Perspectives

Chronic thromboembolic pulmonary hypertension (CTEPH) is an elevation in pulmonary vascular resistance (PVR) resulting from chronic, “scarred-in” thromboembolic material partially occluding the pulmonary arteries. This vascular obstruction, over time, results in failure of the right ventricle and early mortality.

CTEPH was first characterized in an autopsy series from the Massachusetts General Hospital in 1931. On these postmortem examinations, it was noted that the affected patients had large pulmonary artery vascular obstruction, but also normal pulmonary parenchyma distal to this vascular obstruction and extensive bronchial collateral blood flow (Means J. Ann Intern Med. 1931;5:417). Although this observation set the groundwork for the theory that surgically removing the vascular obstruction to this preserved lung tissue could improve the condition of these patients, it would take until the mid-20th century until imaging and cardiac catheterization techniques allowed the recognition of the disease in real time.

CTEPH is thought to begin with an acute pulmonary embolus, but in approximately 3.4% of patients, rather than resolving over time, the thrombus will organize and incorporate into the pulmonary artery intimal layer (Simonneau G, et al. Eur Respir Rev. 2017;26:160112) A history of venous thromboembolism in a patient with persistent dyspnea should spur a screening evaluation for CTEPH; 75% of patients with CTEPH have a history of prior known acute pulmonary embolus and 56% of patients report a prior diagnosis of deep venous thrombosis. An acute pulmonary embolus will fibrinolyse early with the vast majority of the vascular obstruction resolving by the third month. Therefore, if the patient continues to report a significant exercise limitation after 3 months of therapeutic anticoagulation therapy, or has concerning physical exam signs, a workup should be pursued. The initial evaluation for CTEPH begins with a transthoracic echocardiogram (TTE) and ventilation/perfusion (V/Q) scintigraphy. A retrospective study comparing V/Q scan and multidetector CT scan revealed that V/Q scanning had a sensitivity and specificity of 97% and 95% for CTEPH, while CTPA had good specificity at 99% but only 51% sensitivity (Tunariu N, et al. J Nuc Med. 2007;48(5):680). If these are abnormal, then right-sided heart catheterization and invasive biplane digital subtraction pulmonary angiography are recommended. These studies confirm the diagnosis, grade its severity, and allow an evaluation for surgically accessible vs distal disease. Some CTEPH centers utilize additional imaging techniques, such as magnetic resonance angiography, optical resonance imaging, spectral CT scanning with iodine perfusion images, and intravascular ultrasound. These modalities and their place in the diagnostic algorithm are under investigation.

The goal of the initial evaluation process is to determine if the patient can undergo surgical pulmonary thromboendarterectomy (PTE), because in experienced hands, this procedure ensures the best long-term outcome for the patient. The first pulmonary thromboendarterectomy was performed at the University of California San Diego in 1970. Because the disease involves the intimal layer of the pulmonary artery, the surgery had to involve not just removal of the intravascular obstruction but also a pulmonary artery intimectomy. Surgical mortality rates were high in the initial experience. In 1984, a review of 85 worldwide cases reported an average mortality rate of 22%, and as high as 40% in some centers (Chitwood WR, Jr, et al. Clin Chest Med. 1984;5(3):507).

Dr. Bartolome is Associate Professor, Pulmonary and Critical Care Medicine; Director, CTEPH Program; and Associate Director, PH Program; UT Southwestern Medical Center, Dallas, Texas.

Chronic thromboembolic pulmonary hypertension (CTEPH) is an elevation in pulmonary vascular resistance (PVR) resulting from chronic, “scarred-in” thromboembolic material partially occluding the pulmonary arteries. This vascular obstruction, over time, results in failure of the right ventricle and early mortality.

CTEPH was first characterized in an autopsy series from the Massachusetts General Hospital in 1931. On these postmortem examinations, it was noted that the affected patients had large pulmonary artery vascular obstruction, but also normal pulmonary parenchyma distal to this vascular obstruction and extensive bronchial collateral blood flow (Means J. Ann Intern Med. 1931;5:417). Although this observation set the groundwork for the theory that surgically removing the vascular obstruction to this preserved lung tissue could improve the condition of these patients, it would take until the mid-20th century until imaging and cardiac catheterization techniques allowed the recognition of the disease in real time.

CTEPH is thought to begin with an acute pulmonary embolus, but in approximately 3.4% of patients, rather than resolving over time, the thrombus will organize and incorporate into the pulmonary artery intimal layer (Simonneau G, et al. Eur Respir Rev. 2017;26:160112) A history of venous thromboembolism in a patient with persistent dyspnea should spur a screening evaluation for CTEPH; 75% of patients with CTEPH have a history of prior known acute pulmonary embolus and 56% of patients report a prior diagnosis of deep venous thrombosis. An acute pulmonary embolus will fibrinolyse early with the vast majority of the vascular obstruction resolving by the third month. Therefore, if the patient continues to report a significant exercise limitation after 3 months of therapeutic anticoagulation therapy, or has concerning physical exam signs, a workup should be pursued. The initial evaluation for CTEPH begins with a transthoracic echocardiogram (TTE) and ventilation/perfusion (V/Q) scintigraphy. A retrospective study comparing V/Q scan and multidetector CT scan revealed that V/Q scanning had a sensitivity and specificity of 97% and 95% for CTEPH, while CTPA had good specificity at 99% but only 51% sensitivity (Tunariu N, et al. J Nuc Med. 2007;48(5):680). If these are abnormal, then right-sided heart catheterization and invasive biplane digital subtraction pulmonary angiography are recommended. These studies confirm the diagnosis, grade its severity, and allow an evaluation for surgically accessible vs distal disease. Some CTEPH centers utilize additional imaging techniques, such as magnetic resonance angiography, optical resonance imaging, spectral CT scanning with iodine perfusion images, and intravascular ultrasound. These modalities and their place in the diagnostic algorithm are under investigation.

The goal of the initial evaluation process is to determine if the patient can undergo surgical pulmonary thromboendarterectomy (PTE), because in experienced hands, this procedure ensures the best long-term outcome for the patient. The first pulmonary thromboendarterectomy was performed at the University of California San Diego in 1970. Because the disease involves the intimal layer of the pulmonary artery, the surgery had to involve not just removal of the intravascular obstruction but also a pulmonary artery intimectomy. Surgical mortality rates were high in the initial experience. In 1984, a review of 85 worldwide cases reported an average mortality rate of 22%, and as high as 40% in some centers (Chitwood WR, Jr, et al. Clin Chest Med. 1984;5(3):507).

Dr. Bartolome is Associate Professor, Pulmonary and Critical Care Medicine; Director, CTEPH Program; and Associate Director, PH Program; UT Southwestern Medical Center, Dallas, Texas.

Chronic thromboembolic pulmonary hypertension (CTEPH) is an elevation in pulmonary vascular resistance (PVR) resulting from chronic, “scarred-in” thromboembolic material partially occluding the pulmonary arteries. This vascular obstruction, over time, results in failure of the right ventricle and early mortality.

CTEPH was first characterized in an autopsy series from the Massachusetts General Hospital in 1931. On these postmortem examinations, it was noted that the affected patients had large pulmonary artery vascular obstruction, but also normal pulmonary parenchyma distal to this vascular obstruction and extensive bronchial collateral blood flow (Means J. Ann Intern Med. 1931;5:417). Although this observation set the groundwork for the theory that surgically removing the vascular obstruction to this preserved lung tissue could improve the condition of these patients, it would take until the mid-20th century until imaging and cardiac catheterization techniques allowed the recognition of the disease in real time.

CTEPH is thought to begin with an acute pulmonary embolus, but in approximately 3.4% of patients, rather than resolving over time, the thrombus will organize and incorporate into the pulmonary artery intimal layer (Simonneau G, et al. Eur Respir Rev. 2017;26:160112) A history of venous thromboembolism in a patient with persistent dyspnea should spur a screening evaluation for CTEPH; 75% of patients with CTEPH have a history of prior known acute pulmonary embolus and 56% of patients report a prior diagnosis of deep venous thrombosis. An acute pulmonary embolus will fibrinolyse early with the vast majority of the vascular obstruction resolving by the third month. Therefore, if the patient continues to report a significant exercise limitation after 3 months of therapeutic anticoagulation therapy, or has concerning physical exam signs, a workup should be pursued. The initial evaluation for CTEPH begins with a transthoracic echocardiogram (TTE) and ventilation/perfusion (V/Q) scintigraphy. A retrospective study comparing V/Q scan and multidetector CT scan revealed that V/Q scanning had a sensitivity and specificity of 97% and 95% for CTEPH, while CTPA had good specificity at 99% but only 51% sensitivity (Tunariu N, et al. J Nuc Med. 2007;48(5):680). If these are abnormal, then right-sided heart catheterization and invasive biplane digital subtraction pulmonary angiography are recommended. These studies confirm the diagnosis, grade its severity, and allow an evaluation for surgically accessible vs distal disease. Some CTEPH centers utilize additional imaging techniques, such as magnetic resonance angiography, optical resonance imaging, spectral CT scanning with iodine perfusion images, and intravascular ultrasound. These modalities and their place in the diagnostic algorithm are under investigation.

The goal of the initial evaluation process is to determine if the patient can undergo surgical pulmonary thromboendarterectomy (PTE), because in experienced hands, this procedure ensures the best long-term outcome for the patient. The first pulmonary thromboendarterectomy was performed at the University of California San Diego in 1970. Because the disease involves the intimal layer of the pulmonary artery, the surgery had to involve not just removal of the intravascular obstruction but also a pulmonary artery intimectomy. Surgical mortality rates were high in the initial experience. In 1984, a review of 85 worldwide cases reported an average mortality rate of 22%, and as high as 40% in some centers (Chitwood WR, Jr, et al. Clin Chest Med. 1984;5(3):507).

Dr. Bartolome is Associate Professor, Pulmonary and Critical Care Medicine; Director, CTEPH Program; and Associate Director, PH Program; UT Southwestern Medical Center, Dallas, Texas.

Numb and empty, I continued to drive home in a daze. My mind focused only on the light ahead changing from yellow to red. “Remember to step on the brake,” commanded the internal boss to my stunned mind. No tears, I continued to drive as green blinked its eye.

Earlier that afternoon as I stepped out of my second outpatient appointment of the day, the office administrator’s assistant gingerly informed me, “The guy who answered the phone for your no-show said she passed.”

“Passed? Like … died?” I asked in shock.

She nodded. “I looked her up in the system. She passed away 2 Saturdays ago.”

That was only 2 days after the last time I met with her when we celebrated her progress.

“Too soon, too soon in your career,” my attending bemoaned as I shared the news.

Gathering my scattered wit, I smoothed my furrowed brow and forced a smile back into my eyes. I had other patients to see.

Continue to: Soothed by the hum of my car...

Soothed by the hum of my car, my mind replayed our last meeting where hope and active plans had replaced broken hopelessness. For the past 2 weeks, I had erroneously dismissed her no-shows as her volatile borderline personality’s decision to fire me. I was wrong.

Holding things together until a silly domestic dispute unleashed the brewing tornado inside, I stormed upstairs to contain the pain. Behind locked doors, my body shuddered from uncontrollable tears that blinded my eyes. She was the first patient I helped through psychotherapy and the first I lost through suicide.

The news of her death triggered anguish from past suicides of dear friends. Chopper, who blew off his face during our sophomore year of high school. Chopper had already transferred to another school, but those closer to him received a surprise visit with gifts of his personal possessions when he drove up to our school that morning. Later that afternoon, law enforcement found him in a nearby park. In a graduating class of around 100 students, we all grieved.

A few years later, another classmate, Aaron, sank into depression. He, too, shot himself. Just months before I’d received the call requesting my presence at his funeral, he had asked me if I would be his Valentine. Jokingly, I agreed, knowing our paths would never cross after our graduation. At his funeral, his parents insisted that I sat as a member of his immediate family.

Oh … the blinding lies of depression. Those who have fallen prey to suicide never knew the truth: Their lives and their deaths matter.

Even strangers weep.

Numb and empty, I continued to drive home in a daze. My mind focused only on the light ahead changing from yellow to red. “Remember to step on the brake,” commanded the internal boss to my stunned mind. No tears, I continued to drive as green blinked its eye.

Earlier that afternoon as I stepped out of my second outpatient appointment of the day, the office administrator’s assistant gingerly informed me, “The guy who answered the phone for your no-show said she passed.”

“Passed? Like … died?” I asked in shock.

She nodded. “I looked her up in the system. She passed away 2 Saturdays ago.”

That was only 2 days after the last time I met with her when we celebrated her progress.

“Too soon, too soon in your career,” my attending bemoaned as I shared the news.

Gathering my scattered wit, I smoothed my furrowed brow and forced a smile back into my eyes. I had other patients to see.

Continue to: Soothed by the hum of my car...

Soothed by the hum of my car, my mind replayed our last meeting where hope and active plans had replaced broken hopelessness. For the past 2 weeks, I had erroneously dismissed her no-shows as her volatile borderline personality’s decision to fire me. I was wrong.

Holding things together until a silly domestic dispute unleashed the brewing tornado inside, I stormed upstairs to contain the pain. Behind locked doors, my body shuddered from uncontrollable tears that blinded my eyes. She was the first patient I helped through psychotherapy and the first I lost through suicide.

The news of her death triggered anguish from past suicides of dear friends. Chopper, who blew off his face during our sophomore year of high school. Chopper had already transferred to another school, but those closer to him received a surprise visit with gifts of his personal possessions when he drove up to our school that morning. Later that afternoon, law enforcement found him in a nearby park. In a graduating class of around 100 students, we all grieved.

A few years later, another classmate, Aaron, sank into depression. He, too, shot himself. Just months before I’d received the call requesting my presence at his funeral, he had asked me if I would be his Valentine. Jokingly, I agreed, knowing our paths would never cross after our graduation. At his funeral, his parents insisted that I sat as a member of his immediate family.

Oh … the blinding lies of depression. Those who have fallen prey to suicide never knew the truth: Their lives and their deaths matter.

Even strangers weep.

Numb and empty, I continued to drive home in a daze. My mind focused only on the light ahead changing from yellow to red. “Remember to step on the brake,” commanded the internal boss to my stunned mind. No tears, I continued to drive as green blinked its eye.

Earlier that afternoon as I stepped out of my second outpatient appointment of the day, the office administrator’s assistant gingerly informed me, “The guy who answered the phone for your no-show said she passed.”

“Passed? Like … died?” I asked in shock.

She nodded. “I looked her up in the system. She passed away 2 Saturdays ago.”

That was only 2 days after the last time I met with her when we celebrated her progress.

“Too soon, too soon in your career,” my attending bemoaned as I shared the news.

Gathering my scattered wit, I smoothed my furrowed brow and forced a smile back into my eyes. I had other patients to see.

Continue to: Soothed by the hum of my car...

Soothed by the hum of my car, my mind replayed our last meeting where hope and active plans had replaced broken hopelessness. For the past 2 weeks, I had erroneously dismissed her no-shows as her volatile borderline personality’s decision to fire me. I was wrong.

Holding things together until a silly domestic dispute unleashed the brewing tornado inside, I stormed upstairs to contain the pain. Behind locked doors, my body shuddered from uncontrollable tears that blinded my eyes. She was the first patient I helped through psychotherapy and the first I lost through suicide.

The news of her death triggered anguish from past suicides of dear friends. Chopper, who blew off his face during our sophomore year of high school. Chopper had already transferred to another school, but those closer to him received a surprise visit with gifts of his personal possessions when he drove up to our school that morning. Later that afternoon, law enforcement found him in a nearby park. In a graduating class of around 100 students, we all grieved.

A few years later, another classmate, Aaron, sank into depression. He, too, shot himself. Just months before I’d received the call requesting my presence at his funeral, he had asked me if I would be his Valentine. Jokingly, I agreed, knowing our paths would never cross after our graduation. At his funeral, his parents insisted that I sat as a member of his immediate family.

Oh … the blinding lies of depression. Those who have fallen prey to suicide never knew the truth: Their lives and their deaths matter.

Even strangers weep.

Psychiatry has an enormous swath of effects on the social structure of society, perhaps more than any other medical specialty. Its ramifications can be observed and experienced across medical, scientific, legal, financial, political, sexual, religious, cultural, sociological, and artistic aspects of the aggregate of humans living together that we call society.

And yet, despite its pervasive and significant consequences at multiple levels of human communities, psychiatry remains inadequately appreciated or understood. In fact, it is sometimes maligned in a manner that no other medical discipline ever has to face.

I will expound on what may sound like a sweeping statement, and let you decide if society is indeed influenced in myriad ways by the wide array of psychiatric brain disorders that impact various core components of society.

Consider the following major societal repercussions of psychiatric disorders:

• Twenty-five percent of the population suffers from a psychiatric disorder per the landmark Epidemiological Catchment Area (ECA) study,^1,2 funded by the National Institutes of Health. This translates to 85 million children, adolescents, adults, and older adults. No other medical specialty comes close to affecting this massive number of individuals in society.
• According to the World Health Organization (WHO), 4 of the top 10 causes of disability across all medical conditions are psychiatric disorders (Table³). Depression, alcoholism, schizophrenia, and bipolar disorder account for the greatest proportion of individuals with disabilities. Obviously, the impact of psychiatry in society is more significant than any other medical specialty as far as functional disability is concerned.
• The jails and prisons of the country are brimming with psychiatric patients who are arrested, incarcerated, and criminalized because their brain disorder disrupts their behavior. This is one of the most serious (and frankly outrageous) legal problems in our society. It occurred after our society decided to shutter state-supported hospitals (asylums) where psychiatric patients used to be treated as medically ill persons by health care professionals such as physicians, nurses, psychologists, and social workers, not prison guards. Remember that in the 1960s, 50% of all hospital beds in the United States were occupied by psychiatric patients, which is another historical indication of the societal impact of psychiatry.
• Alcohol and drug abuse are undoubtedly one of society’s most intractable problems. They are not only psychiatric disorders, but are often associated with multiple other psychiatric comorbidities and can lead to a host of general medical and surgical consequences. They are not only costly in financial terms, but they also lead to an increase in crime and forensic problems. Premature death is a heavy toll for society due to alcohol and substance use, as the opioid epidemic clearly has demonstrated over the past few years.
• Homelessness is an endemic sociological cancer in the body of society and is very often driven by psychiatric disorders and addictions. Countless numbers of severely mentally ill patients became homeless when asylums were closed and they were “freed” from restrictive institutional settings. Homelessness and imprisonment became the heavy and shameful price of “freedom” for persons with disabling psychiatric disorders in our “advanced” society.
• Suicide, both completed and attempted, is intimately associated with psychiatric disorders. Approximately 47,000 deaths from suicide were reported in the United States in 2017.⁴ Given that more than 30 million Americans suffer from mood disorders, millions of suicide attempts take place, crowding the emergency rooms of the country with individuals who need to receive emergent health care. The tragic toll of suicide and the heavy medical care costs of suicide attempts are incalculable, and unfortunately have been growing steadily over the past 20 years.
• Homicide is sometimes committed by persons with a psychiatric disorder, most commonly antisocial personality disorder. The rate of homicide often is used as a measure of a city’s quality of life, and urban areas where access to psychiatric care is limited tend to have high homicide rates.
• School problems, whether due to attention-deficit/hyperactivity disorder, below-average intellectual abilities, conduct disorder, bullying, impulsive behavior, substance use, broken homes, or dysfunctional families (often due to addictive or psychiatric disorders), are a major societal problem. Whether the problem is truancy, school fights, or dropping out before getting a high school diploma, psychiatric illness is frequently the underlying reason.
• Sexual controversies, such as expanding and evolving gender identity issues and discrimination against non-cisgender individuals, have instigated both positive and negative initiatives in society. Sexual abuse of children and its grave psychiatric implications in adulthood continues to happen despite public outrage and law enforcement efforts, and is often driven by individuals with serious psychopathology. In addition, sexual addiction (and its many biopsychosocial complications) is often associated with neuropsychiatric disorders.
• Poverty and the perpetual underclass are often a result of psychiatric disorders, and represent an ongoing societal challenge that has proven impossible to fix just by throwing money at it. Whether the affected individuals are seriously mentally ill, addicted, cognitively impaired or challenged, or unmotivated because of a neuropsychiatric disorder, poverty is practically impossible to eliminate.
• One positive impact of psychiatry in society is that artistic abilities, writing talent, musical creativity, entrepreneurship, and high productivity are often associated with certain psychiatric conditions, such as bipolar disorder, autism, obsessive-compulsive disorder, and psychosis spectrum disorders. Society is enriched by the creative energy and out-of-the-box thinking of persons with mild to moderate neuropsychiatric disorders.
• The financial impact of psychiatry is massive. The direct and indirect costs of psychiatric and addictive disorders are estimated to be more than $400 billion/year. Even a single serious psychiatric disorder, such as schizophrenia, costs society approximately $70 billion/year. The same holds true for bipolar disorder and depression. Thus, psychiatry accounts for a substantial portion of the financial expenditures in society.
• And last but certainly not least are the impediments to psychiatric treatment for tens of millions of individuals in our society who need treatment the most: the lack of health insurance parity; the stigma of seeking psychiatric help; the serious shortage of psychiatrists, especially in inner-city areas and rural regions; the poor public understanding about psychiatric illness; and the fact that the success rate of psychiatric treatment is very similar to (and sometimes better than) that of serious cardiac, pulmonary, hepatic, or renal diseases. There are also many flawed religious, cultural, or philosophical belief systems that fail to accept that the mind is a product of brain biology and function and that psychiatric disorders are brain disorders that affect thought, mood impulses, cognition, and behavior, just as other brain disorders cause muscle weakness, epileptic seizures, or stroke. The public must understand that depression can be caused by stroke or multiple sclerosis, that Parkinson’s disease can cause hallucinations and delusions, and that brain tumors can cause personality changes.

Continue to: So, what should society do to address...

So, what should society do to address the multiple impacts of psychiatry on its structure and function? I have a brief answer: intensive research. If society would embark on a massive research effort to discover preventions and cures for psychiatric disorders, the return on investment would be tremendous in human and financial terms. Currently, only a miniscule amount of money (<0.5% of the annual cost of psychiatric disorders) is invested in psychiatric brain research. Society should embark on a BHAG (pronounced Bee Hag), an acronym for “Big Hairy Audacious Goal,” a term coined by Jim Collins and Jerry Poras, who authored the seminal book Built to Last: Successful Habits of Visionary Companies. The BHAG is an ambitious and visionary goal that steers a company (or in this case, society) to a much brighter future. It would be on the scale of the Manhattan Project in the 1940s, which developed the nuclear bomb that put an end to World War II. When it comes to psychiatry, society should do no less.

To comment on this editorial or other topics of interest: [email protected].

Psychiatry has an enormous swath of effects on the social structure of society, perhaps more than any other medical specialty. Its ramifications can be observed and experienced across medical, scientific, legal, financial, political, sexual, religious, cultural, sociological, and artistic aspects of the aggregate of humans living together that we call society.

And yet, despite its pervasive and significant consequences at multiple levels of human communities, psychiatry remains inadequately appreciated or understood. In fact, it is sometimes maligned in a manner that no other medical discipline ever has to face.

I will expound on what may sound like a sweeping statement, and let you decide if society is indeed influenced in myriad ways by the wide array of psychiatric brain disorders that impact various core components of society.

Consider the following major societal repercussions of psychiatric disorders:

• Twenty-five percent of the population suffers from a psychiatric disorder per the landmark Epidemiological Catchment Area (ECA) study,^1,2 funded by the National Institutes of Health. This translates to 85 million children, adolescents, adults, and older adults. No other medical specialty comes close to affecting this massive number of individuals in society.
• According to the World Health Organization (WHO), 4 of the top 10 causes of disability across all medical conditions are psychiatric disorders (Table³). Depression, alcoholism, schizophrenia, and bipolar disorder account for the greatest proportion of individuals with disabilities. Obviously, the impact of psychiatry in society is more significant than any other medical specialty as far as functional disability is concerned.
• The jails and prisons of the country are brimming with psychiatric patients who are arrested, incarcerated, and criminalized because their brain disorder disrupts their behavior. This is one of the most serious (and frankly outrageous) legal problems in our society. It occurred after our society decided to shutter state-supported hospitals (asylums) where psychiatric patients used to be treated as medically ill persons by health care professionals such as physicians, nurses, psychologists, and social workers, not prison guards. Remember that in the 1960s, 50% of all hospital beds in the United States were occupied by psychiatric patients, which is another historical indication of the societal impact of psychiatry.
• Alcohol and drug abuse are undoubtedly one of society’s most intractable problems. They are not only psychiatric disorders, but are often associated with multiple other psychiatric comorbidities and can lead to a host of general medical and surgical consequences. They are not only costly in financial terms, but they also lead to an increase in crime and forensic problems. Premature death is a heavy toll for society due to alcohol and substance use, as the opioid epidemic clearly has demonstrated over the past few years.
• Homelessness is an endemic sociological cancer in the body of society and is very often driven by psychiatric disorders and addictions. Countless numbers of severely mentally ill patients became homeless when asylums were closed and they were “freed” from restrictive institutional settings. Homelessness and imprisonment became the heavy and shameful price of “freedom” for persons with disabling psychiatric disorders in our “advanced” society.
• Suicide, both completed and attempted, is intimately associated with psychiatric disorders. Approximately 47,000 deaths from suicide were reported in the United States in 2017.⁴ Given that more than 30 million Americans suffer from mood disorders, millions of suicide attempts take place, crowding the emergency rooms of the country with individuals who need to receive emergent health care. The tragic toll of suicide and the heavy medical care costs of suicide attempts are incalculable, and unfortunately have been growing steadily over the past 20 years.
• Homicide is sometimes committed by persons with a psychiatric disorder, most commonly antisocial personality disorder. The rate of homicide often is used as a measure of a city’s quality of life, and urban areas where access to psychiatric care is limited tend to have high homicide rates.
• School problems, whether due to attention-deficit/hyperactivity disorder, below-average intellectual abilities, conduct disorder, bullying, impulsive behavior, substance use, broken homes, or dysfunctional families (often due to addictive or psychiatric disorders), are a major societal problem. Whether the problem is truancy, school fights, or dropping out before getting a high school diploma, psychiatric illness is frequently the underlying reason.
• Sexual controversies, such as expanding and evolving gender identity issues and discrimination against non-cisgender individuals, have instigated both positive and negative initiatives in society. Sexual abuse of children and its grave psychiatric implications in adulthood continues to happen despite public outrage and law enforcement efforts, and is often driven by individuals with serious psychopathology. In addition, sexual addiction (and its many biopsychosocial complications) is often associated with neuropsychiatric disorders.
• Poverty and the perpetual underclass are often a result of psychiatric disorders, and represent an ongoing societal challenge that has proven impossible to fix just by throwing money at it. Whether the affected individuals are seriously mentally ill, addicted, cognitively impaired or challenged, or unmotivated because of a neuropsychiatric disorder, poverty is practically impossible to eliminate.
• One positive impact of psychiatry in society is that artistic abilities, writing talent, musical creativity, entrepreneurship, and high productivity are often associated with certain psychiatric conditions, such as bipolar disorder, autism, obsessive-compulsive disorder, and psychosis spectrum disorders. Society is enriched by the creative energy and out-of-the-box thinking of persons with mild to moderate neuropsychiatric disorders.
• The financial impact of psychiatry is massive. The direct and indirect costs of psychiatric and addictive disorders are estimated to be more than $400 billion/year. Even a single serious psychiatric disorder, such as schizophrenia, costs society approximately $70 billion/year. The same holds true for bipolar disorder and depression. Thus, psychiatry accounts for a substantial portion of the financial expenditures in society.
• And last but certainly not least are the impediments to psychiatric treatment for tens of millions of individuals in our society who need treatment the most: the lack of health insurance parity; the stigma of seeking psychiatric help; the serious shortage of psychiatrists, especially in inner-city areas and rural regions; the poor public understanding about psychiatric illness; and the fact that the success rate of psychiatric treatment is very similar to (and sometimes better than) that of serious cardiac, pulmonary, hepatic, or renal diseases. There are also many flawed religious, cultural, or philosophical belief systems that fail to accept that the mind is a product of brain biology and function and that psychiatric disorders are brain disorders that affect thought, mood impulses, cognition, and behavior, just as other brain disorders cause muscle weakness, epileptic seizures, or stroke. The public must understand that depression can be caused by stroke or multiple sclerosis, that Parkinson’s disease can cause hallucinations and delusions, and that brain tumors can cause personality changes.

Continue to: So, what should society do to address...

So, what should society do to address the multiple impacts of psychiatry on its structure and function? I have a brief answer: intensive research. If society would embark on a massive research effort to discover preventions and cures for psychiatric disorders, the return on investment would be tremendous in human and financial terms. Currently, only a miniscule amount of money (<0.5% of the annual cost of psychiatric disorders) is invested in psychiatric brain research. Society should embark on a BHAG (pronounced Bee Hag), an acronym for “Big Hairy Audacious Goal,” a term coined by Jim Collins and Jerry Poras, who authored the seminal book Built to Last: Successful Habits of Visionary Companies. The BHAG is an ambitious and visionary goal that steers a company (or in this case, society) to a much brighter future. It would be on the scale of the Manhattan Project in the 1940s, which developed the nuclear bomb that put an end to World War II. When it comes to psychiatry, society should do no less.

To comment on this editorial or other topics of interest: [email protected].

Psychiatry has an enormous swath of effects on the social structure of society, perhaps more than any other medical specialty. Its ramifications can be observed and experienced across medical, scientific, legal, financial, political, sexual, religious, cultural, sociological, and artistic aspects of the aggregate of humans living together that we call society.

And yet, despite its pervasive and significant consequences at multiple levels of human communities, psychiatry remains inadequately appreciated or understood. In fact, it is sometimes maligned in a manner that no other medical discipline ever has to face.

I will expound on what may sound like a sweeping statement, and let you decide if society is indeed influenced in myriad ways by the wide array of psychiatric brain disorders that impact various core components of society.

Consider the following major societal repercussions of psychiatric disorders:

• Twenty-five percent of the population suffers from a psychiatric disorder per the landmark Epidemiological Catchment Area (ECA) study,^1,2 funded by the National Institutes of Health. This translates to 85 million children, adolescents, adults, and older adults. No other medical specialty comes close to affecting this massive number of individuals in society.
• According to the World Health Organization (WHO), 4 of the top 10 causes of disability across all medical conditions are psychiatric disorders (Table³). Depression, alcoholism, schizophrenia, and bipolar disorder account for the greatest proportion of individuals with disabilities. Obviously, the impact of psychiatry in society is more significant than any other medical specialty as far as functional disability is concerned.
• The jails and prisons of the country are brimming with psychiatric patients who are arrested, incarcerated, and criminalized because their brain disorder disrupts their behavior. This is one of the most serious (and frankly outrageous) legal problems in our society. It occurred after our society decided to shutter state-supported hospitals (asylums) where psychiatric patients used to be treated as medically ill persons by health care professionals such as physicians, nurses, psychologists, and social workers, not prison guards. Remember that in the 1960s, 50% of all hospital beds in the United States were occupied by psychiatric patients, which is another historical indication of the societal impact of psychiatry.
• Alcohol and drug abuse are undoubtedly one of society’s most intractable problems. They are not only psychiatric disorders, but are often associated with multiple other psychiatric comorbidities and can lead to a host of general medical and surgical consequences. They are not only costly in financial terms, but they also lead to an increase in crime and forensic problems. Premature death is a heavy toll for society due to alcohol and substance use, as the opioid epidemic clearly has demonstrated over the past few years.
• Homelessness is an endemic sociological cancer in the body of society and is very often driven by psychiatric disorders and addictions. Countless numbers of severely mentally ill patients became homeless when asylums were closed and they were “freed” from restrictive institutional settings. Homelessness and imprisonment became the heavy and shameful price of “freedom” for persons with disabling psychiatric disorders in our “advanced” society.
• Suicide, both completed and attempted, is intimately associated with psychiatric disorders. Approximately 47,000 deaths from suicide were reported in the United States in 2017.⁴ Given that more than 30 million Americans suffer from mood disorders, millions of suicide attempts take place, crowding the emergency rooms of the country with individuals who need to receive emergent health care. The tragic toll of suicide and the heavy medical care costs of suicide attempts are incalculable, and unfortunately have been growing steadily over the past 20 years.
• Homicide is sometimes committed by persons with a psychiatric disorder, most commonly antisocial personality disorder. The rate of homicide often is used as a measure of a city’s quality of life, and urban areas where access to psychiatric care is limited tend to have high homicide rates.
• School problems, whether due to attention-deficit/hyperactivity disorder, below-average intellectual abilities, conduct disorder, bullying, impulsive behavior, substance use, broken homes, or dysfunctional families (often due to addictive or psychiatric disorders), are a major societal problem. Whether the problem is truancy, school fights, or dropping out before getting a high school diploma, psychiatric illness is frequently the underlying reason.
• Sexual controversies, such as expanding and evolving gender identity issues and discrimination against non-cisgender individuals, have instigated both positive and negative initiatives in society. Sexual abuse of children and its grave psychiatric implications in adulthood continues to happen despite public outrage and law enforcement efforts, and is often driven by individuals with serious psychopathology. In addition, sexual addiction (and its many biopsychosocial complications) is often associated with neuropsychiatric disorders.
• Poverty and the perpetual underclass are often a result of psychiatric disorders, and represent an ongoing societal challenge that has proven impossible to fix just by throwing money at it. Whether the affected individuals are seriously mentally ill, addicted, cognitively impaired or challenged, or unmotivated because of a neuropsychiatric disorder, poverty is practically impossible to eliminate.
• One positive impact of psychiatry in society is that artistic abilities, writing talent, musical creativity, entrepreneurship, and high productivity are often associated with certain psychiatric conditions, such as bipolar disorder, autism, obsessive-compulsive disorder, and psychosis spectrum disorders. Society is enriched by the creative energy and out-of-the-box thinking of persons with mild to moderate neuropsychiatric disorders.
• The financial impact of psychiatry is massive. The direct and indirect costs of psychiatric and addictive disorders are estimated to be more than $400 billion/year. Even a single serious psychiatric disorder, such as schizophrenia, costs society approximately $70 billion/year. The same holds true for bipolar disorder and depression. Thus, psychiatry accounts for a substantial portion of the financial expenditures in society.
• And last but certainly not least are the impediments to psychiatric treatment for tens of millions of individuals in our society who need treatment the most: the lack of health insurance parity; the stigma of seeking psychiatric help; the serious shortage of psychiatrists, especially in inner-city areas and rural regions; the poor public understanding about psychiatric illness; and the fact that the success rate of psychiatric treatment is very similar to (and sometimes better than) that of serious cardiac, pulmonary, hepatic, or renal diseases. There are also many flawed religious, cultural, or philosophical belief systems that fail to accept that the mind is a product of brain biology and function and that psychiatric disorders are brain disorders that affect thought, mood impulses, cognition, and behavior, just as other brain disorders cause muscle weakness, epileptic seizures, or stroke. The public must understand that depression can be caused by stroke or multiple sclerosis, that Parkinson’s disease can cause hallucinations and delusions, and that brain tumors can cause personality changes.

Continue to: So, what should society do to address...

So, what should society do to address the multiple impacts of psychiatry on its structure and function? I have a brief answer: intensive research. If society would embark on a massive research effort to discover preventions and cures for psychiatric disorders, the return on investment would be tremendous in human and financial terms. Currently, only a miniscule amount of money (<0.5% of the annual cost of psychiatric disorders) is invested in psychiatric brain research. Society should embark on a BHAG (pronounced Bee Hag), an acronym for “Big Hairy Audacious Goal,” a term coined by Jim Collins and Jerry Poras, who authored the seminal book Built to Last: Successful Habits of Visionary Companies. The BHAG is an ambitious and visionary goal that steers a company (or in this case, society) to a much brighter future. It would be on the scale of the Manhattan Project in the 1940s, which developed the nuclear bomb that put an end to World War II. When it comes to psychiatry, society should do no less.

To comment on this editorial or other topics of interest: [email protected].

Collateral information is a key component obtained during the psychiatric admission process whereby clinicians gather information provided about the patient from the patient’s known contacts. Despite its usefulness in formulating an assessment and plan, collateral information may be misleading and create false biases that lead clinicians to uphold or prolong an involuntary commitment. This raises concern for the need to screen for misleading collateral information, as involuntary admission to an inpatient psychiatric setting can have lasting negative effects on individuals for whom inpatient psychiatric care is not indicated.¹

Here I describe a case in which collateral information obtained about a patient was a primary factor in that patient’s involuntary commitment. However, the patient’s subsequent behavior observed on an inpatient psychiatric unit was entirely inconsistent with those behaviors described by the collateral informant to be “continuous and dangerous.”

CASE

Mr. M, age 18, presented to an emergency psychiatric center for evaluation of dangerous and aggressive behavior. He had a history of autism spectrum disorder (ASD), which was well managed with oral risperidone. He was petitioned for an involuntary psychiatric admission by his foster mother, who reported that Mr. M was aggressive and dangerous, often punching holes in the walls of their home, and that he threatened to assault his foster siblings on several occasions. She detailed a progressively declining history for Mr. M and said that he was “constantly talking to voices in his head that absolutely consume him,” to the extent that Mr. M could not pay attention to his daily tasks. The admitting psychiatrist upheld the petition for involuntary admission, citing that based on the foster’s mother collateral information, Mr. M was deemed to be a danger to others and therefore fulfilled criteria for involuntary psychiatric admission.

Once admitted to the inpatient psychiatric unit, Mr. M was observed to be pleasant, cooperative, and fully engaged in the milieu. At no point during his 7-day admission was he observed to be internally preoccupied or remotely disorganized. Mr. M was switched from oral risperidone to oral haloperidol because he developed acute gynecomastia, and was discharged home.

Does collateral information lead to unfair bias?

The importance of collateral information on the psychiatric admission process must not be understated. It is an opportunity to hear a first-hand account of behaviors consistent with an acute psychiatric disturbance, and guides us in formulating a clinically appropriate assessment and plan. But what happens when our patients’ close contacts or informants provide misleading or unintentionally suboptimal collateral information? How must we reconcile the ethical and legal obligation we have to balance patient autonomy with beneficence?

Studies examining patients’ attitudes toward involuntary admissions have routinely found that patients are less likely than clinical staff to view the involuntary admission as clinically justified.² Consistent with these findings, Mr. M did not view his admission as necessary. At first, he seemed to lack insight regarding the events precipitating his involuntary admission, describing himself not as responding to internal stimuli, but rather, “imaginative because I have autism.” As time went on, though, it was clear that his account of his behavior was in fact correct.

Mr. M’s diagnosis of ASD further complicated the over-reliance on misleading collateral information provided by his foster mother, because the admitting psychiatrist invariably perceived Mr. M as a poor historian. A study examining how subjective histories described by patients with neurologic or psychiatric disorders are perceived by clinicians found physicians had a tendency for negative stereotyping and placed less credence on those patients’ subjective histories.³ Other literature has similarly concluded that there is an urgent need to carefully weigh information supplied to us by collateral informants because the first-hand accounts of perceivably dangerous behavior often are incomplete or misleading.^4-5

Continue to: Ideas for improvement...

Ideas for improvement: respecting patient autonomy

These issues underscore the need for a more thorough review of collateral information to ensure that patient autonomy is not unjustly violated. How do we implement these necessary ideas without creating further undue burden during the admission process? Certainly, I am not suggesting that we evaluate the collateral informant to the degree that we evaluate the patient. However, I have outlined some suggestions for ensuring we act in our patients’ best interest when processing collateral information during an admission:

• Until proven otherwise, the patient’s story is true. If our patient maintains descriptions of his behavior that exist in stark opposition to the collateral information we obtain, we should only not believe the patient if his presentation suggests he may be acutely impaired or a poor historian (such as profound disorganization, overt psychosis, or failing to have capacity).
• Treat symptoms, not diagnoses. In this case, Mr. M was described by his foster mother to be psychotic in addition to having ASD, and an inexperienced psychiatrist may have initiated a titration to a higher antipsychotic dose. However, in the absence of any observable signs of aggression or psychosis, there was simply no indication for further titration of his antipsychotic.
• Document, document, document. When collateral information is supplied to us, it is crucial that we maintain a detailed account of this information. If we have a reason to believe that a patient poses an immediate danger to himself or others, we should carefully document our reasoning so that changes in behavior (if any) can be observed on a day-to-day basis.

Collateral information is a key component obtained during the psychiatric admission process whereby clinicians gather information provided about the patient from the patient’s known contacts. Despite its usefulness in formulating an assessment and plan, collateral information may be misleading and create false biases that lead clinicians to uphold or prolong an involuntary commitment. This raises concern for the need to screen for misleading collateral information, as involuntary admission to an inpatient psychiatric setting can have lasting negative effects on individuals for whom inpatient psychiatric care is not indicated.¹

Here I describe a case in which collateral information obtained about a patient was a primary factor in that patient’s involuntary commitment. However, the patient’s subsequent behavior observed on an inpatient psychiatric unit was entirely inconsistent with those behaviors described by the collateral informant to be “continuous and dangerous.”

CASE

Mr. M, age 18, presented to an emergency psychiatric center for evaluation of dangerous and aggressive behavior. He had a history of autism spectrum disorder (ASD), which was well managed with oral risperidone. He was petitioned for an involuntary psychiatric admission by his foster mother, who reported that Mr. M was aggressive and dangerous, often punching holes in the walls of their home, and that he threatened to assault his foster siblings on several occasions. She detailed a progressively declining history for Mr. M and said that he was “constantly talking to voices in his head that absolutely consume him,” to the extent that Mr. M could not pay attention to his daily tasks. The admitting psychiatrist upheld the petition for involuntary admission, citing that based on the foster’s mother collateral information, Mr. M was deemed to be a danger to others and therefore fulfilled criteria for involuntary psychiatric admission.

Once admitted to the inpatient psychiatric unit, Mr. M was observed to be pleasant, cooperative, and fully engaged in the milieu. At no point during his 7-day admission was he observed to be internally preoccupied or remotely disorganized. Mr. M was switched from oral risperidone to oral haloperidol because he developed acute gynecomastia, and was discharged home.

Does collateral information lead to unfair bias?

The importance of collateral information on the psychiatric admission process must not be understated. It is an opportunity to hear a first-hand account of behaviors consistent with an acute psychiatric disturbance, and guides us in formulating a clinically appropriate assessment and plan. But what happens when our patients’ close contacts or informants provide misleading or unintentionally suboptimal collateral information? How must we reconcile the ethical and legal obligation we have to balance patient autonomy with beneficence?

Studies examining patients’ attitudes toward involuntary admissions have routinely found that patients are less likely than clinical staff to view the involuntary admission as clinically justified.² Consistent with these findings, Mr. M did not view his admission as necessary. At first, he seemed to lack insight regarding the events precipitating his involuntary admission, describing himself not as responding to internal stimuli, but rather, “imaginative because I have autism.” As time went on, though, it was clear that his account of his behavior was in fact correct.

Mr. M’s diagnosis of ASD further complicated the over-reliance on misleading collateral information provided by his foster mother, because the admitting psychiatrist invariably perceived Mr. M as a poor historian. A study examining how subjective histories described by patients with neurologic or psychiatric disorders are perceived by clinicians found physicians had a tendency for negative stereotyping and placed less credence on those patients’ subjective histories.³ Other literature has similarly concluded that there is an urgent need to carefully weigh information supplied to us by collateral informants because the first-hand accounts of perceivably dangerous behavior often are incomplete or misleading.^4-5

Continue to: Ideas for improvement...

Ideas for improvement: respecting patient autonomy

These issues underscore the need for a more thorough review of collateral information to ensure that patient autonomy is not unjustly violated. How do we implement these necessary ideas without creating further undue burden during the admission process? Certainly, I am not suggesting that we evaluate the collateral informant to the degree that we evaluate the patient. However, I have outlined some suggestions for ensuring we act in our patients’ best interest when processing collateral information during an admission:

• Until proven otherwise, the patient’s story is true. If our patient maintains descriptions of his behavior that exist in stark opposition to the collateral information we obtain, we should only not believe the patient if his presentation suggests he may be acutely impaired or a poor historian (such as profound disorganization, overt psychosis, or failing to have capacity).
• Treat symptoms, not diagnoses. In this case, Mr. M was described by his foster mother to be psychotic in addition to having ASD, and an inexperienced psychiatrist may have initiated a titration to a higher antipsychotic dose. However, in the absence of any observable signs of aggression or psychosis, there was simply no indication for further titration of his antipsychotic.
• Document, document, document. When collateral information is supplied to us, it is crucial that we maintain a detailed account of this information. If we have a reason to believe that a patient poses an immediate danger to himself or others, we should carefully document our reasoning so that changes in behavior (if any) can be observed on a day-to-day basis.

Collateral information is a key component obtained during the psychiatric admission process whereby clinicians gather information provided about the patient from the patient’s known contacts. Despite its usefulness in formulating an assessment and plan, collateral information may be misleading and create false biases that lead clinicians to uphold or prolong an involuntary commitment. This raises concern for the need to screen for misleading collateral information, as involuntary admission to an inpatient psychiatric setting can have lasting negative effects on individuals for whom inpatient psychiatric care is not indicated.¹

Here I describe a case in which collateral information obtained about a patient was a primary factor in that patient’s involuntary commitment. However, the patient’s subsequent behavior observed on an inpatient psychiatric unit was entirely inconsistent with those behaviors described by the collateral informant to be “continuous and dangerous.”

CASE

Mr. M, age 18, presented to an emergency psychiatric center for evaluation of dangerous and aggressive behavior. He had a history of autism spectrum disorder (ASD), which was well managed with oral risperidone. He was petitioned for an involuntary psychiatric admission by his foster mother, who reported that Mr. M was aggressive and dangerous, often punching holes in the walls of their home, and that he threatened to assault his foster siblings on several occasions. She detailed a progressively declining history for Mr. M and said that he was “constantly talking to voices in his head that absolutely consume him,” to the extent that Mr. M could not pay attention to his daily tasks. The admitting psychiatrist upheld the petition for involuntary admission, citing that based on the foster’s mother collateral information, Mr. M was deemed to be a danger to others and therefore fulfilled criteria for involuntary psychiatric admission.

Once admitted to the inpatient psychiatric unit, Mr. M was observed to be pleasant, cooperative, and fully engaged in the milieu. At no point during his 7-day admission was he observed to be internally preoccupied or remotely disorganized. Mr. M was switched from oral risperidone to oral haloperidol because he developed acute gynecomastia, and was discharged home.

Does collateral information lead to unfair bias?

The importance of collateral information on the psychiatric admission process must not be understated. It is an opportunity to hear a first-hand account of behaviors consistent with an acute psychiatric disturbance, and guides us in formulating a clinically appropriate assessment and plan. But what happens when our patients’ close contacts or informants provide misleading or unintentionally suboptimal collateral information? How must we reconcile the ethical and legal obligation we have to balance patient autonomy with beneficence?

Studies examining patients’ attitudes toward involuntary admissions have routinely found that patients are less likely than clinical staff to view the involuntary admission as clinically justified.² Consistent with these findings, Mr. M did not view his admission as necessary. At first, he seemed to lack insight regarding the events precipitating his involuntary admission, describing himself not as responding to internal stimuli, but rather, “imaginative because I have autism.” As time went on, though, it was clear that his account of his behavior was in fact correct.

Mr. M’s diagnosis of ASD further complicated the over-reliance on misleading collateral information provided by his foster mother, because the admitting psychiatrist invariably perceived Mr. M as a poor historian. A study examining how subjective histories described by patients with neurologic or psychiatric disorders are perceived by clinicians found physicians had a tendency for negative stereotyping and placed less credence on those patients’ subjective histories.³ Other literature has similarly concluded that there is an urgent need to carefully weigh information supplied to us by collateral informants because the first-hand accounts of perceivably dangerous behavior often are incomplete or misleading.^4-5

Continue to: Ideas for improvement...

Ideas for improvement: respecting patient autonomy

These issues underscore the need for a more thorough review of collateral information to ensure that patient autonomy is not unjustly violated. How do we implement these necessary ideas without creating further undue burden during the admission process? Certainly, I am not suggesting that we evaluate the collateral informant to the degree that we evaluate the patient. However, I have outlined some suggestions for ensuring we act in our patients’ best interest when processing collateral information during an admission:

• Until proven otherwise, the patient’s story is true. If our patient maintains descriptions of his behavior that exist in stark opposition to the collateral information we obtain, we should only not believe the patient if his presentation suggests he may be acutely impaired or a poor historian (such as profound disorganization, overt psychosis, or failing to have capacity).
• Treat symptoms, not diagnoses. In this case, Mr. M was described by his foster mother to be psychotic in addition to having ASD, and an inexperienced psychiatrist may have initiated a titration to a higher antipsychotic dose. However, in the absence of any observable signs of aggression or psychosis, there was simply no indication for further titration of his antipsychotic.
• Document, document, document. When collateral information is supplied to us, it is crucial that we maintain a detailed account of this information. If we have a reason to believe that a patient poses an immediate danger to himself or others, we should carefully document our reasoning so that changes in behavior (if any) can be observed on a day-to-day basis.

The balance between medical research and the pharmaceutical world has always been unsettling. The recent spate of articles in the press reporting the large payments by industry to a number of highly paid medical staff of the Memorial Sloan Kettering Cancer Institute in New York has raised again the continuing issue around that relationship.

When large sums of money are paid to medical leaders for serving on advisory boards, it is reasonable to question whom are they representing: industry or medical science. These relationships are not limited to cancer hospitals and can be presumed to pertain to cardiology and other specialties. One need only look at the disclosure statements of contemporary published articles to become aware of the entanglement of science and industry.

There is little question that both industry and science need to interact to focus direct resources to appropriate targets. No one is better able to do that than well informed scientists working in their disease fields. Industry needs scientific input and scientists need the financial resources of industry. I have been able to see that relationship play out to achieve major impacts on heart disease. But corporate decisions also can be driven by market forces and not altruism. Drug and device research has been redirected or stopped as a result of decisions made by sales forces. At other times, drugs that have great potential in the laboratory have been shelved because of a lack of scientific leadership.


So where is the moral and ethical balance? Published disclosures by authors is not much more than a catharsis in the process where action is required. Medical advisory boards are critical for successful drug and device development. That exchange is crucial to move medical science forward, but the large sums of money raise appropriate questions of what is driving the discussion.

At a more grass roots level, the financial role of investigators and hospitals in clinical trials has raised some concern. Traditionally, the institution and investigators have been reimbursed for their time and expense for recruiting and following patients. Patients, of course, are not reimbursed in clinical trials but are placed at considerable risk of an uncertain result. The reimbursements for marginal expenses seem to be appropriate. More recently, payments to physicians and hospitals have been made at current fee schedules for the implantation of a variety of new devices such as pacemakers and valves. In addition, both physicians and hospitals have invested in the financial success of these clinical trials clouding over their altruistic goals. It has been an incentive for recruiting patients for trials and has been a source of considerable revenue both for the physicians and the institution, without informing the patients of their financial relationship to industry. The image of the patient being placed at risk for the success of a clinical trial of a device by doctors and hospitals seeking financial gain is more than a little disturbing.

There is a lot of money sloshing around in the health care world that has the potential to lead to ethical uncertainty. It is the physician’s responsibility to build up ethical barriers to prevent us from slipping into that morass.

Dr. Goldstein is professor of medicine at Wayne State University and the division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit.

The balance between medical research and the pharmaceutical world has always been unsettling. The recent spate of articles in the press reporting the large payments by industry to a number of highly paid medical staff of the Memorial Sloan Kettering Cancer Institute in New York has raised again the continuing issue around that relationship.

When large sums of money are paid to medical leaders for serving on advisory boards, it is reasonable to question whom are they representing: industry or medical science. These relationships are not limited to cancer hospitals and can be presumed to pertain to cardiology and other specialties. One need only look at the disclosure statements of contemporary published articles to become aware of the entanglement of science and industry.

There is little question that both industry and science need to interact to focus direct resources to appropriate targets. No one is better able to do that than well informed scientists working in their disease fields. Industry needs scientific input and scientists need the financial resources of industry. I have been able to see that relationship play out to achieve major impacts on heart disease. But corporate decisions also can be driven by market forces and not altruism. Drug and device research has been redirected or stopped as a result of decisions made by sales forces. At other times, drugs that have great potential in the laboratory have been shelved because of a lack of scientific leadership.


So where is the moral and ethical balance? Published disclosures by authors is not much more than a catharsis in the process where action is required. Medical advisory boards are critical for successful drug and device development. That exchange is crucial to move medical science forward, but the large sums of money raise appropriate questions of what is driving the discussion.

At a more grass roots level, the financial role of investigators and hospitals in clinical trials has raised some concern. Traditionally, the institution and investigators have been reimbursed for their time and expense for recruiting and following patients. Patients, of course, are not reimbursed in clinical trials but are placed at considerable risk of an uncertain result. The reimbursements for marginal expenses seem to be appropriate. More recently, payments to physicians and hospitals have been made at current fee schedules for the implantation of a variety of new devices such as pacemakers and valves. In addition, both physicians and hospitals have invested in the financial success of these clinical trials clouding over their altruistic goals. It has been an incentive for recruiting patients for trials and has been a source of considerable revenue both for the physicians and the institution, without informing the patients of their financial relationship to industry. The image of the patient being placed at risk for the success of a clinical trial of a device by doctors and hospitals seeking financial gain is more than a little disturbing.

There is a lot of money sloshing around in the health care world that has the potential to lead to ethical uncertainty. It is the physician’s responsibility to build up ethical barriers to prevent us from slipping into that morass.

Dr. Goldstein is professor of medicine at Wayne State University and the division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit.

The balance between medical research and the pharmaceutical world has always been unsettling. The recent spate of articles in the press reporting the large payments by industry to a number of highly paid medical staff of the Memorial Sloan Kettering Cancer Institute in New York has raised again the continuing issue around that relationship.

When large sums of money are paid to medical leaders for serving on advisory boards, it is reasonable to question whom are they representing: industry or medical science. These relationships are not limited to cancer hospitals and can be presumed to pertain to cardiology and other specialties. One need only look at the disclosure statements of contemporary published articles to become aware of the entanglement of science and industry.

There is little question that both industry and science need to interact to focus direct resources to appropriate targets. No one is better able to do that than well informed scientists working in their disease fields. Industry needs scientific input and scientists need the financial resources of industry. I have been able to see that relationship play out to achieve major impacts on heart disease. But corporate decisions also can be driven by market forces and not altruism. Drug and device research has been redirected or stopped as a result of decisions made by sales forces. At other times, drugs that have great potential in the laboratory have been shelved because of a lack of scientific leadership.


So where is the moral and ethical balance? Published disclosures by authors is not much more than a catharsis in the process where action is required. Medical advisory boards are critical for successful drug and device development. That exchange is crucial to move medical science forward, but the large sums of money raise appropriate questions of what is driving the discussion.

At a more grass roots level, the financial role of investigators and hospitals in clinical trials has raised some concern. Traditionally, the institution and investigators have been reimbursed for their time and expense for recruiting and following patients. Patients, of course, are not reimbursed in clinical trials but are placed at considerable risk of an uncertain result. The reimbursements for marginal expenses seem to be appropriate. More recently, payments to physicians and hospitals have been made at current fee schedules for the implantation of a variety of new devices such as pacemakers and valves. In addition, both physicians and hospitals have invested in the financial success of these clinical trials clouding over their altruistic goals. It has been an incentive for recruiting patients for trials and has been a source of considerable revenue both for the physicians and the institution, without informing the patients of their financial relationship to industry. The image of the patient being placed at risk for the success of a clinical trial of a device by doctors and hospitals seeking financial gain is more than a little disturbing.

There is a lot of money sloshing around in the health care world that has the potential to lead to ethical uncertainty. It is the physician’s responsibility to build up ethical barriers to prevent us from slipping into that morass.

Dr. Goldstein is professor of medicine at Wayne State University and the division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit.

This time of year the nonclinical medical journals are full of articles with titles like “Make This Your Best Financial Year!”

pinkomelet/Thinkstock

I read them January after January, but each year they remind me less of January 1st and more of February 2nd – Groundhog Day.

It seems you could republish the same article every year and change the title. All of them mention “collect patient copays” and “submit insurance billings promptly.” I had no idea some offices don’t. To me, this is like suggesting I pay my mortgage each month as a financial tip.

They inevitably also talk about improving my “web presence.” Most small practices don’t have an IT department. I’m it here. My modest (and that’s an exaggeration) web page has a 2003 picture of me that I desperately need to update but don’t have the time or expertise to do these days. People seem to think that small practices are wallowing in time and money, but realistically we have neither.

They also highlight all the free things we can do on the web, like a blog or Twitter account, to promote a practice. They fail to realize how much time it takes to regularly write a blog post. Twitter posts from most practices are either tripe such as “Remember – our office will be closed on Christmas!” or links to some recently published study about the importance of diet and exercise.

Besides, in this day and age pretty much anything can be taken as a claim of a doctor-patient relationship. There’s always someone looking to claim your seemingly innocuous blog post constituted harmful medical advice and try to sue you.

Turn my scheduling over to an online program for greater efficiency? No thanks, I’ll leave that to my awesome secretary. After 15 years here, she knows my personality and can quickly screen out people who will be a bad match for me. She also knows our patients and has a good gestalt for figuring how much time certain people will need. This prevents me from getting too far off schedule. She may not be as efficient as an online booking program, but she’s far more valuable. I’ll take quality over quantity any day.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

This time of year the nonclinical medical journals are full of articles with titles like “Make This Your Best Financial Year!”

pinkomelet/Thinkstock

I read them January after January, but each year they remind me less of January 1st and more of February 2nd – Groundhog Day.

It seems you could republish the same article every year and change the title. All of them mention “collect patient copays” and “submit insurance billings promptly.” I had no idea some offices don’t. To me, this is like suggesting I pay my mortgage each month as a financial tip.

They inevitably also talk about improving my “web presence.” Most small practices don’t have an IT department. I’m it here. My modest (and that’s an exaggeration) web page has a 2003 picture of me that I desperately need to update but don’t have the time or expertise to do these days. People seem to think that small practices are wallowing in time and money, but realistically we have neither.

They also highlight all the free things we can do on the web, like a blog or Twitter account, to promote a practice. They fail to realize how much time it takes to regularly write a blog post. Twitter posts from most practices are either tripe such as “Remember – our office will be closed on Christmas!” or links to some recently published study about the importance of diet and exercise.

Besides, in this day and age pretty much anything can be taken as a claim of a doctor-patient relationship. There’s always someone looking to claim your seemingly innocuous blog post constituted harmful medical advice and try to sue you.

Turn my scheduling over to an online program for greater efficiency? No thanks, I’ll leave that to my awesome secretary. After 15 years here, she knows my personality and can quickly screen out people who will be a bad match for me. She also knows our patients and has a good gestalt for figuring how much time certain people will need. This prevents me from getting too far off schedule. She may not be as efficient as an online booking program, but she’s far more valuable. I’ll take quality over quantity any day.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

This time of year the nonclinical medical journals are full of articles with titles like “Make This Your Best Financial Year!”

pinkomelet/Thinkstock

I read them January after January, but each year they remind me less of January 1st and more of February 2nd – Groundhog Day.

It seems you could republish the same article every year and change the title. All of them mention “collect patient copays” and “submit insurance billings promptly.” I had no idea some offices don’t. To me, this is like suggesting I pay my mortgage each month as a financial tip.

They inevitably also talk about improving my “web presence.” Most small practices don’t have an IT department. I’m it here. My modest (and that’s an exaggeration) web page has a 2003 picture of me that I desperately need to update but don’t have the time or expertise to do these days. People seem to think that small practices are wallowing in time and money, but realistically we have neither.

They also highlight all the free things we can do on the web, like a blog or Twitter account, to promote a practice. They fail to realize how much time it takes to regularly write a blog post. Twitter posts from most practices are either tripe such as “Remember – our office will be closed on Christmas!” or links to some recently published study about the importance of diet and exercise.

Besides, in this day and age pretty much anything can be taken as a claim of a doctor-patient relationship. There’s always someone looking to claim your seemingly innocuous blog post constituted harmful medical advice and try to sue you.

Turn my scheduling over to an online program for greater efficiency? No thanks, I’ll leave that to my awesome secretary. After 15 years here, she knows my personality and can quickly screen out people who will be a bad match for me. She also knows our patients and has a good gestalt for figuring how much time certain people will need. This prevents me from getting too far off schedule. She may not be as efficient as an online booking program, but she’s far more valuable. I’ll take quality over quantity any day.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

My recent column on proper telephone technique for front office employees triggered some interesting commentary. “What about the calls we take?” someone asked. “The phone etiquette among most professionals leaves a lot to be desired.”

alvarez/Getty Images

How true! Haven’t we all answered a call from another physician, only to hear, “Please hold for Dr. ___________”?

Let’s begin with that, since it’s one of my major pet peeves: Long tradition, and common courtesy, dictate that the person initiating a call be on the line when the recipient picks up the receiver. So don’t ask an assistant to dial calls for you. Is it really that much bother to do it yourself? A peer should never answer and then be expected to wait while your employee tracks you down. It is impolite, and implies that you consider your time much more valuable than his or hers.

Speaking of common courtesy: Always give callers your undivided attention; they can tell if you are distracted. If it’s not a good time for you, say so honestly, at the outset. “Listen, I can give you a couple of minutes, but I’m right in the middle of office hours ...” That’s much more polite than abruptly cutting someone off, mid-conversation. If the caller needs more time, offer to call back.

By the same token, if you are the caller, be sure to ask, “Is this a good time for you?” Then, be aware of how long you keep the other person on the line. We all have a finite amount of time, and not everyone knows how to end a phone conversation gracefully. Respect others’ time and get to your point quickly.

When you reach an answering machine or voice mail, talk clearly and distinctly. Few things are more frustrating than a mumbled message that no one can decipher. I always repeat my name and phone number for clarity’s sake. And please don’t leave a callback number that no one answers, or that automatically rejects all unidentified callers.

Mobile phones have become so ubiquitous, it is hard to believe that they were relatively scarce only 15 years ago. A distinct set of faux pas has evolved around them; for example, few things are less professional than a loud, indiscreet, annoying, or profane ring tone. Your recorded voice mail message needs to sound professional too – especially if patients will be hearing it.

It should be obvious that cell phones be turned off in theaters and during meetings, but many still remain on. Vibrate mode doesn’t count; anyone close by will still hear it, and you’ll be tempted to answer it. If you get a call during a movie or show, or at a meeting, and you absolutely have to answer it, quietly excuse yourself, and don’t take the call until you are alone. If you miss the call, you can always call the person back.

Answering phone calls in a restaurant is my wife’s biggest pet peeve. She says it is rude and inappropriate, and she’s right – yet it is now, arguably, the most common etiquette mistake. Never take calls (or worse, answer texts or emails) while seated at the table – which leads to another issue: Don’t put your phone on the table! You can hear it just fine from your purse or pocket; and putting it on the table implies to your companions that you are looking for something – anything – more interesting than their company. If you must take a call or read a message, excuse yourself and go to a private area.

In fact, you shouldn’t answer any nonemergent calls or texts when you are with others; it makes your friends and colleagues feel unimportant and ignored. The people you are with should always take precedence over your phone, unless it is a medical emergency or otherwise extremely urgent. On those rare occasions when it is, be polite: “Do you mind if I take this call? It’s important.” Then, once again, excuse yourself to answer privately.

One final thought: Don’t walk around wearing one of those wireless Bluetooth earpieces on your ear, as if the Governor might call at any moment. Everyone around you has to guess whether you’re addressing them or some unseen caller; and frankly – with all respect – it looks ridiculous. And pretentious.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

My recent column on proper telephone technique for front office employees triggered some interesting commentary. “What about the calls we take?” someone asked. “The phone etiquette among most professionals leaves a lot to be desired.”

alvarez/Getty Images

How true! Haven’t we all answered a call from another physician, only to hear, “Please hold for Dr. ___________”?

Let’s begin with that, since it’s one of my major pet peeves: Long tradition, and common courtesy, dictate that the person initiating a call be on the line when the recipient picks up the receiver. So don’t ask an assistant to dial calls for you. Is it really that much bother to do it yourself? A peer should never answer and then be expected to wait while your employee tracks you down. It is impolite, and implies that you consider your time much more valuable than his or hers.

Speaking of common courtesy: Always give callers your undivided attention; they can tell if you are distracted. If it’s not a good time for you, say so honestly, at the outset. “Listen, I can give you a couple of minutes, but I’m right in the middle of office hours ...” That’s much more polite than abruptly cutting someone off, mid-conversation. If the caller needs more time, offer to call back.

By the same token, if you are the caller, be sure to ask, “Is this a good time for you?” Then, be aware of how long you keep the other person on the line. We all have a finite amount of time, and not everyone knows how to end a phone conversation gracefully. Respect others’ time and get to your point quickly.

When you reach an answering machine or voice mail, talk clearly and distinctly. Few things are more frustrating than a mumbled message that no one can decipher. I always repeat my name and phone number for clarity’s sake. And please don’t leave a callback number that no one answers, or that automatically rejects all unidentified callers.

Mobile phones have become so ubiquitous, it is hard to believe that they were relatively scarce only 15 years ago. A distinct set of faux pas has evolved around them; for example, few things are less professional than a loud, indiscreet, annoying, or profane ring tone. Your recorded voice mail message needs to sound professional too – especially if patients will be hearing it.

It should be obvious that cell phones be turned off in theaters and during meetings, but many still remain on. Vibrate mode doesn’t count; anyone close by will still hear it, and you’ll be tempted to answer it. If you get a call during a movie or show, or at a meeting, and you absolutely have to answer it, quietly excuse yourself, and don’t take the call until you are alone. If you miss the call, you can always call the person back.

Answering phone calls in a restaurant is my wife’s biggest pet peeve. She says it is rude and inappropriate, and she’s right – yet it is now, arguably, the most common etiquette mistake. Never take calls (or worse, answer texts or emails) while seated at the table – which leads to another issue: Don’t put your phone on the table! You can hear it just fine from your purse or pocket; and putting it on the table implies to your companions that you are looking for something – anything – more interesting than their company. If you must take a call or read a message, excuse yourself and go to a private area.

In fact, you shouldn’t answer any nonemergent calls or texts when you are with others; it makes your friends and colleagues feel unimportant and ignored. The people you are with should always take precedence over your phone, unless it is a medical emergency or otherwise extremely urgent. On those rare occasions when it is, be polite: “Do you mind if I take this call? It’s important.” Then, once again, excuse yourself to answer privately.

One final thought: Don’t walk around wearing one of those wireless Bluetooth earpieces on your ear, as if the Governor might call at any moment. Everyone around you has to guess whether you’re addressing them or some unseen caller; and frankly – with all respect – it looks ridiculous. And pretentious.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

My recent column on proper telephone technique for front office employees triggered some interesting commentary. “What about the calls we take?” someone asked. “The phone etiquette among most professionals leaves a lot to be desired.”

alvarez/Getty Images

How true! Haven’t we all answered a call from another physician, only to hear, “Please hold for Dr. ___________”?

Let’s begin with that, since it’s one of my major pet peeves: Long tradition, and common courtesy, dictate that the person initiating a call be on the line when the recipient picks up the receiver. So don’t ask an assistant to dial calls for you. Is it really that much bother to do it yourself? A peer should never answer and then be expected to wait while your employee tracks you down. It is impolite, and implies that you consider your time much more valuable than his or hers.

Speaking of common courtesy: Always give callers your undivided attention; they can tell if you are distracted. If it’s not a good time for you, say so honestly, at the outset. “Listen, I can give you a couple of minutes, but I’m right in the middle of office hours ...” That’s much more polite than abruptly cutting someone off, mid-conversation. If the caller needs more time, offer to call back.

By the same token, if you are the caller, be sure to ask, “Is this a good time for you?” Then, be aware of how long you keep the other person on the line. We all have a finite amount of time, and not everyone knows how to end a phone conversation gracefully. Respect others’ time and get to your point quickly.

When you reach an answering machine or voice mail, talk clearly and distinctly. Few things are more frustrating than a mumbled message that no one can decipher. I always repeat my name and phone number for clarity’s sake. And please don’t leave a callback number that no one answers, or that automatically rejects all unidentified callers.

Mobile phones have become so ubiquitous, it is hard to believe that they were relatively scarce only 15 years ago. A distinct set of faux pas has evolved around them; for example, few things are less professional than a loud, indiscreet, annoying, or profane ring tone. Your recorded voice mail message needs to sound professional too – especially if patients will be hearing it.

It should be obvious that cell phones be turned off in theaters and during meetings, but many still remain on. Vibrate mode doesn’t count; anyone close by will still hear it, and you’ll be tempted to answer it. If you get a call during a movie or show, or at a meeting, and you absolutely have to answer it, quietly excuse yourself, and don’t take the call until you are alone. If you miss the call, you can always call the person back.

Answering phone calls in a restaurant is my wife’s biggest pet peeve. She says it is rude and inappropriate, and she’s right – yet it is now, arguably, the most common etiquette mistake. Never take calls (or worse, answer texts or emails) while seated at the table – which leads to another issue: Don’t put your phone on the table! You can hear it just fine from your purse or pocket; and putting it on the table implies to your companions that you are looking for something – anything – more interesting than their company. If you must take a call or read a message, excuse yourself and go to a private area.

In fact, you shouldn’t answer any nonemergent calls or texts when you are with others; it makes your friends and colleagues feel unimportant and ignored. The people you are with should always take precedence over your phone, unless it is a medical emergency or otherwise extremely urgent. On those rare occasions when it is, be polite: “Do you mind if I take this call? It’s important.” Then, once again, excuse yourself to answer privately.

One final thought: Don’t walk around wearing one of those wireless Bluetooth earpieces on your ear, as if the Governor might call at any moment. Everyone around you has to guess whether you’re addressing them or some unseen caller; and frankly – with all respect – it looks ridiculous. And pretentious.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

Outside the clinic room, I paced the hallway and pressed the phone to my ear, waiting for the resident to pick up.

“I have patient SB in clinic for her appointment now. I’m hoping to get preliminary results of her bone marrow biopsy.”

I had known SB well from her month-long inpatient stay on our leukemia service. She had come in with a white blood cell count through the roof – a relapse of her leukemia, 4 years out from her bone marrow transplant. It was devastating. After a few cycles of chemotherapy and a bone marrow biopsy yesterday to see if it had worked, she was here now to get her results and decide next steps.

“Hello!” I said and we hugged. Her mother and father accompanied her, sitting still with their hands folded nervously. SB had multiple complications during her hospitalization, and we went through how each was doing. Did she get her new heart medication? Did she do okay on the antibiotics? Was the rash improving? With each question, she and her parents seemed more nervous.

There was an elephant in that exam room. Asking a cancer patient in limbo if she refilled her heart medications becomes as trivial as asking her about the weather. SB and her parents were here for one thing, from which everything else was a distraction. The only question that mattered was the one splitting their world in two: Is their daughter in remission or not?

“She’s here with her parents now,” I said outside the door. “What do you think?” The resident told me he had looked at the case this morning, and it looked like 3% blasts. I smiled – anything under 5% is good, considered a remission. But the pathology resident still hadn’t reviewed the sample with his attending.

Inside the room, after exhausting all other conversation, I hesitated. Should I tell SB the preliminary results? Or should I wait for the final diagnosis?

I’d been burned before. Once, I told a patient with a new diagnosis of esophageal cancer that it was early stage. It was not. Upon additional radiology review, the surrounding lymph nodes were enlarged, and they were ultimately found to be metastases. That initial conversation – and the subsequent one, in which I had to walk back my reassurance that the cancer was contained – was seared into my mind.

I learned from it. Giving preliminary results can be dangerous. What if we say all clear and then learn days later it isn’t so? Or what if we reveal the cancer is progressing, causing despair and re-evaluation of life’s priorities, only to find out it was a false alarm? False alarms are terrifying, and false reassurance is cruel, yet all the while, excessive waiting can feel excruciating for the person whose very existence is suspended.

As hematologists and oncologists, we scroll through CT scans, and we look at slides ourselves. But we also value and depend on the expertise of our colleagues in other departments like pathology and radiology who have their own workflow. It’s a process; it’s for quality assurance that we don’t get immediate results, and that’s a good thing.

It depends on the patient, but often I find the most straightforward solution is to say exactly what is true. For some, the combination of incredibly high stakes coupled with extended wait times becomes agonizing. They might incorrectly read into unrelated, benign actions – if my pager goes off or I look at the computer screen a moment too long – as clues into something I know and am not sharing. They might be so distracted we cannot address anything else.

So I’ve walked back from my initial “do not share anything” reaction to “it’s sometimes okay” – as long as the patient understands the nuances of what preliminary results do and do not mean. The problem with my esophageal cancer patient was not that I had shared preliminary results; it was that I hadn’t framed them as such. I had simply stated the findings, portraying them as certain.

Now, I tend to break the fourth wall. I explain that it’s the resident’s read, that it isn’t final, and that it can be amended. Do you still want to know?

Most people say yes.

SB and her parents were in that boat. They had driven 3 hours to make this appointment. They didn’t want to drive home empty handed.

“It’s preliminary,” I carefully qualified.

“Okay.”

“The final results may be different.”

“Okay, yes. We understand.”

The three of them held hands. They were holding their breath.

“It looks like remission.”

SB cried. Her mother threw her arms around my neck. “You know, she broke down when you stepped out,” her father whispered to me. “She was sure it meant bad news.”

I tried to be happy for them and with them, but now I was the one holding my breath. I hoped I wouldn’t have to take it all away.

For the next 24 hours, I compulsively checked SB’s chart, hoping final results would populate that would be consistent with what I had shared.

The next day, the pathologist called me, and I called SB.

“I have the final results,” I said, followed by my favorite phrase in hematology and oncology. “I have good news.”

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

Outside the clinic room, I paced the hallway and pressed the phone to my ear, waiting for the resident to pick up.

“I have patient SB in clinic for her appointment now. I’m hoping to get preliminary results of her bone marrow biopsy.”

I had known SB well from her month-long inpatient stay on our leukemia service. She had come in with a white blood cell count through the roof – a relapse of her leukemia, 4 years out from her bone marrow transplant. It was devastating. After a few cycles of chemotherapy and a bone marrow biopsy yesterday to see if it had worked, she was here now to get her results and decide next steps.

“Hello!” I said and we hugged. Her mother and father accompanied her, sitting still with their hands folded nervously. SB had multiple complications during her hospitalization, and we went through how each was doing. Did she get her new heart medication? Did she do okay on the antibiotics? Was the rash improving? With each question, she and her parents seemed more nervous.

There was an elephant in that exam room. Asking a cancer patient in limbo if she refilled her heart medications becomes as trivial as asking her about the weather. SB and her parents were here for one thing, from which everything else was a distraction. The only question that mattered was the one splitting their world in two: Is their daughter in remission or not?

“She’s here with her parents now,” I said outside the door. “What do you think?” The resident told me he had looked at the case this morning, and it looked like 3% blasts. I smiled – anything under 5% is good, considered a remission. But the pathology resident still hadn’t reviewed the sample with his attending.

Inside the room, after exhausting all other conversation, I hesitated. Should I tell SB the preliminary results? Or should I wait for the final diagnosis?

I’d been burned before. Once, I told a patient with a new diagnosis of esophageal cancer that it was early stage. It was not. Upon additional radiology review, the surrounding lymph nodes were enlarged, and they were ultimately found to be metastases. That initial conversation – and the subsequent one, in which I had to walk back my reassurance that the cancer was contained – was seared into my mind.

I learned from it. Giving preliminary results can be dangerous. What if we say all clear and then learn days later it isn’t so? Or what if we reveal the cancer is progressing, causing despair and re-evaluation of life’s priorities, only to find out it was a false alarm? False alarms are terrifying, and false reassurance is cruel, yet all the while, excessive waiting can feel excruciating for the person whose very existence is suspended.

As hematologists and oncologists, we scroll through CT scans, and we look at slides ourselves. But we also value and depend on the expertise of our colleagues in other departments like pathology and radiology who have their own workflow. It’s a process; it’s for quality assurance that we don’t get immediate results, and that’s a good thing.

It depends on the patient, but often I find the most straightforward solution is to say exactly what is true. For some, the combination of incredibly high stakes coupled with extended wait times becomes agonizing. They might incorrectly read into unrelated, benign actions – if my pager goes off or I look at the computer screen a moment too long – as clues into something I know and am not sharing. They might be so distracted we cannot address anything else.

So I’ve walked back from my initial “do not share anything” reaction to “it’s sometimes okay” – as long as the patient understands the nuances of what preliminary results do and do not mean. The problem with my esophageal cancer patient was not that I had shared preliminary results; it was that I hadn’t framed them as such. I had simply stated the findings, portraying them as certain.

Now, I tend to break the fourth wall. I explain that it’s the resident’s read, that it isn’t final, and that it can be amended. Do you still want to know?

Most people say yes.

SB and her parents were in that boat. They had driven 3 hours to make this appointment. They didn’t want to drive home empty handed.

“It’s preliminary,” I carefully qualified.

“Okay.”

“The final results may be different.”

“Okay, yes. We understand.”

The three of them held hands. They were holding their breath.

“It looks like remission.”

SB cried. Her mother threw her arms around my neck. “You know, she broke down when you stepped out,” her father whispered to me. “She was sure it meant bad news.”

I tried to be happy for them and with them, but now I was the one holding my breath. I hoped I wouldn’t have to take it all away.

For the next 24 hours, I compulsively checked SB’s chart, hoping final results would populate that would be consistent with what I had shared.

The next day, the pathologist called me, and I called SB.

“I have the final results,” I said, followed by my favorite phrase in hematology and oncology. “I have good news.”

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

Outside the clinic room, I paced the hallway and pressed the phone to my ear, waiting for the resident to pick up.

“I have patient SB in clinic for her appointment now. I’m hoping to get preliminary results of her bone marrow biopsy.”

I had known SB well from her month-long inpatient stay on our leukemia service. She had come in with a white blood cell count through the roof – a relapse of her leukemia, 4 years out from her bone marrow transplant. It was devastating. After a few cycles of chemotherapy and a bone marrow biopsy yesterday to see if it had worked, she was here now to get her results and decide next steps.

“Hello!” I said and we hugged. Her mother and father accompanied her, sitting still with their hands folded nervously. SB had multiple complications during her hospitalization, and we went through how each was doing. Did she get her new heart medication? Did she do okay on the antibiotics? Was the rash improving? With each question, she and her parents seemed more nervous.

There was an elephant in that exam room. Asking a cancer patient in limbo if she refilled her heart medications becomes as trivial as asking her about the weather. SB and her parents were here for one thing, from which everything else was a distraction. The only question that mattered was the one splitting their world in two: Is their daughter in remission or not?

“She’s here with her parents now,” I said outside the door. “What do you think?” The resident told me he had looked at the case this morning, and it looked like 3% blasts. I smiled – anything under 5% is good, considered a remission. But the pathology resident still hadn’t reviewed the sample with his attending.

Inside the room, after exhausting all other conversation, I hesitated. Should I tell SB the preliminary results? Or should I wait for the final diagnosis?

I’d been burned before. Once, I told a patient with a new diagnosis of esophageal cancer that it was early stage. It was not. Upon additional radiology review, the surrounding lymph nodes were enlarged, and they were ultimately found to be metastases. That initial conversation – and the subsequent one, in which I had to walk back my reassurance that the cancer was contained – was seared into my mind.

I learned from it. Giving preliminary results can be dangerous. What if we say all clear and then learn days later it isn’t so? Or what if we reveal the cancer is progressing, causing despair and re-evaluation of life’s priorities, only to find out it was a false alarm? False alarms are terrifying, and false reassurance is cruel, yet all the while, excessive waiting can feel excruciating for the person whose very existence is suspended.

As hematologists and oncologists, we scroll through CT scans, and we look at slides ourselves. But we also value and depend on the expertise of our colleagues in other departments like pathology and radiology who have their own workflow. It’s a process; it’s for quality assurance that we don’t get immediate results, and that’s a good thing.

It depends on the patient, but often I find the most straightforward solution is to say exactly what is true. For some, the combination of incredibly high stakes coupled with extended wait times becomes agonizing. They might incorrectly read into unrelated, benign actions – if my pager goes off or I look at the computer screen a moment too long – as clues into something I know and am not sharing. They might be so distracted we cannot address anything else.

So I’ve walked back from my initial “do not share anything” reaction to “it’s sometimes okay” – as long as the patient understands the nuances of what preliminary results do and do not mean. The problem with my esophageal cancer patient was not that I had shared preliminary results; it was that I hadn’t framed them as such. I had simply stated the findings, portraying them as certain.

Now, I tend to break the fourth wall. I explain that it’s the resident’s read, that it isn’t final, and that it can be amended. Do you still want to know?

Most people say yes.

SB and her parents were in that boat. They had driven 3 hours to make this appointment. They didn’t want to drive home empty handed.

“It’s preliminary,” I carefully qualified.

“Okay.”

“The final results may be different.”

“Okay, yes. We understand.”

The three of them held hands. They were holding their breath.

“It looks like remission.”

SB cried. Her mother threw her arms around my neck. “You know, she broke down when you stepped out,” her father whispered to me. “She was sure it meant bad news.”

I tried to be happy for them and with them, but now I was the one holding my breath. I hoped I wouldn’t have to take it all away.

For the next 24 hours, I compulsively checked SB’s chart, hoping final results would populate that would be consistent with what I had shared.

The next day, the pathologist called me, and I called SB.

“I have the final results,” I said, followed by my favorite phrase in hematology and oncology. “I have good news.”

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

My father was a general surgeon in a very small town in West Virginia. He was very successful and his patients loved him. He loved them, too, and chose to practice well into his 70s. In retrospect, he should not have.

Perhaps brilliant in his day, he was less so at the end of his career. I realized his deficiencies when I was in residency. I wondered if, despite his undeniable experience, his age was compromising his clinical acumen.

There are data available that support my suspicions. Investigators from the Department of Health Policy and Management at Harvard T.H. Chan School of Public Health reviewed a random sample of Medicare beneficiaries admitted to a hospital between 2011 and 2014. They hypothesized that physician age may affect outcomes such as 30-day mortality, readmissions, and cost of care. Among the more than 700,000 admissions by more than 18,000 hospitalists, the 30-day mortality rates were significantly higher for physicians aged 60 years and older, compared with younger physicians. Importantly though, there was no difference in mortality for older, but high-volume, physicians, compared with younger ones.

These results were published in the BMJ (2017 May 16;357:j1797. doi: 10.1136/bmj.j1797) by the same group that described a similar reduction in mortality among female versus male internists (JAMA Intern Med. 2017 Feb 1;177[2]:206-13). Both studies attracted widespread media attention.

The BMJ study analyzed outcomes among hospitalists who exclusively manage inpatients. Hematologists, in contrast, are largely based in the outpatient setting or in a lab. Yet, hematologists are often called upon to cover inpatient units of very sick patients. We care for patients with acute leukemia, thrombotic thrombocytopenic purpura, and graft versus host disease, among other debilitating diseases. In that sense, I believe data generated from hospitalists probably apply to inpatient hematology as well.

Having just been the attending on one of these services, I am uncomfortably certain that they apply. I proudly boast that I once attended for 6 months in a year. I was good at it and enjoyed it. With time, though, we hired additional staff and I acquired administrative duties that decreased my attending service time. I now attend for 2 weeks, twice a year.

During the last one of these service times, I began to suspect that I was not as sharp as I once was. I don’t think I missed anything, I just didn’t seem to catch changes in clinical status as quickly as I once did. I was less comfortable with the new medications I was prescribing. I was depending more on the clinical pharmacist and the hematology fellow to keep track of side effects and dose adjustments. I was worried – more than ever – that I would make a mistake. The last thing I want to be is dangerous.


As department chairman, though, it is part of my job to ensure that no one else is dangerous either. The Joint Commission mandates Ongoing Professional Practice Evaluation (OPPE), which is intended to help assess a practitioner’s clinical competence. Yet, the commission recognizes that “Cognitive specialties (internal medicine, family practice, psychiatry, med specialties ...) are very difficult” in terms of identifying meaningful data that can be evaluated.

We do not have adequate tools to assess clinical competency. As a result, we are generally aware that physicians do a poor job of policing our own, in no small part because of a reluctance to identify and confront less competent physicians. Where police departments are accused of hiding behind a blue wall of silence, are physicians guilty of maintaining a white wall of silence?

Of course we are. How many clinically shaky fellows do we graduate into our profession every year? How many of us are aware of colleagues who are unskilled, but are reluctant to speak up about them? Our sins are documented in books such as “Wall of Silence: The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans” by Rosemary Gibson and Janardan Prasad Singh and “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care,” by Marty Makary.

Concern for my own competence notwithstanding, medicine as a profession requires reflection on its role in allowing substandard patient care to continue.

Punishment doesn’t seem to be the best way to right wrongs. The punished may not learn the lesson and the unpunished will be less forthcoming with their own errors.

Taking a lesson from highly reliable industries such as airlines, the medical profession is addressing medical errors better. For example, my institution has mandated thorough checklists before any and all invasive procedures, including bone marrow biopsies. Through a morbidity and mortality review of a case of hepatitis, we developed an automatic method of ordering hepatitis panels in every patient treated with monoclonal antibodies. Making systemic changes to prevent error avoids having to punish those who make errors, while holding accountable those who skirt the built-in safeguards.

We are less successful at applying similar error mitigation techniques to individual physicians who may not be clinically excellent. Examples abound of physicians who provide substandard care, but are allowed to continue. The repercussions continue at Wake Forest Baptist Medical Center, where a pathologist misdiagnosed some cancer cases over at least a 2-year period of time. Physicians, as a group, are not as good at certifying competency as are nurses, advanced practice providers, and pharmacists.

With many academic hematologists having relatively small practices, getting older, and getting burned out, the potential for patient harm as a result of medical error increases. Further, these physicians may not realize their increased risk and may be indignant when confronted.

I am interested in best practices that address this difficult and contentious issue. I hope our readers will offer their policies and procedures so that we can learn from each other. Patients should not have to worry about their doctors’ competency and doctors should be able to hold each other accountable by removing the white wall of silence.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

My father was a general surgeon in a very small town in West Virginia. He was very successful and his patients loved him. He loved them, too, and chose to practice well into his 70s. In retrospect, he should not have.

Perhaps brilliant in his day, he was less so at the end of his career. I realized his deficiencies when I was in residency. I wondered if, despite his undeniable experience, his age was compromising his clinical acumen.

There are data available that support my suspicions. Investigators from the Department of Health Policy and Management at Harvard T.H. Chan School of Public Health reviewed a random sample of Medicare beneficiaries admitted to a hospital between 2011 and 2014. They hypothesized that physician age may affect outcomes such as 30-day mortality, readmissions, and cost of care. Among the more than 700,000 admissions by more than 18,000 hospitalists, the 30-day mortality rates were significantly higher for physicians aged 60 years and older, compared with younger physicians. Importantly though, there was no difference in mortality for older, but high-volume, physicians, compared with younger ones.

These results were published in the BMJ (2017 May 16;357:j1797. doi: 10.1136/bmj.j1797) by the same group that described a similar reduction in mortality among female versus male internists (JAMA Intern Med. 2017 Feb 1;177[2]:206-13). Both studies attracted widespread media attention.

The BMJ study analyzed outcomes among hospitalists who exclusively manage inpatients. Hematologists, in contrast, are largely based in the outpatient setting or in a lab. Yet, hematologists are often called upon to cover inpatient units of very sick patients. We care for patients with acute leukemia, thrombotic thrombocytopenic purpura, and graft versus host disease, among other debilitating diseases. In that sense, I believe data generated from hospitalists probably apply to inpatient hematology as well.

Having just been the attending on one of these services, I am uncomfortably certain that they apply. I proudly boast that I once attended for 6 months in a year. I was good at it and enjoyed it. With time, though, we hired additional staff and I acquired administrative duties that decreased my attending service time. I now attend for 2 weeks, twice a year.

During the last one of these service times, I began to suspect that I was not as sharp as I once was. I don’t think I missed anything, I just didn’t seem to catch changes in clinical status as quickly as I once did. I was less comfortable with the new medications I was prescribing. I was depending more on the clinical pharmacist and the hematology fellow to keep track of side effects and dose adjustments. I was worried – more than ever – that I would make a mistake. The last thing I want to be is dangerous.


As department chairman, though, it is part of my job to ensure that no one else is dangerous either. The Joint Commission mandates Ongoing Professional Practice Evaluation (OPPE), which is intended to help assess a practitioner’s clinical competence. Yet, the commission recognizes that “Cognitive specialties (internal medicine, family practice, psychiatry, med specialties ...) are very difficult” in terms of identifying meaningful data that can be evaluated.

We do not have adequate tools to assess clinical competency. As a result, we are generally aware that physicians do a poor job of policing our own, in no small part because of a reluctance to identify and confront less competent physicians. Where police departments are accused of hiding behind a blue wall of silence, are physicians guilty of maintaining a white wall of silence?

Of course we are. How many clinically shaky fellows do we graduate into our profession every year? How many of us are aware of colleagues who are unskilled, but are reluctant to speak up about them? Our sins are documented in books such as “Wall of Silence: The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans” by Rosemary Gibson and Janardan Prasad Singh and “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care,” by Marty Makary.

Concern for my own competence notwithstanding, medicine as a profession requires reflection on its role in allowing substandard patient care to continue.

Punishment doesn’t seem to be the best way to right wrongs. The punished may not learn the lesson and the unpunished will be less forthcoming with their own errors.

Taking a lesson from highly reliable industries such as airlines, the medical profession is addressing medical errors better. For example, my institution has mandated thorough checklists before any and all invasive procedures, including bone marrow biopsies. Through a morbidity and mortality review of a case of hepatitis, we developed an automatic method of ordering hepatitis panels in every patient treated with monoclonal antibodies. Making systemic changes to prevent error avoids having to punish those who make errors, while holding accountable those who skirt the built-in safeguards.

We are less successful at applying similar error mitigation techniques to individual physicians who may not be clinically excellent. Examples abound of physicians who provide substandard care, but are allowed to continue. The repercussions continue at Wake Forest Baptist Medical Center, where a pathologist misdiagnosed some cancer cases over at least a 2-year period of time. Physicians, as a group, are not as good at certifying competency as are nurses, advanced practice providers, and pharmacists.

With many academic hematologists having relatively small practices, getting older, and getting burned out, the potential for patient harm as a result of medical error increases. Further, these physicians may not realize their increased risk and may be indignant when confronted.

I am interested in best practices that address this difficult and contentious issue. I hope our readers will offer their policies and procedures so that we can learn from each other. Patients should not have to worry about their doctors’ competency and doctors should be able to hold each other accountable by removing the white wall of silence.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

My father was a general surgeon in a very small town in West Virginia. He was very successful and his patients loved him. He loved them, too, and chose to practice well into his 70s. In retrospect, he should not have.

Perhaps brilliant in his day, he was less so at the end of his career. I realized his deficiencies when I was in residency. I wondered if, despite his undeniable experience, his age was compromising his clinical acumen.

There are data available that support my suspicions. Investigators from the Department of Health Policy and Management at Harvard T.H. Chan School of Public Health reviewed a random sample of Medicare beneficiaries admitted to a hospital between 2011 and 2014. They hypothesized that physician age may affect outcomes such as 30-day mortality, readmissions, and cost of care. Among the more than 700,000 admissions by more than 18,000 hospitalists, the 30-day mortality rates were significantly higher for physicians aged 60 years and older, compared with younger physicians. Importantly though, there was no difference in mortality for older, but high-volume, physicians, compared with younger ones.

These results were published in the BMJ (2017 May 16;357:j1797. doi: 10.1136/bmj.j1797) by the same group that described a similar reduction in mortality among female versus male internists (JAMA Intern Med. 2017 Feb 1;177[2]:206-13). Both studies attracted widespread media attention.

The BMJ study analyzed outcomes among hospitalists who exclusively manage inpatients. Hematologists, in contrast, are largely based in the outpatient setting or in a lab. Yet, hematologists are often called upon to cover inpatient units of very sick patients. We care for patients with acute leukemia, thrombotic thrombocytopenic purpura, and graft versus host disease, among other debilitating diseases. In that sense, I believe data generated from hospitalists probably apply to inpatient hematology as well.

Having just been the attending on one of these services, I am uncomfortably certain that they apply. I proudly boast that I once attended for 6 months in a year. I was good at it and enjoyed it. With time, though, we hired additional staff and I acquired administrative duties that decreased my attending service time. I now attend for 2 weeks, twice a year.

During the last one of these service times, I began to suspect that I was not as sharp as I once was. I don’t think I missed anything, I just didn’t seem to catch changes in clinical status as quickly as I once did. I was less comfortable with the new medications I was prescribing. I was depending more on the clinical pharmacist and the hematology fellow to keep track of side effects and dose adjustments. I was worried – more than ever – that I would make a mistake. The last thing I want to be is dangerous.


As department chairman, though, it is part of my job to ensure that no one else is dangerous either. The Joint Commission mandates Ongoing Professional Practice Evaluation (OPPE), which is intended to help assess a practitioner’s clinical competence. Yet, the commission recognizes that “Cognitive specialties (internal medicine, family practice, psychiatry, med specialties ...) are very difficult” in terms of identifying meaningful data that can be evaluated.

We do not have adequate tools to assess clinical competency. As a result, we are generally aware that physicians do a poor job of policing our own, in no small part because of a reluctance to identify and confront less competent physicians. Where police departments are accused of hiding behind a blue wall of silence, are physicians guilty of maintaining a white wall of silence?

Of course we are. How many clinically shaky fellows do we graduate into our profession every year? How many of us are aware of colleagues who are unskilled, but are reluctant to speak up about them? Our sins are documented in books such as “Wall of Silence: The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans” by Rosemary Gibson and Janardan Prasad Singh and “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care,” by Marty Makary.

Concern for my own competence notwithstanding, medicine as a profession requires reflection on its role in allowing substandard patient care to continue.

Punishment doesn’t seem to be the best way to right wrongs. The punished may not learn the lesson and the unpunished will be less forthcoming with their own errors.

Taking a lesson from highly reliable industries such as airlines, the medical profession is addressing medical errors better. For example, my institution has mandated thorough checklists before any and all invasive procedures, including bone marrow biopsies. Through a morbidity and mortality review of a case of hepatitis, we developed an automatic method of ordering hepatitis panels in every patient treated with monoclonal antibodies. Making systemic changes to prevent error avoids having to punish those who make errors, while holding accountable those who skirt the built-in safeguards.

We are less successful at applying similar error mitigation techniques to individual physicians who may not be clinically excellent. Examples abound of physicians who provide substandard care, but are allowed to continue. The repercussions continue at Wake Forest Baptist Medical Center, where a pathologist misdiagnosed some cancer cases over at least a 2-year period of time. Physicians, as a group, are not as good at certifying competency as are nurses, advanced practice providers, and pharmacists.

With many academic hematologists having relatively small practices, getting older, and getting burned out, the potential for patient harm as a result of medical error increases. Further, these physicians may not realize their increased risk and may be indignant when confronted.

I am interested in best practices that address this difficult and contentious issue. I hope our readers will offer their policies and procedures so that we can learn from each other. Patients should not have to worry about their doctors’ competency and doctors should be able to hold each other accountable by removing the white wall of silence.

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

On the first day of my psychiatry clerkship, I sat at a table with another student, 2 residents, and our attending physician. This wasn’t my first clinical rotation, but it was my first formal exposure to psychiatry, and I was excited and a bit anxious because I was considering psychiatry as an area of specialty training for myself. I’d been assigned 1 patient that morning: a 42-year-old man admitted for alcohol withdrawal. Our team, the psychiatry consultation-liaison team, was asked to evaluate the patient’s depressed mood in the context of withdrawal. As I began to present the patient’s story, I spoke of how terrible this man’s life had been, and how depressed he had recently become; this depression, I said, was likely exacerbated by alcohol use, but he was dealing with his depression by drinking more. He now wanted to quit for good. My attending, whom I had just met, interrupted me: “Misery,” she said with an intense look, “is a gift to an addicted person.”

I have ruminated on those surprising words ever since, and in that time I have begun to understand something about misery through the eyes of my patients. Sick people often are miserable; physical ailments can wreck hopes and plans and suck the joy from seemingly everything. Individuals who are ill or in pain often are suffering psychologically as well as physically. This suffering has been especially apparent to me in patients withdrawing from addictive substances: alcohol, cocaine, heroin, nicotine. I have been begged, cursed, praised, thanked, and more based on my ability or inability to relieve someone’s suffering caused by the lack of a certain substance: Please, just one cigarette. Please, something for this pain. Please, something to drink. As a medical student, I did one of 2 things: stood there helpless, or promised I would do the best I could, knowing my resident or attending would likely tell them no.

Withdrawal from addictive substances is, unsurprisingly, not pleasant. Alcohol withdrawal is one of the few that can be fatal, due to its ability to cause autonomic instability and seizures. Withdrawing from alcohol is also unpleasant due to hallucinosis and tremors, on top of the very real cravings for the substance itself. My patient knew this; he had withdrawn from alcohol in the past. As he talked to me, though, it became clear he had finally decided this was the end. In the past, others encouraged him to stop drinking; this time he was doing it for himself. His life had become so dismal that he was willing to undergo the agony of withdrawal to be free from his addiction.

Was his suffering, then, his misery, a gift? As I came to know my attending better, I also came to understand what these jarring words meant to her. They were her version of the old adage: It’s only when you hit rock bottom that you can start climbing back out. It isn’t the misery of withdrawing, but the misery inflicted by the substance that might provide an unexpected opportunity to start fixing things. For my patient, this particular trip to the hospital—which happened to intersect in space and time with me, a third-year medical student keen to learn and to help—was rock bottom, and he knew it. His life had been destroyed by his addiction, and here, at this intersection, the destruction was so great that he was finally willing to make a change for the better.

It is counterintuitive to think of misery as a gift, but then again, this patient—and more broadly, all patients whose lives are tormented by addiction and substance abuse—are often on the receiving end of counterintuitive advice, and it is frequently the only way to enact lasting change. Consider, for example, Alcoholics’ Anonymous, which works for far more individuals than one might expect. It does not seem possible that a small group without formal training could keep people sober simply by talking openly about their struggles; yet every day throughout the world, it does just that.

Patients struggling with addiction—labeled as addicts and drug-seekers by most of the world—are often written off as “difficult patients.” Perhaps because of my inexperience, I didn’t see this man as difficult, or as just another case of alcohol withdrawal. Although it may often be easier to define someone by his or her disease, I believe in choosing to see the human underneath the label. To me, these patients are not difficult; they are broken and miserable, and they desperately need help. Knowing this, I am forced to consider just how bad things have gotten for them, and how hard it must be to make a change. Their brokenness may be an opportunity to start down a new path, but only if we extend that invitation. Such an invitation may be the first step to turning genuine misery into a gift.

When I’m asked why I have chosen psychiatry, willingly entering such a “difficult field,” I think about my experience on that consult service and this patient. I know that I’m still just beginning my journey, and that even more difficult moments and patients lie ahead. But difficulty depends on one’s perspective; certainly that patient, trying to free himself from addiction’s grasp, was “going through a difficult time.” This is of course a platitude; the word “misery” gets much closer to the truth. I usually answer with some variation of the following: Medicine, especially psychiatry, is about caring for those who need it most: hurting, vulnerable people rejected by friends, family, and society. Our business is misery; sometimes we track in the broken, the beat down, the rock bottom. We get down in the depths with our patients to offer comfort and hope. We look at an addict, but we see a human being. We try to see the world from his or her perspective. This isn’t always pleasant—sometimes, it’s downright miserable—but to see the world through the eyes of another is, always, a gift.

On the first day of my psychiatry clerkship, I sat at a table with another student, 2 residents, and our attending physician. This wasn’t my first clinical rotation, but it was my first formal exposure to psychiatry, and I was excited and a bit anxious because I was considering psychiatry as an area of specialty training for myself. I’d been assigned 1 patient that morning: a 42-year-old man admitted for alcohol withdrawal. Our team, the psychiatry consultation-liaison team, was asked to evaluate the patient’s depressed mood in the context of withdrawal. As I began to present the patient’s story, I spoke of how terrible this man’s life had been, and how depressed he had recently become; this depression, I said, was likely exacerbated by alcohol use, but he was dealing with his depression by drinking more. He now wanted to quit for good. My attending, whom I had just met, interrupted me: “Misery,” she said with an intense look, “is a gift to an addicted person.”

I have ruminated on those surprising words ever since, and in that time I have begun to understand something about misery through the eyes of my patients. Sick people often are miserable; physical ailments can wreck hopes and plans and suck the joy from seemingly everything. Individuals who are ill or in pain often are suffering psychologically as well as physically. This suffering has been especially apparent to me in patients withdrawing from addictive substances: alcohol, cocaine, heroin, nicotine. I have been begged, cursed, praised, thanked, and more based on my ability or inability to relieve someone’s suffering caused by the lack of a certain substance: Please, just one cigarette. Please, something for this pain. Please, something to drink. As a medical student, I did one of 2 things: stood there helpless, or promised I would do the best I could, knowing my resident or attending would likely tell them no.

Withdrawal from addictive substances is, unsurprisingly, not pleasant. Alcohol withdrawal is one of the few that can be fatal, due to its ability to cause autonomic instability and seizures. Withdrawing from alcohol is also unpleasant due to hallucinosis and tremors, on top of the very real cravings for the substance itself. My patient knew this; he had withdrawn from alcohol in the past. As he talked to me, though, it became clear he had finally decided this was the end. In the past, others encouraged him to stop drinking; this time he was doing it for himself. His life had become so dismal that he was willing to undergo the agony of withdrawal to be free from his addiction.

Was his suffering, then, his misery, a gift? As I came to know my attending better, I also came to understand what these jarring words meant to her. They were her version of the old adage: It’s only when you hit rock bottom that you can start climbing back out. It isn’t the misery of withdrawing, but the misery inflicted by the substance that might provide an unexpected opportunity to start fixing things. For my patient, this particular trip to the hospital—which happened to intersect in space and time with me, a third-year medical student keen to learn and to help—was rock bottom, and he knew it. His life had been destroyed by his addiction, and here, at this intersection, the destruction was so great that he was finally willing to make a change for the better.

It is counterintuitive to think of misery as a gift, but then again, this patient—and more broadly, all patients whose lives are tormented by addiction and substance abuse—are often on the receiving end of counterintuitive advice, and it is frequently the only way to enact lasting change. Consider, for example, Alcoholics’ Anonymous, which works for far more individuals than one might expect. It does not seem possible that a small group without formal training could keep people sober simply by talking openly about their struggles; yet every day throughout the world, it does just that.

Patients struggling with addiction—labeled as addicts and drug-seekers by most of the world—are often written off as “difficult patients.” Perhaps because of my inexperience, I didn’t see this man as difficult, or as just another case of alcohol withdrawal. Although it may often be easier to define someone by his or her disease, I believe in choosing to see the human underneath the label. To me, these patients are not difficult; they are broken and miserable, and they desperately need help. Knowing this, I am forced to consider just how bad things have gotten for them, and how hard it must be to make a change. Their brokenness may be an opportunity to start down a new path, but only if we extend that invitation. Such an invitation may be the first step to turning genuine misery into a gift.

When I’m asked why I have chosen psychiatry, willingly entering such a “difficult field,” I think about my experience on that consult service and this patient. I know that I’m still just beginning my journey, and that even more difficult moments and patients lie ahead. But difficulty depends on one’s perspective; certainly that patient, trying to free himself from addiction’s grasp, was “going through a difficult time.” This is of course a platitude; the word “misery” gets much closer to the truth. I usually answer with some variation of the following: Medicine, especially psychiatry, is about caring for those who need it most: hurting, vulnerable people rejected by friends, family, and society. Our business is misery; sometimes we track in the broken, the beat down, the rock bottom. We get down in the depths with our patients to offer comfort and hope. We look at an addict, but we see a human being. We try to see the world from his or her perspective. This isn’t always pleasant—sometimes, it’s downright miserable—but to see the world through the eyes of another is, always, a gift.

On the first day of my psychiatry clerkship, I sat at a table with another student, 2 residents, and our attending physician. This wasn’t my first clinical rotation, but it was my first formal exposure to psychiatry, and I was excited and a bit anxious because I was considering psychiatry as an area of specialty training for myself. I’d been assigned 1 patient that morning: a 42-year-old man admitted for alcohol withdrawal. Our team, the psychiatry consultation-liaison team, was asked to evaluate the patient’s depressed mood in the context of withdrawal. As I began to present the patient’s story, I spoke of how terrible this man’s life had been, and how depressed he had recently become; this depression, I said, was likely exacerbated by alcohol use, but he was dealing with his depression by drinking more. He now wanted to quit for good. My attending, whom I had just met, interrupted me: “Misery,” she said with an intense look, “is a gift to an addicted person.”

I have ruminated on those surprising words ever since, and in that time I have begun to understand something about misery through the eyes of my patients. Sick people often are miserable; physical ailments can wreck hopes and plans and suck the joy from seemingly everything. Individuals who are ill or in pain often are suffering psychologically as well as physically. This suffering has been especially apparent to me in patients withdrawing from addictive substances: alcohol, cocaine, heroin, nicotine. I have been begged, cursed, praised, thanked, and more based on my ability or inability to relieve someone’s suffering caused by the lack of a certain substance: Please, just one cigarette. Please, something for this pain. Please, something to drink. As a medical student, I did one of 2 things: stood there helpless, or promised I would do the best I could, knowing my resident or attending would likely tell them no.

Withdrawal from addictive substances is, unsurprisingly, not pleasant. Alcohol withdrawal is one of the few that can be fatal, due to its ability to cause autonomic instability and seizures. Withdrawing from alcohol is also unpleasant due to hallucinosis and tremors, on top of the very real cravings for the substance itself. My patient knew this; he had withdrawn from alcohol in the past. As he talked to me, though, it became clear he had finally decided this was the end. In the past, others encouraged him to stop drinking; this time he was doing it for himself. His life had become so dismal that he was willing to undergo the agony of withdrawal to be free from his addiction.

Was his suffering, then, his misery, a gift? As I came to know my attending better, I also came to understand what these jarring words meant to her. They were her version of the old adage: It’s only when you hit rock bottom that you can start climbing back out. It isn’t the misery of withdrawing, but the misery inflicted by the substance that might provide an unexpected opportunity to start fixing things. For my patient, this particular trip to the hospital—which happened to intersect in space and time with me, a third-year medical student keen to learn and to help—was rock bottom, and he knew it. His life had been destroyed by his addiction, and here, at this intersection, the destruction was so great that he was finally willing to make a change for the better.

It is counterintuitive to think of misery as a gift, but then again, this patient—and more broadly, all patients whose lives are tormented by addiction and substance abuse—are often on the receiving end of counterintuitive advice, and it is frequently the only way to enact lasting change. Consider, for example, Alcoholics’ Anonymous, which works for far more individuals than one might expect. It does not seem possible that a small group without formal training could keep people sober simply by talking openly about their struggles; yet every day throughout the world, it does just that.

Patients struggling with addiction—labeled as addicts and drug-seekers by most of the world—are often written off as “difficult patients.” Perhaps because of my inexperience, I didn’t see this man as difficult, or as just another case of alcohol withdrawal. Although it may often be easier to define someone by his or her disease, I believe in choosing to see the human underneath the label. To me, these patients are not difficult; they are broken and miserable, and they desperately need help. Knowing this, I am forced to consider just how bad things have gotten for them, and how hard it must be to make a change. Their brokenness may be an opportunity to start down a new path, but only if we extend that invitation. Such an invitation may be the first step to turning genuine misery into a gift.

When I’m asked why I have chosen psychiatry, willingly entering such a “difficult field,” I think about my experience on that consult service and this patient. I know that I’m still just beginning my journey, and that even more difficult moments and patients lie ahead. But difficulty depends on one’s perspective; certainly that patient, trying to free himself from addiction’s grasp, was “going through a difficult time.” This is of course a platitude; the word “misery” gets much closer to the truth. I usually answer with some variation of the following: Medicine, especially psychiatry, is about caring for those who need it most: hurting, vulnerable people rejected by friends, family, and society. Our business is misery; sometimes we track in the broken, the beat down, the rock bottom. We get down in the depths with our patients to offer comfort and hope. We look at an addict, but we see a human being. We try to see the world from his or her perspective. This isn’t always pleasant—sometimes, it’s downright miserable—but to see the world through the eyes of another is, always, a gift.