Commentary

To the Editor:

Data from the program director survey of the National Resident Matching Program offer key insights into the 2021 dermatology application process.^1,2 Examination of data from the 2020 (N=12) and 2021 (N=17) program director survey regarding interviewing applicants revealed that specialty-specific letters of recommendation (LORs), personal prior knowledge of an applicant, and personal statement increased in importance by 17%, 7.4%, and 17%, respectively, whereas away rotations within the department decreased in importance by 44.9% (Table).^1,2 Interestingly, for ranking applicants, programs decreased their emphasis on specialty-specific LORs by 25.8% and away rotations within the department by 22.7% and increased emphasis on personal statements by 14.7% and personal prior knowledge of an applicant by 0.8% from 2020 to 2021 (Table).^1,2 These findings align with the prior recommendation to limit away rotations; data are contradictory—when comparing factors for interviewing as compared to ranking applicants—for specialty-specific LORs.

We further compared data from the otolaryngology cycle, which implemented preference signaling by which an applicant can signal their interest in a particular residency program in the 2021 Match, to data from dermatology with no preference signaling. A 90% probability of matching is estimated to require approximately 8 or 9 interviews for dermatology or 12 interviews for otolaryngology for MD senior students in 2020.⁴ In prior dermatology application cycles, the most highly qualified candidates constituted 7% to 21% of all applicants but were estimated to receive half of all interviews, causing a maldistribution of interviews.^5,6

For the 2021 otolaryngology match, the Society of University Otolaryngologists implemented a novel preference signaling system that allowed candidates to show interest in programs by sending 5 preferences, or tokens.⁷ Recent data reports from the otolaryngology cycle demonstrated at least a 2-fold increase in the rate of receiving an interview invitation for signaled programs compared to the closest nonsignaled program if applicants were provided an additional token.⁷ Regarding overall applicant competitiveness (ie, dividing participants into quartiles based on their competitiveness), the highest increase in the overall rate of interview invitations (3.5 [total invitations/total applications]) was demonstrated for fourth-quartile (ie, “lowest quartile”) applicants compared with the increase in the overall rate of interview invitations seen in other quartiles (first quartile, an increase of 2.3; second quartile, an increase of 2.6; and third quartile, an increase of 2.4).⁷ We look forward to seeing the impact of preference signaling on the results of the 2022 dermatology cycle.

Despite changes in the interviewing process to accommodate COVID-19 pandemic safety recommendations, the overall dermatology postgraduate year (PGY) 2 fill rate remained unchanged from 2018 (98.6%) to 2021 (98.7%). Zero PGY-1 positions and 5 PGY-2 positions were unfilled in the 2021 Main Residency Match compared to 1 unfilled PGY-1 position and 4 unfilled PGY-2 positions in 2018.⁸ The coordinated interview invitation release, holistic review of applications, increased number of rankings, and virtual interviews might have helped offset potential obstacles imparted by inability to complete away rotations, inability to obtain LORs, and conducting interviews virtually.⁵

A limitation of our analysis is the low response rate of program directors to National Resident Matching Program surveys.

These strategies—holistic application review and coordinated interview release—may be considered in future cycles given their convenience and negligible impact on the dermatology match rate. For example, virtual interviews relieve the financial and time burdens of in-person interviews—approximately $10,000 for each US senior applicant—thus potentially allowing for a more equitable matching process.³ Inversely, in-person interviews allow participants to effectively network and form more meaningful connections while obtaining a better understanding of facilities and surrounding locales. As such, the medical community should continue to come to a consensus on the optimal format to host interviews.

To the Editor:

Data from the program director survey of the National Resident Matching Program offer key insights into the 2021 dermatology application process.^1,2 Examination of data from the 2020 (N=12) and 2021 (N=17) program director survey regarding interviewing applicants revealed that specialty-specific letters of recommendation (LORs), personal prior knowledge of an applicant, and personal statement increased in importance by 17%, 7.4%, and 17%, respectively, whereas away rotations within the department decreased in importance by 44.9% (Table).^1,2 Interestingly, for ranking applicants, programs decreased their emphasis on specialty-specific LORs by 25.8% and away rotations within the department by 22.7% and increased emphasis on personal statements by 14.7% and personal prior knowledge of an applicant by 0.8% from 2020 to 2021 (Table).^1,2 These findings align with the prior recommendation to limit away rotations; data are contradictory—when comparing factors for interviewing as compared to ranking applicants—for specialty-specific LORs.

We further compared data from the otolaryngology cycle, which implemented preference signaling by which an applicant can signal their interest in a particular residency program in the 2021 Match, to data from dermatology with no preference signaling. A 90% probability of matching is estimated to require approximately 8 or 9 interviews for dermatology or 12 interviews for otolaryngology for MD senior students in 2020.⁴ In prior dermatology application cycles, the most highly qualified candidates constituted 7% to 21% of all applicants but were estimated to receive half of all interviews, causing a maldistribution of interviews.^5,6

For the 2021 otolaryngology match, the Society of University Otolaryngologists implemented a novel preference signaling system that allowed candidates to show interest in programs by sending 5 preferences, or tokens.⁷ Recent data reports from the otolaryngology cycle demonstrated at least a 2-fold increase in the rate of receiving an interview invitation for signaled programs compared to the closest nonsignaled program if applicants were provided an additional token.⁷ Regarding overall applicant competitiveness (ie, dividing participants into quartiles based on their competitiveness), the highest increase in the overall rate of interview invitations (3.5 [total invitations/total applications]) was demonstrated for fourth-quartile (ie, “lowest quartile”) applicants compared with the increase in the overall rate of interview invitations seen in other quartiles (first quartile, an increase of 2.3; second quartile, an increase of 2.6; and third quartile, an increase of 2.4).⁷ We look forward to seeing the impact of preference signaling on the results of the 2022 dermatology cycle.

Despite changes in the interviewing process to accommodate COVID-19 pandemic safety recommendations, the overall dermatology postgraduate year (PGY) 2 fill rate remained unchanged from 2018 (98.6%) to 2021 (98.7%). Zero PGY-1 positions and 5 PGY-2 positions were unfilled in the 2021 Main Residency Match compared to 1 unfilled PGY-1 position and 4 unfilled PGY-2 positions in 2018.⁸ The coordinated interview invitation release, holistic review of applications, increased number of rankings, and virtual interviews might have helped offset potential obstacles imparted by inability to complete away rotations, inability to obtain LORs, and conducting interviews virtually.⁵

A limitation of our analysis is the low response rate of program directors to National Resident Matching Program surveys.

These strategies—holistic application review and coordinated interview release—may be considered in future cycles given their convenience and negligible impact on the dermatology match rate. For example, virtual interviews relieve the financial and time burdens of in-person interviews—approximately $10,000 for each US senior applicant—thus potentially allowing for a more equitable matching process.³ Inversely, in-person interviews allow participants to effectively network and form more meaningful connections while obtaining a better understanding of facilities and surrounding locales. As such, the medical community should continue to come to a consensus on the optimal format to host interviews.

To the Editor:

Data from the program director survey of the National Resident Matching Program offer key insights into the 2021 dermatology application process.^1,2 Examination of data from the 2020 (N=12) and 2021 (N=17) program director survey regarding interviewing applicants revealed that specialty-specific letters of recommendation (LORs), personal prior knowledge of an applicant, and personal statement increased in importance by 17%, 7.4%, and 17%, respectively, whereas away rotations within the department decreased in importance by 44.9% (Table).^1,2 Interestingly, for ranking applicants, programs decreased their emphasis on specialty-specific LORs by 25.8% and away rotations within the department by 22.7% and increased emphasis on personal statements by 14.7% and personal prior knowledge of an applicant by 0.8% from 2020 to 2021 (Table).^1,2 These findings align with the prior recommendation to limit away rotations; data are contradictory—when comparing factors for interviewing as compared to ranking applicants—for specialty-specific LORs.

We further compared data from the otolaryngology cycle, which implemented preference signaling by which an applicant can signal their interest in a particular residency program in the 2021 Match, to data from dermatology with no preference signaling. A 90% probability of matching is estimated to require approximately 8 or 9 interviews for dermatology or 12 interviews for otolaryngology for MD senior students in 2020.⁴ In prior dermatology application cycles, the most highly qualified candidates constituted 7% to 21% of all applicants but were estimated to receive half of all interviews, causing a maldistribution of interviews.^5,6

For the 2021 otolaryngology match, the Society of University Otolaryngologists implemented a novel preference signaling system that allowed candidates to show interest in programs by sending 5 preferences, or tokens.⁷ Recent data reports from the otolaryngology cycle demonstrated at least a 2-fold increase in the rate of receiving an interview invitation for signaled programs compared to the closest nonsignaled program if applicants were provided an additional token.⁷ Regarding overall applicant competitiveness (ie, dividing participants into quartiles based on their competitiveness), the highest increase in the overall rate of interview invitations (3.5 [total invitations/total applications]) was demonstrated for fourth-quartile (ie, “lowest quartile”) applicants compared with the increase in the overall rate of interview invitations seen in other quartiles (first quartile, an increase of 2.3; second quartile, an increase of 2.6; and third quartile, an increase of 2.4).⁷ We look forward to seeing the impact of preference signaling on the results of the 2022 dermatology cycle.

Despite changes in the interviewing process to accommodate COVID-19 pandemic safety recommendations, the overall dermatology postgraduate year (PGY) 2 fill rate remained unchanged from 2018 (98.6%) to 2021 (98.7%). Zero PGY-1 positions and 5 PGY-2 positions were unfilled in the 2021 Main Residency Match compared to 1 unfilled PGY-1 position and 4 unfilled PGY-2 positions in 2018.⁸ The coordinated interview invitation release, holistic review of applications, increased number of rankings, and virtual interviews might have helped offset potential obstacles imparted by inability to complete away rotations, inability to obtain LORs, and conducting interviews virtually.⁵

A limitation of our analysis is the low response rate of program directors to National Resident Matching Program surveys.

These strategies—holistic application review and coordinated interview release—may be considered in future cycles given their convenience and negligible impact on the dermatology match rate. For example, virtual interviews relieve the financial and time burdens of in-person interviews—approximately $10,000 for each US senior applicant—thus potentially allowing for a more equitable matching process.³ Inversely, in-person interviews allow participants to effectively network and form more meaningful connections while obtaining a better understanding of facilities and surrounding locales. As such, the medical community should continue to come to a consensus on the optimal format to host interviews.

Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I’m Dr. F. Perry Wilson of the Yale School of Medicine.

It’s pretty clear at this point that myocarditis – inflammation of the heart muscle – is a complication, albeit a very rare one, of the mRNA COVID vaccines. The big question, of course, is why?

To date, it has been a mystery, like “Glass Onion.” And in the spirit of all the great mysteries, to get to the bottom of this, we’ll need to round up the usual suspects.

Appearing in Circulation, a new study does a great job of systematically evaluating multiple hypotheses linking vaccination to myocarditis, and eliminating them, Poirot-style, one by one until only one remains. We’ll get there.

But first, let’s review the suspects. Why do the mRNA vaccines cause myocarditis in a small subset of people?

There are a few leading candidates.

Number one: antibody responses. There are two flavors here. The quantitative hypothesis suggests that some people simply generate too many antibodies to the vaccine, leading to increased inflammation and heart damage.

The qualitative hypothesis suggests that maybe it’s the nature of the antibodies generated rather than the amount; they might cross-react with some protein on the surface of heart cells for instance.

Or maybe it is driven by T-cell responses, which, of course, are independent of antibody levels.

There’s the idea that myocarditis is due to excessive cytokine release – sort of like what we see in the multisystem inflammatory syndrome in children.

Or it could be due to the viral antigens themselves – the spike protein the mRNA codes for that is generated after vaccination.

Dr. F. Perry Wlson

Circulation

Circulation

Circulation

Circulation

Circulation

Circulation

Circulation

Dr. F. Perry Wilson

Of course, all good detectives need to wrap up the case with a good story: How was it all done?

And here’s where we could use Agatha Christie’s help. How could this all work? The vaccine gets injected; mRNA is taken up into cells, where spike protein is generated and released, generating antibody and T-cell responses all the while. Those responses rapidly clear that spike protein from the system – this has been demonstrated in multiple studies – in adults, at least. But in some small number of people, apparently, spike protein is not cleared. Why? It makes no damn sense. Compels me, though. Some have suggested that inadvertent intravenous injection of vaccine, compared with the appropriate intramuscular route, might distribute the vaccine to sites with less immune surveillance. But that is definitely not proven yet.

We are on the path for sure, but this is, as Benoit Blanc would say, a twisted web – and we are not finished untangling it. Not yet.

F. Perry Wilson, MD, MSCE, is an associate professor of medicine and director of Yale’s Clinical and Translational Research Accelerator. His science communication work can be found in the Huffington Post, on NPR, and here. He tweets @fperrywilson and his new book, “How Medicine Works and When It Doesn’t,” is available for preorder now. He reports no conflicts of interest.
 

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

Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I’m Dr. F. Perry Wilson of the Yale School of Medicine.

It’s pretty clear at this point that myocarditis – inflammation of the heart muscle – is a complication, albeit a very rare one, of the mRNA COVID vaccines. The big question, of course, is why?

To date, it has been a mystery, like “Glass Onion.” And in the spirit of all the great mysteries, to get to the bottom of this, we’ll need to round up the usual suspects.

Appearing in Circulation, a new study does a great job of systematically evaluating multiple hypotheses linking vaccination to myocarditis, and eliminating them, Poirot-style, one by one until only one remains. We’ll get there.

But first, let’s review the suspects. Why do the mRNA vaccines cause myocarditis in a small subset of people?

There are a few leading candidates.

Number one: antibody responses. There are two flavors here. The quantitative hypothesis suggests that some people simply generate too many antibodies to the vaccine, leading to increased inflammation and heart damage.

The qualitative hypothesis suggests that maybe it’s the nature of the antibodies generated rather than the amount; they might cross-react with some protein on the surface of heart cells for instance.

Or maybe it is driven by T-cell responses, which, of course, are independent of antibody levels.

There’s the idea that myocarditis is due to excessive cytokine release – sort of like what we see in the multisystem inflammatory syndrome in children.

Or it could be due to the viral antigens themselves – the spike protein the mRNA codes for that is generated after vaccination.

Dr. F. Perry Wlson

Circulation

Circulation

Circulation

Circulation

Circulation

Circulation

Circulation

Dr. F. Perry Wilson

Of course, all good detectives need to wrap up the case with a good story: How was it all done?

And here’s where we could use Agatha Christie’s help. How could this all work? The vaccine gets injected; mRNA is taken up into cells, where spike protein is generated and released, generating antibody and T-cell responses all the while. Those responses rapidly clear that spike protein from the system – this has been demonstrated in multiple studies – in adults, at least. But in some small number of people, apparently, spike protein is not cleared. Why? It makes no damn sense. Compels me, though. Some have suggested that inadvertent intravenous injection of vaccine, compared with the appropriate intramuscular route, might distribute the vaccine to sites with less immune surveillance. But that is definitely not proven yet.

We are on the path for sure, but this is, as Benoit Blanc would say, a twisted web – and we are not finished untangling it. Not yet.

F. Perry Wilson, MD, MSCE, is an associate professor of medicine and director of Yale’s Clinical and Translational Research Accelerator. His science communication work can be found in the Huffington Post, on NPR, and here. He tweets @fperrywilson and his new book, “How Medicine Works and When It Doesn’t,” is available for preorder now. He reports no conflicts of interest.
 

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

Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I’m Dr. F. Perry Wilson of the Yale School of Medicine.

It’s pretty clear at this point that myocarditis – inflammation of the heart muscle – is a complication, albeit a very rare one, of the mRNA COVID vaccines. The big question, of course, is why?

To date, it has been a mystery, like “Glass Onion.” And in the spirit of all the great mysteries, to get to the bottom of this, we’ll need to round up the usual suspects.

Appearing in Circulation, a new study does a great job of systematically evaluating multiple hypotheses linking vaccination to myocarditis, and eliminating them, Poirot-style, one by one until only one remains. We’ll get there.

But first, let’s review the suspects. Why do the mRNA vaccines cause myocarditis in a small subset of people?

There are a few leading candidates.

Number one: antibody responses. There are two flavors here. The quantitative hypothesis suggests that some people simply generate too many antibodies to the vaccine, leading to increased inflammation and heart damage.

The qualitative hypothesis suggests that maybe it’s the nature of the antibodies generated rather than the amount; they might cross-react with some protein on the surface of heart cells for instance.

Or maybe it is driven by T-cell responses, which, of course, are independent of antibody levels.

There’s the idea that myocarditis is due to excessive cytokine release – sort of like what we see in the multisystem inflammatory syndrome in children.

Or it could be due to the viral antigens themselves – the spike protein the mRNA codes for that is generated after vaccination.

Dr. F. Perry Wlson

Circulation

Circulation

Circulation

Circulation

Circulation

Circulation

Circulation

Dr. F. Perry Wilson

Of course, all good detectives need to wrap up the case with a good story: How was it all done?

And here’s where we could use Agatha Christie’s help. How could this all work? The vaccine gets injected; mRNA is taken up into cells, where spike protein is generated and released, generating antibody and T-cell responses all the while. Those responses rapidly clear that spike protein from the system – this has been demonstrated in multiple studies – in adults, at least. But in some small number of people, apparently, spike protein is not cleared. Why? It makes no damn sense. Compels me, though. Some have suggested that inadvertent intravenous injection of vaccine, compared with the appropriate intramuscular route, might distribute the vaccine to sites with less immune surveillance. But that is definitely not proven yet.

We are on the path for sure, but this is, as Benoit Blanc would say, a twisted web – and we are not finished untangling it. Not yet.

F. Perry Wilson, MD, MSCE, is an associate professor of medicine and director of Yale’s Clinical and Translational Research Accelerator. His science communication work can be found in the Huffington Post, on NPR, and here. He tweets @fperrywilson and his new book, “How Medicine Works and When It Doesn’t,” is available for preorder now. He reports no conflicts of interest.
 

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

I received a call late one night from a colleague in the emergency department of the children’s hospital. “This 2-year-old has a fever, cough, red eyes, and an impressive rash. I’ve personally never seen a case of measles, but I’m worried given that this child has never received the MMR vaccine.”

By the end of the call, I was worried too. Measles is a febrile respiratory illness classically accompanied by cough, coryza, conjunctivitis, and a characteristic maculopapular rash that begins on the face and spreads to the trunk and limbs. It is also highly contagious: 90% percent of susceptible, exposed individuals become infected.

Admittedly, measles is rare. Just 118 cases were reported in the United States in 2022, but 83 of those were in Columbus just 3 hours from where my colleague and I live and work. According to City of Columbus officials, the outbreak occurred almost exclusively in unimmunized children, the majority of whom were 5 years and younger. An unexpectedly high number of children were hospitalized. Typically, one in five people with measles will require hospitalization. In this outbreak, 33 children have been hospitalized as of Jan. 10.

Public health experts warn that 2023 could be much worse unless we increase measles immunization rates in the United States and globally. Immunization of around 95% of eligible people with two doses of measles-containing vaccine is associated with herd immunity. Globally, we’re falling short. Only 81% of the world’s children have received their first measle vaccine dose and only 71% have received the second dose. These are the lowest coverage rates for measles vaccine since 2008.

A 2022 joint press release from the Centers for Disease Control and Prevention and the World Health Organization noted that “measles anywhere is a threat everywhere, as the virus can quickly spread to multiple communities and across international borders.” Some prior measles outbreaks in the United States have started with a case in an international traveler or a U.S. resident who contracted measles during travel abroad.

In the United States, the number of children immunized with multiple routine vaccines has fallen in the last couple of years, in part because of pandemic-related disruptions in health care delivery. Increasing vaccine hesitancy, fueled by debates over the COVID-19 vaccine, may be slowing catch-up immunization in kids who fell behind.

Investigators from Emory University, Atlanta, and Marshfield Clinic Research Institute recently estimated that 9,145,026 U.S. children are susceptible to measles. If pandemic-level immunization rates continue without effective catch-up immunization, that number could rise to more than 15 million.

School vaccination requirements support efforts to ensure that kids are protected against vaccine-preventable diseases, but some data suggest that opposition to requiring MMR vaccine to attend public school is growing. According to a 2022 Kaiser Family Foundation Vaccine Monitor survey, 28% of U.S. adults – and 35% of parents of children under 18 – now say that parents should be able to decide to not vaccinate their children for measles, mumps, and rubella. That’s up from 16% of adults and 23% of parents in a 2019 Pew Research Center poll.

Public confidence in the benefits of MMR has also dropped modestly. About 85% of adults surveyed said that the benefits of MMR vaccine outweigh the risk, down from 88% in 2019. Among adults not vaccinated against COVID-19, only 70% said that benefits of these vaccines outweigh the risks.

While the WHO ramps up efforts to improve measles vaccination globally, pediatric clinicians can take steps now to mitigate the risk of measles outbreaks in their own communities. Query health records to understand how many eligible children in your practice have not yet received MMR vaccine. Notify families that vaccination is strongly recommended and make scheduling an appointment to receive vaccine easy. Some practices may have the bandwidth to offer evening and weekend hours for vaccine catch-up visits.

Curious about immunization rates in your state? The American Academy of Pediatrics has an interactive map that reports immunization coverage levels by state and provides comparisons to national rates and goals.

Prompt recognition and isolation of individuals with measles, along with prophylaxis of susceptible contacts, can limit community transmission. Measles can resemble other illnesses associated with fever and rash. Washington state has developed a screening tool to assist with recognition of measles. The CDC also has a measles outbreak toolkit that includes resources that outline clinical features and diagnoses, as well as strategies for talking to parents about vaccines.
 

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022-2023. The opinions expressed in this article are her own. Dr. Bryant disclosed that she has served as an investigator on clinical trials funded by Pfizer, Enanta, and Gilead. Email her at [email protected].

I received a call late one night from a colleague in the emergency department of the children’s hospital. “This 2-year-old has a fever, cough, red eyes, and an impressive rash. I’ve personally never seen a case of measles, but I’m worried given that this child has never received the MMR vaccine.”

By the end of the call, I was worried too. Measles is a febrile respiratory illness classically accompanied by cough, coryza, conjunctivitis, and a characteristic maculopapular rash that begins on the face and spreads to the trunk and limbs. It is also highly contagious: 90% percent of susceptible, exposed individuals become infected.

Admittedly, measles is rare. Just 118 cases were reported in the United States in 2022, but 83 of those were in Columbus just 3 hours from where my colleague and I live and work. According to City of Columbus officials, the outbreak occurred almost exclusively in unimmunized children, the majority of whom were 5 years and younger. An unexpectedly high number of children were hospitalized. Typically, one in five people with measles will require hospitalization. In this outbreak, 33 children have been hospitalized as of Jan. 10.

Public health experts warn that 2023 could be much worse unless we increase measles immunization rates in the United States and globally. Immunization of around 95% of eligible people with two doses of measles-containing vaccine is associated with herd immunity. Globally, we’re falling short. Only 81% of the world’s children have received their first measle vaccine dose and only 71% have received the second dose. These are the lowest coverage rates for measles vaccine since 2008.

A 2022 joint press release from the Centers for Disease Control and Prevention and the World Health Organization noted that “measles anywhere is a threat everywhere, as the virus can quickly spread to multiple communities and across international borders.” Some prior measles outbreaks in the United States have started with a case in an international traveler or a U.S. resident who contracted measles during travel abroad.

In the United States, the number of children immunized with multiple routine vaccines has fallen in the last couple of years, in part because of pandemic-related disruptions in health care delivery. Increasing vaccine hesitancy, fueled by debates over the COVID-19 vaccine, may be slowing catch-up immunization in kids who fell behind.

Investigators from Emory University, Atlanta, and Marshfield Clinic Research Institute recently estimated that 9,145,026 U.S. children are susceptible to measles. If pandemic-level immunization rates continue without effective catch-up immunization, that number could rise to more than 15 million.

School vaccination requirements support efforts to ensure that kids are protected against vaccine-preventable diseases, but some data suggest that opposition to requiring MMR vaccine to attend public school is growing. According to a 2022 Kaiser Family Foundation Vaccine Monitor survey, 28% of U.S. adults – and 35% of parents of children under 18 – now say that parents should be able to decide to not vaccinate their children for measles, mumps, and rubella. That’s up from 16% of adults and 23% of parents in a 2019 Pew Research Center poll.

Public confidence in the benefits of MMR has also dropped modestly. About 85% of adults surveyed said that the benefits of MMR vaccine outweigh the risk, down from 88% in 2019. Among adults not vaccinated against COVID-19, only 70% said that benefits of these vaccines outweigh the risks.

While the WHO ramps up efforts to improve measles vaccination globally, pediatric clinicians can take steps now to mitigate the risk of measles outbreaks in their own communities. Query health records to understand how many eligible children in your practice have not yet received MMR vaccine. Notify families that vaccination is strongly recommended and make scheduling an appointment to receive vaccine easy. Some practices may have the bandwidth to offer evening and weekend hours for vaccine catch-up visits.

Curious about immunization rates in your state? The American Academy of Pediatrics has an interactive map that reports immunization coverage levels by state and provides comparisons to national rates and goals.

Prompt recognition and isolation of individuals with measles, along with prophylaxis of susceptible contacts, can limit community transmission. Measles can resemble other illnesses associated with fever and rash. Washington state has developed a screening tool to assist with recognition of measles. The CDC also has a measles outbreak toolkit that includes resources that outline clinical features and diagnoses, as well as strategies for talking to parents about vaccines.
 

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022-2023. The opinions expressed in this article are her own. Dr. Bryant disclosed that she has served as an investigator on clinical trials funded by Pfizer, Enanta, and Gilead. Email her at [email protected].

I received a call late one night from a colleague in the emergency department of the children’s hospital. “This 2-year-old has a fever, cough, red eyes, and an impressive rash. I’ve personally never seen a case of measles, but I’m worried given that this child has never received the MMR vaccine.”

By the end of the call, I was worried too. Measles is a febrile respiratory illness classically accompanied by cough, coryza, conjunctivitis, and a characteristic maculopapular rash that begins on the face and spreads to the trunk and limbs. It is also highly contagious: 90% percent of susceptible, exposed individuals become infected.

Admittedly, measles is rare. Just 118 cases were reported in the United States in 2022, but 83 of those were in Columbus just 3 hours from where my colleague and I live and work. According to City of Columbus officials, the outbreak occurred almost exclusively in unimmunized children, the majority of whom were 5 years and younger. An unexpectedly high number of children were hospitalized. Typically, one in five people with measles will require hospitalization. In this outbreak, 33 children have been hospitalized as of Jan. 10.

Public health experts warn that 2023 could be much worse unless we increase measles immunization rates in the United States and globally. Immunization of around 95% of eligible people with two doses of measles-containing vaccine is associated with herd immunity. Globally, we’re falling short. Only 81% of the world’s children have received their first measle vaccine dose and only 71% have received the second dose. These are the lowest coverage rates for measles vaccine since 2008.

A 2022 joint press release from the Centers for Disease Control and Prevention and the World Health Organization noted that “measles anywhere is a threat everywhere, as the virus can quickly spread to multiple communities and across international borders.” Some prior measles outbreaks in the United States have started with a case in an international traveler or a U.S. resident who contracted measles during travel abroad.

In the United States, the number of children immunized with multiple routine vaccines has fallen in the last couple of years, in part because of pandemic-related disruptions in health care delivery. Increasing vaccine hesitancy, fueled by debates over the COVID-19 vaccine, may be slowing catch-up immunization in kids who fell behind.

Investigators from Emory University, Atlanta, and Marshfield Clinic Research Institute recently estimated that 9,145,026 U.S. children are susceptible to measles. If pandemic-level immunization rates continue without effective catch-up immunization, that number could rise to more than 15 million.

School vaccination requirements support efforts to ensure that kids are protected against vaccine-preventable diseases, but some data suggest that opposition to requiring MMR vaccine to attend public school is growing. According to a 2022 Kaiser Family Foundation Vaccine Monitor survey, 28% of U.S. adults – and 35% of parents of children under 18 – now say that parents should be able to decide to not vaccinate their children for measles, mumps, and rubella. That’s up from 16% of adults and 23% of parents in a 2019 Pew Research Center poll.

Public confidence in the benefits of MMR has also dropped modestly. About 85% of adults surveyed said that the benefits of MMR vaccine outweigh the risk, down from 88% in 2019. Among adults not vaccinated against COVID-19, only 70% said that benefits of these vaccines outweigh the risks.

While the WHO ramps up efforts to improve measles vaccination globally, pediatric clinicians can take steps now to mitigate the risk of measles outbreaks in their own communities. Query health records to understand how many eligible children in your practice have not yet received MMR vaccine. Notify families that vaccination is strongly recommended and make scheduling an appointment to receive vaccine easy. Some practices may have the bandwidth to offer evening and weekend hours for vaccine catch-up visits.

Curious about immunization rates in your state? The American Academy of Pediatrics has an interactive map that reports immunization coverage levels by state and provides comparisons to national rates and goals.

Prompt recognition and isolation of individuals with measles, along with prophylaxis of susceptible contacts, can limit community transmission. Measles can resemble other illnesses associated with fever and rash. Washington state has developed a screening tool to assist with recognition of measles. The CDC also has a measles outbreak toolkit that includes resources that outline clinical features and diagnoses, as well as strategies for talking to parents about vaccines.
 

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022-2023. The opinions expressed in this article are her own. Dr. Bryant disclosed that she has served as an investigator on clinical trials funded by Pfizer, Enanta, and Gilead. Email her at [email protected].

Attention-deficit/hyperactivity disorder (ADHD) is often a very challenging condition for parents to manage, both because of the “gleeful mayhem” children with ADHD manifest and because of the nature of effective treatments. Multiple randomized controlled studies and meta-analyses have demonstrated that stimulant medication with behavioral interventions is the optimal first-line treatment for children with both subtypes of ADHD, and that medications alone are superior to behavioral interventions alone. By improving attention and impulse control, the medications effectively decrease the many negative interactions with teachers, peers, and parents, aiding development and healthy self-esteem.

But many parents feel anxious about treating their young children with stimulants. Importantly, how children with ADHD will fare as adults is not predicted by their symptom level, but instead by the quality of their relationships with their parents, their ability to perform at school, and their social skills. Bring this framework to parents as you listen to their questions and help them decide on the best approach for their family. To assist you in these conversations, we will review the evidence for (or against) several of the most common alternatives to medication that parents are likely to ask about.
 

Diets and supplements

Dietary modifications are among the most popular “natural” approaches to managing ADHD in children. Diets that eliminate processed sugars or food additives (particularly artificial food coloring) are among the most common approaches discussed in the lay press. These diets are usually very time-consuming and disruptive for families to follow, and there is no evidence to support their general use in ADHD management. Those studies that rigorously examined them suggest that, for children with severe impairment who have failed to respond to medications for ADHD, a workup for food intolerance or nutritional deficits may reveal a different problem underlying their behavioral difficulties.¹

Similarly, supplementation with high-dose omega-3 fatty acids is modestly helpful only in a subset of children with ADHD symptoms, and not nearly as effective as medications or behavioral interventions. Spending time on an exacting diet or buying expensive supplements is very unlikely to relieve the children’s symptoms and may only add to their stress at home. The “sugar high” parents note may be the rare joy of eating a candy bar and not sugar causing ADHD. Offer parents the guidance to focus on a healthy diet, high in fruits and vegetables, whole grains, and healthy protein, and on meals that emphasize family time instead of struggles around food.
 

Neurofeedback

Neurofeedback is an approach that grew out of the observation that many adults with ADHD had resting patterns of brain wave activity different from those of neurotypical adults. In neurofeedback, patients learn strategies that amplify the brain waves associated with focused mental activity, rather than listless or hyperactive states. Businesses market this service for all sorts of illnesses and challenges, ADHD chief among them. Despite the marketing, there are very few randomized controlled studies of this intervention for ADHD in youth, and those have shown only the possibility of a benefit.

While there is no evidence of serious side effects, these treatments are time-consuming and expensive and unlikely to be covered by any insurance. You might suggest to parents that they could achieve some of the same theoretical benefits by looking for hobbies that invite sustained focus in their children. That is, they should think about activities that interest the children, such as music lessons or karate, that they could practice in classes and at home. If the children find these activities even somewhat interesting (or just enjoy the reward of their parents’ or teachers’ attention), regular practice will be supporting their developing attention while building social skills and authentic self-confidence, rather than the activities feeling like a treatment for an illness or condition.

Sleep and exercise

There are not many businesses or books selling worried and exhausted parents a quick nonmedication solution for their children’s ADHD in the form of healthy sleep and exercise habits. But these are safe and healthy ways to reduce symptoms and support development. Children with ADHD often enjoy and benefit from participating in a sport, and daily exercise can help with sleep and regulating their energy. They also often have difficulty with sleep initiation, and commonly do not get adequate or restful sleep. Inadequate sleep exacerbates inattention, distractibility, and irritability. Children with untreated ADHD also often spend a lot of time on screens, as it is difficult for them to shift away from rewarding activities, and parents can find screen time to be a welcome break from hyperactivity and negative interactions. But excessive screen time, especially close to bedtime, can worsen irritability and make sleep more difficult. Talk with parents about the value of establishing a routine around screen time, modest daily physical activity, and sleep that everyone can follow. If their family life is currently marked by late bedtimes and long hours in front of video games, this change will take effort. But within a few weeks, it could lead to significant improvements in energy, attention, and interactions at home.

Behavioral treatments

Effective behavioral treatments for ADHD do not change ADHD symptoms, but they do help children learn how to manage them. In “parent management training,” younger children and parents learn together how to avoid negative cycles of behavior (i.e., temper outbursts) by focusing on consistent routines and consequences that support children calmly learning to manage their impulses. The only other evidence-based treatment focuses on helping school age and older children develop executive functions – their planning, organization, and time management skills – with a range of age-appropriate tools. Both of these therapies may be more effective if the children are also receiving medication, but medication is not necessary for them to be helpful. It is important to note that play therapy and other evidence-based psychotherapies are not effective for management of ADHD, although they may treat comorbid problems.

Parent treatment

You may have diagnosed children with ADHD only to hear their parents respond by saying that they suspect (or know) that they (or their spouses) also have ADHD. This would not be surprising, as ADHD has one of the highest rates of heritability of psychiatric disorders, at 80%. Somewhere between 25% and 50% of parents of children with ADHD have ADHD themselves.² Screening for adults with ADHD, such as the Adult ADHD Self-Report Scale, is widely available and free. Speak with parents about the fact that behavioral treatments for their children’s ADHD are demanding. Such treatments require patience, calm, organization, and consistency.

If parents have ADHD, it may be very helpful for them to prioritize their own effective treatments, so that their attention and impulse control will support their parenting. They may be interested in learning about how treatment might also improve their performance at work and even the quality of their relationships. While there is some evidence that their children’s treatment outcome will hinge on the parents’ treatment,³ they deserve good care independent of the expectations of parenting.

Families benefit from a comprehensive “ADHD plan” for their children. This would start with an assessment of the severity of their children’s symptoms, specifying their impairment at home, school, and in social relationships. It would include their nonacademic performance, exploration of interests, and developing self-confidence. All of these considerations lead to setting reasonable expectations so the children can feel successful. Parents should think about how best to structure their children’s schedules to promote healthy sleep, exercise, and nutrition, and to expand opportunities for building their frustration tolerance, social skills, and executive function.

Parents will need to consider what kind of supports they themselves need to offer this structure. There are good resources available online for information and support, including Children and Adults with ADHD (chadd.org) and the ADHD Resource Center from the American Academy of Child and Adolescent Psychiatry (aacap.org). This approach may help parents to evaluate the potential risks and benefits of medications as a component of treatment. Most of the quick fixes for childhood ADHD on the market will take a family’s time and money without providing meaningful improvement. Parents should focus instead on the tried-and-true routines and supports that will help them to create the setting at home that will enable their children to flourish.
 

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

References

1. Millichap JG and Yee MM. Pediatrics. 2012 Feb;129(2):330-7.

2. Grimm O et al. Curr Psychiatry Rep. 2020 Feb 27;22(4):18.

3. Chronis-Tuscano A et al. J Abnorm Child Psychol. 2017 Apr;45(3):501-7.

Attention-deficit/hyperactivity disorder (ADHD) is often a very challenging condition for parents to manage, both because of the “gleeful mayhem” children with ADHD manifest and because of the nature of effective treatments. Multiple randomized controlled studies and meta-analyses have demonstrated that stimulant medication with behavioral interventions is the optimal first-line treatment for children with both subtypes of ADHD, and that medications alone are superior to behavioral interventions alone. By improving attention and impulse control, the medications effectively decrease the many negative interactions with teachers, peers, and parents, aiding development and healthy self-esteem.

But many parents feel anxious about treating their young children with stimulants. Importantly, how children with ADHD will fare as adults is not predicted by their symptom level, but instead by the quality of their relationships with their parents, their ability to perform at school, and their social skills. Bring this framework to parents as you listen to their questions and help them decide on the best approach for their family. To assist you in these conversations, we will review the evidence for (or against) several of the most common alternatives to medication that parents are likely to ask about.
 

Diets and supplements

Dietary modifications are among the most popular “natural” approaches to managing ADHD in children. Diets that eliminate processed sugars or food additives (particularly artificial food coloring) are among the most common approaches discussed in the lay press. These diets are usually very time-consuming and disruptive for families to follow, and there is no evidence to support their general use in ADHD management. Those studies that rigorously examined them suggest that, for children with severe impairment who have failed to respond to medications for ADHD, a workup for food intolerance or nutritional deficits may reveal a different problem underlying their behavioral difficulties.¹

Similarly, supplementation with high-dose omega-3 fatty acids is modestly helpful only in a subset of children with ADHD symptoms, and not nearly as effective as medications or behavioral interventions. Spending time on an exacting diet or buying expensive supplements is very unlikely to relieve the children’s symptoms and may only add to their stress at home. The “sugar high” parents note may be the rare joy of eating a candy bar and not sugar causing ADHD. Offer parents the guidance to focus on a healthy diet, high in fruits and vegetables, whole grains, and healthy protein, and on meals that emphasize family time instead of struggles around food.
 

Neurofeedback

Neurofeedback is an approach that grew out of the observation that many adults with ADHD had resting patterns of brain wave activity different from those of neurotypical adults. In neurofeedback, patients learn strategies that amplify the brain waves associated with focused mental activity, rather than listless or hyperactive states. Businesses market this service for all sorts of illnesses and challenges, ADHD chief among them. Despite the marketing, there are very few randomized controlled studies of this intervention for ADHD in youth, and those have shown only the possibility of a benefit.

While there is no evidence of serious side effects, these treatments are time-consuming and expensive and unlikely to be covered by any insurance. You might suggest to parents that they could achieve some of the same theoretical benefits by looking for hobbies that invite sustained focus in their children. That is, they should think about activities that interest the children, such as music lessons or karate, that they could practice in classes and at home. If the children find these activities even somewhat interesting (or just enjoy the reward of their parents’ or teachers’ attention), regular practice will be supporting their developing attention while building social skills and authentic self-confidence, rather than the activities feeling like a treatment for an illness or condition.

Sleep and exercise

There are not many businesses or books selling worried and exhausted parents a quick nonmedication solution for their children’s ADHD in the form of healthy sleep and exercise habits. But these are safe and healthy ways to reduce symptoms and support development. Children with ADHD often enjoy and benefit from participating in a sport, and daily exercise can help with sleep and regulating their energy. They also often have difficulty with sleep initiation, and commonly do not get adequate or restful sleep. Inadequate sleep exacerbates inattention, distractibility, and irritability. Children with untreated ADHD also often spend a lot of time on screens, as it is difficult for them to shift away from rewarding activities, and parents can find screen time to be a welcome break from hyperactivity and negative interactions. But excessive screen time, especially close to bedtime, can worsen irritability and make sleep more difficult. Talk with parents about the value of establishing a routine around screen time, modest daily physical activity, and sleep that everyone can follow. If their family life is currently marked by late bedtimes and long hours in front of video games, this change will take effort. But within a few weeks, it could lead to significant improvements in energy, attention, and interactions at home.

Behavioral treatments

Effective behavioral treatments for ADHD do not change ADHD symptoms, but they do help children learn how to manage them. In “parent management training,” younger children and parents learn together how to avoid negative cycles of behavior (i.e., temper outbursts) by focusing on consistent routines and consequences that support children calmly learning to manage their impulses. The only other evidence-based treatment focuses on helping school age and older children develop executive functions – their planning, organization, and time management skills – with a range of age-appropriate tools. Both of these therapies may be more effective if the children are also receiving medication, but medication is not necessary for them to be helpful. It is important to note that play therapy and other evidence-based psychotherapies are not effective for management of ADHD, although they may treat comorbid problems.

Parent treatment

You may have diagnosed children with ADHD only to hear their parents respond by saying that they suspect (or know) that they (or their spouses) also have ADHD. This would not be surprising, as ADHD has one of the highest rates of heritability of psychiatric disorders, at 80%. Somewhere between 25% and 50% of parents of children with ADHD have ADHD themselves.² Screening for adults with ADHD, such as the Adult ADHD Self-Report Scale, is widely available and free. Speak with parents about the fact that behavioral treatments for their children’s ADHD are demanding. Such treatments require patience, calm, organization, and consistency.

If parents have ADHD, it may be very helpful for them to prioritize their own effective treatments, so that their attention and impulse control will support their parenting. They may be interested in learning about how treatment might also improve their performance at work and even the quality of their relationships. While there is some evidence that their children’s treatment outcome will hinge on the parents’ treatment,³ they deserve good care independent of the expectations of parenting.

Families benefit from a comprehensive “ADHD plan” for their children. This would start with an assessment of the severity of their children’s symptoms, specifying their impairment at home, school, and in social relationships. It would include their nonacademic performance, exploration of interests, and developing self-confidence. All of these considerations lead to setting reasonable expectations so the children can feel successful. Parents should think about how best to structure their children’s schedules to promote healthy sleep, exercise, and nutrition, and to expand opportunities for building their frustration tolerance, social skills, and executive function.

Parents will need to consider what kind of supports they themselves need to offer this structure. There are good resources available online for information and support, including Children and Adults with ADHD (chadd.org) and the ADHD Resource Center from the American Academy of Child and Adolescent Psychiatry (aacap.org). This approach may help parents to evaluate the potential risks and benefits of medications as a component of treatment. Most of the quick fixes for childhood ADHD on the market will take a family’s time and money without providing meaningful improvement. Parents should focus instead on the tried-and-true routines and supports that will help them to create the setting at home that will enable their children to flourish.
 

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

References

1. Millichap JG and Yee MM. Pediatrics. 2012 Feb;129(2):330-7.

2. Grimm O et al. Curr Psychiatry Rep. 2020 Feb 27;22(4):18.

3. Chronis-Tuscano A et al. J Abnorm Child Psychol. 2017 Apr;45(3):501-7.

Attention-deficit/hyperactivity disorder (ADHD) is often a very challenging condition for parents to manage, both because of the “gleeful mayhem” children with ADHD manifest and because of the nature of effective treatments. Multiple randomized controlled studies and meta-analyses have demonstrated that stimulant medication with behavioral interventions is the optimal first-line treatment for children with both subtypes of ADHD, and that medications alone are superior to behavioral interventions alone. By improving attention and impulse control, the medications effectively decrease the many negative interactions with teachers, peers, and parents, aiding development and healthy self-esteem.

But many parents feel anxious about treating their young children with stimulants. Importantly, how children with ADHD will fare as adults is not predicted by their symptom level, but instead by the quality of their relationships with their parents, their ability to perform at school, and their social skills. Bring this framework to parents as you listen to their questions and help them decide on the best approach for their family. To assist you in these conversations, we will review the evidence for (or against) several of the most common alternatives to medication that parents are likely to ask about.
 

Diets and supplements

Dietary modifications are among the most popular “natural” approaches to managing ADHD in children. Diets that eliminate processed sugars or food additives (particularly artificial food coloring) are among the most common approaches discussed in the lay press. These diets are usually very time-consuming and disruptive for families to follow, and there is no evidence to support their general use in ADHD management. Those studies that rigorously examined them suggest that, for children with severe impairment who have failed to respond to medications for ADHD, a workup for food intolerance or nutritional deficits may reveal a different problem underlying their behavioral difficulties.¹

Similarly, supplementation with high-dose omega-3 fatty acids is modestly helpful only in a subset of children with ADHD symptoms, and not nearly as effective as medications or behavioral interventions. Spending time on an exacting diet or buying expensive supplements is very unlikely to relieve the children’s symptoms and may only add to their stress at home. The “sugar high” parents note may be the rare joy of eating a candy bar and not sugar causing ADHD. Offer parents the guidance to focus on a healthy diet, high in fruits and vegetables, whole grains, and healthy protein, and on meals that emphasize family time instead of struggles around food.
 

Neurofeedback

Neurofeedback is an approach that grew out of the observation that many adults with ADHD had resting patterns of brain wave activity different from those of neurotypical adults. In neurofeedback, patients learn strategies that amplify the brain waves associated with focused mental activity, rather than listless or hyperactive states. Businesses market this service for all sorts of illnesses and challenges, ADHD chief among them. Despite the marketing, there are very few randomized controlled studies of this intervention for ADHD in youth, and those have shown only the possibility of a benefit.

While there is no evidence of serious side effects, these treatments are time-consuming and expensive and unlikely to be covered by any insurance. You might suggest to parents that they could achieve some of the same theoretical benefits by looking for hobbies that invite sustained focus in their children. That is, they should think about activities that interest the children, such as music lessons or karate, that they could practice in classes and at home. If the children find these activities even somewhat interesting (or just enjoy the reward of their parents’ or teachers’ attention), regular practice will be supporting their developing attention while building social skills and authentic self-confidence, rather than the activities feeling like a treatment for an illness or condition.

Sleep and exercise

There are not many businesses or books selling worried and exhausted parents a quick nonmedication solution for their children’s ADHD in the form of healthy sleep and exercise habits. But these are safe and healthy ways to reduce symptoms and support development. Children with ADHD often enjoy and benefit from participating in a sport, and daily exercise can help with sleep and regulating their energy. They also often have difficulty with sleep initiation, and commonly do not get adequate or restful sleep. Inadequate sleep exacerbates inattention, distractibility, and irritability. Children with untreated ADHD also often spend a lot of time on screens, as it is difficult for them to shift away from rewarding activities, and parents can find screen time to be a welcome break from hyperactivity and negative interactions. But excessive screen time, especially close to bedtime, can worsen irritability and make sleep more difficult. Talk with parents about the value of establishing a routine around screen time, modest daily physical activity, and sleep that everyone can follow. If their family life is currently marked by late bedtimes and long hours in front of video games, this change will take effort. But within a few weeks, it could lead to significant improvements in energy, attention, and interactions at home.

Behavioral treatments

Effective behavioral treatments for ADHD do not change ADHD symptoms, but they do help children learn how to manage them. In “parent management training,” younger children and parents learn together how to avoid negative cycles of behavior (i.e., temper outbursts) by focusing on consistent routines and consequences that support children calmly learning to manage their impulses. The only other evidence-based treatment focuses on helping school age and older children develop executive functions – their planning, organization, and time management skills – with a range of age-appropriate tools. Both of these therapies may be more effective if the children are also receiving medication, but medication is not necessary for them to be helpful. It is important to note that play therapy and other evidence-based psychotherapies are not effective for management of ADHD, although they may treat comorbid problems.

Parent treatment

You may have diagnosed children with ADHD only to hear their parents respond by saying that they suspect (or know) that they (or their spouses) also have ADHD. This would not be surprising, as ADHD has one of the highest rates of heritability of psychiatric disorders, at 80%. Somewhere between 25% and 50% of parents of children with ADHD have ADHD themselves.² Screening for adults with ADHD, such as the Adult ADHD Self-Report Scale, is widely available and free. Speak with parents about the fact that behavioral treatments for their children’s ADHD are demanding. Such treatments require patience, calm, organization, and consistency.

If parents have ADHD, it may be very helpful for them to prioritize their own effective treatments, so that their attention and impulse control will support their parenting. They may be interested in learning about how treatment might also improve their performance at work and even the quality of their relationships. While there is some evidence that their children’s treatment outcome will hinge on the parents’ treatment,³ they deserve good care independent of the expectations of parenting.

Families benefit from a comprehensive “ADHD plan” for their children. This would start with an assessment of the severity of their children’s symptoms, specifying their impairment at home, school, and in social relationships. It would include their nonacademic performance, exploration of interests, and developing self-confidence. All of these considerations lead to setting reasonable expectations so the children can feel successful. Parents should think about how best to structure their children’s schedules to promote healthy sleep, exercise, and nutrition, and to expand opportunities for building their frustration tolerance, social skills, and executive function.

Parents will need to consider what kind of supports they themselves need to offer this structure. There are good resources available online for information and support, including Children and Adults with ADHD (chadd.org) and the ADHD Resource Center from the American Academy of Child and Adolescent Psychiatry (aacap.org). This approach may help parents to evaluate the potential risks and benefits of medications as a component of treatment. Most of the quick fixes for childhood ADHD on the market will take a family’s time and money without providing meaningful improvement. Parents should focus instead on the tried-and-true routines and supports that will help them to create the setting at home that will enable their children to flourish.
 

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

References

1. Millichap JG and Yee MM. Pediatrics. 2012 Feb;129(2):330-7.

2. Grimm O et al. Curr Psychiatry Rep. 2020 Feb 27;22(4):18.

3. Chronis-Tuscano A et al. J Abnorm Child Psychol. 2017 Apr;45(3):501-7.

This transcript has been edited for clarity.

Hello. This is Dr. JoAnn Manson, professor of medicine at Harvard Medical School and Brigham and Women’s Hospital. I’d like to talk with you about a recent report in JAMA Cardiology on atrial fibrillation (AF), sex differences, and modifiable risk factors.

We looked at these questions in our vitamin D and omega-3 trial VITAL in an ancillary study called VITAL Rhythm, led by Dr. Christine Albert at Cedars-Sinai. And this particular project was led by Dr. Hasan Siddiqi at Vanderbilt.

As you know, AF is the most common arrhythmia in the world, and it’s burgeoning in numbers, primarily because of the aging of the population. It’s also a major cause of stroke, heart failure, and cardiovascular mortality. Although women are known to have lower rates of AF than men, they’re also known to have a higher risk for cardiovascular complications and sequelae, such as higher risk for stroke and CVD mortality. Therefore, we thought that understanding sex differences in risk and modifiable risk factors for AF that could reduce the burden of disease would be important.

It’s known that greater height is a risk factor for AF, but the extent to which it explains the differences in AF risk between men and women isn’t really known. So we looked at these questions in the VITAL cohort. VITAL has more than 25,000 participants. It’s a large, diverse, nationwide cohort. About 51% are women, and all are aged 50 years or older, with a mean age of 67. All were free of known clinical cardiovascular disease at the start of the study.

AF reports were confirmed by medical records and also supplemented by Medicare CMS linkage for fuller ascertainment of outcomes. We had 900 incident cases of AF in the study, and we did see that women were less likely to be diagnosed with AF. They had a 32% lower risk – strongly statistically significant compared with men, with a P < .001. Women were also more likely to be symptomatic: About 77% of women vs. 63% of men had symptoms prior to or at diagnosis.

It was very interesting that adjustment for height eliminated the lower risk for AF in women compared with men. After accounting for height, there was not only no reduction in risk for AF among the women, there was actually a reversal of the association so that there was a slightly higher risk for AF in the women. Other risk factors for AF in the cohort included older age, higher body mass index, hypertension, and higher consumption of alcohol. We did not see an association between diabetes and higher risk for AF. We also saw no clear association with physical activity, although very strenuous physical activity has been linked to AF in some other studies.

We looked at the interventions of vitamin D (2,000 IU/day) and omega-3 fatty acids (460 mg/day of EPA and 380 mg/day of DHA) and found no association with AF, although some other studies have seen increased risk for AF with higher doses of the marine omega-3s > 1 g/day and certainly at doses of 4 g/day. So overall, the findings highlight the fact that many of the risk factors for AF do seem to be modifiable, and it is really important to identify and try to reduce these risk factors in order to reduce the burden of AF. This may be particularly important in women because women are more likely to have stroke and cardiovascular mortality in these adverse cardiovascular outcomes.

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

This transcript has been edited for clarity.

Hello. This is Dr. JoAnn Manson, professor of medicine at Harvard Medical School and Brigham and Women’s Hospital. I’d like to talk with you about a recent report in JAMA Cardiology on atrial fibrillation (AF), sex differences, and modifiable risk factors.

We looked at these questions in our vitamin D and omega-3 trial VITAL in an ancillary study called VITAL Rhythm, led by Dr. Christine Albert at Cedars-Sinai. And this particular project was led by Dr. Hasan Siddiqi at Vanderbilt.

As you know, AF is the most common arrhythmia in the world, and it’s burgeoning in numbers, primarily because of the aging of the population. It’s also a major cause of stroke, heart failure, and cardiovascular mortality. Although women are known to have lower rates of AF than men, they’re also known to have a higher risk for cardiovascular complications and sequelae, such as higher risk for stroke and CVD mortality. Therefore, we thought that understanding sex differences in risk and modifiable risk factors for AF that could reduce the burden of disease would be important.

It’s known that greater height is a risk factor for AF, but the extent to which it explains the differences in AF risk between men and women isn’t really known. So we looked at these questions in the VITAL cohort. VITAL has more than 25,000 participants. It’s a large, diverse, nationwide cohort. About 51% are women, and all are aged 50 years or older, with a mean age of 67. All were free of known clinical cardiovascular disease at the start of the study.

AF reports were confirmed by medical records and also supplemented by Medicare CMS linkage for fuller ascertainment of outcomes. We had 900 incident cases of AF in the study, and we did see that women were less likely to be diagnosed with AF. They had a 32% lower risk – strongly statistically significant compared with men, with a P < .001. Women were also more likely to be symptomatic: About 77% of women vs. 63% of men had symptoms prior to or at diagnosis.

It was very interesting that adjustment for height eliminated the lower risk for AF in women compared with men. After accounting for height, there was not only no reduction in risk for AF among the women, there was actually a reversal of the association so that there was a slightly higher risk for AF in the women. Other risk factors for AF in the cohort included older age, higher body mass index, hypertension, and higher consumption of alcohol. We did not see an association between diabetes and higher risk for AF. We also saw no clear association with physical activity, although very strenuous physical activity has been linked to AF in some other studies.

We looked at the interventions of vitamin D (2,000 IU/day) and omega-3 fatty acids (460 mg/day of EPA and 380 mg/day of DHA) and found no association with AF, although some other studies have seen increased risk for AF with higher doses of the marine omega-3s > 1 g/day and certainly at doses of 4 g/day. So overall, the findings highlight the fact that many of the risk factors for AF do seem to be modifiable, and it is really important to identify and try to reduce these risk factors in order to reduce the burden of AF. This may be particularly important in women because women are more likely to have stroke and cardiovascular mortality in these adverse cardiovascular outcomes.

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

This transcript has been edited for clarity.

Hello. This is Dr. JoAnn Manson, professor of medicine at Harvard Medical School and Brigham and Women’s Hospital. I’d like to talk with you about a recent report in JAMA Cardiology on atrial fibrillation (AF), sex differences, and modifiable risk factors.

We looked at these questions in our vitamin D and omega-3 trial VITAL in an ancillary study called VITAL Rhythm, led by Dr. Christine Albert at Cedars-Sinai. And this particular project was led by Dr. Hasan Siddiqi at Vanderbilt.

As you know, AF is the most common arrhythmia in the world, and it’s burgeoning in numbers, primarily because of the aging of the population. It’s also a major cause of stroke, heart failure, and cardiovascular mortality. Although women are known to have lower rates of AF than men, they’re also known to have a higher risk for cardiovascular complications and sequelae, such as higher risk for stroke and CVD mortality. Therefore, we thought that understanding sex differences in risk and modifiable risk factors for AF that could reduce the burden of disease would be important.

It’s known that greater height is a risk factor for AF, but the extent to which it explains the differences in AF risk between men and women isn’t really known. So we looked at these questions in the VITAL cohort. VITAL has more than 25,000 participants. It’s a large, diverse, nationwide cohort. About 51% are women, and all are aged 50 years or older, with a mean age of 67. All were free of known clinical cardiovascular disease at the start of the study.

AF reports were confirmed by medical records and also supplemented by Medicare CMS linkage for fuller ascertainment of outcomes. We had 900 incident cases of AF in the study, and we did see that women were less likely to be diagnosed with AF. They had a 32% lower risk – strongly statistically significant compared with men, with a P < .001. Women were also more likely to be symptomatic: About 77% of women vs. 63% of men had symptoms prior to or at diagnosis.

It was very interesting that adjustment for height eliminated the lower risk for AF in women compared with men. After accounting for height, there was not only no reduction in risk for AF among the women, there was actually a reversal of the association so that there was a slightly higher risk for AF in the women. Other risk factors for AF in the cohort included older age, higher body mass index, hypertension, and higher consumption of alcohol. We did not see an association between diabetes and higher risk for AF. We also saw no clear association with physical activity, although very strenuous physical activity has been linked to AF in some other studies.

We looked at the interventions of vitamin D (2,000 IU/day) and omega-3 fatty acids (460 mg/day of EPA and 380 mg/day of DHA) and found no association with AF, although some other studies have seen increased risk for AF with higher doses of the marine omega-3s > 1 g/day and certainly at doses of 4 g/day. So overall, the findings highlight the fact that many of the risk factors for AF do seem to be modifiable, and it is really important to identify and try to reduce these risk factors in order to reduce the burden of AF. This may be particularly important in women because women are more likely to have stroke and cardiovascular mortality in these adverse cardiovascular outcomes.

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

During the initial stage of the COVID-19 pandemic U.S. medical students were suspended from in-person clinical interaction. This decision was based on specific guidance from the Association of American Medical Colleges and subsequently implemented in medical schools across the United States.¹ Our research project addressed students’ stress level before and after clinical in-person suspension and assessed medical students perceived COVID-19–related risk level. We were particularly curious to learn about students’ emotional struggles as they navigated the initial pedagogical uncertainty associated with the pandemic.

Our study showed that students had a significantly higher stress level after the clinical suspension of in-person clinical interaction as compared with the time before the suspension of clinical in-person interaction. It is likely that heightened stress was greater than before and the rationale was likely multifactorial in nature.²

One key stressor U.S. medical students faced was the negative impacts of COVID-19 on medical education. U.S. Medical Licensing Examination exam-taking was severely impacted, and some students needed to reschedule their test dates because of increased restrictions at testing centers. Third-year medical students in particular were worried about how COVID-19 would influence their residency application; for example, in-person residency interviews and away rotations as fourth-year medical students. Another concern was not being able to be involved in clinical work during the direst stage of this public health emergency because of personal protective equipment shortages and attempts to reduce community spread of COVID-19.

Our study also showed that students had a relatively lower perceived risk level when it comes to COVID-19 than health care workers in the 2003 SARS epidemic, which we suspect is mostly attributable to the suspension of clinical in-person interaction. We also found that female gender and self-reported mental illness diagnosis were two risk factors for perceived stress level, consistent with our current literature.

The reality of clinical in-person inaction caused by PPE shortage and limited telehealth options, together with social isolation and uncertainty regarding future education opportunities, appear to have had a detrimental effect on medical students’ psychological wellbeing. This did not have to be the case. Some medical students found innovative ways to stay involved.

For example, in 2020 some of Dr. Zhang’s classmates helped proctor virtual group therapy sessions held by the local National Alliance on Mental Illness chapter. Medical students at the Icahn School of Medicine at Mount Sinai, New York were not only able to engage in telehealth but also join other task forces, such as PPE supply, distribution, and coordination, morale promotion, and administrative services.³ Finally, many medical students in New York volunteered in providing child care for frontline doctors to help relieve their burden.⁴ These actions, if implemented more widely, may have had a protective effect on the stress and well-being of medical students at that time.

While our study focused on the academic side of things, the personal impacts from COVID-19 need to be acknowledged – sickness from COVID-19 and its sequelae, family loss fromCOVID-19, financial struggle, and racial targeting of Asians to name a few. COVID-19 has influenced many families’ livelihood and changed our understanding of ourselves, others, and the world in unprecedented ways.

Fast forward to today – medical students are used to learning and living in a world with an ongoing pandemic, and medical education and residency application process have adapted to this new normal. The once-crippling uncertainty surrounding COVID-19 and disastrous PPE shortages have passed. Yet, COVID-19 continues to be a stressor. In fact, burnout related to “COVID-19 fatigue” has been on the rise and one recent national survey shows one in five physicians intends to leave practice within 2 years.⁵

Meanwhile, uncertainty continued to persist, as in August 2022 monkeypox was declared a public health emergency in the United States.⁶ What Dr. Zhang learned as a medical student during the initial months of COVID-19 continues to be relevant: connect with loved ones, understand the changing reality, process the emotions, recognize what is under one’s control, have a solution-oriented mindset, and be forgiving and patient with oneself and others.

Dr. Zhang is a second-year psychiatry resident physician at Saint Elizabeth’s Hospital/DC DBH, Washington. Dr. Himelhoch serves as professor and chair of the department of psychiatry at the University of Kentucky, Lexington. His research focuses on developing and studying the efficacy of innovative strategies aimed at improving the health and welfare among people with co-occurring psychiatric and substance use disorders.

References

1. Association of American Medical Colleges. Important Guidance for Medical Students on Clinical Rotations During the Coronavirus (COVID-19) Outbreak. 2020 Mar 17.

2. Zhang Y et al. Psychiatry Res. 2022;313:114595. doi: 10.1016/j.psychres.2022.114595.

3. Bahethi RR et al. Acad Med. 2021 Jun 1;96(6):859-63. doi: 10.1097/ACM.0000000000003863.

4. Krieger P and Goodnough A. Medical Students, Sidelined for Now, Find New Ways to Fight Coronavirus. The New York Times. 2020 Mar 23.

5. Abbasi J. JAMA. 2022 Apr 19;327(15):1435-7. doi: 10.1001/jama.2022.5074.

6. Department of Health & Human Services. Biden-Harris Administration Bolsters Monkeypox Response; HHS Secretary Becerra Declares Public Health Emergency. 2022 Aug 4.

During the initial stage of the COVID-19 pandemic U.S. medical students were suspended from in-person clinical interaction. This decision was based on specific guidance from the Association of American Medical Colleges and subsequently implemented in medical schools across the United States.¹ Our research project addressed students’ stress level before and after clinical in-person suspension and assessed medical students perceived COVID-19–related risk level. We were particularly curious to learn about students’ emotional struggles as they navigated the initial pedagogical uncertainty associated with the pandemic.

Our study showed that students had a significantly higher stress level after the clinical suspension of in-person clinical interaction as compared with the time before the suspension of clinical in-person interaction. It is likely that heightened stress was greater than before and the rationale was likely multifactorial in nature.²

One key stressor U.S. medical students faced was the negative impacts of COVID-19 on medical education. U.S. Medical Licensing Examination exam-taking was severely impacted, and some students needed to reschedule their test dates because of increased restrictions at testing centers. Third-year medical students in particular were worried about how COVID-19 would influence their residency application; for example, in-person residency interviews and away rotations as fourth-year medical students. Another concern was not being able to be involved in clinical work during the direst stage of this public health emergency because of personal protective equipment shortages and attempts to reduce community spread of COVID-19.

Our study also showed that students had a relatively lower perceived risk level when it comes to COVID-19 than health care workers in the 2003 SARS epidemic, which we suspect is mostly attributable to the suspension of clinical in-person interaction. We also found that female gender and self-reported mental illness diagnosis were two risk factors for perceived stress level, consistent with our current literature.

The reality of clinical in-person inaction caused by PPE shortage and limited telehealth options, together with social isolation and uncertainty regarding future education opportunities, appear to have had a detrimental effect on medical students’ psychological wellbeing. This did not have to be the case. Some medical students found innovative ways to stay involved.

For example, in 2020 some of Dr. Zhang’s classmates helped proctor virtual group therapy sessions held by the local National Alliance on Mental Illness chapter. Medical students at the Icahn School of Medicine at Mount Sinai, New York were not only able to engage in telehealth but also join other task forces, such as PPE supply, distribution, and coordination, morale promotion, and administrative services.³ Finally, many medical students in New York volunteered in providing child care for frontline doctors to help relieve their burden.⁴ These actions, if implemented more widely, may have had a protective effect on the stress and well-being of medical students at that time.

While our study focused on the academic side of things, the personal impacts from COVID-19 need to be acknowledged – sickness from COVID-19 and its sequelae, family loss fromCOVID-19, financial struggle, and racial targeting of Asians to name a few. COVID-19 has influenced many families’ livelihood and changed our understanding of ourselves, others, and the world in unprecedented ways.

Fast forward to today – medical students are used to learning and living in a world with an ongoing pandemic, and medical education and residency application process have adapted to this new normal. The once-crippling uncertainty surrounding COVID-19 and disastrous PPE shortages have passed. Yet, COVID-19 continues to be a stressor. In fact, burnout related to “COVID-19 fatigue” has been on the rise and one recent national survey shows one in five physicians intends to leave practice within 2 years.⁵

Meanwhile, uncertainty continued to persist, as in August 2022 monkeypox was declared a public health emergency in the United States.⁶ What Dr. Zhang learned as a medical student during the initial months of COVID-19 continues to be relevant: connect with loved ones, understand the changing reality, process the emotions, recognize what is under one’s control, have a solution-oriented mindset, and be forgiving and patient with oneself and others.

Dr. Zhang is a second-year psychiatry resident physician at Saint Elizabeth’s Hospital/DC DBH, Washington. Dr. Himelhoch serves as professor and chair of the department of psychiatry at the University of Kentucky, Lexington. His research focuses on developing and studying the efficacy of innovative strategies aimed at improving the health and welfare among people with co-occurring psychiatric and substance use disorders.

References

1. Association of American Medical Colleges. Important Guidance for Medical Students on Clinical Rotations During the Coronavirus (COVID-19) Outbreak. 2020 Mar 17.

2. Zhang Y et al. Psychiatry Res. 2022;313:114595. doi: 10.1016/j.psychres.2022.114595.

3. Bahethi RR et al. Acad Med. 2021 Jun 1;96(6):859-63. doi: 10.1097/ACM.0000000000003863.

4. Krieger P and Goodnough A. Medical Students, Sidelined for Now, Find New Ways to Fight Coronavirus. The New York Times. 2020 Mar 23.

5. Abbasi J. JAMA. 2022 Apr 19;327(15):1435-7. doi: 10.1001/jama.2022.5074.

6. Department of Health & Human Services. Biden-Harris Administration Bolsters Monkeypox Response; HHS Secretary Becerra Declares Public Health Emergency. 2022 Aug 4.

During the initial stage of the COVID-19 pandemic U.S. medical students were suspended from in-person clinical interaction. This decision was based on specific guidance from the Association of American Medical Colleges and subsequently implemented in medical schools across the United States.¹ Our research project addressed students’ stress level before and after clinical in-person suspension and assessed medical students perceived COVID-19–related risk level. We were particularly curious to learn about students’ emotional struggles as they navigated the initial pedagogical uncertainty associated with the pandemic.

Our study showed that students had a significantly higher stress level after the clinical suspension of in-person clinical interaction as compared with the time before the suspension of clinical in-person interaction. It is likely that heightened stress was greater than before and the rationale was likely multifactorial in nature.²

One key stressor U.S. medical students faced was the negative impacts of COVID-19 on medical education. U.S. Medical Licensing Examination exam-taking was severely impacted, and some students needed to reschedule their test dates because of increased restrictions at testing centers. Third-year medical students in particular were worried about how COVID-19 would influence their residency application; for example, in-person residency interviews and away rotations as fourth-year medical students. Another concern was not being able to be involved in clinical work during the direst stage of this public health emergency because of personal protective equipment shortages and attempts to reduce community spread of COVID-19.

Our study also showed that students had a relatively lower perceived risk level when it comes to COVID-19 than health care workers in the 2003 SARS epidemic, which we suspect is mostly attributable to the suspension of clinical in-person interaction. We also found that female gender and self-reported mental illness diagnosis were two risk factors for perceived stress level, consistent with our current literature.

The reality of clinical in-person inaction caused by PPE shortage and limited telehealth options, together with social isolation and uncertainty regarding future education opportunities, appear to have had a detrimental effect on medical students’ psychological wellbeing. This did not have to be the case. Some medical students found innovative ways to stay involved.

For example, in 2020 some of Dr. Zhang’s classmates helped proctor virtual group therapy sessions held by the local National Alliance on Mental Illness chapter. Medical students at the Icahn School of Medicine at Mount Sinai, New York were not only able to engage in telehealth but also join other task forces, such as PPE supply, distribution, and coordination, morale promotion, and administrative services.³ Finally, many medical students in New York volunteered in providing child care for frontline doctors to help relieve their burden.⁴ These actions, if implemented more widely, may have had a protective effect on the stress and well-being of medical students at that time.

While our study focused on the academic side of things, the personal impacts from COVID-19 need to be acknowledged – sickness from COVID-19 and its sequelae, family loss fromCOVID-19, financial struggle, and racial targeting of Asians to name a few. COVID-19 has influenced many families’ livelihood and changed our understanding of ourselves, others, and the world in unprecedented ways.

Fast forward to today – medical students are used to learning and living in a world with an ongoing pandemic, and medical education and residency application process have adapted to this new normal. The once-crippling uncertainty surrounding COVID-19 and disastrous PPE shortages have passed. Yet, COVID-19 continues to be a stressor. In fact, burnout related to “COVID-19 fatigue” has been on the rise and one recent national survey shows one in five physicians intends to leave practice within 2 years.⁵

Meanwhile, uncertainty continued to persist, as in August 2022 monkeypox was declared a public health emergency in the United States.⁶ What Dr. Zhang learned as a medical student during the initial months of COVID-19 continues to be relevant: connect with loved ones, understand the changing reality, process the emotions, recognize what is under one’s control, have a solution-oriented mindset, and be forgiving and patient with oneself and others.

Dr. Zhang is a second-year psychiatry resident physician at Saint Elizabeth’s Hospital/DC DBH, Washington. Dr. Himelhoch serves as professor and chair of the department of psychiatry at the University of Kentucky, Lexington. His research focuses on developing and studying the efficacy of innovative strategies aimed at improving the health and welfare among people with co-occurring psychiatric and substance use disorders.

References

1. Association of American Medical Colleges. Important Guidance for Medical Students on Clinical Rotations During the Coronavirus (COVID-19) Outbreak. 2020 Mar 17.

2. Zhang Y et al. Psychiatry Res. 2022;313:114595. doi: 10.1016/j.psychres.2022.114595.

3. Bahethi RR et al. Acad Med. 2021 Jun 1;96(6):859-63. doi: 10.1097/ACM.0000000000003863.

4. Krieger P and Goodnough A. Medical Students, Sidelined for Now, Find New Ways to Fight Coronavirus. The New York Times. 2020 Mar 23.

5. Abbasi J. JAMA. 2022 Apr 19;327(15):1435-7. doi: 10.1001/jama.2022.5074.

6. Department of Health & Human Services. Biden-Harris Administration Bolsters Monkeypox Response; HHS Secretary Becerra Declares Public Health Emergency. 2022 Aug 4.

I guess we shouldn’t be surprised that vaccination rates in this country fell during the frenzy created by the COVID pandemic. We had a lot on our plates. Schools closed and many of us retreated into what seemed to be the safety of our homes. Parents were reluctant to take their children anywhere, let alone a pediatrician’s office. State health agencies wisely focused on collecting case figures and then shepherding the efforts to immunize against SARS-CoV-2 once vaccines were available. Tracking and promoting the existing children’s vaccinations fell off the priority list, even in places with exemplary vaccination rates.

Whether or not the pandemic is over continues to be a topic for debate, but there is clearly a general shift toward a new normalcy. However, vaccination rates of our children have not rebounded to prepandemic levels. In fact, in some areas they are continuing to fall.

In a recent guest essay in the New York Times, Ezekiel J. Emmanuel, MD, PhD, a physician and professor of medical ethics and health policy at the University of Pennsylvania, and Matthew Guido, his research assistant, explore the reasons for this lack of a significant rebound. The authors cite recent outbreaks of measles in Ohio and polio in New York City as examples of the peril we are facing if we fail to reverse the trend. In some areas measles vaccine rates alarmingly have dipped below the threshold for herd immunity.

While Dr. Emmanuel and Mr. Guido acknowledge that the pandemic was a major driver of the falling vaccination rates they lay blame on the persistent decline on three factors that they view as correctable: nonmedical exemptions, our failure to vigorously enforce existing vaccine requirements, and inadequate public health campaigns.

The authors underestimate the lingering effect of the pandemic on parents’ vaccine hesitancy. As a septuagenarian who often hangs out with other septuagenarians I view the rapid development and effectiveness of the COVID vaccine as astounding and a boost for vaccines in general. However, were I much younger I might treat the vaccine’s success with a shrug. After some initial concern, the younger half of the population didn’t seem to see the illness as much of a threat to themselves or their peers. This attitude was reinforced by the fact that few of their peers, including those who were unvaccinated, were getting seriously ill. Despite all the hype, most parents and their children never ended up getting seriously ill.

You can understand why many parents might be quick to toss what you and I consider a successful COVID vaccine onto what they view as a growing pile of vaccines for diseases that in their experience have never sickened or killed anyone they have known.

Let’s be honest: Over the last half century we have produced several generations of parents who have little knowledge and certainly no personal experience with a childhood disease on the order or magnitude of polio. The vaccines that we have developed during their lifetimes have been targeted at diseases such as haemophilus influenzae meningitis that, while serious and anxiety provoking for pediatricians, occur so sporadically that most parents have no personal experience to motivate them to vaccinate their children.

Dr. Emmanuel and Mr. Guido are correct in advocating for the broader elimination of nonmedical exemptions and urging us to find the political will to vigorously enforce the vaccine requirements we have already enacted. I agree that our promotional campaigns need to be more robust. But, this will be a difficult challenge unless we can impress our audience with our straight talk and honesty. We must acknowledge and then explain why all vaccines are not created equal and that some are of more critical importance than others.

We are slowly learning that education isn’t the cure-all for vaccine hesitancy we once thought it was. And using scare tactics can backfire and create dysfunctional anxiety. We must choosing our words and target audience carefully. And ... having the political will to force parents into doing the right thing will be critical if we wish to restore our vaccination rates.

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].

I guess we shouldn’t be surprised that vaccination rates in this country fell during the frenzy created by the COVID pandemic. We had a lot on our plates. Schools closed and many of us retreated into what seemed to be the safety of our homes. Parents were reluctant to take their children anywhere, let alone a pediatrician’s office. State health agencies wisely focused on collecting case figures and then shepherding the efforts to immunize against SARS-CoV-2 once vaccines were available. Tracking and promoting the existing children’s vaccinations fell off the priority list, even in places with exemplary vaccination rates.

Whether or not the pandemic is over continues to be a topic for debate, but there is clearly a general shift toward a new normalcy. However, vaccination rates of our children have not rebounded to prepandemic levels. In fact, in some areas they are continuing to fall.

In a recent guest essay in the New York Times, Ezekiel J. Emmanuel, MD, PhD, a physician and professor of medical ethics and health policy at the University of Pennsylvania, and Matthew Guido, his research assistant, explore the reasons for this lack of a significant rebound. The authors cite recent outbreaks of measles in Ohio and polio in New York City as examples of the peril we are facing if we fail to reverse the trend. In some areas measles vaccine rates alarmingly have dipped below the threshold for herd immunity.

While Dr. Emmanuel and Mr. Guido acknowledge that the pandemic was a major driver of the falling vaccination rates they lay blame on the persistent decline on three factors that they view as correctable: nonmedical exemptions, our failure to vigorously enforce existing vaccine requirements, and inadequate public health campaigns.

The authors underestimate the lingering effect of the pandemic on parents’ vaccine hesitancy. As a septuagenarian who often hangs out with other septuagenarians I view the rapid development and effectiveness of the COVID vaccine as astounding and a boost for vaccines in general. However, were I much younger I might treat the vaccine’s success with a shrug. After some initial concern, the younger half of the population didn’t seem to see the illness as much of a threat to themselves or their peers. This attitude was reinforced by the fact that few of their peers, including those who were unvaccinated, were getting seriously ill. Despite all the hype, most parents and their children never ended up getting seriously ill.

You can understand why many parents might be quick to toss what you and I consider a successful COVID vaccine onto what they view as a growing pile of vaccines for diseases that in their experience have never sickened or killed anyone they have known.

Let’s be honest: Over the last half century we have produced several generations of parents who have little knowledge and certainly no personal experience with a childhood disease on the order or magnitude of polio. The vaccines that we have developed during their lifetimes have been targeted at diseases such as haemophilus influenzae meningitis that, while serious and anxiety provoking for pediatricians, occur so sporadically that most parents have no personal experience to motivate them to vaccinate their children.

Dr. Emmanuel and Mr. Guido are correct in advocating for the broader elimination of nonmedical exemptions and urging us to find the political will to vigorously enforce the vaccine requirements we have already enacted. I agree that our promotional campaigns need to be more robust. But, this will be a difficult challenge unless we can impress our audience with our straight talk and honesty. We must acknowledge and then explain why all vaccines are not created equal and that some are of more critical importance than others.

We are slowly learning that education isn’t the cure-all for vaccine hesitancy we once thought it was. And using scare tactics can backfire and create dysfunctional anxiety. We must choosing our words and target audience carefully. And ... having the political will to force parents into doing the right thing will be critical if we wish to restore our vaccination rates.

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].

I guess we shouldn’t be surprised that vaccination rates in this country fell during the frenzy created by the COVID pandemic. We had a lot on our plates. Schools closed and many of us retreated into what seemed to be the safety of our homes. Parents were reluctant to take their children anywhere, let alone a pediatrician’s office. State health agencies wisely focused on collecting case figures and then shepherding the efforts to immunize against SARS-CoV-2 once vaccines were available. Tracking and promoting the existing children’s vaccinations fell off the priority list, even in places with exemplary vaccination rates.

Whether or not the pandemic is over continues to be a topic for debate, but there is clearly a general shift toward a new normalcy. However, vaccination rates of our children have not rebounded to prepandemic levels. In fact, in some areas they are continuing to fall.

In a recent guest essay in the New York Times, Ezekiel J. Emmanuel, MD, PhD, a physician and professor of medical ethics and health policy at the University of Pennsylvania, and Matthew Guido, his research assistant, explore the reasons for this lack of a significant rebound. The authors cite recent outbreaks of measles in Ohio and polio in New York City as examples of the peril we are facing if we fail to reverse the trend. In some areas measles vaccine rates alarmingly have dipped below the threshold for herd immunity.

While Dr. Emmanuel and Mr. Guido acknowledge that the pandemic was a major driver of the falling vaccination rates they lay blame on the persistent decline on three factors that they view as correctable: nonmedical exemptions, our failure to vigorously enforce existing vaccine requirements, and inadequate public health campaigns.

The authors underestimate the lingering effect of the pandemic on parents’ vaccine hesitancy. As a septuagenarian who often hangs out with other septuagenarians I view the rapid development and effectiveness of the COVID vaccine as astounding and a boost for vaccines in general. However, were I much younger I might treat the vaccine’s success with a shrug. After some initial concern, the younger half of the population didn’t seem to see the illness as much of a threat to themselves or their peers. This attitude was reinforced by the fact that few of their peers, including those who were unvaccinated, were getting seriously ill. Despite all the hype, most parents and their children never ended up getting seriously ill.

You can understand why many parents might be quick to toss what you and I consider a successful COVID vaccine onto what they view as a growing pile of vaccines for diseases that in their experience have never sickened or killed anyone they have known.

Let’s be honest: Over the last half century we have produced several generations of parents who have little knowledge and certainly no personal experience with a childhood disease on the order or magnitude of polio. The vaccines that we have developed during their lifetimes have been targeted at diseases such as haemophilus influenzae meningitis that, while serious and anxiety provoking for pediatricians, occur so sporadically that most parents have no personal experience to motivate them to vaccinate their children.

Dr. Emmanuel and Mr. Guido are correct in advocating for the broader elimination of nonmedical exemptions and urging us to find the political will to vigorously enforce the vaccine requirements we have already enacted. I agree that our promotional campaigns need to be more robust. But, this will be a difficult challenge unless we can impress our audience with our straight talk and honesty. We must acknowledge and then explain why all vaccines are not created equal and that some are of more critical importance than others.

We are slowly learning that education isn’t the cure-all for vaccine hesitancy we once thought it was. And using scare tactics can backfire and create dysfunctional anxiety. We must choosing our words and target audience carefully. And ... having the political will to force parents into doing the right thing will be critical if we wish to restore our vaccination rates.

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 obvious first statement is that it’s neither wise nor appropriate to speculate on the specifics of Damar Hamlin’s cardiac event during a football game on Jan. 2 (including the possibility of commotio cordis) or his ongoing care. The public nature of his collapse induces intense curiosity but people with illness deserve privacy. Privacy in health care is in short supply. I disagree strongly with those who say his doctors ought to be giving public updates. That’s up to the family.

But there are important general concepts to consider about this incident. These include ...

Cardiac arrest can happen to anyone

People with structural heart disease or other chronic illnesses have a higher risk of arrhythmia, but the notion that athletes are immune from cardiac arrest is wrong. This sentence almost seems too obvious to write, but to this day, I hear clinicians express surprise that an athletic person has heart disease.

Survival turns on rapid and effective intervention

In the old days of electrophysiology, we used to test implantable cardioverter-defibrillators during an implant procedure by inducing ventricular fibrillation (VF) and watching the device convert it. Thankfully, trials have shown that this is no longer necessary for most implants.

When you induce VF In the EP lab, you learn quickly that a) it causes loss of consciousness in a matter of seconds, b) rapid defibrillation restores consciousness, often without the patients knowing or remembering they passed out, and c) the failure of the shock to terminate VF results in deterioration in a matter of 1-2 minutes. Even 1 minute in VF feels so long.

Need is an appropriate word in VF treatment

Clinicians often use the verb need. As in, this patient needs this pill or this procedure. It’s rarely appropriate.

But in the case of treating VF, patients truly need rapid defibrillation. Survival of out-of-hospital cardiac arrest is low because there just aren’t enough automated external defibrillators (AEDs) or people trained to use them. A study of patients who had out-of-hospital cardiac arrest in Denmark found that 30-day survival almost doubled (28.8% vs. 16.4%), when the nearest AED was accessible.

Bystanders must act

The public messages are simple: If a person loses consciousness in front of you, and is not breathing normally, assume it is a cardiac arrest, call 911 to get professional help, and start hands-only chest compressions. Don’t spend time checking for a pulse or trying to wake the person. If this is not a cardiac arrest, they will soon tell you to stop compressing their chest. Seconds matter.

Chest compressions are important but what is really needed is defibrillation. A crucial step in CPR is to send someone to get an AED and get the pads attached. If this is a shockable rhythm, deliver the shock. Hamlin’s collapse emphasizes the importance of the AED; without it, his survival to the hospital would have been unlikely.

Widespread preparticipation screening of young athletes remains a bad idea

Whenever cardiac arrest occurs in an athlete, in such a public way, people think about prevention. Surely it is better to prevent such an event than react to it, goes the thinking. The argument against this idea has four prongs:

The incidence of cardiac disease in a young athlete is extremely low, which sets up a situation where most “positive” tests are false positive. A false positive screening ECG or echocardiogram can create harm in multiple ways. One is the risk from downstream procedures, but worse is the inappropriate disqualification from sport. Healthwise, few harms could be greater than creating long-term fear of exercise in someone.

There is also the problem of false-negative screening tests. An ECG may be normal in the setting of hypertrophic cardiomyopathy. And a normal echocardiogram does not exclude arrhythmogenic right ventricular cardiomyopathy or other genetic causes of cardiac arrest. In a 2018 study from a major sports cardiology center in London, 6 of the 8 sudden cardiac deaths in their series were in athletes who had no detectable abnormalities on screening.

Even when disease is found, it’s not clear that prohibiting participation in sports prevents sudden death. Many previous class III recommendations against participation in sport now carry class II – may be considered – designations.

Finally, screening for any disease loses value as treatments improve. Public education regarding rapid intervention with CPR and AED use is the best treatment option. A great example is the case of Christian Erikson, a Danish soccer player who suffered cardiac arrest during a match at the European Championships in 2021 and was rapidly defibrillated on the field. Therapy was so effective that he was conscious and able to wave to fans on his way out of the stadium. He has now returned to elite competition.

Proponents of screening might oppose my take by saying that National Football League players are intensely screened. But this is different from widespread screening of high school and college athletes. It might sound harsh to say, but professional teams have dualities of interests in the health of their athletes given the million-dollar contracts.

What’s more, professional teams can afford to hire expert cardiologists to perform the testing. This would likely reduce the rate of false-positive findings, compared with screening in the community setting. I often have young people referred to me because of asymptomatic bradycardia found during athletic screening – an obviously normal finding.

Conclusions

As long as there are sports, there will be athletes who suffer cardiac arrest.

We can both hope for Hamlin’s full recovery and learn lessons to help reduce the rate of death from out-of-hospital cardiac arrest. This mostly involves education on how to help fellow humans and a public health commitment to access to AEDs.

John Mandrola, MD, practices cardiac electrophysiology in Louisville, Ky. and is a writer and podcaster for Medscape. He has disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.

The obvious first statement is that it’s neither wise nor appropriate to speculate on the specifics of Damar Hamlin’s cardiac event during a football game on Jan. 2 (including the possibility of commotio cordis) or his ongoing care. The public nature of his collapse induces intense curiosity but people with illness deserve privacy. Privacy in health care is in short supply. I disagree strongly with those who say his doctors ought to be giving public updates. That’s up to the family.

But there are important general concepts to consider about this incident. These include ...

Cardiac arrest can happen to anyone

People with structural heart disease or other chronic illnesses have a higher risk of arrhythmia, but the notion that athletes are immune from cardiac arrest is wrong. This sentence almost seems too obvious to write, but to this day, I hear clinicians express surprise that an athletic person has heart disease.

Survival turns on rapid and effective intervention

In the old days of electrophysiology, we used to test implantable cardioverter-defibrillators during an implant procedure by inducing ventricular fibrillation (VF) and watching the device convert it. Thankfully, trials have shown that this is no longer necessary for most implants.

When you induce VF In the EP lab, you learn quickly that a) it causes loss of consciousness in a matter of seconds, b) rapid defibrillation restores consciousness, often without the patients knowing or remembering they passed out, and c) the failure of the shock to terminate VF results in deterioration in a matter of 1-2 minutes. Even 1 minute in VF feels so long.

Need is an appropriate word in VF treatment

Clinicians often use the verb need. As in, this patient needs this pill or this procedure. It’s rarely appropriate.

But in the case of treating VF, patients truly need rapid defibrillation. Survival of out-of-hospital cardiac arrest is low because there just aren’t enough automated external defibrillators (AEDs) or people trained to use them. A study of patients who had out-of-hospital cardiac arrest in Denmark found that 30-day survival almost doubled (28.8% vs. 16.4%), when the nearest AED was accessible.

Bystanders must act

The public messages are simple: If a person loses consciousness in front of you, and is not breathing normally, assume it is a cardiac arrest, call 911 to get professional help, and start hands-only chest compressions. Don’t spend time checking for a pulse or trying to wake the person. If this is not a cardiac arrest, they will soon tell you to stop compressing their chest. Seconds matter.

Chest compressions are important but what is really needed is defibrillation. A crucial step in CPR is to send someone to get an AED and get the pads attached. If this is a shockable rhythm, deliver the shock. Hamlin’s collapse emphasizes the importance of the AED; without it, his survival to the hospital would have been unlikely.

Widespread preparticipation screening of young athletes remains a bad idea

Whenever cardiac arrest occurs in an athlete, in such a public way, people think about prevention. Surely it is better to prevent such an event than react to it, goes the thinking. The argument against this idea has four prongs:

The incidence of cardiac disease in a young athlete is extremely low, which sets up a situation where most “positive” tests are false positive. A false positive screening ECG or echocardiogram can create harm in multiple ways. One is the risk from downstream procedures, but worse is the inappropriate disqualification from sport. Healthwise, few harms could be greater than creating long-term fear of exercise in someone.

There is also the problem of false-negative screening tests. An ECG may be normal in the setting of hypertrophic cardiomyopathy. And a normal echocardiogram does not exclude arrhythmogenic right ventricular cardiomyopathy or other genetic causes of cardiac arrest. In a 2018 study from a major sports cardiology center in London, 6 of the 8 sudden cardiac deaths in their series were in athletes who had no detectable abnormalities on screening.

Even when disease is found, it’s not clear that prohibiting participation in sports prevents sudden death. Many previous class III recommendations against participation in sport now carry class II – may be considered – designations.

Finally, screening for any disease loses value as treatments improve. Public education regarding rapid intervention with CPR and AED use is the best treatment option. A great example is the case of Christian Erikson, a Danish soccer player who suffered cardiac arrest during a match at the European Championships in 2021 and was rapidly defibrillated on the field. Therapy was so effective that he was conscious and able to wave to fans on his way out of the stadium. He has now returned to elite competition.

Proponents of screening might oppose my take by saying that National Football League players are intensely screened. But this is different from widespread screening of high school and college athletes. It might sound harsh to say, but professional teams have dualities of interests in the health of their athletes given the million-dollar contracts.

What’s more, professional teams can afford to hire expert cardiologists to perform the testing. This would likely reduce the rate of false-positive findings, compared with screening in the community setting. I often have young people referred to me because of asymptomatic bradycardia found during athletic screening – an obviously normal finding.

Conclusions

As long as there are sports, there will be athletes who suffer cardiac arrest.

We can both hope for Hamlin’s full recovery and learn lessons to help reduce the rate of death from out-of-hospital cardiac arrest. This mostly involves education on how to help fellow humans and a public health commitment to access to AEDs.

John Mandrola, MD, practices cardiac electrophysiology in Louisville, Ky. and is a writer and podcaster for Medscape. He has disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.

The obvious first statement is that it’s neither wise nor appropriate to speculate on the specifics of Damar Hamlin’s cardiac event during a football game on Jan. 2 (including the possibility of commotio cordis) or his ongoing care. The public nature of his collapse induces intense curiosity but people with illness deserve privacy. Privacy in health care is in short supply. I disagree strongly with those who say his doctors ought to be giving public updates. That’s up to the family.

But there are important general concepts to consider about this incident. These include ...

Cardiac arrest can happen to anyone

People with structural heart disease or other chronic illnesses have a higher risk of arrhythmia, but the notion that athletes are immune from cardiac arrest is wrong. This sentence almost seems too obvious to write, but to this day, I hear clinicians express surprise that an athletic person has heart disease.

Survival turns on rapid and effective intervention

In the old days of electrophysiology, we used to test implantable cardioverter-defibrillators during an implant procedure by inducing ventricular fibrillation (VF) and watching the device convert it. Thankfully, trials have shown that this is no longer necessary for most implants.

When you induce VF In the EP lab, you learn quickly that a) it causes loss of consciousness in a matter of seconds, b) rapid defibrillation restores consciousness, often without the patients knowing or remembering they passed out, and c) the failure of the shock to terminate VF results in deterioration in a matter of 1-2 minutes. Even 1 minute in VF feels so long.

Need is an appropriate word in VF treatment

Clinicians often use the verb need. As in, this patient needs this pill or this procedure. It’s rarely appropriate.

But in the case of treating VF, patients truly need rapid defibrillation. Survival of out-of-hospital cardiac arrest is low because there just aren’t enough automated external defibrillators (AEDs) or people trained to use them. A study of patients who had out-of-hospital cardiac arrest in Denmark found that 30-day survival almost doubled (28.8% vs. 16.4%), when the nearest AED was accessible.

Bystanders must act

The public messages are simple: If a person loses consciousness in front of you, and is not breathing normally, assume it is a cardiac arrest, call 911 to get professional help, and start hands-only chest compressions. Don’t spend time checking for a pulse or trying to wake the person. If this is not a cardiac arrest, they will soon tell you to stop compressing their chest. Seconds matter.

Chest compressions are important but what is really needed is defibrillation. A crucial step in CPR is to send someone to get an AED and get the pads attached. If this is a shockable rhythm, deliver the shock. Hamlin’s collapse emphasizes the importance of the AED; without it, his survival to the hospital would have been unlikely.

Widespread preparticipation screening of young athletes remains a bad idea

Whenever cardiac arrest occurs in an athlete, in such a public way, people think about prevention. Surely it is better to prevent such an event than react to it, goes the thinking. The argument against this idea has four prongs:

The incidence of cardiac disease in a young athlete is extremely low, which sets up a situation where most “positive” tests are false positive. A false positive screening ECG or echocardiogram can create harm in multiple ways. One is the risk from downstream procedures, but worse is the inappropriate disqualification from sport. Healthwise, few harms could be greater than creating long-term fear of exercise in someone.

There is also the problem of false-negative screening tests. An ECG may be normal in the setting of hypertrophic cardiomyopathy. And a normal echocardiogram does not exclude arrhythmogenic right ventricular cardiomyopathy or other genetic causes of cardiac arrest. In a 2018 study from a major sports cardiology center in London, 6 of the 8 sudden cardiac deaths in their series were in athletes who had no detectable abnormalities on screening.

Even when disease is found, it’s not clear that prohibiting participation in sports prevents sudden death. Many previous class III recommendations against participation in sport now carry class II – may be considered – designations.

Finally, screening for any disease loses value as treatments improve. Public education regarding rapid intervention with CPR and AED use is the best treatment option. A great example is the case of Christian Erikson, a Danish soccer player who suffered cardiac arrest during a match at the European Championships in 2021 and was rapidly defibrillated on the field. Therapy was so effective that he was conscious and able to wave to fans on his way out of the stadium. He has now returned to elite competition.

Proponents of screening might oppose my take by saying that National Football League players are intensely screened. But this is different from widespread screening of high school and college athletes. It might sound harsh to say, but professional teams have dualities of interests in the health of their athletes given the million-dollar contracts.

What’s more, professional teams can afford to hire expert cardiologists to perform the testing. This would likely reduce the rate of false-positive findings, compared with screening in the community setting. I often have young people referred to me because of asymptomatic bradycardia found during athletic screening – an obviously normal finding.

Conclusions

As long as there are sports, there will be athletes who suffer cardiac arrest.

We can both hope for Hamlin’s full recovery and learn lessons to help reduce the rate of death from out-of-hospital cardiac arrest. This mostly involves education on how to help fellow humans and a public health commitment to access to AEDs.

John Mandrola, MD, practices cardiac electrophysiology in Louisville, Ky. and is a writer and podcaster for Medscape. He has disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.

A common refrain in psychiatry is that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, (DSM-5-TR), published in 2022, is the best we can do.

Since the DSM-III was released in 1980, the American Psychiatric Association, which publishes the manual, has espoused the position that we should list symptoms, in a manner that is reminiscent of a checklist. For example, having a depressed mood on most days for a 2-week period, or a loss of interest in pleasurable things, as well as 4 additional symptoms – among them changes in appetite, changes in sleep, changes in psychomotor activity, fatigue, worthlessness, poor concentration, or thoughts of death – can lead to a diagnosis of a major depressive episode as part of a major depressive disorder.

Criticisms of this approach can be apparent. Patients subjected to such checklists, including being repeatedly asked to complete the Patient Health Questionnaire 9 (PHQ-9), which closely follows those criteria, can feel lost and even alienated by their providers. After all, one can ask all those questions and make a diagnosis of depression without even knowing about the patient’s stressors, their history, or their social context.

The DSM permits the diagnosis of psychiatric disorders without an understanding of the narrative of the patient. In its defense, the DSM is not a textbook of psychiatry, it is a guide on how to diagnose individuals. The DSM does not demand that psychiatrists only ask about the symptoms on the checklists; it is the providers who can choose to dismiss asking about the important facets of one’s life.

Yet every time we attend a lecture that starts by enumerating the DSM symptoms of the disorder being discussed, we are left with the dissatisfying impression that a specialist of this disorder should have a more nuanced and interesting description of their disorder of study. This feeling of discontent is compounded when we see a movie that encompasses so much of what is missing in today’s psychiatric parlance, and even more so if that movie is ostensibly made for children. Movies, by design, are particularly adept at encapsulating the narrative of someone’s life in a way that psychiatry can learn from.

Other than the embarrassment of not knowing a patient outside the checklist, the importance of narrative cannot be understated. Dr. Erik Erikson rightfully suggested that the point of life is “the acceptance of one’s one and only life cycle”¹ or rather to know it was okay to have been oneself without additions or substitutions. Therefore, one must know what it has meant to be themselves to reconcile this question and achieve Ego Integrity rather than disgust and despair. Narrative is the way in which we understand who we are and what it has meant to be ourselves. An understanding of our personal narrative presents a unique opportunity in expressing what is missing in the DSM. Below, we provide two of our favorite examples in Disney films, among many.
 

‘Ratatouille’ (2007)

One of the missing features of the DSM is its inability to explain to patients the intrapsychic processes that guide us. One of these processes is how our values can lead us to a deep sense of guilt, shame, and the resulting feelings of alienation. It is extremely common for patients to enter our clinical practice feeling shackled by beliefs that they should accomplish more and be more than they are.

The animated film “Ratatouille” does an excellent job at addressing this feeling. The film follows Remy, the protagonist rat, and his adventures as he explores his passion for cooking. Remy teams up with the inept but good-natured human Alfredo Linguini and guides him through cooking while hiding under his chef’s hat. The primary antagonist, Anton Ego, is a particularly harsh food critic. His presence and appearance are somber. He exudes disdain. His trim physique and scarf suggest a man that will break and react to anything, and his skull-shaped typewriter in his coffin-shaped office informs the viewer that he is out to kill with his cruel words. Anton Ego serves as our projected super-ego. He is not an external judge but the judgment deep inside ourselves, goading us to be better with such severity that we are ultimately left feeling condemned.

Remy is the younger of two siblings. He is less physically adept but more intellectual than his older brother, who does not understand why Remy isn’t content eating scraps from the garbage like the rest of their rat clan. Remy is the creative part within us that wants to challenge the status quo and try something new. Remy also represents our shame and guilt for leaving our home. On one hand, we want to dare greatly, in this case at being an extraordinary chef, but on the other we are shy and cook in secret, hiding within the hat of another person. Remy struggles with the deep feeling that we do not deserve our success, that our family will leave us for being who we are, and that we are better off isolating and segregating from our challenges.

The movie concludes that through talent and hard work, our critics will accept us. Furthermore, once accepted for what we do, we can be further accepted for who we are. The movie ends with Remy cooking the eponymous dish ratatouille. He prepares it so remarkably well, the dish transports Anton Ego back to a sublime experience of eating ratatouille as a child, a touching moment which not only underscores food’s evocative link to memory but gives a glimpse at Anton Ego’s own narrative.

Ego is first won over by the dish, and only afterward learns of Remy’s true identity. Remy’s talent is undeniable though, and even the stuffy Ego must accept the film’s theme that “Anyone can cook,” even a rat – the rat that we all sometimes feel we are deep inside, rotten to the core but trying so hard to be accepted by others, and ultimately by ourselves. In the end, we overcome the disgust inherent in the imagery of a rat in a kitchen and instead embrace our hero’s achievement of ego integrity as he combines his identities as a member of a clan of rats, and one of Paris’s finest chefs.

While modern psychiatry can favor looking at people through the lens of biology rather than narrative, “Ratatouille” can serve as a reminder of the powerful unconscious forces that guide our lives. “Ratatouille” is not a successful movie only because of the compelling narrative, but also because the narrative matches the important psychic paradigms that psychiatry once embraced.
 

‘Inside Out’ (2015)

Another missing feature of the DSM is its inability to explain how symptoms feel and manifest psychologically. One such feeling is that of control – whether one is in control of one’s life, feelings, and action or rather a victim of external forces. It is extremely common for patients to enter our clinical practice feeling traumatized by the life they’ve lived and powerless to produce any change. Part of our role is to guide them through this journey from the object of their lives to the subject of their lives.

In the animated feature “Inside Out,” Riley, a preteen girl, goes through the tribulation of growing up and learning about herself. This seemingly happy child, content playing hockey with her best friend, Meg, on the picturesque frozen lakes of Minnesota, reaches her inevitable conflict. Her parents uproot her life, moving the family to San Francisco. By doing so, they disconnect her from her school, her friends, and her hobbies. While all this is happening, we spend time inside Riley’s psyche with the personified characters of Riley’s emotions as they affect her decisions and daily actions amidst the backdrop of her core memories and islands of personality.

During the move, her parents seemingly change and ultimately destroy every facet of Riley’s sense of self, which is animated as the collapse of her personality islands. Her best friend engages Riley in a video call just to inform her that she has a new friend who plays hockey equally well. Her parents do not hear Riley’s concerns and are portrayed as distracted by their adult problems. Riley feels ridiculed in her new school and unable to share her feelings with her parents, who ask her to still be their “happy girl” and indirectly ask her to fake pleasure to alleviate their own anxiety.

The climax of the movie is when Riley decides to run away from San Francisco and her parents, to return to her perceived true home, Minnesota. The climax is resolved when Riley realizes that her parents’ love, representing the connection we have to others, transcends her need for control. To some degree, we are all powerless in the face of the tremendous forces of life and share the difficult task of accepting the cards we were dealt, thus making the story of Riley so compelling.

Additionally, the climax is further resolved by another argument that psychiatry (and the DSM) should consider embracing. Emotions are not all symptoms and living without negative emotion is not the goal of life. Riley grows from preteen to teenager, and from object to subject of her life, by realizing that her symptoms/feelings are not just nuisances to avoid and hide, but the key to meaning. Our anger drives us to try hard. Our fear protects us from harm. Our sadness attracts the warmth and care of others. Our disgust protects us physically from noxious material (symbolized as a dreaded broccoli floret for preteen Riley) and socially by encouraging us to share societal norms. Similarly, patients and people in general would benefit by being taught that, while symptoms may permit the better assessment of psychiatric conditions using the DSM, life is much more than that.

It is unfair to blame the DSM for things it was not designed to do. The DSM doesn’t advertise itself as a guidebook of all behaviors, at all times. However, for a variety of reasons, it has become the main way psychiatry describes people. While we commend the APA for its effort and do not know that we could make it any better, we are frequently happily reminded that in about 90 minutes, filmmakers are able to display an empathic understanding of personal narratives that biologic psychiatry can miss.

Dr. Pulido is a psychiatry resident at the University of California, San Diego. She is interested in women’s mental health, medical education, and outpatient psychiatry. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. He has no conflicts of interest.

References

1. Erikson, EH. Childhood and society (New York: WW Norton, 1950).

A common refrain in psychiatry is that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, (DSM-5-TR), published in 2022, is the best we can do.

Since the DSM-III was released in 1980, the American Psychiatric Association, which publishes the manual, has espoused the position that we should list symptoms, in a manner that is reminiscent of a checklist. For example, having a depressed mood on most days for a 2-week period, or a loss of interest in pleasurable things, as well as 4 additional symptoms – among them changes in appetite, changes in sleep, changes in psychomotor activity, fatigue, worthlessness, poor concentration, or thoughts of death – can lead to a diagnosis of a major depressive episode as part of a major depressive disorder.

Criticisms of this approach can be apparent. Patients subjected to such checklists, including being repeatedly asked to complete the Patient Health Questionnaire 9 (PHQ-9), which closely follows those criteria, can feel lost and even alienated by their providers. After all, one can ask all those questions and make a diagnosis of depression without even knowing about the patient’s stressors, their history, or their social context.

The DSM permits the diagnosis of psychiatric disorders without an understanding of the narrative of the patient. In its defense, the DSM is not a textbook of psychiatry, it is a guide on how to diagnose individuals. The DSM does not demand that psychiatrists only ask about the symptoms on the checklists; it is the providers who can choose to dismiss asking about the important facets of one’s life.

Yet every time we attend a lecture that starts by enumerating the DSM symptoms of the disorder being discussed, we are left with the dissatisfying impression that a specialist of this disorder should have a more nuanced and interesting description of their disorder of study. This feeling of discontent is compounded when we see a movie that encompasses so much of what is missing in today’s psychiatric parlance, and even more so if that movie is ostensibly made for children. Movies, by design, are particularly adept at encapsulating the narrative of someone’s life in a way that psychiatry can learn from.

Other than the embarrassment of not knowing a patient outside the checklist, the importance of narrative cannot be understated. Dr. Erik Erikson rightfully suggested that the point of life is “the acceptance of one’s one and only life cycle”¹ or rather to know it was okay to have been oneself without additions or substitutions. Therefore, one must know what it has meant to be themselves to reconcile this question and achieve Ego Integrity rather than disgust and despair. Narrative is the way in which we understand who we are and what it has meant to be ourselves. An understanding of our personal narrative presents a unique opportunity in expressing what is missing in the DSM. Below, we provide two of our favorite examples in Disney films, among many.
 

‘Ratatouille’ (2007)

One of the missing features of the DSM is its inability to explain to patients the intrapsychic processes that guide us. One of these processes is how our values can lead us to a deep sense of guilt, shame, and the resulting feelings of alienation. It is extremely common for patients to enter our clinical practice feeling shackled by beliefs that they should accomplish more and be more than they are.

The animated film “Ratatouille” does an excellent job at addressing this feeling. The film follows Remy, the protagonist rat, and his adventures as he explores his passion for cooking. Remy teams up with the inept but good-natured human Alfredo Linguini and guides him through cooking while hiding under his chef’s hat. The primary antagonist, Anton Ego, is a particularly harsh food critic. His presence and appearance are somber. He exudes disdain. His trim physique and scarf suggest a man that will break and react to anything, and his skull-shaped typewriter in his coffin-shaped office informs the viewer that he is out to kill with his cruel words. Anton Ego serves as our projected super-ego. He is not an external judge but the judgment deep inside ourselves, goading us to be better with such severity that we are ultimately left feeling condemned.

Remy is the younger of two siblings. He is less physically adept but more intellectual than his older brother, who does not understand why Remy isn’t content eating scraps from the garbage like the rest of their rat clan. Remy is the creative part within us that wants to challenge the status quo and try something new. Remy also represents our shame and guilt for leaving our home. On one hand, we want to dare greatly, in this case at being an extraordinary chef, but on the other we are shy and cook in secret, hiding within the hat of another person. Remy struggles with the deep feeling that we do not deserve our success, that our family will leave us for being who we are, and that we are better off isolating and segregating from our challenges.

The movie concludes that through talent and hard work, our critics will accept us. Furthermore, once accepted for what we do, we can be further accepted for who we are. The movie ends with Remy cooking the eponymous dish ratatouille. He prepares it so remarkably well, the dish transports Anton Ego back to a sublime experience of eating ratatouille as a child, a touching moment which not only underscores food’s evocative link to memory but gives a glimpse at Anton Ego’s own narrative.

Ego is first won over by the dish, and only afterward learns of Remy’s true identity. Remy’s talent is undeniable though, and even the stuffy Ego must accept the film’s theme that “Anyone can cook,” even a rat – the rat that we all sometimes feel we are deep inside, rotten to the core but trying so hard to be accepted by others, and ultimately by ourselves. In the end, we overcome the disgust inherent in the imagery of a rat in a kitchen and instead embrace our hero’s achievement of ego integrity as he combines his identities as a member of a clan of rats, and one of Paris’s finest chefs.

While modern psychiatry can favor looking at people through the lens of biology rather than narrative, “Ratatouille” can serve as a reminder of the powerful unconscious forces that guide our lives. “Ratatouille” is not a successful movie only because of the compelling narrative, but also because the narrative matches the important psychic paradigms that psychiatry once embraced.
 

‘Inside Out’ (2015)

Another missing feature of the DSM is its inability to explain how symptoms feel and manifest psychologically. One such feeling is that of control – whether one is in control of one’s life, feelings, and action or rather a victim of external forces. It is extremely common for patients to enter our clinical practice feeling traumatized by the life they’ve lived and powerless to produce any change. Part of our role is to guide them through this journey from the object of their lives to the subject of their lives.

In the animated feature “Inside Out,” Riley, a preteen girl, goes through the tribulation of growing up and learning about herself. This seemingly happy child, content playing hockey with her best friend, Meg, on the picturesque frozen lakes of Minnesota, reaches her inevitable conflict. Her parents uproot her life, moving the family to San Francisco. By doing so, they disconnect her from her school, her friends, and her hobbies. While all this is happening, we spend time inside Riley’s psyche with the personified characters of Riley’s emotions as they affect her decisions and daily actions amidst the backdrop of her core memories and islands of personality.

During the move, her parents seemingly change and ultimately destroy every facet of Riley’s sense of self, which is animated as the collapse of her personality islands. Her best friend engages Riley in a video call just to inform her that she has a new friend who plays hockey equally well. Her parents do not hear Riley’s concerns and are portrayed as distracted by their adult problems. Riley feels ridiculed in her new school and unable to share her feelings with her parents, who ask her to still be their “happy girl” and indirectly ask her to fake pleasure to alleviate their own anxiety.

The climax of the movie is when Riley decides to run away from San Francisco and her parents, to return to her perceived true home, Minnesota. The climax is resolved when Riley realizes that her parents’ love, representing the connection we have to others, transcends her need for control. To some degree, we are all powerless in the face of the tremendous forces of life and share the difficult task of accepting the cards we were dealt, thus making the story of Riley so compelling.

Additionally, the climax is further resolved by another argument that psychiatry (and the DSM) should consider embracing. Emotions are not all symptoms and living without negative emotion is not the goal of life. Riley grows from preteen to teenager, and from object to subject of her life, by realizing that her symptoms/feelings are not just nuisances to avoid and hide, but the key to meaning. Our anger drives us to try hard. Our fear protects us from harm. Our sadness attracts the warmth and care of others. Our disgust protects us physically from noxious material (symbolized as a dreaded broccoli floret for preteen Riley) and socially by encouraging us to share societal norms. Similarly, patients and people in general would benefit by being taught that, while symptoms may permit the better assessment of psychiatric conditions using the DSM, life is much more than that.

It is unfair to blame the DSM for things it was not designed to do. The DSM doesn’t advertise itself as a guidebook of all behaviors, at all times. However, for a variety of reasons, it has become the main way psychiatry describes people. While we commend the APA for its effort and do not know that we could make it any better, we are frequently happily reminded that in about 90 minutes, filmmakers are able to display an empathic understanding of personal narratives that biologic psychiatry can miss.

Dr. Pulido is a psychiatry resident at the University of California, San Diego. She is interested in women’s mental health, medical education, and outpatient psychiatry. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. He has no conflicts of interest.

References

1. Erikson, EH. Childhood and society (New York: WW Norton, 1950).

A common refrain in psychiatry is that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, (DSM-5-TR), published in 2022, is the best we can do.

Since the DSM-III was released in 1980, the American Psychiatric Association, which publishes the manual, has espoused the position that we should list symptoms, in a manner that is reminiscent of a checklist. For example, having a depressed mood on most days for a 2-week period, or a loss of interest in pleasurable things, as well as 4 additional symptoms – among them changes in appetite, changes in sleep, changes in psychomotor activity, fatigue, worthlessness, poor concentration, or thoughts of death – can lead to a diagnosis of a major depressive episode as part of a major depressive disorder.

Criticisms of this approach can be apparent. Patients subjected to such checklists, including being repeatedly asked to complete the Patient Health Questionnaire 9 (PHQ-9), which closely follows those criteria, can feel lost and even alienated by their providers. After all, one can ask all those questions and make a diagnosis of depression without even knowing about the patient’s stressors, their history, or their social context.

The DSM permits the diagnosis of psychiatric disorders without an understanding of the narrative of the patient. In its defense, the DSM is not a textbook of psychiatry, it is a guide on how to diagnose individuals. The DSM does not demand that psychiatrists only ask about the symptoms on the checklists; it is the providers who can choose to dismiss asking about the important facets of one’s life.

Yet every time we attend a lecture that starts by enumerating the DSM symptoms of the disorder being discussed, we are left with the dissatisfying impression that a specialist of this disorder should have a more nuanced and interesting description of their disorder of study. This feeling of discontent is compounded when we see a movie that encompasses so much of what is missing in today’s psychiatric parlance, and even more so if that movie is ostensibly made for children. Movies, by design, are particularly adept at encapsulating the narrative of someone’s life in a way that psychiatry can learn from.

Other than the embarrassment of not knowing a patient outside the checklist, the importance of narrative cannot be understated. Dr. Erik Erikson rightfully suggested that the point of life is “the acceptance of one’s one and only life cycle”¹ or rather to know it was okay to have been oneself without additions or substitutions. Therefore, one must know what it has meant to be themselves to reconcile this question and achieve Ego Integrity rather than disgust and despair. Narrative is the way in which we understand who we are and what it has meant to be ourselves. An understanding of our personal narrative presents a unique opportunity in expressing what is missing in the DSM. Below, we provide two of our favorite examples in Disney films, among many.
 

‘Ratatouille’ (2007)

One of the missing features of the DSM is its inability to explain to patients the intrapsychic processes that guide us. One of these processes is how our values can lead us to a deep sense of guilt, shame, and the resulting feelings of alienation. It is extremely common for patients to enter our clinical practice feeling shackled by beliefs that they should accomplish more and be more than they are.

The animated film “Ratatouille” does an excellent job at addressing this feeling. The film follows Remy, the protagonist rat, and his adventures as he explores his passion for cooking. Remy teams up with the inept but good-natured human Alfredo Linguini and guides him through cooking while hiding under his chef’s hat. The primary antagonist, Anton Ego, is a particularly harsh food critic. His presence and appearance are somber. He exudes disdain. His trim physique and scarf suggest a man that will break and react to anything, and his skull-shaped typewriter in his coffin-shaped office informs the viewer that he is out to kill with his cruel words. Anton Ego serves as our projected super-ego. He is not an external judge but the judgment deep inside ourselves, goading us to be better with such severity that we are ultimately left feeling condemned.

Remy is the younger of two siblings. He is less physically adept but more intellectual than his older brother, who does not understand why Remy isn’t content eating scraps from the garbage like the rest of their rat clan. Remy is the creative part within us that wants to challenge the status quo and try something new. Remy also represents our shame and guilt for leaving our home. On one hand, we want to dare greatly, in this case at being an extraordinary chef, but on the other we are shy and cook in secret, hiding within the hat of another person. Remy struggles with the deep feeling that we do not deserve our success, that our family will leave us for being who we are, and that we are better off isolating and segregating from our challenges.

The movie concludes that through talent and hard work, our critics will accept us. Furthermore, once accepted for what we do, we can be further accepted for who we are. The movie ends with Remy cooking the eponymous dish ratatouille. He prepares it so remarkably well, the dish transports Anton Ego back to a sublime experience of eating ratatouille as a child, a touching moment which not only underscores food’s evocative link to memory but gives a glimpse at Anton Ego’s own narrative.

Ego is first won over by the dish, and only afterward learns of Remy’s true identity. Remy’s talent is undeniable though, and even the stuffy Ego must accept the film’s theme that “Anyone can cook,” even a rat – the rat that we all sometimes feel we are deep inside, rotten to the core but trying so hard to be accepted by others, and ultimately by ourselves. In the end, we overcome the disgust inherent in the imagery of a rat in a kitchen and instead embrace our hero’s achievement of ego integrity as he combines his identities as a member of a clan of rats, and one of Paris’s finest chefs.

While modern psychiatry can favor looking at people through the lens of biology rather than narrative, “Ratatouille” can serve as a reminder of the powerful unconscious forces that guide our lives. “Ratatouille” is not a successful movie only because of the compelling narrative, but also because the narrative matches the important psychic paradigms that psychiatry once embraced.
 

‘Inside Out’ (2015)

Another missing feature of the DSM is its inability to explain how symptoms feel and manifest psychologically. One such feeling is that of control – whether one is in control of one’s life, feelings, and action or rather a victim of external forces. It is extremely common for patients to enter our clinical practice feeling traumatized by the life they’ve lived and powerless to produce any change. Part of our role is to guide them through this journey from the object of their lives to the subject of their lives.

In the animated feature “Inside Out,” Riley, a preteen girl, goes through the tribulation of growing up and learning about herself. This seemingly happy child, content playing hockey with her best friend, Meg, on the picturesque frozen lakes of Minnesota, reaches her inevitable conflict. Her parents uproot her life, moving the family to San Francisco. By doing so, they disconnect her from her school, her friends, and her hobbies. While all this is happening, we spend time inside Riley’s psyche with the personified characters of Riley’s emotions as they affect her decisions and daily actions amidst the backdrop of her core memories and islands of personality.

During the move, her parents seemingly change and ultimately destroy every facet of Riley’s sense of self, which is animated as the collapse of her personality islands. Her best friend engages Riley in a video call just to inform her that she has a new friend who plays hockey equally well. Her parents do not hear Riley’s concerns and are portrayed as distracted by their adult problems. Riley feels ridiculed in her new school and unable to share her feelings with her parents, who ask her to still be their “happy girl” and indirectly ask her to fake pleasure to alleviate their own anxiety.

The climax of the movie is when Riley decides to run away from San Francisco and her parents, to return to her perceived true home, Minnesota. The climax is resolved when Riley realizes that her parents’ love, representing the connection we have to others, transcends her need for control. To some degree, we are all powerless in the face of the tremendous forces of life and share the difficult task of accepting the cards we were dealt, thus making the story of Riley so compelling.

Additionally, the climax is further resolved by another argument that psychiatry (and the DSM) should consider embracing. Emotions are not all symptoms and living without negative emotion is not the goal of life. Riley grows from preteen to teenager, and from object to subject of her life, by realizing that her symptoms/feelings are not just nuisances to avoid and hide, but the key to meaning. Our anger drives us to try hard. Our fear protects us from harm. Our sadness attracts the warmth and care of others. Our disgust protects us physically from noxious material (symbolized as a dreaded broccoli floret for preteen Riley) and socially by encouraging us to share societal norms. Similarly, patients and people in general would benefit by being taught that, while symptoms may permit the better assessment of psychiatric conditions using the DSM, life is much more than that.

It is unfair to blame the DSM for things it was not designed to do. The DSM doesn’t advertise itself as a guidebook of all behaviors, at all times. However, for a variety of reasons, it has become the main way psychiatry describes people. While we commend the APA for its effort and do not know that we could make it any better, we are frequently happily reminded that in about 90 minutes, filmmakers are able to display an empathic understanding of personal narratives that biologic psychiatry can miss.

Dr. Pulido is a psychiatry resident at the University of California, San Diego. She is interested in women’s mental health, medical education, and outpatient psychiatry. Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. He has no conflicts of interest.

References

1. Erikson, EH. Childhood and society (New York: WW Norton, 1950).

“More than Jews have kept Shabbat, Shabbat has kept the Jews.” – Ahad Ha’am

You should all be well rested by now. After all, we’ve just come through the festive shutdown of the holiday season where all of your pumpkin/peppermint/marshmallow flavored coffees were sipped while walking around in your jimjams at 10 a.m. It was the time of year for you to take time off to get a proper rest and be energized to get back to work. Yet, I’m not feeling it from you.

So let’s talk about burnout – just kidding, that would only make it worse. “Burned-out’’ is a hackneyed and defective phrase to describe what many of us are feeling. We are not “destroyed, gutted by fire or by overheating.” No, we are, as one of our docs put it to me: “Just tired.” Ah, a much better Old English word! “Tired” captures it. It means to feel “in need of rest.” We are not ruined, we are just depleted. We don’t need discarding. We need some rest.

Ironically, this column, like most of mine, comes to you after my having written it on a Saturday and Sunday. I also just logged on to my EMR and checked results, renewed a few prescriptions, and answered a couple messages. If I didn’t, my Monday’s work would be crushingly heavy.

Maybe I need to be more efficient and finish my work during the week. Or maybe I need to realize that work has not let up since about 600 BCE and taking one day off each week to rest is an obligation to myself, my family and my community.

I wonder if I can choose Mondays.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

“More than Jews have kept Shabbat, Shabbat has kept the Jews.” – Ahad Ha’am

You should all be well rested by now. After all, we’ve just come through the festive shutdown of the holiday season where all of your pumpkin/peppermint/marshmallow flavored coffees were sipped while walking around in your jimjams at 10 a.m. It was the time of year for you to take time off to get a proper rest and be energized to get back to work. Yet, I’m not feeling it from you.

So let’s talk about burnout – just kidding, that would only make it worse. “Burned-out’’ is a hackneyed and defective phrase to describe what many of us are feeling. We are not “destroyed, gutted by fire or by overheating.” No, we are, as one of our docs put it to me: “Just tired.” Ah, a much better Old English word! “Tired” captures it. It means to feel “in need of rest.” We are not ruined, we are just depleted. We don’t need discarding. We need some rest.

Ironically, this column, like most of mine, comes to you after my having written it on a Saturday and Sunday. I also just logged on to my EMR and checked results, renewed a few prescriptions, and answered a couple messages. If I didn’t, my Monday’s work would be crushingly heavy.

Maybe I need to be more efficient and finish my work during the week. Or maybe I need to realize that work has not let up since about 600 BCE and taking one day off each week to rest is an obligation to myself, my family and my community.

I wonder if I can choose Mondays.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

“More than Jews have kept Shabbat, Shabbat has kept the Jews.” – Ahad Ha’am

You should all be well rested by now. After all, we’ve just come through the festive shutdown of the holiday season where all of your pumpkin/peppermint/marshmallow flavored coffees were sipped while walking around in your jimjams at 10 a.m. It was the time of year for you to take time off to get a proper rest and be energized to get back to work. Yet, I’m not feeling it from you.

So let’s talk about burnout – just kidding, that would only make it worse. “Burned-out’’ is a hackneyed and defective phrase to describe what many of us are feeling. We are not “destroyed, gutted by fire or by overheating.” No, we are, as one of our docs put it to me: “Just tired.” Ah, a much better Old English word! “Tired” captures it. It means to feel “in need of rest.” We are not ruined, we are just depleted. We don’t need discarding. We need some rest.

Ironically, this column, like most of mine, comes to you after my having written it on a Saturday and Sunday. I also just logged on to my EMR and checked results, renewed a few prescriptions, and answered a couple messages. If I didn’t, my Monday’s work would be crushingly heavy.

Maybe I need to be more efficient and finish my work during the week. Or maybe I need to realize that work has not let up since about 600 BCE and taking one day off each week to rest is an obligation to myself, my family and my community.

I wonder if I can choose Mondays.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].