Commentary

Andrew N. Wilner, MD: Welcome to Medscape. I’m Dr Andrew Wilner. Today I have a special guest, Dr James Gordon, founder and executive director of the Center for Mind-Body Medicine. Welcome, Dr Gordon.

Courtesy Center for Mind-Body Medicine

James S. Gordon, MD: Thank you very much. It’s good to be with you.

Dr. Wilner: Thanks for joining us. We are recording this in late May 2020, in the midst of the coronavirus pandemic. Millions of people have been infected. Hundreds of thousands have died. Millions have lost their jobs. I think it’s fair to say that people are under a greater degree of stress than they’re normally accustomed to. Would you agree with that?

Dr. Gordon: I think it’s more than fair to say that everybody in the United States, and actually pretty much everyone in the world, is under extreme stress. And that compounds any stresses that they’ve experienced before in their lives. Everyone is affected.

Dr. Wilner: The mind-body medicine concept is one that you’ve pursued for decades. Tell us a little bit about the Center for Mind-Body Medicine and how that’s led to the program that you have to help us deal with the coronavirus.

Dr. Gordon: I started the Center for Mind-Body Medicine about 30 years ago. I’d been a researcher at the National Institute of Mental Health for a number of years, in private practice, and a professor at Georgetown Medical School. But I wanted to really focus on how to change and enrich medicine by making self-care, self-awareness, and group support central to all healthcare.

Western medicine is enormously powerful in certain situations, such as physical trauma, high levels of infection, congenital anomalies. But we’re not so good at working with chronic physical or psychological problems. Those are much more complex.

We’ve been discovering that what is going to make the long-term difference in conditions like type 2 diabetes, pain syndromes, hypertension, depression, and anxiety are those approaches that we can learn to do for ourselves. These are changes we can make in how we deal with stress, eat, exercise, relate to other people, and whether we find meaning and purpose in our lives.

For the past 25 years, the major part of our focus has been on whole populations that have been psychologically traumatized by wars, climate-related disasters, the opioid epidemic, chronic poverty, historical trauma. We do a lot of work with indigenous people here in North America. We’ve worked in a number of communities where school shootings have traumatized everyone.

What we’ve learned over these past 25 years, and what interested me professionally as well as personally over the past 50 years, is what we’re now bringing out on an even larger scale. The kind of approaches that we’ve developed, studied, and published research on are exactly what everyone needs to include and incorporate in their daily life, as well as in their medical and health care, from now on.

Dr. Wilner: Do you have a program that’s specifically for health care providers?

Dr. Gordon: Yes. The Center for Mind-Body Medicine is primarily an educational organization rather than a service organization. Since the beginning, I’ve been focused on training health professionals. My first passion was for training physicians – I’m a physician, so there’s a feeling of fellowship there – but also health care workers and mental health professionals of every kind.

We teach health professionals a whole system, a comprehensive program of techniques of self-awareness and self-care. We teach them so that they can practice on themselves and study the underlying science, so they can then teach what they’ve learned to the patients or clients they work with. They integrate it into what they’re already doing, regardless of their specialty. At times we also offer some of the same kinds of mind-body skills groups that are the fundamental part of our training as a stand-alone intervention. You can’t really teach other people how to take care of themselves unless you’re also doing it yourself. Otherwise, it’s just a theory.

Dr. Wilner: As a neurologist, I’m interested in the mind-body system. You are a psychiatrist and understand that it’s a lot more difficult to objectify certain things. What is stress? What is happiness? What is sadness? It’s very hard to measure. You can have scales, but it requires insight on the part of the individual. So I think it’s certainly an ambitious project.

Dr. Gordon: You’re absolutely right. It requires insight. And one of the shortcomings of our medical education is that it doesn’t encourage us to look inside ourselves enough. There’s so much focus on objectivity and on data, that we’ve lost some of the subjective art of medicine.

My experience with myself, as well as with the thousands of people we’ve trained here in the United States and around the world and the many hundreds of thousands with whom they’ve worked, is that all of us have a greater capacity to understand and help ourselves than we ordinarily think or than most of us learn about in our medical education.

This work is saying to people to take a little bit of time and relax a little in order to allow yourself to come into a meditative state. And I don’t mean anything fancy by that. Meditation is just being relaxed. Moment-to-moment awareness doesn’t have to do with any particular religion or spiritual practice. It’s part of all of them. If you can get into that state, then you can begin to say, “Oh, that’s what’s going on with me. That’s why my pain is worse.”

For example, you often wonder in people with peripheral neuropathy why it becomes worse or better at certain points. I would encourage neurologists and other physicians to ask your patients, “Why do you think it’s worse?” They may say, “I don’t know, doc; that’s why I’m here.” But I would ask them to take a couple of minutes to let me know. They could think it has something to do with the fact that they had a big fight with their wife that morning, they don’t want to go to work, or whatever it is. This is part of the lost art that we need to bring back into medicine for ourselves and especially for our patients.

Dr. Wilner: Can you give me an example of some of the exercises you’d do in a class?

Dr. Gordon: All of the exercises and our entire program that we teach at the Center for Mind-Body Medicine is in this new book of mine, “The Transformation: Discovering Wholeness and Healing After Trauma.” It’s really the distillation of not just the past 25 or 30 years, but really 50 years of work.

Courtesy Center for Mind-Body Medicine

The techniques are all pretty simple and, as we say, evidence based. There is evidence that shows how they work on us physiologically, as well as psychologically. And they’re all pretty easy to teach to anyone.

Myself and about 60 or 70 of our faculty at the Center for Mind-Body Medicine are currently leading online groups. Then several hundred of the other people we’ve trained are also leading these groups. We’re still counting it up, but we probably have between 700 and 1,000 groups going around the world, led by our faculty and by people we’ve trained.

We teach a different technique every week in these online groups. Last week, after getting people energized and focused, we did a written dialogue with an emotion. You put down the initial of your name – in my case, “J” for Jim – and create a dialogue with an emotion, such as sadness. I would write it as fast as I can.

I would say, “OK, Sadness. Why are you here? What are you doing? I don’t enjoy having you around.” And Sadness writes back to me, “But you need me.” And J says, “What do you mean I need you?” And Sadness says, “Well, your brother died 7 weeks ago, didn’t he?” And I say, “Yes, he did.” And Sadness says, “Aren’t you sad?” I say, “Yes. I’m terribly sad and grieving all the time. But I wasn’t thinking about him at this moment.” And Sadness says, “But he’s there with you all the time and that sadness is in you.” And I say, “You mean it’s in me even here, now, as I’m talking with Andrew in this interview?” And Sadness says, “Yes. You can talk about your work. But in between the words, as you take a breath, don’t you feel it in your chest?” That’s the way the dialogue goes.

Dr. Wilner: What about specifically with the coronavirus? Fear is certainly an emotion. Nobody wants to get sick and die. Nobody wants to bring this disease home to their family. People are reluctant to even go outside and you can’t shake someone’s hand. Are there precedents for this?

Dr. Gordon: There are precedents, but only relatively small groups were affected before by, for example, severe acute respiratory syndrome or H1N1, at least in the United States. But we haven’t seen a global pandemic like this since 1918. None of us was around then – or I certainly wasn’t around. So for most everyone, not only has it not happened before, but we’ve never been so globally aware of everything that’s going on and how different groups are reacting.

I’ve been reading Daniel Defoe’s book, “A Journal of the Plague Year.” It’s really very interesting. It’s about the bubonic plague in 1665 London, although he wrote it in the 1720s. Some of the same things were going on then: the enormous fear, the isolation; rich people being able to escape, poor people having nowhere to go; conspiracy theories of one kind or another, about where the plague came from or blaming a group of people for it; magical thinking that it’s just going to go away. All of those things that happened several hundred years ago are going on now.

And we’re all simultaneously aware of all those things. There’s not only the fear, which should be universal because it’s a reasonable response to this situation, but also the terrible confusion about what to do. The President is saying one thing, governors something else; Anthony Fauci is saying something else, and Deborah Birx is saying something a little bit different. There’s this tremendous confusion that overlays the fear, and I think everybody is more or less feeling these things.

So yes, a dialogue with fear is a good thing to do because it can be clarifying. What we need here is a sense of, what is it that makes sense for me to do? What precautions should I take? What precautions shouldn’t I take?

I have a 17-year-old son who lives with his mom in California. He and I were on the phone the other day. He’s a basketball player and very serious about it. He said, “I don’t want to put my life on hold.” And my response was, “If you go outside too soon, your life may be on hold for a hell of a lot longer than if you stay inside because, if you get sick, it’s serious. But you also need to start looking at the evidence and asking yourself the right questions because I can’t be there all the time and neither can your mom.”

Everybody really needs to use these kinds of tools to help themselves. The tools we teach are extremely good at bringing us back into a state of psychological and physiological balance — slow, deep breathing being a very basic one. Because it’s only in that state that we’re going to be able to make the most intelligent decisions about what to do. It’s only in that state that we’re going to be able to really look our fear in the face and find out what we should be afraid of and what we shouldn’t be afraid of.

It’s a process that’s very much integrated. We’re talking now about how to deal with the emotions. But the first part of what we do in our groups and our online trainings and webinars is teach people to just take a few deep breaths. Just take a few deep breaths in through the nose, out through the mouth, with your belly soft and relaxed. You can keep breathing this way while talking. That’s the antidote to the fight-or-flight response. We all learn about fight-or-flight in first-year physiology. We need to deal with it. We need to bring ourselves into balance. That’s the way we’re going to make the wisest decisions for ourselves and be best able to help our patients.
 

Dr. Wilner: As you mentioned, part of modern culture is that we now have access to all of this information worldwide. There’s a continual stream of newsfeeds, people flipping on their phones, receiving constant updates, 24/7. That’s a new phenomenon. Does that steal from us the time we had before for just breathing and synthesizing data as opposed to just acquiring it all the time?

Dr. Gordon: You’re absolutely right. It does and it’s a challenge. It can’t steal from us unless we’re letting our emotional, psychological, and physiological pockets be picked!

What we need to do is to make it our priority to come into balance. I don’t watch news all day long – a little tiny bit in the morning and in the evening, just to get a sense of what’s happening. That’s enough. And I think everybody needs to take a step back, ask if this is really what they want to be doing, and to come into balance.

The other thing that’s really important is physical activity, especially during this time. In addition to using slow, deep breathing to come into balance, physical exercise and movement of any kind is extremely good as an antidote to fight-or-flight and that shut-down, freeze-up response that we get into when we feel completely overwhelmed.

We’ve got to take it into our own hands. The media just want to sell us things. Let’s face it: They’re not here for our good. Our job as physicians and health care professionals is to really reinforce for people not only what we can do for them but what they can do for themselves.

Dr. Wilner: I’m certainly interested in learning more about mind-body medicine. For those who feel the same, where do you recommend they go to learn more?

Dr. Gordon: We have a website, cmbm.org, which features a number of webinars. I do a free webinar there every week. We have mind-body skills groups that meet once a week for 8 weeks. There are six physicians in my group and all kinds of health professionals in other groups. We have a training program that we’re bringing online. We’ve trained well over 6,000 people around the world and would love to train more. You can read about that on the website.

We’re starting to do more and more consulting with health care organizations. We’re working with the largest division of Veterans Affairs, which is in Florida, as well as in south Georgia and the Caribbean. We’re working with a large health system in Indiana and others elsewhere. In addition, we’re working with groups of physicians and mental health professionals, helping them to integrate what we have to offer into what they’re already doing.

That’s our job – to help you do your job.

Dr. Wilner: Dr Gordon, I feel more relaxed just speaking with you. Thank you for talking with me and sharing your experiences with Medscape. I look forward to learning more.

Dr. Gordon: Thank you. My pleasure.

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

Andrew N. Wilner, MD: Welcome to Medscape. I’m Dr Andrew Wilner. Today I have a special guest, Dr James Gordon, founder and executive director of the Center for Mind-Body Medicine. Welcome, Dr Gordon.

Courtesy Center for Mind-Body Medicine

James S. Gordon, MD: Thank you very much. It’s good to be with you.

Dr. Wilner: Thanks for joining us. We are recording this in late May 2020, in the midst of the coronavirus pandemic. Millions of people have been infected. Hundreds of thousands have died. Millions have lost their jobs. I think it’s fair to say that people are under a greater degree of stress than they’re normally accustomed to. Would you agree with that?

Dr. Gordon: I think it’s more than fair to say that everybody in the United States, and actually pretty much everyone in the world, is under extreme stress. And that compounds any stresses that they’ve experienced before in their lives. Everyone is affected.

Dr. Wilner: The mind-body medicine concept is one that you’ve pursued for decades. Tell us a little bit about the Center for Mind-Body Medicine and how that’s led to the program that you have to help us deal with the coronavirus.

Dr. Gordon: I started the Center for Mind-Body Medicine about 30 years ago. I’d been a researcher at the National Institute of Mental Health for a number of years, in private practice, and a professor at Georgetown Medical School. But I wanted to really focus on how to change and enrich medicine by making self-care, self-awareness, and group support central to all healthcare.

Western medicine is enormously powerful in certain situations, such as physical trauma, high levels of infection, congenital anomalies. But we’re not so good at working with chronic physical or psychological problems. Those are much more complex.

We’ve been discovering that what is going to make the long-term difference in conditions like type 2 diabetes, pain syndromes, hypertension, depression, and anxiety are those approaches that we can learn to do for ourselves. These are changes we can make in how we deal with stress, eat, exercise, relate to other people, and whether we find meaning and purpose in our lives.

For the past 25 years, the major part of our focus has been on whole populations that have been psychologically traumatized by wars, climate-related disasters, the opioid epidemic, chronic poverty, historical trauma. We do a lot of work with indigenous people here in North America. We’ve worked in a number of communities where school shootings have traumatized everyone.

What we’ve learned over these past 25 years, and what interested me professionally as well as personally over the past 50 years, is what we’re now bringing out on an even larger scale. The kind of approaches that we’ve developed, studied, and published research on are exactly what everyone needs to include and incorporate in their daily life, as well as in their medical and health care, from now on.

Dr. Wilner: Do you have a program that’s specifically for health care providers?

Dr. Gordon: Yes. The Center for Mind-Body Medicine is primarily an educational organization rather than a service organization. Since the beginning, I’ve been focused on training health professionals. My first passion was for training physicians – I’m a physician, so there’s a feeling of fellowship there – but also health care workers and mental health professionals of every kind.

We teach health professionals a whole system, a comprehensive program of techniques of self-awareness and self-care. We teach them so that they can practice on themselves and study the underlying science, so they can then teach what they’ve learned to the patients or clients they work with. They integrate it into what they’re already doing, regardless of their specialty. At times we also offer some of the same kinds of mind-body skills groups that are the fundamental part of our training as a stand-alone intervention. You can’t really teach other people how to take care of themselves unless you’re also doing it yourself. Otherwise, it’s just a theory.

Dr. Wilner: As a neurologist, I’m interested in the mind-body system. You are a psychiatrist and understand that it’s a lot more difficult to objectify certain things. What is stress? What is happiness? What is sadness? It’s very hard to measure. You can have scales, but it requires insight on the part of the individual. So I think it’s certainly an ambitious project.

Dr. Gordon: You’re absolutely right. It requires insight. And one of the shortcomings of our medical education is that it doesn’t encourage us to look inside ourselves enough. There’s so much focus on objectivity and on data, that we’ve lost some of the subjective art of medicine.

My experience with myself, as well as with the thousands of people we’ve trained here in the United States and around the world and the many hundreds of thousands with whom they’ve worked, is that all of us have a greater capacity to understand and help ourselves than we ordinarily think or than most of us learn about in our medical education.

This work is saying to people to take a little bit of time and relax a little in order to allow yourself to come into a meditative state. And I don’t mean anything fancy by that. Meditation is just being relaxed. Moment-to-moment awareness doesn’t have to do with any particular religion or spiritual practice. It’s part of all of them. If you can get into that state, then you can begin to say, “Oh, that’s what’s going on with me. That’s why my pain is worse.”

For example, you often wonder in people with peripheral neuropathy why it becomes worse or better at certain points. I would encourage neurologists and other physicians to ask your patients, “Why do you think it’s worse?” They may say, “I don’t know, doc; that’s why I’m here.” But I would ask them to take a couple of minutes to let me know. They could think it has something to do with the fact that they had a big fight with their wife that morning, they don’t want to go to work, or whatever it is. This is part of the lost art that we need to bring back into medicine for ourselves and especially for our patients.

Dr. Wilner: Can you give me an example of some of the exercises you’d do in a class?

Dr. Gordon: All of the exercises and our entire program that we teach at the Center for Mind-Body Medicine is in this new book of mine, “The Transformation: Discovering Wholeness and Healing After Trauma.” It’s really the distillation of not just the past 25 or 30 years, but really 50 years of work.

Courtesy Center for Mind-Body Medicine

The techniques are all pretty simple and, as we say, evidence based. There is evidence that shows how they work on us physiologically, as well as psychologically. And they’re all pretty easy to teach to anyone.

Myself and about 60 or 70 of our faculty at the Center for Mind-Body Medicine are currently leading online groups. Then several hundred of the other people we’ve trained are also leading these groups. We’re still counting it up, but we probably have between 700 and 1,000 groups going around the world, led by our faculty and by people we’ve trained.

We teach a different technique every week in these online groups. Last week, after getting people energized and focused, we did a written dialogue with an emotion. You put down the initial of your name – in my case, “J” for Jim – and create a dialogue with an emotion, such as sadness. I would write it as fast as I can.

I would say, “OK, Sadness. Why are you here? What are you doing? I don’t enjoy having you around.” And Sadness writes back to me, “But you need me.” And J says, “What do you mean I need you?” And Sadness says, “Well, your brother died 7 weeks ago, didn’t he?” And I say, “Yes, he did.” And Sadness says, “Aren’t you sad?” I say, “Yes. I’m terribly sad and grieving all the time. But I wasn’t thinking about him at this moment.” And Sadness says, “But he’s there with you all the time and that sadness is in you.” And I say, “You mean it’s in me even here, now, as I’m talking with Andrew in this interview?” And Sadness says, “Yes. You can talk about your work. But in between the words, as you take a breath, don’t you feel it in your chest?” That’s the way the dialogue goes.

Dr. Wilner: What about specifically with the coronavirus? Fear is certainly an emotion. Nobody wants to get sick and die. Nobody wants to bring this disease home to their family. People are reluctant to even go outside and you can’t shake someone’s hand. Are there precedents for this?

Dr. Gordon: There are precedents, but only relatively small groups were affected before by, for example, severe acute respiratory syndrome or H1N1, at least in the United States. But we haven’t seen a global pandemic like this since 1918. None of us was around then – or I certainly wasn’t around. So for most everyone, not only has it not happened before, but we’ve never been so globally aware of everything that’s going on and how different groups are reacting.

I’ve been reading Daniel Defoe’s book, “A Journal of the Plague Year.” It’s really very interesting. It’s about the bubonic plague in 1665 London, although he wrote it in the 1720s. Some of the same things were going on then: the enormous fear, the isolation; rich people being able to escape, poor people having nowhere to go; conspiracy theories of one kind or another, about where the plague came from or blaming a group of people for it; magical thinking that it’s just going to go away. All of those things that happened several hundred years ago are going on now.

And we’re all simultaneously aware of all those things. There’s not only the fear, which should be universal because it’s a reasonable response to this situation, but also the terrible confusion about what to do. The President is saying one thing, governors something else; Anthony Fauci is saying something else, and Deborah Birx is saying something a little bit different. There’s this tremendous confusion that overlays the fear, and I think everybody is more or less feeling these things.

So yes, a dialogue with fear is a good thing to do because it can be clarifying. What we need here is a sense of, what is it that makes sense for me to do? What precautions should I take? What precautions shouldn’t I take?

I have a 17-year-old son who lives with his mom in California. He and I were on the phone the other day. He’s a basketball player and very serious about it. He said, “I don’t want to put my life on hold.” And my response was, “If you go outside too soon, your life may be on hold for a hell of a lot longer than if you stay inside because, if you get sick, it’s serious. But you also need to start looking at the evidence and asking yourself the right questions because I can’t be there all the time and neither can your mom.”

Everybody really needs to use these kinds of tools to help themselves. The tools we teach are extremely good at bringing us back into a state of psychological and physiological balance — slow, deep breathing being a very basic one. Because it’s only in that state that we’re going to be able to make the most intelligent decisions about what to do. It’s only in that state that we’re going to be able to really look our fear in the face and find out what we should be afraid of and what we shouldn’t be afraid of.

It’s a process that’s very much integrated. We’re talking now about how to deal with the emotions. But the first part of what we do in our groups and our online trainings and webinars is teach people to just take a few deep breaths. Just take a few deep breaths in through the nose, out through the mouth, with your belly soft and relaxed. You can keep breathing this way while talking. That’s the antidote to the fight-or-flight response. We all learn about fight-or-flight in first-year physiology. We need to deal with it. We need to bring ourselves into balance. That’s the way we’re going to make the wisest decisions for ourselves and be best able to help our patients.
 

Dr. Wilner: As you mentioned, part of modern culture is that we now have access to all of this information worldwide. There’s a continual stream of newsfeeds, people flipping on their phones, receiving constant updates, 24/7. That’s a new phenomenon. Does that steal from us the time we had before for just breathing and synthesizing data as opposed to just acquiring it all the time?

Dr. Gordon: You’re absolutely right. It does and it’s a challenge. It can’t steal from us unless we’re letting our emotional, psychological, and physiological pockets be picked!

What we need to do is to make it our priority to come into balance. I don’t watch news all day long – a little tiny bit in the morning and in the evening, just to get a sense of what’s happening. That’s enough. And I think everybody needs to take a step back, ask if this is really what they want to be doing, and to come into balance.

The other thing that’s really important is physical activity, especially during this time. In addition to using slow, deep breathing to come into balance, physical exercise and movement of any kind is extremely good as an antidote to fight-or-flight and that shut-down, freeze-up response that we get into when we feel completely overwhelmed.

We’ve got to take it into our own hands. The media just want to sell us things. Let’s face it: They’re not here for our good. Our job as physicians and health care professionals is to really reinforce for people not only what we can do for them but what they can do for themselves.

Dr. Wilner: I’m certainly interested in learning more about mind-body medicine. For those who feel the same, where do you recommend they go to learn more?

Dr. Gordon: We have a website, cmbm.org, which features a number of webinars. I do a free webinar there every week. We have mind-body skills groups that meet once a week for 8 weeks. There are six physicians in my group and all kinds of health professionals in other groups. We have a training program that we’re bringing online. We’ve trained well over 6,000 people around the world and would love to train more. You can read about that on the website.

We’re starting to do more and more consulting with health care organizations. We’re working with the largest division of Veterans Affairs, which is in Florida, as well as in south Georgia and the Caribbean. We’re working with a large health system in Indiana and others elsewhere. In addition, we’re working with groups of physicians and mental health professionals, helping them to integrate what we have to offer into what they’re already doing.

That’s our job – to help you do your job.

Dr. Wilner: Dr Gordon, I feel more relaxed just speaking with you. Thank you for talking with me and sharing your experiences with Medscape. I look forward to learning more.

Dr. Gordon: Thank you. My pleasure.

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

Andrew N. Wilner, MD: Welcome to Medscape. I’m Dr Andrew Wilner. Today I have a special guest, Dr James Gordon, founder and executive director of the Center for Mind-Body Medicine. Welcome, Dr Gordon.

Courtesy Center for Mind-Body Medicine

James S. Gordon, MD: Thank you very much. It’s good to be with you.

Dr. Wilner: Thanks for joining us. We are recording this in late May 2020, in the midst of the coronavirus pandemic. Millions of people have been infected. Hundreds of thousands have died. Millions have lost their jobs. I think it’s fair to say that people are under a greater degree of stress than they’re normally accustomed to. Would you agree with that?

Dr. Gordon: I think it’s more than fair to say that everybody in the United States, and actually pretty much everyone in the world, is under extreme stress. And that compounds any stresses that they’ve experienced before in their lives. Everyone is affected.

Dr. Wilner: The mind-body medicine concept is one that you’ve pursued for decades. Tell us a little bit about the Center for Mind-Body Medicine and how that’s led to the program that you have to help us deal with the coronavirus.

Dr. Gordon: I started the Center for Mind-Body Medicine about 30 years ago. I’d been a researcher at the National Institute of Mental Health for a number of years, in private practice, and a professor at Georgetown Medical School. But I wanted to really focus on how to change and enrich medicine by making self-care, self-awareness, and group support central to all healthcare.

Western medicine is enormously powerful in certain situations, such as physical trauma, high levels of infection, congenital anomalies. But we’re not so good at working with chronic physical or psychological problems. Those are much more complex.

We’ve been discovering that what is going to make the long-term difference in conditions like type 2 diabetes, pain syndromes, hypertension, depression, and anxiety are those approaches that we can learn to do for ourselves. These are changes we can make in how we deal with stress, eat, exercise, relate to other people, and whether we find meaning and purpose in our lives.

For the past 25 years, the major part of our focus has been on whole populations that have been psychologically traumatized by wars, climate-related disasters, the opioid epidemic, chronic poverty, historical trauma. We do a lot of work with indigenous people here in North America. We’ve worked in a number of communities where school shootings have traumatized everyone.

What we’ve learned over these past 25 years, and what interested me professionally as well as personally over the past 50 years, is what we’re now bringing out on an even larger scale. The kind of approaches that we’ve developed, studied, and published research on are exactly what everyone needs to include and incorporate in their daily life, as well as in their medical and health care, from now on.

Dr. Wilner: Do you have a program that’s specifically for health care providers?

Dr. Gordon: Yes. The Center for Mind-Body Medicine is primarily an educational organization rather than a service organization. Since the beginning, I’ve been focused on training health professionals. My first passion was for training physicians – I’m a physician, so there’s a feeling of fellowship there – but also health care workers and mental health professionals of every kind.

We teach health professionals a whole system, a comprehensive program of techniques of self-awareness and self-care. We teach them so that they can practice on themselves and study the underlying science, so they can then teach what they’ve learned to the patients or clients they work with. They integrate it into what they’re already doing, regardless of their specialty. At times we also offer some of the same kinds of mind-body skills groups that are the fundamental part of our training as a stand-alone intervention. You can’t really teach other people how to take care of themselves unless you’re also doing it yourself. Otherwise, it’s just a theory.

Dr. Wilner: As a neurologist, I’m interested in the mind-body system. You are a psychiatrist and understand that it’s a lot more difficult to objectify certain things. What is stress? What is happiness? What is sadness? It’s very hard to measure. You can have scales, but it requires insight on the part of the individual. So I think it’s certainly an ambitious project.

Dr. Gordon: You’re absolutely right. It requires insight. And one of the shortcomings of our medical education is that it doesn’t encourage us to look inside ourselves enough. There’s so much focus on objectivity and on data, that we’ve lost some of the subjective art of medicine.

My experience with myself, as well as with the thousands of people we’ve trained here in the United States and around the world and the many hundreds of thousands with whom they’ve worked, is that all of us have a greater capacity to understand and help ourselves than we ordinarily think or than most of us learn about in our medical education.

This work is saying to people to take a little bit of time and relax a little in order to allow yourself to come into a meditative state. And I don’t mean anything fancy by that. Meditation is just being relaxed. Moment-to-moment awareness doesn’t have to do with any particular religion or spiritual practice. It’s part of all of them. If you can get into that state, then you can begin to say, “Oh, that’s what’s going on with me. That’s why my pain is worse.”

For example, you often wonder in people with peripheral neuropathy why it becomes worse or better at certain points. I would encourage neurologists and other physicians to ask your patients, “Why do you think it’s worse?” They may say, “I don’t know, doc; that’s why I’m here.” But I would ask them to take a couple of minutes to let me know. They could think it has something to do with the fact that they had a big fight with their wife that morning, they don’t want to go to work, or whatever it is. This is part of the lost art that we need to bring back into medicine for ourselves and especially for our patients.

Dr. Wilner: Can you give me an example of some of the exercises you’d do in a class?

Dr. Gordon: All of the exercises and our entire program that we teach at the Center for Mind-Body Medicine is in this new book of mine, “The Transformation: Discovering Wholeness and Healing After Trauma.” It’s really the distillation of not just the past 25 or 30 years, but really 50 years of work.

Courtesy Center for Mind-Body Medicine

The techniques are all pretty simple and, as we say, evidence based. There is evidence that shows how they work on us physiologically, as well as psychologically. And they’re all pretty easy to teach to anyone.

Myself and about 60 or 70 of our faculty at the Center for Mind-Body Medicine are currently leading online groups. Then several hundred of the other people we’ve trained are also leading these groups. We’re still counting it up, but we probably have between 700 and 1,000 groups going around the world, led by our faculty and by people we’ve trained.

We teach a different technique every week in these online groups. Last week, after getting people energized and focused, we did a written dialogue with an emotion. You put down the initial of your name – in my case, “J” for Jim – and create a dialogue with an emotion, such as sadness. I would write it as fast as I can.

I would say, “OK, Sadness. Why are you here? What are you doing? I don’t enjoy having you around.” And Sadness writes back to me, “But you need me.” And J says, “What do you mean I need you?” And Sadness says, “Well, your brother died 7 weeks ago, didn’t he?” And I say, “Yes, he did.” And Sadness says, “Aren’t you sad?” I say, “Yes. I’m terribly sad and grieving all the time. But I wasn’t thinking about him at this moment.” And Sadness says, “But he’s there with you all the time and that sadness is in you.” And I say, “You mean it’s in me even here, now, as I’m talking with Andrew in this interview?” And Sadness says, “Yes. You can talk about your work. But in between the words, as you take a breath, don’t you feel it in your chest?” That’s the way the dialogue goes.

Dr. Wilner: What about specifically with the coronavirus? Fear is certainly an emotion. Nobody wants to get sick and die. Nobody wants to bring this disease home to their family. People are reluctant to even go outside and you can’t shake someone’s hand. Are there precedents for this?

Dr. Gordon: There are precedents, but only relatively small groups were affected before by, for example, severe acute respiratory syndrome or H1N1, at least in the United States. But we haven’t seen a global pandemic like this since 1918. None of us was around then – or I certainly wasn’t around. So for most everyone, not only has it not happened before, but we’ve never been so globally aware of everything that’s going on and how different groups are reacting.

I’ve been reading Daniel Defoe’s book, “A Journal of the Plague Year.” It’s really very interesting. It’s about the bubonic plague in 1665 London, although he wrote it in the 1720s. Some of the same things were going on then: the enormous fear, the isolation; rich people being able to escape, poor people having nowhere to go; conspiracy theories of one kind or another, about where the plague came from or blaming a group of people for it; magical thinking that it’s just going to go away. All of those things that happened several hundred years ago are going on now.

And we’re all simultaneously aware of all those things. There’s not only the fear, which should be universal because it’s a reasonable response to this situation, but also the terrible confusion about what to do. The President is saying one thing, governors something else; Anthony Fauci is saying something else, and Deborah Birx is saying something a little bit different. There’s this tremendous confusion that overlays the fear, and I think everybody is more or less feeling these things.

So yes, a dialogue with fear is a good thing to do because it can be clarifying. What we need here is a sense of, what is it that makes sense for me to do? What precautions should I take? What precautions shouldn’t I take?

I have a 17-year-old son who lives with his mom in California. He and I were on the phone the other day. He’s a basketball player and very serious about it. He said, “I don’t want to put my life on hold.” And my response was, “If you go outside too soon, your life may be on hold for a hell of a lot longer than if you stay inside because, if you get sick, it’s serious. But you also need to start looking at the evidence and asking yourself the right questions because I can’t be there all the time and neither can your mom.”

Everybody really needs to use these kinds of tools to help themselves. The tools we teach are extremely good at bringing us back into a state of psychological and physiological balance — slow, deep breathing being a very basic one. Because it’s only in that state that we’re going to be able to make the most intelligent decisions about what to do. It’s only in that state that we’re going to be able to really look our fear in the face and find out what we should be afraid of and what we shouldn’t be afraid of.

It’s a process that’s very much integrated. We’re talking now about how to deal with the emotions. But the first part of what we do in our groups and our online trainings and webinars is teach people to just take a few deep breaths. Just take a few deep breaths in through the nose, out through the mouth, with your belly soft and relaxed. You can keep breathing this way while talking. That’s the antidote to the fight-or-flight response. We all learn about fight-or-flight in first-year physiology. We need to deal with it. We need to bring ourselves into balance. That’s the way we’re going to make the wisest decisions for ourselves and be best able to help our patients.
 

Dr. Wilner: As you mentioned, part of modern culture is that we now have access to all of this information worldwide. There’s a continual stream of newsfeeds, people flipping on their phones, receiving constant updates, 24/7. That’s a new phenomenon. Does that steal from us the time we had before for just breathing and synthesizing data as opposed to just acquiring it all the time?

Dr. Gordon: You’re absolutely right. It does and it’s a challenge. It can’t steal from us unless we’re letting our emotional, psychological, and physiological pockets be picked!

What we need to do is to make it our priority to come into balance. I don’t watch news all day long – a little tiny bit in the morning and in the evening, just to get a sense of what’s happening. That’s enough. And I think everybody needs to take a step back, ask if this is really what they want to be doing, and to come into balance.

The other thing that’s really important is physical activity, especially during this time. In addition to using slow, deep breathing to come into balance, physical exercise and movement of any kind is extremely good as an antidote to fight-or-flight and that shut-down, freeze-up response that we get into when we feel completely overwhelmed.

We’ve got to take it into our own hands. The media just want to sell us things. Let’s face it: They’re not here for our good. Our job as physicians and health care professionals is to really reinforce for people not only what we can do for them but what they can do for themselves.

Dr. Wilner: I’m certainly interested in learning more about mind-body medicine. For those who feel the same, where do you recommend they go to learn more?

Dr. Gordon: We have a website, cmbm.org, which features a number of webinars. I do a free webinar there every week. We have mind-body skills groups that meet once a week for 8 weeks. There are six physicians in my group and all kinds of health professionals in other groups. We have a training program that we’re bringing online. We’ve trained well over 6,000 people around the world and would love to train more. You can read about that on the website.

We’re starting to do more and more consulting with health care organizations. We’re working with the largest division of Veterans Affairs, which is in Florida, as well as in south Georgia and the Caribbean. We’re working with a large health system in Indiana and others elsewhere. In addition, we’re working with groups of physicians and mental health professionals, helping them to integrate what we have to offer into what they’re already doing.

That’s our job – to help you do your job.

Dr. Wilner: Dr Gordon, I feel more relaxed just speaking with you. Thank you for talking with me and sharing your experiences with Medscape. I look forward to learning more.

Dr. Gordon: Thank you. My pleasure.

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

The destructive toll COVID-19 has caused worldwide is devastating. In the United States, the disproportionate deaths of Black, Indigenous, and Latinx people due to structural racism, amplified by economic adversity, is unacceptable. Meanwhile, the continued murder of Black people by those sworn to protect the public is abhorrent and can no longer be ignored. Black lives matter. These crises have rightly gripped our attention, and should galvanize physicians individually and collectively to use our privileged voices and relative power for justice. We must strive for engaged, passionate, and innovative leadership deliberately aimed toward antiracism and equity.

The COVID-19 pandemic has illuminated the vast inequities in our country. It has highlighted the continued poor outcomes our health and health care systems create for Black, Indigenous, and Latinx communities. It also has demonstrated clearly that we are all connected—one large community, interdependent yet rife with differential power, privilege, and oppression. We must address these racial disparities—not only in the name of justice and good health for all but also because it is a moral and ethical imperative for us as physicians—and SARS-CoV-2 clearly shows us that it is in the best interest of everyone to do so.

First step: A deep dive look at systemic racism

What is first needed is an examination and acknowledgement by medicine and health care at large of the deeply entrenched roots of systemic and institutional racism in our profession and care systems, and their disproportionate and unjust impact on the health and livelihood of communities of color. The COVID-19 pandemic is only a recent example that highlights the perpetuation of a system that harms people of color. Racism, sexism, gender discrimination, economic and social injustice, religious persecution, and violence against women and children are age-old. We have yet to see health care institutions implement system-wide intersectional and antiracist practices to address them. Mandatory implicit bias training, policies for inclusion and diversity, and position statements are necessary first steps; however, they are not a panacea. They are insufficient to create the bold changes we need. The time for words has long passed. It is time to listen, to hear the cries of anguish and outrage, to examine our privileged position, to embrace change and discomfort, and most importantly to act, and to lead in dismantling the structures around us that perpetuate racial inequity.

How can we, as physicians and leaders, join in action and make an impact?

Dr. Camara Jones, past president of the American Public Health Association, describes 3 levels of racism:

• structural or systemic
• individual or personally mediated
• internalized.

Interventions at each level are important if we are to promote equity in health and health care. This framework can help us think about the following strategic initiatives.

Continue to: 1. Commit to becoming an antiracist and engage in independent study...

1. Commit to becoming antiracist and engage in independent study. This is an important first step as it will form the foundations for interventions—one cannot facilitate change without understanding the matter at hand. This step also may be the most personally challenging step forcing all of us to wrestle with discomfort, sadness, fear, guilt, and a host of other emotional responses. Remember that great change has never been born out of comfort, and the discomfort physicians may experience while unlearning racism and learning antiracism pales in comparison to what communities of color experience daily. We must actively work to unlearn the racist and anti-Black culture that is so deeply woven into every aspect of our existence.

Learn the history that was not given to us as kids in school. Read the brilliant literary works of Black, Indigenous, and Latinx artists and scholars on dismantling racism. Expand our vocabulary and knowledge of core concepts in racism, racial justice, and equity. Examine and reflect on our day-to-day practices. Be vocal in our commitment to antiracism—the time has passed for staying silent. If you are white, facilitate conversations about race with your white colleagues; the inherent power of racism relegates it to an issue that can never be on the table, but it is time to dismantle that power. Learn what acts of meaningful and intentional alliances are and when we need to give up power or privilege to a person of color. We also need to recognize that we as physicians, while leaders in many spaces, are not leaders in the powerful racial justice grassroots movements. We should learn from these movements, follow their lead, and use our privilege to uplift racial justice in our settings.

2. Embrace the current complexities with empathy and humility, finding ways to exercise our civic responsibility to the public with compassion. During the COVID-19 pandemic we have seen the devastation that social isolation, job loss, and illness can create. Suddenly those who could never have imagined themselves without food are waiting hours in their cars for food bank donations or are finding empty shelves in stores. Those who were not safe at home were suddenly imprisoned indefinitely in unsafe situations. Those who were comfortable, well-insured, and healthy are facing an invisible health threat, insecurity, fear, anxiety, and loss. Additionally, our civic institutions are failing. Those of us who always took our right to vote for granted are being forced to stand in hours’-long lines to exercise that right; while those who have been systematically disenfranchised are enduring even greater threats to their constitutional right to exercise their political power, disallowing them to speak for their families and communities and to vote for the justice they deserve. This may be an opportunity to stop blaming victims and recognize the toll that structural and systemic contributions to inequity have created over generations.

3. Meaningfully engage with and advocate for patients. In health and health care, we must begin to engage with the communities we serve and truly listen to their needs, desires, and barriers to care, and respond accordingly. Policies that try to address the social determinants of health without that engagement, and without the acknowledgement of the structural issues that cause them, however well-intentioned, are unlikely to accomplish their goals. We need to advocate as physicians and leaders in our settings for every policy, practice, and procedure to be scrutinized using an antiracist lens. To execute this, we need to:

• ask why clinic and hospital practices are built the way they are and how to make them more reflexive and responsive to individual patient’s needs
• examine what the disproportionate impacts might be on different groups of patients from a systems-level
• be ready to dismantle and/or rebuild something that is exacerbating disparate outcomes and experiences
• advocate for change that is built upon the narratives of patients and their communities.

We should include patients in the creation of hospital policies and guidelines in order to shift power toward them and to be transparent about how the system operates in order to facilitate trust and collaboration that centers patients and communities in the systems created to serve them.

Continue to: 4. Intentionally repair and build trust...

4. Intentionally repair and build trust. To create a safe environment, we must repair what we have broken and earn the trust of communities by uplifting their voices and redistributing our power to them in changing the systems and structures that have, for generations, kept Black, Indigenous, and Latinx people oppressed. Building trust requires first owning our histories of colonization, genocide, and slavery—now turned mass incarceration, debasement, and exploitation—that has existed for centuries. We as physicians need to do an honest examination of how we have eroded the trust of the very communities we care for since our profession’s creation. We need to acknowledge, as a white-dominant profession, the medical experimentation on and exploitation of Black and Brown bodies, and how this formed the foundation for a very valid deep distrust and fear of the medical establishment. We need to recognize how our inherent racial biases continue to feed this distrust, like when we don’t treat patients’ pain adequately or make them feel like we believe and listen to their needs and concerns. We must acknowledge our complicity in perpetuating the racial inequities in health, again highlighted by the COVID-19 pandemic.

5. Increase Black, Indigenous, and Latinx representation in physician and other health care professions’ workforce. Racism impacts not only patients but also our colleagues of color. The lack of racial diversity is a symptom of racism and a representation of the continued exclusion and devaluing of physicians of color. We must recognize this legacy of exclusion and facilitate intentional recruitment, retention, inclusion, and belonging of people of color into our workforce. Tokenism, the act of symbolically including one or few people from underrepresented groups, has been a weapon used by our workforce against physicians of color, resulting in isolation, “othering,” demoralization, and other deleterious impacts. We need to reverse this history and diversify our training programs and workforce to ensure justice in our own community.

6. Design multifaceted interventions. Multilevel problems require multilevel solutions. Interventions targeted solely at one level, while helpful, are unlikely to result in the larger scale changes our society needs to implement if we are to eradicate the impact of racism on health. We have long known that it is not just “preexisting conditions” or “poor” individual behaviors that lead to negative and disparate health outcomes—these are impacted by social and structural determinants much larger and more deleterious than that. It is critically important that we allocate and redistribute resources to create safe and affordable housing; childcare and preschool facilities; healthy, available, and affordable food; equitable and affordable educational opportunities; and a clean environment to support the health of all communities—not only those with the highest tax base. It is imperative that we strive to understand the lives of our fellow human beings who have been subjected to intergenerational social injustices and oppressions that have continued to place them at the margins of society. We need to center the lived experiences of communities of color in the design of multilevel interventions, especially Black and Indigenous communities. While we as physicians cannot individually impact education, economic, or food/environment systems, we can use our power to advocate for providing resources for the patients we care for and can create strategies within the health care system to address these needs in order to achieve optimal health. Robust and equitable social structures are the foundations for health, and ensuring equitable access to them is critical to reducing disparities.

Commit to lead

We must commit to unlearning our internalized racism, rebuilding relationships with communities of color, and engaging in antiracist practices. As a profession dedicated to healing, we have an obligation to be leaders in advocating for these changes, and dismantling the inequitable structure of our health care system.

Our challenge now is to articulate solutions. While antiracism should be informed by the lived experiences of communities of color, the work of antiracism is not their responsibility. In fact, it is the responsibility of our white-dominated systems and institutions to change.

There are some solutions that are easier to enumerate because they have easily measurable outcomes or activities, such as:

• collecting data transparently
• identifying inequities in access, treatment, and care
• conducting rigorous root cause analysis of those barriers to care
• increasing diverse racial and gender representation on decision-making bodies, from board rooms to committees, from leadership teams to research participants
• redistribute power by paving the way for underrepresented colleagues to participate in clinical, administrative, educational, executive, and health policy spaces
• mentoring new leaders who come from marginalized communities.

Every patient deserves our expertise and access to high-quality care. We should review our patient panels to ensure we are taking steps personally to be just and eliminate disparities, and we should monitor the results of those efforts.

Continue to: Be open to solutions that may make us “uncomfortable”...

Be open to solutions that may make us “uncomfortable”

There are other solutions, perhaps those that would be more effective on a larger scale, which may be harder to measure using our traditional ways of inquiry or measurement. Solutions that may create discomfort, anger, or fear for those who have held their power or positions for a long time. We need to begin to engage in developing, cultivating, and valuing innovative strategies that produce equally valid knowledge, evidence, and solutions without engaging in a randomized controlled trial. We need to reinvent the way inquiry, investigation, and implementation are done, and utilize novel, justice-informed strategies that include real-world evidence to produce results that are applicable to all (not just those willing to participate in sponsored trials). Only then will we be able to provide equitable health outcomes for all.

We also must accept responsibility for the past and humbly ask communities to work with us as we struggle to eliminate racism and dehumanization of Black lives by calling out our actions or inaction, recognizing the impact of our privileged status, and stepping down or stepping aside to allow others to lead. Sometimes it is as simple as turning off the Zoom camera so others can talk. By redistributing power and focusing this work upon the narratives of marginalized communities, we can improve our system for everyone. We must lead with action within our practices and systems; become advocates within our communities, institutions, and profession; strategize and organize interventions at both structural and individual levels to first recognize and name—then change—the systems; and unlearn behaviors that perpetuate racism.

Inaction is shirking our responsibility among the medical community

Benign inaction and unintentional acquiescence with “the way things are and have always been” abdicates our responsibility as physicians to improve the health of our patients and our communities. The modern Hippocratic Oath reminds us: “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.” We have a professional and ethical responsibility to ensure health equity, and thus racial equity. As physicians, as healers, as leaders we must address racial inequities at all levels as we commit to improving the health of our nation. We can no longer stand silent in the face of the violence, brutality, and injustices our patients, friends, family, neighbors, communities, and society as a whole live through daily. It is unjust and inhumane to do so.

To be silent is to be complicit. As Gandhi said so long ago, we must “be the change we wish to see in the world.” And as Ijeoma Olua teaches us, “Anti-racism is the commitment to fight racism wherever you find it, including in yourself. And it’s the only way forward.”
 

The destructive toll COVID-19 has caused worldwide is devastating. In the United States, the disproportionate deaths of Black, Indigenous, and Latinx people due to structural racism, amplified by economic adversity, is unacceptable. Meanwhile, the continued murder of Black people by those sworn to protect the public is abhorrent and can no longer be ignored. Black lives matter. These crises have rightly gripped our attention, and should galvanize physicians individually and collectively to use our privileged voices and relative power for justice. We must strive for engaged, passionate, and innovative leadership deliberately aimed toward antiracism and equity.

The COVID-19 pandemic has illuminated the vast inequities in our country. It has highlighted the continued poor outcomes our health and health care systems create for Black, Indigenous, and Latinx communities. It also has demonstrated clearly that we are all connected—one large community, interdependent yet rife with differential power, privilege, and oppression. We must address these racial disparities—not only in the name of justice and good health for all but also because it is a moral and ethical imperative for us as physicians—and SARS-CoV-2 clearly shows us that it is in the best interest of everyone to do so.

First step: A deep dive look at systemic racism

What is first needed is an examination and acknowledgement by medicine and health care at large of the deeply entrenched roots of systemic and institutional racism in our profession and care systems, and their disproportionate and unjust impact on the health and livelihood of communities of color. The COVID-19 pandemic is only a recent example that highlights the perpetuation of a system that harms people of color. Racism, sexism, gender discrimination, economic and social injustice, religious persecution, and violence against women and children are age-old. We have yet to see health care institutions implement system-wide intersectional and antiracist practices to address them. Mandatory implicit bias training, policies for inclusion and diversity, and position statements are necessary first steps; however, they are not a panacea. They are insufficient to create the bold changes we need. The time for words has long passed. It is time to listen, to hear the cries of anguish and outrage, to examine our privileged position, to embrace change and discomfort, and most importantly to act, and to lead in dismantling the structures around us that perpetuate racial inequity.

How can we, as physicians and leaders, join in action and make an impact?

Dr. Camara Jones, past president of the American Public Health Association, describes 3 levels of racism:

• structural or systemic
• individual or personally mediated
• internalized.

Interventions at each level are important if we are to promote equity in health and health care. This framework can help us think about the following strategic initiatives.

Continue to: 1. Commit to becoming an antiracist and engage in independent study...

1. Commit to becoming antiracist and engage in independent study. This is an important first step as it will form the foundations for interventions—one cannot facilitate change without understanding the matter at hand. This step also may be the most personally challenging step forcing all of us to wrestle with discomfort, sadness, fear, guilt, and a host of other emotional responses. Remember that great change has never been born out of comfort, and the discomfort physicians may experience while unlearning racism and learning antiracism pales in comparison to what communities of color experience daily. We must actively work to unlearn the racist and anti-Black culture that is so deeply woven into every aspect of our existence.

Learn the history that was not given to us as kids in school. Read the brilliant literary works of Black, Indigenous, and Latinx artists and scholars on dismantling racism. Expand our vocabulary and knowledge of core concepts in racism, racial justice, and equity. Examine and reflect on our day-to-day practices. Be vocal in our commitment to antiracism—the time has passed for staying silent. If you are white, facilitate conversations about race with your white colleagues; the inherent power of racism relegates it to an issue that can never be on the table, but it is time to dismantle that power. Learn what acts of meaningful and intentional alliances are and when we need to give up power or privilege to a person of color. We also need to recognize that we as physicians, while leaders in many spaces, are not leaders in the powerful racial justice grassroots movements. We should learn from these movements, follow their lead, and use our privilege to uplift racial justice in our settings.

2. Embrace the current complexities with empathy and humility, finding ways to exercise our civic responsibility to the public with compassion. During the COVID-19 pandemic we have seen the devastation that social isolation, job loss, and illness can create. Suddenly those who could never have imagined themselves without food are waiting hours in their cars for food bank donations or are finding empty shelves in stores. Those who were not safe at home were suddenly imprisoned indefinitely in unsafe situations. Those who were comfortable, well-insured, and healthy are facing an invisible health threat, insecurity, fear, anxiety, and loss. Additionally, our civic institutions are failing. Those of us who always took our right to vote for granted are being forced to stand in hours’-long lines to exercise that right; while those who have been systematically disenfranchised are enduring even greater threats to their constitutional right to exercise their political power, disallowing them to speak for their families and communities and to vote for the justice they deserve. This may be an opportunity to stop blaming victims and recognize the toll that structural and systemic contributions to inequity have created over generations.

3. Meaningfully engage with and advocate for patients. In health and health care, we must begin to engage with the communities we serve and truly listen to their needs, desires, and barriers to care, and respond accordingly. Policies that try to address the social determinants of health without that engagement, and without the acknowledgement of the structural issues that cause them, however well-intentioned, are unlikely to accomplish their goals. We need to advocate as physicians and leaders in our settings for every policy, practice, and procedure to be scrutinized using an antiracist lens. To execute this, we need to:

• ask why clinic and hospital practices are built the way they are and how to make them more reflexive and responsive to individual patient’s needs
• examine what the disproportionate impacts might be on different groups of patients from a systems-level
• be ready to dismantle and/or rebuild something that is exacerbating disparate outcomes and experiences
• advocate for change that is built upon the narratives of patients and their communities.

We should include patients in the creation of hospital policies and guidelines in order to shift power toward them and to be transparent about how the system operates in order to facilitate trust and collaboration that centers patients and communities in the systems created to serve them.

Continue to: 4. Intentionally repair and build trust...

4. Intentionally repair and build trust. To create a safe environment, we must repair what we have broken and earn the trust of communities by uplifting their voices and redistributing our power to them in changing the systems and structures that have, for generations, kept Black, Indigenous, and Latinx people oppressed. Building trust requires first owning our histories of colonization, genocide, and slavery—now turned mass incarceration, debasement, and exploitation—that has existed for centuries. We as physicians need to do an honest examination of how we have eroded the trust of the very communities we care for since our profession’s creation. We need to acknowledge, as a white-dominant profession, the medical experimentation on and exploitation of Black and Brown bodies, and how this formed the foundation for a very valid deep distrust and fear of the medical establishment. We need to recognize how our inherent racial biases continue to feed this distrust, like when we don’t treat patients’ pain adequately or make them feel like we believe and listen to their needs and concerns. We must acknowledge our complicity in perpetuating the racial inequities in health, again highlighted by the COVID-19 pandemic.

5. Increase Black, Indigenous, and Latinx representation in physician and other health care professions’ workforce. Racism impacts not only patients but also our colleagues of color. The lack of racial diversity is a symptom of racism and a representation of the continued exclusion and devaluing of physicians of color. We must recognize this legacy of exclusion and facilitate intentional recruitment, retention, inclusion, and belonging of people of color into our workforce. Tokenism, the act of symbolically including one or few people from underrepresented groups, has been a weapon used by our workforce against physicians of color, resulting in isolation, “othering,” demoralization, and other deleterious impacts. We need to reverse this history and diversify our training programs and workforce to ensure justice in our own community.

6. Design multifaceted interventions. Multilevel problems require multilevel solutions. Interventions targeted solely at one level, while helpful, are unlikely to result in the larger scale changes our society needs to implement if we are to eradicate the impact of racism on health. We have long known that it is not just “preexisting conditions” or “poor” individual behaviors that lead to negative and disparate health outcomes—these are impacted by social and structural determinants much larger and more deleterious than that. It is critically important that we allocate and redistribute resources to create safe and affordable housing; childcare and preschool facilities; healthy, available, and affordable food; equitable and affordable educational opportunities; and a clean environment to support the health of all communities—not only those with the highest tax base. It is imperative that we strive to understand the lives of our fellow human beings who have been subjected to intergenerational social injustices and oppressions that have continued to place them at the margins of society. We need to center the lived experiences of communities of color in the design of multilevel interventions, especially Black and Indigenous communities. While we as physicians cannot individually impact education, economic, or food/environment systems, we can use our power to advocate for providing resources for the patients we care for and can create strategies within the health care system to address these needs in order to achieve optimal health. Robust and equitable social structures are the foundations for health, and ensuring equitable access to them is critical to reducing disparities.

Commit to lead

We must commit to unlearning our internalized racism, rebuilding relationships with communities of color, and engaging in antiracist practices. As a profession dedicated to healing, we have an obligation to be leaders in advocating for these changes, and dismantling the inequitable structure of our health care system.

Our challenge now is to articulate solutions. While antiracism should be informed by the lived experiences of communities of color, the work of antiracism is not their responsibility. In fact, it is the responsibility of our white-dominated systems and institutions to change.

There are some solutions that are easier to enumerate because they have easily measurable outcomes or activities, such as:

• collecting data transparently
• identifying inequities in access, treatment, and care
• conducting rigorous root cause analysis of those barriers to care
• increasing diverse racial and gender representation on decision-making bodies, from board rooms to committees, from leadership teams to research participants
• redistribute power by paving the way for underrepresented colleagues to participate in clinical, administrative, educational, executive, and health policy spaces
• mentoring new leaders who come from marginalized communities.

Every patient deserves our expertise and access to high-quality care. We should review our patient panels to ensure we are taking steps personally to be just and eliminate disparities, and we should monitor the results of those efforts.

Continue to: Be open to solutions that may make us “uncomfortable”...

Be open to solutions that may make us “uncomfortable”

There are other solutions, perhaps those that would be more effective on a larger scale, which may be harder to measure using our traditional ways of inquiry or measurement. Solutions that may create discomfort, anger, or fear for those who have held their power or positions for a long time. We need to begin to engage in developing, cultivating, and valuing innovative strategies that produce equally valid knowledge, evidence, and solutions without engaging in a randomized controlled trial. We need to reinvent the way inquiry, investigation, and implementation are done, and utilize novel, justice-informed strategies that include real-world evidence to produce results that are applicable to all (not just those willing to participate in sponsored trials). Only then will we be able to provide equitable health outcomes for all.

We also must accept responsibility for the past and humbly ask communities to work with us as we struggle to eliminate racism and dehumanization of Black lives by calling out our actions or inaction, recognizing the impact of our privileged status, and stepping down or stepping aside to allow others to lead. Sometimes it is as simple as turning off the Zoom camera so others can talk. By redistributing power and focusing this work upon the narratives of marginalized communities, we can improve our system for everyone. We must lead with action within our practices and systems; become advocates within our communities, institutions, and profession; strategize and organize interventions at both structural and individual levels to first recognize and name—then change—the systems; and unlearn behaviors that perpetuate racism.

Inaction is shirking our responsibility among the medical community

Benign inaction and unintentional acquiescence with “the way things are and have always been” abdicates our responsibility as physicians to improve the health of our patients and our communities. The modern Hippocratic Oath reminds us: “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.” We have a professional and ethical responsibility to ensure health equity, and thus racial equity. As physicians, as healers, as leaders we must address racial inequities at all levels as we commit to improving the health of our nation. We can no longer stand silent in the face of the violence, brutality, and injustices our patients, friends, family, neighbors, communities, and society as a whole live through daily. It is unjust and inhumane to do so.

To be silent is to be complicit. As Gandhi said so long ago, we must “be the change we wish to see in the world.” And as Ijeoma Olua teaches us, “Anti-racism is the commitment to fight racism wherever you find it, including in yourself. And it’s the only way forward.”
 

The destructive toll COVID-19 has caused worldwide is devastating. In the United States, the disproportionate deaths of Black, Indigenous, and Latinx people due to structural racism, amplified by economic adversity, is unacceptable. Meanwhile, the continued murder of Black people by those sworn to protect the public is abhorrent and can no longer be ignored. Black lives matter. These crises have rightly gripped our attention, and should galvanize physicians individually and collectively to use our privileged voices and relative power for justice. We must strive for engaged, passionate, and innovative leadership deliberately aimed toward antiracism and equity.

The COVID-19 pandemic has illuminated the vast inequities in our country. It has highlighted the continued poor outcomes our health and health care systems create for Black, Indigenous, and Latinx communities. It also has demonstrated clearly that we are all connected—one large community, interdependent yet rife with differential power, privilege, and oppression. We must address these racial disparities—not only in the name of justice and good health for all but also because it is a moral and ethical imperative for us as physicians—and SARS-CoV-2 clearly shows us that it is in the best interest of everyone to do so.

First step: A deep dive look at systemic racism

What is first needed is an examination and acknowledgement by medicine and health care at large of the deeply entrenched roots of systemic and institutional racism in our profession and care systems, and their disproportionate and unjust impact on the health and livelihood of communities of color. The COVID-19 pandemic is only a recent example that highlights the perpetuation of a system that harms people of color. Racism, sexism, gender discrimination, economic and social injustice, religious persecution, and violence against women and children are age-old. We have yet to see health care institutions implement system-wide intersectional and antiracist practices to address them. Mandatory implicit bias training, policies for inclusion and diversity, and position statements are necessary first steps; however, they are not a panacea. They are insufficient to create the bold changes we need. The time for words has long passed. It is time to listen, to hear the cries of anguish and outrage, to examine our privileged position, to embrace change and discomfort, and most importantly to act, and to lead in dismantling the structures around us that perpetuate racial inequity.

How can we, as physicians and leaders, join in action and make an impact?

Dr. Camara Jones, past president of the American Public Health Association, describes 3 levels of racism:

• structural or systemic
• individual or personally mediated
• internalized.

Interventions at each level are important if we are to promote equity in health and health care. This framework can help us think about the following strategic initiatives.

Continue to: 1. Commit to becoming an antiracist and engage in independent study...

1. Commit to becoming antiracist and engage in independent study. This is an important first step as it will form the foundations for interventions—one cannot facilitate change without understanding the matter at hand. This step also may be the most personally challenging step forcing all of us to wrestle with discomfort, sadness, fear, guilt, and a host of other emotional responses. Remember that great change has never been born out of comfort, and the discomfort physicians may experience while unlearning racism and learning antiracism pales in comparison to what communities of color experience daily. We must actively work to unlearn the racist and anti-Black culture that is so deeply woven into every aspect of our existence.

Learn the history that was not given to us as kids in school. Read the brilliant literary works of Black, Indigenous, and Latinx artists and scholars on dismantling racism. Expand our vocabulary and knowledge of core concepts in racism, racial justice, and equity. Examine and reflect on our day-to-day practices. Be vocal in our commitment to antiracism—the time has passed for staying silent. If you are white, facilitate conversations about race with your white colleagues; the inherent power of racism relegates it to an issue that can never be on the table, but it is time to dismantle that power. Learn what acts of meaningful and intentional alliances are and when we need to give up power or privilege to a person of color. We also need to recognize that we as physicians, while leaders in many spaces, are not leaders in the powerful racial justice grassroots movements. We should learn from these movements, follow their lead, and use our privilege to uplift racial justice in our settings.

2. Embrace the current complexities with empathy and humility, finding ways to exercise our civic responsibility to the public with compassion. During the COVID-19 pandemic we have seen the devastation that social isolation, job loss, and illness can create. Suddenly those who could never have imagined themselves without food are waiting hours in their cars for food bank donations or are finding empty shelves in stores. Those who were not safe at home were suddenly imprisoned indefinitely in unsafe situations. Those who were comfortable, well-insured, and healthy are facing an invisible health threat, insecurity, fear, anxiety, and loss. Additionally, our civic institutions are failing. Those of us who always took our right to vote for granted are being forced to stand in hours’-long lines to exercise that right; while those who have been systematically disenfranchised are enduring even greater threats to their constitutional right to exercise their political power, disallowing them to speak for their families and communities and to vote for the justice they deserve. This may be an opportunity to stop blaming victims and recognize the toll that structural and systemic contributions to inequity have created over generations.

3. Meaningfully engage with and advocate for patients. In health and health care, we must begin to engage with the communities we serve and truly listen to their needs, desires, and barriers to care, and respond accordingly. Policies that try to address the social determinants of health without that engagement, and without the acknowledgement of the structural issues that cause them, however well-intentioned, are unlikely to accomplish their goals. We need to advocate as physicians and leaders in our settings for every policy, practice, and procedure to be scrutinized using an antiracist lens. To execute this, we need to:

• ask why clinic and hospital practices are built the way they are and how to make them more reflexive and responsive to individual patient’s needs
• examine what the disproportionate impacts might be on different groups of patients from a systems-level
• be ready to dismantle and/or rebuild something that is exacerbating disparate outcomes and experiences
• advocate for change that is built upon the narratives of patients and their communities.

We should include patients in the creation of hospital policies and guidelines in order to shift power toward them and to be transparent about how the system operates in order to facilitate trust and collaboration that centers patients and communities in the systems created to serve them.

Continue to: 4. Intentionally repair and build trust...

4. Intentionally repair and build trust. To create a safe environment, we must repair what we have broken and earn the trust of communities by uplifting their voices and redistributing our power to them in changing the systems and structures that have, for generations, kept Black, Indigenous, and Latinx people oppressed. Building trust requires first owning our histories of colonization, genocide, and slavery—now turned mass incarceration, debasement, and exploitation—that has existed for centuries. We as physicians need to do an honest examination of how we have eroded the trust of the very communities we care for since our profession’s creation. We need to acknowledge, as a white-dominant profession, the medical experimentation on and exploitation of Black and Brown bodies, and how this formed the foundation for a very valid deep distrust and fear of the medical establishment. We need to recognize how our inherent racial biases continue to feed this distrust, like when we don’t treat patients’ pain adequately or make them feel like we believe and listen to their needs and concerns. We must acknowledge our complicity in perpetuating the racial inequities in health, again highlighted by the COVID-19 pandemic.

5. Increase Black, Indigenous, and Latinx representation in physician and other health care professions’ workforce. Racism impacts not only patients but also our colleagues of color. The lack of racial diversity is a symptom of racism and a representation of the continued exclusion and devaluing of physicians of color. We must recognize this legacy of exclusion and facilitate intentional recruitment, retention, inclusion, and belonging of people of color into our workforce. Tokenism, the act of symbolically including one or few people from underrepresented groups, has been a weapon used by our workforce against physicians of color, resulting in isolation, “othering,” demoralization, and other deleterious impacts. We need to reverse this history and diversify our training programs and workforce to ensure justice in our own community.

6. Design multifaceted interventions. Multilevel problems require multilevel solutions. Interventions targeted solely at one level, while helpful, are unlikely to result in the larger scale changes our society needs to implement if we are to eradicate the impact of racism on health. We have long known that it is not just “preexisting conditions” or “poor” individual behaviors that lead to negative and disparate health outcomes—these are impacted by social and structural determinants much larger and more deleterious than that. It is critically important that we allocate and redistribute resources to create safe and affordable housing; childcare and preschool facilities; healthy, available, and affordable food; equitable and affordable educational opportunities; and a clean environment to support the health of all communities—not only those with the highest tax base. It is imperative that we strive to understand the lives of our fellow human beings who have been subjected to intergenerational social injustices and oppressions that have continued to place them at the margins of society. We need to center the lived experiences of communities of color in the design of multilevel interventions, especially Black and Indigenous communities. While we as physicians cannot individually impact education, economic, or food/environment systems, we can use our power to advocate for providing resources for the patients we care for and can create strategies within the health care system to address these needs in order to achieve optimal health. Robust and equitable social structures are the foundations for health, and ensuring equitable access to them is critical to reducing disparities.

Commit to lead

We must commit to unlearning our internalized racism, rebuilding relationships with communities of color, and engaging in antiracist practices. As a profession dedicated to healing, we have an obligation to be leaders in advocating for these changes, and dismantling the inequitable structure of our health care system.

Our challenge now is to articulate solutions. While antiracism should be informed by the lived experiences of communities of color, the work of antiracism is not their responsibility. In fact, it is the responsibility of our white-dominated systems and institutions to change.

There are some solutions that are easier to enumerate because they have easily measurable outcomes or activities, such as:

• collecting data transparently
• identifying inequities in access, treatment, and care
• conducting rigorous root cause analysis of those barriers to care
• increasing diverse racial and gender representation on decision-making bodies, from board rooms to committees, from leadership teams to research participants
• redistribute power by paving the way for underrepresented colleagues to participate in clinical, administrative, educational, executive, and health policy spaces
• mentoring new leaders who come from marginalized communities.

Every patient deserves our expertise and access to high-quality care. We should review our patient panels to ensure we are taking steps personally to be just and eliminate disparities, and we should monitor the results of those efforts.

Continue to: Be open to solutions that may make us “uncomfortable”...

Be open to solutions that may make us “uncomfortable”

There are other solutions, perhaps those that would be more effective on a larger scale, which may be harder to measure using our traditional ways of inquiry or measurement. Solutions that may create discomfort, anger, or fear for those who have held their power or positions for a long time. We need to begin to engage in developing, cultivating, and valuing innovative strategies that produce equally valid knowledge, evidence, and solutions without engaging in a randomized controlled trial. We need to reinvent the way inquiry, investigation, and implementation are done, and utilize novel, justice-informed strategies that include real-world evidence to produce results that are applicable to all (not just those willing to participate in sponsored trials). Only then will we be able to provide equitable health outcomes for all.

We also must accept responsibility for the past and humbly ask communities to work with us as we struggle to eliminate racism and dehumanization of Black lives by calling out our actions or inaction, recognizing the impact of our privileged status, and stepping down or stepping aside to allow others to lead. Sometimes it is as simple as turning off the Zoom camera so others can talk. By redistributing power and focusing this work upon the narratives of marginalized communities, we can improve our system for everyone. We must lead with action within our practices and systems; become advocates within our communities, institutions, and profession; strategize and organize interventions at both structural and individual levels to first recognize and name—then change—the systems; and unlearn behaviors that perpetuate racism.

Inaction is shirking our responsibility among the medical community

Benign inaction and unintentional acquiescence with “the way things are and have always been” abdicates our responsibility as physicians to improve the health of our patients and our communities. The modern Hippocratic Oath reminds us: “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.” We have a professional and ethical responsibility to ensure health equity, and thus racial equity. As physicians, as healers, as leaders we must address racial inequities at all levels as we commit to improving the health of our nation. We can no longer stand silent in the face of the violence, brutality, and injustices our patients, friends, family, neighbors, communities, and society as a whole live through daily. It is unjust and inhumane to do so.

To be silent is to be complicit. As Gandhi said so long ago, we must “be the change we wish to see in the world.” And as Ijeoma Olua teaches us, “Anti-racism is the commitment to fight racism wherever you find it, including in yourself. And it’s the only way forward.”
 

Simon JA, Al-Hendy A, Archer DF, et al. Elagolix treatment for up to 12 months in women with heavy menstrual bleeding and uterine leiomyomas. Obstet Gynecol. 2020;135:1313-1326.

Expert Commentary

Uterine fibroids are common (occurring in up to 80% of reproductive-age women),^1,2 and often associated with heavy menstrual bleeding (HMB). There are surgical and medical options, but typically medical options are used for short periods of time. Elagolix with hormonal add-back therapy was recently approved (May 29, 2020) by the US Food and Drug Administration (FDA) for treatment of HMB in women with uterine fibroids for up to 24 months.

Elagolix is an oral, nonpeptide gonadotropin-releasing hormone antagonist that results in a dose-dependent reduction of gonadotropins and ovarian sex hormones. There are now 2 approved products containing elagolix, with different indications:

• Orilissa. Elagolix was approved in 2018 by the FDA for moderate to severe pain associated with endometriosis. For that indication there are 2 dose options of elagolix (150 mg for up to 2 years and 200 mg for up to 6 months) and there is no hormonal add-back therapy.
• Oriahnn. Elagolix and hormonal add-back therapy was approved in 2020 for HMB associated with uterine fibroids for up to 24 months. The total daily dose of elagolix is 600 mg (elagolix 300 mg in the morning with estradiol 1 mg/norethindrone acetate 0.5 mg and then in the evening elagolix 300 mg and no hormonal add-back).

This new class of drug, GnRH antagonist, is an important one for women’s health, and emerging science will continue to expand its potential uses, such as in reproductive health, as well as long-term efficacy and safety. The difference in daily dose of elagolix for endometriosis (150 mg for 24 months) compared with HMB associated with fibroids (600 mg for 24 months) is why the hormonal add-back therapy is important and allows for protection of bone density.

This is an important manuscript because it highlights a medical option for women with HMB associated with fibroids, which can be used for a long period of time. Further, the improvement in bleeding is both impressive and maintained in the extension study. Approximately 90% of women show improvement in their menstrual bleeding associated with fibroids.

The question of what to do after 24 months of therapy with elagolix and hormonal add-back therapy is an important one, but providers should recognize that the limiting factor with this elagolix and hormonal add-back therapy is bone mineral density (BMD). We will only learn more and more moving forward if this is a clinically meaningful reason for stopping treatment at 24 months. The FDA takes a strict view of safety, and providers must weigh this with the benefit of therapy.

One other highlight between the 2 approved medications is that Orilissa does not have a black box warning, given that there is no hormonal add-back therapy. Oriahnn does have a warning, regarding thromboembolic disorders and vascular events:

• Estrogen and progestin combinations, including Oriahnn, increase the risk of thrombotic or thromboembolic disorders, especially in women at increased risk for these events.
• Oriahnn is contraindicated in women with current or a history of thrombotic or thromboembolic disorders and in women at increased risk for these events, including women over 35 years of age who smoke or women with uncontrolled hypertension.

Continue to: Details about the study...

Details about the study

The study by Simon et al is an extension study (UF-EXTEND), in that women could participate if they had completed 1 of the 2 pivotal studies on elagolix. The pivotal studies (Elaris UF1 and UF2) were both randomized, double-blinded, placebo-controlled studies with up to 6 months of therapy; for UF-EXTEND, however, participants were randomly assigned to either combined elagolix and hormone replacement therapy or elagolix alone for an additional 6 months of therapy. Although it was known that all participants would receive elagolix in UF-EXTEND, those who received hormonal add-back therapy were blinded. All women were then followed up for an additional 12 months after treatment ended.

The efficacy of elagolix was measured by the objective alkaline hematin method for menstrual blood loss with the a priori coprimary endpoints. The elagolix and hormonal add-back therapy group showed objective improvement in menstrual blood loss at 12 months in 87.9% of women in the extension study (89.4% in the elagolix alone group). This compares with 72.2% improvement at 6 months of treatment in the UF1 and UF2 studies for those taking elagolix and hormonal add-back therapy. These findings illustrate maintenance of the efficacy seen within the 6-month pivotal studies using elagolix over an extended amount of time.

The safety of elagolix also was demonstrated in UF-EXTEND. The 3 most common adverse events were similar to those found in Elaris UF1 and UF2 and included hot flushes, headache, and nausea. In the elagolix and hormonal add-back therapy group during the extension study, the percentage with hot flushes was 7%, headache 6%, and nausea 4%. These are small percentages, which is encouraging for providers and women with HMB associated with fibroids.

Effects on bone density

Bone density was evaluated at baseline in the UF1 and UF2 studies, through treatment, and then 12 months after the extended treatment was stopped. The hormonal add-back therapy of estradiol 1 mg/norethindrone acetate 0.5 mg significantly protected bone density. Some women did not have a decrease in bone density, but for those who did the average was less than 5% for the lumbar spine. The lumbar spine is considered the most reactive, so this illustrates the safety that combined therapy offers women with HMB and fibroids.

The lumbar spine is considered the most reactive, so this site is often used as the main focus with BMD studies. As Simon et al show, the lumbar spine mean BMD percent change from baseline for the elagolix with add-back therapy was -1.5% (95% confidence interval [CI], -1.9 to -1.0) in women who received up to 12 months of treatment at month 6 in the extension study. After stopping elagolix with add-back therapy, at 6 months the elagolix with add-back therapy had a Z-score of -0.6% (95% CI, -1.1 to -0.1). This shows a trend toward baseline, or a recovery within a short time from stopping medication.

Continue to: Study strengths and limitations...

Study strengths and limitations

Strengths of this study include its overall design; efficacy endpoints, which were all established a priori; the fact that measurement of menstrual blood loss was done with the objective alkaline hematin method; and the statistical analysis, which is thorough and well presented. This extension study allowed further evaluation of efficacy and safety for elagolix. Although the authors point out that there may be some selection bias in an extension study, the fact that so many women elected to continue into the extended study is a positive reflection of the treatment.

As providers learn of new therapies for management of HMB associated with fibroids, it is important to consider who will benefit the most. In my opinion, any woman with heavy periods associated with fibroids could be a candidate for elagolix with add-back therapy. This treatment is highly effective, well tolerated, and safe. My approach to management includes educating a woman on all potential therapies and this new option of elagolix and add-back therapy is an important one. The decision for an individual woman on how to manage heavy periods associated with fibroids should consider her contraceptive needs, medical issues, and the risk and benefit of individual therapies. ●

Simon JA, Al-Hendy A, Archer DF, et al. Elagolix treatment for up to 12 months in women with heavy menstrual bleeding and uterine leiomyomas. Obstet Gynecol. 2020;135:1313-1326.

Expert Commentary

Uterine fibroids are common (occurring in up to 80% of reproductive-age women),^1,2 and often associated with heavy menstrual bleeding (HMB). There are surgical and medical options, but typically medical options are used for short periods of time. Elagolix with hormonal add-back therapy was recently approved (May 29, 2020) by the US Food and Drug Administration (FDA) for treatment of HMB in women with uterine fibroids for up to 24 months.

Elagolix is an oral, nonpeptide gonadotropin-releasing hormone antagonist that results in a dose-dependent reduction of gonadotropins and ovarian sex hormones. There are now 2 approved products containing elagolix, with different indications:

• Orilissa. Elagolix was approved in 2018 by the FDA for moderate to severe pain associated with endometriosis. For that indication there are 2 dose options of elagolix (150 mg for up to 2 years and 200 mg for up to 6 months) and there is no hormonal add-back therapy.
• Oriahnn. Elagolix and hormonal add-back therapy was approved in 2020 for HMB associated with uterine fibroids for up to 24 months. The total daily dose of elagolix is 600 mg (elagolix 300 mg in the morning with estradiol 1 mg/norethindrone acetate 0.5 mg and then in the evening elagolix 300 mg and no hormonal add-back).

This new class of drug, GnRH antagonist, is an important one for women’s health, and emerging science will continue to expand its potential uses, such as in reproductive health, as well as long-term efficacy and safety. The difference in daily dose of elagolix for endometriosis (150 mg for 24 months) compared with HMB associated with fibroids (600 mg for 24 months) is why the hormonal add-back therapy is important and allows for protection of bone density.

This is an important manuscript because it highlights a medical option for women with HMB associated with fibroids, which can be used for a long period of time. Further, the improvement in bleeding is both impressive and maintained in the extension study. Approximately 90% of women show improvement in their menstrual bleeding associated with fibroids.

The question of what to do after 24 months of therapy with elagolix and hormonal add-back therapy is an important one, but providers should recognize that the limiting factor with this elagolix and hormonal add-back therapy is bone mineral density (BMD). We will only learn more and more moving forward if this is a clinically meaningful reason for stopping treatment at 24 months. The FDA takes a strict view of safety, and providers must weigh this with the benefit of therapy.

One other highlight between the 2 approved medications is that Orilissa does not have a black box warning, given that there is no hormonal add-back therapy. Oriahnn does have a warning, regarding thromboembolic disorders and vascular events:

• Estrogen and progestin combinations, including Oriahnn, increase the risk of thrombotic or thromboembolic disorders, especially in women at increased risk for these events.
• Oriahnn is contraindicated in women with current or a history of thrombotic or thromboembolic disorders and in women at increased risk for these events, including women over 35 years of age who smoke or women with uncontrolled hypertension.

Continue to: Details about the study...

Details about the study

The study by Simon et al is an extension study (UF-EXTEND), in that women could participate if they had completed 1 of the 2 pivotal studies on elagolix. The pivotal studies (Elaris UF1 and UF2) were both randomized, double-blinded, placebo-controlled studies with up to 6 months of therapy; for UF-EXTEND, however, participants were randomly assigned to either combined elagolix and hormone replacement therapy or elagolix alone for an additional 6 months of therapy. Although it was known that all participants would receive elagolix in UF-EXTEND, those who received hormonal add-back therapy were blinded. All women were then followed up for an additional 12 months after treatment ended.

The efficacy of elagolix was measured by the objective alkaline hematin method for menstrual blood loss with the a priori coprimary endpoints. The elagolix and hormonal add-back therapy group showed objective improvement in menstrual blood loss at 12 months in 87.9% of women in the extension study (89.4% in the elagolix alone group). This compares with 72.2% improvement at 6 months of treatment in the UF1 and UF2 studies for those taking elagolix and hormonal add-back therapy. These findings illustrate maintenance of the efficacy seen within the 6-month pivotal studies using elagolix over an extended amount of time.

The safety of elagolix also was demonstrated in UF-EXTEND. The 3 most common adverse events were similar to those found in Elaris UF1 and UF2 and included hot flushes, headache, and nausea. In the elagolix and hormonal add-back therapy group during the extension study, the percentage with hot flushes was 7%, headache 6%, and nausea 4%. These are small percentages, which is encouraging for providers and women with HMB associated with fibroids.

Effects on bone density

Bone density was evaluated at baseline in the UF1 and UF2 studies, through treatment, and then 12 months after the extended treatment was stopped. The hormonal add-back therapy of estradiol 1 mg/norethindrone acetate 0.5 mg significantly protected bone density. Some women did not have a decrease in bone density, but for those who did the average was less than 5% for the lumbar spine. The lumbar spine is considered the most reactive, so this illustrates the safety that combined therapy offers women with HMB and fibroids.

The lumbar spine is considered the most reactive, so this site is often used as the main focus with BMD studies. As Simon et al show, the lumbar spine mean BMD percent change from baseline for the elagolix with add-back therapy was -1.5% (95% confidence interval [CI], -1.9 to -1.0) in women who received up to 12 months of treatment at month 6 in the extension study. After stopping elagolix with add-back therapy, at 6 months the elagolix with add-back therapy had a Z-score of -0.6% (95% CI, -1.1 to -0.1). This shows a trend toward baseline, or a recovery within a short time from stopping medication.

Continue to: Study strengths and limitations...

Study strengths and limitations

Strengths of this study include its overall design; efficacy endpoints, which were all established a priori; the fact that measurement of menstrual blood loss was done with the objective alkaline hematin method; and the statistical analysis, which is thorough and well presented. This extension study allowed further evaluation of efficacy and safety for elagolix. Although the authors point out that there may be some selection bias in an extension study, the fact that so many women elected to continue into the extended study is a positive reflection of the treatment.

As providers learn of new therapies for management of HMB associated with fibroids, it is important to consider who will benefit the most. In my opinion, any woman with heavy periods associated with fibroids could be a candidate for elagolix with add-back therapy. This treatment is highly effective, well tolerated, and safe. My approach to management includes educating a woman on all potential therapies and this new option of elagolix and add-back therapy is an important one. The decision for an individual woman on how to manage heavy periods associated with fibroids should consider her contraceptive needs, medical issues, and the risk and benefit of individual therapies. ●

Simon JA, Al-Hendy A, Archer DF, et al. Elagolix treatment for up to 12 months in women with heavy menstrual bleeding and uterine leiomyomas. Obstet Gynecol. 2020;135:1313-1326.

Expert Commentary

Uterine fibroids are common (occurring in up to 80% of reproductive-age women),^1,2 and often associated with heavy menstrual bleeding (HMB). There are surgical and medical options, but typically medical options are used for short periods of time. Elagolix with hormonal add-back therapy was recently approved (May 29, 2020) by the US Food and Drug Administration (FDA) for treatment of HMB in women with uterine fibroids for up to 24 months.

Elagolix is an oral, nonpeptide gonadotropin-releasing hormone antagonist that results in a dose-dependent reduction of gonadotropins and ovarian sex hormones. There are now 2 approved products containing elagolix, with different indications:

• Orilissa. Elagolix was approved in 2018 by the FDA for moderate to severe pain associated with endometriosis. For that indication there are 2 dose options of elagolix (150 mg for up to 2 years and 200 mg for up to 6 months) and there is no hormonal add-back therapy.
• Oriahnn. Elagolix and hormonal add-back therapy was approved in 2020 for HMB associated with uterine fibroids for up to 24 months. The total daily dose of elagolix is 600 mg (elagolix 300 mg in the morning with estradiol 1 mg/norethindrone acetate 0.5 mg and then in the evening elagolix 300 mg and no hormonal add-back).

This new class of drug, GnRH antagonist, is an important one for women’s health, and emerging science will continue to expand its potential uses, such as in reproductive health, as well as long-term efficacy and safety. The difference in daily dose of elagolix for endometriosis (150 mg for 24 months) compared with HMB associated with fibroids (600 mg for 24 months) is why the hormonal add-back therapy is important and allows for protection of bone density.

This is an important manuscript because it highlights a medical option for women with HMB associated with fibroids, which can be used for a long period of time. Further, the improvement in bleeding is both impressive and maintained in the extension study. Approximately 90% of women show improvement in their menstrual bleeding associated with fibroids.

The question of what to do after 24 months of therapy with elagolix and hormonal add-back therapy is an important one, but providers should recognize that the limiting factor with this elagolix and hormonal add-back therapy is bone mineral density (BMD). We will only learn more and more moving forward if this is a clinically meaningful reason for stopping treatment at 24 months. The FDA takes a strict view of safety, and providers must weigh this with the benefit of therapy.

One other highlight between the 2 approved medications is that Orilissa does not have a black box warning, given that there is no hormonal add-back therapy. Oriahnn does have a warning, regarding thromboembolic disorders and vascular events:

• Estrogen and progestin combinations, including Oriahnn, increase the risk of thrombotic or thromboembolic disorders, especially in women at increased risk for these events.
• Oriahnn is contraindicated in women with current or a history of thrombotic or thromboembolic disorders and in women at increased risk for these events, including women over 35 years of age who smoke or women with uncontrolled hypertension.

Continue to: Details about the study...

Details about the study

The study by Simon et al is an extension study (UF-EXTEND), in that women could participate if they had completed 1 of the 2 pivotal studies on elagolix. The pivotal studies (Elaris UF1 and UF2) were both randomized, double-blinded, placebo-controlled studies with up to 6 months of therapy; for UF-EXTEND, however, participants were randomly assigned to either combined elagolix and hormone replacement therapy or elagolix alone for an additional 6 months of therapy. Although it was known that all participants would receive elagolix in UF-EXTEND, those who received hormonal add-back therapy were blinded. All women were then followed up for an additional 12 months after treatment ended.

The efficacy of elagolix was measured by the objective alkaline hematin method for menstrual blood loss with the a priori coprimary endpoints. The elagolix and hormonal add-back therapy group showed objective improvement in menstrual blood loss at 12 months in 87.9% of women in the extension study (89.4% in the elagolix alone group). This compares with 72.2% improvement at 6 months of treatment in the UF1 and UF2 studies for those taking elagolix and hormonal add-back therapy. These findings illustrate maintenance of the efficacy seen within the 6-month pivotal studies using elagolix over an extended amount of time.

The safety of elagolix also was demonstrated in UF-EXTEND. The 3 most common adverse events were similar to those found in Elaris UF1 and UF2 and included hot flushes, headache, and nausea. In the elagolix and hormonal add-back therapy group during the extension study, the percentage with hot flushes was 7%, headache 6%, and nausea 4%. These are small percentages, which is encouraging for providers and women with HMB associated with fibroids.

Effects on bone density

Bone density was evaluated at baseline in the UF1 and UF2 studies, through treatment, and then 12 months after the extended treatment was stopped. The hormonal add-back therapy of estradiol 1 mg/norethindrone acetate 0.5 mg significantly protected bone density. Some women did not have a decrease in bone density, but for those who did the average was less than 5% for the lumbar spine. The lumbar spine is considered the most reactive, so this illustrates the safety that combined therapy offers women with HMB and fibroids.

The lumbar spine is considered the most reactive, so this site is often used as the main focus with BMD studies. As Simon et al show, the lumbar spine mean BMD percent change from baseline for the elagolix with add-back therapy was -1.5% (95% confidence interval [CI], -1.9 to -1.0) in women who received up to 12 months of treatment at month 6 in the extension study. After stopping elagolix with add-back therapy, at 6 months the elagolix with add-back therapy had a Z-score of -0.6% (95% CI, -1.1 to -0.1). This shows a trend toward baseline, or a recovery within a short time from stopping medication.

Continue to: Study strengths and limitations...

Study strengths and limitations

Strengths of this study include its overall design; efficacy endpoints, which were all established a priori; the fact that measurement of menstrual blood loss was done with the objective alkaline hematin method; and the statistical analysis, which is thorough and well presented. This extension study allowed further evaluation of efficacy and safety for elagolix. Although the authors point out that there may be some selection bias in an extension study, the fact that so many women elected to continue into the extended study is a positive reflection of the treatment.

As providers learn of new therapies for management of HMB associated with fibroids, it is important to consider who will benefit the most. In my opinion, any woman with heavy periods associated with fibroids could be a candidate for elagolix with add-back therapy. This treatment is highly effective, well tolerated, and safe. My approach to management includes educating a woman on all potential therapies and this new option of elagolix and add-back therapy is an important one. The decision for an individual woman on how to manage heavy periods associated with fibroids should consider her contraceptive needs, medical issues, and the risk and benefit of individual therapies. ●

One might immediately think of the deaths of Eric Garner, George Floyd, or even the fictional character Radio Raheem from Spike Lee’s critically acclaimed film, “Do the Right Thing,” when they hear the words “I can’t breathe.” These words are a cry for help. The deaths of these unarmed black men is devastating and has led to a state of rage, palpable pain, and protest across the world.

However, in this moment, I am talking about the health inequity exposed by the COVID-19 pandemic. Whether it be acute respiratory distress syndrome (ARDS) secondary to severe COVID-19, or the subsequent hypercoagulable state of COVID-19 that leads to venous thromboembolism, many black people in this country are left breathless. Many black patients who had no employee-based health insurance also had no primary care physician to order a SARS-CoV2 PCR lab test for them. Many of these patients have preexisting conditions, such as asthma from living in redlined communities affected by environmental racism. Many grew up in food deserts, where no fresh-produce store was interested enough to set up shop in their neighborhoods. They have been eating fast food since early childhood, as a fast-food burger is still cheaper than a salad. The result is obesity, an epidemic that can lead to diabetes mellitus, hypertension that can lead to coronary artery disease, stroke, and end-stage renal disease. 

Earlier in my career, I once had a colleague gleefully tell me that all black people drank Kool-Aid while in discussion of the effects of high-sugar diets in our patients; this colleague was sure I would agree. Not all black people drink Kool-Aid. Secondary to my fear of the backlash that can come from the discomfort of “white fragility” that Robin DiAngelo describes in her New York Times bestseller by the same name, ”White Fragility: Why It’s So Hard for White People to Talk About Racism,” I refrained from expressing my own hurt, and I did not offer explicit correction. I, instead, took a serious pause. That pause, which lasted only minutes, seemed to last 400 years. It was a brief reflection of the 400 years of systemic racism seeping into everyday life. This included the circumstances that would lead to the health inequities that result in the health disparities from which many black patients suffer. It is that same systemic racism that could create two America’s in which my colleague might not have to know the historic context in which that question could be hurtful. I retorted with modified shock and a chuckle so that I could muster up enough strength to repeat what was said and leave it open for reflection. The goal was for my colleague to realize the obvious implicit bias that lingered, despite intention. The chuckle was also to cover my pain.

Whether we know it or not, we all carry some form of implicit bias, regardless of race, class, gender, ethnicity, sexual preference, or socioeconomic status. In this case, it is the same implicit bias that causes physicians to ignore some black patients when they have said that they are in pain. A groundbreaking April 2016 article in Proceedings of the National Academy of Sciences, “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs about Biological Differences Between Blacks and Whites” (doi: 10.1073/pnas.1516047113), revealed that racial disparities in pain assessment and treatment recommendations can be directly connected to the racial bias of the provider. It could be possible that this phenomenon has affected black patients who have walked into clinics and emergency departments and said, “I’m short of breath. I think that I might have coronavirus and need to be tested.” It may be that same implicit bias that has cut the air supply to a patient encounter. Instead of inquiring further, the patient might be met with minimum questions while their provider obtains their history and physical. Assumptions and blame on behavior and lack of personal responsibility secretly replace questions that could have been asked. Differentials between exacerbations and other etiologies are not explored. Could that patient have been sent home without a SARS-CoV2 polymerase chain reaction test? Well, what if the tests were in short supply? Sometimes they may have been sent home without a chest x-ray. In most cases, there are no funds to send them home with a pulse oximeter.

The act of assuming a person’s story that we consider to be one dimensional is always dangerous – and even more so during this pandemic. That person we can relate to – secondary to a cool pop culture moment, a TikTok song, or a negative stereotype – is not one dimensional. That assumption and that stereotype can make room for implicit bias. That same implicit bias is the knee on a neck of any marginalized patient. Implicit bias is the choke hold that slowly removes the light and life from a person who has a story, who has a family, and who has been an essential worker who can’t work from home. That person is telling us that they can’t breathe, but sometimes the only things seen are comorbidities through a misinformed or biased lens that suggest an assumed lack of personal responsibility. In a May 2020 New England Journal of Medicine perspective, “Racial health disparities and Covid-19” (doi: 10.1056/NEJMp2012910), Merlin Chowkwanyun, PhD, MPH, and Adolph L. Reed Jr., PhD, caution us against creating race-based explanations for presumed behavioral patterns.

Systemic racism has created the myth that the playing field has been leveled since the end of enslavement. It hasn’t. That black man, woman, or nonbinary person is telling you “I can’t breathe. I’m tired. I’m short of breath ... I have a cough ... I’m feeling weak these days, Doc.” However, implicit bias is still that knee that won’t let up. It has not let up. Communities with lower-income black and Hispanic patients have already seen local hospitals and frontline workers fight to save their lives while losing their own to COVID-19. We all witnessed the battle for scarce resources and PPE [personal protective equipment]. In contrast, some wealthy neighborhoods have occupants who most likely have access to a primary care physician and more testing centers.

As we reexamine ourselves and look at these cases of police brutality against unarmed black men, women, and children with the appropriate shame and outrage, let us reflect upon the privileges that we enjoy. Let us find our voice as we speak up for black lives. Let us look deeply into the history of medicine as it relates to black patients by reading “Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present” by Harriet A. Washington. Let us examine that painful legacy, which, while having moments of good intention, still carries the stain of indifference, racism, neglect, and even experimentation without informed consent.

Why should we do these things? Because some of our black patients have also yelled or whispered, “I can’t breathe,” and we were not always listening either.
 

Dr. Ajala is a hospitalist and associate site director for education at Grady Memorial Hospital in Atlanta. She is a member of the executive council for SHM’s Care for Vulnerable Populations special interest group.

One might immediately think of the deaths of Eric Garner, George Floyd, or even the fictional character Radio Raheem from Spike Lee’s critically acclaimed film, “Do the Right Thing,” when they hear the words “I can’t breathe.” These words are a cry for help. The deaths of these unarmed black men is devastating and has led to a state of rage, palpable pain, and protest across the world.

However, in this moment, I am talking about the health inequity exposed by the COVID-19 pandemic. Whether it be acute respiratory distress syndrome (ARDS) secondary to severe COVID-19, or the subsequent hypercoagulable state of COVID-19 that leads to venous thromboembolism, many black people in this country are left breathless. Many black patients who had no employee-based health insurance also had no primary care physician to order a SARS-CoV2 PCR lab test for them. Many of these patients have preexisting conditions, such as asthma from living in redlined communities affected by environmental racism. Many grew up in food deserts, where no fresh-produce store was interested enough to set up shop in their neighborhoods. They have been eating fast food since early childhood, as a fast-food burger is still cheaper than a salad. The result is obesity, an epidemic that can lead to diabetes mellitus, hypertension that can lead to coronary artery disease, stroke, and end-stage renal disease. 

Earlier in my career, I once had a colleague gleefully tell me that all black people drank Kool-Aid while in discussion of the effects of high-sugar diets in our patients; this colleague was sure I would agree. Not all black people drink Kool-Aid. Secondary to my fear of the backlash that can come from the discomfort of “white fragility” that Robin DiAngelo describes in her New York Times bestseller by the same name, ”White Fragility: Why It’s So Hard for White People to Talk About Racism,” I refrained from expressing my own hurt, and I did not offer explicit correction. I, instead, took a serious pause. That pause, which lasted only minutes, seemed to last 400 years. It was a brief reflection of the 400 years of systemic racism seeping into everyday life. This included the circumstances that would lead to the health inequities that result in the health disparities from which many black patients suffer. It is that same systemic racism that could create two America’s in which my colleague might not have to know the historic context in which that question could be hurtful. I retorted with modified shock and a chuckle so that I could muster up enough strength to repeat what was said and leave it open for reflection. The goal was for my colleague to realize the obvious implicit bias that lingered, despite intention. The chuckle was also to cover my pain.

Whether we know it or not, we all carry some form of implicit bias, regardless of race, class, gender, ethnicity, sexual preference, or socioeconomic status. In this case, it is the same implicit bias that causes physicians to ignore some black patients when they have said that they are in pain. A groundbreaking April 2016 article in Proceedings of the National Academy of Sciences, “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs about Biological Differences Between Blacks and Whites” (doi: 10.1073/pnas.1516047113), revealed that racial disparities in pain assessment and treatment recommendations can be directly connected to the racial bias of the provider. It could be possible that this phenomenon has affected black patients who have walked into clinics and emergency departments and said, “I’m short of breath. I think that I might have coronavirus and need to be tested.” It may be that same implicit bias that has cut the air supply to a patient encounter. Instead of inquiring further, the patient might be met with minimum questions while their provider obtains their history and physical. Assumptions and blame on behavior and lack of personal responsibility secretly replace questions that could have been asked. Differentials between exacerbations and other etiologies are not explored. Could that patient have been sent home without a SARS-CoV2 polymerase chain reaction test? Well, what if the tests were in short supply? Sometimes they may have been sent home without a chest x-ray. In most cases, there are no funds to send them home with a pulse oximeter.

The act of assuming a person’s story that we consider to be one dimensional is always dangerous – and even more so during this pandemic. That person we can relate to – secondary to a cool pop culture moment, a TikTok song, or a negative stereotype – is not one dimensional. That assumption and that stereotype can make room for implicit bias. That same implicit bias is the knee on a neck of any marginalized patient. Implicit bias is the choke hold that slowly removes the light and life from a person who has a story, who has a family, and who has been an essential worker who can’t work from home. That person is telling us that they can’t breathe, but sometimes the only things seen are comorbidities through a misinformed or biased lens that suggest an assumed lack of personal responsibility. In a May 2020 New England Journal of Medicine perspective, “Racial health disparities and Covid-19” (doi: 10.1056/NEJMp2012910), Merlin Chowkwanyun, PhD, MPH, and Adolph L. Reed Jr., PhD, caution us against creating race-based explanations for presumed behavioral patterns.

Systemic racism has created the myth that the playing field has been leveled since the end of enslavement. It hasn’t. That black man, woman, or nonbinary person is telling you “I can’t breathe. I’m tired. I’m short of breath ... I have a cough ... I’m feeling weak these days, Doc.” However, implicit bias is still that knee that won’t let up. It has not let up. Communities with lower-income black and Hispanic patients have already seen local hospitals and frontline workers fight to save their lives while losing their own to COVID-19. We all witnessed the battle for scarce resources and PPE [personal protective equipment]. In contrast, some wealthy neighborhoods have occupants who most likely have access to a primary care physician and more testing centers.

As we reexamine ourselves and look at these cases of police brutality against unarmed black men, women, and children with the appropriate shame and outrage, let us reflect upon the privileges that we enjoy. Let us find our voice as we speak up for black lives. Let us look deeply into the history of medicine as it relates to black patients by reading “Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present” by Harriet A. Washington. Let us examine that painful legacy, which, while having moments of good intention, still carries the stain of indifference, racism, neglect, and even experimentation without informed consent.

Why should we do these things? Because some of our black patients have also yelled or whispered, “I can’t breathe,” and we were not always listening either.
 

Dr. Ajala is a hospitalist and associate site director for education at Grady Memorial Hospital in Atlanta. She is a member of the executive council for SHM’s Care for Vulnerable Populations special interest group.

One might immediately think of the deaths of Eric Garner, George Floyd, or even the fictional character Radio Raheem from Spike Lee’s critically acclaimed film, “Do the Right Thing,” when they hear the words “I can’t breathe.” These words are a cry for help. The deaths of these unarmed black men is devastating and has led to a state of rage, palpable pain, and protest across the world.

However, in this moment, I am talking about the health inequity exposed by the COVID-19 pandemic. Whether it be acute respiratory distress syndrome (ARDS) secondary to severe COVID-19, or the subsequent hypercoagulable state of COVID-19 that leads to venous thromboembolism, many black people in this country are left breathless. Many black patients who had no employee-based health insurance also had no primary care physician to order a SARS-CoV2 PCR lab test for them. Many of these patients have preexisting conditions, such as asthma from living in redlined communities affected by environmental racism. Many grew up in food deserts, where no fresh-produce store was interested enough to set up shop in their neighborhoods. They have been eating fast food since early childhood, as a fast-food burger is still cheaper than a salad. The result is obesity, an epidemic that can lead to diabetes mellitus, hypertension that can lead to coronary artery disease, stroke, and end-stage renal disease. 

Earlier in my career, I once had a colleague gleefully tell me that all black people drank Kool-Aid while in discussion of the effects of high-sugar diets in our patients; this colleague was sure I would agree. Not all black people drink Kool-Aid. Secondary to my fear of the backlash that can come from the discomfort of “white fragility” that Robin DiAngelo describes in her New York Times bestseller by the same name, ”White Fragility: Why It’s So Hard for White People to Talk About Racism,” I refrained from expressing my own hurt, and I did not offer explicit correction. I, instead, took a serious pause. That pause, which lasted only minutes, seemed to last 400 years. It was a brief reflection of the 400 years of systemic racism seeping into everyday life. This included the circumstances that would lead to the health inequities that result in the health disparities from which many black patients suffer. It is that same systemic racism that could create two America’s in which my colleague might not have to know the historic context in which that question could be hurtful. I retorted with modified shock and a chuckle so that I could muster up enough strength to repeat what was said and leave it open for reflection. The goal was for my colleague to realize the obvious implicit bias that lingered, despite intention. The chuckle was also to cover my pain.

Whether we know it or not, we all carry some form of implicit bias, regardless of race, class, gender, ethnicity, sexual preference, or socioeconomic status. In this case, it is the same implicit bias that causes physicians to ignore some black patients when they have said that they are in pain. A groundbreaking April 2016 article in Proceedings of the National Academy of Sciences, “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs about Biological Differences Between Blacks and Whites” (doi: 10.1073/pnas.1516047113), revealed that racial disparities in pain assessment and treatment recommendations can be directly connected to the racial bias of the provider. It could be possible that this phenomenon has affected black patients who have walked into clinics and emergency departments and said, “I’m short of breath. I think that I might have coronavirus and need to be tested.” It may be that same implicit bias that has cut the air supply to a patient encounter. Instead of inquiring further, the patient might be met with minimum questions while their provider obtains their history and physical. Assumptions and blame on behavior and lack of personal responsibility secretly replace questions that could have been asked. Differentials between exacerbations and other etiologies are not explored. Could that patient have been sent home without a SARS-CoV2 polymerase chain reaction test? Well, what if the tests were in short supply? Sometimes they may have been sent home without a chest x-ray. In most cases, there are no funds to send them home with a pulse oximeter.

The act of assuming a person’s story that we consider to be one dimensional is always dangerous – and even more so during this pandemic. That person we can relate to – secondary to a cool pop culture moment, a TikTok song, or a negative stereotype – is not one dimensional. That assumption and that stereotype can make room for implicit bias. That same implicit bias is the knee on a neck of any marginalized patient. Implicit bias is the choke hold that slowly removes the light and life from a person who has a story, who has a family, and who has been an essential worker who can’t work from home. That person is telling us that they can’t breathe, but sometimes the only things seen are comorbidities through a misinformed or biased lens that suggest an assumed lack of personal responsibility. In a May 2020 New England Journal of Medicine perspective, “Racial health disparities and Covid-19” (doi: 10.1056/NEJMp2012910), Merlin Chowkwanyun, PhD, MPH, and Adolph L. Reed Jr., PhD, caution us against creating race-based explanations for presumed behavioral patterns.

Systemic racism has created the myth that the playing field has been leveled since the end of enslavement. It hasn’t. That black man, woman, or nonbinary person is telling you “I can’t breathe. I’m tired. I’m short of breath ... I have a cough ... I’m feeling weak these days, Doc.” However, implicit bias is still that knee that won’t let up. It has not let up. Communities with lower-income black and Hispanic patients have already seen local hospitals and frontline workers fight to save their lives while losing their own to COVID-19. We all witnessed the battle for scarce resources and PPE [personal protective equipment]. In contrast, some wealthy neighborhoods have occupants who most likely have access to a primary care physician and more testing centers.

As we reexamine ourselves and look at these cases of police brutality against unarmed black men, women, and children with the appropriate shame and outrage, let us reflect upon the privileges that we enjoy. Let us find our voice as we speak up for black lives. Let us look deeply into the history of medicine as it relates to black patients by reading “Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present” by Harriet A. Washington. Let us examine that painful legacy, which, while having moments of good intention, still carries the stain of indifference, racism, neglect, and even experimentation without informed consent.

Why should we do these things? Because some of our black patients have also yelled or whispered, “I can’t breathe,” and we were not always listening either.
 

Dr. Ajala is a hospitalist and associate site director for education at Grady Memorial Hospital in Atlanta. She is a member of the executive council for SHM’s Care for Vulnerable Populations special interest group.

Do you want to know what keeps us up at night? As 4th-year medical students born, raised, and living in Haiti, we worry about the impact of COVID-19 on our patients.

The pandemic has shaken the world, and Haiti is no exception.

Courtesy Schneider Dorcela

It has taken several months for the disease to spread, and it began with two confirmed cases, one from France and the other from Belgium, on March 19.¹ Much of the spread of COVID-19 in Haiti has been tied to workers returning from the Dominican Republic. As of June 29, Haiti had 5,975 confirmed cases and 105 deaths.² Of course, those numbers sound minuscule, compared with those in the United States, where the number of deaths from COVID-19 surpassed 100,000 several weeks ago. But the population of Haiti is 30 times smaller than that of the United States, and Haiti is the poorest country in the Western Hemisphere. We have watched in horror as the virus has ravaged marginalized groups in the United States and worry that it will do the same in our own country.

Just as the Haitian Ministry of Health worked with various groups to reach the 1-year free of cholera mark in Haiti, groups such as Doctors Without Borders must mobilize to rein in COVID-19.
 

Community transmission rapid

After the first two cases were confirmed, a state of health emergency was immediately declared. Haitian President Jovenel Moïse and other government officials called for the implementation of several measures aimed at limiting the spread of COVID-19.

Schools, universities, clinical training programs, vocational centers, factories, airports, and ports, except for the transport of goods, were all ordered to close until further notice. Gatherings of larger than 10 people were banned. A curfew from 8 p.m. EST time to 5 a.m. EST was imposed. Measures such as those encouraged by U.S. Centers for Disease Control and Prevention, such as hand washing, physical distancing, and staying at home were also encouraged by the Haitian Ministry of Health. Mask wearing in public places was deemed mandatory.

The latest testing data show that community spread has been occurring among the Haitian population at a rapid rate. According to Jean William Pape, MD, Haiti’s top infectious diseases expert and founder of GHESKIO, an iconic infectious disease center that cares for people with HIV-AIDS and tuberculosis, a COVID-19 simulation from Cornell University in New York shows that about 35% of the Haitian population will be infected by the end of August 2020. A simulation by the University of Oxford (England) paints an even more dire picture. That simulation shows that 86% of the population could be infected, More than 9,000 additional hospital beds would be needed, and 20,000 people would be likely to die from COVID-19, Dr. Pape said in an interview with Haiti’s Nouvelliste newspaper.³
 

Medical response

We know that there is a global shortage of health care workers^,4 and Haiti is no exception. According to a 2018 report from the Haitian Ministry of Health, the country has 11,775 health care professionals, including about 3,354 medical doctors, to care for more than 11 million people. That translates to about 23.4 physicians per 100,000.⁵

The pandemic has led some members of this already anemic health care workforce to stay home because of a lack of personal protective equipment. Others, because of reduced hospital or clinic budgets, have been furloughed, making the COVID-19 national health emergency even harder to manage. The rationing of electricity and limited access to clean water⁶ in some areas are other complications that undermine our ability to provide quality care.

But a severe health care shortage is not the only challenge facing Haiti. It spends about $131 U.S. per capita, which makes Haiti one of most vulnerable among low- and middle-income countries in the world. As a poor country,⁷ its health care infrastructure is among the most inadequate and weakest. Prior to COVID-19, medical advocacy groups already had started movements and strikes demanding that the government improve the health care system. The country’s precarious health care infrastructure includes a lack of hospital beds, and basic medical supplies and equipment, such as oxygen and ventilators.⁸ The emergence of COVID-19 has only exacerbated the situation.

Clinical training programs have been suspended, many doctors and nurses are on quarantine, and some hospitals and clinics are closing. We have witnessed makeshift voodoo clinics built by Haitian voodoo leaders to receive, hospitalize, and treat COVID-19 patients through rituals and herbal remedies. In some areas of the country, residents have protested against the opening of several COVID-19 treatment and management centers.
 

Unique cultural challenges

Public health officials around the world are facing challenges persuading citizens to engage in behaviors that could protect them from the virus.

Just as in America, where many people opt to not wear face coverings^9,10 despite the public health risks, deep distrust of the Haitian government has undermined the messages of President Moïse and public healthofficials about the role of masks in limiting the spread of COVID.We see large numbers of unmasked people on the streets in the informal markets every day. Crammed tap-taps and overloaded motorcycles are moving everywhere. This also could be tied to cultural attitudes about COVID that persist among some Haitians.For example, many people with signs and symptoms of COVID-19 are afraid of going to the hospital to get tested and receive care, and resort to going to the voodoo clinics. Along with rituals, voodoo priests have been serving up teas with ingredients, including moringa, eucalyptus, ginger, and honey to those seeking COVID-19 care in the centers. The voodoo priests claim that the teas they serve strengthen the immune system.

In addition, it is difficult for poor people who live in small quarters with several other people to adhere to physical distancing.¹¹
 

Stigma and violence

Other barriers in the fight against COVID-19 in Haiti are stigma and violence. If widespread testing were available, some Haitians would opt not to do so – despite clear signs and symptoms of the infection. Some people who would get tested if they could are afraid to do so because of fears tied to being attacked by neighbors.

When Haitian University professor Bellamy Nelson and his girlfriend returned to Haiti from the United States in March and began experiencing some pain and fever, he experienced attacks from neighbors, he said in an interview. He said neighbors threatened to burn down his house. When an ambulance arrived at his house to transport him to a hospital, it had to drive through back roads to avoid people armed with rocks, fire, and machetes, he told us. No hospital wanted to admit him. Eventually, Professor Nelson self-quarantined at home, he said.

In another incident, a national ambulance center in Gonaïves, a town toward the northern region of Haiti, reportedly was vandalized, because COVID-19 equipment and supplies used to treat people had been stored there. Hospital Bernard Mevs, along with many other hospitals, was forced by the area’s residents to suspend the plan to open a center for COVID-19 management. Threats to burn down the hospitals caused the leaders of the hospitals to back down and give up a plan to build a 20-bed COVID-19 response center.
 

Maternal health

Another concern we have about the pandemic is the risk it could be to pregnant women. On average, 94,000 deaths occur annually in Haiti. Out of this number, maternal mortality accounts for 1,000. In 2017, for every 100,000 live births for women of reproductive age from 15 to 49 years old, 480 women died. In contrast, in the Dominican Republic, 95 women died per 100,000 that same year. In the United States, 19 died, and in Norway, no more than 2 died that year.¹²

Some of the primary factors contributing to the crisis are limited accessibility, inadequate health care facilities, and an inadequate number of trained health care practitioners; low percentages of skilled attendants at deliveries and of prenatal and postnatal visits; and high numbers of high-risk deliveries in nonqualified health facilities.

During the COVID-19 national health emergency, with most hospitals reducing their health care personnel either because of budget-related reasons or because they are on quarantine, this maternal-fetal health crisis has escalated.

One of the biggest hospitals in Jacmel, a town in the southern region of Haiti, has stopped its prenatal care program. In Delmas, the city with the highest incidence and prevalence of COVID-19, Hôpital Universitaire de la Paix has reduced this program to 50% of its capacity and gynecologic care has been completely suspended. Hôpital St. Luc, one of the first hospitals in the western region of Haiti to open its doors to care for COVID-19 patients, has recently shut down the entire maternal-fetal department.

So, access to prenatal and postnatal care, including the ability to deliver babies in health care institutions, is significantly reduced because of COVID-19. This leaves thousands of already vulnerable pregnant women at risk and having to deliver domestically with little to no health care professional assistance. We worry that, in light of the data, more women and babies will die because of the COVID-19 pandemic.
 

A call to action

Despite these conditions, there are reasons for hope. Various groups, both from the international community and locally have mobilized to respond to the pandemic.

International health care organizations such as Doctors Without Borders and Partners in Health, and local groups such as GHESKIO, the St. Luke Foundation for Haiti, and others have been collaborating with the Haitian Ministry of Health to devise and strategic plans and deploy valuable resources with the common goal of saving lives from COVID-19.

GHESKIO, for example, under Dr. Pape’s leadership, currently has one of the three COVID-19 testing centers in the country. It also has two COVID-19 treatment centers in full operation, in Port-au-Prince, the capital city, managing and treating 520 patients with confirmed COVID-19. GHESKIO, which has been in the front lines of previous major infectious disease outbreaks,¹³ has trained about 200 clinicians from both public and private health care institutions to care for COVID-19 patients.

Doctors Without Borders has been investing in efforts to support the Ministry of Health by converting and renovating its Burn Center in Drouillard, a small section of the city of Cité Soleil, one of the country’s biggest slums. In May, as part of its COVID-19 response, it launched a 20-bed capacity center that can accommodate up to 45 beds to care for patients who have tested positive for COVID-19.

Partners in Health, the Boston-based nonprofit health care organization cofounded in 1987 by American anthropologist and infectious disease specialist, Paul Farmer, MD, and the largest nonprofit health care provider in Haiti, also joined the Ministry of Health through its national and public health efforts to tackle COVID-19 in Haiti. Partners in Health, through its sister organization, Zanmi Lasante, has pioneered the movement of diagnosing and treating people with HIV-AIDS and TB. Since the late 1990s, its efforts against both infectious diseases have helped 15,000 HIV-positive patients begin and remain on treatment. And every year, 1,500 TB patients have started treatment on the path to a cure.

Early in the pandemic in Haiti, Partners in Health, through its state-of-the-art 300-bed university hospital (Hôpital Universitaire de Mirebalais de Mirebalais), was the first to open a COVID-19 center with a 20-bed capacity and has been caring for COVID-19 patients since then. In June, Partners in Health supported and inaugurated the renovation of the internal medicine department at one of its affiliated community hospitals, Hôpital Saint-Nicolas de Saint Marc. That department will have a 24-bed capacity that can extend up to 36 beds to manage and treat COVID-19 patients.

In total, currently, 26 COVID-19 centers with a capacity of 1,011 beds are available to serve, manage, and treat Haitian patients affected with COVID-19. But are those efforts enough? No.

Haiti, as a weak state even before COVID-19, continues to need funding from the international community so it can strengthen its health care infrastructure to be effective and strong in fighting against COVID-19.

In addition, we would like to see preventive initiatives implemented on the local level. Our family has taken on a role that, we think, could help conquer COVID-19 if others followed suit on a large scale.

As part of our contribution in tackling COVID-19, the two of us have launched a small-scale community experiment. We have educated our family in Delmas about COVID-19 and subsequently launched an awareness campaign in the community. We dispatched small groups that go door to door in the community to educate neighbors about the disease in an effort to help them understand that COVID-19 is real and it is normal for people that feel they may have the disease to seek medical care. This approach helps suppress the transmission of the virus. This pilot project could be reproduced in several other communities. It is easy to operate, rapid, effective, and cost-free. The community has been very receptive to and grateful for our efforts.

Like other countries across the world, Haiti was not ready for COVID-19. But we are confident that, with help from the international community, organizations such as GHESKIO,¹⁴ and with due diligence on the local level, we are strong and resilient enough to beat COVID. We must act together – quickly.

 

References

1. Sénat JD. Coronavirus: 2 cas confirmés en Haïti, Jovenel Moïse décrète l’état d’ur-gence sanitaire. 2020 Le Nouvelliste.

2. Haitian Ministry of Health.

3. “Entre appel a la solidarite et de sombres previsions, le Dr William Pape fait le point.” Le Nouvelliste.

4. Darzi A and Evans T. Lancet. 2016 Nov-Dec 26. 388;10060:2576-7.

5. Rapport Statistique 2018. 2019 Republic of Haiti.

6. Sentlinger K. “Water Crisis in Haiti.” The Water Project.

7. The World Bank in Haiti. worldbank.org.

8. Cenat JM. Travel Med Infect Dis. 2020 Mar 28. doi: 10.1016/jtmaid.2020.101684.

9. Block D. “Why some Americans resist wearing face masks.” voanews.com. 2020 May 31.

10. Panceski B and Douglas J. “Masks could help stop coronavirus. So why are they still controversial?” wsj.com. Updated 29 Jun 2020.

11. Bojarski S. “Social distancing: A luxury Haiti’s poor cannot afford. The Haitian Times. 2020 Apr.

12. World Health Organization, UNICEF, World Bank Group, and the U.N. Population Division. Maternal mortality ratio, Haiti.

13. Feliciano I and Kargbo C. “As COVID cases surge, Haiti’s Dr. Pape is on the front line again.” PBS NewsHour Weekend. 2020 Jun 13.

14. Liautaud B and Deschamps MM. New Engl J Med. 2020 Jun 16.
 

Mr. Dorcela is a senior medical student at Faculté des Sciences de la Santé Université Quisqueya in Port-au-Prince, Haiti. He also is a medical intern at Unité de Médecine Familiale Hôpital Saint Nicolas in Saint-Marc. Mr. Dorcela has no disclosures. Mr. St. Jean, who is Mr. Dorcela’s brother, is also a senior medical student at Faculté des Sciences de la Santé Université Quisqueya in Port-au-Prince. He has no disclosures.

Do you want to know what keeps us up at night? As 4th-year medical students born, raised, and living in Haiti, we worry about the impact of COVID-19 on our patients.

The pandemic has shaken the world, and Haiti is no exception.

Courtesy Schneider Dorcela

It has taken several months for the disease to spread, and it began with two confirmed cases, one from France and the other from Belgium, on March 19.¹ Much of the spread of COVID-19 in Haiti has been tied to workers returning from the Dominican Republic. As of June 29, Haiti had 5,975 confirmed cases and 105 deaths.² Of course, those numbers sound minuscule, compared with those in the United States, where the number of deaths from COVID-19 surpassed 100,000 several weeks ago. But the population of Haiti is 30 times smaller than that of the United States, and Haiti is the poorest country in the Western Hemisphere. We have watched in horror as the virus has ravaged marginalized groups in the United States and worry that it will do the same in our own country.

Just as the Haitian Ministry of Health worked with various groups to reach the 1-year free of cholera mark in Haiti, groups such as Doctors Without Borders must mobilize to rein in COVID-19.
 

Community transmission rapid

After the first two cases were confirmed, a state of health emergency was immediately declared. Haitian President Jovenel Moïse and other government officials called for the implementation of several measures aimed at limiting the spread of COVID-19.

Schools, universities, clinical training programs, vocational centers, factories, airports, and ports, except for the transport of goods, were all ordered to close until further notice. Gatherings of larger than 10 people were banned. A curfew from 8 p.m. EST time to 5 a.m. EST was imposed. Measures such as those encouraged by U.S. Centers for Disease Control and Prevention, such as hand washing, physical distancing, and staying at home were also encouraged by the Haitian Ministry of Health. Mask wearing in public places was deemed mandatory.

The latest testing data show that community spread has been occurring among the Haitian population at a rapid rate. According to Jean William Pape, MD, Haiti’s top infectious diseases expert and founder of GHESKIO, an iconic infectious disease center that cares for people with HIV-AIDS and tuberculosis, a COVID-19 simulation from Cornell University in New York shows that about 35% of the Haitian population will be infected by the end of August 2020. A simulation by the University of Oxford (England) paints an even more dire picture. That simulation shows that 86% of the population could be infected, More than 9,000 additional hospital beds would be needed, and 20,000 people would be likely to die from COVID-19, Dr. Pape said in an interview with Haiti’s Nouvelliste newspaper.³
 

Medical response

We know that there is a global shortage of health care workers^,4 and Haiti is no exception. According to a 2018 report from the Haitian Ministry of Health, the country has 11,775 health care professionals, including about 3,354 medical doctors, to care for more than 11 million people. That translates to about 23.4 physicians per 100,000.⁵

The pandemic has led some members of this already anemic health care workforce to stay home because of a lack of personal protective equipment. Others, because of reduced hospital or clinic budgets, have been furloughed, making the COVID-19 national health emergency even harder to manage. The rationing of electricity and limited access to clean water⁶ in some areas are other complications that undermine our ability to provide quality care.

But a severe health care shortage is not the only challenge facing Haiti. It spends about $131 U.S. per capita, which makes Haiti one of most vulnerable among low- and middle-income countries in the world. As a poor country,⁷ its health care infrastructure is among the most inadequate and weakest. Prior to COVID-19, medical advocacy groups already had started movements and strikes demanding that the government improve the health care system. The country’s precarious health care infrastructure includes a lack of hospital beds, and basic medical supplies and equipment, such as oxygen and ventilators.⁸ The emergence of COVID-19 has only exacerbated the situation.

Clinical training programs have been suspended, many doctors and nurses are on quarantine, and some hospitals and clinics are closing. We have witnessed makeshift voodoo clinics built by Haitian voodoo leaders to receive, hospitalize, and treat COVID-19 patients through rituals and herbal remedies. In some areas of the country, residents have protested against the opening of several COVID-19 treatment and management centers.
 

Unique cultural challenges

Public health officials around the world are facing challenges persuading citizens to engage in behaviors that could protect them from the virus.

Just as in America, where many people opt to not wear face coverings^9,10 despite the public health risks, deep distrust of the Haitian government has undermined the messages of President Moïse and public healthofficials about the role of masks in limiting the spread of COVID.We see large numbers of unmasked people on the streets in the informal markets every day. Crammed tap-taps and overloaded motorcycles are moving everywhere. This also could be tied to cultural attitudes about COVID that persist among some Haitians.For example, many people with signs and symptoms of COVID-19 are afraid of going to the hospital to get tested and receive care, and resort to going to the voodoo clinics. Along with rituals, voodoo priests have been serving up teas with ingredients, including moringa, eucalyptus, ginger, and honey to those seeking COVID-19 care in the centers. The voodoo priests claim that the teas they serve strengthen the immune system.

In addition, it is difficult for poor people who live in small quarters with several other people to adhere to physical distancing.¹¹
 

Stigma and violence

Other barriers in the fight against COVID-19 in Haiti are stigma and violence. If widespread testing were available, some Haitians would opt not to do so – despite clear signs and symptoms of the infection. Some people who would get tested if they could are afraid to do so because of fears tied to being attacked by neighbors.

When Haitian University professor Bellamy Nelson and his girlfriend returned to Haiti from the United States in March and began experiencing some pain and fever, he experienced attacks from neighbors, he said in an interview. He said neighbors threatened to burn down his house. When an ambulance arrived at his house to transport him to a hospital, it had to drive through back roads to avoid people armed with rocks, fire, and machetes, he told us. No hospital wanted to admit him. Eventually, Professor Nelson self-quarantined at home, he said.

In another incident, a national ambulance center in Gonaïves, a town toward the northern region of Haiti, reportedly was vandalized, because COVID-19 equipment and supplies used to treat people had been stored there. Hospital Bernard Mevs, along with many other hospitals, was forced by the area’s residents to suspend the plan to open a center for COVID-19 management. Threats to burn down the hospitals caused the leaders of the hospitals to back down and give up a plan to build a 20-bed COVID-19 response center.
 

Maternal health

Another concern we have about the pandemic is the risk it could be to pregnant women. On average, 94,000 deaths occur annually in Haiti. Out of this number, maternal mortality accounts for 1,000. In 2017, for every 100,000 live births for women of reproductive age from 15 to 49 years old, 480 women died. In contrast, in the Dominican Republic, 95 women died per 100,000 that same year. In the United States, 19 died, and in Norway, no more than 2 died that year.¹²

Some of the primary factors contributing to the crisis are limited accessibility, inadequate health care facilities, and an inadequate number of trained health care practitioners; low percentages of skilled attendants at deliveries and of prenatal and postnatal visits; and high numbers of high-risk deliveries in nonqualified health facilities.

During the COVID-19 national health emergency, with most hospitals reducing their health care personnel either because of budget-related reasons or because they are on quarantine, this maternal-fetal health crisis has escalated.

One of the biggest hospitals in Jacmel, a town in the southern region of Haiti, has stopped its prenatal care program. In Delmas, the city with the highest incidence and prevalence of COVID-19, Hôpital Universitaire de la Paix has reduced this program to 50% of its capacity and gynecologic care has been completely suspended. Hôpital St. Luc, one of the first hospitals in the western region of Haiti to open its doors to care for COVID-19 patients, has recently shut down the entire maternal-fetal department.

So, access to prenatal and postnatal care, including the ability to deliver babies in health care institutions, is significantly reduced because of COVID-19. This leaves thousands of already vulnerable pregnant women at risk and having to deliver domestically with little to no health care professional assistance. We worry that, in light of the data, more women and babies will die because of the COVID-19 pandemic.
 

A call to action

Despite these conditions, there are reasons for hope. Various groups, both from the international community and locally have mobilized to respond to the pandemic.

International health care organizations such as Doctors Without Borders and Partners in Health, and local groups such as GHESKIO, the St. Luke Foundation for Haiti, and others have been collaborating with the Haitian Ministry of Health to devise and strategic plans and deploy valuable resources with the common goal of saving lives from COVID-19.

GHESKIO, for example, under Dr. Pape’s leadership, currently has one of the three COVID-19 testing centers in the country. It also has two COVID-19 treatment centers in full operation, in Port-au-Prince, the capital city, managing and treating 520 patients with confirmed COVID-19. GHESKIO, which has been in the front lines of previous major infectious disease outbreaks,¹³ has trained about 200 clinicians from both public and private health care institutions to care for COVID-19 patients.

Doctors Without Borders has been investing in efforts to support the Ministry of Health by converting and renovating its Burn Center in Drouillard, a small section of the city of Cité Soleil, one of the country’s biggest slums. In May, as part of its COVID-19 response, it launched a 20-bed capacity center that can accommodate up to 45 beds to care for patients who have tested positive for COVID-19.

Partners in Health, the Boston-based nonprofit health care organization cofounded in 1987 by American anthropologist and infectious disease specialist, Paul Farmer, MD, and the largest nonprofit health care provider in Haiti, also joined the Ministry of Health through its national and public health efforts to tackle COVID-19 in Haiti. Partners in Health, through its sister organization, Zanmi Lasante, has pioneered the movement of diagnosing and treating people with HIV-AIDS and TB. Since the late 1990s, its efforts against both infectious diseases have helped 15,000 HIV-positive patients begin and remain on treatment. And every year, 1,500 TB patients have started treatment on the path to a cure.

Early in the pandemic in Haiti, Partners in Health, through its state-of-the-art 300-bed university hospital (Hôpital Universitaire de Mirebalais de Mirebalais), was the first to open a COVID-19 center with a 20-bed capacity and has been caring for COVID-19 patients since then. In June, Partners in Health supported and inaugurated the renovation of the internal medicine department at one of its affiliated community hospitals, Hôpital Saint-Nicolas de Saint Marc. That department will have a 24-bed capacity that can extend up to 36 beds to manage and treat COVID-19 patients.

In total, currently, 26 COVID-19 centers with a capacity of 1,011 beds are available to serve, manage, and treat Haitian patients affected with COVID-19. But are those efforts enough? No.

Haiti, as a weak state even before COVID-19, continues to need funding from the international community so it can strengthen its health care infrastructure to be effective and strong in fighting against COVID-19.

In addition, we would like to see preventive initiatives implemented on the local level. Our family has taken on a role that, we think, could help conquer COVID-19 if others followed suit on a large scale.

As part of our contribution in tackling COVID-19, the two of us have launched a small-scale community experiment. We have educated our family in Delmas about COVID-19 and subsequently launched an awareness campaign in the community. We dispatched small groups that go door to door in the community to educate neighbors about the disease in an effort to help them understand that COVID-19 is real and it is normal for people that feel they may have the disease to seek medical care. This approach helps suppress the transmission of the virus. This pilot project could be reproduced in several other communities. It is easy to operate, rapid, effective, and cost-free. The community has been very receptive to and grateful for our efforts.

Like other countries across the world, Haiti was not ready for COVID-19. But we are confident that, with help from the international community, organizations such as GHESKIO,¹⁴ and with due diligence on the local level, we are strong and resilient enough to beat COVID. We must act together – quickly.

 

References

1. Sénat JD. Coronavirus: 2 cas confirmés en Haïti, Jovenel Moïse décrète l’état d’ur-gence sanitaire. 2020 Le Nouvelliste.

2. Haitian Ministry of Health.

3. “Entre appel a la solidarite et de sombres previsions, le Dr William Pape fait le point.” Le Nouvelliste.

4. Darzi A and Evans T. Lancet. 2016 Nov-Dec 26. 388;10060:2576-7.

5. Rapport Statistique 2018. 2019 Republic of Haiti.

6. Sentlinger K. “Water Crisis in Haiti.” The Water Project.

7. The World Bank in Haiti. worldbank.org.

8. Cenat JM. Travel Med Infect Dis. 2020 Mar 28. doi: 10.1016/jtmaid.2020.101684.

9. Block D. “Why some Americans resist wearing face masks.” voanews.com. 2020 May 31.

10. Panceski B and Douglas J. “Masks could help stop coronavirus. So why are they still controversial?” wsj.com. Updated 29 Jun 2020.

11. Bojarski S. “Social distancing: A luxury Haiti’s poor cannot afford. The Haitian Times. 2020 Apr.

12. World Health Organization, UNICEF, World Bank Group, and the U.N. Population Division. Maternal mortality ratio, Haiti.

13. Feliciano I and Kargbo C. “As COVID cases surge, Haiti’s Dr. Pape is on the front line again.” PBS NewsHour Weekend. 2020 Jun 13.

14. Liautaud B and Deschamps MM. New Engl J Med. 2020 Jun 16.
 

Mr. Dorcela is a senior medical student at Faculté des Sciences de la Santé Université Quisqueya in Port-au-Prince, Haiti. He also is a medical intern at Unité de Médecine Familiale Hôpital Saint Nicolas in Saint-Marc. Mr. Dorcela has no disclosures. Mr. St. Jean, who is Mr. Dorcela’s brother, is also a senior medical student at Faculté des Sciences de la Santé Université Quisqueya in Port-au-Prince. He has no disclosures.

Do you want to know what keeps us up at night? As 4th-year medical students born, raised, and living in Haiti, we worry about the impact of COVID-19 on our patients.

The pandemic has shaken the world, and Haiti is no exception.

Courtesy Schneider Dorcela

It has taken several months for the disease to spread, and it began with two confirmed cases, one from France and the other from Belgium, on March 19.¹ Much of the spread of COVID-19 in Haiti has been tied to workers returning from the Dominican Republic. As of June 29, Haiti had 5,975 confirmed cases and 105 deaths.² Of course, those numbers sound minuscule, compared with those in the United States, where the number of deaths from COVID-19 surpassed 100,000 several weeks ago. But the population of Haiti is 30 times smaller than that of the United States, and Haiti is the poorest country in the Western Hemisphere. We have watched in horror as the virus has ravaged marginalized groups in the United States and worry that it will do the same in our own country.

Just as the Haitian Ministry of Health worked with various groups to reach the 1-year free of cholera mark in Haiti, groups such as Doctors Without Borders must mobilize to rein in COVID-19.
 

Community transmission rapid

After the first two cases were confirmed, a state of health emergency was immediately declared. Haitian President Jovenel Moïse and other government officials called for the implementation of several measures aimed at limiting the spread of COVID-19.

Schools, universities, clinical training programs, vocational centers, factories, airports, and ports, except for the transport of goods, were all ordered to close until further notice. Gatherings of larger than 10 people were banned. A curfew from 8 p.m. EST time to 5 a.m. EST was imposed. Measures such as those encouraged by U.S. Centers for Disease Control and Prevention, such as hand washing, physical distancing, and staying at home were also encouraged by the Haitian Ministry of Health. Mask wearing in public places was deemed mandatory.

The latest testing data show that community spread has been occurring among the Haitian population at a rapid rate. According to Jean William Pape, MD, Haiti’s top infectious diseases expert and founder of GHESKIO, an iconic infectious disease center that cares for people with HIV-AIDS and tuberculosis, a COVID-19 simulation from Cornell University in New York shows that about 35% of the Haitian population will be infected by the end of August 2020. A simulation by the University of Oxford (England) paints an even more dire picture. That simulation shows that 86% of the population could be infected, More than 9,000 additional hospital beds would be needed, and 20,000 people would be likely to die from COVID-19, Dr. Pape said in an interview with Haiti’s Nouvelliste newspaper.³
 

Medical response

We know that there is a global shortage of health care workers^,4 and Haiti is no exception. According to a 2018 report from the Haitian Ministry of Health, the country has 11,775 health care professionals, including about 3,354 medical doctors, to care for more than 11 million people. That translates to about 23.4 physicians per 100,000.⁵

The pandemic has led some members of this already anemic health care workforce to stay home because of a lack of personal protective equipment. Others, because of reduced hospital or clinic budgets, have been furloughed, making the COVID-19 national health emergency even harder to manage. The rationing of electricity and limited access to clean water⁶ in some areas are other complications that undermine our ability to provide quality care.

But a severe health care shortage is not the only challenge facing Haiti. It spends about $131 U.S. per capita, which makes Haiti one of most vulnerable among low- and middle-income countries in the world. As a poor country,⁷ its health care infrastructure is among the most inadequate and weakest. Prior to COVID-19, medical advocacy groups already had started movements and strikes demanding that the government improve the health care system. The country’s precarious health care infrastructure includes a lack of hospital beds, and basic medical supplies and equipment, such as oxygen and ventilators.⁸ The emergence of COVID-19 has only exacerbated the situation.

Clinical training programs have been suspended, many doctors and nurses are on quarantine, and some hospitals and clinics are closing. We have witnessed makeshift voodoo clinics built by Haitian voodoo leaders to receive, hospitalize, and treat COVID-19 patients through rituals and herbal remedies. In some areas of the country, residents have protested against the opening of several COVID-19 treatment and management centers.
 

Unique cultural challenges

Public health officials around the world are facing challenges persuading citizens to engage in behaviors that could protect them from the virus.

Just as in America, where many people opt to not wear face coverings^9,10 despite the public health risks, deep distrust of the Haitian government has undermined the messages of President Moïse and public healthofficials about the role of masks in limiting the spread of COVID.We see large numbers of unmasked people on the streets in the informal markets every day. Crammed tap-taps and overloaded motorcycles are moving everywhere. This also could be tied to cultural attitudes about COVID that persist among some Haitians.For example, many people with signs and symptoms of COVID-19 are afraid of going to the hospital to get tested and receive care, and resort to going to the voodoo clinics. Along with rituals, voodoo priests have been serving up teas with ingredients, including moringa, eucalyptus, ginger, and honey to those seeking COVID-19 care in the centers. The voodoo priests claim that the teas they serve strengthen the immune system.

In addition, it is difficult for poor people who live in small quarters with several other people to adhere to physical distancing.¹¹
 

Stigma and violence

Other barriers in the fight against COVID-19 in Haiti are stigma and violence. If widespread testing were available, some Haitians would opt not to do so – despite clear signs and symptoms of the infection. Some people who would get tested if they could are afraid to do so because of fears tied to being attacked by neighbors.

When Haitian University professor Bellamy Nelson and his girlfriend returned to Haiti from the United States in March and began experiencing some pain and fever, he experienced attacks from neighbors, he said in an interview. He said neighbors threatened to burn down his house. When an ambulance arrived at his house to transport him to a hospital, it had to drive through back roads to avoid people armed with rocks, fire, and machetes, he told us. No hospital wanted to admit him. Eventually, Professor Nelson self-quarantined at home, he said.

In another incident, a national ambulance center in Gonaïves, a town toward the northern region of Haiti, reportedly was vandalized, because COVID-19 equipment and supplies used to treat people had been stored there. Hospital Bernard Mevs, along with many other hospitals, was forced by the area’s residents to suspend the plan to open a center for COVID-19 management. Threats to burn down the hospitals caused the leaders of the hospitals to back down and give up a plan to build a 20-bed COVID-19 response center.
 

Maternal health

Another concern we have about the pandemic is the risk it could be to pregnant women. On average, 94,000 deaths occur annually in Haiti. Out of this number, maternal mortality accounts for 1,000. In 2017, for every 100,000 live births for women of reproductive age from 15 to 49 years old, 480 women died. In contrast, in the Dominican Republic, 95 women died per 100,000 that same year. In the United States, 19 died, and in Norway, no more than 2 died that year.¹²

Some of the primary factors contributing to the crisis are limited accessibility, inadequate health care facilities, and an inadequate number of trained health care practitioners; low percentages of skilled attendants at deliveries and of prenatal and postnatal visits; and high numbers of high-risk deliveries in nonqualified health facilities.

During the COVID-19 national health emergency, with most hospitals reducing their health care personnel either because of budget-related reasons or because they are on quarantine, this maternal-fetal health crisis has escalated.

One of the biggest hospitals in Jacmel, a town in the southern region of Haiti, has stopped its prenatal care program. In Delmas, the city with the highest incidence and prevalence of COVID-19, Hôpital Universitaire de la Paix has reduced this program to 50% of its capacity and gynecologic care has been completely suspended. Hôpital St. Luc, one of the first hospitals in the western region of Haiti to open its doors to care for COVID-19 patients, has recently shut down the entire maternal-fetal department.

So, access to prenatal and postnatal care, including the ability to deliver babies in health care institutions, is significantly reduced because of COVID-19. This leaves thousands of already vulnerable pregnant women at risk and having to deliver domestically with little to no health care professional assistance. We worry that, in light of the data, more women and babies will die because of the COVID-19 pandemic.
 

A call to action

Despite these conditions, there are reasons for hope. Various groups, both from the international community and locally have mobilized to respond to the pandemic.

International health care organizations such as Doctors Without Borders and Partners in Health, and local groups such as GHESKIO, the St. Luke Foundation for Haiti, and others have been collaborating with the Haitian Ministry of Health to devise and strategic plans and deploy valuable resources with the common goal of saving lives from COVID-19.

GHESKIO, for example, under Dr. Pape’s leadership, currently has one of the three COVID-19 testing centers in the country. It also has two COVID-19 treatment centers in full operation, in Port-au-Prince, the capital city, managing and treating 520 patients with confirmed COVID-19. GHESKIO, which has been in the front lines of previous major infectious disease outbreaks,¹³ has trained about 200 clinicians from both public and private health care institutions to care for COVID-19 patients.

Doctors Without Borders has been investing in efforts to support the Ministry of Health by converting and renovating its Burn Center in Drouillard, a small section of the city of Cité Soleil, one of the country’s biggest slums. In May, as part of its COVID-19 response, it launched a 20-bed capacity center that can accommodate up to 45 beds to care for patients who have tested positive for COVID-19.

Partners in Health, the Boston-based nonprofit health care organization cofounded in 1987 by American anthropologist and infectious disease specialist, Paul Farmer, MD, and the largest nonprofit health care provider in Haiti, also joined the Ministry of Health through its national and public health efforts to tackle COVID-19 in Haiti. Partners in Health, through its sister organization, Zanmi Lasante, has pioneered the movement of diagnosing and treating people with HIV-AIDS and TB. Since the late 1990s, its efforts against both infectious diseases have helped 15,000 HIV-positive patients begin and remain on treatment. And every year, 1,500 TB patients have started treatment on the path to a cure.

Early in the pandemic in Haiti, Partners in Health, through its state-of-the-art 300-bed university hospital (Hôpital Universitaire de Mirebalais de Mirebalais), was the first to open a COVID-19 center with a 20-bed capacity and has been caring for COVID-19 patients since then. In June, Partners in Health supported and inaugurated the renovation of the internal medicine department at one of its affiliated community hospitals, Hôpital Saint-Nicolas de Saint Marc. That department will have a 24-bed capacity that can extend up to 36 beds to manage and treat COVID-19 patients.

In total, currently, 26 COVID-19 centers with a capacity of 1,011 beds are available to serve, manage, and treat Haitian patients affected with COVID-19. But are those efforts enough? No.

Haiti, as a weak state even before COVID-19, continues to need funding from the international community so it can strengthen its health care infrastructure to be effective and strong in fighting against COVID-19.

In addition, we would like to see preventive initiatives implemented on the local level. Our family has taken on a role that, we think, could help conquer COVID-19 if others followed suit on a large scale.

As part of our contribution in tackling COVID-19, the two of us have launched a small-scale community experiment. We have educated our family in Delmas about COVID-19 and subsequently launched an awareness campaign in the community. We dispatched small groups that go door to door in the community to educate neighbors about the disease in an effort to help them understand that COVID-19 is real and it is normal for people that feel they may have the disease to seek medical care. This approach helps suppress the transmission of the virus. This pilot project could be reproduced in several other communities. It is easy to operate, rapid, effective, and cost-free. The community has been very receptive to and grateful for our efforts.

Like other countries across the world, Haiti was not ready for COVID-19. But we are confident that, with help from the international community, organizations such as GHESKIO,¹⁴ and with due diligence on the local level, we are strong and resilient enough to beat COVID. We must act together – quickly.

 

References

1. Sénat JD. Coronavirus: 2 cas confirmés en Haïti, Jovenel Moïse décrète l’état d’ur-gence sanitaire. 2020 Le Nouvelliste.

2. Haitian Ministry of Health.

3. “Entre appel a la solidarite et de sombres previsions, le Dr William Pape fait le point.” Le Nouvelliste.

4. Darzi A and Evans T. Lancet. 2016 Nov-Dec 26. 388;10060:2576-7.

5. Rapport Statistique 2018. 2019 Republic of Haiti.

6. Sentlinger K. “Water Crisis in Haiti.” The Water Project.

7. The World Bank in Haiti. worldbank.org.

8. Cenat JM. Travel Med Infect Dis. 2020 Mar 28. doi: 10.1016/jtmaid.2020.101684.

9. Block D. “Why some Americans resist wearing face masks.” voanews.com. 2020 May 31.

10. Panceski B and Douglas J. “Masks could help stop coronavirus. So why are they still controversial?” wsj.com. Updated 29 Jun 2020.

11. Bojarski S. “Social distancing: A luxury Haiti’s poor cannot afford. The Haitian Times. 2020 Apr.

12. World Health Organization, UNICEF, World Bank Group, and the U.N. Population Division. Maternal mortality ratio, Haiti.

13. Feliciano I and Kargbo C. “As COVID cases surge, Haiti’s Dr. Pape is on the front line again.” PBS NewsHour Weekend. 2020 Jun 13.

14. Liautaud B and Deschamps MM. New Engl J Med. 2020 Jun 16.
 

Mr. Dorcela is a senior medical student at Faculté des Sciences de la Santé Université Quisqueya in Port-au-Prince, Haiti. He also is a medical intern at Unité de Médecine Familiale Hôpital Saint Nicolas in Saint-Marc. Mr. Dorcela has no disclosures. Mr. St. Jean, who is Mr. Dorcela’s brother, is also a senior medical student at Faculté des Sciences de la Santé Université Quisqueya in Port-au-Prince. He has no disclosures.

This editorial is the first to be published in GI & Hepatology News since the murder of George Floyd in Minneapolis. The corner of 38th and Chicago is 9 miles from my home in Bloomington, Minn. This corner became the epicenter of protests that have spread around the nation and world. Early on, protests were accompanied by widespread riots, looting, and destruction. In the ensuing weeks, this corner has become a memorial for Mr. Floyd and a place where people now go to reflect, pray, pay tribute, and pledge to work for change.

A coalition of willing businesses has formed in the area around 38th and Chicago. The largest employer in the area is Allina Health (I sit on the Governing Board of Allina Health). Our flagship hospital is 8 blocks from the site of George Floyd’s memorial. We will be a change leader by committing funds for local rebuilding, ensuring use of construction firms that promote minority workers (as was done when the Viking’s stadium was built), examining our investment portfolio with racial equity as one guiding principle, increasing our focus on barriers to access, enhancing equity education of our workforce, and working with city and state leaders to promote police reform.

As the Editor in Chief of the official newspaper of the AGA, I invited our board of editors to stand united in our condemnation of the racial injustices that led to the protests we now see. We each agree with the message from the combined Governing Boards of our GI societies (published June 2, 2020) stating “As health care providers, we have dedicated our lives to caring for our fellow human beings. Therefore, we are compelled to speak out against any treatment that results in unacceptable disparities that marginalize the vulnerable among us.”

Our responsibility as editors is to guide the content we deliver, ensuring its relevancy to our readers. In this light, we commit to delivering content that highlights racial injustices and health disparities for all people, as we seek to understand the many factors that result in barriers to health. We will emphasize content that leads to impactful change and will highlight progress we make as a specialty. We hope our collective work will help ensure that George Floyd’s memory, and the memories of all such victims, become a catalyst for permanent cultural change.
 

Editor in Chief, GI & Hepatology News
John I. Allen, MD, MBA, AGAF

Editor in Chief, The New Gastroenterologist
Vijaya L. Rao, MD

Associate Editors
Megan A. Adams, MD, JD, MSc
Ziad Gellad, MD, MPH, AGAF
Kim L. Isaacs, MD, PhD, AGAF
Charles J. Kahi, MD, MS, AGAF
Gyanprakash A. Ketwaroo, MD, MSc
Larry R. Kosinski, MD, MBA, AGAF
Sonia S. Kupfer, MD
Wajahat Mehal, MD, PhD

This editorial is the first to be published in GI & Hepatology News since the murder of George Floyd in Minneapolis. The corner of 38th and Chicago is 9 miles from my home in Bloomington, Minn. This corner became the epicenter of protests that have spread around the nation and world. Early on, protests were accompanied by widespread riots, looting, and destruction. In the ensuing weeks, this corner has become a memorial for Mr. Floyd and a place where people now go to reflect, pray, pay tribute, and pledge to work for change.

A coalition of willing businesses has formed in the area around 38th and Chicago. The largest employer in the area is Allina Health (I sit on the Governing Board of Allina Health). Our flagship hospital is 8 blocks from the site of George Floyd’s memorial. We will be a change leader by committing funds for local rebuilding, ensuring use of construction firms that promote minority workers (as was done when the Viking’s stadium was built), examining our investment portfolio with racial equity as one guiding principle, increasing our focus on barriers to access, enhancing equity education of our workforce, and working with city and state leaders to promote police reform.

As the Editor in Chief of the official newspaper of the AGA, I invited our board of editors to stand united in our condemnation of the racial injustices that led to the protests we now see. We each agree with the message from the combined Governing Boards of our GI societies (published June 2, 2020) stating “As health care providers, we have dedicated our lives to caring for our fellow human beings. Therefore, we are compelled to speak out against any treatment that results in unacceptable disparities that marginalize the vulnerable among us.”

Our responsibility as editors is to guide the content we deliver, ensuring its relevancy to our readers. In this light, we commit to delivering content that highlights racial injustices and health disparities for all people, as we seek to understand the many factors that result in barriers to health. We will emphasize content that leads to impactful change and will highlight progress we make as a specialty. We hope our collective work will help ensure that George Floyd’s memory, and the memories of all such victims, become a catalyst for permanent cultural change.
 

Editor in Chief, GI & Hepatology News
John I. Allen, MD, MBA, AGAF

Editor in Chief, The New Gastroenterologist
Vijaya L. Rao, MD

Associate Editors
Megan A. Adams, MD, JD, MSc
Ziad Gellad, MD, MPH, AGAF
Kim L. Isaacs, MD, PhD, AGAF
Charles J. Kahi, MD, MS, AGAF
Gyanprakash A. Ketwaroo, MD, MSc
Larry R. Kosinski, MD, MBA, AGAF
Sonia S. Kupfer, MD
Wajahat Mehal, MD, PhD

This editorial is the first to be published in GI & Hepatology News since the murder of George Floyd in Minneapolis. The corner of 38th and Chicago is 9 miles from my home in Bloomington, Minn. This corner became the epicenter of protests that have spread around the nation and world. Early on, protests were accompanied by widespread riots, looting, and destruction. In the ensuing weeks, this corner has become a memorial for Mr. Floyd and a place where people now go to reflect, pray, pay tribute, and pledge to work for change.

A coalition of willing businesses has formed in the area around 38th and Chicago. The largest employer in the area is Allina Health (I sit on the Governing Board of Allina Health). Our flagship hospital is 8 blocks from the site of George Floyd’s memorial. We will be a change leader by committing funds for local rebuilding, ensuring use of construction firms that promote minority workers (as was done when the Viking’s stadium was built), examining our investment portfolio with racial equity as one guiding principle, increasing our focus on barriers to access, enhancing equity education of our workforce, and working with city and state leaders to promote police reform.

As the Editor in Chief of the official newspaper of the AGA, I invited our board of editors to stand united in our condemnation of the racial injustices that led to the protests we now see. We each agree with the message from the combined Governing Boards of our GI societies (published June 2, 2020) stating “As health care providers, we have dedicated our lives to caring for our fellow human beings. Therefore, we are compelled to speak out against any treatment that results in unacceptable disparities that marginalize the vulnerable among us.”

Our responsibility as editors is to guide the content we deliver, ensuring its relevancy to our readers. In this light, we commit to delivering content that highlights racial injustices and health disparities for all people, as we seek to understand the many factors that result in barriers to health. We will emphasize content that leads to impactful change and will highlight progress we make as a specialty. We hope our collective work will help ensure that George Floyd’s memory, and the memories of all such victims, become a catalyst for permanent cultural change.
 

Editor in Chief, GI & Hepatology News
John I. Allen, MD, MBA, AGAF

Editor in Chief, The New Gastroenterologist
Vijaya L. Rao, MD

Associate Editors
Megan A. Adams, MD, JD, MSc
Ziad Gellad, MD, MPH, AGAF
Kim L. Isaacs, MD, PhD, AGAF
Charles J. Kahi, MD, MS, AGAF
Gyanprakash A. Ketwaroo, MD, MSc
Larry R. Kosinski, MD, MBA, AGAF
Sonia S. Kupfer, MD
Wajahat Mehal, MD, PhD

Coronavirus disease 2019 (COVID-19) is affecting every aspect of medical care. Much has been written about overwhelmed hospital settings, the financial devastation to outpatient treatment centers, and an impending pandemic of mental illness that the existing underfunded and fragmented mental health system would not be prepared to weather. Although COVID-19 has undeniably affected the practice of emergency psychiatry, its impact has been surprising and complex. In this article, I describe the effects COVID-19 has had on our psychiatric emergency service, and how the pandemic has affected me personally.

How the pandemic affected our psychiatric ED

The Comprehensive Psychiatric Emergency Program (CPEP) in Buffalo, New York, is part of the emergency department (ED) in the local county hospital and is staffed by faculty from the Department of Psychiatry at the University at Buffalo. It was developed to provide evaluations of acutely psychiatrically ill individuals, to determine their treatment needs and facilitate access to the appropriate level of care.

Before COVID-19, as the only fully staffed psychiatric emergency service in the region, CPEP would routinely be called upon to serve many functions for which it was not designed. For example, people who had difficulty accessing psychiatric care in the community might come to CPEP expecting treatment for chronic conditions. Additionally, due to systemic deficiencies and limited resources, police and other community agencies refer individuals to CPEP who either have illnesses unrelated to current circumstances or who are not psychiatrically ill but unmanageable because of aggression or otherwise unresolvable social challenges such as homelessness, criminal behavior, poor parenting and other family strains, or general dissatisfaction with life. Parents unable to set limits with bored or defiant children might leave them in CPEP, hoping to transfer the parenting role, just as law enforcement officers who feel impotent to apply meaningful sanctions to non-felonious offenders might bring them to CPEP seeking containment. Labeling these problems as psychiatric emergencies has made it more palatable to leave these individuals in our care. These types of visits have contributed to the substantial growth of CPEP in recent years, in terms of annual patient visits, number of children abandoned and their lengths of stay in the CPEP, among other metrics.

The impact of the COVID-19 pandemic on an emergency psychiatry service that is expected to be all things to all people has been interesting. For the first few weeks of the societal shutdown, the patient flow was unchanged. However, during this time, the usual overcrowding created a feeling of vulnerability to contagion that sparked an urgency to minimize the census. Superhuman efforts were fueled by an unspoken sense of impending doom, and wait times dropped from approximately 17 hours to 3 or 4 hours. This state of hypervigilance was impossible to sustain indefinitely, and inevitably those efforts were exhausted. As adrenaline waned, the focus turned toward family and self-preservation. Nursing and social work staff began cancelling shifts, as did part-time physicians who contracted services with our department. Others, however, were drawn to join the front-line fight.

Trends in psychiatric ED usage during the pandemic

As COVID-19 spread, local media reported the paucity of personal protective equipment (PPE) and created the sense that no one would receive hospital treatment unless they were on the brink of death. Consequently, total visits to the ED began to slow. During April, CPEP saw 25% fewer visits than average. This reduction was partly attributable to cohorting patients with any suspicion of infection in a designated area within the medical ED, with access to remote evaluation by CPEP psychiatrists via telemedicine. In addition, the characteristics and circumstances of patients presenting to CPEP began to change (Table).

Children/adolescents. In the months before COVID-19’s spread to the United States, there had been an exponential surge in child visits to CPEP, with >200 such visits in January 2020. When schools closed on March 13, school-related stress abruptly abated, and during April, child visits dropped to 89. This reduction might have been due in part to increased access to outpatient treatment via telemedicine or telephone appointments. In our affiliated clinics, both new patient visits and remote attendance to appointments by established patients increased substantially, likely contributing to a decreased reliance on the CPEP for treatment. Limited Family Court operations, though, left already-frustrated police without much recourse when called to intervene with adolescent offenders. CPEP once again served an untraditional role, facilitating the removal of these disruptive individuals from potentially dangerous circumstances, under the guise of behavioral emergencies.

Suicidality. While nonemergent visits declined, presentations related to suicidality persisted. In the United States, suicide rates have increased annually for decades. This trend has also been observed locally, with early evidence suggesting that the changes inflicted by COVID-19 perpetuated the surge in suicidal thinking and behavior, but with a change in character. Some of this is likely related to financial stress and social disruption, though job loss seems more likely to result in increased substance use than suicidality. Even more distressing to those coming to CPEP was anxiety about the illness itself, social isolation, and loss. The death of a loved one is painful enough, but disrupting the grief process by preventing people from visiting family members dying in hospitals or gathering for funerals has been devastating. Reports of increased gun sales undoubtedly associated with fears of social decay caused by the pandemic are concerning with regard to patients with suicidality, because shooting has emerged as the means most likely to result in completed suicide.¹ The imposition of social distancing directly isolated some individuals, increasing suicidality. Limitations on gathering in groups disrupted other sources of social support as well, such as religious services, clubhouses, and meetings of 12-step programs such as Alcoholics Anonymous. This could increase suicidality, either directly for more vulnerable patients or indirectly by compromising sobriety and thereby adding to the risk for suicide.

Continue to: Substance use disorders (SUDs)

Substance use disorders (SUDs). Present­ations to CPEP by patients with SUDs surged, but the patient profile changed, undoubtedly influenced by the pandemic. Requests for detoxification became less frequent because people who were not in severe distress avoided the hospital. At the same time, alcohol-dependent individuals who might typically avoid clinical attention were requiring emergent medical attention for delirium. This is attributable to a combination of factors, including nutritional depletion, and a lack of access to alcohol leading to abrupt withdrawal or consumption of unconventional sources of alcohol, such as hand sanitizer, or hard liquor (over beer). Amphetamine use appears to have increased, although the observed surge may simply be related to the conspicuousness of stimulant intoxication for someone who is sheltering in place. There was a noticeable uptick in overdoses (primarily with opioids) requiring CPEP evaluation, which was possibly related to a reduction of available beds in inpatient rehabilitation facilities as a result of social distancing rules.

Patients with chronic mental illness. Many experts anticipated an increase in hospital visits by individuals with chronic mental illness expected to decompensate as a result of reduced access to community treatment resources.² Closing courts did not prevent remote sessions for inpatient retention and treatment over objection, but did result in the expiration of many Assisted Outpatient Treatment orders by restricting renewal hearings, which is circuitously beginning to fulfill this prediction. On the other hand, an impressive community response has managed to continue meeting the needs of most of these patients. Dedicated mental health clinics have recruited mobile teams or developed carefully scheduled, nursing-run “shot clinics” to ensure that patients who require long-acting injectable medications or medication-assisted treatment for SUDs continue to receive treatment.

New-onset psychosis. A new population of patients with acute mania and psychosis also seems to have surfaced during this pandemic. Previously high-functioning individuals in their 30s, 40s, and 50s without a history of mental illness were presenting with new-onset psychotic symptoms. These are individuals who may have been characteristically anxious, or had a “Type A personality,” but were social and employed. The cause is unclear, but given the extreme uncertainty and the political climate COVID-19 brings, it is possible that the pandemic may have triggered these episodes. These individuals and their families now have the stress of learning to navigate the mental health system added to the anxiety COVID-19 brings to most households.

Homelessness. Limitations on occupancy have reduced the availability of beds in shelters and residences, resulting in increased homelessness. Locally, authorities estimated that the homeless population has grown nearly threefold as a result of bussing in from neighboring counties with fewer resources, flight from New York City, and the urgent release from jail of nonviolent offenders, many of whom had no place to go for shelter. New emergency shelter beds have not fully compensated for the relative shortage, leading individuals who had been avoiding the hospital due to fear of infection to CPEP looking for a place to stay.

Home stressors. Whereas CPEP visits by children initially decreased, after 6 weeks, the relief from school pressures appears to have been replaced by weariness from stresses at home, and the number of children presenting with depression, SUDs, and behavioral disruptions has increased. Domestic violence involving children and adults increased. Factors that might be contributing to this include the forced proximity of family members who would typically need intermittent interpersonal distance, and an obligation to care for children who would normally be in school or for disabled loved ones now unable to attend day programs or respite services. After months of enduring the pressure of these conflicts and the resulting emotional strain, patient volumes in CPEP have begun slowly returning toward the expected average, particularly since the perceived threat of coming to the hospital has attenuated.

Continue to: Personal challenges

Personal challenges

For me, COVID-19 has brought the chance to grow and learn, fumbling at times to provide the best care when crisis abounds and when not much can be said to ease the appropriate emotional distress our patients experience. The lines between what is pathological anxiety, what level of anxiety causes functional impairment, and what can realistically be expected to respond to psychiatric treatment have become blurred. At the same time, I have come across some of the sickest patients I have ever encountered.

In some ways, my passion for psychiatry has been rekindled by COVID-19, sparking an enthusiasm to teach and inspire students to pursue careers in this wonderful field of medicine. Helping to care for patients in the absence of a cure can necessitate the application of creativity and thoughtfulness to relieve suffering, thereby teaching the art of healing above offering treatment alone. Unfortunately, replacing actual patient contact with remote learning deprives students of this unique educational opportunity. Residents who attempt to continue training while limiting exposure to patients may mitigate their own risk but could also be missing an opportunity to learn how to balance their needs with making their patients’ well-being a priority. This raises the question of how the next generation of medical students and residents will learn to navigate future crises. Gruesome media depictions of haunting experiences witnessed by medical professionals exposed to an enormity of loss and death, magnified by the suicide deaths of 2 front-line workers in New York City, undoubtedly contribute to the instinct driving the protection of students and residents in this way.

The gratitude the public expresses toward me for simply continuing to do my job brings an expectation of heroism I did not seek, and with which I am uncomfortable. For me, exceptionally poised to analyze and over-analyze myriad aspects of an internal conflict that is exhausting to balance, it all generates frustration and guilt more than anything.

I am theoretically at lower risk than intubating anesthesiologists, emergency medicine physicians, and emergency medical technicians who face patients with active COVID-19. Nevertheless, daily proximity to so many patients naturally generates fear. I convince myself that performing video consultations to the medical ED is an adaptation necessary to preserve PPE, to keep me healthy through reduced exposure, to be available to patients longer, and to support the emotional health of the medical staff who are handing over that headset to patients “under investigation.” At the same time, I am secretly relieved to avoid entering those rooms and taunting death, or even worse, risking exposing my family to the virus. The threat of COVID-19 can be so consuming that it becomes easy to forget that most individuals infected are asymptomatic and therefore difficult to quickly identify.

So I continue to sit with patients face-to-face all day. Many of them are not capable of following masking and distancing recommendations, and are more prone to spitting and biting than their counterparts in the medical ED. I must ignore this threat and convince myself I am safe to be able to place my responsibility to patient care above my own needs and do my job.

Continue to: Most of my colleagues exhibit...

Most of my colleagues exhibit an effortless bravery, even if we all naturally waver briefly at times. I am proud to stand shoulder-to-shoulder every day with these clinicians, and other staff, from police to custodians, as we continue to care for the people of this community. Despite the lower clinical burden, each day we expend significant emotional energy struggling with unexpected and unique challenges, including the burden of facing the unknown. Everyone is under stress right now. For most, the effects will be transient. For some, the damage might be permanent. For others, this stress has brought out the best in us. But knowing that physicians are particularly prone to burnout, how long can the current state of hypervigilance be maintained?

What will the future hold?

The COVID-19 era has brought fewer patients through the door of my psychiatric ED; however, just like everywhere else in the world, everything has changed. The only thing that is certain is that further change is inevitable, and we must adapt to the challenge and learn from it. As unsettling as disruptions to the status quo can be, human behavior dictates that we have the option to seize opportunities created by instability to produce superior outcomes, which can be accomplished only by looking at things anew. The question is whether we will revert to the pre-COVID-19 dysfunctional use of psychiatric emergency services, or can we use what we have learned—particularly about the value of telepsychiatry—to pursue a more effective system based on an improved understanding of the mental health treatment needs of our community. While technology is proving that social distancing requires only space between people, and not necessarily social separation, there is a risk that excessive use of remote treatment could compromise the therapeutic relationship with our patients. Despite emerging opportunities, it is difficult to direct change in a productive way when the future is uncertain.

The continuous outpouring of respect for clinicians is morale-boosting. Behind closed doors, however, news that this county hospital failed to qualify for any of the second round of federal support funding because the management of COVID-19 patients has been too effective brought a new layer of unanticipated stress. This is the only hospital in 7 counties operating a psychiatric emergency service. The mandatory, “voluntary” furloughs expected of nursing and social work staff are only now being scheduled to occur over the next couple of months. And just in time for patient volumes to return to normal. How can we continue to provide quality care, let alone build changes into practice, with reduced nursing and support staff?

It is promising, however, that in the midst of social distancing, the shared experience of endeavoring to overcome COVID-19 has promoted a connectedness among individuals who might otherwise never cross paths. This observation has bolstered my confidence in the capacity for resilience of the mental health system and the individuals within it. The reality is that we are all in this together. Differences should matter less in the face of altered perceptions of mortality. Despite the stress, suicide becomes a less reasonable choice when the value of life is magnified by pandemic circumstances. Maybe there will be even less of a need for psychiatric emergency services in the wake of COVID-19, rather than the anticipated wave of mental health crises. Until we know for sure, it is only through fellowship and continued dedication to healing that the ED experience will continue to be a positive one.

Bottom Line

Coronavirus disease 2019 (COVID-19) led to changes in the characteristics and circumstances of patients presenting to our psychiatric emergency service. Despite a lower clinical burden, each day we expended significant emotional energy struggling with unexpected and unique challenges. We can use what we have learned from COVID-19 to pursue a more effective system based on an improved understanding of the mental health treatment needs of our community.

Related Resource

• American Association for Emergency Psychiatry, American College of Emergency Physicians, American Psychiatric Association, Coalition on Psychiatric Emergencies, Crisis Residential Association, and the Emergency Nurses Association. Joint statement for care of patients with behavioral health emergencies and suspected or confirmed COVID-19. https://aaep.memberclicks.net/assets/joint-statement-covid-behavioral-health.pdf.

Coronavirus disease 2019 (COVID-19) is affecting every aspect of medical care. Much has been written about overwhelmed hospital settings, the financial devastation to outpatient treatment centers, and an impending pandemic of mental illness that the existing underfunded and fragmented mental health system would not be prepared to weather. Although COVID-19 has undeniably affected the practice of emergency psychiatry, its impact has been surprising and complex. In this article, I describe the effects COVID-19 has had on our psychiatric emergency service, and how the pandemic has affected me personally.

How the pandemic affected our psychiatric ED

The Comprehensive Psychiatric Emergency Program (CPEP) in Buffalo, New York, is part of the emergency department (ED) in the local county hospital and is staffed by faculty from the Department of Psychiatry at the University at Buffalo. It was developed to provide evaluations of acutely psychiatrically ill individuals, to determine their treatment needs and facilitate access to the appropriate level of care.

Before COVID-19, as the only fully staffed psychiatric emergency service in the region, CPEP would routinely be called upon to serve many functions for which it was not designed. For example, people who had difficulty accessing psychiatric care in the community might come to CPEP expecting treatment for chronic conditions. Additionally, due to systemic deficiencies and limited resources, police and other community agencies refer individuals to CPEP who either have illnesses unrelated to current circumstances or who are not psychiatrically ill but unmanageable because of aggression or otherwise unresolvable social challenges such as homelessness, criminal behavior, poor parenting and other family strains, or general dissatisfaction with life. Parents unable to set limits with bored or defiant children might leave them in CPEP, hoping to transfer the parenting role, just as law enforcement officers who feel impotent to apply meaningful sanctions to non-felonious offenders might bring them to CPEP seeking containment. Labeling these problems as psychiatric emergencies has made it more palatable to leave these individuals in our care. These types of visits have contributed to the substantial growth of CPEP in recent years, in terms of annual patient visits, number of children abandoned and their lengths of stay in the CPEP, among other metrics.

The impact of the COVID-19 pandemic on an emergency psychiatry service that is expected to be all things to all people has been interesting. For the first few weeks of the societal shutdown, the patient flow was unchanged. However, during this time, the usual overcrowding created a feeling of vulnerability to contagion that sparked an urgency to minimize the census. Superhuman efforts were fueled by an unspoken sense of impending doom, and wait times dropped from approximately 17 hours to 3 or 4 hours. This state of hypervigilance was impossible to sustain indefinitely, and inevitably those efforts were exhausted. As adrenaline waned, the focus turned toward family and self-preservation. Nursing and social work staff began cancelling shifts, as did part-time physicians who contracted services with our department. Others, however, were drawn to join the front-line fight.

Trends in psychiatric ED usage during the pandemic

As COVID-19 spread, local media reported the paucity of personal protective equipment (PPE) and created the sense that no one would receive hospital treatment unless they were on the brink of death. Consequently, total visits to the ED began to slow. During April, CPEP saw 25% fewer visits than average. This reduction was partly attributable to cohorting patients with any suspicion of infection in a designated area within the medical ED, with access to remote evaluation by CPEP psychiatrists via telemedicine. In addition, the characteristics and circumstances of patients presenting to CPEP began to change (Table).

Children/adolescents. In the months before COVID-19’s spread to the United States, there had been an exponential surge in child visits to CPEP, with >200 such visits in January 2020. When schools closed on March 13, school-related stress abruptly abated, and during April, child visits dropped to 89. This reduction might have been due in part to increased access to outpatient treatment via telemedicine or telephone appointments. In our affiliated clinics, both new patient visits and remote attendance to appointments by established patients increased substantially, likely contributing to a decreased reliance on the CPEP for treatment. Limited Family Court operations, though, left already-frustrated police without much recourse when called to intervene with adolescent offenders. CPEP once again served an untraditional role, facilitating the removal of these disruptive individuals from potentially dangerous circumstances, under the guise of behavioral emergencies.

Suicidality. While nonemergent visits declined, presentations related to suicidality persisted. In the United States, suicide rates have increased annually for decades. This trend has also been observed locally, with early evidence suggesting that the changes inflicted by COVID-19 perpetuated the surge in suicidal thinking and behavior, but with a change in character. Some of this is likely related to financial stress and social disruption, though job loss seems more likely to result in increased substance use than suicidality. Even more distressing to those coming to CPEP was anxiety about the illness itself, social isolation, and loss. The death of a loved one is painful enough, but disrupting the grief process by preventing people from visiting family members dying in hospitals or gathering for funerals has been devastating. Reports of increased gun sales undoubtedly associated with fears of social decay caused by the pandemic are concerning with regard to patients with suicidality, because shooting has emerged as the means most likely to result in completed suicide.¹ The imposition of social distancing directly isolated some individuals, increasing suicidality. Limitations on gathering in groups disrupted other sources of social support as well, such as religious services, clubhouses, and meetings of 12-step programs such as Alcoholics Anonymous. This could increase suicidality, either directly for more vulnerable patients or indirectly by compromising sobriety and thereby adding to the risk for suicide.

Continue to: Substance use disorders (SUDs)

Substance use disorders (SUDs). Present­ations to CPEP by patients with SUDs surged, but the patient profile changed, undoubtedly influenced by the pandemic. Requests for detoxification became less frequent because people who were not in severe distress avoided the hospital. At the same time, alcohol-dependent individuals who might typically avoid clinical attention were requiring emergent medical attention for delirium. This is attributable to a combination of factors, including nutritional depletion, and a lack of access to alcohol leading to abrupt withdrawal or consumption of unconventional sources of alcohol, such as hand sanitizer, or hard liquor (over beer). Amphetamine use appears to have increased, although the observed surge may simply be related to the conspicuousness of stimulant intoxication for someone who is sheltering in place. There was a noticeable uptick in overdoses (primarily with opioids) requiring CPEP evaluation, which was possibly related to a reduction of available beds in inpatient rehabilitation facilities as a result of social distancing rules.

Patients with chronic mental illness. Many experts anticipated an increase in hospital visits by individuals with chronic mental illness expected to decompensate as a result of reduced access to community treatment resources.² Closing courts did not prevent remote sessions for inpatient retention and treatment over objection, but did result in the expiration of many Assisted Outpatient Treatment orders by restricting renewal hearings, which is circuitously beginning to fulfill this prediction. On the other hand, an impressive community response has managed to continue meeting the needs of most of these patients. Dedicated mental health clinics have recruited mobile teams or developed carefully scheduled, nursing-run “shot clinics” to ensure that patients who require long-acting injectable medications or medication-assisted treatment for SUDs continue to receive treatment.

New-onset psychosis. A new population of patients with acute mania and psychosis also seems to have surfaced during this pandemic. Previously high-functioning individuals in their 30s, 40s, and 50s without a history of mental illness were presenting with new-onset psychotic symptoms. These are individuals who may have been characteristically anxious, or had a “Type A personality,” but were social and employed. The cause is unclear, but given the extreme uncertainty and the political climate COVID-19 brings, it is possible that the pandemic may have triggered these episodes. These individuals and their families now have the stress of learning to navigate the mental health system added to the anxiety COVID-19 brings to most households.

Homelessness. Limitations on occupancy have reduced the availability of beds in shelters and residences, resulting in increased homelessness. Locally, authorities estimated that the homeless population has grown nearly threefold as a result of bussing in from neighboring counties with fewer resources, flight from New York City, and the urgent release from jail of nonviolent offenders, many of whom had no place to go for shelter. New emergency shelter beds have not fully compensated for the relative shortage, leading individuals who had been avoiding the hospital due to fear of infection to CPEP looking for a place to stay.

Home stressors. Whereas CPEP visits by children initially decreased, after 6 weeks, the relief from school pressures appears to have been replaced by weariness from stresses at home, and the number of children presenting with depression, SUDs, and behavioral disruptions has increased. Domestic violence involving children and adults increased. Factors that might be contributing to this include the forced proximity of family members who would typically need intermittent interpersonal distance, and an obligation to care for children who would normally be in school or for disabled loved ones now unable to attend day programs or respite services. After months of enduring the pressure of these conflicts and the resulting emotional strain, patient volumes in CPEP have begun slowly returning toward the expected average, particularly since the perceived threat of coming to the hospital has attenuated.

Continue to: Personal challenges

Personal challenges

For me, COVID-19 has brought the chance to grow and learn, fumbling at times to provide the best care when crisis abounds and when not much can be said to ease the appropriate emotional distress our patients experience. The lines between what is pathological anxiety, what level of anxiety causes functional impairment, and what can realistically be expected to respond to psychiatric treatment have become blurred. At the same time, I have come across some of the sickest patients I have ever encountered.

In some ways, my passion for psychiatry has been rekindled by COVID-19, sparking an enthusiasm to teach and inspire students to pursue careers in this wonderful field of medicine. Helping to care for patients in the absence of a cure can necessitate the application of creativity and thoughtfulness to relieve suffering, thereby teaching the art of healing above offering treatment alone. Unfortunately, replacing actual patient contact with remote learning deprives students of this unique educational opportunity. Residents who attempt to continue training while limiting exposure to patients may mitigate their own risk but could also be missing an opportunity to learn how to balance their needs with making their patients’ well-being a priority. This raises the question of how the next generation of medical students and residents will learn to navigate future crises. Gruesome media depictions of haunting experiences witnessed by medical professionals exposed to an enormity of loss and death, magnified by the suicide deaths of 2 front-line workers in New York City, undoubtedly contribute to the instinct driving the protection of students and residents in this way.

The gratitude the public expresses toward me for simply continuing to do my job brings an expectation of heroism I did not seek, and with which I am uncomfortable. For me, exceptionally poised to analyze and over-analyze myriad aspects of an internal conflict that is exhausting to balance, it all generates frustration and guilt more than anything.

I am theoretically at lower risk than intubating anesthesiologists, emergency medicine physicians, and emergency medical technicians who face patients with active COVID-19. Nevertheless, daily proximity to so many patients naturally generates fear. I convince myself that performing video consultations to the medical ED is an adaptation necessary to preserve PPE, to keep me healthy through reduced exposure, to be available to patients longer, and to support the emotional health of the medical staff who are handing over that headset to patients “under investigation.” At the same time, I am secretly relieved to avoid entering those rooms and taunting death, or even worse, risking exposing my family to the virus. The threat of COVID-19 can be so consuming that it becomes easy to forget that most individuals infected are asymptomatic and therefore difficult to quickly identify.

So I continue to sit with patients face-to-face all day. Many of them are not capable of following masking and distancing recommendations, and are more prone to spitting and biting than their counterparts in the medical ED. I must ignore this threat and convince myself I am safe to be able to place my responsibility to patient care above my own needs and do my job.

Continue to: Most of my colleagues exhibit...

Most of my colleagues exhibit an effortless bravery, even if we all naturally waver briefly at times. I am proud to stand shoulder-to-shoulder every day with these clinicians, and other staff, from police to custodians, as we continue to care for the people of this community. Despite the lower clinical burden, each day we expend significant emotional energy struggling with unexpected and unique challenges, including the burden of facing the unknown. Everyone is under stress right now. For most, the effects will be transient. For some, the damage might be permanent. For others, this stress has brought out the best in us. But knowing that physicians are particularly prone to burnout, how long can the current state of hypervigilance be maintained?

What will the future hold?

The COVID-19 era has brought fewer patients through the door of my psychiatric ED; however, just like everywhere else in the world, everything has changed. The only thing that is certain is that further change is inevitable, and we must adapt to the challenge and learn from it. As unsettling as disruptions to the status quo can be, human behavior dictates that we have the option to seize opportunities created by instability to produce superior outcomes, which can be accomplished only by looking at things anew. The question is whether we will revert to the pre-COVID-19 dysfunctional use of psychiatric emergency services, or can we use what we have learned—particularly about the value of telepsychiatry—to pursue a more effective system based on an improved understanding of the mental health treatment needs of our community. While technology is proving that social distancing requires only space between people, and not necessarily social separation, there is a risk that excessive use of remote treatment could compromise the therapeutic relationship with our patients. Despite emerging opportunities, it is difficult to direct change in a productive way when the future is uncertain.

The continuous outpouring of respect for clinicians is morale-boosting. Behind closed doors, however, news that this county hospital failed to qualify for any of the second round of federal support funding because the management of COVID-19 patients has been too effective brought a new layer of unanticipated stress. This is the only hospital in 7 counties operating a psychiatric emergency service. The mandatory, “voluntary” furloughs expected of nursing and social work staff are only now being scheduled to occur over the next couple of months. And just in time for patient volumes to return to normal. How can we continue to provide quality care, let alone build changes into practice, with reduced nursing and support staff?

It is promising, however, that in the midst of social distancing, the shared experience of endeavoring to overcome COVID-19 has promoted a connectedness among individuals who might otherwise never cross paths. This observation has bolstered my confidence in the capacity for resilience of the mental health system and the individuals within it. The reality is that we are all in this together. Differences should matter less in the face of altered perceptions of mortality. Despite the stress, suicide becomes a less reasonable choice when the value of life is magnified by pandemic circumstances. Maybe there will be even less of a need for psychiatric emergency services in the wake of COVID-19, rather than the anticipated wave of mental health crises. Until we know for sure, it is only through fellowship and continued dedication to healing that the ED experience will continue to be a positive one.

Bottom Line

Coronavirus disease 2019 (COVID-19) led to changes in the characteristics and circumstances of patients presenting to our psychiatric emergency service. Despite a lower clinical burden, each day we expended significant emotional energy struggling with unexpected and unique challenges. We can use what we have learned from COVID-19 to pursue a more effective system based on an improved understanding of the mental health treatment needs of our community.

Related Resource

• American Association for Emergency Psychiatry, American College of Emergency Physicians, American Psychiatric Association, Coalition on Psychiatric Emergencies, Crisis Residential Association, and the Emergency Nurses Association. Joint statement for care of patients with behavioral health emergencies and suspected or confirmed COVID-19. https://aaep.memberclicks.net/assets/joint-statement-covid-behavioral-health.pdf.

Coronavirus disease 2019 (COVID-19) is affecting every aspect of medical care. Much has been written about overwhelmed hospital settings, the financial devastation to outpatient treatment centers, and an impending pandemic of mental illness that the existing underfunded and fragmented mental health system would not be prepared to weather. Although COVID-19 has undeniably affected the practice of emergency psychiatry, its impact has been surprising and complex. In this article, I describe the effects COVID-19 has had on our psychiatric emergency service, and how the pandemic has affected me personally.

How the pandemic affected our psychiatric ED

The Comprehensive Psychiatric Emergency Program (CPEP) in Buffalo, New York, is part of the emergency department (ED) in the local county hospital and is staffed by faculty from the Department of Psychiatry at the University at Buffalo. It was developed to provide evaluations of acutely psychiatrically ill individuals, to determine their treatment needs and facilitate access to the appropriate level of care.

Before COVID-19, as the only fully staffed psychiatric emergency service in the region, CPEP would routinely be called upon to serve many functions for which it was not designed. For example, people who had difficulty accessing psychiatric care in the community might come to CPEP expecting treatment for chronic conditions. Additionally, due to systemic deficiencies and limited resources, police and other community agencies refer individuals to CPEP who either have illnesses unrelated to current circumstances or who are not psychiatrically ill but unmanageable because of aggression or otherwise unresolvable social challenges such as homelessness, criminal behavior, poor parenting and other family strains, or general dissatisfaction with life. Parents unable to set limits with bored or defiant children might leave them in CPEP, hoping to transfer the parenting role, just as law enforcement officers who feel impotent to apply meaningful sanctions to non-felonious offenders might bring them to CPEP seeking containment. Labeling these problems as psychiatric emergencies has made it more palatable to leave these individuals in our care. These types of visits have contributed to the substantial growth of CPEP in recent years, in terms of annual patient visits, number of children abandoned and their lengths of stay in the CPEP, among other metrics.

The impact of the COVID-19 pandemic on an emergency psychiatry service that is expected to be all things to all people has been interesting. For the first few weeks of the societal shutdown, the patient flow was unchanged. However, during this time, the usual overcrowding created a feeling of vulnerability to contagion that sparked an urgency to minimize the census. Superhuman efforts were fueled by an unspoken sense of impending doom, and wait times dropped from approximately 17 hours to 3 or 4 hours. This state of hypervigilance was impossible to sustain indefinitely, and inevitably those efforts were exhausted. As adrenaline waned, the focus turned toward family and self-preservation. Nursing and social work staff began cancelling shifts, as did part-time physicians who contracted services with our department. Others, however, were drawn to join the front-line fight.

Trends in psychiatric ED usage during the pandemic

As COVID-19 spread, local media reported the paucity of personal protective equipment (PPE) and created the sense that no one would receive hospital treatment unless they were on the brink of death. Consequently, total visits to the ED began to slow. During April, CPEP saw 25% fewer visits than average. This reduction was partly attributable to cohorting patients with any suspicion of infection in a designated area within the medical ED, with access to remote evaluation by CPEP psychiatrists via telemedicine. In addition, the characteristics and circumstances of patients presenting to CPEP began to change (Table).

Children/adolescents. In the months before COVID-19’s spread to the United States, there had been an exponential surge in child visits to CPEP, with >200 such visits in January 2020. When schools closed on March 13, school-related stress abruptly abated, and during April, child visits dropped to 89. This reduction might have been due in part to increased access to outpatient treatment via telemedicine or telephone appointments. In our affiliated clinics, both new patient visits and remote attendance to appointments by established patients increased substantially, likely contributing to a decreased reliance on the CPEP for treatment. Limited Family Court operations, though, left already-frustrated police without much recourse when called to intervene with adolescent offenders. CPEP once again served an untraditional role, facilitating the removal of these disruptive individuals from potentially dangerous circumstances, under the guise of behavioral emergencies.

Suicidality. While nonemergent visits declined, presentations related to suicidality persisted. In the United States, suicide rates have increased annually for decades. This trend has also been observed locally, with early evidence suggesting that the changes inflicted by COVID-19 perpetuated the surge in suicidal thinking and behavior, but with a change in character. Some of this is likely related to financial stress and social disruption, though job loss seems more likely to result in increased substance use than suicidality. Even more distressing to those coming to CPEP was anxiety about the illness itself, social isolation, and loss. The death of a loved one is painful enough, but disrupting the grief process by preventing people from visiting family members dying in hospitals or gathering for funerals has been devastating. Reports of increased gun sales undoubtedly associated with fears of social decay caused by the pandemic are concerning with regard to patients with suicidality, because shooting has emerged as the means most likely to result in completed suicide.¹ The imposition of social distancing directly isolated some individuals, increasing suicidality. Limitations on gathering in groups disrupted other sources of social support as well, such as religious services, clubhouses, and meetings of 12-step programs such as Alcoholics Anonymous. This could increase suicidality, either directly for more vulnerable patients or indirectly by compromising sobriety and thereby adding to the risk for suicide.

Continue to: Substance use disorders (SUDs)

Substance use disorders (SUDs). Present­ations to CPEP by patients with SUDs surged, but the patient profile changed, undoubtedly influenced by the pandemic. Requests for detoxification became less frequent because people who were not in severe distress avoided the hospital. At the same time, alcohol-dependent individuals who might typically avoid clinical attention were requiring emergent medical attention for delirium. This is attributable to a combination of factors, including nutritional depletion, and a lack of access to alcohol leading to abrupt withdrawal or consumption of unconventional sources of alcohol, such as hand sanitizer, or hard liquor (over beer). Amphetamine use appears to have increased, although the observed surge may simply be related to the conspicuousness of stimulant intoxication for someone who is sheltering in place. There was a noticeable uptick in overdoses (primarily with opioids) requiring CPEP evaluation, which was possibly related to a reduction of available beds in inpatient rehabilitation facilities as a result of social distancing rules.

Patients with chronic mental illness. Many experts anticipated an increase in hospital visits by individuals with chronic mental illness expected to decompensate as a result of reduced access to community treatment resources.² Closing courts did not prevent remote sessions for inpatient retention and treatment over objection, but did result in the expiration of many Assisted Outpatient Treatment orders by restricting renewal hearings, which is circuitously beginning to fulfill this prediction. On the other hand, an impressive community response has managed to continue meeting the needs of most of these patients. Dedicated mental health clinics have recruited mobile teams or developed carefully scheduled, nursing-run “shot clinics” to ensure that patients who require long-acting injectable medications or medication-assisted treatment for SUDs continue to receive treatment.

New-onset psychosis. A new population of patients with acute mania and psychosis also seems to have surfaced during this pandemic. Previously high-functioning individuals in their 30s, 40s, and 50s without a history of mental illness were presenting with new-onset psychotic symptoms. These are individuals who may have been characteristically anxious, or had a “Type A personality,” but were social and employed. The cause is unclear, but given the extreme uncertainty and the political climate COVID-19 brings, it is possible that the pandemic may have triggered these episodes. These individuals and their families now have the stress of learning to navigate the mental health system added to the anxiety COVID-19 brings to most households.

Homelessness. Limitations on occupancy have reduced the availability of beds in shelters and residences, resulting in increased homelessness. Locally, authorities estimated that the homeless population has grown nearly threefold as a result of bussing in from neighboring counties with fewer resources, flight from New York City, and the urgent release from jail of nonviolent offenders, many of whom had no place to go for shelter. New emergency shelter beds have not fully compensated for the relative shortage, leading individuals who had been avoiding the hospital due to fear of infection to CPEP looking for a place to stay.

Home stressors. Whereas CPEP visits by children initially decreased, after 6 weeks, the relief from school pressures appears to have been replaced by weariness from stresses at home, and the number of children presenting with depression, SUDs, and behavioral disruptions has increased. Domestic violence involving children and adults increased. Factors that might be contributing to this include the forced proximity of family members who would typically need intermittent interpersonal distance, and an obligation to care for children who would normally be in school or for disabled loved ones now unable to attend day programs or respite services. After months of enduring the pressure of these conflicts and the resulting emotional strain, patient volumes in CPEP have begun slowly returning toward the expected average, particularly since the perceived threat of coming to the hospital has attenuated.

Continue to: Personal challenges

Personal challenges

For me, COVID-19 has brought the chance to grow and learn, fumbling at times to provide the best care when crisis abounds and when not much can be said to ease the appropriate emotional distress our patients experience. The lines between what is pathological anxiety, what level of anxiety causes functional impairment, and what can realistically be expected to respond to psychiatric treatment have become blurred. At the same time, I have come across some of the sickest patients I have ever encountered.

In some ways, my passion for psychiatry has been rekindled by COVID-19, sparking an enthusiasm to teach and inspire students to pursue careers in this wonderful field of medicine. Helping to care for patients in the absence of a cure can necessitate the application of creativity and thoughtfulness to relieve suffering, thereby teaching the art of healing above offering treatment alone. Unfortunately, replacing actual patient contact with remote learning deprives students of this unique educational opportunity. Residents who attempt to continue training while limiting exposure to patients may mitigate their own risk but could also be missing an opportunity to learn how to balance their needs with making their patients’ well-being a priority. This raises the question of how the next generation of medical students and residents will learn to navigate future crises. Gruesome media depictions of haunting experiences witnessed by medical professionals exposed to an enormity of loss and death, magnified by the suicide deaths of 2 front-line workers in New York City, undoubtedly contribute to the instinct driving the protection of students and residents in this way.

The gratitude the public expresses toward me for simply continuing to do my job brings an expectation of heroism I did not seek, and with which I am uncomfortable. For me, exceptionally poised to analyze and over-analyze myriad aspects of an internal conflict that is exhausting to balance, it all generates frustration and guilt more than anything.

I am theoretically at lower risk than intubating anesthesiologists, emergency medicine physicians, and emergency medical technicians who face patients with active COVID-19. Nevertheless, daily proximity to so many patients naturally generates fear. I convince myself that performing video consultations to the medical ED is an adaptation necessary to preserve PPE, to keep me healthy through reduced exposure, to be available to patients longer, and to support the emotional health of the medical staff who are handing over that headset to patients “under investigation.” At the same time, I am secretly relieved to avoid entering those rooms and taunting death, or even worse, risking exposing my family to the virus. The threat of COVID-19 can be so consuming that it becomes easy to forget that most individuals infected are asymptomatic and therefore difficult to quickly identify.

So I continue to sit with patients face-to-face all day. Many of them are not capable of following masking and distancing recommendations, and are more prone to spitting and biting than their counterparts in the medical ED. I must ignore this threat and convince myself I am safe to be able to place my responsibility to patient care above my own needs and do my job.

Continue to: Most of my colleagues exhibit...

Most of my colleagues exhibit an effortless bravery, even if we all naturally waver briefly at times. I am proud to stand shoulder-to-shoulder every day with these clinicians, and other staff, from police to custodians, as we continue to care for the people of this community. Despite the lower clinical burden, each day we expend significant emotional energy struggling with unexpected and unique challenges, including the burden of facing the unknown. Everyone is under stress right now. For most, the effects will be transient. For some, the damage might be permanent. For others, this stress has brought out the best in us. But knowing that physicians are particularly prone to burnout, how long can the current state of hypervigilance be maintained?

What will the future hold?

The COVID-19 era has brought fewer patients through the door of my psychiatric ED; however, just like everywhere else in the world, everything has changed. The only thing that is certain is that further change is inevitable, and we must adapt to the challenge and learn from it. As unsettling as disruptions to the status quo can be, human behavior dictates that we have the option to seize opportunities created by instability to produce superior outcomes, which can be accomplished only by looking at things anew. The question is whether we will revert to the pre-COVID-19 dysfunctional use of psychiatric emergency services, or can we use what we have learned—particularly about the value of telepsychiatry—to pursue a more effective system based on an improved understanding of the mental health treatment needs of our community. While technology is proving that social distancing requires only space between people, and not necessarily social separation, there is a risk that excessive use of remote treatment could compromise the therapeutic relationship with our patients. Despite emerging opportunities, it is difficult to direct change in a productive way when the future is uncertain.

The continuous outpouring of respect for clinicians is morale-boosting. Behind closed doors, however, news that this county hospital failed to qualify for any of the second round of federal support funding because the management of COVID-19 patients has been too effective brought a new layer of unanticipated stress. This is the only hospital in 7 counties operating a psychiatric emergency service. The mandatory, “voluntary” furloughs expected of nursing and social work staff are only now being scheduled to occur over the next couple of months. And just in time for patient volumes to return to normal. How can we continue to provide quality care, let alone build changes into practice, with reduced nursing and support staff?

It is promising, however, that in the midst of social distancing, the shared experience of endeavoring to overcome COVID-19 has promoted a connectedness among individuals who might otherwise never cross paths. This observation has bolstered my confidence in the capacity for resilience of the mental health system and the individuals within it. The reality is that we are all in this together. Differences should matter less in the face of altered perceptions of mortality. Despite the stress, suicide becomes a less reasonable choice when the value of life is magnified by pandemic circumstances. Maybe there will be even less of a need for psychiatric emergency services in the wake of COVID-19, rather than the anticipated wave of mental health crises. Until we know for sure, it is only through fellowship and continued dedication to healing that the ED experience will continue to be a positive one.

Bottom Line

Coronavirus disease 2019 (COVID-19) led to changes in the characteristics and circumstances of patients presenting to our psychiatric emergency service. Despite a lower clinical burden, each day we expended significant emotional energy struggling with unexpected and unique challenges. We can use what we have learned from COVID-19 to pursue a more effective system based on an improved understanding of the mental health treatment needs of our community.

Related Resource

• American Association for Emergency Psychiatry, American College of Emergency Physicians, American Psychiatric Association, Coalition on Psychiatric Emergencies, Crisis Residential Association, and the Emergency Nurses Association. Joint statement for care of patients with behavioral health emergencies and suspected or confirmed COVID-19. https://aaep.memberclicks.net/assets/joint-statement-covid-behavioral-health.pdf.

“You are what you eat,” my mother always said, and structured our dinner plates according to the USDA food pyramid. We dutifully consumed leafy greens, and prior to medical school I invested time and money into healthy diet choices. I drank green smoothies, pureed baby food for my children, read up on the pH balancing diet, grew sprouts on windowsills, bought organic.

With the stressors and time constraints of managing medical school and a family, nutrition tumbled down the ladder of priorities until eventually my family was subsisting on chicken nuggets, pizza, and peanut butter. Intern year has only added the occasional candy bar from the doctors’ lounge. I experienced a vague sense of loss for something I had once valued, but simultaneously felt dismissive of trendy topics such as omega-3 fatty acids and antioxidants in the face of myocardial infarctions and liver failure. A biochemistry professor once scoffed at “the laypeople’s obsession with toxins,” and nutrition received zero attention in our medical school curriculum or board exams.

However, a clinical experience on the inpatient psychiatric unit made me reevaluate the importance nutrition should have in both our personal lives and the practice of medicine. This is the case of an otherwise healthy young man with no psychiatric history who suffered a psychotic break after ingesting an excess of a supplement he purchased online with the purpose of improving his performance at a high-stress job.

CASE REPORT

Mr. K, a 28-year-old computer programmer, was voluntarily admitted to the inpatient psychiatry unit for paranoia and persecutory delusions along with auditory hallucinations. His father reported that Mr. K had been behaving erratically for several days prior to admission and was subsequently found wandering in the street.

On admission, Mr. K was not oriented to place or situation. He was unkempt and guarded, and claimed people were following him. His urine toxicology screen and blood alcohol levels were negative.

While hospitalized, Mr. K was hyperverbal and delusional. He related that at work he had been developing programs to make slaves in the computer, “algorithms for orchestration,” and that he was uncomfortable with the ethical implications. He eventually endorsed having purchased the supplement phenylethylamine (PEA) to improve his focus, and ingesting “two substantial scoops of the crystalline substance.”

We did not initiate any psychiatric medications. On the third day of his hospitalization, Mr. K was alert, oriented, euthymic, relaxed, and had a full range of affect; upon discharge we advised him to discard the PEA and avoid stimulants. He complied, quit his high-stress job, and had no subsequent psychotic symptoms in the 7 months since discharge.

Continue to: Dietary supplements carry risks

According to the FDA, dietary supplements are regulated as food, but many have strong biologic effects or may even contain drugs.¹ More than 18% of Americans use herbal or nutritional therapies as part of their health regimen.² However, many over-the-counter remedies have been found to exhibit psychotropic effects,³ and many more are purported to impact mental and physical health with little to no scientific research into these claims or potential adverse effects.

Phenylethylamine is sold as a nutritional supplement and marketed for its purported beneficial effects on weight loss, mood, and focus.⁴ However, PEA is known to act as a natural amphetamine and to play a role in the development of neuropsychiatric disorders.⁵ It is an endogenous psychotogenic molecule that has been previously theorized as a cause for primary psychosis.⁶ Phenylethylamine interacts with the same receptor ligand that responds to amphetamine and related compounds (such as methamphetamine and 3,4-methylenedioxy-methamphetamine [MDMA]), the genetic coding for which is located in an area of DNA associated with schizophrenia: chromosome 6q23.2.⁷ While the mechanisms and details of these interactions remain poorly understood, this case of PEA-induced psychosis represents a glimpse into the potential psychoactive properties of this readily available nutritional supplement.

This patient’s cautionary tale has given me pause regarding both my family’s nutrition and the oft-neglected dietary portion of the social history. Also, several subsequent patient experiences hearken back to my mother’s words regarding the importance of healthy eating. A patient with phenylketonuria presented with psychosis after running out of her formula and consuming junk food. Another patient with severely elevated blood glucose levels presented with confusion. I have come to realize that ingestion impacts presentation, or, in other words, you are what you eat.

“You are what you eat,” my mother always said, and structured our dinner plates according to the USDA food pyramid. We dutifully consumed leafy greens, and prior to medical school I invested time and money into healthy diet choices. I drank green smoothies, pureed baby food for my children, read up on the pH balancing diet, grew sprouts on windowsills, bought organic.

With the stressors and time constraints of managing medical school and a family, nutrition tumbled down the ladder of priorities until eventually my family was subsisting on chicken nuggets, pizza, and peanut butter. Intern year has only added the occasional candy bar from the doctors’ lounge. I experienced a vague sense of loss for something I had once valued, but simultaneously felt dismissive of trendy topics such as omega-3 fatty acids and antioxidants in the face of myocardial infarctions and liver failure. A biochemistry professor once scoffed at “the laypeople’s obsession with toxins,” and nutrition received zero attention in our medical school curriculum or board exams.

However, a clinical experience on the inpatient psychiatric unit made me reevaluate the importance nutrition should have in both our personal lives and the practice of medicine. This is the case of an otherwise healthy young man with no psychiatric history who suffered a psychotic break after ingesting an excess of a supplement he purchased online with the purpose of improving his performance at a high-stress job.

CASE REPORT

Mr. K, a 28-year-old computer programmer, was voluntarily admitted to the inpatient psychiatry unit for paranoia and persecutory delusions along with auditory hallucinations. His father reported that Mr. K had been behaving erratically for several days prior to admission and was subsequently found wandering in the street.

On admission, Mr. K was not oriented to place or situation. He was unkempt and guarded, and claimed people were following him. His urine toxicology screen and blood alcohol levels were negative.

While hospitalized, Mr. K was hyperverbal and delusional. He related that at work he had been developing programs to make slaves in the computer, “algorithms for orchestration,” and that he was uncomfortable with the ethical implications. He eventually endorsed having purchased the supplement phenylethylamine (PEA) to improve his focus, and ingesting “two substantial scoops of the crystalline substance.”

We did not initiate any psychiatric medications. On the third day of his hospitalization, Mr. K was alert, oriented, euthymic, relaxed, and had a full range of affect; upon discharge we advised him to discard the PEA and avoid stimulants. He complied, quit his high-stress job, and had no subsequent psychotic symptoms in the 7 months since discharge.

Continue to: Dietary supplements carry risks

According to the FDA, dietary supplements are regulated as food, but many have strong biologic effects or may even contain drugs.¹ More than 18% of Americans use herbal or nutritional therapies as part of their health regimen.² However, many over-the-counter remedies have been found to exhibit psychotropic effects,³ and many more are purported to impact mental and physical health with little to no scientific research into these claims or potential adverse effects.

Phenylethylamine is sold as a nutritional supplement and marketed for its purported beneficial effects on weight loss, mood, and focus.⁴ However, PEA is known to act as a natural amphetamine and to play a role in the development of neuropsychiatric disorders.⁵ It is an endogenous psychotogenic molecule that has been previously theorized as a cause for primary psychosis.⁶ Phenylethylamine interacts with the same receptor ligand that responds to amphetamine and related compounds (such as methamphetamine and 3,4-methylenedioxy-methamphetamine [MDMA]), the genetic coding for which is located in an area of DNA associated with schizophrenia: chromosome 6q23.2.⁷ While the mechanisms and details of these interactions remain poorly understood, this case of PEA-induced psychosis represents a glimpse into the potential psychoactive properties of this readily available nutritional supplement.

This patient’s cautionary tale has given me pause regarding both my family’s nutrition and the oft-neglected dietary portion of the social history. Also, several subsequent patient experiences hearken back to my mother’s words regarding the importance of healthy eating. A patient with phenylketonuria presented with psychosis after running out of her formula and consuming junk food. Another patient with severely elevated blood glucose levels presented with confusion. I have come to realize that ingestion impacts presentation, or, in other words, you are what you eat.

“You are what you eat,” my mother always said, and structured our dinner plates according to the USDA food pyramid. We dutifully consumed leafy greens, and prior to medical school I invested time and money into healthy diet choices. I drank green smoothies, pureed baby food for my children, read up on the pH balancing diet, grew sprouts on windowsills, bought organic.

With the stressors and time constraints of managing medical school and a family, nutrition tumbled down the ladder of priorities until eventually my family was subsisting on chicken nuggets, pizza, and peanut butter. Intern year has only added the occasional candy bar from the doctors’ lounge. I experienced a vague sense of loss for something I had once valued, but simultaneously felt dismissive of trendy topics such as omega-3 fatty acids and antioxidants in the face of myocardial infarctions and liver failure. A biochemistry professor once scoffed at “the laypeople’s obsession with toxins,” and nutrition received zero attention in our medical school curriculum or board exams.

However, a clinical experience on the inpatient psychiatric unit made me reevaluate the importance nutrition should have in both our personal lives and the practice of medicine. This is the case of an otherwise healthy young man with no psychiatric history who suffered a psychotic break after ingesting an excess of a supplement he purchased online with the purpose of improving his performance at a high-stress job.

CASE REPORT

Mr. K, a 28-year-old computer programmer, was voluntarily admitted to the inpatient psychiatry unit for paranoia and persecutory delusions along with auditory hallucinations. His father reported that Mr. K had been behaving erratically for several days prior to admission and was subsequently found wandering in the street.

On admission, Mr. K was not oriented to place or situation. He was unkempt and guarded, and claimed people were following him. His urine toxicology screen and blood alcohol levels were negative.

While hospitalized, Mr. K was hyperverbal and delusional. He related that at work he had been developing programs to make slaves in the computer, “algorithms for orchestration,” and that he was uncomfortable with the ethical implications. He eventually endorsed having purchased the supplement phenylethylamine (PEA) to improve his focus, and ingesting “two substantial scoops of the crystalline substance.”

We did not initiate any psychiatric medications. On the third day of his hospitalization, Mr. K was alert, oriented, euthymic, relaxed, and had a full range of affect; upon discharge we advised him to discard the PEA and avoid stimulants. He complied, quit his high-stress job, and had no subsequent psychotic symptoms in the 7 months since discharge.

Continue to: Dietary supplements carry risks

According to the FDA, dietary supplements are regulated as food, but many have strong biologic effects or may even contain drugs.¹ More than 18% of Americans use herbal or nutritional therapies as part of their health regimen.² However, many over-the-counter remedies have been found to exhibit psychotropic effects,³ and many more are purported to impact mental and physical health with little to no scientific research into these claims or potential adverse effects.

Phenylethylamine is sold as a nutritional supplement and marketed for its purported beneficial effects on weight loss, mood, and focus.⁴ However, PEA is known to act as a natural amphetamine and to play a role in the development of neuropsychiatric disorders.⁵ It is an endogenous psychotogenic molecule that has been previously theorized as a cause for primary psychosis.⁶ Phenylethylamine interacts with the same receptor ligand that responds to amphetamine and related compounds (such as methamphetamine and 3,4-methylenedioxy-methamphetamine [MDMA]), the genetic coding for which is located in an area of DNA associated with schizophrenia: chromosome 6q23.2.⁷ While the mechanisms and details of these interactions remain poorly understood, this case of PEA-induced psychosis represents a glimpse into the potential psychoactive properties of this readily available nutritional supplement.

This patient’s cautionary tale has given me pause regarding both my family’s nutrition and the oft-neglected dietary portion of the social history. Also, several subsequent patient experiences hearken back to my mother’s words regarding the importance of healthy eating. A patient with phenylketonuria presented with psychosis after running out of her formula and consuming junk food. Another patient with severely elevated blood glucose levels presented with confusion. I have come to realize that ingestion impacts presentation, or, in other words, you are what you eat.

In December 2019, Seattle Seahawks wide receiver Josh Gordon was suspended indefinitely from the NFL for violation of the league’s substance abuse policy. Gordon, once known as one of the most promising wide receivers of the last few decades, had a tumultuous relationship with the NFL as a result of his struggles with substance use. However, the headlines from major sports and news outlets often describe Gordon and other professional and collegiate athletes who struggle with substance use as “violating policies of abuse.” Media coverage of such athletes frequently imposes labels such as “violation” and “abuse,” implying a greater level of personal responsibility and willful misconduct than the biological process of addiction would typically allow. Gordon’s story brought attention not only to the adversity and impairments of substance use, but also the stigmatizing language that often accompanies it.

Shifting to less stigmatizing terminology

In DMS-5, use of the terminology substance use disorder fosters a more biologically-based model of behavior, and encourages recovery-oriented terminology.¹ However, for most collegiate and professional sports leagues, the policies regarding substance use often use the term substance abuse, which can perpetuate stigma and a misunderstanding of the underpinnings of substance use, insinuating a sense of personal responsibility, deliberate misconduct, and criminality. When an individual is referred to as an “abuser” of substances, this might suggest that they are willful perpetrators of the disease on themselves, and thus may be undeserving of care.² Individuals referred to as “substance abusers” rather than having a substance use disorder are more likely to be subjected to negative perceptions and evaluations of their behaviors, particularly by clinicians.

Individuals with substance use disorders are often viewed more negatively than individuals with physical or other psychiatric disorders, and are among the most stigmatized and marginalized groups in health care.^4,5 Today, lawmakers, advocates, and health care professionals across the country are working to integrate destigmatizing language into media, policy, and educational settings in order to characterize substance use as a neurobiological process rather than a moral fault.⁶ For example, legislation in Maine passed in 2018 removed references to stigmatizing terms in policies related to substance use, replacing substance abuse and drug addict with recovery-oriented terminology such as substance use disorder and person with a substance use disorder.⁷

Individuals with substance use disorders often fear judgment and stigma during clinical encounters, and commonly cite this as a reason to avoid seeking care.⁸ Words matter, and if we are not careful, the language we use can convey meaning and attitudes that perpetuate the stigma that prevents so many from accessing treatment.^9,10 Individuals with a substance use disorder should feel institutionally supported, and the language of policies and the clinicians who treat these patients should reflect this as well.

In December 2019, Seattle Seahawks wide receiver Josh Gordon was suspended indefinitely from the NFL for violation of the league’s substance abuse policy. Gordon, once known as one of the most promising wide receivers of the last few decades, had a tumultuous relationship with the NFL as a result of his struggles with substance use. However, the headlines from major sports and news outlets often describe Gordon and other professional and collegiate athletes who struggle with substance use as “violating policies of abuse.” Media coverage of such athletes frequently imposes labels such as “violation” and “abuse,” implying a greater level of personal responsibility and willful misconduct than the biological process of addiction would typically allow. Gordon’s story brought attention not only to the adversity and impairments of substance use, but also the stigmatizing language that often accompanies it.

Shifting to less stigmatizing terminology

In DMS-5, use of the terminology substance use disorder fosters a more biologically-based model of behavior, and encourages recovery-oriented terminology.¹ However, for most collegiate and professional sports leagues, the policies regarding substance use often use the term substance abuse, which can perpetuate stigma and a misunderstanding of the underpinnings of substance use, insinuating a sense of personal responsibility, deliberate misconduct, and criminality. When an individual is referred to as an “abuser” of substances, this might suggest that they are willful perpetrators of the disease on themselves, and thus may be undeserving of care.² Individuals referred to as “substance abusers” rather than having a substance use disorder are more likely to be subjected to negative perceptions and evaluations of their behaviors, particularly by clinicians.

Individuals with substance use disorders are often viewed more negatively than individuals with physical or other psychiatric disorders, and are among the most stigmatized and marginalized groups in health care.^4,5 Today, lawmakers, advocates, and health care professionals across the country are working to integrate destigmatizing language into media, policy, and educational settings in order to characterize substance use as a neurobiological process rather than a moral fault.⁶ For example, legislation in Maine passed in 2018 removed references to stigmatizing terms in policies related to substance use, replacing substance abuse and drug addict with recovery-oriented terminology such as substance use disorder and person with a substance use disorder.⁷

Individuals with substance use disorders often fear judgment and stigma during clinical encounters, and commonly cite this as a reason to avoid seeking care.⁸ Words matter, and if we are not careful, the language we use can convey meaning and attitudes that perpetuate the stigma that prevents so many from accessing treatment.^9,10 Individuals with a substance use disorder should feel institutionally supported, and the language of policies and the clinicians who treat these patients should reflect this as well.

In December 2019, Seattle Seahawks wide receiver Josh Gordon was suspended indefinitely from the NFL for violation of the league’s substance abuse policy. Gordon, once known as one of the most promising wide receivers of the last few decades, had a tumultuous relationship with the NFL as a result of his struggles with substance use. However, the headlines from major sports and news outlets often describe Gordon and other professional and collegiate athletes who struggle with substance use as “violating policies of abuse.” Media coverage of such athletes frequently imposes labels such as “violation” and “abuse,” implying a greater level of personal responsibility and willful misconduct than the biological process of addiction would typically allow. Gordon’s story brought attention not only to the adversity and impairments of substance use, but also the stigmatizing language that often accompanies it.

Shifting to less stigmatizing terminology

In DMS-5, use of the terminology substance use disorder fosters a more biologically-based model of behavior, and encourages recovery-oriented terminology.¹ However, for most collegiate and professional sports leagues, the policies regarding substance use often use the term substance abuse, which can perpetuate stigma and a misunderstanding of the underpinnings of substance use, insinuating a sense of personal responsibility, deliberate misconduct, and criminality. When an individual is referred to as an “abuser” of substances, this might suggest that they are willful perpetrators of the disease on themselves, and thus may be undeserving of care.² Individuals referred to as “substance abusers” rather than having a substance use disorder are more likely to be subjected to negative perceptions and evaluations of their behaviors, particularly by clinicians.

Individuals with substance use disorders are often viewed more negatively than individuals with physical or other psychiatric disorders, and are among the most stigmatized and marginalized groups in health care.^4,5 Today, lawmakers, advocates, and health care professionals across the country are working to integrate destigmatizing language into media, policy, and educational settings in order to characterize substance use as a neurobiological process rather than a moral fault.⁶ For example, legislation in Maine passed in 2018 removed references to stigmatizing terms in policies related to substance use, replacing substance abuse and drug addict with recovery-oriented terminology such as substance use disorder and person with a substance use disorder.⁷

Individuals with substance use disorders often fear judgment and stigma during clinical encounters, and commonly cite this as a reason to avoid seeking care.⁸ Words matter, and if we are not careful, the language we use can convey meaning and attitudes that perpetuate the stigma that prevents so many from accessing treatment.^9,10 Individuals with a substance use disorder should feel institutionally supported, and the language of policies and the clinicians who treat these patients should reflect this as well.

We were delighted to read Dr. Nasrallah’s coruscating editorial about the deceptive, unethical, and clinically harmful practice of insurance companies requiring pre-authorization before granting coverage of psychotropic medications that are not on their short list of inexpensive alternatives (“Pre-authorization is illegal, unethical, and adversely disrupts patient care.” From the Editor, Current Psychiatry. April 2020, p. 5,10-11). Obtaining pre-authorization is time-consuming for busy doctors, often prohibitively so—and sometimes simply impossible, regardless of the time and effort invested. In this way, insurers can cleverly withhold optimal treatment while still being able to assert that they will cover all “medically necessary” treatments, as initially determined by a nonphysician reviewer working from a checklist. In a recently published survey of 1,000 psychiatrists we conducted (Barnett BS, Bodkin JA. A survey of American psychiatrists concerning medication prior authorization requirements. J Nerv Ment Dis. 2020;208(7):566-573), respondents predominantly believed the obligation to obtain prior authorization negatively impacts patient care and reduces psychiatrists’ job satisfaction.

Brian S. Barnett, MD
Staff Psychiatrist
Cleveland Clinic
Lutheran Hospital
Cleveland, Ohio

J. Alexander Bodkin, MD
Chief
Clinical Psychopharmacology
Research Program
McLean Hospital
Harvard Medical School
Belmont, Massachusetts

Disclosures: The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

I thank Dr. Nasrallah for bringing up the issue of pre-authorization in his editorial and could not agree with him more. As a practicing geriatric psychiatrist—for several decades—I experienced all of what he so nicely summarized, and more. The amount and degree of humiliation, frustration, and (mainly) waste of time have been painful and unacceptable. As he said: It must be stopped! The question is “How?” Hopefully this editorial triggers some activity against pre-authorization. It was time somebody addressed this problem.

Istvan Boksay, MD, PhD
Private psychiatric practice
New York, New York

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Continue to: I thank Dr. Nasrallah...

I thank Dr. Nasrallah for his editorial about pre-authorization, which was well organized and had a perfect headline. In succinct paragraphs, it says what we practitioners have wanted to say for years. If only the American Psychiatric Association and American Medical Association would take up the cause, perhaps some limitations might be put on this corporate intrusion into our practice. Pre-authorization may save insurance companies money, but its cost in time, frustration, and clinical outcomes adds a considerable burden to the financial problems of health care in the United States.

John Buckley, MD
Private psychiatric practice
Glen Arm, Maryland

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

I thank Dr. Nasrallah so much for his editorial. These types of clinically useless administrative tasks are invisible barriers to mental health care access, because the time utilized to complete these tasks can easily be used to see one more patient who needs to be treated. However, I also wonder how we as psychiatrists can move forward so that our psychiatric organizations and legislative bodies can take further action to the real barriers to health care and effective interventions. 

Ranvinder Kaur Rai, MD
Private psychiatric practice
Fremont, California

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Continue to: I read with interest...

I read with interest Dr. Nasrallah’s editorials “We are physicians, not providers, and we treat patients, not clients!” (From the Editor, Current Psychiatry. February 2020, p. 5,10-11) and “Pre-authorization is illegal, unethical, and adversely disrupts patient care.” I can’t help but link the 2 editorials together.

Dr. Nasrallah’s strong advocacy against the use of the term “provider” is long overdue. I distinctly remember the insidious onset of the use of the terms provider and “consumer” during my years as a medical director of a mental health center. The inception of the provider/consumer terminology can be construed as striving for cultural correctness when psychiatry was going through its own identity crisis in response to deinstitutionalization and the destruction of the so-called myth of psychiatrists as paternalistic and all-powerful. Managed care as the business model of medicine further destroyed the perception of the psychiatric physician as noble and caring, and demythologized the physician–patient relationship. It is amazing how the term provider has persisted and become part of the language of medicine. During the last 20 years or so, psychiatric and medical professional organizations have done little to squash the usage of the term.

Furthermore, the concept of pre-authorization is not new to medicine, but has insidiously become part of the tasks of the psychiatric physician. It has morphed into more than having to obtain approval for using a branded medication over a cheaper generic alternative to having to obtain approval for the use of any medication that does not fall under the approved tier. Even antipsychotics (generally a protected class) have not been immune.

Both the use of the term provider and the concept of pre-authorization require more than the frustration and indignation of a clinical psychiatrist. It requires the determination of professional psychiatric organizations and those with power to fight the gradual but ever-deteriorating authority of medical practice and the role of the psychiatric physician.

Elizabeth A. Varas, MD
Private psychiatric practice
Westwood, New Jersey

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

We were delighted to read Dr. Nasrallah’s coruscating editorial about the deceptive, unethical, and clinically harmful practice of insurance companies requiring pre-authorization before granting coverage of psychotropic medications that are not on their short list of inexpensive alternatives (“Pre-authorization is illegal, unethical, and adversely disrupts patient care.” From the Editor, Current Psychiatry. April 2020, p. 5,10-11). Obtaining pre-authorization is time-consuming for busy doctors, often prohibitively so—and sometimes simply impossible, regardless of the time and effort invested. In this way, insurers can cleverly withhold optimal treatment while still being able to assert that they will cover all “medically necessary” treatments, as initially determined by a nonphysician reviewer working from a checklist. In a recently published survey of 1,000 psychiatrists we conducted (Barnett BS, Bodkin JA. A survey of American psychiatrists concerning medication prior authorization requirements. J Nerv Ment Dis. 2020;208(7):566-573), respondents predominantly believed the obligation to obtain prior authorization negatively impacts patient care and reduces psychiatrists’ job satisfaction.

Brian S. Barnett, MD
Staff Psychiatrist
Cleveland Clinic
Lutheran Hospital
Cleveland, Ohio

J. Alexander Bodkin, MD
Chief
Clinical Psychopharmacology
Research Program
McLean Hospital
Harvard Medical School
Belmont, Massachusetts

Disclosures: The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

I thank Dr. Nasrallah for bringing up the issue of pre-authorization in his editorial and could not agree with him more. As a practicing geriatric psychiatrist—for several decades—I experienced all of what he so nicely summarized, and more. The amount and degree of humiliation, frustration, and (mainly) waste of time have been painful and unacceptable. As he said: It must be stopped! The question is “How?” Hopefully this editorial triggers some activity against pre-authorization. It was time somebody addressed this problem.

Istvan Boksay, MD, PhD
Private psychiatric practice
New York, New York

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Continue to: I thank Dr. Nasrallah...

I thank Dr. Nasrallah for his editorial about pre-authorization, which was well organized and had a perfect headline. In succinct paragraphs, it says what we practitioners have wanted to say for years. If only the American Psychiatric Association and American Medical Association would take up the cause, perhaps some limitations might be put on this corporate intrusion into our practice. Pre-authorization may save insurance companies money, but its cost in time, frustration, and clinical outcomes adds a considerable burden to the financial problems of health care in the United States.

John Buckley, MD
Private psychiatric practice
Glen Arm, Maryland

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

I thank Dr. Nasrallah so much for his editorial. These types of clinically useless administrative tasks are invisible barriers to mental health care access, because the time utilized to complete these tasks can easily be used to see one more patient who needs to be treated. However, I also wonder how we as psychiatrists can move forward so that our psychiatric organizations and legislative bodies can take further action to the real barriers to health care and effective interventions. 

Ranvinder Kaur Rai, MD
Private psychiatric practice
Fremont, California

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Continue to: I read with interest...

I read with interest Dr. Nasrallah’s editorials “We are physicians, not providers, and we treat patients, not clients!” (From the Editor, Current Psychiatry. February 2020, p. 5,10-11) and “Pre-authorization is illegal, unethical, and adversely disrupts patient care.” I can’t help but link the 2 editorials together.

Dr. Nasrallah’s strong advocacy against the use of the term “provider” is long overdue. I distinctly remember the insidious onset of the use of the terms provider and “consumer” during my years as a medical director of a mental health center. The inception of the provider/consumer terminology can be construed as striving for cultural correctness when psychiatry was going through its own identity crisis in response to deinstitutionalization and the destruction of the so-called myth of psychiatrists as paternalistic and all-powerful. Managed care as the business model of medicine further destroyed the perception of the psychiatric physician as noble and caring, and demythologized the physician–patient relationship. It is amazing how the term provider has persisted and become part of the language of medicine. During the last 20 years or so, psychiatric and medical professional organizations have done little to squash the usage of the term.

Furthermore, the concept of pre-authorization is not new to medicine, but has insidiously become part of the tasks of the psychiatric physician. It has morphed into more than having to obtain approval for using a branded medication over a cheaper generic alternative to having to obtain approval for the use of any medication that does not fall under the approved tier. Even antipsychotics (generally a protected class) have not been immune.

Both the use of the term provider and the concept of pre-authorization require more than the frustration and indignation of a clinical psychiatrist. It requires the determination of professional psychiatric organizations and those with power to fight the gradual but ever-deteriorating authority of medical practice and the role of the psychiatric physician.

Elizabeth A. Varas, MD
Private psychiatric practice
Westwood, New Jersey

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

We were delighted to read Dr. Nasrallah’s coruscating editorial about the deceptive, unethical, and clinically harmful practice of insurance companies requiring pre-authorization before granting coverage of psychotropic medications that are not on their short list of inexpensive alternatives (“Pre-authorization is illegal, unethical, and adversely disrupts patient care.” From the Editor, Current Psychiatry. April 2020, p. 5,10-11). Obtaining pre-authorization is time-consuming for busy doctors, often prohibitively so—and sometimes simply impossible, regardless of the time and effort invested. In this way, insurers can cleverly withhold optimal treatment while still being able to assert that they will cover all “medically necessary” treatments, as initially determined by a nonphysician reviewer working from a checklist. In a recently published survey of 1,000 psychiatrists we conducted (Barnett BS, Bodkin JA. A survey of American psychiatrists concerning medication prior authorization requirements. J Nerv Ment Dis. 2020;208(7):566-573), respondents predominantly believed the obligation to obtain prior authorization negatively impacts patient care and reduces psychiatrists’ job satisfaction.

Brian S. Barnett, MD
Staff Psychiatrist
Cleveland Clinic
Lutheran Hospital
Cleveland, Ohio

J. Alexander Bodkin, MD
Chief
Clinical Psychopharmacology
Research Program
McLean Hospital
Harvard Medical School
Belmont, Massachusetts

Disclosures: The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

I thank Dr. Nasrallah for bringing up the issue of pre-authorization in his editorial and could not agree with him more. As a practicing geriatric psychiatrist—for several decades—I experienced all of what he so nicely summarized, and more. The amount and degree of humiliation, frustration, and (mainly) waste of time have been painful and unacceptable. As he said: It must be stopped! The question is “How?” Hopefully this editorial triggers some activity against pre-authorization. It was time somebody addressed this problem.

Istvan Boksay, MD, PhD
Private psychiatric practice
New York, New York

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Continue to: I thank Dr. Nasrallah...

I thank Dr. Nasrallah for his editorial about pre-authorization, which was well organized and had a perfect headline. In succinct paragraphs, it says what we practitioners have wanted to say for years. If only the American Psychiatric Association and American Medical Association would take up the cause, perhaps some limitations might be put on this corporate intrusion into our practice. Pre-authorization may save insurance companies money, but its cost in time, frustration, and clinical outcomes adds a considerable burden to the financial problems of health care in the United States.

John Buckley, MD
Private psychiatric practice
Glen Arm, Maryland

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

I thank Dr. Nasrallah so much for his editorial. These types of clinically useless administrative tasks are invisible barriers to mental health care access, because the time utilized to complete these tasks can easily be used to see one more patient who needs to be treated. However, I also wonder how we as psychiatrists can move forward so that our psychiatric organizations and legislative bodies can take further action to the real barriers to health care and effective interventions. 

Ranvinder Kaur Rai, MD
Private psychiatric practice
Fremont, California

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Continue to: I read with interest...

I read with interest Dr. Nasrallah’s editorials “We are physicians, not providers, and we treat patients, not clients!” (From the Editor, Current Psychiatry. February 2020, p. 5,10-11) and “Pre-authorization is illegal, unethical, and adversely disrupts patient care.” I can’t help but link the 2 editorials together.

Dr. Nasrallah’s strong advocacy against the use of the term “provider” is long overdue. I distinctly remember the insidious onset of the use of the terms provider and “consumer” during my years as a medical director of a mental health center. The inception of the provider/consumer terminology can be construed as striving for cultural correctness when psychiatry was going through its own identity crisis in response to deinstitutionalization and the destruction of the so-called myth of psychiatrists as paternalistic and all-powerful. Managed care as the business model of medicine further destroyed the perception of the psychiatric physician as noble and caring, and demythologized the physician–patient relationship. It is amazing how the term provider has persisted and become part of the language of medicine. During the last 20 years or so, psychiatric and medical professional organizations have done little to squash the usage of the term.

Furthermore, the concept of pre-authorization is not new to medicine, but has insidiously become part of the tasks of the psychiatric physician. It has morphed into more than having to obtain approval for using a branded medication over a cheaper generic alternative to having to obtain approval for the use of any medication that does not fall under the approved tier. Even antipsychotics (generally a protected class) have not been immune.

Both the use of the term provider and the concept of pre-authorization require more than the frustration and indignation of a clinical psychiatrist. It requires the determination of professional psychiatric organizations and those with power to fight the gradual but ever-deteriorating authority of medical practice and the role of the psychiatric physician.

Elizabeth A. Varas, MD
Private psychiatric practice
Westwood, New Jersey

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.