Perspectives

Over the past several years, the number of patients seeking gender-affirming services has exponentially increased.¹ Unfortunately, the number of patients presenting for treatment has exceeded evidence-based guidelines, research, and the number of providers familiar with gender-affirming care. Many institutions and associations such as the American College of Obstetricians and Gynecologists and the World Professional Association for Transgender Health (WPATH) advocate for training of providers; however, many patients will be seen by providers who are not qualified in diagnosing gender dysphoria. As a result, many practitioners rely on the mental health evaluation of gender-diverse individuals prior to prescribing hormonal therapy or before planning surgery.

Practitioners qualified to provide mental health services can include persons within in the field of psychology, psychiatry, social work, licensed professional counseling, nursing, or family medicine (with specific training in mental health).² WPATH also defines specific criteria as part of the mental health assessment. For example, providers should have a master’s degree or higher in clinical behavioral science, competence in using the DSM/ICD, the ability to recognize and diagnose coexisting mental health concerns, and undergo continuing education in the treatment of gender dysphoria.² Unfortunately, the demand for gender-competent mental health professionals exceeds the number available, and many patients are seen by therapists lacking experience within this field.³ This discrepancy can present an additional barrier to the health needs of transgender patients and sometimes inhibit access to hormone therapy, or even more catastrophically, compromise their presurgical assessment and surgical outcome.

For patients seeking chest surgery (mastectomy or breast augmentation), one letter from a mental health provider is necessary. If a patient is interested in pursuing genital surgery or the removal or reproductive organs, two letters from two separate mental health providers are required. Typically, one letter is from the patient’s primary therapist, and the other is often a second opinion. These letters must include a patient’s general characteristics, psychosocial assessment results, duration of the mental health professional’s relationship with the client, an explanation that the criteria for surgery have been met, a statement supporting the patient’s request for surgery and that informed consent was obtained, and a statement that the mental health professional is available for coordination of care.² It is crucial to delineate that while a mental health evaluation is mandated, psychotherapy is not.

A therapist’s letter is not essential prior to initiating hormones; however, it is recommended if practitioners are unfamiliar with gender-diverse patients and current standards of care. If a provider such as a family physician, endocrinologist, or obstetrician/gynecologist is knowledgeable about the diagnostic criteria for gender dysphoria, they can prescribe hormones without a therapist’s letter. Additional considerations include establishing whether a patient has persistent gender dysphoria, has the capacity to give informed consent, and has “reasonably well-controlled” mental illness.³ The prevalence of both depression and anxiety is exceptionally high in this population, whereas rates of bipolar disorder and schizophrenia mirror that of the general population.³ Mental illness is not a contraindication to hormone therapy because there is sufficient evidence to support the benefits of gender-affirming hormones in reducing both anxiety and depression.

In contrast, concurrent severe psychiatric illness (i.e., bipolar disorder, schizophrenia, borderline personality disorder) that is not well controlled could prohibit patients from undergoing gender-affirming surgeries. Even the most well-educated patients do not truly understand the process of surgery and the rigorous postoperative care required, particularly after genital surgery. Many patients underestimate the need for a support system in the postoperative period and cannot predict their emotional response after undergoing such complex procedures. During a surgical consultation, the surgeon can help identify any mental, physical, monetary, or social constraints patients may have and work closely with other providers, including a well-trained mental health professional, to optimize a patient’s surgical recovery. Ideally, patients undergoing surgery are seen at multidisciplinary centers with the capabilities of addressing these concerns.

The patient’s perspective on the need for a therapist is often mixed. Historically, therapist letters have been viewed by patients as a form of “gatekeeping” and an additional barrier they are forced to overcome to receive treatment. However, the role of a mental health provider who specializes in gender-affirming care cannot be overstated. In the context of surgery, I often try to reframe the role the therapist as an integral part of the multidisciplinary team. Mental health assessments preoperatively can better prepare patients for their upcoming surgery. More importantly, this multidisciplinary approach can help identify potential issues with coping strategies or exacerbations of other mental health conditions that may arise in the immediate postoperative period.

There is no question that exceptional gender-affirming care requires a multidisciplinary approach. Establishing strong relationships between hormone prescribers, surgeons, and behavioral health specialists in an essential step toward providing competent patient-centered care.
 

Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.

References

1. Ettner R. Mental health evaluation for gender confirmation surgery. Clin Plastic Surg. 2018;45(3):307-11.

2. Karasic D. Mental health care for the adult transgender patient. In: Ferrando CA, ed. Comprehensive Care of the Transgender Patient. Philadelphia: Elsevier; 2020:8-11.

3. World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people. 7th ed. Minneapolis: WPATH; 2012.

Over the past several years, the number of patients seeking gender-affirming services has exponentially increased.¹ Unfortunately, the number of patients presenting for treatment has exceeded evidence-based guidelines, research, and the number of providers familiar with gender-affirming care. Many institutions and associations such as the American College of Obstetricians and Gynecologists and the World Professional Association for Transgender Health (WPATH) advocate for training of providers; however, many patients will be seen by providers who are not qualified in diagnosing gender dysphoria. As a result, many practitioners rely on the mental health evaluation of gender-diverse individuals prior to prescribing hormonal therapy or before planning surgery.

Practitioners qualified to provide mental health services can include persons within in the field of psychology, psychiatry, social work, licensed professional counseling, nursing, or family medicine (with specific training in mental health).² WPATH also defines specific criteria as part of the mental health assessment. For example, providers should have a master’s degree or higher in clinical behavioral science, competence in using the DSM/ICD, the ability to recognize and diagnose coexisting mental health concerns, and undergo continuing education in the treatment of gender dysphoria.² Unfortunately, the demand for gender-competent mental health professionals exceeds the number available, and many patients are seen by therapists lacking experience within this field.³ This discrepancy can present an additional barrier to the health needs of transgender patients and sometimes inhibit access to hormone therapy, or even more catastrophically, compromise their presurgical assessment and surgical outcome.

For patients seeking chest surgery (mastectomy or breast augmentation), one letter from a mental health provider is necessary. If a patient is interested in pursuing genital surgery or the removal or reproductive organs, two letters from two separate mental health providers are required. Typically, one letter is from the patient’s primary therapist, and the other is often a second opinion. These letters must include a patient’s general characteristics, psychosocial assessment results, duration of the mental health professional’s relationship with the client, an explanation that the criteria for surgery have been met, a statement supporting the patient’s request for surgery and that informed consent was obtained, and a statement that the mental health professional is available for coordination of care.² It is crucial to delineate that while a mental health evaluation is mandated, psychotherapy is not.

A therapist’s letter is not essential prior to initiating hormones; however, it is recommended if practitioners are unfamiliar with gender-diverse patients and current standards of care. If a provider such as a family physician, endocrinologist, or obstetrician/gynecologist is knowledgeable about the diagnostic criteria for gender dysphoria, they can prescribe hormones without a therapist’s letter. Additional considerations include establishing whether a patient has persistent gender dysphoria, has the capacity to give informed consent, and has “reasonably well-controlled” mental illness.³ The prevalence of both depression and anxiety is exceptionally high in this population, whereas rates of bipolar disorder and schizophrenia mirror that of the general population.³ Mental illness is not a contraindication to hormone therapy because there is sufficient evidence to support the benefits of gender-affirming hormones in reducing both anxiety and depression.

In contrast, concurrent severe psychiatric illness (i.e., bipolar disorder, schizophrenia, borderline personality disorder) that is not well controlled could prohibit patients from undergoing gender-affirming surgeries. Even the most well-educated patients do not truly understand the process of surgery and the rigorous postoperative care required, particularly after genital surgery. Many patients underestimate the need for a support system in the postoperative period and cannot predict their emotional response after undergoing such complex procedures. During a surgical consultation, the surgeon can help identify any mental, physical, monetary, or social constraints patients may have and work closely with other providers, including a well-trained mental health professional, to optimize a patient’s surgical recovery. Ideally, patients undergoing surgery are seen at multidisciplinary centers with the capabilities of addressing these concerns.

The patient’s perspective on the need for a therapist is often mixed. Historically, therapist letters have been viewed by patients as a form of “gatekeeping” and an additional barrier they are forced to overcome to receive treatment. However, the role of a mental health provider who specializes in gender-affirming care cannot be overstated. In the context of surgery, I often try to reframe the role the therapist as an integral part of the multidisciplinary team. Mental health assessments preoperatively can better prepare patients for their upcoming surgery. More importantly, this multidisciplinary approach can help identify potential issues with coping strategies or exacerbations of other mental health conditions that may arise in the immediate postoperative period.

There is no question that exceptional gender-affirming care requires a multidisciplinary approach. Establishing strong relationships between hormone prescribers, surgeons, and behavioral health specialists in an essential step toward providing competent patient-centered care.
 

Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.

References

1. Ettner R. Mental health evaluation for gender confirmation surgery. Clin Plastic Surg. 2018;45(3):307-11.

2. Karasic D. Mental health care for the adult transgender patient. In: Ferrando CA, ed. Comprehensive Care of the Transgender Patient. Philadelphia: Elsevier; 2020:8-11.

3. World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people. 7th ed. Minneapolis: WPATH; 2012.

Over the past several years, the number of patients seeking gender-affirming services has exponentially increased.¹ Unfortunately, the number of patients presenting for treatment has exceeded evidence-based guidelines, research, and the number of providers familiar with gender-affirming care. Many institutions and associations such as the American College of Obstetricians and Gynecologists and the World Professional Association for Transgender Health (WPATH) advocate for training of providers; however, many patients will be seen by providers who are not qualified in diagnosing gender dysphoria. As a result, many practitioners rely on the mental health evaluation of gender-diverse individuals prior to prescribing hormonal therapy or before planning surgery.

Practitioners qualified to provide mental health services can include persons within in the field of psychology, psychiatry, social work, licensed professional counseling, nursing, or family medicine (with specific training in mental health).² WPATH also defines specific criteria as part of the mental health assessment. For example, providers should have a master’s degree or higher in clinical behavioral science, competence in using the DSM/ICD, the ability to recognize and diagnose coexisting mental health concerns, and undergo continuing education in the treatment of gender dysphoria.² Unfortunately, the demand for gender-competent mental health professionals exceeds the number available, and many patients are seen by therapists lacking experience within this field.³ This discrepancy can present an additional barrier to the health needs of transgender patients and sometimes inhibit access to hormone therapy, or even more catastrophically, compromise their presurgical assessment and surgical outcome.

For patients seeking chest surgery (mastectomy or breast augmentation), one letter from a mental health provider is necessary. If a patient is interested in pursuing genital surgery or the removal or reproductive organs, two letters from two separate mental health providers are required. Typically, one letter is from the patient’s primary therapist, and the other is often a second opinion. These letters must include a patient’s general characteristics, psychosocial assessment results, duration of the mental health professional’s relationship with the client, an explanation that the criteria for surgery have been met, a statement supporting the patient’s request for surgery and that informed consent was obtained, and a statement that the mental health professional is available for coordination of care.² It is crucial to delineate that while a mental health evaluation is mandated, psychotherapy is not.

A therapist’s letter is not essential prior to initiating hormones; however, it is recommended if practitioners are unfamiliar with gender-diverse patients and current standards of care. If a provider such as a family physician, endocrinologist, or obstetrician/gynecologist is knowledgeable about the diagnostic criteria for gender dysphoria, they can prescribe hormones without a therapist’s letter. Additional considerations include establishing whether a patient has persistent gender dysphoria, has the capacity to give informed consent, and has “reasonably well-controlled” mental illness.³ The prevalence of both depression and anxiety is exceptionally high in this population, whereas rates of bipolar disorder and schizophrenia mirror that of the general population.³ Mental illness is not a contraindication to hormone therapy because there is sufficient evidence to support the benefits of gender-affirming hormones in reducing both anxiety and depression.

In contrast, concurrent severe psychiatric illness (i.e., bipolar disorder, schizophrenia, borderline personality disorder) that is not well controlled could prohibit patients from undergoing gender-affirming surgeries. Even the most well-educated patients do not truly understand the process of surgery and the rigorous postoperative care required, particularly after genital surgery. Many patients underestimate the need for a support system in the postoperative period and cannot predict their emotional response after undergoing such complex procedures. During a surgical consultation, the surgeon can help identify any mental, physical, monetary, or social constraints patients may have and work closely with other providers, including a well-trained mental health professional, to optimize a patient’s surgical recovery. Ideally, patients undergoing surgery are seen at multidisciplinary centers with the capabilities of addressing these concerns.

The patient’s perspective on the need for a therapist is often mixed. Historically, therapist letters have been viewed by patients as a form of “gatekeeping” and an additional barrier they are forced to overcome to receive treatment. However, the role of a mental health provider who specializes in gender-affirming care cannot be overstated. In the context of surgery, I often try to reframe the role the therapist as an integral part of the multidisciplinary team. Mental health assessments preoperatively can better prepare patients for their upcoming surgery. More importantly, this multidisciplinary approach can help identify potential issues with coping strategies or exacerbations of other mental health conditions that may arise in the immediate postoperative period.

There is no question that exceptional gender-affirming care requires a multidisciplinary approach. Establishing strong relationships between hormone prescribers, surgeons, and behavioral health specialists in an essential step toward providing competent patient-centered care.
 

Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.

References

1. Ettner R. Mental health evaluation for gender confirmation surgery. Clin Plastic Surg. 2018;45(3):307-11.

2. Karasic D. Mental health care for the adult transgender patient. In: Ferrando CA, ed. Comprehensive Care of the Transgender Patient. Philadelphia: Elsevier; 2020:8-11.

3. World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people. 7th ed. Minneapolis: WPATH; 2012.

There was a recent post on Sermo about medical office staff cross-training. It talked about the importance of the scheduler being able to cover for the medical assistant (to an extent), a billing person being able to room patients, and so on.

Here, in my little three-person office, the only thing my staff can’t do is see patients.

Actually, more than 2 years out since the pandemic changed everyone’s lives, we’ve settled into a very different cross-training routine. I’m the only one at my office. My medical assistant works from home, far north of me, and so does my scheduler, who is across town.

So, at the office, I handle it all. I check people in, copy insurance cards, collect copays, see patients, and make follow-ups.

At this time, I’ve not only gotten used to it, but really don’t mind it.

We don’t worry about freeway traffic. My staff starts at the exact time each day, and so I don’t worry about one of them being an hour late, trapped behind a rush-hour pile-up on the 101. Staying at home with a sick kid isn’t an issue either, anymore. If my secretary has to make her young daughter lunch, or run her over to a birthday party, I don’t even notice it. If there are any problems, she knows how to reach me. Same with my medical assistant.

Nobody worries about what to throw together for dinner if they get home late.

In an era where other businesses want to reverse the work-from-home trend, I don’t see an issue with its continuing for some jobs. It saves money on rent, and money and time on transportation.

Gas prices, at least for driving to and from work for them, don’t have to be factored into the wage equations. I’d guess it’s about 1,000 gallons of gas a year saved. On a national scale that’s nothing, but to my staff right now that’s $3,000-$4,000 more in their pockets at the end of the year. Not to mention it’s two more cars off the road.

Granted, this doesn’t change what I’m doing. Seeing patients in person is a key part of being a doctor. Some things can be handled equally well over the phone or Zoom, but many can’t. It’s what I signed up for, and I really don’t mind it. Seeing patients is still what I enjoy.

My staff is a lot happier with this arrangement, and I don’t mind it either. I always, by nature, kept a reasonably paced schedule. Trying to shoehorn patients in has never been my way, so I have time to run a credit card or scan insurance information.

When one of my staff goes out of town, the other covers her calls and relays messages to me. Yes, it’s extra work, but no more so than if they were here in person. Probably less.

I’m sure many physicians wouldn’t agree with my office model, but it suits me fine. Cross-training and all.

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

There was a recent post on Sermo about medical office staff cross-training. It talked about the importance of the scheduler being able to cover for the medical assistant (to an extent), a billing person being able to room patients, and so on.

Here, in my little three-person office, the only thing my staff can’t do is see patients.

Actually, more than 2 years out since the pandemic changed everyone’s lives, we’ve settled into a very different cross-training routine. I’m the only one at my office. My medical assistant works from home, far north of me, and so does my scheduler, who is across town.

So, at the office, I handle it all. I check people in, copy insurance cards, collect copays, see patients, and make follow-ups.

At this time, I’ve not only gotten used to it, but really don’t mind it.

We don’t worry about freeway traffic. My staff starts at the exact time each day, and so I don’t worry about one of them being an hour late, trapped behind a rush-hour pile-up on the 101. Staying at home with a sick kid isn’t an issue either, anymore. If my secretary has to make her young daughter lunch, or run her over to a birthday party, I don’t even notice it. If there are any problems, she knows how to reach me. Same with my medical assistant.

Nobody worries about what to throw together for dinner if they get home late.

In an era where other businesses want to reverse the work-from-home trend, I don’t see an issue with its continuing for some jobs. It saves money on rent, and money and time on transportation.

Gas prices, at least for driving to and from work for them, don’t have to be factored into the wage equations. I’d guess it’s about 1,000 gallons of gas a year saved. On a national scale that’s nothing, but to my staff right now that’s $3,000-$4,000 more in their pockets at the end of the year. Not to mention it’s two more cars off the road.

Granted, this doesn’t change what I’m doing. Seeing patients in person is a key part of being a doctor. Some things can be handled equally well over the phone or Zoom, but many can’t. It’s what I signed up for, and I really don’t mind it. Seeing patients is still what I enjoy.

My staff is a lot happier with this arrangement, and I don’t mind it either. I always, by nature, kept a reasonably paced schedule. Trying to shoehorn patients in has never been my way, so I have time to run a credit card or scan insurance information.

When one of my staff goes out of town, the other covers her calls and relays messages to me. Yes, it’s extra work, but no more so than if they were here in person. Probably less.

I’m sure many physicians wouldn’t agree with my office model, but it suits me fine. Cross-training and all.

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

There was a recent post on Sermo about medical office staff cross-training. It talked about the importance of the scheduler being able to cover for the medical assistant (to an extent), a billing person being able to room patients, and so on.

Here, in my little three-person office, the only thing my staff can’t do is see patients.

Actually, more than 2 years out since the pandemic changed everyone’s lives, we’ve settled into a very different cross-training routine. I’m the only one at my office. My medical assistant works from home, far north of me, and so does my scheduler, who is across town.

So, at the office, I handle it all. I check people in, copy insurance cards, collect copays, see patients, and make follow-ups.

At this time, I’ve not only gotten used to it, but really don’t mind it.

We don’t worry about freeway traffic. My staff starts at the exact time each day, and so I don’t worry about one of them being an hour late, trapped behind a rush-hour pile-up on the 101. Staying at home with a sick kid isn’t an issue either, anymore. If my secretary has to make her young daughter lunch, or run her over to a birthday party, I don’t even notice it. If there are any problems, she knows how to reach me. Same with my medical assistant.

Nobody worries about what to throw together for dinner if they get home late.

In an era where other businesses want to reverse the work-from-home trend, I don’t see an issue with its continuing for some jobs. It saves money on rent, and money and time on transportation.

Gas prices, at least for driving to and from work for them, don’t have to be factored into the wage equations. I’d guess it’s about 1,000 gallons of gas a year saved. On a national scale that’s nothing, but to my staff right now that’s $3,000-$4,000 more in their pockets at the end of the year. Not to mention it’s two more cars off the road.

Granted, this doesn’t change what I’m doing. Seeing patients in person is a key part of being a doctor. Some things can be handled equally well over the phone or Zoom, but many can’t. It’s what I signed up for, and I really don’t mind it. Seeing patients is still what I enjoy.

My staff is a lot happier with this arrangement, and I don’t mind it either. I always, by nature, kept a reasonably paced schedule. Trying to shoehorn patients in has never been my way, so I have time to run a credit card or scan insurance information.

When one of my staff goes out of town, the other covers her calls and relays messages to me. Yes, it’s extra work, but no more so than if they were here in person. Probably less.

I’m sure many physicians wouldn’t agree with my office model, but it suits me fine. Cross-training and all.

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

Since the overturn of Roe v. Wade, my mind has been flooded with the emotions of disappointment, fear, helplessness, and rage. While I process the news and try to move forward, a sense of survivor’s guilt remains. Currently, I am a Complex Family Planning fellow in California, but prior to last year, I spent my entire life in Florida. I continue to provide abortion care without the fear of prosecution. Meanwhile, my family, friends, and colleagues back home remain trapped as they scramble to figure out what to do in the aftermath of this tragedy.

The day the Supreme Court decision was announced, I was in the operating room performing an abortion. As I went through a 24-week dilation and evacuation procedure, I could hear my phone vibrating as text messages and social media alerts started to flood in. Those who have met me know how much I care about reproductive rights. I was not surprised when family, friends, and former colleagues reached out to check on me. While I appreciated the support, I could not help but think how it was not me who needed the comforting. I did not have to question whether my team could complete our full day of abortion procedures. I knew there were providers across the country making devastating calls canceling and denying appointments for patients needing abortion care. They were meeting with their staffs, administrators, and lawyers, and fielding responses from the media. I thought about all the patients and the fear they must be experiencing as they scrambled to make arrangements for possible travel to other clinics or self-management of their abortion. I know that for many, their only option is forced pregnancy.

Like any other day, the patients we cared for that day were seeking an abortion for a variety of reasons. There was a patient who recently learned her desired pregnancy was complicated by a lethal fetal malformation. One patient shared that she experienced contraception failure. Another patient feared pregnancy because her last pregnancy was complicated by severe preeclampsia and hemorrhage. Our last patient told us she missed her period and knew she did not want to be pregnant. While each individual experience is unique, these stories are not exclusive to people living in California – these stories are the same ones I heard from patients and friends seeking an abortion in Florida - across the country.

The Supreme Court majority argued it was handing the question of abortion over to the states and their voters to decide. Recent surveys found 61% of U.S. adults believe abortion should be legal in all or most cases,¹ but in several states, within hours to days of the SCOTUS decision, patients were forced to make other plans as their prior fundamental right to an abortion was immediately removed. There were no further conversations, elections, or votes. It no longer matters what the majority supports or what the details are about the lives of those people making the personal decision to have an abortion. All that matters now is the ZIP code someone happens to reside in.

After I completed the first case, the graduating resident on our team expertly completed the remaining procedures. I felt confident that she would be leaving the program able to take care of any patient needing an abortion. She would also be able to manage any emergency that requires the quick evacuation of a uterus. Dread set in as I thought about the residents back home in Florida and other restrictive states. Many of these programs already struggle to provide abortion training, and their ability to do so in a post-Roe world will be near impossible. Around 50% of current ob.gyn. residents are training in a state that is expected to or already has banned abortions.² Even in states without abortion bans, residents often are not exposed to full spectrum abortion care for a variety of reasons.

During my time in residency, a family planning rotation was developed thanks to a few dedicated educators. While there were no laws prohibiting abortion at that time, like most hospitals in the state, our primary training site only allowed terminations for a select list of indications. An all too familiar story was the transfer of a patient from a nearby hospital after a failed multiday induction for a pregnancy loss or lethal fetal anomaly. They would arrive with heavy bleeding, infections, and hemodynamic instability. Most of these patients told us they were only offered an induction because there were no providers who could or would perform a dilation and evacuation. Even at our top-rated hospital, it was often a struggle coordinating emergent care for these patients because of the limited number of proficient abortion providers. These situations will become the new norm across the country as hundreds of residents will no longer learn these critical skills. As a result, these states will see more maternal morbidity and mortality for years to come.

The reversal of Roe v. Wade affects everyone, not just people who can become pregnant. It will have a devastating effect on medical training. It will change the trajectory of people’s careers and it will result in people losing their jobs. I am so proud to be an abortion provider and cannot imagine doing anything else. I am also a proud Floridian and always envisioned a future where I could live near family while caring for the people in my community. After this decision, I don’t what my future holds. I am concerned for the next generation of health care providers. I imagine many medical students may think twice about obstetrics and gynecology given concern about prosecution for exercising the full scope of the specialty. Most importantly, I am afraid for the patients who will no longer have access to essential abortion care. While we all process this traumatic event, the prochoice community of health care providers, lawyers, politicians, researchers, students, organizers, and volunteers will continue the fight for reproductive justice. For now, I will push this feeling of guilt aside as I take advantage of working in this protected space and embrace every opportunity to provide the best abortion care possible.
 

Dr. Brown is a complex family planning fellow at the University of California, Davis.

References

1. America’s Abortion Quandary [Internet]. Pew Res. Cent. Relig. Public Life Proj. 2022.

2. Vinekar K et al. Obstet Gynecol. 2022.

Since the overturn of Roe v. Wade, my mind has been flooded with the emotions of disappointment, fear, helplessness, and rage. While I process the news and try to move forward, a sense of survivor’s guilt remains. Currently, I am a Complex Family Planning fellow in California, but prior to last year, I spent my entire life in Florida. I continue to provide abortion care without the fear of prosecution. Meanwhile, my family, friends, and colleagues back home remain trapped as they scramble to figure out what to do in the aftermath of this tragedy.

The day the Supreme Court decision was announced, I was in the operating room performing an abortion. As I went through a 24-week dilation and evacuation procedure, I could hear my phone vibrating as text messages and social media alerts started to flood in. Those who have met me know how much I care about reproductive rights. I was not surprised when family, friends, and former colleagues reached out to check on me. While I appreciated the support, I could not help but think how it was not me who needed the comforting. I did not have to question whether my team could complete our full day of abortion procedures. I knew there were providers across the country making devastating calls canceling and denying appointments for patients needing abortion care. They were meeting with their staffs, administrators, and lawyers, and fielding responses from the media. I thought about all the patients and the fear they must be experiencing as they scrambled to make arrangements for possible travel to other clinics or self-management of their abortion. I know that for many, their only option is forced pregnancy.

Like any other day, the patients we cared for that day were seeking an abortion for a variety of reasons. There was a patient who recently learned her desired pregnancy was complicated by a lethal fetal malformation. One patient shared that she experienced contraception failure. Another patient feared pregnancy because her last pregnancy was complicated by severe preeclampsia and hemorrhage. Our last patient told us she missed her period and knew she did not want to be pregnant. While each individual experience is unique, these stories are not exclusive to people living in California – these stories are the same ones I heard from patients and friends seeking an abortion in Florida - across the country.

The Supreme Court majority argued it was handing the question of abortion over to the states and their voters to decide. Recent surveys found 61% of U.S. adults believe abortion should be legal in all or most cases,¹ but in several states, within hours to days of the SCOTUS decision, patients were forced to make other plans as their prior fundamental right to an abortion was immediately removed. There were no further conversations, elections, or votes. It no longer matters what the majority supports or what the details are about the lives of those people making the personal decision to have an abortion. All that matters now is the ZIP code someone happens to reside in.

After I completed the first case, the graduating resident on our team expertly completed the remaining procedures. I felt confident that she would be leaving the program able to take care of any patient needing an abortion. She would also be able to manage any emergency that requires the quick evacuation of a uterus. Dread set in as I thought about the residents back home in Florida and other restrictive states. Many of these programs already struggle to provide abortion training, and their ability to do so in a post-Roe world will be near impossible. Around 50% of current ob.gyn. residents are training in a state that is expected to or already has banned abortions.² Even in states without abortion bans, residents often are not exposed to full spectrum abortion care for a variety of reasons.

During my time in residency, a family planning rotation was developed thanks to a few dedicated educators. While there were no laws prohibiting abortion at that time, like most hospitals in the state, our primary training site only allowed terminations for a select list of indications. An all too familiar story was the transfer of a patient from a nearby hospital after a failed multiday induction for a pregnancy loss or lethal fetal anomaly. They would arrive with heavy bleeding, infections, and hemodynamic instability. Most of these patients told us they were only offered an induction because there were no providers who could or would perform a dilation and evacuation. Even at our top-rated hospital, it was often a struggle coordinating emergent care for these patients because of the limited number of proficient abortion providers. These situations will become the new norm across the country as hundreds of residents will no longer learn these critical skills. As a result, these states will see more maternal morbidity and mortality for years to come.

The reversal of Roe v. Wade affects everyone, not just people who can become pregnant. It will have a devastating effect on medical training. It will change the trajectory of people’s careers and it will result in people losing their jobs. I am so proud to be an abortion provider and cannot imagine doing anything else. I am also a proud Floridian and always envisioned a future where I could live near family while caring for the people in my community. After this decision, I don’t what my future holds. I am concerned for the next generation of health care providers. I imagine many medical students may think twice about obstetrics and gynecology given concern about prosecution for exercising the full scope of the specialty. Most importantly, I am afraid for the patients who will no longer have access to essential abortion care. While we all process this traumatic event, the prochoice community of health care providers, lawyers, politicians, researchers, students, organizers, and volunteers will continue the fight for reproductive justice. For now, I will push this feeling of guilt aside as I take advantage of working in this protected space and embrace every opportunity to provide the best abortion care possible.
 

Dr. Brown is a complex family planning fellow at the University of California, Davis.

References

1. America’s Abortion Quandary [Internet]. Pew Res. Cent. Relig. Public Life Proj. 2022.

2. Vinekar K et al. Obstet Gynecol. 2022.

Since the overturn of Roe v. Wade, my mind has been flooded with the emotions of disappointment, fear, helplessness, and rage. While I process the news and try to move forward, a sense of survivor’s guilt remains. Currently, I am a Complex Family Planning fellow in California, but prior to last year, I spent my entire life in Florida. I continue to provide abortion care without the fear of prosecution. Meanwhile, my family, friends, and colleagues back home remain trapped as they scramble to figure out what to do in the aftermath of this tragedy.

The day the Supreme Court decision was announced, I was in the operating room performing an abortion. As I went through a 24-week dilation and evacuation procedure, I could hear my phone vibrating as text messages and social media alerts started to flood in. Those who have met me know how much I care about reproductive rights. I was not surprised when family, friends, and former colleagues reached out to check on me. While I appreciated the support, I could not help but think how it was not me who needed the comforting. I did not have to question whether my team could complete our full day of abortion procedures. I knew there were providers across the country making devastating calls canceling and denying appointments for patients needing abortion care. They were meeting with their staffs, administrators, and lawyers, and fielding responses from the media. I thought about all the patients and the fear they must be experiencing as they scrambled to make arrangements for possible travel to other clinics or self-management of their abortion. I know that for many, their only option is forced pregnancy.

Like any other day, the patients we cared for that day were seeking an abortion for a variety of reasons. There was a patient who recently learned her desired pregnancy was complicated by a lethal fetal malformation. One patient shared that she experienced contraception failure. Another patient feared pregnancy because her last pregnancy was complicated by severe preeclampsia and hemorrhage. Our last patient told us she missed her period and knew she did not want to be pregnant. While each individual experience is unique, these stories are not exclusive to people living in California – these stories are the same ones I heard from patients and friends seeking an abortion in Florida - across the country.

The Supreme Court majority argued it was handing the question of abortion over to the states and their voters to decide. Recent surveys found 61% of U.S. adults believe abortion should be legal in all or most cases,¹ but in several states, within hours to days of the SCOTUS decision, patients were forced to make other plans as their prior fundamental right to an abortion was immediately removed. There were no further conversations, elections, or votes. It no longer matters what the majority supports or what the details are about the lives of those people making the personal decision to have an abortion. All that matters now is the ZIP code someone happens to reside in.

After I completed the first case, the graduating resident on our team expertly completed the remaining procedures. I felt confident that she would be leaving the program able to take care of any patient needing an abortion. She would also be able to manage any emergency that requires the quick evacuation of a uterus. Dread set in as I thought about the residents back home in Florida and other restrictive states. Many of these programs already struggle to provide abortion training, and their ability to do so in a post-Roe world will be near impossible. Around 50% of current ob.gyn. residents are training in a state that is expected to or already has banned abortions.² Even in states without abortion bans, residents often are not exposed to full spectrum abortion care for a variety of reasons.

During my time in residency, a family planning rotation was developed thanks to a few dedicated educators. While there were no laws prohibiting abortion at that time, like most hospitals in the state, our primary training site only allowed terminations for a select list of indications. An all too familiar story was the transfer of a patient from a nearby hospital after a failed multiday induction for a pregnancy loss or lethal fetal anomaly. They would arrive with heavy bleeding, infections, and hemodynamic instability. Most of these patients told us they were only offered an induction because there were no providers who could or would perform a dilation and evacuation. Even at our top-rated hospital, it was often a struggle coordinating emergent care for these patients because of the limited number of proficient abortion providers. These situations will become the new norm across the country as hundreds of residents will no longer learn these critical skills. As a result, these states will see more maternal morbidity and mortality for years to come.

The reversal of Roe v. Wade affects everyone, not just people who can become pregnant. It will have a devastating effect on medical training. It will change the trajectory of people’s careers and it will result in people losing their jobs. I am so proud to be an abortion provider and cannot imagine doing anything else. I am also a proud Floridian and always envisioned a future where I could live near family while caring for the people in my community. After this decision, I don’t what my future holds. I am concerned for the next generation of health care providers. I imagine many medical students may think twice about obstetrics and gynecology given concern about prosecution for exercising the full scope of the specialty. Most importantly, I am afraid for the patients who will no longer have access to essential abortion care. While we all process this traumatic event, the prochoice community of health care providers, lawyers, politicians, researchers, students, organizers, and volunteers will continue the fight for reproductive justice. For now, I will push this feeling of guilt aside as I take advantage of working in this protected space and embrace every opportunity to provide the best abortion care possible.
 

Dr. Brown is a complex family planning fellow at the University of California, Davis.

References

1. America’s Abortion Quandary [Internet]. Pew Res. Cent. Relig. Public Life Proj. 2022.

2. Vinekar K et al. Obstet Gynecol. 2022.

I was a resident, young and naive, when I bumped into my neighbor in the hospital hallway as he walked out of a psychiatrist’s office.

“Why are you here?” I asked, thinking that my neighbor, a theology professor, had some professional reason to be meeting with a psychiatrist, perhaps some type of community project. As the question escaped from my lips, however, I had an instant sense of regret and made a “note to self” in bold, all capital letters with a few exclamation points: Don’t ever ask friends or neighbors why they are visiting a psychiatrist. 

Fast-forward a number of decades, and I received an email from that neighbor. Charles Marsh, is now a professor of religious studies at the University of Virginia, Charlottesville, director of the Lived Theology Project, and author of several books. He sent me a link to an article he’d written about his treatment for an anxiety disorder and let me know he was working on a book on the topic. I later received the galleys for his manuscript, Evangelical Anxiety: A Memoir, which was released last month by HarperOne.

Professor Marsh opens his story as he’s sitting with his family in church, listening to his pastor’s sermon. It is a quiet April day, and as they are throughout this memoir, his descriptions are so vivid that the reader is sitting next to him in his familiar pew, there in that church on that Sunday, seeing what he sees, smelling what he smells, and feeling what he feels. The pastor confers a wish on his congregants: He’d like them all to have a nervous breakdown in their youth. He goes on to say that if Martin Luther had lived in the days of Prozac, his inner torment would have been quelled, and there would have been no Protestant reformation. Professor Marsh then treats us to the first of many humorous moments – he rushes home and swallows a tablet of Ativan.

Professor Marsh focuses on a single dividing point for his life, a day in the fall of 1981. He was resting on his bed in his dorm room at Harvard Divinity School at the ripe age of 23 years, 6 months, and 3 days (but who’s counting), when all of who he was changed. He described what he went through that night:

It was then that a high pandemonium ripped away everything protecting me from the world outside. I was no longer a person alone in his room. In an instant, I could hear all things inside my body in their deepest repercussions. My heart and its soft aortic murmur, my breath’s every exhalation and inhalation, the downward silences, the laborious intake – would this one be the last? How much noise the body makes when amped up on fear! I could hear the hiss of molecules colliding. And outside in the yellow night, the compressors harrumphing atop the nearby physics building, the sound of car engines and slamming doors. All these things I heard as tormenting assault, a soundscape I could not mute. I’d become a thought thinking about thinking itself and nothing else, metaphysics’ ancient curse. A cogitation cycling through every autonomous body function, placing on each a question mark like flowers for the dead.

This moment in time – this “breakdown,” as Professor Marsh repeatedly refers to it – bifurcated his life. He went from being a person who lived “disguised to myself as unaghast and free” to someone who could no longer find escape in his reading, who struggled in his own skin and his own mind, and who, for lack of a better description, was tortured. The “breakdown” passed, and Professor Marsh diagnosed himself with generalized anxiety disorder.

That night, he did not go to an emergency department nor did he seek help from services that were available to Harvard students. There was no psychiatrist, no therapy, no medication. It was, for him, with his fundamentalist Christian background, a religious event of sorts.

I counted it all joy if I should suffer. My sorrow, my soul’s sin-sickness, was not unintelligible – it was a kind of blessing, something that might draw me, like a medieval saint, to the suffering of my Lord, something that would testify wordlessly to my heroic exertion to attain purity. And, at least during those late days of autumn 1981, the heavens above and the earth below, spirit and flesh, felt miraculously aligned. Though suffering, this was the life I had craved.

Charles Marsh grew up as a Baptist pastor’s son in the Deep South during a time when the civil rights movement came to a head, and life was marked by fear and change. The memoir is not simply about one man’s struggle with an anxiety disorder, but a beautifully written account of life as an evangelical Christian during a tumultuous time of racial tensions and horrible violence. He details his life as a lonely only child in a God-fearing world cast in dark shadows, one where he struggled to belong and called out to his mother in the nights. Inside this world, Professor Marsh searched for his own religious identity, with the pride of being a high school “Jesus freak,” running alongside his repressed and frustrated sexual longings.

It was a world of good and bad, of heaven and hell, only the two became so confused as he talked about his existence full of fears: The windows were barred; violence and fear were central in his Alabama hometown, “the epicenter of white terrorism,” and then later when his family moved to Mississippi. He feared the barking dogs that guarded the houses, the bullies who tormented him, and the bullying in which, he too, joined in. He feared the switch-wielding adults – his mother, his principals, his coaches, and his youth pastor, all set on “breaking the will of the child,” a term he explains to be a Christian concept in which the child’s own will is broken so that he will be submissive to his parents and to God. 

Professor Marsh wanted so much to be good. And we’re not sure he even knew what that was as he battled his desire to conform and belong, and his ever-present sexual impulses. Even as an adult, he was certain his mother would know if he had premarital sex and he would have to kill himself. Sex outside of marriage was the one unpardonable sin.

He suffered in silence and shame. It was not until a few years later that he entered psychotherapy as a doctoral student. When he moved to Baltimore, he again looked for a therapist and eventually found himself with a psychiatrist who was training to be a psychoanalyst in the hospital where I was a resident. This psychoanalysis proved to be transformative and healing, but first, Professor Marsh needed to reconcile his treatment with his religious beliefs, as therapy and fundamental religion travel different roads.

Analysis and faith traverse similar terrain – they understand how language and narrative heal. They may see each other as strangers or competitors, but they need not. Like prayer, the analytic dialogue slows down to ponder, to meander, to piece together, to redeem; both inspire the mind toward hope under the influence of an empathetic listener. Neither needs the other to effectuate its truths, but they follow parallel tracks into the mysteries of being human, where all truth is God’s truth. It’s more than fine that they neither merge nor collide.

He goes on to describe how powerful the process was for him and his healing. 

Analysis is the space where one feels – where I felt in an embodied way, in the unhurried hours over months and years – a trust in the beautiful interplay between the center and the extremes. My body and mind would not be raised in resurrected splendor in the course of the treatment. I wish to emphasize the point. It was tempting to think that it would, that I would undergo a miraculous transformation. If not resurrected splendor, then surely I would take on the “new man.” Instead, I received the gift of mortal life: the freedom to be imperfect, to have fears and face them, to accept brokenness, to let go of the will to control all outcomes.

Evangelical Anxiety is a beautifully written book, and a look into two worlds that can feel so secretive to the outsider. Professor Marsh’s use of language is extraordinary; he has a gift for metaphors and descriptions, and he carries the reader alongside him on a splendid journey. It has to be said, however, that he assumes a lot: He is a sophisticated scholar who mentions religious leaders, philosophers, historical characters, and the occasional rock song, with no patience for those who don’t follow his quick transitions and impressive vocabulary; I could have read this book with a dictionary beside me (but I didn’t).

It’s an illuminating journey, often sad and disturbing, sometimes funny and endearing, and ultimately uplifting. In our skeptical world where psychiatrists are so are often undone, it is refreshing to read a memoir where the psychiatrist is the good guy and the patient emerges healed and whole.
 

Dr. Miller, is a coauthor of Committed: The Battle Over Involuntary Psychiatric Care (Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins in Baltimore. She has disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.

I was a resident, young and naive, when I bumped into my neighbor in the hospital hallway as he walked out of a psychiatrist’s office.

“Why are you here?” I asked, thinking that my neighbor, a theology professor, had some professional reason to be meeting with a psychiatrist, perhaps some type of community project. As the question escaped from my lips, however, I had an instant sense of regret and made a “note to self” in bold, all capital letters with a few exclamation points: Don’t ever ask friends or neighbors why they are visiting a psychiatrist. 

Fast-forward a number of decades, and I received an email from that neighbor. Charles Marsh, is now a professor of religious studies at the University of Virginia, Charlottesville, director of the Lived Theology Project, and author of several books. He sent me a link to an article he’d written about his treatment for an anxiety disorder and let me know he was working on a book on the topic. I later received the galleys for his manuscript, Evangelical Anxiety: A Memoir, which was released last month by HarperOne.

Professor Marsh opens his story as he’s sitting with his family in church, listening to his pastor’s sermon. It is a quiet April day, and as they are throughout this memoir, his descriptions are so vivid that the reader is sitting next to him in his familiar pew, there in that church on that Sunday, seeing what he sees, smelling what he smells, and feeling what he feels. The pastor confers a wish on his congregants: He’d like them all to have a nervous breakdown in their youth. He goes on to say that if Martin Luther had lived in the days of Prozac, his inner torment would have been quelled, and there would have been no Protestant reformation. Professor Marsh then treats us to the first of many humorous moments – he rushes home and swallows a tablet of Ativan.

Professor Marsh focuses on a single dividing point for his life, a day in the fall of 1981. He was resting on his bed in his dorm room at Harvard Divinity School at the ripe age of 23 years, 6 months, and 3 days (but who’s counting), when all of who he was changed. He described what he went through that night:

It was then that a high pandemonium ripped away everything protecting me from the world outside. I was no longer a person alone in his room. In an instant, I could hear all things inside my body in their deepest repercussions. My heart and its soft aortic murmur, my breath’s every exhalation and inhalation, the downward silences, the laborious intake – would this one be the last? How much noise the body makes when amped up on fear! I could hear the hiss of molecules colliding. And outside in the yellow night, the compressors harrumphing atop the nearby physics building, the sound of car engines and slamming doors. All these things I heard as tormenting assault, a soundscape I could not mute. I’d become a thought thinking about thinking itself and nothing else, metaphysics’ ancient curse. A cogitation cycling through every autonomous body function, placing on each a question mark like flowers for the dead.

This moment in time – this “breakdown,” as Professor Marsh repeatedly refers to it – bifurcated his life. He went from being a person who lived “disguised to myself as unaghast and free” to someone who could no longer find escape in his reading, who struggled in his own skin and his own mind, and who, for lack of a better description, was tortured. The “breakdown” passed, and Professor Marsh diagnosed himself with generalized anxiety disorder.

That night, he did not go to an emergency department nor did he seek help from services that were available to Harvard students. There was no psychiatrist, no therapy, no medication. It was, for him, with his fundamentalist Christian background, a religious event of sorts.

I counted it all joy if I should suffer. My sorrow, my soul’s sin-sickness, was not unintelligible – it was a kind of blessing, something that might draw me, like a medieval saint, to the suffering of my Lord, something that would testify wordlessly to my heroic exertion to attain purity. And, at least during those late days of autumn 1981, the heavens above and the earth below, spirit and flesh, felt miraculously aligned. Though suffering, this was the life I had craved.

Charles Marsh grew up as a Baptist pastor’s son in the Deep South during a time when the civil rights movement came to a head, and life was marked by fear and change. The memoir is not simply about one man’s struggle with an anxiety disorder, but a beautifully written account of life as an evangelical Christian during a tumultuous time of racial tensions and horrible violence. He details his life as a lonely only child in a God-fearing world cast in dark shadows, one where he struggled to belong and called out to his mother in the nights. Inside this world, Professor Marsh searched for his own religious identity, with the pride of being a high school “Jesus freak,” running alongside his repressed and frustrated sexual longings.

It was a world of good and bad, of heaven and hell, only the two became so confused as he talked about his existence full of fears: The windows were barred; violence and fear were central in his Alabama hometown, “the epicenter of white terrorism,” and then later when his family moved to Mississippi. He feared the barking dogs that guarded the houses, the bullies who tormented him, and the bullying in which, he too, joined in. He feared the switch-wielding adults – his mother, his principals, his coaches, and his youth pastor, all set on “breaking the will of the child,” a term he explains to be a Christian concept in which the child’s own will is broken so that he will be submissive to his parents and to God. 

Professor Marsh wanted so much to be good. And we’re not sure he even knew what that was as he battled his desire to conform and belong, and his ever-present sexual impulses. Even as an adult, he was certain his mother would know if he had premarital sex and he would have to kill himself. Sex outside of marriage was the one unpardonable sin.

He suffered in silence and shame. It was not until a few years later that he entered psychotherapy as a doctoral student. When he moved to Baltimore, he again looked for a therapist and eventually found himself with a psychiatrist who was training to be a psychoanalyst in the hospital where I was a resident. This psychoanalysis proved to be transformative and healing, but first, Professor Marsh needed to reconcile his treatment with his religious beliefs, as therapy and fundamental religion travel different roads.

Analysis and faith traverse similar terrain – they understand how language and narrative heal. They may see each other as strangers or competitors, but they need not. Like prayer, the analytic dialogue slows down to ponder, to meander, to piece together, to redeem; both inspire the mind toward hope under the influence of an empathetic listener. Neither needs the other to effectuate its truths, but they follow parallel tracks into the mysteries of being human, where all truth is God’s truth. It’s more than fine that they neither merge nor collide.

He goes on to describe how powerful the process was for him and his healing. 

Analysis is the space where one feels – where I felt in an embodied way, in the unhurried hours over months and years – a trust in the beautiful interplay between the center and the extremes. My body and mind would not be raised in resurrected splendor in the course of the treatment. I wish to emphasize the point. It was tempting to think that it would, that I would undergo a miraculous transformation. If not resurrected splendor, then surely I would take on the “new man.” Instead, I received the gift of mortal life: the freedom to be imperfect, to have fears and face them, to accept brokenness, to let go of the will to control all outcomes.

Evangelical Anxiety is a beautifully written book, and a look into two worlds that can feel so secretive to the outsider. Professor Marsh’s use of language is extraordinary; he has a gift for metaphors and descriptions, and he carries the reader alongside him on a splendid journey. It has to be said, however, that he assumes a lot: He is a sophisticated scholar who mentions religious leaders, philosophers, historical characters, and the occasional rock song, with no patience for those who don’t follow his quick transitions and impressive vocabulary; I could have read this book with a dictionary beside me (but I didn’t).

It’s an illuminating journey, often sad and disturbing, sometimes funny and endearing, and ultimately uplifting. In our skeptical world where psychiatrists are so are often undone, it is refreshing to read a memoir where the psychiatrist is the good guy and the patient emerges healed and whole.
 

Dr. Miller, is a coauthor of Committed: The Battle Over Involuntary Psychiatric Care (Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins in Baltimore. She has disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.

I was a resident, young and naive, when I bumped into my neighbor in the hospital hallway as he walked out of a psychiatrist’s office.

“Why are you here?” I asked, thinking that my neighbor, a theology professor, had some professional reason to be meeting with a psychiatrist, perhaps some type of community project. As the question escaped from my lips, however, I had an instant sense of regret and made a “note to self” in bold, all capital letters with a few exclamation points: Don’t ever ask friends or neighbors why they are visiting a psychiatrist. 

Fast-forward a number of decades, and I received an email from that neighbor. Charles Marsh, is now a professor of religious studies at the University of Virginia, Charlottesville, director of the Lived Theology Project, and author of several books. He sent me a link to an article he’d written about his treatment for an anxiety disorder and let me know he was working on a book on the topic. I later received the galleys for his manuscript, Evangelical Anxiety: A Memoir, which was released last month by HarperOne.

Professor Marsh opens his story as he’s sitting with his family in church, listening to his pastor’s sermon. It is a quiet April day, and as they are throughout this memoir, his descriptions are so vivid that the reader is sitting next to him in his familiar pew, there in that church on that Sunday, seeing what he sees, smelling what he smells, and feeling what he feels. The pastor confers a wish on his congregants: He’d like them all to have a nervous breakdown in their youth. He goes on to say that if Martin Luther had lived in the days of Prozac, his inner torment would have been quelled, and there would have been no Protestant reformation. Professor Marsh then treats us to the first of many humorous moments – he rushes home and swallows a tablet of Ativan.

Professor Marsh focuses on a single dividing point for his life, a day in the fall of 1981. He was resting on his bed in his dorm room at Harvard Divinity School at the ripe age of 23 years, 6 months, and 3 days (but who’s counting), when all of who he was changed. He described what he went through that night:

It was then that a high pandemonium ripped away everything protecting me from the world outside. I was no longer a person alone in his room. In an instant, I could hear all things inside my body in their deepest repercussions. My heart and its soft aortic murmur, my breath’s every exhalation and inhalation, the downward silences, the laborious intake – would this one be the last? How much noise the body makes when amped up on fear! I could hear the hiss of molecules colliding. And outside in the yellow night, the compressors harrumphing atop the nearby physics building, the sound of car engines and slamming doors. All these things I heard as tormenting assault, a soundscape I could not mute. I’d become a thought thinking about thinking itself and nothing else, metaphysics’ ancient curse. A cogitation cycling through every autonomous body function, placing on each a question mark like flowers for the dead.

This moment in time – this “breakdown,” as Professor Marsh repeatedly refers to it – bifurcated his life. He went from being a person who lived “disguised to myself as unaghast and free” to someone who could no longer find escape in his reading, who struggled in his own skin and his own mind, and who, for lack of a better description, was tortured. The “breakdown” passed, and Professor Marsh diagnosed himself with generalized anxiety disorder.

That night, he did not go to an emergency department nor did he seek help from services that were available to Harvard students. There was no psychiatrist, no therapy, no medication. It was, for him, with his fundamentalist Christian background, a religious event of sorts.

I counted it all joy if I should suffer. My sorrow, my soul’s sin-sickness, was not unintelligible – it was a kind of blessing, something that might draw me, like a medieval saint, to the suffering of my Lord, something that would testify wordlessly to my heroic exertion to attain purity. And, at least during those late days of autumn 1981, the heavens above and the earth below, spirit and flesh, felt miraculously aligned. Though suffering, this was the life I had craved.

Charles Marsh grew up as a Baptist pastor’s son in the Deep South during a time when the civil rights movement came to a head, and life was marked by fear and change. The memoir is not simply about one man’s struggle with an anxiety disorder, but a beautifully written account of life as an evangelical Christian during a tumultuous time of racial tensions and horrible violence. He details his life as a lonely only child in a God-fearing world cast in dark shadows, one where he struggled to belong and called out to his mother in the nights. Inside this world, Professor Marsh searched for his own religious identity, with the pride of being a high school “Jesus freak,” running alongside his repressed and frustrated sexual longings.

It was a world of good and bad, of heaven and hell, only the two became so confused as he talked about his existence full of fears: The windows were barred; violence and fear were central in his Alabama hometown, “the epicenter of white terrorism,” and then later when his family moved to Mississippi. He feared the barking dogs that guarded the houses, the bullies who tormented him, and the bullying in which, he too, joined in. He feared the switch-wielding adults – his mother, his principals, his coaches, and his youth pastor, all set on “breaking the will of the child,” a term he explains to be a Christian concept in which the child’s own will is broken so that he will be submissive to his parents and to God. 

Professor Marsh wanted so much to be good. And we’re not sure he even knew what that was as he battled his desire to conform and belong, and his ever-present sexual impulses. Even as an adult, he was certain his mother would know if he had premarital sex and he would have to kill himself. Sex outside of marriage was the one unpardonable sin.

He suffered in silence and shame. It was not until a few years later that he entered psychotherapy as a doctoral student. When he moved to Baltimore, he again looked for a therapist and eventually found himself with a psychiatrist who was training to be a psychoanalyst in the hospital where I was a resident. This psychoanalysis proved to be transformative and healing, but first, Professor Marsh needed to reconcile his treatment with his religious beliefs, as therapy and fundamental religion travel different roads.

Analysis and faith traverse similar terrain – they understand how language and narrative heal. They may see each other as strangers or competitors, but they need not. Like prayer, the analytic dialogue slows down to ponder, to meander, to piece together, to redeem; both inspire the mind toward hope under the influence of an empathetic listener. Neither needs the other to effectuate its truths, but they follow parallel tracks into the mysteries of being human, where all truth is God’s truth. It’s more than fine that they neither merge nor collide.

He goes on to describe how powerful the process was for him and his healing. 

Analysis is the space where one feels – where I felt in an embodied way, in the unhurried hours over months and years – a trust in the beautiful interplay between the center and the extremes. My body and mind would not be raised in resurrected splendor in the course of the treatment. I wish to emphasize the point. It was tempting to think that it would, that I would undergo a miraculous transformation. If not resurrected splendor, then surely I would take on the “new man.” Instead, I received the gift of mortal life: the freedom to be imperfect, to have fears and face them, to accept brokenness, to let go of the will to control all outcomes.

Evangelical Anxiety is a beautifully written book, and a look into two worlds that can feel so secretive to the outsider. Professor Marsh’s use of language is extraordinary; he has a gift for metaphors and descriptions, and he carries the reader alongside him on a splendid journey. It has to be said, however, that he assumes a lot: He is a sophisticated scholar who mentions religious leaders, philosophers, historical characters, and the occasional rock song, with no patience for those who don’t follow his quick transitions and impressive vocabulary; I could have read this book with a dictionary beside me (but I didn’t).

It’s an illuminating journey, often sad and disturbing, sometimes funny and endearing, and ultimately uplifting. In our skeptical world where psychiatrists are so are often undone, it is refreshing to read a memoir where the psychiatrist is the good guy and the patient emerges healed and whole.
 

Dr. Miller, is a coauthor of Committed: The Battle Over Involuntary Psychiatric Care (Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins in Baltimore. She has disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.

Rheumatologists who administer medications in their office for Medicare patients, specifically those that are infused, have in recent years encountered problems providing certain medication formulations as well as coding and billing for their administration. In attempting to resolve these issues, rheumatologists and their professional organizations have found themselves caught in a morass of Medicare agency “ping-pong,” where it is unclear who the decision makers are.

The private health care insurers that process medical claims for Medicare beneficiaries, called A/B Medicare Administrative Contractors or more commonly known as MACs, are the operational intermediary between the Centers for Medicare & Medicaid Services’ fee-for-service program and the physicians enrolled in it. The country is divided into 12 sections, each with a MAC that has jurisdiction over that area. Among other things, the MACs establish local coverage and payment policies based on their understanding of CMS’ rules, regulations, and the Medicare statute, and therein lies the problem: When a physician has a question on a policy or decision that was made by a MAC, it is very difficult to determine the origins of the issue and who can address the problem. It’s a lot of “running in circles” between the MACs and CMS headquarters, hoping that someone will take the time to listen to your concern, but more importantly, work toward resolving the problem.

Who can address problems?

Meaningful, solutions-driven engagement with the MACs and CMS has become frustrating for physicians and advocacy organizations attempting to address a host of problems. The two issues alluded to above include the Self-Administered Drug Exclusion List (SAD List), which excludes certain Part B medication formulations from coverage under certain conditions and the “down coding” of certain infusion administration codes when specific drugs are delivered. These problems are compounded by the curtailment of physician stakeholder input via Contractor Advisory Committees (CACs). Each state has its own CAC, but the CAC meetings have been restructured as a result of the 21st Century Cures Act, and ultimately eradicated the involvement of these physician advisers in policy development at the local level.

This has left many of rheumatology representatives to the CACs demoralized and generally unhappy about certain decisions being made without their input. There is also inconsistency in terms of coverage and payment policies throughout the country. For example, in one MAC jurisdiction, a certain medication may be on the SAD List and excluded from Part B coverage, meaning beneficiary access is only available through Part D (and assuming they can afford it), while in an adjacent MAC jurisdiction, both formulations are covered.

The Coalition of State Rheumatology Organizations, along with the American College of Rheumatology and other specialty groups, is attempting to address these issues from many different angles. There is not enough space to explain the nuances of local coverage policy development, but the timeline below highlights the long and winding road that we have travelled to resolve these issues.

• February 2021: CSRO meets with CMS’ Coverage and Analysis Group (CAG) to raise concerns about ustekinumab (Stelara) and its inclusion on the SAD List.
• April 2021: CSRO follows up with CMS’ CAG on SAD List concerns in a letter.
• May 2021: Most MACs issue or revise local coverage articles, or “billing and coding” articles, that down code the administration of certain biologic medications, with some expanding the list of biologic medications subject to the policy, prompting a strong response from CSRO.
• September 2021: CSRO meets with multijurisdictional MAC Contract Medical Director (CMD) work group to discuss down coding, SAD List, and physician/CAC engagement.
• October 2021: At the suggestion of the CMDs, CSRO re-engages with CMS’ CAG to raise concerns about down-coding policies and physician/CAC engagement, and continue the SAD List discussion.
• November 2021: CSRO is connected with CMS’ “payment ombudsman” on down coding and the SAD List.
• January 2022: CSRO signs on to multispecialty coalition effort aimed at improving local coverage and payment policy and restoring the importance of the CAC.
• February 2022: CSRO participates in CMS CAG meeting with multispecialty coalition, raising concerns about the down-coding and SAD List policies.
• March/April 2022: Through its coalition partner, the Alliance of Specialty Medicine, CSRO meets with the principal deputy CMS administrator and raises awareness to these issues.
• May 2022: CSRO participates in follow-up discussion with CMS’ CAG as part of multispecialty coalition, reiterating concerns about the down coding and SAD List policies. With the assistance of the CMS’ Office of the Administrator, CSRO meets with CMS’ Center for Program Integrity to seek a “pause” in down-coding policies for certain biologic medications.
• June 2022: CMS notifies CSRO of a “temporary pause” in medical review while the agency reviews various manuals and policies to determine the appropriate steps forward. To assist the agency, CSRO works with practices to develop a resource that CMS can use to establish criteria for determining when a medication warrants use of complex drug administration codes. CSRO re-engages with multijurisdictional MAC CMD workgroup to continue discussions on SAD List.
• July 2022: CSRO meets with new multijurisdictional MAC CMD workgroup focused on improving the process for developing local coverage and payment policy.

Our dialogue with CMS leadership and staff continues. In the most recent communication, staff in the CMS administrator’s office informed us that the issue is complicated and crosses several different parts of the agency, and they are still determining next steps.

The rheumatology community’s journey toward solving the challenges facing practices and patients is emblematic of the communication problem between provider groups and the CMS-MAC establishment. While we understand this is how bureaucracy works, it is not to the benefit of Medicare beneficiaries to have a system that is so difficult to navigate, even by the best of the regulatory gurus. This is not an indictment of any specific group but a call to action on the part of the government and their contractors to create a clear, transparent path to getting answers when we have a problem.

And by the way, we do have another meeting with yet another CMS “center” regarding the SAD List in August.

Dr. Feldman is a rheumatologist in private practice with The Rheumatology Group in New Orleans. She is president of the CSRO, past chair of the Alliance for Safe Biologic Medicines, and a past member of the American College of Rheumatology insurance subcommittee. You can reach her at [email protected].

Rheumatologists who administer medications in their office for Medicare patients, specifically those that are infused, have in recent years encountered problems providing certain medication formulations as well as coding and billing for their administration. In attempting to resolve these issues, rheumatologists and their professional organizations have found themselves caught in a morass of Medicare agency “ping-pong,” where it is unclear who the decision makers are.

The private health care insurers that process medical claims for Medicare beneficiaries, called A/B Medicare Administrative Contractors or more commonly known as MACs, are the operational intermediary between the Centers for Medicare & Medicaid Services’ fee-for-service program and the physicians enrolled in it. The country is divided into 12 sections, each with a MAC that has jurisdiction over that area. Among other things, the MACs establish local coverage and payment policies based on their understanding of CMS’ rules, regulations, and the Medicare statute, and therein lies the problem: When a physician has a question on a policy or decision that was made by a MAC, it is very difficult to determine the origins of the issue and who can address the problem. It’s a lot of “running in circles” between the MACs and CMS headquarters, hoping that someone will take the time to listen to your concern, but more importantly, work toward resolving the problem.

Who can address problems?

Meaningful, solutions-driven engagement with the MACs and CMS has become frustrating for physicians and advocacy organizations attempting to address a host of problems. The two issues alluded to above include the Self-Administered Drug Exclusion List (SAD List), which excludes certain Part B medication formulations from coverage under certain conditions and the “down coding” of certain infusion administration codes when specific drugs are delivered. These problems are compounded by the curtailment of physician stakeholder input via Contractor Advisory Committees (CACs). Each state has its own CAC, but the CAC meetings have been restructured as a result of the 21st Century Cures Act, and ultimately eradicated the involvement of these physician advisers in policy development at the local level.

This has left many of rheumatology representatives to the CACs demoralized and generally unhappy about certain decisions being made without their input. There is also inconsistency in terms of coverage and payment policies throughout the country. For example, in one MAC jurisdiction, a certain medication may be on the SAD List and excluded from Part B coverage, meaning beneficiary access is only available through Part D (and assuming they can afford it), while in an adjacent MAC jurisdiction, both formulations are covered.

The Coalition of State Rheumatology Organizations, along with the American College of Rheumatology and other specialty groups, is attempting to address these issues from many different angles. There is not enough space to explain the nuances of local coverage policy development, but the timeline below highlights the long and winding road that we have travelled to resolve these issues.

• February 2021: CSRO meets with CMS’ Coverage and Analysis Group (CAG) to raise concerns about ustekinumab (Stelara) and its inclusion on the SAD List.
• April 2021: CSRO follows up with CMS’ CAG on SAD List concerns in a letter.
• May 2021: Most MACs issue or revise local coverage articles, or “billing and coding” articles, that down code the administration of certain biologic medications, with some expanding the list of biologic medications subject to the policy, prompting a strong response from CSRO.
• September 2021: CSRO meets with multijurisdictional MAC Contract Medical Director (CMD) work group to discuss down coding, SAD List, and physician/CAC engagement.
• October 2021: At the suggestion of the CMDs, CSRO re-engages with CMS’ CAG to raise concerns about down-coding policies and physician/CAC engagement, and continue the SAD List discussion.
• November 2021: CSRO is connected with CMS’ “payment ombudsman” on down coding and the SAD List.
• January 2022: CSRO signs on to multispecialty coalition effort aimed at improving local coverage and payment policy and restoring the importance of the CAC.
• February 2022: CSRO participates in CMS CAG meeting with multispecialty coalition, raising concerns about the down-coding and SAD List policies.
• March/April 2022: Through its coalition partner, the Alliance of Specialty Medicine, CSRO meets with the principal deputy CMS administrator and raises awareness to these issues.
• May 2022: CSRO participates in follow-up discussion with CMS’ CAG as part of multispecialty coalition, reiterating concerns about the down coding and SAD List policies. With the assistance of the CMS’ Office of the Administrator, CSRO meets with CMS’ Center for Program Integrity to seek a “pause” in down-coding policies for certain biologic medications.
• June 2022: CMS notifies CSRO of a “temporary pause” in medical review while the agency reviews various manuals and policies to determine the appropriate steps forward. To assist the agency, CSRO works with practices to develop a resource that CMS can use to establish criteria for determining when a medication warrants use of complex drug administration codes. CSRO re-engages with multijurisdictional MAC CMD workgroup to continue discussions on SAD List.
• July 2022: CSRO meets with new multijurisdictional MAC CMD workgroup focused on improving the process for developing local coverage and payment policy.

Our dialogue with CMS leadership and staff continues. In the most recent communication, staff in the CMS administrator’s office informed us that the issue is complicated and crosses several different parts of the agency, and they are still determining next steps.

The rheumatology community’s journey toward solving the challenges facing practices and patients is emblematic of the communication problem between provider groups and the CMS-MAC establishment. While we understand this is how bureaucracy works, it is not to the benefit of Medicare beneficiaries to have a system that is so difficult to navigate, even by the best of the regulatory gurus. This is not an indictment of any specific group but a call to action on the part of the government and their contractors to create a clear, transparent path to getting answers when we have a problem.

And by the way, we do have another meeting with yet another CMS “center” regarding the SAD List in August.

Dr. Feldman is a rheumatologist in private practice with The Rheumatology Group in New Orleans. She is president of the CSRO, past chair of the Alliance for Safe Biologic Medicines, and a past member of the American College of Rheumatology insurance subcommittee. You can reach her at [email protected].

Rheumatologists who administer medications in their office for Medicare patients, specifically those that are infused, have in recent years encountered problems providing certain medication formulations as well as coding and billing for their administration. In attempting to resolve these issues, rheumatologists and their professional organizations have found themselves caught in a morass of Medicare agency “ping-pong,” where it is unclear who the decision makers are.

The private health care insurers that process medical claims for Medicare beneficiaries, called A/B Medicare Administrative Contractors or more commonly known as MACs, are the operational intermediary between the Centers for Medicare & Medicaid Services’ fee-for-service program and the physicians enrolled in it. The country is divided into 12 sections, each with a MAC that has jurisdiction over that area. Among other things, the MACs establish local coverage and payment policies based on their understanding of CMS’ rules, regulations, and the Medicare statute, and therein lies the problem: When a physician has a question on a policy or decision that was made by a MAC, it is very difficult to determine the origins of the issue and who can address the problem. It’s a lot of “running in circles” between the MACs and CMS headquarters, hoping that someone will take the time to listen to your concern, but more importantly, work toward resolving the problem.

Who can address problems?

Meaningful, solutions-driven engagement with the MACs and CMS has become frustrating for physicians and advocacy organizations attempting to address a host of problems. The two issues alluded to above include the Self-Administered Drug Exclusion List (SAD List), which excludes certain Part B medication formulations from coverage under certain conditions and the “down coding” of certain infusion administration codes when specific drugs are delivered. These problems are compounded by the curtailment of physician stakeholder input via Contractor Advisory Committees (CACs). Each state has its own CAC, but the CAC meetings have been restructured as a result of the 21st Century Cures Act, and ultimately eradicated the involvement of these physician advisers in policy development at the local level.

This has left many of rheumatology representatives to the CACs demoralized and generally unhappy about certain decisions being made without their input. There is also inconsistency in terms of coverage and payment policies throughout the country. For example, in one MAC jurisdiction, a certain medication may be on the SAD List and excluded from Part B coverage, meaning beneficiary access is only available through Part D (and assuming they can afford it), while in an adjacent MAC jurisdiction, both formulations are covered.

The Coalition of State Rheumatology Organizations, along with the American College of Rheumatology and other specialty groups, is attempting to address these issues from many different angles. There is not enough space to explain the nuances of local coverage policy development, but the timeline below highlights the long and winding road that we have travelled to resolve these issues.

• February 2021: CSRO meets with CMS’ Coverage and Analysis Group (CAG) to raise concerns about ustekinumab (Stelara) and its inclusion on the SAD List.
• April 2021: CSRO follows up with CMS’ CAG on SAD List concerns in a letter.
• May 2021: Most MACs issue or revise local coverage articles, or “billing and coding” articles, that down code the administration of certain biologic medications, with some expanding the list of biologic medications subject to the policy, prompting a strong response from CSRO.
• September 2021: CSRO meets with multijurisdictional MAC Contract Medical Director (CMD) work group to discuss down coding, SAD List, and physician/CAC engagement.
• October 2021: At the suggestion of the CMDs, CSRO re-engages with CMS’ CAG to raise concerns about down-coding policies and physician/CAC engagement, and continue the SAD List discussion.
• November 2021: CSRO is connected with CMS’ “payment ombudsman” on down coding and the SAD List.
• January 2022: CSRO signs on to multispecialty coalition effort aimed at improving local coverage and payment policy and restoring the importance of the CAC.
• February 2022: CSRO participates in CMS CAG meeting with multispecialty coalition, raising concerns about the down-coding and SAD List policies.
• March/April 2022: Through its coalition partner, the Alliance of Specialty Medicine, CSRO meets with the principal deputy CMS administrator and raises awareness to these issues.
• May 2022: CSRO participates in follow-up discussion with CMS’ CAG as part of multispecialty coalition, reiterating concerns about the down coding and SAD List policies. With the assistance of the CMS’ Office of the Administrator, CSRO meets with CMS’ Center for Program Integrity to seek a “pause” in down-coding policies for certain biologic medications.
• June 2022: CMS notifies CSRO of a “temporary pause” in medical review while the agency reviews various manuals and policies to determine the appropriate steps forward. To assist the agency, CSRO works with practices to develop a resource that CMS can use to establish criteria for determining when a medication warrants use of complex drug administration codes. CSRO re-engages with multijurisdictional MAC CMD workgroup to continue discussions on SAD List.
• July 2022: CSRO meets with new multijurisdictional MAC CMD workgroup focused on improving the process for developing local coverage and payment policy.

Our dialogue with CMS leadership and staff continues. In the most recent communication, staff in the CMS administrator’s office informed us that the issue is complicated and crosses several different parts of the agency, and they are still determining next steps.

The rheumatology community’s journey toward solving the challenges facing practices and patients is emblematic of the communication problem between provider groups and the CMS-MAC establishment. While we understand this is how bureaucracy works, it is not to the benefit of Medicare beneficiaries to have a system that is so difficult to navigate, even by the best of the regulatory gurus. This is not an indictment of any specific group but a call to action on the part of the government and their contractors to create a clear, transparent path to getting answers when we have a problem.

And by the way, we do have another meeting with yet another CMS “center” regarding the SAD List in August.

Dr. Feldman is a rheumatologist in private practice with The Rheumatology Group in New Orleans. She is president of the CSRO, past chair of the Alliance for Safe Biologic Medicines, and a past member of the American College of Rheumatology insurance subcommittee. You can reach her at [email protected].

In a video posted to TikTok by the comedian Will Flanary, MD, better known to his followers as Dr. Glaucomflecken, he imitates a neurosurgical residency interview. With glasses perched on the bridge of his nose, Dr. Glaucomflecken poses as the attending, asking: “What are your weaknesses?”

The residency applicant answers without hesitation: “My physiological need for sleep.” “What are your strengths?” The resident replies with the hard, steely stare of the determined and uninitiated: “My desire to eliminate my physiological need for sleep.”

If you follow Dr. Glaucomflecken on Twitter, you might know the skit I’m referencing. For many physicians and physicians-in-training, what makes the satire successful is its reflection of reality.

Many things have changed in medicine since his time, but the tired trope of the sleepless surgeon hangs on. Undaunted, I spent my second and third year of medical school accumulating accolades, conducting research, and connecting with mentors with the singular goal of joining the surgical ranks.

Midway through my third year, I completed a month-long surgical subinternship designed to give students a taste of what life would look like as an intern. I loved the operating room; it felt like the difference between being on dry land and being underwater. There were fewer distractions – your patient in the spotlight while everything else receded to the shadows.

However, as the month wore on, something stronger took hold. I couldn’t keep my eyes open in the darkened operating rooms and had to decline stools, fearing that I would fall asleep if I sat down.

On early morning prerounds, it’s 4:50 a.m. when I glance at the clock and pull back the curtain, already apologizing. My patient rolls over, flashing a wry smile. “Do you ever go home?” I’ve seen residents respond to this exact question in various ways. I live here. Yes. No. Soon. Not enough. My partner doesn’t think so.

There are days and, yes, years when we are led to believe this is what we live for: to be constantly available to our patients. It feels like a hollow victory when the patient, 2 days out from a total colectomy, begins to worry about your personal life. I ask her how she slept (not enough), any fevers (no), vomiting (no), urinating (I pause – she has a catheter).

My favorite part of these early morning rounds is the pause in my scripted litany of questions to listen to heart and lungs. It never fails to feel sacred: Patients become so quiet and still that I can’t help but think they have faith in me. Without prompting, she slides the back of her hospital gown forward like a curtain, already taking deep breaths so I can hear her lungs.

I look outside. The streetlights are still on, and from the seventh-floor window, I can watch staff making their way through the sliding double-doors, just beyond the yellowed pools of streetlight. I smile. I love medicine. I’m so tired.

For many in medicine, we are treated, and thus behave, as though our ability to manipulate physiology should also apply within the borders of our bodies: commanding less sleep, food, or bathroom breaks.

It places health care workers solidly in the realm of superhuman, living beyond one’s corporeal needs. The pandemic only heightened this misappropriation – adding hero and setting out a pedestal for health care workers to make their ungainly ascent. This kind of unsolicited admiration implicitly implies inhumanness, an otherness.

What would it look like if we started treating ourselves less like physicians and more like patients? I wish I was offering a solution, but really this is just a story. Maybe it’s not more sleep you need but something just as critical to the delicate physiologic and psychological scales of well-being.

To students rising through the ranks of medical training, identify what it is you need early and often. I can count on one hand how many physicians I’ve seen take a lunch break – even 10 minutes. Embrace hard work and self-preservation equally. My hope is that if enough of us take this path, it just might become a matter of course.

Dr. Meffert is a resident in the department of emergency medicine, MedStar Georgetown University Hospital, Washington Hospital Center, Washington. Dr. Meffert disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In a video posted to TikTok by the comedian Will Flanary, MD, better known to his followers as Dr. Glaucomflecken, he imitates a neurosurgical residency interview. With glasses perched on the bridge of his nose, Dr. Glaucomflecken poses as the attending, asking: “What are your weaknesses?”

The residency applicant answers without hesitation: “My physiological need for sleep.” “What are your strengths?” The resident replies with the hard, steely stare of the determined and uninitiated: “My desire to eliminate my physiological need for sleep.”

If you follow Dr. Glaucomflecken on Twitter, you might know the skit I’m referencing. For many physicians and physicians-in-training, what makes the satire successful is its reflection of reality.

Many things have changed in medicine since his time, but the tired trope of the sleepless surgeon hangs on. Undaunted, I spent my second and third year of medical school accumulating accolades, conducting research, and connecting with mentors with the singular goal of joining the surgical ranks.

Midway through my third year, I completed a month-long surgical subinternship designed to give students a taste of what life would look like as an intern. I loved the operating room; it felt like the difference between being on dry land and being underwater. There were fewer distractions – your patient in the spotlight while everything else receded to the shadows.

However, as the month wore on, something stronger took hold. I couldn’t keep my eyes open in the darkened operating rooms and had to decline stools, fearing that I would fall asleep if I sat down.

On early morning prerounds, it’s 4:50 a.m. when I glance at the clock and pull back the curtain, already apologizing. My patient rolls over, flashing a wry smile. “Do you ever go home?” I’ve seen residents respond to this exact question in various ways. I live here. Yes. No. Soon. Not enough. My partner doesn’t think so.

There are days and, yes, years when we are led to believe this is what we live for: to be constantly available to our patients. It feels like a hollow victory when the patient, 2 days out from a total colectomy, begins to worry about your personal life. I ask her how she slept (not enough), any fevers (no), vomiting (no), urinating (I pause – she has a catheter).

My favorite part of these early morning rounds is the pause in my scripted litany of questions to listen to heart and lungs. It never fails to feel sacred: Patients become so quiet and still that I can’t help but think they have faith in me. Without prompting, she slides the back of her hospital gown forward like a curtain, already taking deep breaths so I can hear her lungs.

I look outside. The streetlights are still on, and from the seventh-floor window, I can watch staff making their way through the sliding double-doors, just beyond the yellowed pools of streetlight. I smile. I love medicine. I’m so tired.

For many in medicine, we are treated, and thus behave, as though our ability to manipulate physiology should also apply within the borders of our bodies: commanding less sleep, food, or bathroom breaks.

It places health care workers solidly in the realm of superhuman, living beyond one’s corporeal needs. The pandemic only heightened this misappropriation – adding hero and setting out a pedestal for health care workers to make their ungainly ascent. This kind of unsolicited admiration implicitly implies inhumanness, an otherness.

What would it look like if we started treating ourselves less like physicians and more like patients? I wish I was offering a solution, but really this is just a story. Maybe it’s not more sleep you need but something just as critical to the delicate physiologic and psychological scales of well-being.

To students rising through the ranks of medical training, identify what it is you need early and often. I can count on one hand how many physicians I’ve seen take a lunch break – even 10 minutes. Embrace hard work and self-preservation equally. My hope is that if enough of us take this path, it just might become a matter of course.

Dr. Meffert is a resident in the department of emergency medicine, MedStar Georgetown University Hospital, Washington Hospital Center, Washington. Dr. Meffert disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In a video posted to TikTok by the comedian Will Flanary, MD, better known to his followers as Dr. Glaucomflecken, he imitates a neurosurgical residency interview. With glasses perched on the bridge of his nose, Dr. Glaucomflecken poses as the attending, asking: “What are your weaknesses?”

The residency applicant answers without hesitation: “My physiological need for sleep.” “What are your strengths?” The resident replies with the hard, steely stare of the determined and uninitiated: “My desire to eliminate my physiological need for sleep.”

If you follow Dr. Glaucomflecken on Twitter, you might know the skit I’m referencing. For many physicians and physicians-in-training, what makes the satire successful is its reflection of reality.

Many things have changed in medicine since his time, but the tired trope of the sleepless surgeon hangs on. Undaunted, I spent my second and third year of medical school accumulating accolades, conducting research, and connecting with mentors with the singular goal of joining the surgical ranks.

Midway through my third year, I completed a month-long surgical subinternship designed to give students a taste of what life would look like as an intern. I loved the operating room; it felt like the difference between being on dry land and being underwater. There were fewer distractions – your patient in the spotlight while everything else receded to the shadows.

However, as the month wore on, something stronger took hold. I couldn’t keep my eyes open in the darkened operating rooms and had to decline stools, fearing that I would fall asleep if I sat down.

On early morning prerounds, it’s 4:50 a.m. when I glance at the clock and pull back the curtain, already apologizing. My patient rolls over, flashing a wry smile. “Do you ever go home?” I’ve seen residents respond to this exact question in various ways. I live here. Yes. No. Soon. Not enough. My partner doesn’t think so.

There are days and, yes, years when we are led to believe this is what we live for: to be constantly available to our patients. It feels like a hollow victory when the patient, 2 days out from a total colectomy, begins to worry about your personal life. I ask her how she slept (not enough), any fevers (no), vomiting (no), urinating (I pause – she has a catheter).

My favorite part of these early morning rounds is the pause in my scripted litany of questions to listen to heart and lungs. It never fails to feel sacred: Patients become so quiet and still that I can’t help but think they have faith in me. Without prompting, she slides the back of her hospital gown forward like a curtain, already taking deep breaths so I can hear her lungs.

I look outside. The streetlights are still on, and from the seventh-floor window, I can watch staff making their way through the sliding double-doors, just beyond the yellowed pools of streetlight. I smile. I love medicine. I’m so tired.

For many in medicine, we are treated, and thus behave, as though our ability to manipulate physiology should also apply within the borders of our bodies: commanding less sleep, food, or bathroom breaks.

It places health care workers solidly in the realm of superhuman, living beyond one’s corporeal needs. The pandemic only heightened this misappropriation – adding hero and setting out a pedestal for health care workers to make their ungainly ascent. This kind of unsolicited admiration implicitly implies inhumanness, an otherness.

What would it look like if we started treating ourselves less like physicians and more like patients? I wish I was offering a solution, but really this is just a story. Maybe it’s not more sleep you need but something just as critical to the delicate physiologic and psychological scales of well-being.

To students rising through the ranks of medical training, identify what it is you need early and often. I can count on one hand how many physicians I’ve seen take a lunch break – even 10 minutes. Embrace hard work and self-preservation equally. My hope is that if enough of us take this path, it just might become a matter of course.

Dr. Meffert is a resident in the department of emergency medicine, MedStar Georgetown University Hospital, Washington Hospital Center, Washington. Dr. Meffert disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

It is no secret that the COVID-19 pandemic resulted in widespread disruptions in health care services. While providers and resources were limited and many patients were apprehensive to present to health care settings out of concern of disease contraction, telehealth services did offer some relief.

Compared to other specialty care services, mental health care providers were well equipped to handle the expansion of telehealth services, as extensive treatment literature provides strong support for the use of psychotherapeutic interventions over telehealth mediums.¹ This holds true in the context of obsessive-compulsive disorder (OCD), where an impressive literature supports the use of telehealth delivery for the gold-standard psychotherapeutic, exposure and response prevention (ERP).^2,3,4

Through ERP, patients work with a clinician to systematically expose themselves to anxiety-providing triggers while actively resisting compulsive behaviors to learn the distress does go away with time and/or the distress is within their ability to cope. This intervention is conceptually similar to repeatedly watching a scary film, by which continued exposure results in less pronounced emotional reaction with subsequent viewings.

Fortunately for patients and providers, the expansion of telehealth ERP across different treatment settings has had many unintended benefits, including increased access to care, lower no-show rates due to the ease of attending appointments, and the ability to offer higher levels of care, including intensive outpatient programs, over telehealth mediums. Anecdotally, our clinic has been able to increase patient reach by providing telehealth ERP to those who historically would not have been able to access care due to geography. Even for those living within driving distance to our clinic, the ease of joining a video visit for a 45-minute appointment far outweighs driving into the clinic, in many circumstances. With these benefits, the delivery of ERP over telehealth appears likely to stay, although OCD providers delivering ERP will need to consider when and for whom this medium may not be appropriate.

To this end, we recently conducted a study examining ERP providers perceptions of telehealth and in-person ERP, patient characteristics best suited for telehealth services, and provider ability to identify and address factors that adversely impact the course of treatment (e.g., substance use, limited symptom insight, distractions during ERP, etc.).⁵ Providers reported lower feasibility ratings for telehealth compared to in-person ERP for younger patients (aged under 13 years), and patients with more severe OCD presentations. Providers also reported more difficulty identifying and addressing ERP interfering factors over telehealth relative to in-person. The findings from our research do not necessarily speak to the effectiveness of telehealth ERP, which has repeatedly been documented in treatment literature, but rather our findings highlight that ERP providers endorse reservations about the feasibility of ERP for certain OCD patient profiles, and that telehealth ERP may not be appropriate for all patients with OCD.

Mental health care providers, including those delivering ERP, should consider when telehealth is and is not appropriate. Importantly, telehealth offers a limited field of view compared to in-person, and providers can only observe what is captured by the camera. In the context of telehealth ERP, patients may engage in subtle avoidant behaviors that are more difficult to observe, which may prevent them from experiencing necessary anxiety during exposure practice. Many providers may have firsthand experience with this, or patients who appear distracted over telehealth mediums because of environmental factors that can be controlled for during in-person services.

As telehealth treatment options appear increasingly likely to stay, ERP providers and intervention researchers should continue identifying patient characteristics that are more and less appropriate for telehealth settings in order to maximize treatment outcomes. Providers should share concerns with patients when delivering telehealth ERP and work to address interfering factors impacting the course of treatment. In circumstances where this is not possible, such as when the patients age or symptom severity prevents effective telehealth ERP, or when treatment progress stalls, providers should speak with patients to determine if it would be beneficial to transition to in-person services.

Both in-person and telehealth ERP are fundamentally the same, however it does appear that subtle differences across these modalities may have differential impacts on treatment outcomes for certain OCD patient presentations. Telehealth ERP, and more broadly telehealth psychotherapy, offers many benefits for patients and providers, however appropriate caution should be exhibited, and providers should use clinical judgment when offering telehealth services.

Dr. Wiese is a clinical psychologist in the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston, Texas. He is primarily focused on conducting research on OCD and related disorders and providing empirically supported treatments to individuals diagnosed with these conditions.

References

1. Fernandez E et al. Live psychotherapy by video versus in‐person: A meta‐analysis of efficacy and its relationship to types and targets of treatment. Clin Psychol Psychother. 2021 Nov;28(6):1535-49. doi: 10.1002/cpp.2594.

2. Storch EA et al. Preliminary investigation of web-camera delivered cognitive-behavioral therapy for youth with obsessive-compulsive disorder. Psychiatry Res. 2011 Oct 30;189(3):407-12. doi: 10.1016/j.psychres.2011.05.047.

3. Fletcher TL et al. A pilot open trial of video telehealth-delivered exposure and response prevention for obsessive-compulsive disorder in rural Veterans. Mil Psychol. 2021 Oct 28;34(1):83-90. doi: 10.1080/08995605.2021.1970983.

4. Wootton BM. Remote cognitive–behavior therapy for obsessive–compulsive symptoms: a meta-analysis. Clin Psychol Rev. 2016 Feb;43:103-13. doi: 10.1016/j.cpr.2015.10.001.

5. Wiese AD et al. Provider perceptions of telehealth and in-person exposure and response prevention for obsessive–compulsive disorder. Psychiatry Res. 2022 Jul;313:114610. doi: 10.1016/j.psychres.2022.114610.

It is no secret that the COVID-19 pandemic resulted in widespread disruptions in health care services. While providers and resources were limited and many patients were apprehensive to present to health care settings out of concern of disease contraction, telehealth services did offer some relief.

Compared to other specialty care services, mental health care providers were well equipped to handle the expansion of telehealth services, as extensive treatment literature provides strong support for the use of psychotherapeutic interventions over telehealth mediums.¹ This holds true in the context of obsessive-compulsive disorder (OCD), where an impressive literature supports the use of telehealth delivery for the gold-standard psychotherapeutic, exposure and response prevention (ERP).^2,3,4

Through ERP, patients work with a clinician to systematically expose themselves to anxiety-providing triggers while actively resisting compulsive behaviors to learn the distress does go away with time and/or the distress is within their ability to cope. This intervention is conceptually similar to repeatedly watching a scary film, by which continued exposure results in less pronounced emotional reaction with subsequent viewings.

Fortunately for patients and providers, the expansion of telehealth ERP across different treatment settings has had many unintended benefits, including increased access to care, lower no-show rates due to the ease of attending appointments, and the ability to offer higher levels of care, including intensive outpatient programs, over telehealth mediums. Anecdotally, our clinic has been able to increase patient reach by providing telehealth ERP to those who historically would not have been able to access care due to geography. Even for those living within driving distance to our clinic, the ease of joining a video visit for a 45-minute appointment far outweighs driving into the clinic, in many circumstances. With these benefits, the delivery of ERP over telehealth appears likely to stay, although OCD providers delivering ERP will need to consider when and for whom this medium may not be appropriate.

To this end, we recently conducted a study examining ERP providers perceptions of telehealth and in-person ERP, patient characteristics best suited for telehealth services, and provider ability to identify and address factors that adversely impact the course of treatment (e.g., substance use, limited symptom insight, distractions during ERP, etc.).⁵ Providers reported lower feasibility ratings for telehealth compared to in-person ERP for younger patients (aged under 13 years), and patients with more severe OCD presentations. Providers also reported more difficulty identifying and addressing ERP interfering factors over telehealth relative to in-person. The findings from our research do not necessarily speak to the effectiveness of telehealth ERP, which has repeatedly been documented in treatment literature, but rather our findings highlight that ERP providers endorse reservations about the feasibility of ERP for certain OCD patient profiles, and that telehealth ERP may not be appropriate for all patients with OCD.

Mental health care providers, including those delivering ERP, should consider when telehealth is and is not appropriate. Importantly, telehealth offers a limited field of view compared to in-person, and providers can only observe what is captured by the camera. In the context of telehealth ERP, patients may engage in subtle avoidant behaviors that are more difficult to observe, which may prevent them from experiencing necessary anxiety during exposure practice. Many providers may have firsthand experience with this, or patients who appear distracted over telehealth mediums because of environmental factors that can be controlled for during in-person services.

As telehealth treatment options appear increasingly likely to stay, ERP providers and intervention researchers should continue identifying patient characteristics that are more and less appropriate for telehealth settings in order to maximize treatment outcomes. Providers should share concerns with patients when delivering telehealth ERP and work to address interfering factors impacting the course of treatment. In circumstances where this is not possible, such as when the patients age or symptom severity prevents effective telehealth ERP, or when treatment progress stalls, providers should speak with patients to determine if it would be beneficial to transition to in-person services.

Both in-person and telehealth ERP are fundamentally the same, however it does appear that subtle differences across these modalities may have differential impacts on treatment outcomes for certain OCD patient presentations. Telehealth ERP, and more broadly telehealth psychotherapy, offers many benefits for patients and providers, however appropriate caution should be exhibited, and providers should use clinical judgment when offering telehealth services.

Dr. Wiese is a clinical psychologist in the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston, Texas. He is primarily focused on conducting research on OCD and related disorders and providing empirically supported treatments to individuals diagnosed with these conditions.

References

1. Fernandez E et al. Live psychotherapy by video versus in‐person: A meta‐analysis of efficacy and its relationship to types and targets of treatment. Clin Psychol Psychother. 2021 Nov;28(6):1535-49. doi: 10.1002/cpp.2594.

2. Storch EA et al. Preliminary investigation of web-camera delivered cognitive-behavioral therapy for youth with obsessive-compulsive disorder. Psychiatry Res. 2011 Oct 30;189(3):407-12. doi: 10.1016/j.psychres.2011.05.047.

3. Fletcher TL et al. A pilot open trial of video telehealth-delivered exposure and response prevention for obsessive-compulsive disorder in rural Veterans. Mil Psychol. 2021 Oct 28;34(1):83-90. doi: 10.1080/08995605.2021.1970983.

4. Wootton BM. Remote cognitive–behavior therapy for obsessive–compulsive symptoms: a meta-analysis. Clin Psychol Rev. 2016 Feb;43:103-13. doi: 10.1016/j.cpr.2015.10.001.

5. Wiese AD et al. Provider perceptions of telehealth and in-person exposure and response prevention for obsessive–compulsive disorder. Psychiatry Res. 2022 Jul;313:114610. doi: 10.1016/j.psychres.2022.114610.

It is no secret that the COVID-19 pandemic resulted in widespread disruptions in health care services. While providers and resources were limited and many patients were apprehensive to present to health care settings out of concern of disease contraction, telehealth services did offer some relief.

Compared to other specialty care services, mental health care providers were well equipped to handle the expansion of telehealth services, as extensive treatment literature provides strong support for the use of psychotherapeutic interventions over telehealth mediums.¹ This holds true in the context of obsessive-compulsive disorder (OCD), where an impressive literature supports the use of telehealth delivery for the gold-standard psychotherapeutic, exposure and response prevention (ERP).^2,3,4

Through ERP, patients work with a clinician to systematically expose themselves to anxiety-providing triggers while actively resisting compulsive behaviors to learn the distress does go away with time and/or the distress is within their ability to cope. This intervention is conceptually similar to repeatedly watching a scary film, by which continued exposure results in less pronounced emotional reaction with subsequent viewings.

Fortunately for patients and providers, the expansion of telehealth ERP across different treatment settings has had many unintended benefits, including increased access to care, lower no-show rates due to the ease of attending appointments, and the ability to offer higher levels of care, including intensive outpatient programs, over telehealth mediums. Anecdotally, our clinic has been able to increase patient reach by providing telehealth ERP to those who historically would not have been able to access care due to geography. Even for those living within driving distance to our clinic, the ease of joining a video visit for a 45-minute appointment far outweighs driving into the clinic, in many circumstances. With these benefits, the delivery of ERP over telehealth appears likely to stay, although OCD providers delivering ERP will need to consider when and for whom this medium may not be appropriate.

To this end, we recently conducted a study examining ERP providers perceptions of telehealth and in-person ERP, patient characteristics best suited for telehealth services, and provider ability to identify and address factors that adversely impact the course of treatment (e.g., substance use, limited symptom insight, distractions during ERP, etc.).⁵ Providers reported lower feasibility ratings for telehealth compared to in-person ERP for younger patients (aged under 13 years), and patients with more severe OCD presentations. Providers also reported more difficulty identifying and addressing ERP interfering factors over telehealth relative to in-person. The findings from our research do not necessarily speak to the effectiveness of telehealth ERP, which has repeatedly been documented in treatment literature, but rather our findings highlight that ERP providers endorse reservations about the feasibility of ERP for certain OCD patient profiles, and that telehealth ERP may not be appropriate for all patients with OCD.

Mental health care providers, including those delivering ERP, should consider when telehealth is and is not appropriate. Importantly, telehealth offers a limited field of view compared to in-person, and providers can only observe what is captured by the camera. In the context of telehealth ERP, patients may engage in subtle avoidant behaviors that are more difficult to observe, which may prevent them from experiencing necessary anxiety during exposure practice. Many providers may have firsthand experience with this, or patients who appear distracted over telehealth mediums because of environmental factors that can be controlled for during in-person services.

As telehealth treatment options appear increasingly likely to stay, ERP providers and intervention researchers should continue identifying patient characteristics that are more and less appropriate for telehealth settings in order to maximize treatment outcomes. Providers should share concerns with patients when delivering telehealth ERP and work to address interfering factors impacting the course of treatment. In circumstances where this is not possible, such as when the patients age or symptom severity prevents effective telehealth ERP, or when treatment progress stalls, providers should speak with patients to determine if it would be beneficial to transition to in-person services.

Both in-person and telehealth ERP are fundamentally the same, however it does appear that subtle differences across these modalities may have differential impacts on treatment outcomes for certain OCD patient presentations. Telehealth ERP, and more broadly telehealth psychotherapy, offers many benefits for patients and providers, however appropriate caution should be exhibited, and providers should use clinical judgment when offering telehealth services.

Dr. Wiese is a clinical psychologist in the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston, Texas. He is primarily focused on conducting research on OCD and related disorders and providing empirically supported treatments to individuals diagnosed with these conditions.

References

1. Fernandez E et al. Live psychotherapy by video versus in‐person: A meta‐analysis of efficacy and its relationship to types and targets of treatment. Clin Psychol Psychother. 2021 Nov;28(6):1535-49. doi: 10.1002/cpp.2594.

2. Storch EA et al. Preliminary investigation of web-camera delivered cognitive-behavioral therapy for youth with obsessive-compulsive disorder. Psychiatry Res. 2011 Oct 30;189(3):407-12. doi: 10.1016/j.psychres.2011.05.047.

3. Fletcher TL et al. A pilot open trial of video telehealth-delivered exposure and response prevention for obsessive-compulsive disorder in rural Veterans. Mil Psychol. 2021 Oct 28;34(1):83-90. doi: 10.1080/08995605.2021.1970983.

4. Wootton BM. Remote cognitive–behavior therapy for obsessive–compulsive symptoms: a meta-analysis. Clin Psychol Rev. 2016 Feb;43:103-13. doi: 10.1016/j.cpr.2015.10.001.

5. Wiese AD et al. Provider perceptions of telehealth and in-person exposure and response prevention for obsessive–compulsive disorder. Psychiatry Res. 2022 Jul;313:114610. doi: 10.1016/j.psychres.2022.114610.

The shell game is probably the world’s oldest confidence game, going back 2,000-3,000 years. You still see people getting lured into it in cities today.

It’s also played, albeit legally, in physician offices and pharmacies around the country.

The medical equivalent of the shell game involves one of those ubiquitous manufacturer copay coupons. You know, the ones piled up in your sample cabinet. Get a month free of Whateveritscalled to try and/or have your copay reduced to $0 or something reasonably low. All, of course, subject to terms and conditions in the small print and that of your insurance carrier. Your mileage may vary.

In my experience these things often don’t work as well as advertised. Sometimes it’s because the patient doesn’t understand how to use them, other times because their pharmacy doesn’t want to have anything to do with the cards, and still other times because their insurance has some exclusion against them.

But they do sometimes work ... until they don’t. Sometimes, out of the blue, they’ll stop. Maybe there was an insurance change, or the pharmacy policy changed, or the manufacturer’s program changed, or the offer expired. I usually don’t know and rarely find out.

So the shell game begins. The patients call multiple pharmacies, trying to find one that may be able to honor the coupons. Then they call my office and ask me to switch the script. So I do. They they go to the pharmacy. Sometimes they can get the script, sometimes not. If not, they move to another pharmacy and call my office to switch it again. Wash, rinse, repeat.

Other times it’s more complicated. They want a new card for each try, so they show up at my office asking for one (usually they can be downloaded online so some try that. Others do both). Like pebbles under a shell, the prescriptions and cards get switched from pharmacy to pharmacy.

This isn’t exclusive to manufacturers’ copay cards. I see the same phenomenon with GoodRx and similar cost-saving programs. People move scripts around to find the best deal. It may be helping them, but it certainly doesn’t help me and my staff as we try to keep up, or the badly overworked pharmacy staff.

I’ve even had some patients take the audacious step of asking me to write a script in the name of their spouses so they can double their supply. Obviously, such requests are refused. I’m not going to play that game.

I understand new drugs are costly, and often outside the reach of many patients today. I know the manufacturers are trying to get their products tried, or even make them more affordable for those who need it.

But, in many cases, this becomes (unintentionally or intentionally; I’m not sure) a shell game. Legal, perhaps, but still equally frustrating for all of us who are trying to keep up with it.

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

The shell game is probably the world’s oldest confidence game, going back 2,000-3,000 years. You still see people getting lured into it in cities today.

It’s also played, albeit legally, in physician offices and pharmacies around the country.

The medical equivalent of the shell game involves one of those ubiquitous manufacturer copay coupons. You know, the ones piled up in your sample cabinet. Get a month free of Whateveritscalled to try and/or have your copay reduced to $0 or something reasonably low. All, of course, subject to terms and conditions in the small print and that of your insurance carrier. Your mileage may vary.

In my experience these things often don’t work as well as advertised. Sometimes it’s because the patient doesn’t understand how to use them, other times because their pharmacy doesn’t want to have anything to do with the cards, and still other times because their insurance has some exclusion against them.

But they do sometimes work ... until they don’t. Sometimes, out of the blue, they’ll stop. Maybe there was an insurance change, or the pharmacy policy changed, or the manufacturer’s program changed, or the offer expired. I usually don’t know and rarely find out.

So the shell game begins. The patients call multiple pharmacies, trying to find one that may be able to honor the coupons. Then they call my office and ask me to switch the script. So I do. They they go to the pharmacy. Sometimes they can get the script, sometimes not. If not, they move to another pharmacy and call my office to switch it again. Wash, rinse, repeat.

Other times it’s more complicated. They want a new card for each try, so they show up at my office asking for one (usually they can be downloaded online so some try that. Others do both). Like pebbles under a shell, the prescriptions and cards get switched from pharmacy to pharmacy.

This isn’t exclusive to manufacturers’ copay cards. I see the same phenomenon with GoodRx and similar cost-saving programs. People move scripts around to find the best deal. It may be helping them, but it certainly doesn’t help me and my staff as we try to keep up, or the badly overworked pharmacy staff.

I’ve even had some patients take the audacious step of asking me to write a script in the name of their spouses so they can double their supply. Obviously, such requests are refused. I’m not going to play that game.

I understand new drugs are costly, and often outside the reach of many patients today. I know the manufacturers are trying to get their products tried, or even make them more affordable for those who need it.

But, in many cases, this becomes (unintentionally or intentionally; I’m not sure) a shell game. Legal, perhaps, but still equally frustrating for all of us who are trying to keep up with it.

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

The shell game is probably the world’s oldest confidence game, going back 2,000-3,000 years. You still see people getting lured into it in cities today.

It’s also played, albeit legally, in physician offices and pharmacies around the country.

The medical equivalent of the shell game involves one of those ubiquitous manufacturer copay coupons. You know, the ones piled up in your sample cabinet. Get a month free of Whateveritscalled to try and/or have your copay reduced to $0 or something reasonably low. All, of course, subject to terms and conditions in the small print and that of your insurance carrier. Your mileage may vary.

In my experience these things often don’t work as well as advertised. Sometimes it’s because the patient doesn’t understand how to use them, other times because their pharmacy doesn’t want to have anything to do with the cards, and still other times because their insurance has some exclusion against them.

But they do sometimes work ... until they don’t. Sometimes, out of the blue, they’ll stop. Maybe there was an insurance change, or the pharmacy policy changed, or the manufacturer’s program changed, or the offer expired. I usually don’t know and rarely find out.

So the shell game begins. The patients call multiple pharmacies, trying to find one that may be able to honor the coupons. Then they call my office and ask me to switch the script. So I do. They they go to the pharmacy. Sometimes they can get the script, sometimes not. If not, they move to another pharmacy and call my office to switch it again. Wash, rinse, repeat.

Other times it’s more complicated. They want a new card for each try, so they show up at my office asking for one (usually they can be downloaded online so some try that. Others do both). Like pebbles under a shell, the prescriptions and cards get switched from pharmacy to pharmacy.

This isn’t exclusive to manufacturers’ copay cards. I see the same phenomenon with GoodRx and similar cost-saving programs. People move scripts around to find the best deal. It may be helping them, but it certainly doesn’t help me and my staff as we try to keep up, or the badly overworked pharmacy staff.

I’ve even had some patients take the audacious step of asking me to write a script in the name of their spouses so they can double their supply. Obviously, such requests are refused. I’m not going to play that game.

I understand new drugs are costly, and often outside the reach of many patients today. I know the manufacturers are trying to get their products tried, or even make them more affordable for those who need it.

But, in many cases, this becomes (unintentionally or intentionally; I’m not sure) a shell game. Legal, perhaps, but still equally frustrating for all of us who are trying to keep up with it.

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

Tragic, embarrassing, criminal ... Choose your own adjective. The maternal mortality rate in this country is the worst of any developed nation in the world. And the numbers are getting worse with an increase of 14% over the previous year. One-third of these deaths occur weeks or months after the delivery.

In a recent issue of Harvard Public Health, researchers at the T.H. Chan School of Public Health discuss some of the possible remedies for what they describe as a crisis. While some of the solutions they list will require major restructuring of how we deliver health care to mothers, others could take advantage of our current systems by employing a slight shift in emphasis. And here is where those of us on the frontline of care delivery can make a difference.

The researchers point out that “More than 90% of maternal deaths could be prevented if women had access to quality care.” They also observe that most mothers have a single postpartum check with the ob.gyn. facility that delivered the baby and then are often left to navigate the health system because transfer to their primary care and/or mental health professional is haphazard or lacking in follow-up.

As I read through the article it struck me that as pediatricians we could and should be playing a larger role in this critical postpartum period when so many women seem to be falling through the cracks in our health care nonsystem. This is not a great “Ah-ha” moment for which I deserve any credit. In 2010 the American Academy of Pediatrics recommended that mothers be screened for depression at the 1-, 2-, and 4-month visits using either a validated 10-question screening instrument or a more direct 2-question tool (Pediatrics 2010;126[5]:1032-9). However, a periodic survey of AAP members 3 years later revealed that less than a third of the respondents were screening regularly for postpartum depression. In 2019 the academy reemphasized the important role that pediatric primary care givers can play in the detection and early management of the condition.

The reasons for the disappointing response include the list of usual suspects of inadequate training, workload demands, reimbursement, liability concerns, and the difficulty in finding and establishing effective referral networks. Unfortunately, these factors continue to exist, and many cases have multiplied in the wake of the pandemic.

In some states, educational outreach, funding, and changes in the reimbursement structure have resulted in improved outcomes. Not all of us are fortunate enough to live in a state that has made postpartum depression detection and management a priority. However, simply making it our own professional priority can save lives, ease suffering, and improve postpartum outcomes. Here I am talking about first caring and then inquiring about a mother’s mental health. Asking how much sleep she is getting. And then spending the time to give personalized advice on feeding and sleep schedules. Even, if this means ignoring half of the topics on the recommended health maintenance. It doesn’t take but a few minutes to convince yourself that the baby is healthy, and you know that 90% of them are.

However, a new mother who is sleep deprived and already has one foot on the spiral staircase down into postpartum depression represents an emergency. And, you should have the skills to turn it around. But, you have to care about the problem and make it your own priority – high enough on the list to make a follow-up appointment or call in a week instead of waiting a month or 2 until the next visit.

Unfortunately, even with your best efforts there are some families who need services beyond the scope of your practice. Making the necessary referrals can be frustrating and time consuming but not dropping ball until it lands in the appropriate place may save a life.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Tragic, embarrassing, criminal ... Choose your own adjective. The maternal mortality rate in this country is the worst of any developed nation in the world. And the numbers are getting worse with an increase of 14% over the previous year. One-third of these deaths occur weeks or months after the delivery.

In a recent issue of Harvard Public Health, researchers at the T.H. Chan School of Public Health discuss some of the possible remedies for what they describe as a crisis. While some of the solutions they list will require major restructuring of how we deliver health care to mothers, others could take advantage of our current systems by employing a slight shift in emphasis. And here is where those of us on the frontline of care delivery can make a difference.

The researchers point out that “More than 90% of maternal deaths could be prevented if women had access to quality care.” They also observe that most mothers have a single postpartum check with the ob.gyn. facility that delivered the baby and then are often left to navigate the health system because transfer to their primary care and/or mental health professional is haphazard or lacking in follow-up.

As I read through the article it struck me that as pediatricians we could and should be playing a larger role in this critical postpartum period when so many women seem to be falling through the cracks in our health care nonsystem. This is not a great “Ah-ha” moment for which I deserve any credit. In 2010 the American Academy of Pediatrics recommended that mothers be screened for depression at the 1-, 2-, and 4-month visits using either a validated 10-question screening instrument or a more direct 2-question tool (Pediatrics 2010;126[5]:1032-9). However, a periodic survey of AAP members 3 years later revealed that less than a third of the respondents were screening regularly for postpartum depression. In 2019 the academy reemphasized the important role that pediatric primary care givers can play in the detection and early management of the condition.

The reasons for the disappointing response include the list of usual suspects of inadequate training, workload demands, reimbursement, liability concerns, and the difficulty in finding and establishing effective referral networks. Unfortunately, these factors continue to exist, and many cases have multiplied in the wake of the pandemic.

In some states, educational outreach, funding, and changes in the reimbursement structure have resulted in improved outcomes. Not all of us are fortunate enough to live in a state that has made postpartum depression detection and management a priority. However, simply making it our own professional priority can save lives, ease suffering, and improve postpartum outcomes. Here I am talking about first caring and then inquiring about a mother’s mental health. Asking how much sleep she is getting. And then spending the time to give personalized advice on feeding and sleep schedules. Even, if this means ignoring half of the topics on the recommended health maintenance. It doesn’t take but a few minutes to convince yourself that the baby is healthy, and you know that 90% of them are.

However, a new mother who is sleep deprived and already has one foot on the spiral staircase down into postpartum depression represents an emergency. And, you should have the skills to turn it around. But, you have to care about the problem and make it your own priority – high enough on the list to make a follow-up appointment or call in a week instead of waiting a month or 2 until the next visit.

Unfortunately, even with your best efforts there are some families who need services beyond the scope of your practice. Making the necessary referrals can be frustrating and time consuming but not dropping ball until it lands in the appropriate place may save a life.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Tragic, embarrassing, criminal ... Choose your own adjective. The maternal mortality rate in this country is the worst of any developed nation in the world. And the numbers are getting worse with an increase of 14% over the previous year. One-third of these deaths occur weeks or months after the delivery.

In a recent issue of Harvard Public Health, researchers at the T.H. Chan School of Public Health discuss some of the possible remedies for what they describe as a crisis. While some of the solutions they list will require major restructuring of how we deliver health care to mothers, others could take advantage of our current systems by employing a slight shift in emphasis. And here is where those of us on the frontline of care delivery can make a difference.

The researchers point out that “More than 90% of maternal deaths could be prevented if women had access to quality care.” They also observe that most mothers have a single postpartum check with the ob.gyn. facility that delivered the baby and then are often left to navigate the health system because transfer to their primary care and/or mental health professional is haphazard or lacking in follow-up.

As I read through the article it struck me that as pediatricians we could and should be playing a larger role in this critical postpartum period when so many women seem to be falling through the cracks in our health care nonsystem. This is not a great “Ah-ha” moment for which I deserve any credit. In 2010 the American Academy of Pediatrics recommended that mothers be screened for depression at the 1-, 2-, and 4-month visits using either a validated 10-question screening instrument or a more direct 2-question tool (Pediatrics 2010;126[5]:1032-9). However, a periodic survey of AAP members 3 years later revealed that less than a third of the respondents were screening regularly for postpartum depression. In 2019 the academy reemphasized the important role that pediatric primary care givers can play in the detection and early management of the condition.

The reasons for the disappointing response include the list of usual suspects of inadequate training, workload demands, reimbursement, liability concerns, and the difficulty in finding and establishing effective referral networks. Unfortunately, these factors continue to exist, and many cases have multiplied in the wake of the pandemic.

In some states, educational outreach, funding, and changes in the reimbursement structure have resulted in improved outcomes. Not all of us are fortunate enough to live in a state that has made postpartum depression detection and management a priority. However, simply making it our own professional priority can save lives, ease suffering, and improve postpartum outcomes. Here I am talking about first caring and then inquiring about a mother’s mental health. Asking how much sleep she is getting. And then spending the time to give personalized advice on feeding and sleep schedules. Even, if this means ignoring half of the topics on the recommended health maintenance. It doesn’t take but a few minutes to convince yourself that the baby is healthy, and you know that 90% of them are.

However, a new mother who is sleep deprived and already has one foot on the spiral staircase down into postpartum depression represents an emergency. And, you should have the skills to turn it around. But, you have to care about the problem and make it your own priority – high enough on the list to make a follow-up appointment or call in a week instead of waiting a month or 2 until the next visit.

Unfortunately, even with your best efforts there are some families who need services beyond the scope of your practice. Making the necessary referrals can be frustrating and time consuming but not dropping ball until it lands in the appropriate place may save a life.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

The Supreme Court decision to strike down the 50-year ruling on Roe v. Wade, which allowed legal abortion, will affect all patients and families seeking care in pediatric and adolescent medicine clinics. Regardless of how you view abortion, the reality is your adolescent female patients and their parents will seek your counsel.

The overturning of Roe has resulted in much confusion for both patients and providers. The overall effect of this decision in Wisconsin is yet to be known but currently we have had to create road maps to direct adolescent patients who experience an unplanned pregnancy and wish to abort. Unfortunately, these road maps include only resources out of state or online. Providing adolescents confidential care may be challenged as the teens may need to disclose the unplanned pregnancy to an adult to access resources.

Providers remain unsettled regarding their risk of assisting an adolescent who discloses an unplanned pregnancy. Recently, many questions arose regarding dispensing Plan B and the risk to prescribers. Communication was needed to assure providers that Plan B is contraception and at this time contraception remains legal in our state.

Daily I educate adolescent females on the risks of unplanned pregnancy and what the Supreme Court decision will mean to them if they become pregnant. Unfortunately, many teens do not understand the ruling and how this decision affects them personally. Education is needed today more than ever regarding pregnancy prevention.

The recent AAP policy statement reaffirms its position that the rights of adolescents to seek confidential care when considering abortion must be protected.¹ It further reaffirms access to safe and legal abortion is a core tenant of sexual and reproductive health care.

A recent article published in AAP News by Elise D. Berlan, MD, “AAP’s teen reproductive health policies reaffirm right to comprehensive care,” further advises on the role of the pediatric provider.² Pediatric providers should continue offering option counseling for pregnant adolescents, be prepared to provide accurate information regarding these options with awareness that some options such as the IUD may no longer be available, remain supportive of the decision they choose, and encourage discussion with a family member to support their decisions. It is imperative that we familiarize ourselves with the abortion policies in our states, advocate to prevent government interference with the patient-doctor relationship, and recognize the impact restrictive abortion has regarding marginalized individuals, she stated. Finally we must recognize our own bias regarding option counseling and refer appropriately to another professional if we are unable to confidently offer guidance.

Ms. Thew is the medical director of the department of adolescent medicine at Children’s Wisconsin in Milwaukee.

References

1. AAP Committee on Adolescence. Pediatrics. 2022. doi: 10.1542/peds.2022-058780.

2. Berlan ED. AAP’s teen reproductive health policies reaffirm right to comprehensive care. 2022. AAP News.

The Supreme Court decision to strike down the 50-year ruling on Roe v. Wade, which allowed legal abortion, will affect all patients and families seeking care in pediatric and adolescent medicine clinics. Regardless of how you view abortion, the reality is your adolescent female patients and their parents will seek your counsel.

The overturning of Roe has resulted in much confusion for both patients and providers. The overall effect of this decision in Wisconsin is yet to be known but currently we have had to create road maps to direct adolescent patients who experience an unplanned pregnancy and wish to abort. Unfortunately, these road maps include only resources out of state or online. Providing adolescents confidential care may be challenged as the teens may need to disclose the unplanned pregnancy to an adult to access resources.

Providers remain unsettled regarding their risk of assisting an adolescent who discloses an unplanned pregnancy. Recently, many questions arose regarding dispensing Plan B and the risk to prescribers. Communication was needed to assure providers that Plan B is contraception and at this time contraception remains legal in our state.

Daily I educate adolescent females on the risks of unplanned pregnancy and what the Supreme Court decision will mean to them if they become pregnant. Unfortunately, many teens do not understand the ruling and how this decision affects them personally. Education is needed today more than ever regarding pregnancy prevention.

The recent AAP policy statement reaffirms its position that the rights of adolescents to seek confidential care when considering abortion must be protected.¹ It further reaffirms access to safe and legal abortion is a core tenant of sexual and reproductive health care.

A recent article published in AAP News by Elise D. Berlan, MD, “AAP’s teen reproductive health policies reaffirm right to comprehensive care,” further advises on the role of the pediatric provider.² Pediatric providers should continue offering option counseling for pregnant adolescents, be prepared to provide accurate information regarding these options with awareness that some options such as the IUD may no longer be available, remain supportive of the decision they choose, and encourage discussion with a family member to support their decisions. It is imperative that we familiarize ourselves with the abortion policies in our states, advocate to prevent government interference with the patient-doctor relationship, and recognize the impact restrictive abortion has regarding marginalized individuals, she stated. Finally we must recognize our own bias regarding option counseling and refer appropriately to another professional if we are unable to confidently offer guidance.

Ms. Thew is the medical director of the department of adolescent medicine at Children’s Wisconsin in Milwaukee.

References

1. AAP Committee on Adolescence. Pediatrics. 2022. doi: 10.1542/peds.2022-058780.

2. Berlan ED. AAP’s teen reproductive health policies reaffirm right to comprehensive care. 2022. AAP News.

The Supreme Court decision to strike down the 50-year ruling on Roe v. Wade, which allowed legal abortion, will affect all patients and families seeking care in pediatric and adolescent medicine clinics. Regardless of how you view abortion, the reality is your adolescent female patients and their parents will seek your counsel.

The overturning of Roe has resulted in much confusion for both patients and providers. The overall effect of this decision in Wisconsin is yet to be known but currently we have had to create road maps to direct adolescent patients who experience an unplanned pregnancy and wish to abort. Unfortunately, these road maps include only resources out of state or online. Providing adolescents confidential care may be challenged as the teens may need to disclose the unplanned pregnancy to an adult to access resources.

Providers remain unsettled regarding their risk of assisting an adolescent who discloses an unplanned pregnancy. Recently, many questions arose regarding dispensing Plan B and the risk to prescribers. Communication was needed to assure providers that Plan B is contraception and at this time contraception remains legal in our state.

Daily I educate adolescent females on the risks of unplanned pregnancy and what the Supreme Court decision will mean to them if they become pregnant. Unfortunately, many teens do not understand the ruling and how this decision affects them personally. Education is needed today more than ever regarding pregnancy prevention.

The recent AAP policy statement reaffirms its position that the rights of adolescents to seek confidential care when considering abortion must be protected.¹ It further reaffirms access to safe and legal abortion is a core tenant of sexual and reproductive health care.

A recent article published in AAP News by Elise D. Berlan, MD, “AAP’s teen reproductive health policies reaffirm right to comprehensive care,” further advises on the role of the pediatric provider.² Pediatric providers should continue offering option counseling for pregnant adolescents, be prepared to provide accurate information regarding these options with awareness that some options such as the IUD may no longer be available, remain supportive of the decision they choose, and encourage discussion with a family member to support their decisions. It is imperative that we familiarize ourselves with the abortion policies in our states, advocate to prevent government interference with the patient-doctor relationship, and recognize the impact restrictive abortion has regarding marginalized individuals, she stated. Finally we must recognize our own bias regarding option counseling and refer appropriately to another professional if we are unable to confidently offer guidance.

Ms. Thew is the medical director of the department of adolescent medicine at Children’s Wisconsin in Milwaukee.

References

1. AAP Committee on Adolescence. Pediatrics. 2022. doi: 10.1542/peds.2022-058780.

2. Berlan ED. AAP’s teen reproductive health policies reaffirm right to comprehensive care. 2022. AAP News.