practice staff who were responsible for administering or overseeing patient screening.6 The staff, who were unaware of the sensitivity findings, were asked what they thought about the acceptability to patients of each of the three tools and their usability in practice.
Most of the participating staff preferred the 4P’s Plus screening tool for several reasons: It is easy to understand, is brief and to the point, and it has nonjudgmental language and tone. The screener first asks the patient about her parents’ and her partner’s use of alcohol and drugs, and then asks the patient about her own use of alcohol and tobacco. Affirmative responses to these questions lead to additional questions.
The premise is that one’s genetics, history, and current exposures – as well as one’s own use of tobacco and alcohol – are significantly associated with the use of illicit substances. If the patient reports no parental history or partner usage, and has never drank or smoked before, it’s extremely unlikely that she is using other drugs. The progression of questions does indeed seem less judgmental than immediately asking: “Do you use drugs?”
For us, the insight from this staff perception study combined with the findings on accuracy mean that the 4P’s Plus may be the most useful and acceptable screening tool for routine use in prenatal care.
Talking with our patients
The increase in the use of cannabis before and after pregnancy parallels the movement toward state legalization and decriminalization. Historically, clinicians often have relied on illegality as their main focus of counseling when giving recommendations for cessation and abstinence in pregnancy.2 This approach not only leads to punitive counseling, which can fracture the doctor-patient relationship, but increasingly it is no longer valid. In our changing legal climate, we need to provide medically based counseling and be very clear with our patients that legalization does not equate to safety.
It is important that we neither minimize nor overstate the risks. The evidence base for adverse birth outcomes of cannabis use in pregnancy is quite robust, but the associations can be subtle and are moderated by other behaviors and environmental factors that continue to challenge researchers.
As with alcohol, there likely are dose-or trimester-dependent differences in perinatal outcomes, and it’s quite possible that different cannabis products and routes of consumption have different effects. At this point, however, we don’t know the full story, nor do we know the extent to which the literature is biased toward positive correlations – the reporting of adverse effects – compared with negative findings. It is our job as medical care providers to be comfortable in that gray area and to still counsel patients on what we do know, providing the best-possible medical advice based on the information available to us.
In talking with patients, I explain that cannabis may cause a spectrum of problems and that there certainly are risks. I also tell them that we’re uncertain about the conditions and magnitude of that risk and that some babies who are exposed to cannabis in utero may have no perceivable consequences. Such honesty is important for maintaining trust, especially as some patients may see friends and relatives who also are cannabis users have normal pregnancy outcomes.
Much of my concern about cannabis in pregnancy centers on its effect on the developing brain and on long-term neurologic development. I share this with patients – I tell them that cannabis crosses the placenta and may well affect their baby’s brain as it is developing. I explain that I do not know whether this effect would be big or small, but that it’s not a chance I’m willing to take for their baby.
It is also important to educate patients that cannabis products are untested and unregulated and that they may be contaminated with heavy metals, pesticides, and other toxins that may be harmful to themselves and their babies. Patients also should know that the potency of cannabis has been dramatically increasing; research shows that the tetrahydrocannabinol – the psychoactive component – concentration has tripled over the past 2 decades.7
Research tells us that women who use illicit drugs and alcohol categorically engage in some form of harm reduction once they learn they are pregnant, and the same is true for cannabis. This is seen in dramatically different rates of first- and third-trimester use in the new analysis of NSDUH data; third-trimester use is approximately halved.
Some women will not be able to discontinue use, however, or they may try to quit and fail in their attempts. As we should with substance use more broadly, we must meet patients where they are, view cannabis use as a chronic medical problem, offer our assistance in helping them reduce harms of their use, and understand that quitting is a process.
Screening for mental health disorders and trauma is, of course, especially important in patients who use cannabis and other substances recreationally. In cases of medical marijuana usage, I recommend, as ACOG and other have done, that we discuss the risks and benefits of continuing cannabis versus shifting to alternative medications if options exist.
All patients should be welcomed, congratulated on their pregnancy and on coming for prenatal care, and engaged in the overall process of optimizing their health and the health of their baby. Like any other health issue during pregnancy, cannabis use needs to be screened for and treated in an evidence-based manner, but it does not define the trajectory or success of a woman’s pregnancy or her ability to be a successful parent.
Dr. Mark is associate professor of obstetrics, gynecology, and reproductive sciences at the University of Maryland School of Medicine.
References
1. JAMA. 2019 Jul 9;322(2):145-52.
2. Preventive Medicine 2017 May 18;104:46-9.
3. JAMA. 2019 Jul 9;322(2):167-9.
4. JAMA Netw Open. 2019 Jul 3;2(7):e196471.
5. Obstet Gynecol. 2019 May;133(5):952-61.
6. J. Addict Med. 2019 May 10. doi: 10.1097/ADM.0000000000000543.
7. Biol Psychiatry. 2016 Apr 1;79(7):613-9.
A flurry of research papers published this year has simultaneously documented a rise in the use of cannabis during pregnancy and offered more data about its potential harms. This confluence of findings is concerning and highlights the importance of screening our patients for cannabis use and engaging with them in a way in which we can maintain their trust and their commitment to prenatal care.
A retrospective cohort study involving 661,617 women in Ontario found a significant association between self-reported cannabis use in pregnancy and an increased risk of preterm birth (relative risk, 1.41), as well as a greater likelihood of small-for-gestational-age babies (RR, 1.53), placental abruption (RR, 1.72), and transfer to neonatal intensive care (RR, 1.40).1 The study, reported in JAMA in July 2019, carefully matched users with nonusers who had the same characteristics – for example, tobacco use or not.
This new information builds upon other meta-analyses that have demonstrated a decrease in birth weight and greater admittance to the neonatal ICU associated with cannabis use in pregnancy – and it supplements what some research suggests about long-term neurologic development and a potentially increased risk of attention and behavioral problems. Other outcomes that have been noted in long-term neurologic studies of children who were exposed to cannabis in utero include impaired visual acuity, verbal reasoning and comprehension, and short-term memory.2
Increases in use were recently documented in two studies. One, an analysis of data from the National Survey on Drug Use and Health (NSDUH) published in JAMA in June 2019, showed that, between 2002-2003 and 2016-2017, the use of cannabis “in the past month” increased from 3.4% to 7.0% among pregnant women overall, and from 6% to 12% during the first trimester.3
The use of cannabis on a daily or near-daily basis, moreover, increased from 0.9% to 3% among pregnant women overall and from 2% to 5% during the first trimester. The data were collected during face-to-face interviews and were adjusted for age, race/ethnicity, and family income.
In the second study – a cross-sectional study of 367,403 pregnancies among women who filled out a questionnaire on cannabis use during standard prenatal care at Kaiser Permanente Northern California – the adjusted prevalence of use in the year before pregnancy increased from 7% in 2009 to 13% in 2017, and the adjusted prevalence during pregnancy increased from 2% to 3%.4
As in the NSDUH analysis, daily use increased most rapidly (compared with weekly or monthly) such that, by 2017, 25% of those who reported using cannabis in the year before pregnancy – and 21% of those who used cannabis during pregnancy – were daily users. It is notable that Kaiser’s population is diverse in all respects, and that the annual relative rates of increase in cannabis use before and during pregnancy (at each level of frequency) were consistent across racial/ethnic and household income groups.
It’s also worth noting that, in earlier research covering a similar time period (2009-2016), the investigators found significant increases in use via urine toxicology testing that occurs at the first prenatal visit at Kaiser. The increase found through questionnaires, therefore, reflects more than a greater willingness to self-report.
Choosing a screening tool
Universal prenatal substance use screening is recommended by the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention, but we don’t have any specific recommendations on what this means. Who should be screening, and what should that screening look like? Should we use a biologic screen, a standardized screening tool, or simply ask patients whether they use illicit substances?
Screening tools seem advantageous in that they are low cost, noninvasive, potentially comprehensive, and not subject to false-positive results as biologic screens can be – but which tool or tools are best? There are several validated screening tools that can be used outside of pregnancy to determine an individual’s use of illicit substances and whether or not that use is problematic, but previous studies have not used biologic markers to validate substance use screeners in pregnancy. Nor have studies compared screeners in pregnancy.
In our prenatal population in Baltimore, we have not been getting the answers we want using various nonvalidated screening tools. Approximately 30% of patients are positive for cannabis by urine screen, but only half tell us about their use.
Through research in our two prenatal care practices (one serving mostly privately insured and the other serving primarily Medicaid-eligible patients), we assessed both the accuracy and the acceptability of three substance use screening tools that are brief and that have been validated (for the general population) by the World Health Organization for screening of multiple substances: the 4P’s Plus (Parents, Partner, Past, and Pregnancy), the National Institute on Drug Abuse Quick Screen–ASSIST (Modified Alcohol, Smoking and Substance Involvement Screening Test), and the SURP-P (Substance Use Risk Profile–Pregnancy) scale.
In one study, published in May 2019 in Obstetrics & Gynecology, we recruited 500 pregnant women and administered these three tests to each of them.5 We then compared results with those of urine and hair drug testing, and checked the test-retest reliability of each test by readministering them (albeit by telephone) a week later. Although hair testing is not an indicator of current substance use, we used it to validate the screening tools on less-recent use.
The tests with the highest sensitivity and negative predictive values – the qualities we most want for screening – were the SURP-P and the 4P’s Plus (sensitivity of 92.4% and 90.2%, respectively). Overall they were highly sensitive screening tools across all trimesters, races, and age groups, making them more ideal screening tests than the NIDA Quick Screen–ASSIST.
Of the two tests, the 4P’s Plus screening tool was the one preferred by staff from both practices. In a companion qualitative study, we conducted focus-group discussions with 40 practice staff who were responsible for administering or overseeing patient screening.6 The staff, who were unaware of the sensitivity findings, were asked what they thought about the acceptability to patients of each of the three tools and their usability in practice.
Most of the participating staff preferred the 4P’s Plus screening tool for several reasons: It is easy to understand, is brief and to the point, and it has nonjudgmental language and tone. The screener first asks the patient about her parents’ and her partner’s use of alcohol and drugs, and then asks the patient about her own use of alcohol and tobacco. Affirmative responses to these questions lead to additional questions.
The premise is that one’s genetics, history, and current exposures – as well as one’s own use of tobacco and alcohol – are significantly associated with the use of illicit substances. If the patient reports no parental history or partner usage, and has never drank or smoked before, it’s extremely unlikely that she is using other drugs. The progression of questions does indeed seem less judgmental than immediately asking: “Do you use drugs?”
For us, the insight from this staff perception study combined with the findings on accuracy mean that the 4P’s Plus may be the most useful and acceptable screening tool for routine use in prenatal care.
Talking with our patients
The increase in the use of cannabis before and after pregnancy parallels the movement toward state legalization and decriminalization. Historically, clinicians often have relied on illegality as their main focus of counseling when giving recommendations for cessation and abstinence in pregnancy.2 This approach not only leads to punitive counseling, which can fracture the doctor-patient relationship, but increasingly it is no longer valid. In our changing legal climate, we need to provide medically based counseling and be very clear with our patients that legalization does not equate to safety.
It is important that we neither minimize nor overstate the risks. The evidence base for adverse birth outcomes of cannabis use in pregnancy is quite robust, but the associations can be subtle and are moderated by other behaviors and environmental factors that continue to challenge researchers.
As with alcohol, there likely are dose-or trimester-dependent differences in perinatal outcomes, and it’s quite possible that different cannabis products and routes of consumption have different effects. At this point, however, we don’t know the full story, nor do we know the extent to which the literature is biased toward positive correlations – the reporting of adverse effects – compared with negative findings. It is our job as medical care providers to be comfortable in that gray area and to still counsel patients on what we do know, providing the best-possible medical advice based on the information available to us.
In talking with patients, I explain that cannabis may cause a spectrum of problems and that there certainly are risks. I also tell them that we’re uncertain about the conditions and magnitude of that risk and that some babies who are exposed to cannabis in utero may have no perceivable consequences. Such honesty is important for maintaining trust, especially as some patients may see friends and relatives who also are cannabis users have normal pregnancy outcomes.
Much of my concern about cannabis in pregnancy centers on its effect on the developing brain and on long-term neurologic development. I share this with patients – I tell them that cannabis crosses the placenta and may well affect their baby’s brain as it is developing. I explain that I do not know whether this effect would be big or small, but that it’s not a chance I’m willing to take for their baby.
It is also important to educate patients that cannabis products are untested and unregulated and that they may be contaminated with heavy metals, pesticides, and other toxins that may be harmful to themselves and their babies. Patients also should know that the potency of cannabis has been dramatically increasing; research shows that the tetrahydrocannabinol – the psychoactive component – concentration has tripled over the past 2 decades.7
Research tells us that women who use illicit drugs and alcohol categorically engage in some form of harm reduction once they learn they are pregnant, and the same is true for cannabis. This is seen in dramatically different rates of first- and third-trimester use in the new analysis of NSDUH data; third-trimester use is approximately halved.
Some women will not be able to discontinue use, however, or they may try to quit and fail in their attempts. As we should with substance use more broadly, we must meet patients where they are, view cannabis use as a chronic medical problem, offer our assistance in helping them reduce harms of their use, and understand that quitting is a process.
Screening for mental health disorders and trauma is, of course, especially important in patients who use cannabis and other substances recreationally. In cases of medical marijuana usage, I recommend, as ACOG and other have done, that we discuss the risks and benefits of continuing cannabis versus shifting to alternative medications if options exist.
All patients should be welcomed, congratulated on their pregnancy and on coming for prenatal care, and engaged in the overall process of optimizing their health and the health of their baby. Like any other health issue during pregnancy, cannabis use needs to be screened for and treated in an evidence-based manner, but it does not define the trajectory or success of a woman’s pregnancy or her ability to be a successful parent.
Dr. Mark is associate professor of obstetrics, gynecology, and reproductive sciences at the University of Maryland School of Medicine.
References
1. JAMA. 2019 Jul 9;322(2):145-52.
2. Preventive Medicine 2017 May 18;104:46-9.
3. JAMA. 2019 Jul 9;322(2):167-9.
4. JAMA Netw Open. 2019 Jul 3;2(7):e196471.
5. Obstet Gynecol. 2019 May;133(5):952-61.
6. J. Addict Med. 2019 May 10. doi: 10.1097/ADM.0000000000000543.
7. Biol Psychiatry. 2016 Apr 1;79(7):613-9.
Moroccan Health Care: A Link to Radicalization and Proposed Solution
The relationship between the Kingdom of Morocco and the US began just after the US declared its own independence. It is one of the oldest of US partnerships with a foreign country, and since the end of the First Barbary War in 1805 it has remained one of the most stable. The Utah National Guard (UTNG) has an active state partnership program (SPP) with Morocco, which helps maintain that stability and fosters the relationship. The SPP provides the Kingdom of Morocco assistance in the areas of disaster medicine, prehospital medicine, and rural access to health care.
The objective of this review is to highlight the role the SPP plays in ensuring Morocco’s continued stability, enhancing its role as a leader among African nations, aiding its medically vulnerable rural populations to prevent recruitment by terrorist organizations, and maintaining its long-term relationship with the US.
Background
The Kingdom of Morocco resides in a geologically and politically unstable part of the world, yet it has been a stable constitutional monarchy. Like California, Morocco has a long coastline of more than 1,000 miles. It sits along an active earthquake fault line with a disaster response program that is only in its infancy. The Kingdom has a high youth unemployment rate and lacks adequate public education opportunities, which exacerbate feelings of government indifference. Morocco’s medical system is highly centralized, and large parts of the rural population lack access to basic medical care—potentially alienating the population. The Moroccan current disaster plan ORSEC (plan d’ Organization des Secours) was established in 1966 and updated in 2005 but does not provide a comprehensive, unified disaster response. The ORSEC plan is of French derivation and is not a list of actions but a general plan of organization and supply. 1
When governments fail to provide basic services—health care being just one—those services may be filled by groups seeking to influence the government and population by threatening acts of violence to achieve political, religious, and ideologic gain; for example, the Taliban in Afghanistan, the Muslim brotherhood in Egypt and in the West Bank, and the Islamic State in Iraq and Syria (ISIS) in Syria.2-5 These groups gain a foothold and legitimacy by providing mosques, youth groups, clinics, hospitals, and schools. 2-5
Identified Needs
Morocco is at risk of experiencing an earthquake and possible subsequent tsunami. In 1755, Morocco was impacted by the Great Lisbon earthquake and tsunami. Witnesses reported 15-meter waves with 24-meter crests.6 Building codes and architecture laws have changed little since the 1960 Agadir earthquake, which killed 12,000 people. The disaster response program—although improved since the 1960s—is still in the early stages of development, and another earthquake and possible subsequent tsunami would result in a disaster that could overwhelm the medical community of Morocco.
Perceived Government Indifference
The Moroccan constitutional monarchy is more stable than are the governments of its North African neighbors. King Mohammed VI presides over the government, and regular elections are held for members of Parliament, which names a prime minister. However, in August 2019, overall unemployment was at 8.5%, and youth unemployment was 22.3%.7 A United Nations report in August 2019 stated that literacy rates for Morocco were 71.7%. These data were from a 2015 census, the last year data were collected.8 These deficits in employment and education can foster anger toward the Moroccan government for not adequately providing these services and possibly introduce radicalization as a result of the population’s perceived government indifference and lack of economic mobility.
Access to Medical Care
Morocco has a 2-tiered medical system for providing services: urban and rural. In 2018 the Legatum Prosperity Index ranked Morocco 103 of 149 countries in health care. The prosperity index measures health variables, which include but were not limited to basic physical and mental health, health infrastructure, and preventive care.9 Outside the metropolitan areas, emergency medical care is nonexistent, primary care is sporadic, and there is little modern technology available.
Despite humanitarian efforts over many years, there is little to no medical care in the rural “medical desert.” A 2017 study from the University of Washington Institute for Health Metrics and Evaluation compared the global burden of disease in similar countries. The study found that Morocco was significantly higher than the mean in the prevalence of ischemic heart disease and Alzheimer disease, lower than the mean in the areas of neonatal disorders, lower respiratory infections, and tuberculosis, and statistically indistinct from the mean in stroke, congenital defects, road injuries, diabetes mellitus, and hypertensive heart disease compared with the disease prevalence of other countries of similar size and economic measures.10 The study also found a particularly acute disparity in access to health care in rural areas. In 2016, the Oxford Business Group reported staff shortages and disproportionate distribution of resources in the Moroccan health care system.11
Additionally, the lack of trained health care personnel has added to an already overstressed health care system. A chief stressor in a health care system is an insufficient replacement rate. Health employees working for the Moroccan Ministry of Health retire at a rate of 1,500 per year.10,11 These shortages may serve to further the feelings of frustration and government indifference. This frustration is momentarily decreased by humanitarian efforts that have taken place in the African continent in the past decades, but this band-aid approach to assisting the population that is medically underserved has done little to alleviate the long-term problem of access to care. And feelings of government abandonment can sow the seeds of discontent in the rural population, creating fertile ground for recruitment by terrorist organizations.2,3
Lack of Health Care and Radicalism
It has been postulated that there is a link between radicalization and lack of medical care. Depression and perceived government indifference are considered contributors to radicalization.12-16 In 2005, Victoroff suggested that there are certain psychological traits characteristic of “typical" terrorists: these include high affective valence regarding an ideologic issue, a personal stake (perceived oppression, persecution or humiliation, need for identity, glory, or vengeance), low cognitive ability, low tolerance for ambiguity, and a capacity to suppress instinctive and learned moral constraints against harming innocents.15 In 2009, Lafree and Ackerman suggested that terrorism feeds on the ability of groups to portray governments and their agents as illegitimate.16 It is possible that part of the illegitimacy campaign of radicalization and terrorist recruitment may be identification of the lack of health care by the government thus magnifying feelings of government abandonment in a vulnerable population.
In 2011, the new Moroccan constitution identified access to basic health care as a right of the Moroccan people.17 Additionally, in 2013, a government white paper was produced outlining the need to increase access to health care, particularly in rural areas, including a focus on infant and maternal mortality, diabetes mellitus (DM), heart disease, and respiratory problems.17,18
Proposed Solutions, A Beginning
A health outreach program with a regional health professional training center in a relatively stable country within the African Union (AU) would be a step toward delivering health care to Morocco and interested AU members. Interested nations have been and will continue to be invited to train at the Moroccan center and return to their countries and start training programs. This idea was echoed by the World Bank in a 2015 loan proposal to Morocco, which suggested that addressing disparities in access to health care is a social justice issue, with other benefits such as increased productivity, employment, lower out-of-pocket expenditures, and promotion of good governance.17
In 2012, Buhi reported that a positive regard for authorities and healthier influences seemed to be a protective factor against radicalization. He also suggested a public health approach to understanding and preventing violent radicalization.19 The solutions are complex, especially in rural areas and in vulnerable nations common to Africa.
Medical training efforts by the US Department of Defense (DoD), Medical Readiness Training Institute (DMRT), and international health specialists working with the military and civilian entities in neighboring African countries have improved response to regional disasters. However, to address the broader issues, a more permanent, cooperative possible solution may begin with the establishment in Morocco of a regional education center for disaster preparedness and for health care providers (HCPs). This would serve as a training program for disaster first responders. Graduates of the program would receive additional training to become HCPs similar to physician assistant (PA) and nurse practitioner (NP) programs in the US. Morocco is uniquely positioned to accomplish this due to its location, political stability, and ties with other African nations.
The goal of the Moroccan regional education center (within the King Mohammed V Hospital) is to bring together global health experts and increase the intellectual infrastructure of not only Morocco, but also offer this training program to interested countries within the AU. Advancement of the regional education center will require legislative changes to expand prescriptive privileges and scope of practice within each country. The medical element of the SPP as presently constituted without the regional education center will continue its humanitarian goals, but the proposed creation of the regional education center will educate participants to serve the rural communities within each participating country. Eventually the entire educational program will be the responsibility of the Moroccan military and the AU participants. This will require reprioritizing resources from the provision of humanitarian health care services to an HCP education approach.
Disaster Response
Deficits in disaster response capabilities have been identified by members of the Moroccan military with the assistance of the UTNG. The most glaring deficit identified was the disparity in training between military and civilian first responders. Thus, a training program was initiated by the Moroccan military and the UTNG that combined internationally recognized, durable, robust emergency training programs. These programs consisted of, but were not limited to, parts or entire programs of the following: basic disaster life support, advanced disaster life support, disaster casualty care, and advanced trauma life support. The goal of this training was to improve communication, reduce mortality, and create strike teams, which can quickly provide health care independent of a hospital during a disaster.
Patients can overwhelm hospitals in a disaster when need exceeds resources. In 1996, Mallonee reported that at least 67% of the patients who sought care at a hospital during the Oklahoma City bombing disaster did not need advanced medical treatment.20 Such patients could be seen at an identified casualty collection point by a strike team and treated and released rather than traveling to the hospital and using staff and resources that could be used more judiciously for the more seriously injured.21 These teams consist of trained first responders with an experienced HCP (physician, PA, NP) and a nurse and are trained to operate for up to 72 hours in a predetermined location and serve as a “filter” for the hospital. Their role is to treat and release the less severely injured and refer only the more severely injured to the hospital after basic stabilization, thus preserving precious resources necessary for the more seriously injured.
This disaster response training program was offered to the Moroccan military, ministry of health and ministry of tourism, and quickly turned into an Africa-wide interest. A regional training center was proposed. This was assisted with the cooperation of Weber State University in Ogden Utah, Utah Valley University in Orem, and private interests in a public/private/military state partnership. Program supplies and didactic instruction were and will be provided by the UTNG and supplemented through the DoD Africa command. Instruction will be a cooperative effort agreed on between the UTNG and the Moroccan military medical specialists within their specific area of expertise.
Underserved Communities
Finally, from this pool of interested strike team members, a health care provider school will be formed to educate, certify, and service the needs of the underserved communities in Morocco and interested AU countries. This program will be similar to the PA and NP programs in the US and will be geared to those graduates from the previous programs with intense classroom instruction for one year followed by a year of one-on-one preceptorship with an experienced physician. The goal of the program is to prepare individuals with patient care experience to fulfill a bigger role in health care in an underserved (usually austere, rural) area that currently has minimal health care presence. This fills a need identified by the World Bank in 2015 that the Moroccan government needs to respond to the demand for improved access to and quality of health care services—particularly to the rural poor.17
The Moroccan military has a presence in many medically underserved areas. The logical fit for the HCP program will be drawn from a pool of active-duty military individuals who express an interest and qualify through attendance in all phases of the training.
Conclusion
This program of disaster medical education, strike teams, and HCPs is currently training more than 200 students a year throughout Morocco. The proposed direction of this cooperative program to produce HCPs in rural areas will increase access to health care for the Moroccan people who are now underserved. Morocco, as a health care training hub in Africa, will increase access to health care for interested African countries. The goal politically will be to reduce feelings of government indifference in vulnerable populations and reduce recruitment into radical ideologies.
1. Nahon M, Michaloux M. L’organisation de la réponse de la sécurité civile: le dispositif ORSEC Organisation of civilian emergency services: The ORSEC plan. https://www.sciencedirect.com/science/article/pii/S2211423816300499#! Published July 2016. Accessed October 7, 2019.
2. Berman E. Hamas, Taliban and the Jewish underground: an economist's view of radical religious militias. NBER Working Paper No. w10004. https://ssrn.com/abstract=450885. Published September 2003. Accessed October 7, 2019.
3. Jordan J. Attacking the leader. Missing the mark; why terrorist groups survive decapitation strikes. Int Secur. 2014;38(4):7-38.
4. Grynkewich A. Welfare as warfare: how violent non-state groups use social services to attack the state. Stud Conflict Terrorism. 2008;31(4):350-370.
5. Marin M, Solomon H. Islamic State: understanding the nature of the beast and its funding. Contemp Rev Middle East. 2017;4(1):18-49.
6. Bressan D. November 1, 1755: the earthquake of Lisbon: wrath of god or natural disaster? Scientific American, History of Geology. https://blogs.scientificamerican.com/history-of-geology/november-1-1755-the-earthquake-of-lisbon-wraith-of-god-or-natural-disaster. Published November 2011. Accessed October 7, 2019.
7. Trading Economics. Morocco unemployment rate. Second quarter statistics. August 2019. https://tradingeconomics.com/morocco/unemployment-rate. Accessed October 7, 2019.
8. Knoema World Data Atlas 2015. Morocco adult literacy rates. https://knoema.com/atlas/Morocco/topics/Education/Literacy/Adult-literacy-rate. Accessed October 4, 2019.
9. The Legatum Prosperity Index 2018. Morocco. https://www.prosperity.com/globe/morocco. Accessed October 7, 2019.
10. University of Washington, Institute for Health Metrics and Evaluation. Morocco. http://www.healthdata.org/morocco. Published 2018. Accessed October 7, 2019.
11. Oxford Business Group. Access to health care broadens in Morocco. https://oxfordbusinessgroup.com/overview/forward-steps-access-care-has-broadened-and-infrastructure-improved-challenges-remain. Accessed September 12. 2019.
12. Wright NMJ, Hankins FM. Preventing radicalization and terrorism: Is there a GP response? Br J Gen Pract. 2016;66(647):288-289.
13. Buhi K, Everitt K, Jones E. Might depression psychosocial adversity, and limited social assets explain vulnerability to and resistance against violent radicalization? PlosOne. 2014;9(9):e105918.
14. DeAngelis T. Understanding terrorism. apa.org/monitor/2009/11/terrorism. Published November 2009. Accessed October 14, 2019.
15. Victoroff J. The mind of the terrorist: a review and critique of psychological approaches. J Conflict Resolut. 2005;49(1):3-42.
16. Lafree G, Ackerman G. The empirical study of terrorism: social and legal research. Ann Rev Law Soc Sci. 2009;5:347-374.
17. World Bank. Morocco—improving primary health in rural areas program-for-results project (English). http://documents.worldbank.org/curated/en/716821468274482723/Morocco-Improving-Primary-Health-in-Rural-Areas-Program-for-Results-Project. Published 2015. Accessed September 16, 2019.
18. Royaume du Maroc, Ministère de la Santé. Livre blanc: pour une nouvelle gouvernance du secteur de la santé. Paper presented at: 2nd National Health Conference; July 1-3, 2013; Marrakesh, Morocco.
19. Buhi K, Hicks MH, Lashley M, Jones E. A public health approach to understanding and preventing violent radicalization. BMC Med. 2012;10:16.
20. Mallonee S, Sahriat S, Stennies G, Waxweiler R, Hogan D, Jordan F. Physical injuries and fatalities resulting from the Oklahoma City bombing. JAMA. 1996;276(5):382-387.
21. Ushizawa H, Foxwell AR, Bice S, et al. Needs for disaster medicine: lessons from the field of the Great East Japan Earthquake. Western Pac Surveil Response J. 2013;4(1):51-55.
The relationship between the Kingdom of Morocco and the US began just after the US declared its own independence. It is one of the oldest of US partnerships with a foreign country, and since the end of the First Barbary War in 1805 it has remained one of the most stable. The Utah National Guard (UTNG) has an active state partnership program (SPP) with Morocco, which helps maintain that stability and fosters the relationship. The SPP provides the Kingdom of Morocco assistance in the areas of disaster medicine, prehospital medicine, and rural access to health care.
The objective of this review is to highlight the role the SPP plays in ensuring Morocco’s continued stability, enhancing its role as a leader among African nations, aiding its medically vulnerable rural populations to prevent recruitment by terrorist organizations, and maintaining its long-term relationship with the US.
Background
The Kingdom of Morocco resides in a geologically and politically unstable part of the world, yet it has been a stable constitutional monarchy. Like California, Morocco has a long coastline of more than 1,000 miles. It sits along an active earthquake fault line with a disaster response program that is only in its infancy. The Kingdom has a high youth unemployment rate and lacks adequate public education opportunities, which exacerbate feelings of government indifference. Morocco’s medical system is highly centralized, and large parts of the rural population lack access to basic medical care—potentially alienating the population. The Moroccan current disaster plan ORSEC (plan d’ Organization des Secours) was established in 1966 and updated in 2005 but does not provide a comprehensive, unified disaster response. The ORSEC plan is of French derivation and is not a list of actions but a general plan of organization and supply. 1
When governments fail to provide basic services—health care being just one—those services may be filled by groups seeking to influence the government and population by threatening acts of violence to achieve political, religious, and ideologic gain; for example, the Taliban in Afghanistan, the Muslim brotherhood in Egypt and in the West Bank, and the Islamic State in Iraq and Syria (ISIS) in Syria.2-5 These groups gain a foothold and legitimacy by providing mosques, youth groups, clinics, hospitals, and schools. 2-5
Identified Needs
Morocco is at risk of experiencing an earthquake and possible subsequent tsunami. In 1755, Morocco was impacted by the Great Lisbon earthquake and tsunami. Witnesses reported 15-meter waves with 24-meter crests.6 Building codes and architecture laws have changed little since the 1960 Agadir earthquake, which killed 12,000 people. The disaster response program—although improved since the 1960s—is still in the early stages of development, and another earthquake and possible subsequent tsunami would result in a disaster that could overwhelm the medical community of Morocco.
Perceived Government Indifference
The Moroccan constitutional monarchy is more stable than are the governments of its North African neighbors. King Mohammed VI presides over the government, and regular elections are held for members of Parliament, which names a prime minister. However, in August 2019, overall unemployment was at 8.5%, and youth unemployment was 22.3%.7 A United Nations report in August 2019 stated that literacy rates for Morocco were 71.7%. These data were from a 2015 census, the last year data were collected.8 These deficits in employment and education can foster anger toward the Moroccan government for not adequately providing these services and possibly introduce radicalization as a result of the population’s perceived government indifference and lack of economic mobility.
Access to Medical Care
Morocco has a 2-tiered medical system for providing services: urban and rural. In 2018 the Legatum Prosperity Index ranked Morocco 103 of 149 countries in health care. The prosperity index measures health variables, which include but were not limited to basic physical and mental health, health infrastructure, and preventive care.9 Outside the metropolitan areas, emergency medical care is nonexistent, primary care is sporadic, and there is little modern technology available.
Despite humanitarian efforts over many years, there is little to no medical care in the rural “medical desert.” A 2017 study from the University of Washington Institute for Health Metrics and Evaluation compared the global burden of disease in similar countries. The study found that Morocco was significantly higher than the mean in the prevalence of ischemic heart disease and Alzheimer disease, lower than the mean in the areas of neonatal disorders, lower respiratory infections, and tuberculosis, and statistically indistinct from the mean in stroke, congenital defects, road injuries, diabetes mellitus, and hypertensive heart disease compared with the disease prevalence of other countries of similar size and economic measures.10 The study also found a particularly acute disparity in access to health care in rural areas. In 2016, the Oxford Business Group reported staff shortages and disproportionate distribution of resources in the Moroccan health care system.11
Additionally, the lack of trained health care personnel has added to an already overstressed health care system. A chief stressor in a health care system is an insufficient replacement rate. Health employees working for the Moroccan Ministry of Health retire at a rate of 1,500 per year.10,11 These shortages may serve to further the feelings of frustration and government indifference. This frustration is momentarily decreased by humanitarian efforts that have taken place in the African continent in the past decades, but this band-aid approach to assisting the population that is medically underserved has done little to alleviate the long-term problem of access to care. And feelings of government abandonment can sow the seeds of discontent in the rural population, creating fertile ground for recruitment by terrorist organizations.2,3
Lack of Health Care and Radicalism
It has been postulated that there is a link between radicalization and lack of medical care. Depression and perceived government indifference are considered contributors to radicalization.12-16 In 2005, Victoroff suggested that there are certain psychological traits characteristic of “typical" terrorists: these include high affective valence regarding an ideologic issue, a personal stake (perceived oppression, persecution or humiliation, need for identity, glory, or vengeance), low cognitive ability, low tolerance for ambiguity, and a capacity to suppress instinctive and learned moral constraints against harming innocents.15 In 2009, Lafree and Ackerman suggested that terrorism feeds on the ability of groups to portray governments and their agents as illegitimate.16 It is possible that part of the illegitimacy campaign of radicalization and terrorist recruitment may be identification of the lack of health care by the government thus magnifying feelings of government abandonment in a vulnerable population.
In 2011, the new Moroccan constitution identified access to basic health care as a right of the Moroccan people.17 Additionally, in 2013, a government white paper was produced outlining the need to increase access to health care, particularly in rural areas, including a focus on infant and maternal mortality, diabetes mellitus (DM), heart disease, and respiratory problems.17,18
Proposed Solutions, A Beginning
A health outreach program with a regional health professional training center in a relatively stable country within the African Union (AU) would be a step toward delivering health care to Morocco and interested AU members. Interested nations have been and will continue to be invited to train at the Moroccan center and return to their countries and start training programs. This idea was echoed by the World Bank in a 2015 loan proposal to Morocco, which suggested that addressing disparities in access to health care is a social justice issue, with other benefits such as increased productivity, employment, lower out-of-pocket expenditures, and promotion of good governance.17
In 2012, Buhi reported that a positive regard for authorities and healthier influences seemed to be a protective factor against radicalization. He also suggested a public health approach to understanding and preventing violent radicalization.19 The solutions are complex, especially in rural areas and in vulnerable nations common to Africa.
Medical training efforts by the US Department of Defense (DoD), Medical Readiness Training Institute (DMRT), and international health specialists working with the military and civilian entities in neighboring African countries have improved response to regional disasters. However, to address the broader issues, a more permanent, cooperative possible solution may begin with the establishment in Morocco of a regional education center for disaster preparedness and for health care providers (HCPs). This would serve as a training program for disaster first responders. Graduates of the program would receive additional training to become HCPs similar to physician assistant (PA) and nurse practitioner (NP) programs in the US. Morocco is uniquely positioned to accomplish this due to its location, political stability, and ties with other African nations.
The goal of the Moroccan regional education center (within the King Mohammed V Hospital) is to bring together global health experts and increase the intellectual infrastructure of not only Morocco, but also offer this training program to interested countries within the AU. Advancement of the regional education center will require legislative changes to expand prescriptive privileges and scope of practice within each country. The medical element of the SPP as presently constituted without the regional education center will continue its humanitarian goals, but the proposed creation of the regional education center will educate participants to serve the rural communities within each participating country. Eventually the entire educational program will be the responsibility of the Moroccan military and the AU participants. This will require reprioritizing resources from the provision of humanitarian health care services to an HCP education approach.
Disaster Response
Deficits in disaster response capabilities have been identified by members of the Moroccan military with the assistance of the UTNG. The most glaring deficit identified was the disparity in training between military and civilian first responders. Thus, a training program was initiated by the Moroccan military and the UTNG that combined internationally recognized, durable, robust emergency training programs. These programs consisted of, but were not limited to, parts or entire programs of the following: basic disaster life support, advanced disaster life support, disaster casualty care, and advanced trauma life support. The goal of this training was to improve communication, reduce mortality, and create strike teams, which can quickly provide health care independent of a hospital during a disaster.
Patients can overwhelm hospitals in a disaster when need exceeds resources. In 1996, Mallonee reported that at least 67% of the patients who sought care at a hospital during the Oklahoma City bombing disaster did not need advanced medical treatment.20 Such patients could be seen at an identified casualty collection point by a strike team and treated and released rather than traveling to the hospital and using staff and resources that could be used more judiciously for the more seriously injured.21 These teams consist of trained first responders with an experienced HCP (physician, PA, NP) and a nurse and are trained to operate for up to 72 hours in a predetermined location and serve as a “filter” for the hospital. Their role is to treat and release the less severely injured and refer only the more severely injured to the hospital after basic stabilization, thus preserving precious resources necessary for the more seriously injured.
This disaster response training program was offered to the Moroccan military, ministry of health and ministry of tourism, and quickly turned into an Africa-wide interest. A regional training center was proposed. This was assisted with the cooperation of Weber State University in Ogden Utah, Utah Valley University in Orem, and private interests in a public/private/military state partnership. Program supplies and didactic instruction were and will be provided by the UTNG and supplemented through the DoD Africa command. Instruction will be a cooperative effort agreed on between the UTNG and the Moroccan military medical specialists within their specific area of expertise.
Underserved Communities
Finally, from this pool of interested strike team members, a health care provider school will be formed to educate, certify, and service the needs of the underserved communities in Morocco and interested AU countries. This program will be similar to the PA and NP programs in the US and will be geared to those graduates from the previous programs with intense classroom instruction for one year followed by a year of one-on-one preceptorship with an experienced physician. The goal of the program is to prepare individuals with patient care experience to fulfill a bigger role in health care in an underserved (usually austere, rural) area that currently has minimal health care presence. This fills a need identified by the World Bank in 2015 that the Moroccan government needs to respond to the demand for improved access to and quality of health care services—particularly to the rural poor.17
The Moroccan military has a presence in many medically underserved areas. The logical fit for the HCP program will be drawn from a pool of active-duty military individuals who express an interest and qualify through attendance in all phases of the training.
Conclusion
This program of disaster medical education, strike teams, and HCPs is currently training more than 200 students a year throughout Morocco. The proposed direction of this cooperative program to produce HCPs in rural areas will increase access to health care for the Moroccan people who are now underserved. Morocco, as a health care training hub in Africa, will increase access to health care for interested African countries. The goal politically will be to reduce feelings of government indifference in vulnerable populations and reduce recruitment into radical ideologies.
The relationship between the Kingdom of Morocco and the US began just after the US declared its own independence. It is one of the oldest of US partnerships with a foreign country, and since the end of the First Barbary War in 1805 it has remained one of the most stable. The Utah National Guard (UTNG) has an active state partnership program (SPP) with Morocco, which helps maintain that stability and fosters the relationship. The SPP provides the Kingdom of Morocco assistance in the areas of disaster medicine, prehospital medicine, and rural access to health care.
The objective of this review is to highlight the role the SPP plays in ensuring Morocco’s continued stability, enhancing its role as a leader among African nations, aiding its medically vulnerable rural populations to prevent recruitment by terrorist organizations, and maintaining its long-term relationship with the US.
Background
The Kingdom of Morocco resides in a geologically and politically unstable part of the world, yet it has been a stable constitutional monarchy. Like California, Morocco has a long coastline of more than 1,000 miles. It sits along an active earthquake fault line with a disaster response program that is only in its infancy. The Kingdom has a high youth unemployment rate and lacks adequate public education opportunities, which exacerbate feelings of government indifference. Morocco’s medical system is highly centralized, and large parts of the rural population lack access to basic medical care—potentially alienating the population. The Moroccan current disaster plan ORSEC (plan d’ Organization des Secours) was established in 1966 and updated in 2005 but does not provide a comprehensive, unified disaster response. The ORSEC plan is of French derivation and is not a list of actions but a general plan of organization and supply. 1
When governments fail to provide basic services—health care being just one—those services may be filled by groups seeking to influence the government and population by threatening acts of violence to achieve political, religious, and ideologic gain; for example, the Taliban in Afghanistan, the Muslim brotherhood in Egypt and in the West Bank, and the Islamic State in Iraq and Syria (ISIS) in Syria.2-5 These groups gain a foothold and legitimacy by providing mosques, youth groups, clinics, hospitals, and schools. 2-5
Identified Needs
Morocco is at risk of experiencing an earthquake and possible subsequent tsunami. In 1755, Morocco was impacted by the Great Lisbon earthquake and tsunami. Witnesses reported 15-meter waves with 24-meter crests.6 Building codes and architecture laws have changed little since the 1960 Agadir earthquake, which killed 12,000 people. The disaster response program—although improved since the 1960s—is still in the early stages of development, and another earthquake and possible subsequent tsunami would result in a disaster that could overwhelm the medical community of Morocco.
Perceived Government Indifference
The Moroccan constitutional monarchy is more stable than are the governments of its North African neighbors. King Mohammed VI presides over the government, and regular elections are held for members of Parliament, which names a prime minister. However, in August 2019, overall unemployment was at 8.5%, and youth unemployment was 22.3%.7 A United Nations report in August 2019 stated that literacy rates for Morocco were 71.7%. These data were from a 2015 census, the last year data were collected.8 These deficits in employment and education can foster anger toward the Moroccan government for not adequately providing these services and possibly introduce radicalization as a result of the population’s perceived government indifference and lack of economic mobility.
Access to Medical Care
Morocco has a 2-tiered medical system for providing services: urban and rural. In 2018 the Legatum Prosperity Index ranked Morocco 103 of 149 countries in health care. The prosperity index measures health variables, which include but were not limited to basic physical and mental health, health infrastructure, and preventive care.9 Outside the metropolitan areas, emergency medical care is nonexistent, primary care is sporadic, and there is little modern technology available.
Despite humanitarian efforts over many years, there is little to no medical care in the rural “medical desert.” A 2017 study from the University of Washington Institute for Health Metrics and Evaluation compared the global burden of disease in similar countries. The study found that Morocco was significantly higher than the mean in the prevalence of ischemic heart disease and Alzheimer disease, lower than the mean in the areas of neonatal disorders, lower respiratory infections, and tuberculosis, and statistically indistinct from the mean in stroke, congenital defects, road injuries, diabetes mellitus, and hypertensive heart disease compared with the disease prevalence of other countries of similar size and economic measures.10 The study also found a particularly acute disparity in access to health care in rural areas. In 2016, the Oxford Business Group reported staff shortages and disproportionate distribution of resources in the Moroccan health care system.11
Additionally, the lack of trained health care personnel has added to an already overstressed health care system. A chief stressor in a health care system is an insufficient replacement rate. Health employees working for the Moroccan Ministry of Health retire at a rate of 1,500 per year.10,11 These shortages may serve to further the feelings of frustration and government indifference. This frustration is momentarily decreased by humanitarian efforts that have taken place in the African continent in the past decades, but this band-aid approach to assisting the population that is medically underserved has done little to alleviate the long-term problem of access to care. And feelings of government abandonment can sow the seeds of discontent in the rural population, creating fertile ground for recruitment by terrorist organizations.2,3
Lack of Health Care and Radicalism
It has been postulated that there is a link between radicalization and lack of medical care. Depression and perceived government indifference are considered contributors to radicalization.12-16 In 2005, Victoroff suggested that there are certain psychological traits characteristic of “typical" terrorists: these include high affective valence regarding an ideologic issue, a personal stake (perceived oppression, persecution or humiliation, need for identity, glory, or vengeance), low cognitive ability, low tolerance for ambiguity, and a capacity to suppress instinctive and learned moral constraints against harming innocents.15 In 2009, Lafree and Ackerman suggested that terrorism feeds on the ability of groups to portray governments and their agents as illegitimate.16 It is possible that part of the illegitimacy campaign of radicalization and terrorist recruitment may be identification of the lack of health care by the government thus magnifying feelings of government abandonment in a vulnerable population.
In 2011, the new Moroccan constitution identified access to basic health care as a right of the Moroccan people.17 Additionally, in 2013, a government white paper was produced outlining the need to increase access to health care, particularly in rural areas, including a focus on infant and maternal mortality, diabetes mellitus (DM), heart disease, and respiratory problems.17,18
Proposed Solutions, A Beginning
A health outreach program with a regional health professional training center in a relatively stable country within the African Union (AU) would be a step toward delivering health care to Morocco and interested AU members. Interested nations have been and will continue to be invited to train at the Moroccan center and return to their countries and start training programs. This idea was echoed by the World Bank in a 2015 loan proposal to Morocco, which suggested that addressing disparities in access to health care is a social justice issue, with other benefits such as increased productivity, employment, lower out-of-pocket expenditures, and promotion of good governance.17
In 2012, Buhi reported that a positive regard for authorities and healthier influences seemed to be a protective factor against radicalization. He also suggested a public health approach to understanding and preventing violent radicalization.19 The solutions are complex, especially in rural areas and in vulnerable nations common to Africa.
Medical training efforts by the US Department of Defense (DoD), Medical Readiness Training Institute (DMRT), and international health specialists working with the military and civilian entities in neighboring African countries have improved response to regional disasters. However, to address the broader issues, a more permanent, cooperative possible solution may begin with the establishment in Morocco of a regional education center for disaster preparedness and for health care providers (HCPs). This would serve as a training program for disaster first responders. Graduates of the program would receive additional training to become HCPs similar to physician assistant (PA) and nurse practitioner (NP) programs in the US. Morocco is uniquely positioned to accomplish this due to its location, political stability, and ties with other African nations.
The goal of the Moroccan regional education center (within the King Mohammed V Hospital) is to bring together global health experts and increase the intellectual infrastructure of not only Morocco, but also offer this training program to interested countries within the AU. Advancement of the regional education center will require legislative changes to expand prescriptive privileges and scope of practice within each country. The medical element of the SPP as presently constituted without the regional education center will continue its humanitarian goals, but the proposed creation of the regional education center will educate participants to serve the rural communities within each participating country. Eventually the entire educational program will be the responsibility of the Moroccan military and the AU participants. This will require reprioritizing resources from the provision of humanitarian health care services to an HCP education approach.
Disaster Response
Deficits in disaster response capabilities have been identified by members of the Moroccan military with the assistance of the UTNG. The most glaring deficit identified was the disparity in training between military and civilian first responders. Thus, a training program was initiated by the Moroccan military and the UTNG that combined internationally recognized, durable, robust emergency training programs. These programs consisted of, but were not limited to, parts or entire programs of the following: basic disaster life support, advanced disaster life support, disaster casualty care, and advanced trauma life support. The goal of this training was to improve communication, reduce mortality, and create strike teams, which can quickly provide health care independent of a hospital during a disaster.
Patients can overwhelm hospitals in a disaster when need exceeds resources. In 1996, Mallonee reported that at least 67% of the patients who sought care at a hospital during the Oklahoma City bombing disaster did not need advanced medical treatment.20 Such patients could be seen at an identified casualty collection point by a strike team and treated and released rather than traveling to the hospital and using staff and resources that could be used more judiciously for the more seriously injured.21 These teams consist of trained first responders with an experienced HCP (physician, PA, NP) and a nurse and are trained to operate for up to 72 hours in a predetermined location and serve as a “filter” for the hospital. Their role is to treat and release the less severely injured and refer only the more severely injured to the hospital after basic stabilization, thus preserving precious resources necessary for the more seriously injured.
This disaster response training program was offered to the Moroccan military, ministry of health and ministry of tourism, and quickly turned into an Africa-wide interest. A regional training center was proposed. This was assisted with the cooperation of Weber State University in Ogden Utah, Utah Valley University in Orem, and private interests in a public/private/military state partnership. Program supplies and didactic instruction were and will be provided by the UTNG and supplemented through the DoD Africa command. Instruction will be a cooperative effort agreed on between the UTNG and the Moroccan military medical specialists within their specific area of expertise.
Underserved Communities
Finally, from this pool of interested strike team members, a health care provider school will be formed to educate, certify, and service the needs of the underserved communities in Morocco and interested AU countries. This program will be similar to the PA and NP programs in the US and will be geared to those graduates from the previous programs with intense classroom instruction for one year followed by a year of one-on-one preceptorship with an experienced physician. The goal of the program is to prepare individuals with patient care experience to fulfill a bigger role in health care in an underserved (usually austere, rural) area that currently has minimal health care presence. This fills a need identified by the World Bank in 2015 that the Moroccan government needs to respond to the demand for improved access to and quality of health care services—particularly to the rural poor.17
The Moroccan military has a presence in many medically underserved areas. The logical fit for the HCP program will be drawn from a pool of active-duty military individuals who express an interest and qualify through attendance in all phases of the training.
Conclusion
This program of disaster medical education, strike teams, and HCPs is currently training more than 200 students a year throughout Morocco. The proposed direction of this cooperative program to produce HCPs in rural areas will increase access to health care for the Moroccan people who are now underserved. Morocco, as a health care training hub in Africa, will increase access to health care for interested African countries. The goal politically will be to reduce feelings of government indifference in vulnerable populations and reduce recruitment into radical ideologies.
1. Nahon M, Michaloux M. L’organisation de la réponse de la sécurité civile: le dispositif ORSEC Organisation of civilian emergency services: The ORSEC plan. https://www.sciencedirect.com/science/article/pii/S2211423816300499#! Published July 2016. Accessed October 7, 2019.
2. Berman E. Hamas, Taliban and the Jewish underground: an economist's view of radical religious militias. NBER Working Paper No. w10004. https://ssrn.com/abstract=450885. Published September 2003. Accessed October 7, 2019.
3. Jordan J. Attacking the leader. Missing the mark; why terrorist groups survive decapitation strikes. Int Secur. 2014;38(4):7-38.
4. Grynkewich A. Welfare as warfare: how violent non-state groups use social services to attack the state. Stud Conflict Terrorism. 2008;31(4):350-370.
5. Marin M, Solomon H. Islamic State: understanding the nature of the beast and its funding. Contemp Rev Middle East. 2017;4(1):18-49.
6. Bressan D. November 1, 1755: the earthquake of Lisbon: wrath of god or natural disaster? Scientific American, History of Geology. https://blogs.scientificamerican.com/history-of-geology/november-1-1755-the-earthquake-of-lisbon-wraith-of-god-or-natural-disaster. Published November 2011. Accessed October 7, 2019.
7. Trading Economics. Morocco unemployment rate. Second quarter statistics. August 2019. https://tradingeconomics.com/morocco/unemployment-rate. Accessed October 7, 2019.
8. Knoema World Data Atlas 2015. Morocco adult literacy rates. https://knoema.com/atlas/Morocco/topics/Education/Literacy/Adult-literacy-rate. Accessed October 4, 2019.
9. The Legatum Prosperity Index 2018. Morocco. https://www.prosperity.com/globe/morocco. Accessed October 7, 2019.
10. University of Washington, Institute for Health Metrics and Evaluation. Morocco. http://www.healthdata.org/morocco. Published 2018. Accessed October 7, 2019.
11. Oxford Business Group. Access to health care broadens in Morocco. https://oxfordbusinessgroup.com/overview/forward-steps-access-care-has-broadened-and-infrastructure-improved-challenges-remain. Accessed September 12. 2019.
12. Wright NMJ, Hankins FM. Preventing radicalization and terrorism: Is there a GP response? Br J Gen Pract. 2016;66(647):288-289.
13. Buhi K, Everitt K, Jones E. Might depression psychosocial adversity, and limited social assets explain vulnerability to and resistance against violent radicalization? PlosOne. 2014;9(9):e105918.
14. DeAngelis T. Understanding terrorism. apa.org/monitor/2009/11/terrorism. Published November 2009. Accessed October 14, 2019.
15. Victoroff J. The mind of the terrorist: a review and critique of psychological approaches. J Conflict Resolut. 2005;49(1):3-42.
16. Lafree G, Ackerman G. The empirical study of terrorism: social and legal research. Ann Rev Law Soc Sci. 2009;5:347-374.
17. World Bank. Morocco—improving primary health in rural areas program-for-results project (English). http://documents.worldbank.org/curated/en/716821468274482723/Morocco-Improving-Primary-Health-in-Rural-Areas-Program-for-Results-Project. Published 2015. Accessed September 16, 2019.
18. Royaume du Maroc, Ministère de la Santé. Livre blanc: pour une nouvelle gouvernance du secteur de la santé. Paper presented at: 2nd National Health Conference; July 1-3, 2013; Marrakesh, Morocco.
19. Buhi K, Hicks MH, Lashley M, Jones E. A public health approach to understanding and preventing violent radicalization. BMC Med. 2012;10:16.
20. Mallonee S, Sahriat S, Stennies G, Waxweiler R, Hogan D, Jordan F. Physical injuries and fatalities resulting from the Oklahoma City bombing. JAMA. 1996;276(5):382-387.
21. Ushizawa H, Foxwell AR, Bice S, et al. Needs for disaster medicine: lessons from the field of the Great East Japan Earthquake. Western Pac Surveil Response J. 2013;4(1):51-55.
1. Nahon M, Michaloux M. L’organisation de la réponse de la sécurité civile: le dispositif ORSEC Organisation of civilian emergency services: The ORSEC plan. https://www.sciencedirect.com/science/article/pii/S2211423816300499#! Published July 2016. Accessed October 7, 2019.
2. Berman E. Hamas, Taliban and the Jewish underground: an economist's view of radical religious militias. NBER Working Paper No. w10004. https://ssrn.com/abstract=450885. Published September 2003. Accessed October 7, 2019.
3. Jordan J. Attacking the leader. Missing the mark; why terrorist groups survive decapitation strikes. Int Secur. 2014;38(4):7-38.
4. Grynkewich A. Welfare as warfare: how violent non-state groups use social services to attack the state. Stud Conflict Terrorism. 2008;31(4):350-370.
5. Marin M, Solomon H. Islamic State: understanding the nature of the beast and its funding. Contemp Rev Middle East. 2017;4(1):18-49.
6. Bressan D. November 1, 1755: the earthquake of Lisbon: wrath of god or natural disaster? Scientific American, History of Geology. https://blogs.scientificamerican.com/history-of-geology/november-1-1755-the-earthquake-of-lisbon-wraith-of-god-or-natural-disaster. Published November 2011. Accessed October 7, 2019.
7. Trading Economics. Morocco unemployment rate. Second quarter statistics. August 2019. https://tradingeconomics.com/morocco/unemployment-rate. Accessed October 7, 2019.
8. Knoema World Data Atlas 2015. Morocco adult literacy rates. https://knoema.com/atlas/Morocco/topics/Education/Literacy/Adult-literacy-rate. Accessed October 4, 2019.
9. The Legatum Prosperity Index 2018. Morocco. https://www.prosperity.com/globe/morocco. Accessed October 7, 2019.
10. University of Washington, Institute for Health Metrics and Evaluation. Morocco. http://www.healthdata.org/morocco. Published 2018. Accessed October 7, 2019.
11. Oxford Business Group. Access to health care broadens in Morocco. https://oxfordbusinessgroup.com/overview/forward-steps-access-care-has-broadened-and-infrastructure-improved-challenges-remain. Accessed September 12. 2019.
12. Wright NMJ, Hankins FM. Preventing radicalization and terrorism: Is there a GP response? Br J Gen Pract. 2016;66(647):288-289.
13. Buhi K, Everitt K, Jones E. Might depression psychosocial adversity, and limited social assets explain vulnerability to and resistance against violent radicalization? PlosOne. 2014;9(9):e105918.
14. DeAngelis T. Understanding terrorism. apa.org/monitor/2009/11/terrorism. Published November 2009. Accessed October 14, 2019.
15. Victoroff J. The mind of the terrorist: a review and critique of psychological approaches. J Conflict Resolut. 2005;49(1):3-42.
16. Lafree G, Ackerman G. The empirical study of terrorism: social and legal research. Ann Rev Law Soc Sci. 2009;5:347-374.
17. World Bank. Morocco—improving primary health in rural areas program-for-results project (English). http://documents.worldbank.org/curated/en/716821468274482723/Morocco-Improving-Primary-Health-in-Rural-Areas-Program-for-Results-Project. Published 2015. Accessed September 16, 2019.
18. Royaume du Maroc, Ministère de la Santé. Livre blanc: pour une nouvelle gouvernance du secteur de la santé. Paper presented at: 2nd National Health Conference; July 1-3, 2013; Marrakesh, Morocco.
19. Buhi K, Hicks MH, Lashley M, Jones E. A public health approach to understanding and preventing violent radicalization. BMC Med. 2012;10:16.
20. Mallonee S, Sahriat S, Stennies G, Waxweiler R, Hogan D, Jordan F. Physical injuries and fatalities resulting from the Oklahoma City bombing. JAMA. 1996;276(5):382-387.
21. Ushizawa H, Foxwell AR, Bice S, et al. Needs for disaster medicine: lessons from the field of the Great East Japan Earthquake. Western Pac Surveil Response J. 2013;4(1):51-55.
Disparity in endometrial cancer outcomes: What can we do?
While the incidence of most cancers is falling, endometrial cancer rates continue to rise, in large part because of increasing life expectancy and obesity rates. However, what is even more alarming is the observation that there is a clear disparity in outcomes between black and white women with this disease. But there are things that all health care providers, including nononcologists, can do to help to overcome this disparity.
Black women are nearly twice as likely as non-Hispanic white women to die from the endometrial cancer. The 5-year survival for stage III and IV cancer is 43% for non-Hispanic white women, yet only 25% for black women.1 For a long time, this survival disparity was assumed to be a function of the more aggressive cancer histologies, such as serous, which are more commonly seen in black women. These high-grade cancers are more likely to present in advanced stages and with poorer responses to treatments; however, the predisposition to aggressive cancers tells only part of the story of racial disparities in endometrial cancer and their presentation at later stages. Indeed, fueling the problem are the findings that black women report symptoms less, experience more delays in diagnosis or more frequent deviations from guideline-directed diagnostics, undergo more morbid surgical approaches, receive less surgical staging, are enrolled less in clinical trials, have lower socioeconomic status and lower rates of health insurance, and receive less differential administration of adjuvant therapies, as well as have a background of higher all-cause mortality and comorbidities. While this array of contributing factors may seem overwhelming, it also can be considered a guide for health care providers because most of these factors, unlike histologic cell type, are modifiable, and it is important that we all consider what role we can play in dismantling them.
Black women are less likely to receive guideline-recommended care upon presentation. Research by Kemi M. Doll, MD, from the University of Washington, Seattle, demonstrated that, among women with endometrial cancers, black women were less likely to have documented histories of postmenopausal bleeding within 2 years of the diagnosis, presumably because of factors related to underreporting and inadequate ascertainment by medical professionals of whether or not they had experienced postmenopausal bleeding.2 Additionally, when postmenopausal bleeding was reported by these women, they were less likely to receive the appropriate diagnostic work-up as described by American College of Obstetricians and Gynecologists guidelines, and their bleeding was more likely to be ascribed to nonmalignant pathologies. Her work raises the important question about how black women view the health care profession and their willingness to engage early in good faith that their concerns will be met. These concerns are understandable given the documented different responsiveness of providers to black patients’ symptoms such as pain.3
both of which are considered the standard of care.1,4 Lower rates of minimally invasive surgery expose black women to increased morbidity and are deleterious to quality of life, return to work, and functionality. If surgical staging is omitted, which is more common for these women, clinicians are less able to appropriately prescribe adjuvant therapies which might prevent lethal recurrences from unrecognized advanced cancer or they may overtreat early-stage cancers with adjuvant therapy to make up for gaps in staging information.1,5 However, adjuvant therapy is not a benign intervention, and itself is associated with morbidity.
As mentioned earlier, black women are at a higher risk for developing more aggressive cancer subtypes, and this phenomenon may appear unmodifiable. However, important research is looking at the concept of epigenetics and how modifiable environmental factors may contribute to the development of more aggressive types of cancer through gene expression. Additionally, differences in the gene mutations and gene expression of cancers more frequently acquired by black women may negatively influence how these cancers respond to conventional therapies. In the GOG210 study, which evaluated the outcomes of women with comprehensively staged endometrial cancer, black women demonstrated worse survival from cancer, even though they were more likely to receive chemotherapy.5 One explanation for this finding is that these women’s cancers were less responsive to conventional chemotherapy agents.
This raises a critical issue of disparity in clinical trial inclusion. Black women are underrepresented in clinical trials in the United States. There is a dark history in medical research and minority populations, particularly African American populations, which continues to be remembered and felt. However, not all of this underrepresentation may be from unwillingness to participate: For black women, issues of lack of access to or being considered for clinical trials is also a factor. But without adequate representation in trials of novel agents, we will not know whether they are effective for all populations, and indeed it would appear that we should not assume they are equally effective based on the results to date.
So how can we all individually help to overcome these disparities in endometrial cancer outcomes? To begin with, it is important to acknowledge that black women commonly report negative experiences with reproductive health care. From early in their lives, we must sensitively engage all of our patients and ensure they all feel heard and valued. They should know that their symptoms, including pain or bleeding, are taken and treated seriously. If we can do better with this throughout a woman’s earlier reproductive health care experiences, perhaps later in her life, when she experiences postmenopausal bleeding, she will feel comfortable raising this issue with her health care provider who in turn must take this symptom seriously and expeditiously engage all of the appropriate diagnostic resources. Health care delivery is about more than simply offering the best treatment. We also are responsible for education and shared decision making to ensure that we can deliver the best treatment.
We also can support organizations such as ECANA (Endometrial Cancer Action Network for African Americans) which serves to inform black women in their communities about the threat that endometrial cancer plays and empowers them through education about its symptoms and the need to seek care.
Systematically we must ensure black women have access to the same standards in surgical and nonsurgical management of these cancers. This includes referral of all women with cancer, including minorities, to high-volume centers with oncology specialists and explaining to those who may be reluctant to travel that this is associated with improved outcomes in the short and long term. We also must actively consider our black patients for clinical trials, sensitively educate them about their benefits, and overcome barriers to access. One simple way to do this is to explain that the treatments that we have developed for endometrial cancer have mostly been tested on white women, which may explain in part why they do not work so well for nonwhite women.
The racial disparity in endometrial cancer outcomes cannot entirely be attributed to the passive phenomenon of patient and tumor genetics, particularly with consideration that race is a social construct rather than a biological phenomenon. We can all make a difference through advocacy, access, education, and heightened awareness to combat this inequity and overcome these disparate outcomes.
Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She said she had no relevant financial disclosures. Email her at [email protected].
References
1. Gynecol Oncol. 2016 Oct;143(1):98-104.
2. Am J Obstet Gynecol. 2018 Dec;219(6):593.e1-14.
3. J Clin Oncol. 2012 Jun 1;30(16):1980-8.
4. Obstet Gynecol. 2016 Sep;128(3):526-34.
5. Am J Obstet Gynecol. 2018 Nov;219(5):459.e1-11.
While the incidence of most cancers is falling, endometrial cancer rates continue to rise, in large part because of increasing life expectancy and obesity rates. However, what is even more alarming is the observation that there is a clear disparity in outcomes between black and white women with this disease. But there are things that all health care providers, including nononcologists, can do to help to overcome this disparity.
Black women are nearly twice as likely as non-Hispanic white women to die from the endometrial cancer. The 5-year survival for stage III and IV cancer is 43% for non-Hispanic white women, yet only 25% for black women.1 For a long time, this survival disparity was assumed to be a function of the more aggressive cancer histologies, such as serous, which are more commonly seen in black women. These high-grade cancers are more likely to present in advanced stages and with poorer responses to treatments; however, the predisposition to aggressive cancers tells only part of the story of racial disparities in endometrial cancer and their presentation at later stages. Indeed, fueling the problem are the findings that black women report symptoms less, experience more delays in diagnosis or more frequent deviations from guideline-directed diagnostics, undergo more morbid surgical approaches, receive less surgical staging, are enrolled less in clinical trials, have lower socioeconomic status and lower rates of health insurance, and receive less differential administration of adjuvant therapies, as well as have a background of higher all-cause mortality and comorbidities. While this array of contributing factors may seem overwhelming, it also can be considered a guide for health care providers because most of these factors, unlike histologic cell type, are modifiable, and it is important that we all consider what role we can play in dismantling them.
Black women are less likely to receive guideline-recommended care upon presentation. Research by Kemi M. Doll, MD, from the University of Washington, Seattle, demonstrated that, among women with endometrial cancers, black women were less likely to have documented histories of postmenopausal bleeding within 2 years of the diagnosis, presumably because of factors related to underreporting and inadequate ascertainment by medical professionals of whether or not they had experienced postmenopausal bleeding.2 Additionally, when postmenopausal bleeding was reported by these women, they were less likely to receive the appropriate diagnostic work-up as described by American College of Obstetricians and Gynecologists guidelines, and their bleeding was more likely to be ascribed to nonmalignant pathologies. Her work raises the important question about how black women view the health care profession and their willingness to engage early in good faith that their concerns will be met. These concerns are understandable given the documented different responsiveness of providers to black patients’ symptoms such as pain.3
both of which are considered the standard of care.1,4 Lower rates of minimally invasive surgery expose black women to increased morbidity and are deleterious to quality of life, return to work, and functionality. If surgical staging is omitted, which is more common for these women, clinicians are less able to appropriately prescribe adjuvant therapies which might prevent lethal recurrences from unrecognized advanced cancer or they may overtreat early-stage cancers with adjuvant therapy to make up for gaps in staging information.1,5 However, adjuvant therapy is not a benign intervention, and itself is associated with morbidity.
As mentioned earlier, black women are at a higher risk for developing more aggressive cancer subtypes, and this phenomenon may appear unmodifiable. However, important research is looking at the concept of epigenetics and how modifiable environmental factors may contribute to the development of more aggressive types of cancer through gene expression. Additionally, differences in the gene mutations and gene expression of cancers more frequently acquired by black women may negatively influence how these cancers respond to conventional therapies. In the GOG210 study, which evaluated the outcomes of women with comprehensively staged endometrial cancer, black women demonstrated worse survival from cancer, even though they were more likely to receive chemotherapy.5 One explanation for this finding is that these women’s cancers were less responsive to conventional chemotherapy agents.
This raises a critical issue of disparity in clinical trial inclusion. Black women are underrepresented in clinical trials in the United States. There is a dark history in medical research and minority populations, particularly African American populations, which continues to be remembered and felt. However, not all of this underrepresentation may be from unwillingness to participate: For black women, issues of lack of access to or being considered for clinical trials is also a factor. But without adequate representation in trials of novel agents, we will not know whether they are effective for all populations, and indeed it would appear that we should not assume they are equally effective based on the results to date.
So how can we all individually help to overcome these disparities in endometrial cancer outcomes? To begin with, it is important to acknowledge that black women commonly report negative experiences with reproductive health care. From early in their lives, we must sensitively engage all of our patients and ensure they all feel heard and valued. They should know that their symptoms, including pain or bleeding, are taken and treated seriously. If we can do better with this throughout a woman’s earlier reproductive health care experiences, perhaps later in her life, when she experiences postmenopausal bleeding, she will feel comfortable raising this issue with her health care provider who in turn must take this symptom seriously and expeditiously engage all of the appropriate diagnostic resources. Health care delivery is about more than simply offering the best treatment. We also are responsible for education and shared decision making to ensure that we can deliver the best treatment.
We also can support organizations such as ECANA (Endometrial Cancer Action Network for African Americans) which serves to inform black women in their communities about the threat that endometrial cancer plays and empowers them through education about its symptoms and the need to seek care.
Systematically we must ensure black women have access to the same standards in surgical and nonsurgical management of these cancers. This includes referral of all women with cancer, including minorities, to high-volume centers with oncology specialists and explaining to those who may be reluctant to travel that this is associated with improved outcomes in the short and long term. We also must actively consider our black patients for clinical trials, sensitively educate them about their benefits, and overcome barriers to access. One simple way to do this is to explain that the treatments that we have developed for endometrial cancer have mostly been tested on white women, which may explain in part why they do not work so well for nonwhite women.
The racial disparity in endometrial cancer outcomes cannot entirely be attributed to the passive phenomenon of patient and tumor genetics, particularly with consideration that race is a social construct rather than a biological phenomenon. We can all make a difference through advocacy, access, education, and heightened awareness to combat this inequity and overcome these disparate outcomes.
Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She said she had no relevant financial disclosures. Email her at [email protected].
References
1. Gynecol Oncol. 2016 Oct;143(1):98-104.
2. Am J Obstet Gynecol. 2018 Dec;219(6):593.e1-14.
3. J Clin Oncol. 2012 Jun 1;30(16):1980-8.
4. Obstet Gynecol. 2016 Sep;128(3):526-34.
5. Am J Obstet Gynecol. 2018 Nov;219(5):459.e1-11.
While the incidence of most cancers is falling, endometrial cancer rates continue to rise, in large part because of increasing life expectancy and obesity rates. However, what is even more alarming is the observation that there is a clear disparity in outcomes between black and white women with this disease. But there are things that all health care providers, including nononcologists, can do to help to overcome this disparity.
Black women are nearly twice as likely as non-Hispanic white women to die from the endometrial cancer. The 5-year survival for stage III and IV cancer is 43% for non-Hispanic white women, yet only 25% for black women.1 For a long time, this survival disparity was assumed to be a function of the more aggressive cancer histologies, such as serous, which are more commonly seen in black women. These high-grade cancers are more likely to present in advanced stages and with poorer responses to treatments; however, the predisposition to aggressive cancers tells only part of the story of racial disparities in endometrial cancer and their presentation at later stages. Indeed, fueling the problem are the findings that black women report symptoms less, experience more delays in diagnosis or more frequent deviations from guideline-directed diagnostics, undergo more morbid surgical approaches, receive less surgical staging, are enrolled less in clinical trials, have lower socioeconomic status and lower rates of health insurance, and receive less differential administration of adjuvant therapies, as well as have a background of higher all-cause mortality and comorbidities. While this array of contributing factors may seem overwhelming, it also can be considered a guide for health care providers because most of these factors, unlike histologic cell type, are modifiable, and it is important that we all consider what role we can play in dismantling them.
Black women are less likely to receive guideline-recommended care upon presentation. Research by Kemi M. Doll, MD, from the University of Washington, Seattle, demonstrated that, among women with endometrial cancers, black women were less likely to have documented histories of postmenopausal bleeding within 2 years of the diagnosis, presumably because of factors related to underreporting and inadequate ascertainment by medical professionals of whether or not they had experienced postmenopausal bleeding.2 Additionally, when postmenopausal bleeding was reported by these women, they were less likely to receive the appropriate diagnostic work-up as described by American College of Obstetricians and Gynecologists guidelines, and their bleeding was more likely to be ascribed to nonmalignant pathologies. Her work raises the important question about how black women view the health care profession and their willingness to engage early in good faith that their concerns will be met. These concerns are understandable given the documented different responsiveness of providers to black patients’ symptoms such as pain.3
both of which are considered the standard of care.1,4 Lower rates of minimally invasive surgery expose black women to increased morbidity and are deleterious to quality of life, return to work, and functionality. If surgical staging is omitted, which is more common for these women, clinicians are less able to appropriately prescribe adjuvant therapies which might prevent lethal recurrences from unrecognized advanced cancer or they may overtreat early-stage cancers with adjuvant therapy to make up for gaps in staging information.1,5 However, adjuvant therapy is not a benign intervention, and itself is associated with morbidity.
As mentioned earlier, black women are at a higher risk for developing more aggressive cancer subtypes, and this phenomenon may appear unmodifiable. However, important research is looking at the concept of epigenetics and how modifiable environmental factors may contribute to the development of more aggressive types of cancer through gene expression. Additionally, differences in the gene mutations and gene expression of cancers more frequently acquired by black women may negatively influence how these cancers respond to conventional therapies. In the GOG210 study, which evaluated the outcomes of women with comprehensively staged endometrial cancer, black women demonstrated worse survival from cancer, even though they were more likely to receive chemotherapy.5 One explanation for this finding is that these women’s cancers were less responsive to conventional chemotherapy agents.
This raises a critical issue of disparity in clinical trial inclusion. Black women are underrepresented in clinical trials in the United States. There is a dark history in medical research and minority populations, particularly African American populations, which continues to be remembered and felt. However, not all of this underrepresentation may be from unwillingness to participate: For black women, issues of lack of access to or being considered for clinical trials is also a factor. But without adequate representation in trials of novel agents, we will not know whether they are effective for all populations, and indeed it would appear that we should not assume they are equally effective based on the results to date.
So how can we all individually help to overcome these disparities in endometrial cancer outcomes? To begin with, it is important to acknowledge that black women commonly report negative experiences with reproductive health care. From early in their lives, we must sensitively engage all of our patients and ensure they all feel heard and valued. They should know that their symptoms, including pain or bleeding, are taken and treated seriously. If we can do better with this throughout a woman’s earlier reproductive health care experiences, perhaps later in her life, when she experiences postmenopausal bleeding, she will feel comfortable raising this issue with her health care provider who in turn must take this symptom seriously and expeditiously engage all of the appropriate diagnostic resources. Health care delivery is about more than simply offering the best treatment. We also are responsible for education and shared decision making to ensure that we can deliver the best treatment.
We also can support organizations such as ECANA (Endometrial Cancer Action Network for African Americans) which serves to inform black women in their communities about the threat that endometrial cancer plays and empowers them through education about its symptoms and the need to seek care.
Systematically we must ensure black women have access to the same standards in surgical and nonsurgical management of these cancers. This includes referral of all women with cancer, including minorities, to high-volume centers with oncology specialists and explaining to those who may be reluctant to travel that this is associated with improved outcomes in the short and long term. We also must actively consider our black patients for clinical trials, sensitively educate them about their benefits, and overcome barriers to access. One simple way to do this is to explain that the treatments that we have developed for endometrial cancer have mostly been tested on white women, which may explain in part why they do not work so well for nonwhite women.
The racial disparity in endometrial cancer outcomes cannot entirely be attributed to the passive phenomenon of patient and tumor genetics, particularly with consideration that race is a social construct rather than a biological phenomenon. We can all make a difference through advocacy, access, education, and heightened awareness to combat this inequity and overcome these disparate outcomes.
Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She said she had no relevant financial disclosures. Email her at [email protected].
References
1. Gynecol Oncol. 2016 Oct;143(1):98-104.
2. Am J Obstet Gynecol. 2018 Dec;219(6):593.e1-14.
3. J Clin Oncol. 2012 Jun 1;30(16):1980-8.
4. Obstet Gynecol. 2016 Sep;128(3):526-34.
5. Am J Obstet Gynecol. 2018 Nov;219(5):459.e1-11.
‘How did I get cancer?’
We are 20 minutes into the visit. My patient is 77 years old, a retired school administrator. She was sent to the oncology clinic for a new diagnosis of lung cancer with metastases to the liver and bones.
I was asking my usual questions – how did this all begin? – and I was hearing the usual answers. The cough that didn’t get better with antibiotics. The unintentional weight loss. The chest x-ray that looked “fuzzy.”
I continue: How many packs of cigarettes a day, and for how many years? Any family history of cancer?
These were my standard questions. They were met by hers: “How did I get this?”
I recently hosted a podcast on common, difficult questions we hear in hematology and oncology. How long do I have to live? What would you do if this were your family member?
This was another. There are variations to be sure. How, why, why me, what did I do, what didn’t I do, did my doctor miss it, if I had this or that test would they have caught it sooner?
When I was an internist, I talked about prevention. Meeting a new patient meant sizing them up for risk factors. In their habits I saw opportunities for healthier choices. In their family histories I gathered warning signs.
Now, I ask the same probing questions, but the purpose is not the same. Smoking, alcohol, family history, I ask these of everyone, I reassure them. It’s no longer about assessing risk. It’s not to place blame. But they read into the fact that I am asking, because they have asked themselves the same.
They ask why.
I try not to overdo the pity. I say that I’m sorry this is happening, but I don’t dwell. What I want to convey is the opposite – it’s normalcy. What I want to convey is: I’ve seen this a million times. This is where we are, and here is where we go. We don’t dwell or regret or wonder what if. My patients don’t want sympathy – at least, not from their doctor. They want a plan.
They ask: How did I get this?
It’s bad luck, I say. It’s a genetic mutation causing a cell to replicate.
My answers do not always satisfy their questions. Because it’s not a question seeking an informational answer. The truth is, medically and existentially, I don’t know. None of us do. The question is an existential itch no medical jargon can scratch.
I have a modern Hippocratic oath tacked to a wall in my room. “I will prevent disease whenever I can, because prevention is preferable to cure,” it says. True, but that offers little solace to those who already have the illness. Yes, we need prevention. And we need a path forward when tragedy has already struck.
I am humbled when I meet a new cancer patient because the visit is a metaphor for a nonjudgmental life. There’s something beautiful about meeting someone exactly where they are, where decisions made in the past are as irrelevant to me now as they were to the cancer.
When they inevitably ask “how did I get this?” and I answer, what I’m really saying is this: I don’t care what you did, or didn’t do, or how we got here. But we are here, and so I am here with you, and from now on the only place we care about is here and now, the only direction forward.
Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz and listen to her each week on the Blood & Cancer podcast.
We are 20 minutes into the visit. My patient is 77 years old, a retired school administrator. She was sent to the oncology clinic for a new diagnosis of lung cancer with metastases to the liver and bones.
I was asking my usual questions – how did this all begin? – and I was hearing the usual answers. The cough that didn’t get better with antibiotics. The unintentional weight loss. The chest x-ray that looked “fuzzy.”
I continue: How many packs of cigarettes a day, and for how many years? Any family history of cancer?
These were my standard questions. They were met by hers: “How did I get this?”
I recently hosted a podcast on common, difficult questions we hear in hematology and oncology. How long do I have to live? What would you do if this were your family member?
This was another. There are variations to be sure. How, why, why me, what did I do, what didn’t I do, did my doctor miss it, if I had this or that test would they have caught it sooner?
When I was an internist, I talked about prevention. Meeting a new patient meant sizing them up for risk factors. In their habits I saw opportunities for healthier choices. In their family histories I gathered warning signs.
Now, I ask the same probing questions, but the purpose is not the same. Smoking, alcohol, family history, I ask these of everyone, I reassure them. It’s no longer about assessing risk. It’s not to place blame. But they read into the fact that I am asking, because they have asked themselves the same.
They ask why.
I try not to overdo the pity. I say that I’m sorry this is happening, but I don’t dwell. What I want to convey is the opposite – it’s normalcy. What I want to convey is: I’ve seen this a million times. This is where we are, and here is where we go. We don’t dwell or regret or wonder what if. My patients don’t want sympathy – at least, not from their doctor. They want a plan.
They ask: How did I get this?
It’s bad luck, I say. It’s a genetic mutation causing a cell to replicate.
My answers do not always satisfy their questions. Because it’s not a question seeking an informational answer. The truth is, medically and existentially, I don’t know. None of us do. The question is an existential itch no medical jargon can scratch.
I have a modern Hippocratic oath tacked to a wall in my room. “I will prevent disease whenever I can, because prevention is preferable to cure,” it says. True, but that offers little solace to those who already have the illness. Yes, we need prevention. And we need a path forward when tragedy has already struck.
I am humbled when I meet a new cancer patient because the visit is a metaphor for a nonjudgmental life. There’s something beautiful about meeting someone exactly where they are, where decisions made in the past are as irrelevant to me now as they were to the cancer.
When they inevitably ask “how did I get this?” and I answer, what I’m really saying is this: I don’t care what you did, or didn’t do, or how we got here. But we are here, and so I am here with you, and from now on the only place we care about is here and now, the only direction forward.
Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz and listen to her each week on the Blood & Cancer podcast.
We are 20 minutes into the visit. My patient is 77 years old, a retired school administrator. She was sent to the oncology clinic for a new diagnosis of lung cancer with metastases to the liver and bones.
I was asking my usual questions – how did this all begin? – and I was hearing the usual answers. The cough that didn’t get better with antibiotics. The unintentional weight loss. The chest x-ray that looked “fuzzy.”
I continue: How many packs of cigarettes a day, and for how many years? Any family history of cancer?
These were my standard questions. They were met by hers: “How did I get this?”
I recently hosted a podcast on common, difficult questions we hear in hematology and oncology. How long do I have to live? What would you do if this were your family member?
This was another. There are variations to be sure. How, why, why me, what did I do, what didn’t I do, did my doctor miss it, if I had this or that test would they have caught it sooner?
When I was an internist, I talked about prevention. Meeting a new patient meant sizing them up for risk factors. In their habits I saw opportunities for healthier choices. In their family histories I gathered warning signs.
Now, I ask the same probing questions, but the purpose is not the same. Smoking, alcohol, family history, I ask these of everyone, I reassure them. It’s no longer about assessing risk. It’s not to place blame. But they read into the fact that I am asking, because they have asked themselves the same.
They ask why.
I try not to overdo the pity. I say that I’m sorry this is happening, but I don’t dwell. What I want to convey is the opposite – it’s normalcy. What I want to convey is: I’ve seen this a million times. This is where we are, and here is where we go. We don’t dwell or regret or wonder what if. My patients don’t want sympathy – at least, not from their doctor. They want a plan.
They ask: How did I get this?
It’s bad luck, I say. It’s a genetic mutation causing a cell to replicate.
My answers do not always satisfy their questions. Because it’s not a question seeking an informational answer. The truth is, medically and existentially, I don’t know. None of us do. The question is an existential itch no medical jargon can scratch.
I have a modern Hippocratic oath tacked to a wall in my room. “I will prevent disease whenever I can, because prevention is preferable to cure,” it says. True, but that offers little solace to those who already have the illness. Yes, we need prevention. And we need a path forward when tragedy has already struck.
I am humbled when I meet a new cancer patient because the visit is a metaphor for a nonjudgmental life. There’s something beautiful about meeting someone exactly where they are, where decisions made in the past are as irrelevant to me now as they were to the cancer.
When they inevitably ask “how did I get this?” and I answer, what I’m really saying is this: I don’t care what you did, or didn’t do, or how we got here. But we are here, and so I am here with you, and from now on the only place we care about is here and now, the only direction forward.
Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz and listen to her each week on the Blood & Cancer podcast.
AI and machine learning
Recent advances in neuroscience and genetics are providing a new view of brain function in health and disease.1 As discussed in Drs. Hripsime Kalanderian and Henry Nasrallah’s article “Artificial intelligence in psychiatry” (Evidence-Based Reviews,
In a 2016 article, Dr. Arshya Vahabzadeh2 wrote, “In the near term, humans will continue to make the majority of psychiatric diagnoses and provide treatment.” He predicted that data science—specifically machine learning—will help revolutionize how we diagnose, treat, and monitor depression. He foresees a future where AI machines or learning machines will more accurately diagnose and treat depression.
These predictions remind us of the promises made with the introduction of psychoactive drugs to the practice of psychiatry. In the 1970s, the increased emphasis on neurotransmitters led to new biologic models of mental illness and the expansion of the Diagnostic and Statistical Manual of Mental Disorders. The increased use of psychoactive medications relegated the practice of psychotherapy to other mental health professionals. Psychiatry became a “drug-intensive” specialty, and psychiatrists saw themselves as psychopharmacologists.3 During this time, psychiatry became progressively dominated by the pharmaceutical industry. The deregulation of the markets and the for-profit ideology of the pharmaceutical industry resulted in an economically and mutually beneficial alliance between pharmaceutical companies, academic faculty, and individual psychiatrists.
Using the same for-profit ideology and ethics of the pharmaceutical industry, technology-based corporations are making massive investments in the application of these technologies in neuroscience research and clinical practice. The “promise” that AI will diagnose and treat depression more accurately than clinicians will again radically change the psychiatrist’s role. Most of a psychiatrist’s clinical work eventually will be replicated by machine learning and technicians. The human-to-human encounter that is at core of the profession will be replaced by the machine-to-human encounter.4
From the social economic perspective, the American health care system is designed to increase profit and maximize the earnings of the industries.5 Unless social policy changes, expensive new technologies will increase the cost and limit accessibility to health care, benefiting the few at the expense of the majority of people. These technologies will produce a robust return on investment, but the wealth they create will benefit fewer and fewer people.
Several writers have called attention to the social, economic, and ethical consequences of these advances and recommended that the academics and technologists who support AI and machine learning in medicine must “receive sufficient training in ethics” and gain exposure to social and economic issues.6 Darcy et al7 warns of the risks of introducing these advanced technologies in medicine: “As machine learning enters the state-of-the-art clinical practice, medicine thus has the immense obligation to ensure that this technology is harnessed for societal and individual good, fulfilling the ethical basis of the profession.… Ethical design thinking is essential at every stage of development and application of machine learning in advancing health. Toward this
Marco T. Carpio, MD
Psychiatrist, Private Practice
Lynbrook, New York
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
1. Bargeman CI. How the new neuroscience will advance medicine. JAMA. 2015;314(3):221-222.
2. Vahabzadeh A. Can machine learning decode depression? Psychiatric News. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2016.4a3. Published April 11, 2016. Accessed October 16, 2019.
3. Angell M. The illusions of psychiatry. The New York Review. https://www.nybooks.com/articles/2011/07/14/illusions-of-psychiatry/. Published July 14, 2011. Accessed October 16, 2019.
4. Heath I, Nessa J. Objectification of physicians and loss of therapeutic power. Lancet. 2007;369(9565):886-888.
5. Wang D. Health care, American style: how did we arrive? Where will we go? Psychiatric Annals. 2014;44(7):342-348.
6. Nourbakhsh IR. The coming robot dystopia. Foreign Affairs. https://www.foreignaffairs.com/articles/2015-06-16/coming-robot-dystopia. Published July 2015. Accessed October 16, 2019.
7. Darcy AM, Louie AK, Roberts LW. Machine learning and the profession of medicine. JAMA. 2016;315(6):551-552.
Recent advances in neuroscience and genetics are providing a new view of brain function in health and disease.1 As discussed in Drs. Hripsime Kalanderian and Henry Nasrallah’s article “Artificial intelligence in psychiatry” (Evidence-Based Reviews,
In a 2016 article, Dr. Arshya Vahabzadeh2 wrote, “In the near term, humans will continue to make the majority of psychiatric diagnoses and provide treatment.” He predicted that data science—specifically machine learning—will help revolutionize how we diagnose, treat, and monitor depression. He foresees a future where AI machines or learning machines will more accurately diagnose and treat depression.
These predictions remind us of the promises made with the introduction of psychoactive drugs to the practice of psychiatry. In the 1970s, the increased emphasis on neurotransmitters led to new biologic models of mental illness and the expansion of the Diagnostic and Statistical Manual of Mental Disorders. The increased use of psychoactive medications relegated the practice of psychotherapy to other mental health professionals. Psychiatry became a “drug-intensive” specialty, and psychiatrists saw themselves as psychopharmacologists.3 During this time, psychiatry became progressively dominated by the pharmaceutical industry. The deregulation of the markets and the for-profit ideology of the pharmaceutical industry resulted in an economically and mutually beneficial alliance between pharmaceutical companies, academic faculty, and individual psychiatrists.
Using the same for-profit ideology and ethics of the pharmaceutical industry, technology-based corporations are making massive investments in the application of these technologies in neuroscience research and clinical practice. The “promise” that AI will diagnose and treat depression more accurately than clinicians will again radically change the psychiatrist’s role. Most of a psychiatrist’s clinical work eventually will be replicated by machine learning and technicians. The human-to-human encounter that is at core of the profession will be replaced by the machine-to-human encounter.4
From the social economic perspective, the American health care system is designed to increase profit and maximize the earnings of the industries.5 Unless social policy changes, expensive new technologies will increase the cost and limit accessibility to health care, benefiting the few at the expense of the majority of people. These technologies will produce a robust return on investment, but the wealth they create will benefit fewer and fewer people.
Several writers have called attention to the social, economic, and ethical consequences of these advances and recommended that the academics and technologists who support AI and machine learning in medicine must “receive sufficient training in ethics” and gain exposure to social and economic issues.6 Darcy et al7 warns of the risks of introducing these advanced technologies in medicine: “As machine learning enters the state-of-the-art clinical practice, medicine thus has the immense obligation to ensure that this technology is harnessed for societal and individual good, fulfilling the ethical basis of the profession.… Ethical design thinking is essential at every stage of development and application of machine learning in advancing health. Toward this
Marco T. Carpio, MD
Psychiatrist, Private Practice
Lynbrook, New York
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Recent advances in neuroscience and genetics are providing a new view of brain function in health and disease.1 As discussed in Drs. Hripsime Kalanderian and Henry Nasrallah’s article “Artificial intelligence in psychiatry” (Evidence-Based Reviews,
In a 2016 article, Dr. Arshya Vahabzadeh2 wrote, “In the near term, humans will continue to make the majority of psychiatric diagnoses and provide treatment.” He predicted that data science—specifically machine learning—will help revolutionize how we diagnose, treat, and monitor depression. He foresees a future where AI machines or learning machines will more accurately diagnose and treat depression.
These predictions remind us of the promises made with the introduction of psychoactive drugs to the practice of psychiatry. In the 1970s, the increased emphasis on neurotransmitters led to new biologic models of mental illness and the expansion of the Diagnostic and Statistical Manual of Mental Disorders. The increased use of psychoactive medications relegated the practice of psychotherapy to other mental health professionals. Psychiatry became a “drug-intensive” specialty, and psychiatrists saw themselves as psychopharmacologists.3 During this time, psychiatry became progressively dominated by the pharmaceutical industry. The deregulation of the markets and the for-profit ideology of the pharmaceutical industry resulted in an economically and mutually beneficial alliance between pharmaceutical companies, academic faculty, and individual psychiatrists.
Using the same for-profit ideology and ethics of the pharmaceutical industry, technology-based corporations are making massive investments in the application of these technologies in neuroscience research and clinical practice. The “promise” that AI will diagnose and treat depression more accurately than clinicians will again radically change the psychiatrist’s role. Most of a psychiatrist’s clinical work eventually will be replicated by machine learning and technicians. The human-to-human encounter that is at core of the profession will be replaced by the machine-to-human encounter.4
From the social economic perspective, the American health care system is designed to increase profit and maximize the earnings of the industries.5 Unless social policy changes, expensive new technologies will increase the cost and limit accessibility to health care, benefiting the few at the expense of the majority of people. These technologies will produce a robust return on investment, but the wealth they create will benefit fewer and fewer people.
Several writers have called attention to the social, economic, and ethical consequences of these advances and recommended that the academics and technologists who support AI and machine learning in medicine must “receive sufficient training in ethics” and gain exposure to social and economic issues.6 Darcy et al7 warns of the risks of introducing these advanced technologies in medicine: “As machine learning enters the state-of-the-art clinical practice, medicine thus has the immense obligation to ensure that this technology is harnessed for societal and individual good, fulfilling the ethical basis of the profession.… Ethical design thinking is essential at every stage of development and application of machine learning in advancing health. Toward this
Marco T. Carpio, MD
Psychiatrist, Private Practice
Lynbrook, New York
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
1. Bargeman CI. How the new neuroscience will advance medicine. JAMA. 2015;314(3):221-222.
2. Vahabzadeh A. Can machine learning decode depression? Psychiatric News. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2016.4a3. Published April 11, 2016. Accessed October 16, 2019.
3. Angell M. The illusions of psychiatry. The New York Review. https://www.nybooks.com/articles/2011/07/14/illusions-of-psychiatry/. Published July 14, 2011. Accessed October 16, 2019.
4. Heath I, Nessa J. Objectification of physicians and loss of therapeutic power. Lancet. 2007;369(9565):886-888.
5. Wang D. Health care, American style: how did we arrive? Where will we go? Psychiatric Annals. 2014;44(7):342-348.
6. Nourbakhsh IR. The coming robot dystopia. Foreign Affairs. https://www.foreignaffairs.com/articles/2015-06-16/coming-robot-dystopia. Published July 2015. Accessed October 16, 2019.
7. Darcy AM, Louie AK, Roberts LW. Machine learning and the profession of medicine. JAMA. 2016;315(6):551-552.
1. Bargeman CI. How the new neuroscience will advance medicine. JAMA. 2015;314(3):221-222.
2. Vahabzadeh A. Can machine learning decode depression? Psychiatric News. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2016.4a3. Published April 11, 2016. Accessed October 16, 2019.
3. Angell M. The illusions of psychiatry. The New York Review. https://www.nybooks.com/articles/2011/07/14/illusions-of-psychiatry/. Published July 14, 2011. Accessed October 16, 2019.
4. Heath I, Nessa J. Objectification of physicians and loss of therapeutic power. Lancet. 2007;369(9565):886-888.
5. Wang D. Health care, American style: how did we arrive? Where will we go? Psychiatric Annals. 2014;44(7):342-348.
6. Nourbakhsh IR. The coming robot dystopia. Foreign Affairs. https://www.foreignaffairs.com/articles/2015-06-16/coming-robot-dystopia. Published July 2015. Accessed October 16, 2019.
7. Darcy AM, Louie AK, Roberts LW. Machine learning and the profession of medicine. JAMA. 2016;315(6):551-552.
Anathemas of psychiatric practice
The quarterly report of the State Medical Board can be a sobering read. In addition to the usual updates about new regulations or requirements for licensed physicians, there is always the disciplinary actions “blacklist” of dozens of medical practitioners in all specialties whose licenses were revoked or suspended due to a shocking array of serious violations.
Those infractions range from Medicare billing fraud to prescribing narcotics to fictitious patients to engaging in sex with a patient to walking into the operating room drunk. It is truly disheartening to see dozens of physicians destroy their careers by committing a panoply of odious, repugnant, or illegal actions.
The term “anathema” comes to mind when I read about those miscreants. This Greek term is occasionally used in scholarly or religious publications, but rarely in everyday conversations or articles. Anathema refers to something detested, shunned, or denounced. When used by the clergy, it connotes something to condemn, such as a sinful or evil act.
Like all other medical specialists, we psychiatrists have a noble mission of treating and relieving the suffering of those afflicted with brain disorders that manifest as mood, thought, perceptual, behavioral, or cognitive abnormalities. Our main goal is to restore health, wellness, and quality of life to the millions of individuals who buckle under the weight of genetic redispersion, adverse environmental events, or both. So psychiatrists do a lot of “good,” which benefits all those who live with mental illness. However, psychiatric practice may have some pitfalls that occasionally lead to anathemas, no matter how diligently a practitioner tries to avoid them. The code of psychiatric ethics is a shield that can preempt anathemas from contaminating clinical practice, but human error will occur when the ethical compass fails.
Here are some examples of anathemas that may rear their ugly heads if a practitioner is not constantly on the alert. It is likely you, the readers of
- Sexual contact with a patient. This major anathema must not occur under any circumstance. It will have grave professional consequences for the practitioner and serious emotional repercussions for the patient.
- Breach of confidentiality. This is a sacred rule in psychiatric practice that must not be broken under any circumstance. Breaching confidentiality will rupture the therapeutic bond and trust that a patient has with a psychiatrist (or psychiatric nurse practitioner).
- Causing physical or emotional harm. This anathema can have serious legal implications in addition to being an unacceptable professional violation.
- Failure to assess patients for suicidal or homicidal risk. The life of the patient, and others, may be at stake if this critical component is missing in the evaluation of psychiatric patients, even if they appear “stable.”
- Irrational and hazardous polypharmacy. This type of harm must never occur during medical management of psychiatric patients, and may have legal consequences.
- Not seeking collateral information. This may seem like a “minor” anathema, but it can have major repercussions if a gap of clinically important data about the patient leads to erroneous diagnosis or inappropriate treatment. Regrettably, informants are sometimes unavailable.
- Assessing patients from the neck up only. Psychiatrists are, first and foremost, physicians who must evaluate the entire medical status of the patient, not just his/her mind. There are numerous bidirectional effects between the body and the brain that can influence diagnosis, holistic treatment, medical outcomes, and prognosis.
- Treating patients with medication only, without any concomitant psychotherapy. Such a suboptimal practice is an anathema that is not excusable due to a “lack of time.” Every psychiatric patient deserves a biopsychosocial treatment approach.
- Not inquiring about adherence at every visit. It is impossible to assess the effectiveness of treatment if adherence is partial or poor. Patients must be constantly reminded that while their psychiatrists are committed to their care, full adherence is a vital responsibility for them to fulfill to ensure optimal outcome.
- Ignoring the patient’s cues, both verbal and nonverbal. Being rushed by a large workload, a full schedule, or the demands of electronic medical records that distract a psychiatrist from fully attending to what the patient’s words, facial expressions, or body language convey can lead to a failure to meet the patient’s needs. Even worse, it may lead to missing a serious message a patient is consciously or unconsciously trying to relay.
- Lowering expectations. Nothing is more devastating for patients than to feel that the psychiatrist does not believe he/she will ever achieve wellness, or that they are beyond help and will never improve, recover, or overcome disabling psychiatric illness. This will generate profound hopelessness in vulnerable patients, who crave having a normal life free from illness or disability.
- Using the same medication for all patients. This is an anathema because one size does not fit all, and patients deserve to have their psychiatrists customize their pharmacotherapy to match their medical status and tolerability. For example, the 11 FDA-approved second-generation antipsychotics are not all the same, and a psychiatrist must select the member of that class that is most likely to be a good match for each patient based on that patient’s medical history and the safety/tolerability profile of each antipsychotic.
- Not continuously upgrading one’s practice to incorporate new evidence-based findings of more effective therapeutic strategies. It is an anathema to continue practicing what was learned in residency 25 to 30 years ago when there’s new knowledge and many advances permeating psychiatric practice today.
- Using alcohol or recreational drugs during a shift in the clinic or the hospital. No explanation is needed for this anathema!
- Prescribing for patients without a full evaluation. That’s poor clinical practice, and also is illegal.
- Billing for patients who were never examined. That’s fraudulent, and stupid!
In an editorial I wrote last year intended for graduates of psychiatry residency training programs about the “DNA of psychiatric practice,” I described what comprises good psychiatric practice.1 Anathemas can be regarded as “mutations” within the DNA of psychiatric practice. It is always my hope that none of the freshly minted psychiatrists going into practice will ever commit an anathema, and end up on the “list of shame” in their State Medical Board’s quarterly report….
1. Nasrallah HA. The DNA of psychiatric practice: a covenant with our patients. Current Psychiatry. 2018;17(5):20,22.
The quarterly report of the State Medical Board can be a sobering read. In addition to the usual updates about new regulations or requirements for licensed physicians, there is always the disciplinary actions “blacklist” of dozens of medical practitioners in all specialties whose licenses were revoked or suspended due to a shocking array of serious violations.
Those infractions range from Medicare billing fraud to prescribing narcotics to fictitious patients to engaging in sex with a patient to walking into the operating room drunk. It is truly disheartening to see dozens of physicians destroy their careers by committing a panoply of odious, repugnant, or illegal actions.
The term “anathema” comes to mind when I read about those miscreants. This Greek term is occasionally used in scholarly or religious publications, but rarely in everyday conversations or articles. Anathema refers to something detested, shunned, or denounced. When used by the clergy, it connotes something to condemn, such as a sinful or evil act.
Like all other medical specialists, we psychiatrists have a noble mission of treating and relieving the suffering of those afflicted with brain disorders that manifest as mood, thought, perceptual, behavioral, or cognitive abnormalities. Our main goal is to restore health, wellness, and quality of life to the millions of individuals who buckle under the weight of genetic redispersion, adverse environmental events, or both. So psychiatrists do a lot of “good,” which benefits all those who live with mental illness. However, psychiatric practice may have some pitfalls that occasionally lead to anathemas, no matter how diligently a practitioner tries to avoid them. The code of psychiatric ethics is a shield that can preempt anathemas from contaminating clinical practice, but human error will occur when the ethical compass fails.
Here are some examples of anathemas that may rear their ugly heads if a practitioner is not constantly on the alert. It is likely you, the readers of
- Sexual contact with a patient. This major anathema must not occur under any circumstance. It will have grave professional consequences for the practitioner and serious emotional repercussions for the patient.
- Breach of confidentiality. This is a sacred rule in psychiatric practice that must not be broken under any circumstance. Breaching confidentiality will rupture the therapeutic bond and trust that a patient has with a psychiatrist (or psychiatric nurse practitioner).
- Causing physical or emotional harm. This anathema can have serious legal implications in addition to being an unacceptable professional violation.
- Failure to assess patients for suicidal or homicidal risk. The life of the patient, and others, may be at stake if this critical component is missing in the evaluation of psychiatric patients, even if they appear “stable.”
- Irrational and hazardous polypharmacy. This type of harm must never occur during medical management of psychiatric patients, and may have legal consequences.
- Not seeking collateral information. This may seem like a “minor” anathema, but it can have major repercussions if a gap of clinically important data about the patient leads to erroneous diagnosis or inappropriate treatment. Regrettably, informants are sometimes unavailable.
- Assessing patients from the neck up only. Psychiatrists are, first and foremost, physicians who must evaluate the entire medical status of the patient, not just his/her mind. There are numerous bidirectional effects between the body and the brain that can influence diagnosis, holistic treatment, medical outcomes, and prognosis.
- Treating patients with medication only, without any concomitant psychotherapy. Such a suboptimal practice is an anathema that is not excusable due to a “lack of time.” Every psychiatric patient deserves a biopsychosocial treatment approach.
- Not inquiring about adherence at every visit. It is impossible to assess the effectiveness of treatment if adherence is partial or poor. Patients must be constantly reminded that while their psychiatrists are committed to their care, full adherence is a vital responsibility for them to fulfill to ensure optimal outcome.
- Ignoring the patient’s cues, both verbal and nonverbal. Being rushed by a large workload, a full schedule, or the demands of electronic medical records that distract a psychiatrist from fully attending to what the patient’s words, facial expressions, or body language convey can lead to a failure to meet the patient’s needs. Even worse, it may lead to missing a serious message a patient is consciously or unconsciously trying to relay.
- Lowering expectations. Nothing is more devastating for patients than to feel that the psychiatrist does not believe he/she will ever achieve wellness, or that they are beyond help and will never improve, recover, or overcome disabling psychiatric illness. This will generate profound hopelessness in vulnerable patients, who crave having a normal life free from illness or disability.
- Using the same medication for all patients. This is an anathema because one size does not fit all, and patients deserve to have their psychiatrists customize their pharmacotherapy to match their medical status and tolerability. For example, the 11 FDA-approved second-generation antipsychotics are not all the same, and a psychiatrist must select the member of that class that is most likely to be a good match for each patient based on that patient’s medical history and the safety/tolerability profile of each antipsychotic.
- Not continuously upgrading one’s practice to incorporate new evidence-based findings of more effective therapeutic strategies. It is an anathema to continue practicing what was learned in residency 25 to 30 years ago when there’s new knowledge and many advances permeating psychiatric practice today.
- Using alcohol or recreational drugs during a shift in the clinic or the hospital. No explanation is needed for this anathema!
- Prescribing for patients without a full evaluation. That’s poor clinical practice, and also is illegal.
- Billing for patients who were never examined. That’s fraudulent, and stupid!
In an editorial I wrote last year intended for graduates of psychiatry residency training programs about the “DNA of psychiatric practice,” I described what comprises good psychiatric practice.1 Anathemas can be regarded as “mutations” within the DNA of psychiatric practice. It is always my hope that none of the freshly minted psychiatrists going into practice will ever commit an anathema, and end up on the “list of shame” in their State Medical Board’s quarterly report….
The quarterly report of the State Medical Board can be a sobering read. In addition to the usual updates about new regulations or requirements for licensed physicians, there is always the disciplinary actions “blacklist” of dozens of medical practitioners in all specialties whose licenses were revoked or suspended due to a shocking array of serious violations.
Those infractions range from Medicare billing fraud to prescribing narcotics to fictitious patients to engaging in sex with a patient to walking into the operating room drunk. It is truly disheartening to see dozens of physicians destroy their careers by committing a panoply of odious, repugnant, or illegal actions.
The term “anathema” comes to mind when I read about those miscreants. This Greek term is occasionally used in scholarly or religious publications, but rarely in everyday conversations or articles. Anathema refers to something detested, shunned, or denounced. When used by the clergy, it connotes something to condemn, such as a sinful or evil act.
Like all other medical specialists, we psychiatrists have a noble mission of treating and relieving the suffering of those afflicted with brain disorders that manifest as mood, thought, perceptual, behavioral, or cognitive abnormalities. Our main goal is to restore health, wellness, and quality of life to the millions of individuals who buckle under the weight of genetic redispersion, adverse environmental events, or both. So psychiatrists do a lot of “good,” which benefits all those who live with mental illness. However, psychiatric practice may have some pitfalls that occasionally lead to anathemas, no matter how diligently a practitioner tries to avoid them. The code of psychiatric ethics is a shield that can preempt anathemas from contaminating clinical practice, but human error will occur when the ethical compass fails.
Here are some examples of anathemas that may rear their ugly heads if a practitioner is not constantly on the alert. It is likely you, the readers of
- Sexual contact with a patient. This major anathema must not occur under any circumstance. It will have grave professional consequences for the practitioner and serious emotional repercussions for the patient.
- Breach of confidentiality. This is a sacred rule in psychiatric practice that must not be broken under any circumstance. Breaching confidentiality will rupture the therapeutic bond and trust that a patient has with a psychiatrist (or psychiatric nurse practitioner).
- Causing physical or emotional harm. This anathema can have serious legal implications in addition to being an unacceptable professional violation.
- Failure to assess patients for suicidal or homicidal risk. The life of the patient, and others, may be at stake if this critical component is missing in the evaluation of psychiatric patients, even if they appear “stable.”
- Irrational and hazardous polypharmacy. This type of harm must never occur during medical management of psychiatric patients, and may have legal consequences.
- Not seeking collateral information. This may seem like a “minor” anathema, but it can have major repercussions if a gap of clinically important data about the patient leads to erroneous diagnosis or inappropriate treatment. Regrettably, informants are sometimes unavailable.
- Assessing patients from the neck up only. Psychiatrists are, first and foremost, physicians who must evaluate the entire medical status of the patient, not just his/her mind. There are numerous bidirectional effects between the body and the brain that can influence diagnosis, holistic treatment, medical outcomes, and prognosis.
- Treating patients with medication only, without any concomitant psychotherapy. Such a suboptimal practice is an anathema that is not excusable due to a “lack of time.” Every psychiatric patient deserves a biopsychosocial treatment approach.
- Not inquiring about adherence at every visit. It is impossible to assess the effectiveness of treatment if adherence is partial or poor. Patients must be constantly reminded that while their psychiatrists are committed to their care, full adherence is a vital responsibility for them to fulfill to ensure optimal outcome.
- Ignoring the patient’s cues, both verbal and nonverbal. Being rushed by a large workload, a full schedule, or the demands of electronic medical records that distract a psychiatrist from fully attending to what the patient’s words, facial expressions, or body language convey can lead to a failure to meet the patient’s needs. Even worse, it may lead to missing a serious message a patient is consciously or unconsciously trying to relay.
- Lowering expectations. Nothing is more devastating for patients than to feel that the psychiatrist does not believe he/she will ever achieve wellness, or that they are beyond help and will never improve, recover, or overcome disabling psychiatric illness. This will generate profound hopelessness in vulnerable patients, who crave having a normal life free from illness or disability.
- Using the same medication for all patients. This is an anathema because one size does not fit all, and patients deserve to have their psychiatrists customize their pharmacotherapy to match their medical status and tolerability. For example, the 11 FDA-approved second-generation antipsychotics are not all the same, and a psychiatrist must select the member of that class that is most likely to be a good match for each patient based on that patient’s medical history and the safety/tolerability profile of each antipsychotic.
- Not continuously upgrading one’s practice to incorporate new evidence-based findings of more effective therapeutic strategies. It is an anathema to continue practicing what was learned in residency 25 to 30 years ago when there’s new knowledge and many advances permeating psychiatric practice today.
- Using alcohol or recreational drugs during a shift in the clinic or the hospital. No explanation is needed for this anathema!
- Prescribing for patients without a full evaluation. That’s poor clinical practice, and also is illegal.
- Billing for patients who were never examined. That’s fraudulent, and stupid!
In an editorial I wrote last year intended for graduates of psychiatry residency training programs about the “DNA of psychiatric practice,” I described what comprises good psychiatric practice.1 Anathemas can be regarded as “mutations” within the DNA of psychiatric practice. It is always my hope that none of the freshly minted psychiatrists going into practice will ever commit an anathema, and end up on the “list of shame” in their State Medical Board’s quarterly report….
1. Nasrallah HA. The DNA of psychiatric practice: a covenant with our patients. Current Psychiatry. 2018;17(5):20,22.
1. Nasrallah HA. The DNA of psychiatric practice: a covenant with our patients. Current Psychiatry. 2018;17(5):20,22.
Should psychiatrists prescribe nonpsychotropic medications?
In our experience, most psychiatrists are uncomfortable with prescribing a medication when they feel that doing so would be outside their scope of practice. But there are many situations when prescribing a nonpsychotropic medication would be the correct choice. In this article, we discuss the scope of psychiatric practice, and present 4 case studies that illustrate situations in which psychiatrists should feel comfortable prescribing nonpsychotropic medications.
Defining the scope of practice
What is the scope of a psychiatrist’s practice? Scope of practice usually describes activities that a health care practitioner is allowed to undertake as defined by the terms of his/her license. A license to practice medicine does not include any stipulation restricting practice to a specific medical specialty. However, a local entity may delineate scope of practice within its organization. For instance, local practice standards held by the Detroit Wayne Mental Health Authority (DWMHA) state “Psychiatrists…shall not exceed their scope of practice as per DWMHA credentialing and privileging. For example, a Psychiatrist…who [has] not been appropriately privileged to deliver services to children shall not treat children, excepting crisis situations.”1
Like physicians in other specialties, psychiatrists are not limited to prescribing only a subset of medications commonly associated with their specialty. But for many psychiatrists, prescribing nonpsychotropic medications is complicated by individual and local factors. On one hand, some psychiatrists do not feel it is their role to prescribe nonpsychotropic medications,2 or even some psychotropic medications that may be more complex to prescribe, such as lithium, clozapine, or monoamine oxidase inhibitors.3-5 However, many feel comfortable prescribing complex combinations of psychotropic medications, or prescribing in a way that does not necessarily make sense (eg, prescribing benztropine as prophylaxis for dystonia when starting an antipsychotic).
Reviewing an average day at one urban psychiatric clinic, these questions seem to come up in half of the patient population, especially in patients with chronic mental illness, multiple medical comorbidities, and limited access to health care. When a young patient walks in without an appointment with an acute dystonic reaction secondary to the initiation of antipsychotics a couple of days ago, there is no hesitation to swiftly and appropriately prescribe an IM anticholinergic medication. But why are psychiatrists often hesitant to prescribe nonpsychotropic medications to treat other adverse effects of medications? Lack of knowledge? Lack of training?
Psychiatrists who practice in hospital systems often have immediate access to consultants, and this availability may encourage them to defer to the consultant for treatment of certain adverse effects. We have seen psychiatrists consult Neurology regarding the prescription of donepezil for mild neurocognitive disorder due to Alzheimer’s disease, or Endocrinology regarding prescription of levothyroxine for lithium-induced hypothyroidism.
However, there are numerous scenarios in which psychiatrists should feel comfortable prescribing nonpsychotropic medications or managing medication adverse effects, regardless of whether they consider it to be within or outside their scope of practice. The following case examples illustrate several such situations.
CASE 1
Ms. W, age 30, has been diagnosed with schizophrenia. She requests a refill of quetiapine, 800 mg/d. This medication has been clearly beneficial in alleviating her psychotic symptoms. However, since her last visit 3 months ago, her face appears more round, and she has gained 9 kg. Further evaluation indicates that she has developed metabolic syndrome and pre-diabetes.
Continue to: Metabolic adverse effects
Metabolic adverse effects, such as metabolic syndrome, diabetic ketoacidosis, and cardiovascular disease, are well-known risks of prescribing second-generation antipsychotics.6 In such situations, psychiatrists often advise patients to modify their diet, increase physical activity, and follow up with their primary care physician to determine if other medications are needed. However, getting a patient with a serious mental illness to exercise and modify her/his diet is difficult, and many of these patients do not have a primary care physician.
For patients such as Ms. W, a psychiatrist should consider prescribing metformin. Wu et al7 found that in addition to lifestyle modifications, metformin had the greatest effect on antipsychotic-induced weight gain. In this study, metformin alone had more impact on reversing weight gain and increasing insulin sensitivity than lifestyle modifications alone.7 This is crucial because these patients are especially vulnerable to cardiac disease.8 Metformin is well tolerated and has a low risk of causing hypoglycemia. Concerns regarding lactic acidosis have abated to the extent that the estimated glomerular filtration rate (eGFR) limits for using metformin have been lowered significantly. After reviewing the contraindications, the only knowledge needed to prescribe metformin is the patient’s kidney function and a brief understanding of the titration needed to minimize gastrointestinal adverse effects.9 Thus, prescribing metformin would be a fairly logical and easy first step for managing metabolic syndrome, especially in a patient whose motivation for increasing physical activity and modifying his/her diet is doubtful.
CASE 2
Mr. B, age 45, has major depressive disorder that has been well-controlled on paroxetine, 40 mg/d, for the past 2 years. He has no history of physical illness. On his most recent visit, he appears uncomfortable and nervous. After a long discussion, he discloses that his sex life isn’t what it used to be since starting paroxetine. He is bothered by erectile problems and asks whether he can “get some Viagra.”
Sexual adverse effects, such as erectile dysfunction, are frequently associated with the use of selective serotonin reuptake inhibitors.10 Although managing these adverse effects requires careful evaluation, in most cases, psychiatrists should be able to treat them.10 The logical choice in this case would be to prescribe one of the 4 FDA-approved phosphodiesterase-5 inhibitors (sildenafil [Viagra], tadalafil [Cialis], vardenafil [Levitra], and avanafil [Stendra]. However, Balon et al11 found that few psychiatrists prescribe phosphodiesterase-5 inhibitors, although they believed that they should be prescribing to treat their patients’ sexual dysfunction. Managing these adverse effects is important not only for the patient’s quality of life and relationship with his/her partner, but also for the therapeutic alliance. In a systematic review of 23 trials, Taylor et al12 examined >1,800 patients who were prescribed a medication to address sexual dysfunction secondary to antidepressants. They found that for men, adding a phosphodiesterase-5 inhibitor was appropriate and effective, and for women, adding bupropion at high doses should be considered.12 Like many other adverse effects, sexual adverse effects surely play a role in medication compliance. Dording et al13 found that the addition of sildenafil, 50 to 100 mg as needed, resulted in increased treatment satisfaction and overall contentment in 102 patients who complained of sexual dysfunction in the follow-up phase of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) antidepressant trials. In most cases, with proper psychoeducation, prescription of
CASE 3
Ms. G, age 22, was recently discharged from an inpatient psychiatric unit after an episode of mania. She was prescribed carbamazepine, 600 mg/d, and ziprasidone, 40 mg twice a day, and appears to be doing well on this regimen. When asked about what led to her admission, she recalls having an elevated mood, increased energy, hypersexuality, impulsivity, and poor judgment. She reveals that she had several sexual partners during her manic episode, and worries that if such behavior occurs again, she may get pregnant. Yet Ms. G was not prescribed birth control upon discharge.
Continue to: Contraception
Contraception. We believe that psychiatrists have an obligation to protect patients from consequences of mental illness. Much the same way that psychiatrists hope to prevent suicide in a patient who has depression, patients should be protected from risks encountered in the manic phase of bipolar disorder. Another reason to prescribe contraceptives in such patients is the teratogenic effects of mood stabilizers. Pagano et al14 reviewed 6 studies that examined common forms of hormonal birth control to determine their safety in patients with depression or bipolar disorder. They found that overall, use of hormonal contraception was not associated with a worse clinical course of disease.
Many available forms of birth control are available. When prescribing in an outpatient setting, a daily oral medication or a monthly depot injection are convenient options.
CASE 4
Mr. P, age 65, has bipolar I disorder and is stable on risperidone long-acting injection, 37.7 mg bimonthly, and lithium, 1,200 mg/d. He reports that he is doing well but has noticed a recent decrease in energy and weight gain without any change in mood. Laboratory testing conducted prior to this visit revealed a thyroid-stimulating hormone (TSH) level of 4 mU/L (normal range: 0.4 to 4.0 mU/L). Six months ago, Mr. P’s TSH level was 2.8 mU/L. The resident supervisor suggests discussing the case with an endocrinologist.
Thyroid function. The impact of lithium on the thyroid gland is well established; however, psychiatrists’ response to such changes are not.15 Gitlin16 reviewed the many adverse effects of lithium and presented various management strategies to address findings such as Mr. P’s. Two important points are that lithium should not be discontinued in light of hypothyroidism, and synthetic thyroxine (levothyroxine) can be initiated and titrated to return TSH levels to a normal range.16 Levothyroxine can be started at low doses (eg, 25 to 50 mcg/d) and increased every 6 weeks until a normal TSH level is achieved.17 Managing lithium-induced clinical or subclinical hypothyroidism can prevent further pathology and possible relapse to depression.
Incorporating integrated care
In all these cases, the prescription of a medication with which some psychiatrists are not comfortable prescribing would have been the logical, easiest, and preferable choice. Of course, when initiating any medication, boxed warnings, contraindications, and drug–drug interactions should be reviewed. Initial dosages and titration schedules can be found in every medication’s FDA-approved prescribing information document (package insert), as well as in numerous reference books and articles.
Continue to: We acknowledge...
We acknowledge that prescribing a nonpsychotropic medication is not always a psychiatrist’s best choice, and that in patients with multiple medical comorbidities and drug–drug interactions that are not clearly defined, referring to or consulting a specialist is appropriate. We in no way support reckless prescribing, but instead present an opportunity to expand the perception of what should be considered within a psychiatrist’s scope of practice, and call for further education of psychiatrists so that they are more comfortable managing these adverse effects and/or prescribing at least some nonpsychotropic medications.
We exhort integrated medical care during this time of a physician shortage; however, we do not practice this way. Interestingly, physicians in primary care, such as those in family medicine or obstetrics and gynecology, frequently attempt to treat patients with psychiatric conditions in an attempt to provide integrated care. Numerous articles have discussed these efforts.18-20 However, this type of integrated care seems less frequent in psychiatry, even though the practice of modern psychiatry in the United States shows substantial overlap with the practice of physicians in primary care specialties.21 There are few articles or practical guidelines for psychiatrists who wish to treat patients’ physical illnesses, particularly patients with severe mental illness (see Related Resources, page 56). If we practice in an integrated manner to treat one of the simple conditions we described above, we can eliminate the need for a patient to visit a second physician, pay another co-pay, pay another bus fare, and take another day off work. This can be particularly helpful for patients who at times have to decide between paying for groceries or for medications. Having one clinician manage a patient’s medications also can decrease the risk of polypharmacy.
In addition to the case scenarios described in this article, there are more clinical situations and nonpsychotropic medications that psychiatrists could manage. Considering them outside the scope of psychiatric practice and being uncomfortable or ambivalent about them is not an excuse. We hope that psychiatrists can increase their expertise in this area, and can start to practice as the primary care physicians they claim they are, and should be.
Bottom Line
Many psychiatrists are uncomfortable prescribing nonpsychotropic medications, but there are numerous clinical scenarios in which the practice would make sense. This could include cases of metabolic syndrome, sexual dysfunction secondary to antidepressant use, or other adverse effects of commonly prescribed psychotropic medications.
Related Resources
- McCarron RM, Xiong GL, Keenan CR, et al. Preventive medical care in psychiatry. A practical guide for clinicians. Arlington, VA: American Psychiatric Association Publishing; 2015.
- McCarron RM, Xiong GL, Keenan CR, et al. Study guide to preventive medical care in psychiatry. Arlington, VA: American Psychiatric Association Publishing; 2017.
- Goldberg JF, Ernst CL. Managing the side effects of psychotropic medications. Washington, DC: American Psychiatric Association Publishing; 2019.
Drug Brand Names
Avanafil • Stendra
Benztropine • Cogentin
Bupropion • Wellbutrin, Zyban
Carbamazepine • Carbatrol, Tegretol
Clozapine • Clozaril
Donepezil • Aricept
Levothyroxine • Levoxyl, Synthroid
Lithium • Eskalith, Lithobid
Metformin • Fortamet, Glucophage
Paroxetine • Paxil
Quetiapine • Seroquel
Risperidone long-acting injection • Risperdal Consta
Sildenafil • Viagra
Tadalafil • Cialis
Vardenafil • Levitra
Ziprasidone • Geodon
1. Detroit Wayne Integrated Health Network. DWMHA psychiatric practice standards. http://dwihn.org/files/2015/6451/9628/Psychiatric_Practice_Standards.pdf. Revised June 2018. Accessed October 8, 2019.
2. Seaman JJ, Cornfield RM, Cummings DM, et al. Exploring psychiatric prescribing practices: the relationship between the role of the provider and the appropriateness of prescribing. Gen Hosp Psychiatry. 1987;9(3):220-224.
3. Zivanovic O. Lithium: a classic drug—frequently discussed, but, sadly, seldom prescribed! Aust N Z J Psychiatry. 2017;51(9):886-896.
4. Stroup TS, Gerhard T, Crystal S, et al. Geographic and clinical variation in clozapine use in the United States. Psychiatric Services. 2014;65(2):186-192.
5. Balon R, Mufti R, Arfken C. A survey of prescribing practices for monoamine oxidase inhibitors. Psychiatric Services. 1999;50(7):945-947.
6. Rummel-Kluge C, Komossa K, Schwarz S, et al. Head-to-head comparisons of metabolic side effects of second generation antipsychotics in the treatment of schizophrenia: a systematic review and meta-analysis. Schizophr Res. 2010;123(2-3):225-233.
7. Wu RR, Zhao JP, Jin H, et al. Lifestyle intervention and metformin for treatment of antipsychotic-induced weight gain: a randomized controlled trial. JAMA. 2008;299(2):185-193.
8. De Hert M, Correll CU, Bobes J, et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry. 2011;10(1):52-77.
9. Kirpichnikov D, McFarlane SI, Sowers JR. Metformin: an update. Ann Internal Med. 2002;137(1):25-33.
10. Balon R. SSRI-associated sexual dysfunction. Am J Psychiatry. 2006;163(9):1504-1509.
11. Balon R, Morreale MK, Segraves RT. Prescribing of phosphodiesterase-5 inhibitors among psychiatrists. J Sex Marital Ther. 2014;40(3):165-169.
12. Taylor MJ, Rudkin L, Bullemor-Day P, et al. Strategies for managing sexual dysfunction induced by antidepressant medication. Cochrane Database Syst Rev. 2013;(5):CD003382.
13. Dording CM, LaRocca RA, Hails KA, et al. The effect of sildenafil on quality of life. Ann Clin Psychiatry. 2013;25(1):3-10.
14. Pagano HP, Zapata LB, Berry-Bibee EN, et al. Safety of hormonal contraception and intrauterine devices among women with depressive and bipolar disorders: a systematic review. Contraception. 2016;94(6):641-649.
15. Kibirige D, Luzinda K, Ssekitoleko R. Spectrum of lithium induced thyroid abnormalities: a current perspective. Thyroid Res. 2013;6(1):3.
16. Gitlin M. Lithium side effects and toxicity: prevalence and management strategies. Int J Bipolar Disord. 2016;4(1):27.
17. Devdhar M, Ousman YH, Burman KD. Hypothyroidism. Endocrinol Metab Clin North Am. 2007;36(3):595-615.
18. Hackley B, Sharma C, Kedzior A, et al. Managing mental health conditions in primary care settings. J Midwifery Women’s Health. 2010;55(1):9-19.
19. Fitelson E, McGibbon C. Evaluation and management of behavioral health disorders in women: an overview of major depression, bipolar disorder, anxiety disorders, and sleep in the primary care setting. Obstet Gynecol Clin North Am. 2016;43(2):231-246.
20. Colorafi K, Vanselow J, Nelson T. Treating anxiety and depression in primary care: reducing barriers to access. Fam Pract Manag. 2017;24(4):11-16.
21. McCall WV. Defining the unique scope of psychiatric practice in 2015. J ECT. 2015;31(4):203-204.
In our experience, most psychiatrists are uncomfortable with prescribing a medication when they feel that doing so would be outside their scope of practice. But there are many situations when prescribing a nonpsychotropic medication would be the correct choice. In this article, we discuss the scope of psychiatric practice, and present 4 case studies that illustrate situations in which psychiatrists should feel comfortable prescribing nonpsychotropic medications.
Defining the scope of practice
What is the scope of a psychiatrist’s practice? Scope of practice usually describes activities that a health care practitioner is allowed to undertake as defined by the terms of his/her license. A license to practice medicine does not include any stipulation restricting practice to a specific medical specialty. However, a local entity may delineate scope of practice within its organization. For instance, local practice standards held by the Detroit Wayne Mental Health Authority (DWMHA) state “Psychiatrists…shall not exceed their scope of practice as per DWMHA credentialing and privileging. For example, a Psychiatrist…who [has] not been appropriately privileged to deliver services to children shall not treat children, excepting crisis situations.”1
Like physicians in other specialties, psychiatrists are not limited to prescribing only a subset of medications commonly associated with their specialty. But for many psychiatrists, prescribing nonpsychotropic medications is complicated by individual and local factors. On one hand, some psychiatrists do not feel it is their role to prescribe nonpsychotropic medications,2 or even some psychotropic medications that may be more complex to prescribe, such as lithium, clozapine, or monoamine oxidase inhibitors.3-5 However, many feel comfortable prescribing complex combinations of psychotropic medications, or prescribing in a way that does not necessarily make sense (eg, prescribing benztropine as prophylaxis for dystonia when starting an antipsychotic).
Reviewing an average day at one urban psychiatric clinic, these questions seem to come up in half of the patient population, especially in patients with chronic mental illness, multiple medical comorbidities, and limited access to health care. When a young patient walks in without an appointment with an acute dystonic reaction secondary to the initiation of antipsychotics a couple of days ago, there is no hesitation to swiftly and appropriately prescribe an IM anticholinergic medication. But why are psychiatrists often hesitant to prescribe nonpsychotropic medications to treat other adverse effects of medications? Lack of knowledge? Lack of training?
Psychiatrists who practice in hospital systems often have immediate access to consultants, and this availability may encourage them to defer to the consultant for treatment of certain adverse effects. We have seen psychiatrists consult Neurology regarding the prescription of donepezil for mild neurocognitive disorder due to Alzheimer’s disease, or Endocrinology regarding prescription of levothyroxine for lithium-induced hypothyroidism.
However, there are numerous scenarios in which psychiatrists should feel comfortable prescribing nonpsychotropic medications or managing medication adverse effects, regardless of whether they consider it to be within or outside their scope of practice. The following case examples illustrate several such situations.
CASE 1
Ms. W, age 30, has been diagnosed with schizophrenia. She requests a refill of quetiapine, 800 mg/d. This medication has been clearly beneficial in alleviating her psychotic symptoms. However, since her last visit 3 months ago, her face appears more round, and she has gained 9 kg. Further evaluation indicates that she has developed metabolic syndrome and pre-diabetes.
Continue to: Metabolic adverse effects
Metabolic adverse effects, such as metabolic syndrome, diabetic ketoacidosis, and cardiovascular disease, are well-known risks of prescribing second-generation antipsychotics.6 In such situations, psychiatrists often advise patients to modify their diet, increase physical activity, and follow up with their primary care physician to determine if other medications are needed. However, getting a patient with a serious mental illness to exercise and modify her/his diet is difficult, and many of these patients do not have a primary care physician.
For patients such as Ms. W, a psychiatrist should consider prescribing metformin. Wu et al7 found that in addition to lifestyle modifications, metformin had the greatest effect on antipsychotic-induced weight gain. In this study, metformin alone had more impact on reversing weight gain and increasing insulin sensitivity than lifestyle modifications alone.7 This is crucial because these patients are especially vulnerable to cardiac disease.8 Metformin is well tolerated and has a low risk of causing hypoglycemia. Concerns regarding lactic acidosis have abated to the extent that the estimated glomerular filtration rate (eGFR) limits for using metformin have been lowered significantly. After reviewing the contraindications, the only knowledge needed to prescribe metformin is the patient’s kidney function and a brief understanding of the titration needed to minimize gastrointestinal adverse effects.9 Thus, prescribing metformin would be a fairly logical and easy first step for managing metabolic syndrome, especially in a patient whose motivation for increasing physical activity and modifying his/her diet is doubtful.
CASE 2
Mr. B, age 45, has major depressive disorder that has been well-controlled on paroxetine, 40 mg/d, for the past 2 years. He has no history of physical illness. On his most recent visit, he appears uncomfortable and nervous. After a long discussion, he discloses that his sex life isn’t what it used to be since starting paroxetine. He is bothered by erectile problems and asks whether he can “get some Viagra.”
Sexual adverse effects, such as erectile dysfunction, are frequently associated with the use of selective serotonin reuptake inhibitors.10 Although managing these adverse effects requires careful evaluation, in most cases, psychiatrists should be able to treat them.10 The logical choice in this case would be to prescribe one of the 4 FDA-approved phosphodiesterase-5 inhibitors (sildenafil [Viagra], tadalafil [Cialis], vardenafil [Levitra], and avanafil [Stendra]. However, Balon et al11 found that few psychiatrists prescribe phosphodiesterase-5 inhibitors, although they believed that they should be prescribing to treat their patients’ sexual dysfunction. Managing these adverse effects is important not only for the patient’s quality of life and relationship with his/her partner, but also for the therapeutic alliance. In a systematic review of 23 trials, Taylor et al12 examined >1,800 patients who were prescribed a medication to address sexual dysfunction secondary to antidepressants. They found that for men, adding a phosphodiesterase-5 inhibitor was appropriate and effective, and for women, adding bupropion at high doses should be considered.12 Like many other adverse effects, sexual adverse effects surely play a role in medication compliance. Dording et al13 found that the addition of sildenafil, 50 to 100 mg as needed, resulted in increased treatment satisfaction and overall contentment in 102 patients who complained of sexual dysfunction in the follow-up phase of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) antidepressant trials. In most cases, with proper psychoeducation, prescription of
CASE 3
Ms. G, age 22, was recently discharged from an inpatient psychiatric unit after an episode of mania. She was prescribed carbamazepine, 600 mg/d, and ziprasidone, 40 mg twice a day, and appears to be doing well on this regimen. When asked about what led to her admission, she recalls having an elevated mood, increased energy, hypersexuality, impulsivity, and poor judgment. She reveals that she had several sexual partners during her manic episode, and worries that if such behavior occurs again, she may get pregnant. Yet Ms. G was not prescribed birth control upon discharge.
Continue to: Contraception
Contraception. We believe that psychiatrists have an obligation to protect patients from consequences of mental illness. Much the same way that psychiatrists hope to prevent suicide in a patient who has depression, patients should be protected from risks encountered in the manic phase of bipolar disorder. Another reason to prescribe contraceptives in such patients is the teratogenic effects of mood stabilizers. Pagano et al14 reviewed 6 studies that examined common forms of hormonal birth control to determine their safety in patients with depression or bipolar disorder. They found that overall, use of hormonal contraception was not associated with a worse clinical course of disease.
Many available forms of birth control are available. When prescribing in an outpatient setting, a daily oral medication or a monthly depot injection are convenient options.
CASE 4
Mr. P, age 65, has bipolar I disorder and is stable on risperidone long-acting injection, 37.7 mg bimonthly, and lithium, 1,200 mg/d. He reports that he is doing well but has noticed a recent decrease in energy and weight gain without any change in mood. Laboratory testing conducted prior to this visit revealed a thyroid-stimulating hormone (TSH) level of 4 mU/L (normal range: 0.4 to 4.0 mU/L). Six months ago, Mr. P’s TSH level was 2.8 mU/L. The resident supervisor suggests discussing the case with an endocrinologist.
Thyroid function. The impact of lithium on the thyroid gland is well established; however, psychiatrists’ response to such changes are not.15 Gitlin16 reviewed the many adverse effects of lithium and presented various management strategies to address findings such as Mr. P’s. Two important points are that lithium should not be discontinued in light of hypothyroidism, and synthetic thyroxine (levothyroxine) can be initiated and titrated to return TSH levels to a normal range.16 Levothyroxine can be started at low doses (eg, 25 to 50 mcg/d) and increased every 6 weeks until a normal TSH level is achieved.17 Managing lithium-induced clinical or subclinical hypothyroidism can prevent further pathology and possible relapse to depression.
Incorporating integrated care
In all these cases, the prescription of a medication with which some psychiatrists are not comfortable prescribing would have been the logical, easiest, and preferable choice. Of course, when initiating any medication, boxed warnings, contraindications, and drug–drug interactions should be reviewed. Initial dosages and titration schedules can be found in every medication’s FDA-approved prescribing information document (package insert), as well as in numerous reference books and articles.
Continue to: We acknowledge...
We acknowledge that prescribing a nonpsychotropic medication is not always a psychiatrist’s best choice, and that in patients with multiple medical comorbidities and drug–drug interactions that are not clearly defined, referring to or consulting a specialist is appropriate. We in no way support reckless prescribing, but instead present an opportunity to expand the perception of what should be considered within a psychiatrist’s scope of practice, and call for further education of psychiatrists so that they are more comfortable managing these adverse effects and/or prescribing at least some nonpsychotropic medications.
We exhort integrated medical care during this time of a physician shortage; however, we do not practice this way. Interestingly, physicians in primary care, such as those in family medicine or obstetrics and gynecology, frequently attempt to treat patients with psychiatric conditions in an attempt to provide integrated care. Numerous articles have discussed these efforts.18-20 However, this type of integrated care seems less frequent in psychiatry, even though the practice of modern psychiatry in the United States shows substantial overlap with the practice of physicians in primary care specialties.21 There are few articles or practical guidelines for psychiatrists who wish to treat patients’ physical illnesses, particularly patients with severe mental illness (see Related Resources, page 56). If we practice in an integrated manner to treat one of the simple conditions we described above, we can eliminate the need for a patient to visit a second physician, pay another co-pay, pay another bus fare, and take another day off work. This can be particularly helpful for patients who at times have to decide between paying for groceries or for medications. Having one clinician manage a patient’s medications also can decrease the risk of polypharmacy.
In addition to the case scenarios described in this article, there are more clinical situations and nonpsychotropic medications that psychiatrists could manage. Considering them outside the scope of psychiatric practice and being uncomfortable or ambivalent about them is not an excuse. We hope that psychiatrists can increase their expertise in this area, and can start to practice as the primary care physicians they claim they are, and should be.
Bottom Line
Many psychiatrists are uncomfortable prescribing nonpsychotropic medications, but there are numerous clinical scenarios in which the practice would make sense. This could include cases of metabolic syndrome, sexual dysfunction secondary to antidepressant use, or other adverse effects of commonly prescribed psychotropic medications.
Related Resources
- McCarron RM, Xiong GL, Keenan CR, et al. Preventive medical care in psychiatry. A practical guide for clinicians. Arlington, VA: American Psychiatric Association Publishing; 2015.
- McCarron RM, Xiong GL, Keenan CR, et al. Study guide to preventive medical care in psychiatry. Arlington, VA: American Psychiatric Association Publishing; 2017.
- Goldberg JF, Ernst CL. Managing the side effects of psychotropic medications. Washington, DC: American Psychiatric Association Publishing; 2019.
Drug Brand Names
Avanafil • Stendra
Benztropine • Cogentin
Bupropion • Wellbutrin, Zyban
Carbamazepine • Carbatrol, Tegretol
Clozapine • Clozaril
Donepezil • Aricept
Levothyroxine • Levoxyl, Synthroid
Lithium • Eskalith, Lithobid
Metformin • Fortamet, Glucophage
Paroxetine • Paxil
Quetiapine • Seroquel
Risperidone long-acting injection • Risperdal Consta
Sildenafil • Viagra
Tadalafil • Cialis
Vardenafil • Levitra
Ziprasidone • Geodon
In our experience, most psychiatrists are uncomfortable with prescribing a medication when they feel that doing so would be outside their scope of practice. But there are many situations when prescribing a nonpsychotropic medication would be the correct choice. In this article, we discuss the scope of psychiatric practice, and present 4 case studies that illustrate situations in which psychiatrists should feel comfortable prescribing nonpsychotropic medications.
Defining the scope of practice
What is the scope of a psychiatrist’s practice? Scope of practice usually describes activities that a health care practitioner is allowed to undertake as defined by the terms of his/her license. A license to practice medicine does not include any stipulation restricting practice to a specific medical specialty. However, a local entity may delineate scope of practice within its organization. For instance, local practice standards held by the Detroit Wayne Mental Health Authority (DWMHA) state “Psychiatrists…shall not exceed their scope of practice as per DWMHA credentialing and privileging. For example, a Psychiatrist…who [has] not been appropriately privileged to deliver services to children shall not treat children, excepting crisis situations.”1
Like physicians in other specialties, psychiatrists are not limited to prescribing only a subset of medications commonly associated with their specialty. But for many psychiatrists, prescribing nonpsychotropic medications is complicated by individual and local factors. On one hand, some psychiatrists do not feel it is their role to prescribe nonpsychotropic medications,2 or even some psychotropic medications that may be more complex to prescribe, such as lithium, clozapine, or monoamine oxidase inhibitors.3-5 However, many feel comfortable prescribing complex combinations of psychotropic medications, or prescribing in a way that does not necessarily make sense (eg, prescribing benztropine as prophylaxis for dystonia when starting an antipsychotic).
Reviewing an average day at one urban psychiatric clinic, these questions seem to come up in half of the patient population, especially in patients with chronic mental illness, multiple medical comorbidities, and limited access to health care. When a young patient walks in without an appointment with an acute dystonic reaction secondary to the initiation of antipsychotics a couple of days ago, there is no hesitation to swiftly and appropriately prescribe an IM anticholinergic medication. But why are psychiatrists often hesitant to prescribe nonpsychotropic medications to treat other adverse effects of medications? Lack of knowledge? Lack of training?
Psychiatrists who practice in hospital systems often have immediate access to consultants, and this availability may encourage them to defer to the consultant for treatment of certain adverse effects. We have seen psychiatrists consult Neurology regarding the prescription of donepezil for mild neurocognitive disorder due to Alzheimer’s disease, or Endocrinology regarding prescription of levothyroxine for lithium-induced hypothyroidism.
However, there are numerous scenarios in which psychiatrists should feel comfortable prescribing nonpsychotropic medications or managing medication adverse effects, regardless of whether they consider it to be within or outside their scope of practice. The following case examples illustrate several such situations.
CASE 1
Ms. W, age 30, has been diagnosed with schizophrenia. She requests a refill of quetiapine, 800 mg/d. This medication has been clearly beneficial in alleviating her psychotic symptoms. However, since her last visit 3 months ago, her face appears more round, and she has gained 9 kg. Further evaluation indicates that she has developed metabolic syndrome and pre-diabetes.
Continue to: Metabolic adverse effects
Metabolic adverse effects, such as metabolic syndrome, diabetic ketoacidosis, and cardiovascular disease, are well-known risks of prescribing second-generation antipsychotics.6 In such situations, psychiatrists often advise patients to modify their diet, increase physical activity, and follow up with their primary care physician to determine if other medications are needed. However, getting a patient with a serious mental illness to exercise and modify her/his diet is difficult, and many of these patients do not have a primary care physician.
For patients such as Ms. W, a psychiatrist should consider prescribing metformin. Wu et al7 found that in addition to lifestyle modifications, metformin had the greatest effect on antipsychotic-induced weight gain. In this study, metformin alone had more impact on reversing weight gain and increasing insulin sensitivity than lifestyle modifications alone.7 This is crucial because these patients are especially vulnerable to cardiac disease.8 Metformin is well tolerated and has a low risk of causing hypoglycemia. Concerns regarding lactic acidosis have abated to the extent that the estimated glomerular filtration rate (eGFR) limits for using metformin have been lowered significantly. After reviewing the contraindications, the only knowledge needed to prescribe metformin is the patient’s kidney function and a brief understanding of the titration needed to minimize gastrointestinal adverse effects.9 Thus, prescribing metformin would be a fairly logical and easy first step for managing metabolic syndrome, especially in a patient whose motivation for increasing physical activity and modifying his/her diet is doubtful.
CASE 2
Mr. B, age 45, has major depressive disorder that has been well-controlled on paroxetine, 40 mg/d, for the past 2 years. He has no history of physical illness. On his most recent visit, he appears uncomfortable and nervous. After a long discussion, he discloses that his sex life isn’t what it used to be since starting paroxetine. He is bothered by erectile problems and asks whether he can “get some Viagra.”
Sexual adverse effects, such as erectile dysfunction, are frequently associated with the use of selective serotonin reuptake inhibitors.10 Although managing these adverse effects requires careful evaluation, in most cases, psychiatrists should be able to treat them.10 The logical choice in this case would be to prescribe one of the 4 FDA-approved phosphodiesterase-5 inhibitors (sildenafil [Viagra], tadalafil [Cialis], vardenafil [Levitra], and avanafil [Stendra]. However, Balon et al11 found that few psychiatrists prescribe phosphodiesterase-5 inhibitors, although they believed that they should be prescribing to treat their patients’ sexual dysfunction. Managing these adverse effects is important not only for the patient’s quality of life and relationship with his/her partner, but also for the therapeutic alliance. In a systematic review of 23 trials, Taylor et al12 examined >1,800 patients who were prescribed a medication to address sexual dysfunction secondary to antidepressants. They found that for men, adding a phosphodiesterase-5 inhibitor was appropriate and effective, and for women, adding bupropion at high doses should be considered.12 Like many other adverse effects, sexual adverse effects surely play a role in medication compliance. Dording et al13 found that the addition of sildenafil, 50 to 100 mg as needed, resulted in increased treatment satisfaction and overall contentment in 102 patients who complained of sexual dysfunction in the follow-up phase of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) antidepressant trials. In most cases, with proper psychoeducation, prescription of
CASE 3
Ms. G, age 22, was recently discharged from an inpatient psychiatric unit after an episode of mania. She was prescribed carbamazepine, 600 mg/d, and ziprasidone, 40 mg twice a day, and appears to be doing well on this regimen. When asked about what led to her admission, she recalls having an elevated mood, increased energy, hypersexuality, impulsivity, and poor judgment. She reveals that she had several sexual partners during her manic episode, and worries that if such behavior occurs again, she may get pregnant. Yet Ms. G was not prescribed birth control upon discharge.
Continue to: Contraception
Contraception. We believe that psychiatrists have an obligation to protect patients from consequences of mental illness. Much the same way that psychiatrists hope to prevent suicide in a patient who has depression, patients should be protected from risks encountered in the manic phase of bipolar disorder. Another reason to prescribe contraceptives in such patients is the teratogenic effects of mood stabilizers. Pagano et al14 reviewed 6 studies that examined common forms of hormonal birth control to determine their safety in patients with depression or bipolar disorder. They found that overall, use of hormonal contraception was not associated with a worse clinical course of disease.
Many available forms of birth control are available. When prescribing in an outpatient setting, a daily oral medication or a monthly depot injection are convenient options.
CASE 4
Mr. P, age 65, has bipolar I disorder and is stable on risperidone long-acting injection, 37.7 mg bimonthly, and lithium, 1,200 mg/d. He reports that he is doing well but has noticed a recent decrease in energy and weight gain without any change in mood. Laboratory testing conducted prior to this visit revealed a thyroid-stimulating hormone (TSH) level of 4 mU/L (normal range: 0.4 to 4.0 mU/L). Six months ago, Mr. P’s TSH level was 2.8 mU/L. The resident supervisor suggests discussing the case with an endocrinologist.
Thyroid function. The impact of lithium on the thyroid gland is well established; however, psychiatrists’ response to such changes are not.15 Gitlin16 reviewed the many adverse effects of lithium and presented various management strategies to address findings such as Mr. P’s. Two important points are that lithium should not be discontinued in light of hypothyroidism, and synthetic thyroxine (levothyroxine) can be initiated and titrated to return TSH levels to a normal range.16 Levothyroxine can be started at low doses (eg, 25 to 50 mcg/d) and increased every 6 weeks until a normal TSH level is achieved.17 Managing lithium-induced clinical or subclinical hypothyroidism can prevent further pathology and possible relapse to depression.
Incorporating integrated care
In all these cases, the prescription of a medication with which some psychiatrists are not comfortable prescribing would have been the logical, easiest, and preferable choice. Of course, when initiating any medication, boxed warnings, contraindications, and drug–drug interactions should be reviewed. Initial dosages and titration schedules can be found in every medication’s FDA-approved prescribing information document (package insert), as well as in numerous reference books and articles.
Continue to: We acknowledge...
We acknowledge that prescribing a nonpsychotropic medication is not always a psychiatrist’s best choice, and that in patients with multiple medical comorbidities and drug–drug interactions that are not clearly defined, referring to or consulting a specialist is appropriate. We in no way support reckless prescribing, but instead present an opportunity to expand the perception of what should be considered within a psychiatrist’s scope of practice, and call for further education of psychiatrists so that they are more comfortable managing these adverse effects and/or prescribing at least some nonpsychotropic medications.
We exhort integrated medical care during this time of a physician shortage; however, we do not practice this way. Interestingly, physicians in primary care, such as those in family medicine or obstetrics and gynecology, frequently attempt to treat patients with psychiatric conditions in an attempt to provide integrated care. Numerous articles have discussed these efforts.18-20 However, this type of integrated care seems less frequent in psychiatry, even though the practice of modern psychiatry in the United States shows substantial overlap with the practice of physicians in primary care specialties.21 There are few articles or practical guidelines for psychiatrists who wish to treat patients’ physical illnesses, particularly patients with severe mental illness (see Related Resources, page 56). If we practice in an integrated manner to treat one of the simple conditions we described above, we can eliminate the need for a patient to visit a second physician, pay another co-pay, pay another bus fare, and take another day off work. This can be particularly helpful for patients who at times have to decide between paying for groceries or for medications. Having one clinician manage a patient’s medications also can decrease the risk of polypharmacy.
In addition to the case scenarios described in this article, there are more clinical situations and nonpsychotropic medications that psychiatrists could manage. Considering them outside the scope of psychiatric practice and being uncomfortable or ambivalent about them is not an excuse. We hope that psychiatrists can increase their expertise in this area, and can start to practice as the primary care physicians they claim they are, and should be.
Bottom Line
Many psychiatrists are uncomfortable prescribing nonpsychotropic medications, but there are numerous clinical scenarios in which the practice would make sense. This could include cases of metabolic syndrome, sexual dysfunction secondary to antidepressant use, or other adverse effects of commonly prescribed psychotropic medications.
Related Resources
- McCarron RM, Xiong GL, Keenan CR, et al. Preventive medical care in psychiatry. A practical guide for clinicians. Arlington, VA: American Psychiatric Association Publishing; 2015.
- McCarron RM, Xiong GL, Keenan CR, et al. Study guide to preventive medical care in psychiatry. Arlington, VA: American Psychiatric Association Publishing; 2017.
- Goldberg JF, Ernst CL. Managing the side effects of psychotropic medications. Washington, DC: American Psychiatric Association Publishing; 2019.
Drug Brand Names
Avanafil • Stendra
Benztropine • Cogentin
Bupropion • Wellbutrin, Zyban
Carbamazepine • Carbatrol, Tegretol
Clozapine • Clozaril
Donepezil • Aricept
Levothyroxine • Levoxyl, Synthroid
Lithium • Eskalith, Lithobid
Metformin • Fortamet, Glucophage
Paroxetine • Paxil
Quetiapine • Seroquel
Risperidone long-acting injection • Risperdal Consta
Sildenafil • Viagra
Tadalafil • Cialis
Vardenafil • Levitra
Ziprasidone • Geodon
1. Detroit Wayne Integrated Health Network. DWMHA psychiatric practice standards. http://dwihn.org/files/2015/6451/9628/Psychiatric_Practice_Standards.pdf. Revised June 2018. Accessed October 8, 2019.
2. Seaman JJ, Cornfield RM, Cummings DM, et al. Exploring psychiatric prescribing practices: the relationship between the role of the provider and the appropriateness of prescribing. Gen Hosp Psychiatry. 1987;9(3):220-224.
3. Zivanovic O. Lithium: a classic drug—frequently discussed, but, sadly, seldom prescribed! Aust N Z J Psychiatry. 2017;51(9):886-896.
4. Stroup TS, Gerhard T, Crystal S, et al. Geographic and clinical variation in clozapine use in the United States. Psychiatric Services. 2014;65(2):186-192.
5. Balon R, Mufti R, Arfken C. A survey of prescribing practices for monoamine oxidase inhibitors. Psychiatric Services. 1999;50(7):945-947.
6. Rummel-Kluge C, Komossa K, Schwarz S, et al. Head-to-head comparisons of metabolic side effects of second generation antipsychotics in the treatment of schizophrenia: a systematic review and meta-analysis. Schizophr Res. 2010;123(2-3):225-233.
7. Wu RR, Zhao JP, Jin H, et al. Lifestyle intervention and metformin for treatment of antipsychotic-induced weight gain: a randomized controlled trial. JAMA. 2008;299(2):185-193.
8. De Hert M, Correll CU, Bobes J, et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry. 2011;10(1):52-77.
9. Kirpichnikov D, McFarlane SI, Sowers JR. Metformin: an update. Ann Internal Med. 2002;137(1):25-33.
10. Balon R. SSRI-associated sexual dysfunction. Am J Psychiatry. 2006;163(9):1504-1509.
11. Balon R, Morreale MK, Segraves RT. Prescribing of phosphodiesterase-5 inhibitors among psychiatrists. J Sex Marital Ther. 2014;40(3):165-169.
12. Taylor MJ, Rudkin L, Bullemor-Day P, et al. Strategies for managing sexual dysfunction induced by antidepressant medication. Cochrane Database Syst Rev. 2013;(5):CD003382.
13. Dording CM, LaRocca RA, Hails KA, et al. The effect of sildenafil on quality of life. Ann Clin Psychiatry. 2013;25(1):3-10.
14. Pagano HP, Zapata LB, Berry-Bibee EN, et al. Safety of hormonal contraception and intrauterine devices among women with depressive and bipolar disorders: a systematic review. Contraception. 2016;94(6):641-649.
15. Kibirige D, Luzinda K, Ssekitoleko R. Spectrum of lithium induced thyroid abnormalities: a current perspective. Thyroid Res. 2013;6(1):3.
16. Gitlin M. Lithium side effects and toxicity: prevalence and management strategies. Int J Bipolar Disord. 2016;4(1):27.
17. Devdhar M, Ousman YH, Burman KD. Hypothyroidism. Endocrinol Metab Clin North Am. 2007;36(3):595-615.
18. Hackley B, Sharma C, Kedzior A, et al. Managing mental health conditions in primary care settings. J Midwifery Women’s Health. 2010;55(1):9-19.
19. Fitelson E, McGibbon C. Evaluation and management of behavioral health disorders in women: an overview of major depression, bipolar disorder, anxiety disorders, and sleep in the primary care setting. Obstet Gynecol Clin North Am. 2016;43(2):231-246.
20. Colorafi K, Vanselow J, Nelson T. Treating anxiety and depression in primary care: reducing barriers to access. Fam Pract Manag. 2017;24(4):11-16.
21. McCall WV. Defining the unique scope of psychiatric practice in 2015. J ECT. 2015;31(4):203-204.
1. Detroit Wayne Integrated Health Network. DWMHA psychiatric practice standards. http://dwihn.org/files/2015/6451/9628/Psychiatric_Practice_Standards.pdf. Revised June 2018. Accessed October 8, 2019.
2. Seaman JJ, Cornfield RM, Cummings DM, et al. Exploring psychiatric prescribing practices: the relationship between the role of the provider and the appropriateness of prescribing. Gen Hosp Psychiatry. 1987;9(3):220-224.
3. Zivanovic O. Lithium: a classic drug—frequently discussed, but, sadly, seldom prescribed! Aust N Z J Psychiatry. 2017;51(9):886-896.
4. Stroup TS, Gerhard T, Crystal S, et al. Geographic and clinical variation in clozapine use in the United States. Psychiatric Services. 2014;65(2):186-192.
5. Balon R, Mufti R, Arfken C. A survey of prescribing practices for monoamine oxidase inhibitors. Psychiatric Services. 1999;50(7):945-947.
6. Rummel-Kluge C, Komossa K, Schwarz S, et al. Head-to-head comparisons of metabolic side effects of second generation antipsychotics in the treatment of schizophrenia: a systematic review and meta-analysis. Schizophr Res. 2010;123(2-3):225-233.
7. Wu RR, Zhao JP, Jin H, et al. Lifestyle intervention and metformin for treatment of antipsychotic-induced weight gain: a randomized controlled trial. JAMA. 2008;299(2):185-193.
8. De Hert M, Correll CU, Bobes J, et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry. 2011;10(1):52-77.
9. Kirpichnikov D, McFarlane SI, Sowers JR. Metformin: an update. Ann Internal Med. 2002;137(1):25-33.
10. Balon R. SSRI-associated sexual dysfunction. Am J Psychiatry. 2006;163(9):1504-1509.
11. Balon R, Morreale MK, Segraves RT. Prescribing of phosphodiesterase-5 inhibitors among psychiatrists. J Sex Marital Ther. 2014;40(3):165-169.
12. Taylor MJ, Rudkin L, Bullemor-Day P, et al. Strategies for managing sexual dysfunction induced by antidepressant medication. Cochrane Database Syst Rev. 2013;(5):CD003382.
13. Dording CM, LaRocca RA, Hails KA, et al. The effect of sildenafil on quality of life. Ann Clin Psychiatry. 2013;25(1):3-10.
14. Pagano HP, Zapata LB, Berry-Bibee EN, et al. Safety of hormonal contraception and intrauterine devices among women with depressive and bipolar disorders: a systematic review. Contraception. 2016;94(6):641-649.
15. Kibirige D, Luzinda K, Ssekitoleko R. Spectrum of lithium induced thyroid abnormalities: a current perspective. Thyroid Res. 2013;6(1):3.
16. Gitlin M. Lithium side effects and toxicity: prevalence and management strategies. Int J Bipolar Disord. 2016;4(1):27.
17. Devdhar M, Ousman YH, Burman KD. Hypothyroidism. Endocrinol Metab Clin North Am. 2007;36(3):595-615.
18. Hackley B, Sharma C, Kedzior A, et al. Managing mental health conditions in primary care settings. J Midwifery Women’s Health. 2010;55(1):9-19.
19. Fitelson E, McGibbon C. Evaluation and management of behavioral health disorders in women: an overview of major depression, bipolar disorder, anxiety disorders, and sleep in the primary care setting. Obstet Gynecol Clin North Am. 2016;43(2):231-246.
20. Colorafi K, Vanselow J, Nelson T. Treating anxiety and depression in primary care: reducing barriers to access. Fam Pract Manag. 2017;24(4):11-16.
21. McCall WV. Defining the unique scope of psychiatric practice in 2015. J ECT. 2015;31(4):203-204.
