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Long-term care insurance
A few years ago, my seemingly indestructible 94-year-old mother suffered a series of medical setbacks. As her health problems accumulated, so did the complexity and cost of her care, progressing from her home to an assisted-living facility to a nursing home. It was heartbreaking – and expensive. My wife likened it to “putting another kid through college” – an elite private college, at that.
Medicare, of course, did not cover any of this, except for physician visits and some of her medications. When it was finally over, my wife and I resolved that, should we face a similar situation in our final years, we could not put ourselves or our children through a similar financial ordeal.
, in-home services, and other end-of-life expenses. (Covered services vary by policy; and as always, I have no financial interest in any product or service mentioned here.)
According to the American Association for Long-Term Care Insurance (AALTCI), the average annual LTCI premium for a 60-year-old couple is $3,490. Not cheap; but there are ways to lower premiums without gutting your coverage.
The best way to keep costs down is to get in early. In general, the younger you are and the better health you are in, the lower your premiums will be. For example – again according to the AALTCI – that “average” annual premium of $3,490 for a hypothetical 60-year-old couple would increase 34%, to $4,675, if they waited until they were 65 to buy the policy. And if their health were to decline in the interim, they might not be able to obtain adequate coverage at all.
You can also lower premiums by decreasing daily benefits, or increasing the “elimination period” – the length of time after you become eligible for benefits that the policy starts paying them; 30-, 60-, and 90-day periods are common. As long as you have sufficient savings to realistically cover costs until the elimination period is over, choosing a longer one can reduce your costs significantly.
Another variable is the maximum length of time the policy will pay out benefits. Ideally, you would want a payout to continue for as long as necessary, but few if any companies are willing to write uncapped policies anymore. Two to five years of benefits is a common time frame. (The “average” premiums quoted above assume a benefit of $150 per day with a 3-year cap and a 90-day elimination period.)
As with any insurance, it is important not to overbuy LTCI. It isn’t necessary to obtain coverage that will pay for 100% of your long-term care costs – just the portion that your projected retirement income (Social Security, pensions, income from savings) may not be sufficient to cover. Buying only the amount of coverage you need will substantially reduce your premium costs over the life of the policy.
If you work for a hospital or a large group, it’s worth checking to see if your employer offers LTCI. Employer-sponsored plans are often offered at discounted group rates, and you can usually keep the policy even if you leave. If you’re a member of any social or religious groups, check their insurance plans as well.
To be sure, there is considerable debate about whether LTCI is worth the cost. Premiums for new policies are rising at a steep clip – 9% annually, according to the AALTCI – and insurers are allowed to raise premiums even after you buy the policy, so you’ll need to factor that possibility into your budget.
But forgoing coverage can be costly too: If you know you will have to cover your own long-term care costs, you won’t be able to spend that money on things you really care about – like your grandkids, or travel, or charitable work. You might even forgo necessary medical care for fear of running out of money.
Everyone must make their own decision. My wife and I decided that a few thousand dollars per year is a fair price to pay for the peace of mind of knowing we will be able to afford proper supportive care, without help from our children or anyone else, regardless of what happens in the years to come.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
A few years ago, my seemingly indestructible 94-year-old mother suffered a series of medical setbacks. As her health problems accumulated, so did the complexity and cost of her care, progressing from her home to an assisted-living facility to a nursing home. It was heartbreaking – and expensive. My wife likened it to “putting another kid through college” – an elite private college, at that.
Medicare, of course, did not cover any of this, except for physician visits and some of her medications. When it was finally over, my wife and I resolved that, should we face a similar situation in our final years, we could not put ourselves or our children through a similar financial ordeal.
, in-home services, and other end-of-life expenses. (Covered services vary by policy; and as always, I have no financial interest in any product or service mentioned here.)
According to the American Association for Long-Term Care Insurance (AALTCI), the average annual LTCI premium for a 60-year-old couple is $3,490. Not cheap; but there are ways to lower premiums without gutting your coverage.
The best way to keep costs down is to get in early. In general, the younger you are and the better health you are in, the lower your premiums will be. For example – again according to the AALTCI – that “average” annual premium of $3,490 for a hypothetical 60-year-old couple would increase 34%, to $4,675, if they waited until they were 65 to buy the policy. And if their health were to decline in the interim, they might not be able to obtain adequate coverage at all.
You can also lower premiums by decreasing daily benefits, or increasing the “elimination period” – the length of time after you become eligible for benefits that the policy starts paying them; 30-, 60-, and 90-day periods are common. As long as you have sufficient savings to realistically cover costs until the elimination period is over, choosing a longer one can reduce your costs significantly.
Another variable is the maximum length of time the policy will pay out benefits. Ideally, you would want a payout to continue for as long as necessary, but few if any companies are willing to write uncapped policies anymore. Two to five years of benefits is a common time frame. (The “average” premiums quoted above assume a benefit of $150 per day with a 3-year cap and a 90-day elimination period.)
As with any insurance, it is important not to overbuy LTCI. It isn’t necessary to obtain coverage that will pay for 100% of your long-term care costs – just the portion that your projected retirement income (Social Security, pensions, income from savings) may not be sufficient to cover. Buying only the amount of coverage you need will substantially reduce your premium costs over the life of the policy.
If you work for a hospital or a large group, it’s worth checking to see if your employer offers LTCI. Employer-sponsored plans are often offered at discounted group rates, and you can usually keep the policy even if you leave. If you’re a member of any social or religious groups, check their insurance plans as well.
To be sure, there is considerable debate about whether LTCI is worth the cost. Premiums for new policies are rising at a steep clip – 9% annually, according to the AALTCI – and insurers are allowed to raise premiums even after you buy the policy, so you’ll need to factor that possibility into your budget.
But forgoing coverage can be costly too: If you know you will have to cover your own long-term care costs, you won’t be able to spend that money on things you really care about – like your grandkids, or travel, or charitable work. You might even forgo necessary medical care for fear of running out of money.
Everyone must make their own decision. My wife and I decided that a few thousand dollars per year is a fair price to pay for the peace of mind of knowing we will be able to afford proper supportive care, without help from our children or anyone else, regardless of what happens in the years to come.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
A few years ago, my seemingly indestructible 94-year-old mother suffered a series of medical setbacks. As her health problems accumulated, so did the complexity and cost of her care, progressing from her home to an assisted-living facility to a nursing home. It was heartbreaking – and expensive. My wife likened it to “putting another kid through college” – an elite private college, at that.
Medicare, of course, did not cover any of this, except for physician visits and some of her medications. When it was finally over, my wife and I resolved that, should we face a similar situation in our final years, we could not put ourselves or our children through a similar financial ordeal.
, in-home services, and other end-of-life expenses. (Covered services vary by policy; and as always, I have no financial interest in any product or service mentioned here.)
According to the American Association for Long-Term Care Insurance (AALTCI), the average annual LTCI premium for a 60-year-old couple is $3,490. Not cheap; but there are ways to lower premiums without gutting your coverage.
The best way to keep costs down is to get in early. In general, the younger you are and the better health you are in, the lower your premiums will be. For example – again according to the AALTCI – that “average” annual premium of $3,490 for a hypothetical 60-year-old couple would increase 34%, to $4,675, if they waited until they were 65 to buy the policy. And if their health were to decline in the interim, they might not be able to obtain adequate coverage at all.
You can also lower premiums by decreasing daily benefits, or increasing the “elimination period” – the length of time after you become eligible for benefits that the policy starts paying them; 30-, 60-, and 90-day periods are common. As long as you have sufficient savings to realistically cover costs until the elimination period is over, choosing a longer one can reduce your costs significantly.
Another variable is the maximum length of time the policy will pay out benefits. Ideally, you would want a payout to continue for as long as necessary, but few if any companies are willing to write uncapped policies anymore. Two to five years of benefits is a common time frame. (The “average” premiums quoted above assume a benefit of $150 per day with a 3-year cap and a 90-day elimination period.)
As with any insurance, it is important not to overbuy LTCI. It isn’t necessary to obtain coverage that will pay for 100% of your long-term care costs – just the portion that your projected retirement income (Social Security, pensions, income from savings) may not be sufficient to cover. Buying only the amount of coverage you need will substantially reduce your premium costs over the life of the policy.
If you work for a hospital or a large group, it’s worth checking to see if your employer offers LTCI. Employer-sponsored plans are often offered at discounted group rates, and you can usually keep the policy even if you leave. If you’re a member of any social or religious groups, check their insurance plans as well.
To be sure, there is considerable debate about whether LTCI is worth the cost. Premiums for new policies are rising at a steep clip – 9% annually, according to the AALTCI – and insurers are allowed to raise premiums even after you buy the policy, so you’ll need to factor that possibility into your budget.
But forgoing coverage can be costly too: If you know you will have to cover your own long-term care costs, you won’t be able to spend that money on things you really care about – like your grandkids, or travel, or charitable work. You might even forgo necessary medical care for fear of running out of money.
Everyone must make their own decision. My wife and I decided that a few thousand dollars per year is a fair price to pay for the peace of mind of knowing we will be able to afford proper supportive care, without help from our children or anyone else, regardless of what happens in the years to come.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
How I became a better doctor
I became a better doctor on the day I became a cardiac patient. On that day, I experienced the helpless, vulnerable, and needy feelings of a patient’s dependency and blind trust of a physician whom I did not know. I suddenly realized how it feels to be a patient.
My entire life, I had always been an athlete in excellent shape. My 7-day-a-week daily schedule included seeing patients, being an expert psychiatric witness for disability cases, playing 2 hours of tennis, walking/running for 1 hour, and ending the night with 1 hour on a stationary bike.
I get to see my children all the time. I am so fortunate to get to travel with them and play national father-son and father-daughter tennis tournaments. We have been ranked No. 1 in the country many times. I have won 16 gold balls in these tournaments, each symbolic of a U.S. championship.
As a busy board-certified psychiatrist, I had been featured in an article, “Well being: Tennis is doctor’s favorite medicine,” by Art Carey, in the Philadelphia Inquirer, posted May 2, 2011. The author discussed my diet and exercise regime, and how I used exercise to stay healthy and to deal with the stress of being a physician.
‘Take me to the hospital’
At the end of 2018, I had a complete blood count performed, and the results indicated that I had a lipid panel of a healthy 30-year-old; however, my delusional bubble burst in March 2019. I was the No. 1 seed in a National Father-Daughter Tennis Tournament in Chicago. We were in the semifinal match, we had won the first set, and we were up 3-0. I fell, hit my head on the net post, and was feeling nauseated. I checked for bleeding and continued playing, though I was not feeling well. Five minutes later, I experienced symptoms of very extreme gastrointestinal pain and nausea. I ran off the tennis court wanting to vomit and get rid of the symptom so I could go back and finish the match. I wanted to play in the finals the following day and try to win the tournament.
The kind, competent, compassionate, and warm tournament director said I looked gray – and he promptly called 911. The paramedics came and said they thought I may be having a heart attack. I was in denial since I had no chest pain and I thought I was super healthy; therefore, I could not be experiencing an acute myocardial infarction. I finally agreed to let technicians perform an EKG, and they told me that I had ST elevation. Reality finally set in and I realized I was having a heart attack. “Take me to the hospital,” I said.
At the Chicago hospital where I was taken, I told doctors and staff I was a physician. To my surprise, they did not care. I was not going to get any prioritized treatment. Despite all of my devotion to medicine, I was not even getting their top physician to treat me. I was being evaluated by a resident. I felt even more deflated.
They performed a cardiac catheterization and put in one stent in one vessel in the right cardiac vessel. I had many questions to ask, but everyone seemed very impatient and abrupt with me, acting like this was just a very routine procedure. No one ever adequately answered my questions. I was very disillusioned, and I felt very insignificant, scared, and invisible.
I was discharged a few days later and was told my heart problem was fixed. I was instructed to follow up with a cardiologist in Philadelphia when I got home.
The first night home, I experienced chest pain. I was alarmed and thought my stent may have collapsed, so I went to the emergency room of the Philadelphia area hospital I knew had the best cardiac staff. After another blood test, indicating raised troponin levels, I was informed they needed to perform another cardiac catheterization. I learned I had two more coronary artery blockages, each 95%-99%, in the left ventricle.
I was shocked. How could the doctor in Chicago have made such a significant mistake? What happened? I would never know.
The interventional cardiologist in Philadelphia was able to repair one coronary artery, but the other blockage in the LED vessel (yes, the widow maker) had calcified too much for a stent. I would need cardiac bypass surgery. This was very unbelievable to me, and furthermore, I would have to wait 2 long weeks for the anticoagulant effect of the Brilinta to wear off before I could undergo bypass surgery.
While I anxiously waited for the big day, I was calling either my cardiologist, surgeon, or his nurse practitioner almost daily with questions and concerns; after all, this was a life-threatening and momentous event. Thankfully, I was met with great patience, understanding, and promptness of detailed answers and explanations by all involved with my cardiac care. The reactions of the staff made me mindful of the importance of really hearing my patients’ concerns and addressing their issues in a prompt, nonjudgmental, patient, and genuine manner. I am grateful that my robotic cardiac bypass surgery on March 26, 2019, went very well, and I am now back to work, playing tennis, jogging slowly, and riding my stationery bike.
Changed perspective on practice
I had always thought of myself as a warm, caring, and empathic psychiatrist, but my experience as a cardiac patient made me realize that there is always room for improvement in treating my patients.
Remember, every doctor will become a patient one day, and the reality of illness, injury, and mortality may really hit you hard, as it did me. You may not receive any prioritized treatment and you will know what it feels like to be helpless, vulnerable, and at the mercy of a physician while you regress in the service of the ego and become a patient.
You can be a better doctor now if you are mindful that whatever the physical, emotional, or mental issue facing your patients, the problem may be catastrophic to them. They need your undivided attention. Any problem is a significant event to your presenting patient. Really listen to his or her concerns or questions, and address every one with patience, understanding, and accurate information. If you follow these lessons, which I learned the hard way, you can become a better doctor.
I followed my doctor’s instructions and I started hitting tennis balls gradually. I worked myself back into shape and with my daughter Julia Cohen, and we won the USTA National Father Daughter Clay Court Championship in Florida 6 months after I had the heart attack during a national tennis tournament. This is the comeback of the year in tennis!
Dr. Cohen has had a private practice in psychiatry for more than 35 years. He is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University in Philadelphia. Dr. Cohen has been a nationally ranked tennis player from age 12 to the present, served as captain of the University of Pennsylvania tennis team, and ranked No. 1 in tennis in the middle states section and in the country in various categories and times. He was inducted into the Philadelphia Jewish Sports Hall of Fame in 2012.
I became a better doctor on the day I became a cardiac patient. On that day, I experienced the helpless, vulnerable, and needy feelings of a patient’s dependency and blind trust of a physician whom I did not know. I suddenly realized how it feels to be a patient.
My entire life, I had always been an athlete in excellent shape. My 7-day-a-week daily schedule included seeing patients, being an expert psychiatric witness for disability cases, playing 2 hours of tennis, walking/running for 1 hour, and ending the night with 1 hour on a stationary bike.
I get to see my children all the time. I am so fortunate to get to travel with them and play national father-son and father-daughter tennis tournaments. We have been ranked No. 1 in the country many times. I have won 16 gold balls in these tournaments, each symbolic of a U.S. championship.
As a busy board-certified psychiatrist, I had been featured in an article, “Well being: Tennis is doctor’s favorite medicine,” by Art Carey, in the Philadelphia Inquirer, posted May 2, 2011. The author discussed my diet and exercise regime, and how I used exercise to stay healthy and to deal with the stress of being a physician.
‘Take me to the hospital’
At the end of 2018, I had a complete blood count performed, and the results indicated that I had a lipid panel of a healthy 30-year-old; however, my delusional bubble burst in March 2019. I was the No. 1 seed in a National Father-Daughter Tennis Tournament in Chicago. We were in the semifinal match, we had won the first set, and we were up 3-0. I fell, hit my head on the net post, and was feeling nauseated. I checked for bleeding and continued playing, though I was not feeling well. Five minutes later, I experienced symptoms of very extreme gastrointestinal pain and nausea. I ran off the tennis court wanting to vomit and get rid of the symptom so I could go back and finish the match. I wanted to play in the finals the following day and try to win the tournament.
The kind, competent, compassionate, and warm tournament director said I looked gray – and he promptly called 911. The paramedics came and said they thought I may be having a heart attack. I was in denial since I had no chest pain and I thought I was super healthy; therefore, I could not be experiencing an acute myocardial infarction. I finally agreed to let technicians perform an EKG, and they told me that I had ST elevation. Reality finally set in and I realized I was having a heart attack. “Take me to the hospital,” I said.
At the Chicago hospital where I was taken, I told doctors and staff I was a physician. To my surprise, they did not care. I was not going to get any prioritized treatment. Despite all of my devotion to medicine, I was not even getting their top physician to treat me. I was being evaluated by a resident. I felt even more deflated.
They performed a cardiac catheterization and put in one stent in one vessel in the right cardiac vessel. I had many questions to ask, but everyone seemed very impatient and abrupt with me, acting like this was just a very routine procedure. No one ever adequately answered my questions. I was very disillusioned, and I felt very insignificant, scared, and invisible.
I was discharged a few days later and was told my heart problem was fixed. I was instructed to follow up with a cardiologist in Philadelphia when I got home.
The first night home, I experienced chest pain. I was alarmed and thought my stent may have collapsed, so I went to the emergency room of the Philadelphia area hospital I knew had the best cardiac staff. After another blood test, indicating raised troponin levels, I was informed they needed to perform another cardiac catheterization. I learned I had two more coronary artery blockages, each 95%-99%, in the left ventricle.
I was shocked. How could the doctor in Chicago have made such a significant mistake? What happened? I would never know.
The interventional cardiologist in Philadelphia was able to repair one coronary artery, but the other blockage in the LED vessel (yes, the widow maker) had calcified too much for a stent. I would need cardiac bypass surgery. This was very unbelievable to me, and furthermore, I would have to wait 2 long weeks for the anticoagulant effect of the Brilinta to wear off before I could undergo bypass surgery.
While I anxiously waited for the big day, I was calling either my cardiologist, surgeon, or his nurse practitioner almost daily with questions and concerns; after all, this was a life-threatening and momentous event. Thankfully, I was met with great patience, understanding, and promptness of detailed answers and explanations by all involved with my cardiac care. The reactions of the staff made me mindful of the importance of really hearing my patients’ concerns and addressing their issues in a prompt, nonjudgmental, patient, and genuine manner. I am grateful that my robotic cardiac bypass surgery on March 26, 2019, went very well, and I am now back to work, playing tennis, jogging slowly, and riding my stationery bike.
Changed perspective on practice
I had always thought of myself as a warm, caring, and empathic psychiatrist, but my experience as a cardiac patient made me realize that there is always room for improvement in treating my patients.
Remember, every doctor will become a patient one day, and the reality of illness, injury, and mortality may really hit you hard, as it did me. You may not receive any prioritized treatment and you will know what it feels like to be helpless, vulnerable, and at the mercy of a physician while you regress in the service of the ego and become a patient.
You can be a better doctor now if you are mindful that whatever the physical, emotional, or mental issue facing your patients, the problem may be catastrophic to them. They need your undivided attention. Any problem is a significant event to your presenting patient. Really listen to his or her concerns or questions, and address every one with patience, understanding, and accurate information. If you follow these lessons, which I learned the hard way, you can become a better doctor.
I followed my doctor’s instructions and I started hitting tennis balls gradually. I worked myself back into shape and with my daughter Julia Cohen, and we won the USTA National Father Daughter Clay Court Championship in Florida 6 months after I had the heart attack during a national tennis tournament. This is the comeback of the year in tennis!
Dr. Cohen has had a private practice in psychiatry for more than 35 years. He is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University in Philadelphia. Dr. Cohen has been a nationally ranked tennis player from age 12 to the present, served as captain of the University of Pennsylvania tennis team, and ranked No. 1 in tennis in the middle states section and in the country in various categories and times. He was inducted into the Philadelphia Jewish Sports Hall of Fame in 2012.
I became a better doctor on the day I became a cardiac patient. On that day, I experienced the helpless, vulnerable, and needy feelings of a patient’s dependency and blind trust of a physician whom I did not know. I suddenly realized how it feels to be a patient.
My entire life, I had always been an athlete in excellent shape. My 7-day-a-week daily schedule included seeing patients, being an expert psychiatric witness for disability cases, playing 2 hours of tennis, walking/running for 1 hour, and ending the night with 1 hour on a stationary bike.
I get to see my children all the time. I am so fortunate to get to travel with them and play national father-son and father-daughter tennis tournaments. We have been ranked No. 1 in the country many times. I have won 16 gold balls in these tournaments, each symbolic of a U.S. championship.
As a busy board-certified psychiatrist, I had been featured in an article, “Well being: Tennis is doctor’s favorite medicine,” by Art Carey, in the Philadelphia Inquirer, posted May 2, 2011. The author discussed my diet and exercise regime, and how I used exercise to stay healthy and to deal with the stress of being a physician.
‘Take me to the hospital’
At the end of 2018, I had a complete blood count performed, and the results indicated that I had a lipid panel of a healthy 30-year-old; however, my delusional bubble burst in March 2019. I was the No. 1 seed in a National Father-Daughter Tennis Tournament in Chicago. We were in the semifinal match, we had won the first set, and we were up 3-0. I fell, hit my head on the net post, and was feeling nauseated. I checked for bleeding and continued playing, though I was not feeling well. Five minutes later, I experienced symptoms of very extreme gastrointestinal pain and nausea. I ran off the tennis court wanting to vomit and get rid of the symptom so I could go back and finish the match. I wanted to play in the finals the following day and try to win the tournament.
The kind, competent, compassionate, and warm tournament director said I looked gray – and he promptly called 911. The paramedics came and said they thought I may be having a heart attack. I was in denial since I had no chest pain and I thought I was super healthy; therefore, I could not be experiencing an acute myocardial infarction. I finally agreed to let technicians perform an EKG, and they told me that I had ST elevation. Reality finally set in and I realized I was having a heart attack. “Take me to the hospital,” I said.
At the Chicago hospital where I was taken, I told doctors and staff I was a physician. To my surprise, they did not care. I was not going to get any prioritized treatment. Despite all of my devotion to medicine, I was not even getting their top physician to treat me. I was being evaluated by a resident. I felt even more deflated.
They performed a cardiac catheterization and put in one stent in one vessel in the right cardiac vessel. I had many questions to ask, but everyone seemed very impatient and abrupt with me, acting like this was just a very routine procedure. No one ever adequately answered my questions. I was very disillusioned, and I felt very insignificant, scared, and invisible.
I was discharged a few days later and was told my heart problem was fixed. I was instructed to follow up with a cardiologist in Philadelphia when I got home.
The first night home, I experienced chest pain. I was alarmed and thought my stent may have collapsed, so I went to the emergency room of the Philadelphia area hospital I knew had the best cardiac staff. After another blood test, indicating raised troponin levels, I was informed they needed to perform another cardiac catheterization. I learned I had two more coronary artery blockages, each 95%-99%, in the left ventricle.
I was shocked. How could the doctor in Chicago have made such a significant mistake? What happened? I would never know.
The interventional cardiologist in Philadelphia was able to repair one coronary artery, but the other blockage in the LED vessel (yes, the widow maker) had calcified too much for a stent. I would need cardiac bypass surgery. This was very unbelievable to me, and furthermore, I would have to wait 2 long weeks for the anticoagulant effect of the Brilinta to wear off before I could undergo bypass surgery.
While I anxiously waited for the big day, I was calling either my cardiologist, surgeon, or his nurse practitioner almost daily with questions and concerns; after all, this was a life-threatening and momentous event. Thankfully, I was met with great patience, understanding, and promptness of detailed answers and explanations by all involved with my cardiac care. The reactions of the staff made me mindful of the importance of really hearing my patients’ concerns and addressing their issues in a prompt, nonjudgmental, patient, and genuine manner. I am grateful that my robotic cardiac bypass surgery on March 26, 2019, went very well, and I am now back to work, playing tennis, jogging slowly, and riding my stationery bike.
Changed perspective on practice
I had always thought of myself as a warm, caring, and empathic psychiatrist, but my experience as a cardiac patient made me realize that there is always room for improvement in treating my patients.
Remember, every doctor will become a patient one day, and the reality of illness, injury, and mortality may really hit you hard, as it did me. You may not receive any prioritized treatment and you will know what it feels like to be helpless, vulnerable, and at the mercy of a physician while you regress in the service of the ego and become a patient.
You can be a better doctor now if you are mindful that whatever the physical, emotional, or mental issue facing your patients, the problem may be catastrophic to them. They need your undivided attention. Any problem is a significant event to your presenting patient. Really listen to his or her concerns or questions, and address every one with patience, understanding, and accurate information. If you follow these lessons, which I learned the hard way, you can become a better doctor.
I followed my doctor’s instructions and I started hitting tennis balls gradually. I worked myself back into shape and with my daughter Julia Cohen, and we won the USTA National Father Daughter Clay Court Championship in Florida 6 months after I had the heart attack during a national tennis tournament. This is the comeback of the year in tennis!
Dr. Cohen has had a private practice in psychiatry for more than 35 years. He is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University in Philadelphia. Dr. Cohen has been a nationally ranked tennis player from age 12 to the present, served as captain of the University of Pennsylvania tennis team, and ranked No. 1 in tennis in the middle states section and in the country in various categories and times. He was inducted into the Philadelphia Jewish Sports Hall of Fame in 2012.
Letters From Maine: Adult ADHD is on the rise
A study of more than 5 million Kaiser Permanente/Northern California patients suggests that the prevalence of adults diagnosed with ADHD has dramatically increased over the last 10 years (JAMA Netw Open. 2019 Nov 1. doi: 10.1001/jamanetworkopen.2019.14344).
Over the interval between 2007 and 2016, the prevalence of ADHD went from 0.43% to 0.96%, an increase of more than 120%. For adults, being white, male, younger, employed, and better educated increased one’s chances of receiving an ADHD diagnosis. Having a comorbid mental health diagnosis such as an eating disorder, anxiety, depression, or being labeled as bipolar also increased the odds of acquiring the ADHD label.
Are our screening tools too coarse, allowing a significant number of children to slip through the cracks only to land in the laps of our colleagues in internal medicine and family practice? If this were the case, does this mean that adult and youth ADHD are basically the same condition, but in some individuals the signs and symptoms become more obvious with aging? Does it also suggest that there is a genetic basis to ADHD with variable expression? Could it be that individuals with adult ADHD exhibited a few of the hallmarks of the diagnosis when they were young, but aggravating factors in the environment such as job stress or marital discord unmasked the signs and symptoms that had been percolating just under our radar for decades?
As usual, there is no simple answer that explains the findings unearthed by these researchers. One gets a sense from reading their paper that the authors feel that ADHD is being diagnosed more often as more individuals have access to physicians and other professionals who are attuned to the diagnosis. The fact that white, better-educated, and employed men are more likely to acquire the diagnosis might support the argument that as segments of the population who have been underserved by the health care system come on board we will continue to see a rise in the number of adults with the diagnosis. The more patients who see health care providers who are primed to make the diagnosis, the more often the diagnosis will be made.
I am sure there is a segment of the population who enter the world with some genetically mediated chemical or structural vulnerability that results in the signs and symptoms of ADHD. Most, but not all, of these individuals have symptoms that are so obvious that they present in childhood. However, a larger number of children and most adults who are labeled with ADHD are exhibiting the symptoms of inattention, distractibility, and impulsiveness as the result of environmental factors such as sleep deprivation, family or job stress, and other comorbid mental health conditions, or simply because they were young for their school cohort.
Pediatricians need not feel that we have missed another opportunity for prevention because the prevalence of the diagnosis of adult ADHD is increasing dramatically. However, that increase should serve as another reminder to us that there can be multiple factors that can result in signs and symptoms that attract the label of ADHD. We must be careful and look long and hard before we diagnose and reach for our prescription pad.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
A study of more than 5 million Kaiser Permanente/Northern California patients suggests that the prevalence of adults diagnosed with ADHD has dramatically increased over the last 10 years (JAMA Netw Open. 2019 Nov 1. doi: 10.1001/jamanetworkopen.2019.14344).
Over the interval between 2007 and 2016, the prevalence of ADHD went from 0.43% to 0.96%, an increase of more than 120%. For adults, being white, male, younger, employed, and better educated increased one’s chances of receiving an ADHD diagnosis. Having a comorbid mental health diagnosis such as an eating disorder, anxiety, depression, or being labeled as bipolar also increased the odds of acquiring the ADHD label.
Are our screening tools too coarse, allowing a significant number of children to slip through the cracks only to land in the laps of our colleagues in internal medicine and family practice? If this were the case, does this mean that adult and youth ADHD are basically the same condition, but in some individuals the signs and symptoms become more obvious with aging? Does it also suggest that there is a genetic basis to ADHD with variable expression? Could it be that individuals with adult ADHD exhibited a few of the hallmarks of the diagnosis when they were young, but aggravating factors in the environment such as job stress or marital discord unmasked the signs and symptoms that had been percolating just under our radar for decades?
As usual, there is no simple answer that explains the findings unearthed by these researchers. One gets a sense from reading their paper that the authors feel that ADHD is being diagnosed more often as more individuals have access to physicians and other professionals who are attuned to the diagnosis. The fact that white, better-educated, and employed men are more likely to acquire the diagnosis might support the argument that as segments of the population who have been underserved by the health care system come on board we will continue to see a rise in the number of adults with the diagnosis. The more patients who see health care providers who are primed to make the diagnosis, the more often the diagnosis will be made.
I am sure there is a segment of the population who enter the world with some genetically mediated chemical or structural vulnerability that results in the signs and symptoms of ADHD. Most, but not all, of these individuals have symptoms that are so obvious that they present in childhood. However, a larger number of children and most adults who are labeled with ADHD are exhibiting the symptoms of inattention, distractibility, and impulsiveness as the result of environmental factors such as sleep deprivation, family or job stress, and other comorbid mental health conditions, or simply because they were young for their school cohort.
Pediatricians need not feel that we have missed another opportunity for prevention because the prevalence of the diagnosis of adult ADHD is increasing dramatically. However, that increase should serve as another reminder to us that there can be multiple factors that can result in signs and symptoms that attract the label of ADHD. We must be careful and look long and hard before we diagnose and reach for our prescription pad.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
A study of more than 5 million Kaiser Permanente/Northern California patients suggests that the prevalence of adults diagnosed with ADHD has dramatically increased over the last 10 years (JAMA Netw Open. 2019 Nov 1. doi: 10.1001/jamanetworkopen.2019.14344).
Over the interval between 2007 and 2016, the prevalence of ADHD went from 0.43% to 0.96%, an increase of more than 120%. For adults, being white, male, younger, employed, and better educated increased one’s chances of receiving an ADHD diagnosis. Having a comorbid mental health diagnosis such as an eating disorder, anxiety, depression, or being labeled as bipolar also increased the odds of acquiring the ADHD label.
Are our screening tools too coarse, allowing a significant number of children to slip through the cracks only to land in the laps of our colleagues in internal medicine and family practice? If this were the case, does this mean that adult and youth ADHD are basically the same condition, but in some individuals the signs and symptoms become more obvious with aging? Does it also suggest that there is a genetic basis to ADHD with variable expression? Could it be that individuals with adult ADHD exhibited a few of the hallmarks of the diagnosis when they were young, but aggravating factors in the environment such as job stress or marital discord unmasked the signs and symptoms that had been percolating just under our radar for decades?
As usual, there is no simple answer that explains the findings unearthed by these researchers. One gets a sense from reading their paper that the authors feel that ADHD is being diagnosed more often as more individuals have access to physicians and other professionals who are attuned to the diagnosis. The fact that white, better-educated, and employed men are more likely to acquire the diagnosis might support the argument that as segments of the population who have been underserved by the health care system come on board we will continue to see a rise in the number of adults with the diagnosis. The more patients who see health care providers who are primed to make the diagnosis, the more often the diagnosis will be made.
I am sure there is a segment of the population who enter the world with some genetically mediated chemical or structural vulnerability that results in the signs and symptoms of ADHD. Most, but not all, of these individuals have symptoms that are so obvious that they present in childhood. However, a larger number of children and most adults who are labeled with ADHD are exhibiting the symptoms of inattention, distractibility, and impulsiveness as the result of environmental factors such as sleep deprivation, family or job stress, and other comorbid mental health conditions, or simply because they were young for their school cohort.
Pediatricians need not feel that we have missed another opportunity for prevention because the prevalence of the diagnosis of adult ADHD is increasing dramatically. However, that increase should serve as another reminder to us that there can be multiple factors that can result in signs and symptoms that attract the label of ADHD. We must be careful and look long and hard before we diagnose and reach for our prescription pad.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
It’s time to get to know AI
This month’s cover story on artificial intelligence (AI) and machine learning provides a glimpse into the future of medical care. The article’s title, “An FP’s guide to AI-enabled clinical decision support” points to the fact that practical and useful applications of AI and machine learning are making inroads into medicine. However, other industries are far ahead of medicine when it comes to AI.
For example, I met with a financial advisor last week, and our discussion included a display of the likelihood that my wife and I would have sufficient funds in our retirement account based on a Monte Carlo simulation using 500 trials! In other words, our advisor used a huge database of financial information, analyzed that data with a sophisticated statistical technique, and applied the results to our personal situation. (No, we won’t run out of money—with 99% certainty.)
So as physicians, how can we further increase our certainty in the diagnoses we make and the guidance we offer our patients?
Halamka and Cerrato provide some insights. They discuss 2 clinical applications of AI and machine learning that are ready to use in primary care: screening for diabetic retinopathy and risk assessment for colon cancer. The first is an example of using AI for diagnosis and the second for risk assessment; both are core functions of primary care clinicians. These tools were developed with very sophisticated computer programs, but they are not unlike a plethora of clinical decision aids already widely used in primary care for diagnosis and risk assessment, such as the Ottawa Ankle Rules, the Gail Model for breast cancer risk, the FRAX tool for osteoporosis-related fracture risk, the ASCVD Risk Calculator for cardiovascular risk, and the CHA2DS2-VASC score for prediction of thrombosis and bleeding risk from anticoagulation therapy.
Some express concern that sophisticated AI could eventually replace primary care clinicians, similar to how automation reduces the need for routine labor in manufacturing. I think this is highly unlikely, but I do think AI will be widely deployed in clinical tools that improve our diagnostic accuracy and provide better personalized data to inform shared decision making. For example, the colon cancer risk calculator may actually help some patients decide NOT to be screened because their personal risk is so low.
It’s incumbent upon us, then, to familiarize ourselves with the potential that these AI tools offer. It’s time to get to know AI.
Editor-in-Chief
Editor-in-Chief
Editor-in-Chief
This month’s cover story on artificial intelligence (AI) and machine learning provides a glimpse into the future of medical care. The article’s title, “An FP’s guide to AI-enabled clinical decision support” points to the fact that practical and useful applications of AI and machine learning are making inroads into medicine. However, other industries are far ahead of medicine when it comes to AI.
For example, I met with a financial advisor last week, and our discussion included a display of the likelihood that my wife and I would have sufficient funds in our retirement account based on a Monte Carlo simulation using 500 trials! In other words, our advisor used a huge database of financial information, analyzed that data with a sophisticated statistical technique, and applied the results to our personal situation. (No, we won’t run out of money—with 99% certainty.)
So as physicians, how can we further increase our certainty in the diagnoses we make and the guidance we offer our patients?
Halamka and Cerrato provide some insights. They discuss 2 clinical applications of AI and machine learning that are ready to use in primary care: screening for diabetic retinopathy and risk assessment for colon cancer. The first is an example of using AI for diagnosis and the second for risk assessment; both are core functions of primary care clinicians. These tools were developed with very sophisticated computer programs, but they are not unlike a plethora of clinical decision aids already widely used in primary care for diagnosis and risk assessment, such as the Ottawa Ankle Rules, the Gail Model for breast cancer risk, the FRAX tool for osteoporosis-related fracture risk, the ASCVD Risk Calculator for cardiovascular risk, and the CHA2DS2-VASC score for prediction of thrombosis and bleeding risk from anticoagulation therapy.
Some express concern that sophisticated AI could eventually replace primary care clinicians, similar to how automation reduces the need for routine labor in manufacturing. I think this is highly unlikely, but I do think AI will be widely deployed in clinical tools that improve our diagnostic accuracy and provide better personalized data to inform shared decision making. For example, the colon cancer risk calculator may actually help some patients decide NOT to be screened because their personal risk is so low.
It’s incumbent upon us, then, to familiarize ourselves with the potential that these AI tools offer. It’s time to get to know AI.
This month’s cover story on artificial intelligence (AI) and machine learning provides a glimpse into the future of medical care. The article’s title, “An FP’s guide to AI-enabled clinical decision support” points to the fact that practical and useful applications of AI and machine learning are making inroads into medicine. However, other industries are far ahead of medicine when it comes to AI.
For example, I met with a financial advisor last week, and our discussion included a display of the likelihood that my wife and I would have sufficient funds in our retirement account based on a Monte Carlo simulation using 500 trials! In other words, our advisor used a huge database of financial information, analyzed that data with a sophisticated statistical technique, and applied the results to our personal situation. (No, we won’t run out of money—with 99% certainty.)
So as physicians, how can we further increase our certainty in the diagnoses we make and the guidance we offer our patients?
Halamka and Cerrato provide some insights. They discuss 2 clinical applications of AI and machine learning that are ready to use in primary care: screening for diabetic retinopathy and risk assessment for colon cancer. The first is an example of using AI for diagnosis and the second for risk assessment; both are core functions of primary care clinicians. These tools were developed with very sophisticated computer programs, but they are not unlike a plethora of clinical decision aids already widely used in primary care for diagnosis and risk assessment, such as the Ottawa Ankle Rules, the Gail Model for breast cancer risk, the FRAX tool for osteoporosis-related fracture risk, the ASCVD Risk Calculator for cardiovascular risk, and the CHA2DS2-VASC score for prediction of thrombosis and bleeding risk from anticoagulation therapy.
Some express concern that sophisticated AI could eventually replace primary care clinicians, similar to how automation reduces the need for routine labor in manufacturing. I think this is highly unlikely, but I do think AI will be widely deployed in clinical tools that improve our diagnostic accuracy and provide better personalized data to inform shared decision making. For example, the colon cancer risk calculator may actually help some patients decide NOT to be screened because their personal risk is so low.
It’s incumbent upon us, then, to familiarize ourselves with the potential that these AI tools offer. It’s time to get to know AI.
Letters: Reframing Clinician Distress: Moral Injury Not Burnout
To the Editor: In the September 2019 guest editorial “Reframing Clinician Distress: Moral Injury Not Burnout,” the authors have advanced a thoughtful and provocative hypothesis addressing a salient issue.1 Their argument is that burnout does not accurately capture physician distress. Furthermore, they posit the term burnout focuses remediation strategies at the individual provider level, thereby discounting the contribution of the larger health care system. This is not the first effort to argue that burnout is not a syndrome of mental illness (eg, depression) located within the person but rather a disrupted physician-work relationship.2
As the authors cite, population and practice changes have contributed significantly to physician distress and dissatisfaction. Indeed, recent findings indicate that female physicians may suffer increased prevalence of burnout, which represents a challenge given the growing numbers of women in medicine.3 Unfortunately, by shifting focus almost exclusively to the system level to address burnout, the authors discount a large body of literature examining associations and contributors at the individual and clinic level.
Burnout is conceptualized as consisting of 3 domains: depersonalization, emotional exhaustion, and personal accomplishment.4 While this conceptualization may not capture the totality of physician distress, it has provided a body of literature focused on decreasing symptoms of burnout. Successful interventions have been targeted at the individual provider level (ie, stress management, small group discussion, mindfulness) as well as the organizational level (ie, reduction in duty hours, scribes).5,6 Recent studies have also suggested that increasing the occurrence of social encounters that are civil and respectful decreases reported physician burnout.7
Frustration, the annoyance or anger at being unable to change or achieve something, also can be a leading cause of burnout and moral injury. The inability to deal with unresolvable issues due to a lack of skills or inability to create a positive reframe can lead to a constellation of symptoms that are detrimental to the individual provider. Nevertheless, system rigidity, inability to recognitize pain and pressure, and goals perceived as unachievable can also lead to frustration. Physicians may experience growing frustration if they are unable to influence their systems. Thus, experiencing personal frustration, combined with an inability or lack of energy or time to influence a system can snowball.
Just as we counsel our patients that good medical care involves not only engagement with the medical system, but also individual engagement in their care (eg, nutrition, exercise), this problem requires a multicomponent solution. While advocating and working for a system that induces less moral injury, frustration, and burnout, physicians need to examine the resources available to them and their colleagues in a more immediate way.
Physician distress is a serious problem with both personal, patient, occupational, and public health costs. Thus, it is important that we grapple with the complexity of a multiconstruct definition amenable to multilevel interventions. The concept of moral injury is an important component and opens additional lines of both clinical inquiry and intervention. However, in our view, to subsume all burnout under this construct is overly reductive.
In closing, this topic is too important not to discuss. Let the conversations continue!
Lynne Padgett, PhD; and Joao L. Ascensao, MD, PhD
Author affiliations: Departments of Medicine and Mental Health, Washington DC VA Medical Center and Department of Medicine, George Washington University School of Medicine
Correspondence: Lynne Padgett ([email protected])
Disclosures: The authors report no conflict of interest with regard to this article.
References
1. Dean W, Talbot S, Dean A. Reframing clinical distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.
2. Epstein RM, Privitera MR. Doing something about physician burnout. Lancet. 2016;388(10057):2216-2217.
3. Templeton K, Bernstein CA, Sukhera J, et al. Gender-based differences in burnout: issues faced by women physicians. NAM Perspectives. Discussion Paper. Washington, DC: National Academy of Medicine; 2019. https://nam.edu/wp-content/uploads/2019/05/Gender-Based-Differences-in-Burnout.pdf. Published May 28, 2019. Accessed October 10, 2019.
4. Eckleberry-Hunt J Kirkpatrick H, Barbera T. The problems with burnout research. Acad Med. 2018;93(3):367-370.
5. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281.
6. Squiers JJ, Lobdell KW, Fann JI, DiMaio JM. Physician burnout: are we treating the symptom instead of the disease? Ann Thorac Surg. 2017;104(4):1117-1122.
7. Maslach C, Leiter MP. New insights into burnout and health care: strategies for improving civility and alleviating burnout. Med Teach. 2017;39(2):160-163.
To the Editor: We applaud Dean and her colleagues for their thought-provoking commentary on clinicians’ distress, a problem that has surged in recent years and has now reached epidemic proportions.1 Their argument focuses on the language used to define and frame clinical distress. Do we label this distress as burnout, as moral injury, or as something else? Moral injury occurs any time clinicians are impeded from doing the right thing at the right time in the right way; or even worse, doing the wrong thing to serve the needs of health system stakeholders other than the patient. These other stakeholders may include administrators, corporations, insurance adjusters, and others.
Naming the problem correctly is crucial to finding the solution. The name frames the discussion and impacts the solution. Burnout implies difficulty coping with the many stresses of health care and of personal responsibility for the problem. The solution would therefore be to help individuals to cope with their stresses. Moral injury on the other hand implies a corrupt system; thereby, reframing the discussion to systems issues and suggesting solutions by changing the business of health care delivery.
These authors state that current clinical distress is due to moral injury and not to burnout. Therefore, the business in which health care is performed needs to change.
The authors define the drivers of moral injury in our current system, mostly as (1) a massive information technology overload that has largely overtaken the patient as center of attention; and (2) the profit motive of the health care corporation and its shareholders. A focus on making profits has increased in the wake of falling reimbursements; the result is pressure on clinicians to see more patients more quickly and to do more even when not necessary. This has diverted the focus on healing patients to a focus on making profits. These major drivers of clinician distress—the electronic health record and the pressure to bill more—are fundamentally driven by the corporatization of American medicine in which profit is the measured outcome.
Thus rather than having their highest loyalty to patients and their families, clinicians now have other loyalties—the electronic health record, insurers, the hospital, the health care system, and even their own salaries.
Therein lies the moral injury felt by increasing numbers of clinicians, leading to soaring rates of clinical distress. Many physicians are now recognizing moral injury as the basis of their pain. For example, Gawande has described unceasing computer data entry as a cause of physician distress and physician loneliness in the interesting essay, “Why Doctors Hate Their Computers.”2 Topol has suggested that corporate interference and attention away from patient care is a reason doctors should unite and organize for a more healthful environment.3 Ofri has gone so far as to suggest that the health care system is surviving because it can exploit its physicians for every drop of energy, diverting the focus of clinical encounters on billing rather than healing.4 However, it may be simplistic to imply or state that all clinical distress is related to moral injury. Other factors in caring for the sick and dying also can cause distress to health care providers. Physicians work long, hard hours and listen to many stories of distress and suffering from patients. Some of this is internalized and processed as one’s own suffering. Clinicians also have enormous amounts of information to absorb and assimilate, keep long hours, and are often sleep deprived, all of which may harm their well-being. In addition, clinicians may have work/life imbalances, be hesitant to reveal their weaknesses, and have perfectionist personalities. Still other factors may also be involved, such as a hostile environment in which managers can overuse their power; racism that can limit opportunities for advancement; and/or a family-unfriendly environment.
Just as the treatment of cancer depends on good surgery, radiation and/or chemotherapy as well as reducing underlying predisposing cause (ie, smoking, drinking, obesity, antiviral therapy) and leading a healthy lifestyle, so too treatment of clinical distress needs a multipronged approach. Fixing the business framework is an important step forward but may not always be enough. We agree with the authors’ suggestions for improvement: bringing administrators and clinicians into conversation with each other, making clinician satisfaction a financial priority, assuring that physician leaders have cell phone numbers of their legislators, and reestablishing a sense of community among clinicians. However, none of these goals will be easy to accomplish and some may be impossible to realize in some settings.
A necessary corollary to the suggestions by Dean and colleagues is research. Much research is needed to discover all of the factors of clinician distress, whatever we name the problem. We need to know vulnerabilities of different populations of clinicians and differences in prevalence in different types of health care systems.
It is likely that physicians in a government-owned health care system, such as the US Department of Veterans Affairs (VA) hospitals, have lower distress since there are no corporate interests or profit motives. In our experience, we have noted that many VA providers are expatriates of private health care systems due to their moral distress. If profit making and corporatization are important factors in distress, then clinicians in the VA system should have much lower distress; however, this is not known.
We also need research in pilot projects that relieve clinician distress. These could relate to collegial activities to bring physicians—and administrators—together in community, allowing more time with patients than the usual 15-minute allotments, allowing more time for creative, narrative experiences in medicine, developing forums for discussion and resolution of distress-inducing situations, etc.
An important yet overlooked issue in this discussion is that clinician distress, regardless of its name or cause, is a public health crisis. Clinician distress not only affects the clinician most directly and most crucially, but also affects every person in his/her community. Physicians who are distressed for whatever reason deliver less adequate care, make more medical errors, and are less invested in their patients. Patients of distressed clinicians have less favorable outcomes and suffer more. Medical errors are now the third leading cause of death in the US. Much of this is due to inadequate care by focusing attention on profit-making over health improvement and to clinician distress. Clinician distress due to moral injury or any other factor is a public health crisis and needs much more attention, research, and prioritization of clinician satisfaction.
Paulette Mehta, MD, MPH; and Jay Mehta, PhD
Author Affiliations: Central Arkansas Veterans Health Care System; University of Arkansas for Medical Sciences
Correspondence: Paulette Mehta ([email protected])
Disclosures: The authors report no conflict of interest with regard to this article.
References
1. Dean W, Talbot S, Dean A. Reframing clinical distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.
2. Gawande A. Why doctors hate their computers. New Yorker. November 12, 2018. https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers. Accessed October 16, 2019.
3. Topol E. Why doctors should organize. New Yorker. August 5, 2019. https://www.newyorker.com/culture/annals-of-inquiry/why-doctors-should-organize. Accessed October 16, 2019.
4. Ofri D. The business of healthcare depends on exploiting doctors and nurses. The New York Times. June 8, 2019. https://www.nytimes.com/2019/06/08/opinion/sunday/hospitals-doctors-nurses-burnout.html. Accessed October 16, 2019.
To the Editor: The September 2019 editorial “Reframing clinician distress: moral injury not burnout” argues for a renaming of what has been called burnout to moral injury.1 The article by Dean, Talbot, and Dean compares the experience of health care providers to soldiers and other service members who have served in combat and suffer as a result of their experiences. I would like to comment on 2 areas: Whether the term burnout should be replaced with moral injury; and the adequacy of the recommendations made by Dean, Talbot, and Dean.
Briefly, my own credentials to opine on the topic include being both a physician and a soldier. I served in the US Army as a psychiatrist from 1986 to 2010 and deployed to various hazardous locations, including South Korea, Somalia, Iraq, and Guantanamo Bay, Cuba. Since my retirement from the Army I have worked as a psychiatrist on different front lines, with both veterans and the chronically mentally ill and often homeless population.
Moral injury is a term that was popularized by Johnathan Shay after the Vietnam War, especially in his masterful book Achilles in Vietnam.1 Most authors who have written on the subject of moral injury, including myself, think of it as feelings of guilt and shame related to (1) killing civilians (especially children or innocents); (2) surviving while other comrades did not; and/or (3) feeling betrayed by the government they served.2,3
While also arising in combat settings, moral injury is related but separate from posttraumatic stress disorder (PTSD). It comes from an affront to our morals rather than our physical well-being. It is not considered a medical diagnosis, treatments are experimental, and the literature is anecdotal.
I have mixed feelings about equating the moral injury from combat to working as a physician or other health care provider. On the one hand, certainly health care providers may sacrifice health and safety to taking care of patients. They may feel guilty when they cannot do enough for their patients. But does it rise to the same level as actually combat and having numerous comrades killed or maimed?
On the other hand, working on an inpatient psychiatry ward with an inner-city population who generally have severe mental illness and are often on phencyclidine and related drugs, has its own share of risks. Unfortunately, physical attacks on staff are way too common.
The term burnout also has a robust background of research into both causes and possible solutions. Indeed, there was even a journal devoted to it: Burnout Research.4 Moral injury research is on different populations, and generally the remedies are focused more on spiritual and existential support.
Which brings me to the recommendations and solutions part of the editorial. I agree that yoga and meditation, while beneficial, do not curb the feelings of frustration and betrayal that often arise when you cannot treat patients the way you feel they deserve. The recommendations listed in the editorial are a start, but much more should be done.
Now comes the hard part. Specifically, what more should be done? All the easy solutions have already been tried. Ones that would really make a difference, such as making an electronic health record that allows you to still look at and connect to the patient, seem to elude us. Many of us in the health care industry would love to have a single payer system across the board, to avoid all the inequities cited in the article. But health care, like climate change, is mired in our political deadlocks.
Therefore, I will finish by focusing on one of their recommendations, which is achievable: tie the incentives for the executive leadership to the satisfaction of health care providers, as is done for patient satisfaction. That is both doable and will benefit various institutions in the long run. Health care providers will be more likely to stay in a health care system and thus patient satisfaction improves. Win-win.
COL (Ret) Elspeth Cameron Ritchie, MD, MPH, USA
Author Affiliation: Uniformed Services University of the Health Sciences
Correspondence: Elspeth Cameron Ritchie ([email protected])
Disclosures: The author reports no conflict of interest with regard to this article.
References
1. Shay J. Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York: Atheneum; 1994.
2. Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin. Psychol Rev. 2009;29(8):695-706.
3. Ritchie EC. Moral injury: a profound sense of alienation and abject shame. Time. April 17, 2013. http://nation.time.com/2013/04/17/moral-injury-a-profound-sense-of-alienation-and-abject-shame.
4. Burnout Research. 2014;1(1):1-56. https://www.sciencedirect.com/journal/burnout-research/vol/1/issue/1. Accessed October 17, 2019.
Response: We appreciate the very thoughtful and thorough responses of Mehta. Mehta, Padgett, Ascensao, and Ritchie. Common themes in the responses were the suggestion that supplanting the term burnout with moral injury may not be appropriate and that changing the underlying drivers of distress requires a multifaceted approach, which is likely to require prolonged effort. We agree with both of these themes, believing the concept of moral injury and mitigation strategies do not benefit from reductionism.
Burnout is a nonspecific symptom constellation of emotional exhaustion, depersonalization, and a lack of a sense of accomplishment.1 Because it is nonspecific, the symptoms can arise from any number of situations, not only moral injury. However, from our conversations over the past 15 months, moral injury fuels a large percentage of burnout in health care. In a recent informal survey conducted at the ORExcellence meeting, almost all respondents believed they were experiencing moral injury rather than burnout when both terms were explained. When clinicians are physically and emotionally exhausted with battling a broken system in their efforts to provide good care—when they have incurred innumerable moral insults, amassing to a moral injury—many give up. This is the end stage of moral injury, or burnout.We absolutely agree research is necessary to validate this concept, which has been applied only to health care since July 2018. We are pursuing various avenues of inquiry and are validating a new assessment tool. But we do not believe that intervention must wait until there are data to support what resonates so profoundly with so many and, as we have heard dozens of times, “finally gives language to my experience.”Finally, we would not suggest that civilian physician experience is equivalent to combat experience. But just as there are multiple etiologies for posttraumatic stress disorder (PTSD), such as combat exposure, physical abuse, sexual assault, there are likely multiple ways one can incur moral injury. Witnessing or participating in a situation that transgresses deeply held moral beliefs is the prerequisite for moral injury rather than physical danger. In different contexts, physicians and service members may ultimately face similar accumulated risk to their moral integrity, though of widely disparate intensity, frequency, and duration. Physicians face low-intensity, high-frequency threats over years; service members more often face high-intensity, less frequent threats during time-limited deployments. Just because moral injury was first applied to combat veterans—as was PTSD—does not mean we should limit the use of a powerfully resonant concept to a military population any more than we limited the use of Letterman’s ambulances or Morel’s tourniquets to the battlefield.2,3
Wendy Dean, MD; and Simon Talbot, MD
Author affiliations: Wendy Dean is President and co-founder of Moral Injury of Healthcare. Simon Talbot is a reconstructive plastic surgeon at Brigham and Women’s Hospital and associate professor of surgery at Harvard Medical School, Boston, Massachusetts.
Correspondence: Wendy Dean (wdean@moralinjury. Healthcare,@WDeanMD)
Disclosures: Wendy Dean and Simon Talbot founded Moral Injury of Healthcare, a nonprofit organization; they report no other actual or potential conflicts of interest with regard to this article.
References
1. Freudenberger HJ. The staff burn-out syndrome in alternative institutions. Psychother Theory Res Pract. 1975;12(1):73-82.
2. Place RJ. The strategic genius of Jonathan Letterman: the relevancy of the American Civil War to current health care policy makers. Mil Med. 2015;180(3):259-262.
3. Welling DR, McKay PL, Rasmussen TE, Rich NM. A brief history of the tourniquet. J Vasc Surg. 2012;55(1):286-290.
To the Editor: In the September 2019 guest editorial “Reframing Clinician Distress: Moral Injury Not Burnout,” the authors have advanced a thoughtful and provocative hypothesis addressing a salient issue.1 Their argument is that burnout does not accurately capture physician distress. Furthermore, they posit the term burnout focuses remediation strategies at the individual provider level, thereby discounting the contribution of the larger health care system. This is not the first effort to argue that burnout is not a syndrome of mental illness (eg, depression) located within the person but rather a disrupted physician-work relationship.2
As the authors cite, population and practice changes have contributed significantly to physician distress and dissatisfaction. Indeed, recent findings indicate that female physicians may suffer increased prevalence of burnout, which represents a challenge given the growing numbers of women in medicine.3 Unfortunately, by shifting focus almost exclusively to the system level to address burnout, the authors discount a large body of literature examining associations and contributors at the individual and clinic level.
Burnout is conceptualized as consisting of 3 domains: depersonalization, emotional exhaustion, and personal accomplishment.4 While this conceptualization may not capture the totality of physician distress, it has provided a body of literature focused on decreasing symptoms of burnout. Successful interventions have been targeted at the individual provider level (ie, stress management, small group discussion, mindfulness) as well as the organizational level (ie, reduction in duty hours, scribes).5,6 Recent studies have also suggested that increasing the occurrence of social encounters that are civil and respectful decreases reported physician burnout.7
Frustration, the annoyance or anger at being unable to change or achieve something, also can be a leading cause of burnout and moral injury. The inability to deal with unresolvable issues due to a lack of skills or inability to create a positive reframe can lead to a constellation of symptoms that are detrimental to the individual provider. Nevertheless, system rigidity, inability to recognitize pain and pressure, and goals perceived as unachievable can also lead to frustration. Physicians may experience growing frustration if they are unable to influence their systems. Thus, experiencing personal frustration, combined with an inability or lack of energy or time to influence a system can snowball.
Just as we counsel our patients that good medical care involves not only engagement with the medical system, but also individual engagement in their care (eg, nutrition, exercise), this problem requires a multicomponent solution. While advocating and working for a system that induces less moral injury, frustration, and burnout, physicians need to examine the resources available to them and their colleagues in a more immediate way.
Physician distress is a serious problem with both personal, patient, occupational, and public health costs. Thus, it is important that we grapple with the complexity of a multiconstruct definition amenable to multilevel interventions. The concept of moral injury is an important component and opens additional lines of both clinical inquiry and intervention. However, in our view, to subsume all burnout under this construct is overly reductive.
In closing, this topic is too important not to discuss. Let the conversations continue!
Lynne Padgett, PhD; and Joao L. Ascensao, MD, PhD
Author affiliations: Departments of Medicine and Mental Health, Washington DC VA Medical Center and Department of Medicine, George Washington University School of Medicine
Correspondence: Lynne Padgett ([email protected])
Disclosures: The authors report no conflict of interest with regard to this article.
References
1. Dean W, Talbot S, Dean A. Reframing clinical distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.
2. Epstein RM, Privitera MR. Doing something about physician burnout. Lancet. 2016;388(10057):2216-2217.
3. Templeton K, Bernstein CA, Sukhera J, et al. Gender-based differences in burnout: issues faced by women physicians. NAM Perspectives. Discussion Paper. Washington, DC: National Academy of Medicine; 2019. https://nam.edu/wp-content/uploads/2019/05/Gender-Based-Differences-in-Burnout.pdf. Published May 28, 2019. Accessed October 10, 2019.
4. Eckleberry-Hunt J Kirkpatrick H, Barbera T. The problems with burnout research. Acad Med. 2018;93(3):367-370.
5. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281.
6. Squiers JJ, Lobdell KW, Fann JI, DiMaio JM. Physician burnout: are we treating the symptom instead of the disease? Ann Thorac Surg. 2017;104(4):1117-1122.
7. Maslach C, Leiter MP. New insights into burnout and health care: strategies for improving civility and alleviating burnout. Med Teach. 2017;39(2):160-163.
To the Editor: We applaud Dean and her colleagues for their thought-provoking commentary on clinicians’ distress, a problem that has surged in recent years and has now reached epidemic proportions.1 Their argument focuses on the language used to define and frame clinical distress. Do we label this distress as burnout, as moral injury, or as something else? Moral injury occurs any time clinicians are impeded from doing the right thing at the right time in the right way; or even worse, doing the wrong thing to serve the needs of health system stakeholders other than the patient. These other stakeholders may include administrators, corporations, insurance adjusters, and others.
Naming the problem correctly is crucial to finding the solution. The name frames the discussion and impacts the solution. Burnout implies difficulty coping with the many stresses of health care and of personal responsibility for the problem. The solution would therefore be to help individuals to cope with their stresses. Moral injury on the other hand implies a corrupt system; thereby, reframing the discussion to systems issues and suggesting solutions by changing the business of health care delivery.
These authors state that current clinical distress is due to moral injury and not to burnout. Therefore, the business in which health care is performed needs to change.
The authors define the drivers of moral injury in our current system, mostly as (1) a massive information technology overload that has largely overtaken the patient as center of attention; and (2) the profit motive of the health care corporation and its shareholders. A focus on making profits has increased in the wake of falling reimbursements; the result is pressure on clinicians to see more patients more quickly and to do more even when not necessary. This has diverted the focus on healing patients to a focus on making profits. These major drivers of clinician distress—the electronic health record and the pressure to bill more—are fundamentally driven by the corporatization of American medicine in which profit is the measured outcome.
Thus rather than having their highest loyalty to patients and their families, clinicians now have other loyalties—the electronic health record, insurers, the hospital, the health care system, and even their own salaries.
Therein lies the moral injury felt by increasing numbers of clinicians, leading to soaring rates of clinical distress. Many physicians are now recognizing moral injury as the basis of their pain. For example, Gawande has described unceasing computer data entry as a cause of physician distress and physician loneliness in the interesting essay, “Why Doctors Hate Their Computers.”2 Topol has suggested that corporate interference and attention away from patient care is a reason doctors should unite and organize for a more healthful environment.3 Ofri has gone so far as to suggest that the health care system is surviving because it can exploit its physicians for every drop of energy, diverting the focus of clinical encounters on billing rather than healing.4 However, it may be simplistic to imply or state that all clinical distress is related to moral injury. Other factors in caring for the sick and dying also can cause distress to health care providers. Physicians work long, hard hours and listen to many stories of distress and suffering from patients. Some of this is internalized and processed as one’s own suffering. Clinicians also have enormous amounts of information to absorb and assimilate, keep long hours, and are often sleep deprived, all of which may harm their well-being. In addition, clinicians may have work/life imbalances, be hesitant to reveal their weaknesses, and have perfectionist personalities. Still other factors may also be involved, such as a hostile environment in which managers can overuse their power; racism that can limit opportunities for advancement; and/or a family-unfriendly environment.
Just as the treatment of cancer depends on good surgery, radiation and/or chemotherapy as well as reducing underlying predisposing cause (ie, smoking, drinking, obesity, antiviral therapy) and leading a healthy lifestyle, so too treatment of clinical distress needs a multipronged approach. Fixing the business framework is an important step forward but may not always be enough. We agree with the authors’ suggestions for improvement: bringing administrators and clinicians into conversation with each other, making clinician satisfaction a financial priority, assuring that physician leaders have cell phone numbers of their legislators, and reestablishing a sense of community among clinicians. However, none of these goals will be easy to accomplish and some may be impossible to realize in some settings.
A necessary corollary to the suggestions by Dean and colleagues is research. Much research is needed to discover all of the factors of clinician distress, whatever we name the problem. We need to know vulnerabilities of different populations of clinicians and differences in prevalence in different types of health care systems.
It is likely that physicians in a government-owned health care system, such as the US Department of Veterans Affairs (VA) hospitals, have lower distress since there are no corporate interests or profit motives. In our experience, we have noted that many VA providers are expatriates of private health care systems due to their moral distress. If profit making and corporatization are important factors in distress, then clinicians in the VA system should have much lower distress; however, this is not known.
We also need research in pilot projects that relieve clinician distress. These could relate to collegial activities to bring physicians—and administrators—together in community, allowing more time with patients than the usual 15-minute allotments, allowing more time for creative, narrative experiences in medicine, developing forums for discussion and resolution of distress-inducing situations, etc.
An important yet overlooked issue in this discussion is that clinician distress, regardless of its name or cause, is a public health crisis. Clinician distress not only affects the clinician most directly and most crucially, but also affects every person in his/her community. Physicians who are distressed for whatever reason deliver less adequate care, make more medical errors, and are less invested in their patients. Patients of distressed clinicians have less favorable outcomes and suffer more. Medical errors are now the third leading cause of death in the US. Much of this is due to inadequate care by focusing attention on profit-making over health improvement and to clinician distress. Clinician distress due to moral injury or any other factor is a public health crisis and needs much more attention, research, and prioritization of clinician satisfaction.
Paulette Mehta, MD, MPH; and Jay Mehta, PhD
Author Affiliations: Central Arkansas Veterans Health Care System; University of Arkansas for Medical Sciences
Correspondence: Paulette Mehta ([email protected])
Disclosures: The authors report no conflict of interest with regard to this article.
References
1. Dean W, Talbot S, Dean A. Reframing clinical distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.
2. Gawande A. Why doctors hate their computers. New Yorker. November 12, 2018. https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers. Accessed October 16, 2019.
3. Topol E. Why doctors should organize. New Yorker. August 5, 2019. https://www.newyorker.com/culture/annals-of-inquiry/why-doctors-should-organize. Accessed October 16, 2019.
4. Ofri D. The business of healthcare depends on exploiting doctors and nurses. The New York Times. June 8, 2019. https://www.nytimes.com/2019/06/08/opinion/sunday/hospitals-doctors-nurses-burnout.html. Accessed October 16, 2019.
To the Editor: The September 2019 editorial “Reframing clinician distress: moral injury not burnout” argues for a renaming of what has been called burnout to moral injury.1 The article by Dean, Talbot, and Dean compares the experience of health care providers to soldiers and other service members who have served in combat and suffer as a result of their experiences. I would like to comment on 2 areas: Whether the term burnout should be replaced with moral injury; and the adequacy of the recommendations made by Dean, Talbot, and Dean.
Briefly, my own credentials to opine on the topic include being both a physician and a soldier. I served in the US Army as a psychiatrist from 1986 to 2010 and deployed to various hazardous locations, including South Korea, Somalia, Iraq, and Guantanamo Bay, Cuba. Since my retirement from the Army I have worked as a psychiatrist on different front lines, with both veterans and the chronically mentally ill and often homeless population.
Moral injury is a term that was popularized by Johnathan Shay after the Vietnam War, especially in his masterful book Achilles in Vietnam.1 Most authors who have written on the subject of moral injury, including myself, think of it as feelings of guilt and shame related to (1) killing civilians (especially children or innocents); (2) surviving while other comrades did not; and/or (3) feeling betrayed by the government they served.2,3
While also arising in combat settings, moral injury is related but separate from posttraumatic stress disorder (PTSD). It comes from an affront to our morals rather than our physical well-being. It is not considered a medical diagnosis, treatments are experimental, and the literature is anecdotal.
I have mixed feelings about equating the moral injury from combat to working as a physician or other health care provider. On the one hand, certainly health care providers may sacrifice health and safety to taking care of patients. They may feel guilty when they cannot do enough for their patients. But does it rise to the same level as actually combat and having numerous comrades killed or maimed?
On the other hand, working on an inpatient psychiatry ward with an inner-city population who generally have severe mental illness and are often on phencyclidine and related drugs, has its own share of risks. Unfortunately, physical attacks on staff are way too common.
The term burnout also has a robust background of research into both causes and possible solutions. Indeed, there was even a journal devoted to it: Burnout Research.4 Moral injury research is on different populations, and generally the remedies are focused more on spiritual and existential support.
Which brings me to the recommendations and solutions part of the editorial. I agree that yoga and meditation, while beneficial, do not curb the feelings of frustration and betrayal that often arise when you cannot treat patients the way you feel they deserve. The recommendations listed in the editorial are a start, but much more should be done.
Now comes the hard part. Specifically, what more should be done? All the easy solutions have already been tried. Ones that would really make a difference, such as making an electronic health record that allows you to still look at and connect to the patient, seem to elude us. Many of us in the health care industry would love to have a single payer system across the board, to avoid all the inequities cited in the article. But health care, like climate change, is mired in our political deadlocks.
Therefore, I will finish by focusing on one of their recommendations, which is achievable: tie the incentives for the executive leadership to the satisfaction of health care providers, as is done for patient satisfaction. That is both doable and will benefit various institutions in the long run. Health care providers will be more likely to stay in a health care system and thus patient satisfaction improves. Win-win.
COL (Ret) Elspeth Cameron Ritchie, MD, MPH, USA
Author Affiliation: Uniformed Services University of the Health Sciences
Correspondence: Elspeth Cameron Ritchie ([email protected])
Disclosures: The author reports no conflict of interest with regard to this article.
References
1. Shay J. Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York: Atheneum; 1994.
2. Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin. Psychol Rev. 2009;29(8):695-706.
3. Ritchie EC. Moral injury: a profound sense of alienation and abject shame. Time. April 17, 2013. http://nation.time.com/2013/04/17/moral-injury-a-profound-sense-of-alienation-and-abject-shame.
4. Burnout Research. 2014;1(1):1-56. https://www.sciencedirect.com/journal/burnout-research/vol/1/issue/1. Accessed October 17, 2019.
Response: We appreciate the very thoughtful and thorough responses of Mehta. Mehta, Padgett, Ascensao, and Ritchie. Common themes in the responses were the suggestion that supplanting the term burnout with moral injury may not be appropriate and that changing the underlying drivers of distress requires a multifaceted approach, which is likely to require prolonged effort. We agree with both of these themes, believing the concept of moral injury and mitigation strategies do not benefit from reductionism.
Burnout is a nonspecific symptom constellation of emotional exhaustion, depersonalization, and a lack of a sense of accomplishment.1 Because it is nonspecific, the symptoms can arise from any number of situations, not only moral injury. However, from our conversations over the past 15 months, moral injury fuels a large percentage of burnout in health care. In a recent informal survey conducted at the ORExcellence meeting, almost all respondents believed they were experiencing moral injury rather than burnout when both terms were explained. When clinicians are physically and emotionally exhausted with battling a broken system in their efforts to provide good care—when they have incurred innumerable moral insults, amassing to a moral injury—many give up. This is the end stage of moral injury, or burnout.We absolutely agree research is necessary to validate this concept, which has been applied only to health care since July 2018. We are pursuing various avenues of inquiry and are validating a new assessment tool. But we do not believe that intervention must wait until there are data to support what resonates so profoundly with so many and, as we have heard dozens of times, “finally gives language to my experience.”Finally, we would not suggest that civilian physician experience is equivalent to combat experience. But just as there are multiple etiologies for posttraumatic stress disorder (PTSD), such as combat exposure, physical abuse, sexual assault, there are likely multiple ways one can incur moral injury. Witnessing or participating in a situation that transgresses deeply held moral beliefs is the prerequisite for moral injury rather than physical danger. In different contexts, physicians and service members may ultimately face similar accumulated risk to their moral integrity, though of widely disparate intensity, frequency, and duration. Physicians face low-intensity, high-frequency threats over years; service members more often face high-intensity, less frequent threats during time-limited deployments. Just because moral injury was first applied to combat veterans—as was PTSD—does not mean we should limit the use of a powerfully resonant concept to a military population any more than we limited the use of Letterman’s ambulances or Morel’s tourniquets to the battlefield.2,3
Wendy Dean, MD; and Simon Talbot, MD
Author affiliations: Wendy Dean is President and co-founder of Moral Injury of Healthcare. Simon Talbot is a reconstructive plastic surgeon at Brigham and Women’s Hospital and associate professor of surgery at Harvard Medical School, Boston, Massachusetts.
Correspondence: Wendy Dean (wdean@moralinjury. Healthcare,@WDeanMD)
Disclosures: Wendy Dean and Simon Talbot founded Moral Injury of Healthcare, a nonprofit organization; they report no other actual or potential conflicts of interest with regard to this article.
References
1. Freudenberger HJ. The staff burn-out syndrome in alternative institutions. Psychother Theory Res Pract. 1975;12(1):73-82.
2. Place RJ. The strategic genius of Jonathan Letterman: the relevancy of the American Civil War to current health care policy makers. Mil Med. 2015;180(3):259-262.
3. Welling DR, McKay PL, Rasmussen TE, Rich NM. A brief history of the tourniquet. J Vasc Surg. 2012;55(1):286-290.
To the Editor: In the September 2019 guest editorial “Reframing Clinician Distress: Moral Injury Not Burnout,” the authors have advanced a thoughtful and provocative hypothesis addressing a salient issue.1 Their argument is that burnout does not accurately capture physician distress. Furthermore, they posit the term burnout focuses remediation strategies at the individual provider level, thereby discounting the contribution of the larger health care system. This is not the first effort to argue that burnout is not a syndrome of mental illness (eg, depression) located within the person but rather a disrupted physician-work relationship.2
As the authors cite, population and practice changes have contributed significantly to physician distress and dissatisfaction. Indeed, recent findings indicate that female physicians may suffer increased prevalence of burnout, which represents a challenge given the growing numbers of women in medicine.3 Unfortunately, by shifting focus almost exclusively to the system level to address burnout, the authors discount a large body of literature examining associations and contributors at the individual and clinic level.
Burnout is conceptualized as consisting of 3 domains: depersonalization, emotional exhaustion, and personal accomplishment.4 While this conceptualization may not capture the totality of physician distress, it has provided a body of literature focused on decreasing symptoms of burnout. Successful interventions have been targeted at the individual provider level (ie, stress management, small group discussion, mindfulness) as well as the organizational level (ie, reduction in duty hours, scribes).5,6 Recent studies have also suggested that increasing the occurrence of social encounters that are civil and respectful decreases reported physician burnout.7
Frustration, the annoyance or anger at being unable to change or achieve something, also can be a leading cause of burnout and moral injury. The inability to deal with unresolvable issues due to a lack of skills or inability to create a positive reframe can lead to a constellation of symptoms that are detrimental to the individual provider. Nevertheless, system rigidity, inability to recognitize pain and pressure, and goals perceived as unachievable can also lead to frustration. Physicians may experience growing frustration if they are unable to influence their systems. Thus, experiencing personal frustration, combined with an inability or lack of energy or time to influence a system can snowball.
Just as we counsel our patients that good medical care involves not only engagement with the medical system, but also individual engagement in their care (eg, nutrition, exercise), this problem requires a multicomponent solution. While advocating and working for a system that induces less moral injury, frustration, and burnout, physicians need to examine the resources available to them and their colleagues in a more immediate way.
Physician distress is a serious problem with both personal, patient, occupational, and public health costs. Thus, it is important that we grapple with the complexity of a multiconstruct definition amenable to multilevel interventions. The concept of moral injury is an important component and opens additional lines of both clinical inquiry and intervention. However, in our view, to subsume all burnout under this construct is overly reductive.
In closing, this topic is too important not to discuss. Let the conversations continue!
Lynne Padgett, PhD; and Joao L. Ascensao, MD, PhD
Author affiliations: Departments of Medicine and Mental Health, Washington DC VA Medical Center and Department of Medicine, George Washington University School of Medicine
Correspondence: Lynne Padgett ([email protected])
Disclosures: The authors report no conflict of interest with regard to this article.
References
1. Dean W, Talbot S, Dean A. Reframing clinical distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.
2. Epstein RM, Privitera MR. Doing something about physician burnout. Lancet. 2016;388(10057):2216-2217.
3. Templeton K, Bernstein CA, Sukhera J, et al. Gender-based differences in burnout: issues faced by women physicians. NAM Perspectives. Discussion Paper. Washington, DC: National Academy of Medicine; 2019. https://nam.edu/wp-content/uploads/2019/05/Gender-Based-Differences-in-Burnout.pdf. Published May 28, 2019. Accessed October 10, 2019.
4. Eckleberry-Hunt J Kirkpatrick H, Barbera T. The problems with burnout research. Acad Med. 2018;93(3):367-370.
5. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281.
6. Squiers JJ, Lobdell KW, Fann JI, DiMaio JM. Physician burnout: are we treating the symptom instead of the disease? Ann Thorac Surg. 2017;104(4):1117-1122.
7. Maslach C, Leiter MP. New insights into burnout and health care: strategies for improving civility and alleviating burnout. Med Teach. 2017;39(2):160-163.
To the Editor: We applaud Dean and her colleagues for their thought-provoking commentary on clinicians’ distress, a problem that has surged in recent years and has now reached epidemic proportions.1 Their argument focuses on the language used to define and frame clinical distress. Do we label this distress as burnout, as moral injury, or as something else? Moral injury occurs any time clinicians are impeded from doing the right thing at the right time in the right way; or even worse, doing the wrong thing to serve the needs of health system stakeholders other than the patient. These other stakeholders may include administrators, corporations, insurance adjusters, and others.
Naming the problem correctly is crucial to finding the solution. The name frames the discussion and impacts the solution. Burnout implies difficulty coping with the many stresses of health care and of personal responsibility for the problem. The solution would therefore be to help individuals to cope with their stresses. Moral injury on the other hand implies a corrupt system; thereby, reframing the discussion to systems issues and suggesting solutions by changing the business of health care delivery.
These authors state that current clinical distress is due to moral injury and not to burnout. Therefore, the business in which health care is performed needs to change.
The authors define the drivers of moral injury in our current system, mostly as (1) a massive information technology overload that has largely overtaken the patient as center of attention; and (2) the profit motive of the health care corporation and its shareholders. A focus on making profits has increased in the wake of falling reimbursements; the result is pressure on clinicians to see more patients more quickly and to do more even when not necessary. This has diverted the focus on healing patients to a focus on making profits. These major drivers of clinician distress—the electronic health record and the pressure to bill more—are fundamentally driven by the corporatization of American medicine in which profit is the measured outcome.
Thus rather than having their highest loyalty to patients and their families, clinicians now have other loyalties—the electronic health record, insurers, the hospital, the health care system, and even their own salaries.
Therein lies the moral injury felt by increasing numbers of clinicians, leading to soaring rates of clinical distress. Many physicians are now recognizing moral injury as the basis of their pain. For example, Gawande has described unceasing computer data entry as a cause of physician distress and physician loneliness in the interesting essay, “Why Doctors Hate Their Computers.”2 Topol has suggested that corporate interference and attention away from patient care is a reason doctors should unite and organize for a more healthful environment.3 Ofri has gone so far as to suggest that the health care system is surviving because it can exploit its physicians for every drop of energy, diverting the focus of clinical encounters on billing rather than healing.4 However, it may be simplistic to imply or state that all clinical distress is related to moral injury. Other factors in caring for the sick and dying also can cause distress to health care providers. Physicians work long, hard hours and listen to many stories of distress and suffering from patients. Some of this is internalized and processed as one’s own suffering. Clinicians also have enormous amounts of information to absorb and assimilate, keep long hours, and are often sleep deprived, all of which may harm their well-being. In addition, clinicians may have work/life imbalances, be hesitant to reveal their weaknesses, and have perfectionist personalities. Still other factors may also be involved, such as a hostile environment in which managers can overuse their power; racism that can limit opportunities for advancement; and/or a family-unfriendly environment.
Just as the treatment of cancer depends on good surgery, radiation and/or chemotherapy as well as reducing underlying predisposing cause (ie, smoking, drinking, obesity, antiviral therapy) and leading a healthy lifestyle, so too treatment of clinical distress needs a multipronged approach. Fixing the business framework is an important step forward but may not always be enough. We agree with the authors’ suggestions for improvement: bringing administrators and clinicians into conversation with each other, making clinician satisfaction a financial priority, assuring that physician leaders have cell phone numbers of their legislators, and reestablishing a sense of community among clinicians. However, none of these goals will be easy to accomplish and some may be impossible to realize in some settings.
A necessary corollary to the suggestions by Dean and colleagues is research. Much research is needed to discover all of the factors of clinician distress, whatever we name the problem. We need to know vulnerabilities of different populations of clinicians and differences in prevalence in different types of health care systems.
It is likely that physicians in a government-owned health care system, such as the US Department of Veterans Affairs (VA) hospitals, have lower distress since there are no corporate interests or profit motives. In our experience, we have noted that many VA providers are expatriates of private health care systems due to their moral distress. If profit making and corporatization are important factors in distress, then clinicians in the VA system should have much lower distress; however, this is not known.
We also need research in pilot projects that relieve clinician distress. These could relate to collegial activities to bring physicians—and administrators—together in community, allowing more time with patients than the usual 15-minute allotments, allowing more time for creative, narrative experiences in medicine, developing forums for discussion and resolution of distress-inducing situations, etc.
An important yet overlooked issue in this discussion is that clinician distress, regardless of its name or cause, is a public health crisis. Clinician distress not only affects the clinician most directly and most crucially, but also affects every person in his/her community. Physicians who are distressed for whatever reason deliver less adequate care, make more medical errors, and are less invested in their patients. Patients of distressed clinicians have less favorable outcomes and suffer more. Medical errors are now the third leading cause of death in the US. Much of this is due to inadequate care by focusing attention on profit-making over health improvement and to clinician distress. Clinician distress due to moral injury or any other factor is a public health crisis and needs much more attention, research, and prioritization of clinician satisfaction.
Paulette Mehta, MD, MPH; and Jay Mehta, PhD
Author Affiliations: Central Arkansas Veterans Health Care System; University of Arkansas for Medical Sciences
Correspondence: Paulette Mehta ([email protected])
Disclosures: The authors report no conflict of interest with regard to this article.
References
1. Dean W, Talbot S, Dean A. Reframing clinical distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.
2. Gawande A. Why doctors hate their computers. New Yorker. November 12, 2018. https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers. Accessed October 16, 2019.
3. Topol E. Why doctors should organize. New Yorker. August 5, 2019. https://www.newyorker.com/culture/annals-of-inquiry/why-doctors-should-organize. Accessed October 16, 2019.
4. Ofri D. The business of healthcare depends on exploiting doctors and nurses. The New York Times. June 8, 2019. https://www.nytimes.com/2019/06/08/opinion/sunday/hospitals-doctors-nurses-burnout.html. Accessed October 16, 2019.
To the Editor: The September 2019 editorial “Reframing clinician distress: moral injury not burnout” argues for a renaming of what has been called burnout to moral injury.1 The article by Dean, Talbot, and Dean compares the experience of health care providers to soldiers and other service members who have served in combat and suffer as a result of their experiences. I would like to comment on 2 areas: Whether the term burnout should be replaced with moral injury; and the adequacy of the recommendations made by Dean, Talbot, and Dean.
Briefly, my own credentials to opine on the topic include being both a physician and a soldier. I served in the US Army as a psychiatrist from 1986 to 2010 and deployed to various hazardous locations, including South Korea, Somalia, Iraq, and Guantanamo Bay, Cuba. Since my retirement from the Army I have worked as a psychiatrist on different front lines, with both veterans and the chronically mentally ill and often homeless population.
Moral injury is a term that was popularized by Johnathan Shay after the Vietnam War, especially in his masterful book Achilles in Vietnam.1 Most authors who have written on the subject of moral injury, including myself, think of it as feelings of guilt and shame related to (1) killing civilians (especially children or innocents); (2) surviving while other comrades did not; and/or (3) feeling betrayed by the government they served.2,3
While also arising in combat settings, moral injury is related but separate from posttraumatic stress disorder (PTSD). It comes from an affront to our morals rather than our physical well-being. It is not considered a medical diagnosis, treatments are experimental, and the literature is anecdotal.
I have mixed feelings about equating the moral injury from combat to working as a physician or other health care provider. On the one hand, certainly health care providers may sacrifice health and safety to taking care of patients. They may feel guilty when they cannot do enough for their patients. But does it rise to the same level as actually combat and having numerous comrades killed or maimed?
On the other hand, working on an inpatient psychiatry ward with an inner-city population who generally have severe mental illness and are often on phencyclidine and related drugs, has its own share of risks. Unfortunately, physical attacks on staff are way too common.
The term burnout also has a robust background of research into both causes and possible solutions. Indeed, there was even a journal devoted to it: Burnout Research.4 Moral injury research is on different populations, and generally the remedies are focused more on spiritual and existential support.
Which brings me to the recommendations and solutions part of the editorial. I agree that yoga and meditation, while beneficial, do not curb the feelings of frustration and betrayal that often arise when you cannot treat patients the way you feel they deserve. The recommendations listed in the editorial are a start, but much more should be done.
Now comes the hard part. Specifically, what more should be done? All the easy solutions have already been tried. Ones that would really make a difference, such as making an electronic health record that allows you to still look at and connect to the patient, seem to elude us. Many of us in the health care industry would love to have a single payer system across the board, to avoid all the inequities cited in the article. But health care, like climate change, is mired in our political deadlocks.
Therefore, I will finish by focusing on one of their recommendations, which is achievable: tie the incentives for the executive leadership to the satisfaction of health care providers, as is done for patient satisfaction. That is both doable and will benefit various institutions in the long run. Health care providers will be more likely to stay in a health care system and thus patient satisfaction improves. Win-win.
COL (Ret) Elspeth Cameron Ritchie, MD, MPH, USA
Author Affiliation: Uniformed Services University of the Health Sciences
Correspondence: Elspeth Cameron Ritchie ([email protected])
Disclosures: The author reports no conflict of interest with regard to this article.
References
1. Shay J. Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York: Atheneum; 1994.
2. Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin. Psychol Rev. 2009;29(8):695-706.
3. Ritchie EC. Moral injury: a profound sense of alienation and abject shame. Time. April 17, 2013. http://nation.time.com/2013/04/17/moral-injury-a-profound-sense-of-alienation-and-abject-shame.
4. Burnout Research. 2014;1(1):1-56. https://www.sciencedirect.com/journal/burnout-research/vol/1/issue/1. Accessed October 17, 2019.
Response: We appreciate the very thoughtful and thorough responses of Mehta. Mehta, Padgett, Ascensao, and Ritchie. Common themes in the responses were the suggestion that supplanting the term burnout with moral injury may not be appropriate and that changing the underlying drivers of distress requires a multifaceted approach, which is likely to require prolonged effort. We agree with both of these themes, believing the concept of moral injury and mitigation strategies do not benefit from reductionism.
Burnout is a nonspecific symptom constellation of emotional exhaustion, depersonalization, and a lack of a sense of accomplishment.1 Because it is nonspecific, the symptoms can arise from any number of situations, not only moral injury. However, from our conversations over the past 15 months, moral injury fuels a large percentage of burnout in health care. In a recent informal survey conducted at the ORExcellence meeting, almost all respondents believed they were experiencing moral injury rather than burnout when both terms were explained. When clinicians are physically and emotionally exhausted with battling a broken system in their efforts to provide good care—when they have incurred innumerable moral insults, amassing to a moral injury—many give up. This is the end stage of moral injury, or burnout.We absolutely agree research is necessary to validate this concept, which has been applied only to health care since July 2018. We are pursuing various avenues of inquiry and are validating a new assessment tool. But we do not believe that intervention must wait until there are data to support what resonates so profoundly with so many and, as we have heard dozens of times, “finally gives language to my experience.”Finally, we would not suggest that civilian physician experience is equivalent to combat experience. But just as there are multiple etiologies for posttraumatic stress disorder (PTSD), such as combat exposure, physical abuse, sexual assault, there are likely multiple ways one can incur moral injury. Witnessing or participating in a situation that transgresses deeply held moral beliefs is the prerequisite for moral injury rather than physical danger. In different contexts, physicians and service members may ultimately face similar accumulated risk to their moral integrity, though of widely disparate intensity, frequency, and duration. Physicians face low-intensity, high-frequency threats over years; service members more often face high-intensity, less frequent threats during time-limited deployments. Just because moral injury was first applied to combat veterans—as was PTSD—does not mean we should limit the use of a powerfully resonant concept to a military population any more than we limited the use of Letterman’s ambulances or Morel’s tourniquets to the battlefield.2,3
Wendy Dean, MD; and Simon Talbot, MD
Author affiliations: Wendy Dean is President and co-founder of Moral Injury of Healthcare. Simon Talbot is a reconstructive plastic surgeon at Brigham and Women’s Hospital and associate professor of surgery at Harvard Medical School, Boston, Massachusetts.
Correspondence: Wendy Dean (wdean@moralinjury. Healthcare,@WDeanMD)
Disclosures: Wendy Dean and Simon Talbot founded Moral Injury of Healthcare, a nonprofit organization; they report no other actual or potential conflicts of interest with regard to this article.
References
1. Freudenberger HJ. The staff burn-out syndrome in alternative institutions. Psychother Theory Res Pract. 1975;12(1):73-82.
2. Place RJ. The strategic genius of Jonathan Letterman: the relevancy of the American Civil War to current health care policy makers. Mil Med. 2015;180(3):259-262.
3. Welling DR, McKay PL, Rasmussen TE, Rich NM. A brief history of the tourniquet. J Vasc Surg. 2012;55(1):286-290.
The Jewel in the Lotus: A Meditation on Memory for Veterans Day 2019
On the 11th day of the 11th month, we celebrate Veterans Day (no apostrophe because it is not a day that veterans possess or that belongs to any individual veteran).2,3 Interestingly, the US Department of Defense (DoD) and the US Department of Veterans Affairs (VA) have web pages correcting any confusion about the meaning of Memorial Day and Veterans Day so that the public understands the unique purpose of each holiday. Memorial Day commemorates all those who lost their lives in the line of duty to the nation, whereas Veterans Day commemorates all those who have honorably served their country as service members. While Memorial Day is a solemn occasion of remembering and respect for those who have died, Veterans Day is an event of gratitude and appreciation focused on veterans still living. The dual mission of the 2 holidays is to remind the public of the debt of remembrance and reverence we owe all veterans both those who have gone before us and those who remain with us.
Memory is what most intrinsically unites the 2 commemorations. In fact, in Great Britain, Canada, and Australia, November 11 is called Remembrance Day.2 Yet memory is a double-edged sword that can be raised in tribute to service members or can deeply lacerate them. Many of the wounds that cause the most prolonged and deepest suffering are not physical—they are mental. Disturbances of memory are among the criteria for posttraumatic stress disorder (PTSD). Under its section on intrusive cluster, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) lists “recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).” The avoidance cluster underscores how the afflicted mind tries to escape itself: “Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).”4
PTSD was first recognized as a psychiatric diagnosis in DSM-III in 1980, and since then VA and DoD have devoted enormous resources to developing effective treatments for the disorder, most notably evidence-based psychotherapies. Sadly ironic, the only psychiatric disorder whose etiology is understood has proved to be the most difficult to treat much less cure. As with most serious mental illnesses, some cases become chronic and refractory to the best of care. These tormented individuals live as if in a twilight zone between the past and the present.
Memory and war have a long history in literature, poetry, and history. Haunting memories of PTSD are found in the ancient epics of Homer. On the long treacherous journey home from sacking Troy, Odysseus and his army arrive in the land of the Lotus-eaters, where native sweet fruit induces a state of timeless forgetfulness in which torment and tragedy dissolve along with motivation and meaning.5 Jonathan Shay, VA psychiatrist and pioneer of the Homer-PTSD connection, suggested the analogy between the land of the Lotus-eaters and addiction: Each is a self-medication of the psychic aftermath of war.6
But what if those devastating memories could be selectively erased or even better blocked before they were formed? Although this solution may seem like science fiction, research into these possibilities is in reality science fact. Over the past decades, the DoD and the VA have sought such a neuroscience jewel in the lotus. Studies in rodents and humans have looked at the ability of a number of medications, most recently β blockers, such as propranolol, to interfere with the consolidation of emotionally traumatic memories (memory erasure) and disrupting their retention once consolidated (memory extinction).7 While researchers cannot yet completely wipe out a selected memory, like in the movie Star Trek, it has been shown that medications at least in study settings do reduce fear and can attenuate the development of PTSD when combined with psychotherapy. Neuroscientists call these more realistic alterations of recall memory dampening. Though these medications are not ready for regular clinical application, the unprecedented pace of neuroscience makes it nearly inevitable that in the not so distant future some significant blunting of traumatic memory will be possible.
Once science answers in the affirmative the question, “Is this intervention something we could conceivably do?” The next question belongs to ethics, “Is this intervention something we should do even if we can?” As early as 2001, the President’s Council on Bioethics answered the latter with “probably not.”
Use of memory-blunters at the time of traumatic events could interfere with the normal psychic work and adaptive value of emotionally charged memory....Thus, by blunting the emotional impact of events, beta-blockers or their successors would concomitantly weaken our recollection of the traumatic events we have just experienced. Yet often it is important in the after of such events that at least someone remember them clearly. For legal reasons, to say nothing of deeper social and personal ones, the wisdom of routinely interfering with the memories of traumatic survivors and witnesses is highly questionable.8
Many neuroscientists and neuroethicists objected to the perspective of the Bioethics Council as being too puritanical and its position overly pessimistic:
Whereas memory dampening has its drawbacks, such may be the price we pay in order to heal immense suffering. In some contexts, there may be steps that ought to be taken to preserve valuable factual or emotional information contained in memory, even when we must delay or otherwise impose limits on access to memory dampening. None of these concerns, however, even if they find empirical support, are strong enough to justify brushed restrictions on memory dampening.9
The proponents of the 2 views propose and oppose the contrarian position on issues both philosophical and practical, such as the function of traumatic experience in personal growth; how the preservation of memory is related to the integrity of the person and authenticity of the life lived; how blunting of memories of especially combat trauma may normalize our reactions to suffering and evil; and most important for this Veterans Day essay, whether remembering is an ethical duty and if so whose is it to discharge, the individual, his family, community, or country.
More pragmatic, there would be a need to refine our understanding of the risk factors for chronic and disabling PTSD; to determine when in the course of the trauma experience to pharmacologically interfere with memory and to what degree and scope; how to protect the autonomy of the service member to consent or to refuse the procedure within the recognized confines of military ethics; and most important for this essay, how to prevent governments, corporations, or any other entity from exploiting neurobiologic discoveries for power or profit.
Elie Wiesel is an important modern prophet of the critical role of memory in the survival of civilization. His prophecy is rooted in the incomprehensible anguish and horror he personally and communally witnessed in the Holocaust. He suggests in this editorial’s epigraph that there are deep and profound issues to be pondered about memory and its inextricable link to suffering. Meditations offer thoughts, not answers, and I encourage readers to spend a few minutes considering the solemn ones presented here this Veterans Day.
1. Wiesel E. Nobel lecture: hope, despair and memory. https://www.nobelprize.org/prizes/peace/1986/wiesel/lecture. Published December 11, 1986. Accessed October 20, 2019.
2. US Department of Veterans Affairs, Office of Public and Intergovernmental Affairs. Veterans Day frequently asked questions. https://www.va.gov/opa/vetsday/vetday_faq.asp. Accessed October 29, 2019.
3. Lange K. Five facts to know about Veterans Day. https://www.defense.gov/explore/story/article/1675470/5-facts-to-know-about-veterans-day. Published November 5, 2019. Accessed October 29, 2019.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.
5. Homer. The Odyssey. Wilson E, trans. New York: Norton; 2018:Bk 9:90 ff.
6. Shay J. Odysseus in America. New York: Scribner’s; 2002:35-41. 7. Giustino TF, Fitzgerald PJ, Maren S. Revisiting propranolol and PTSD: memory erasure or extinction enhancement. Neurobiol Learn Mem. 2016;130:26-33.
8. President’s Council on Bioethics. Beyond therapy: biotechnology and the pursuit of happiness. https://bioethicsarchive.georgetown.edu/pcbe/reports/beyondtherapy/fulldoc.html. Published October 15, 2003. Accessed October 30, 2019.
9. Kobler AJ. Ethical implications of memory dampening. In: Farah MJ, ed. Neuroethics: An Introduction with Readings. Cambridge MA: MIT Press; 2010:112.
On the 11th day of the 11th month, we celebrate Veterans Day (no apostrophe because it is not a day that veterans possess or that belongs to any individual veteran).2,3 Interestingly, the US Department of Defense (DoD) and the US Department of Veterans Affairs (VA) have web pages correcting any confusion about the meaning of Memorial Day and Veterans Day so that the public understands the unique purpose of each holiday. Memorial Day commemorates all those who lost their lives in the line of duty to the nation, whereas Veterans Day commemorates all those who have honorably served their country as service members. While Memorial Day is a solemn occasion of remembering and respect for those who have died, Veterans Day is an event of gratitude and appreciation focused on veterans still living. The dual mission of the 2 holidays is to remind the public of the debt of remembrance and reverence we owe all veterans both those who have gone before us and those who remain with us.
Memory is what most intrinsically unites the 2 commemorations. In fact, in Great Britain, Canada, and Australia, November 11 is called Remembrance Day.2 Yet memory is a double-edged sword that can be raised in tribute to service members or can deeply lacerate them. Many of the wounds that cause the most prolonged and deepest suffering are not physical—they are mental. Disturbances of memory are among the criteria for posttraumatic stress disorder (PTSD). Under its section on intrusive cluster, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) lists “recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).” The avoidance cluster underscores how the afflicted mind tries to escape itself: “Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).”4
PTSD was first recognized as a psychiatric diagnosis in DSM-III in 1980, and since then VA and DoD have devoted enormous resources to developing effective treatments for the disorder, most notably evidence-based psychotherapies. Sadly ironic, the only psychiatric disorder whose etiology is understood has proved to be the most difficult to treat much less cure. As with most serious mental illnesses, some cases become chronic and refractory to the best of care. These tormented individuals live as if in a twilight zone between the past and the present.
Memory and war have a long history in literature, poetry, and history. Haunting memories of PTSD are found in the ancient epics of Homer. On the long treacherous journey home from sacking Troy, Odysseus and his army arrive in the land of the Lotus-eaters, where native sweet fruit induces a state of timeless forgetfulness in which torment and tragedy dissolve along with motivation and meaning.5 Jonathan Shay, VA psychiatrist and pioneer of the Homer-PTSD connection, suggested the analogy between the land of the Lotus-eaters and addiction: Each is a self-medication of the psychic aftermath of war.6
But what if those devastating memories could be selectively erased or even better blocked before they were formed? Although this solution may seem like science fiction, research into these possibilities is in reality science fact. Over the past decades, the DoD and the VA have sought such a neuroscience jewel in the lotus. Studies in rodents and humans have looked at the ability of a number of medications, most recently β blockers, such as propranolol, to interfere with the consolidation of emotionally traumatic memories (memory erasure) and disrupting their retention once consolidated (memory extinction).7 While researchers cannot yet completely wipe out a selected memory, like in the movie Star Trek, it has been shown that medications at least in study settings do reduce fear and can attenuate the development of PTSD when combined with psychotherapy. Neuroscientists call these more realistic alterations of recall memory dampening. Though these medications are not ready for regular clinical application, the unprecedented pace of neuroscience makes it nearly inevitable that in the not so distant future some significant blunting of traumatic memory will be possible.
Once science answers in the affirmative the question, “Is this intervention something we could conceivably do?” The next question belongs to ethics, “Is this intervention something we should do even if we can?” As early as 2001, the President’s Council on Bioethics answered the latter with “probably not.”
Use of memory-blunters at the time of traumatic events could interfere with the normal psychic work and adaptive value of emotionally charged memory....Thus, by blunting the emotional impact of events, beta-blockers or their successors would concomitantly weaken our recollection of the traumatic events we have just experienced. Yet often it is important in the after of such events that at least someone remember them clearly. For legal reasons, to say nothing of deeper social and personal ones, the wisdom of routinely interfering with the memories of traumatic survivors and witnesses is highly questionable.8
Many neuroscientists and neuroethicists objected to the perspective of the Bioethics Council as being too puritanical and its position overly pessimistic:
Whereas memory dampening has its drawbacks, such may be the price we pay in order to heal immense suffering. In some contexts, there may be steps that ought to be taken to preserve valuable factual or emotional information contained in memory, even when we must delay or otherwise impose limits on access to memory dampening. None of these concerns, however, even if they find empirical support, are strong enough to justify brushed restrictions on memory dampening.9
The proponents of the 2 views propose and oppose the contrarian position on issues both philosophical and practical, such as the function of traumatic experience in personal growth; how the preservation of memory is related to the integrity of the person and authenticity of the life lived; how blunting of memories of especially combat trauma may normalize our reactions to suffering and evil; and most important for this Veterans Day essay, whether remembering is an ethical duty and if so whose is it to discharge, the individual, his family, community, or country.
More pragmatic, there would be a need to refine our understanding of the risk factors for chronic and disabling PTSD; to determine when in the course of the trauma experience to pharmacologically interfere with memory and to what degree and scope; how to protect the autonomy of the service member to consent or to refuse the procedure within the recognized confines of military ethics; and most important for this essay, how to prevent governments, corporations, or any other entity from exploiting neurobiologic discoveries for power or profit.
Elie Wiesel is an important modern prophet of the critical role of memory in the survival of civilization. His prophecy is rooted in the incomprehensible anguish and horror he personally and communally witnessed in the Holocaust. He suggests in this editorial’s epigraph that there are deep and profound issues to be pondered about memory and its inextricable link to suffering. Meditations offer thoughts, not answers, and I encourage readers to spend a few minutes considering the solemn ones presented here this Veterans Day.
On the 11th day of the 11th month, we celebrate Veterans Day (no apostrophe because it is not a day that veterans possess or that belongs to any individual veteran).2,3 Interestingly, the US Department of Defense (DoD) and the US Department of Veterans Affairs (VA) have web pages correcting any confusion about the meaning of Memorial Day and Veterans Day so that the public understands the unique purpose of each holiday. Memorial Day commemorates all those who lost their lives in the line of duty to the nation, whereas Veterans Day commemorates all those who have honorably served their country as service members. While Memorial Day is a solemn occasion of remembering and respect for those who have died, Veterans Day is an event of gratitude and appreciation focused on veterans still living. The dual mission of the 2 holidays is to remind the public of the debt of remembrance and reverence we owe all veterans both those who have gone before us and those who remain with us.
Memory is what most intrinsically unites the 2 commemorations. In fact, in Great Britain, Canada, and Australia, November 11 is called Remembrance Day.2 Yet memory is a double-edged sword that can be raised in tribute to service members or can deeply lacerate them. Many of the wounds that cause the most prolonged and deepest suffering are not physical—they are mental. Disturbances of memory are among the criteria for posttraumatic stress disorder (PTSD). Under its section on intrusive cluster, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) lists “recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).” The avoidance cluster underscores how the afflicted mind tries to escape itself: “Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).”4
PTSD was first recognized as a psychiatric diagnosis in DSM-III in 1980, and since then VA and DoD have devoted enormous resources to developing effective treatments for the disorder, most notably evidence-based psychotherapies. Sadly ironic, the only psychiatric disorder whose etiology is understood has proved to be the most difficult to treat much less cure. As with most serious mental illnesses, some cases become chronic and refractory to the best of care. These tormented individuals live as if in a twilight zone between the past and the present.
Memory and war have a long history in literature, poetry, and history. Haunting memories of PTSD are found in the ancient epics of Homer. On the long treacherous journey home from sacking Troy, Odysseus and his army arrive in the land of the Lotus-eaters, where native sweet fruit induces a state of timeless forgetfulness in which torment and tragedy dissolve along with motivation and meaning.5 Jonathan Shay, VA psychiatrist and pioneer of the Homer-PTSD connection, suggested the analogy between the land of the Lotus-eaters and addiction: Each is a self-medication of the psychic aftermath of war.6
But what if those devastating memories could be selectively erased or even better blocked before they were formed? Although this solution may seem like science fiction, research into these possibilities is in reality science fact. Over the past decades, the DoD and the VA have sought such a neuroscience jewel in the lotus. Studies in rodents and humans have looked at the ability of a number of medications, most recently β blockers, such as propranolol, to interfere with the consolidation of emotionally traumatic memories (memory erasure) and disrupting their retention once consolidated (memory extinction).7 While researchers cannot yet completely wipe out a selected memory, like in the movie Star Trek, it has been shown that medications at least in study settings do reduce fear and can attenuate the development of PTSD when combined with psychotherapy. Neuroscientists call these more realistic alterations of recall memory dampening. Though these medications are not ready for regular clinical application, the unprecedented pace of neuroscience makes it nearly inevitable that in the not so distant future some significant blunting of traumatic memory will be possible.
Once science answers in the affirmative the question, “Is this intervention something we could conceivably do?” The next question belongs to ethics, “Is this intervention something we should do even if we can?” As early as 2001, the President’s Council on Bioethics answered the latter with “probably not.”
Use of memory-blunters at the time of traumatic events could interfere with the normal psychic work and adaptive value of emotionally charged memory....Thus, by blunting the emotional impact of events, beta-blockers or their successors would concomitantly weaken our recollection of the traumatic events we have just experienced. Yet often it is important in the after of such events that at least someone remember them clearly. For legal reasons, to say nothing of deeper social and personal ones, the wisdom of routinely interfering with the memories of traumatic survivors and witnesses is highly questionable.8
Many neuroscientists and neuroethicists objected to the perspective of the Bioethics Council as being too puritanical and its position overly pessimistic:
Whereas memory dampening has its drawbacks, such may be the price we pay in order to heal immense suffering. In some contexts, there may be steps that ought to be taken to preserve valuable factual or emotional information contained in memory, even when we must delay or otherwise impose limits on access to memory dampening. None of these concerns, however, even if they find empirical support, are strong enough to justify brushed restrictions on memory dampening.9
The proponents of the 2 views propose and oppose the contrarian position on issues both philosophical and practical, such as the function of traumatic experience in personal growth; how the preservation of memory is related to the integrity of the person and authenticity of the life lived; how blunting of memories of especially combat trauma may normalize our reactions to suffering and evil; and most important for this Veterans Day essay, whether remembering is an ethical duty and if so whose is it to discharge, the individual, his family, community, or country.
More pragmatic, there would be a need to refine our understanding of the risk factors for chronic and disabling PTSD; to determine when in the course of the trauma experience to pharmacologically interfere with memory and to what degree and scope; how to protect the autonomy of the service member to consent or to refuse the procedure within the recognized confines of military ethics; and most important for this essay, how to prevent governments, corporations, or any other entity from exploiting neurobiologic discoveries for power or profit.
Elie Wiesel is an important modern prophet of the critical role of memory in the survival of civilization. His prophecy is rooted in the incomprehensible anguish and horror he personally and communally witnessed in the Holocaust. He suggests in this editorial’s epigraph that there are deep and profound issues to be pondered about memory and its inextricable link to suffering. Meditations offer thoughts, not answers, and I encourage readers to spend a few minutes considering the solemn ones presented here this Veterans Day.
1. Wiesel E. Nobel lecture: hope, despair and memory. https://www.nobelprize.org/prizes/peace/1986/wiesel/lecture. Published December 11, 1986. Accessed October 20, 2019.
2. US Department of Veterans Affairs, Office of Public and Intergovernmental Affairs. Veterans Day frequently asked questions. https://www.va.gov/opa/vetsday/vetday_faq.asp. Accessed October 29, 2019.
3. Lange K. Five facts to know about Veterans Day. https://www.defense.gov/explore/story/article/1675470/5-facts-to-know-about-veterans-day. Published November 5, 2019. Accessed October 29, 2019.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.
5. Homer. The Odyssey. Wilson E, trans. New York: Norton; 2018:Bk 9:90 ff.
6. Shay J. Odysseus in America. New York: Scribner’s; 2002:35-41. 7. Giustino TF, Fitzgerald PJ, Maren S. Revisiting propranolol and PTSD: memory erasure or extinction enhancement. Neurobiol Learn Mem. 2016;130:26-33.
8. President’s Council on Bioethics. Beyond therapy: biotechnology and the pursuit of happiness. https://bioethicsarchive.georgetown.edu/pcbe/reports/beyondtherapy/fulldoc.html. Published October 15, 2003. Accessed October 30, 2019.
9. Kobler AJ. Ethical implications of memory dampening. In: Farah MJ, ed. Neuroethics: An Introduction with Readings. Cambridge MA: MIT Press; 2010:112.
1. Wiesel E. Nobel lecture: hope, despair and memory. https://www.nobelprize.org/prizes/peace/1986/wiesel/lecture. Published December 11, 1986. Accessed October 20, 2019.
2. US Department of Veterans Affairs, Office of Public and Intergovernmental Affairs. Veterans Day frequently asked questions. https://www.va.gov/opa/vetsday/vetday_faq.asp. Accessed October 29, 2019.
3. Lange K. Five facts to know about Veterans Day. https://www.defense.gov/explore/story/article/1675470/5-facts-to-know-about-veterans-day. Published November 5, 2019. Accessed October 29, 2019.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.
5. Homer. The Odyssey. Wilson E, trans. New York: Norton; 2018:Bk 9:90 ff.
6. Shay J. Odysseus in America. New York: Scribner’s; 2002:35-41. 7. Giustino TF, Fitzgerald PJ, Maren S. Revisiting propranolol and PTSD: memory erasure or extinction enhancement. Neurobiol Learn Mem. 2016;130:26-33.
8. President’s Council on Bioethics. Beyond therapy: biotechnology and the pursuit of happiness. https://bioethicsarchive.georgetown.edu/pcbe/reports/beyondtherapy/fulldoc.html. Published October 15, 2003. Accessed October 30, 2019.
9. Kobler AJ. Ethical implications of memory dampening. In: Farah MJ, ed. Neuroethics: An Introduction with Readings. Cambridge MA: MIT Press; 2010:112.
Ask about vaping and e-cigarette use
When we studied the knowledge and practice of e-cigarette use among pregnant women in one of our outpatient practices, we found that 43% of more than 300 survey participants believed e-cigarettes are less harmful to a fetus than traditional cigarettes. Just over half – 57% – believed that e-cigarettes contain nicotine.
This study from 5 years ago demonstrated the need for more patient education.1 Today, we have even more clarity that, while there may be health benefits of switching to noncombustible forms of nicotine consumption outside of pregnancy, these potential benefits do not extend to pregnancy. Both human and animal studies have demonstrated that nicotine itself is harmful to the developing fetus; the Centers for Disease Control and Prevention warns against the use of e-cigarettes in pregnancy for this reason.
A 2018 literature review on the use of e-cigarettes in pregnancy and the effects on perinatal/neonatal outcomes reported that the amount of nicotine consumed by e-cigarette users is similar to that of cigarette smokers and that most animal studies suggest a potential danger to the fetus, primarily because of the nicotine.2 Effects on the immune system, neural development, lung function, and cardiac function were all noted in the review. Other research has shown that e-cigarette fluid can contain formaldehyde and other harmful substances.
A new analysis of data from the 2014-2017 National Health Interview Survey shows a significantly lower prevalence of conventional cigarette use among pregnant women than in nonpregnant women, and an almost identical prevalence of e-cigarette use among pregnant and nonpregnant women of reproductive age.3 This discrepancy again suggests that women may not be aware of the potential harms of e-cigarettes in pregnancy, which is not surprising considering that prenatal care clinicians often are not appropriately screening or counseling regarding e-cigarette use.4
and counsel women that the use of e-cigarettes is not a safer alternative to cigarette smoking. I urge patients who have switched to e-cigarettes as a means of smoking cessation or as a choice they perceive to be safer to work together with me to find another way to reduce potential harm to their baby.
References
1. J Addict Med. 2015 Jul-Aug;9(4):266-72.
2. Obstet Gynecol Surv. 2018 Sep;73(9):544-9.
3. JAMA Pediatr. 2019 Jun 1;173(6):600-2.
4. Am J Obstet Gynecol. 2014 Dec;211(6):695.e1-7.
When we studied the knowledge and practice of e-cigarette use among pregnant women in one of our outpatient practices, we found that 43% of more than 300 survey participants believed e-cigarettes are less harmful to a fetus than traditional cigarettes. Just over half – 57% – believed that e-cigarettes contain nicotine.
This study from 5 years ago demonstrated the need for more patient education.1 Today, we have even more clarity that, while there may be health benefits of switching to noncombustible forms of nicotine consumption outside of pregnancy, these potential benefits do not extend to pregnancy. Both human and animal studies have demonstrated that nicotine itself is harmful to the developing fetus; the Centers for Disease Control and Prevention warns against the use of e-cigarettes in pregnancy for this reason.
A 2018 literature review on the use of e-cigarettes in pregnancy and the effects on perinatal/neonatal outcomes reported that the amount of nicotine consumed by e-cigarette users is similar to that of cigarette smokers and that most animal studies suggest a potential danger to the fetus, primarily because of the nicotine.2 Effects on the immune system, neural development, lung function, and cardiac function were all noted in the review. Other research has shown that e-cigarette fluid can contain formaldehyde and other harmful substances.
A new analysis of data from the 2014-2017 National Health Interview Survey shows a significantly lower prevalence of conventional cigarette use among pregnant women than in nonpregnant women, and an almost identical prevalence of e-cigarette use among pregnant and nonpregnant women of reproductive age.3 This discrepancy again suggests that women may not be aware of the potential harms of e-cigarettes in pregnancy, which is not surprising considering that prenatal care clinicians often are not appropriately screening or counseling regarding e-cigarette use.4
and counsel women that the use of e-cigarettes is not a safer alternative to cigarette smoking. I urge patients who have switched to e-cigarettes as a means of smoking cessation or as a choice they perceive to be safer to work together with me to find another way to reduce potential harm to their baby.
References
1. J Addict Med. 2015 Jul-Aug;9(4):266-72.
2. Obstet Gynecol Surv. 2018 Sep;73(9):544-9.
3. JAMA Pediatr. 2019 Jun 1;173(6):600-2.
4. Am J Obstet Gynecol. 2014 Dec;211(6):695.e1-7.
When we studied the knowledge and practice of e-cigarette use among pregnant women in one of our outpatient practices, we found that 43% of more than 300 survey participants believed e-cigarettes are less harmful to a fetus than traditional cigarettes. Just over half – 57% – believed that e-cigarettes contain nicotine.
This study from 5 years ago demonstrated the need for more patient education.1 Today, we have even more clarity that, while there may be health benefits of switching to noncombustible forms of nicotine consumption outside of pregnancy, these potential benefits do not extend to pregnancy. Both human and animal studies have demonstrated that nicotine itself is harmful to the developing fetus; the Centers for Disease Control and Prevention warns against the use of e-cigarettes in pregnancy for this reason.
A 2018 literature review on the use of e-cigarettes in pregnancy and the effects on perinatal/neonatal outcomes reported that the amount of nicotine consumed by e-cigarette users is similar to that of cigarette smokers and that most animal studies suggest a potential danger to the fetus, primarily because of the nicotine.2 Effects on the immune system, neural development, lung function, and cardiac function were all noted in the review. Other research has shown that e-cigarette fluid can contain formaldehyde and other harmful substances.
A new analysis of data from the 2014-2017 National Health Interview Survey shows a significantly lower prevalence of conventional cigarette use among pregnant women than in nonpregnant women, and an almost identical prevalence of e-cigarette use among pregnant and nonpregnant women of reproductive age.3 This discrepancy again suggests that women may not be aware of the potential harms of e-cigarettes in pregnancy, which is not surprising considering that prenatal care clinicians often are not appropriately screening or counseling regarding e-cigarette use.4
and counsel women that the use of e-cigarettes is not a safer alternative to cigarette smoking. I urge patients who have switched to e-cigarettes as a means of smoking cessation or as a choice they perceive to be safer to work together with me to find another way to reduce potential harm to their baby.
References
1. J Addict Med. 2015 Jul-Aug;9(4):266-72.
2. Obstet Gynecol Surv. 2018 Sep;73(9):544-9.
3. JAMA Pediatr. 2019 Jun 1;173(6):600-2.
4. Am J Obstet Gynecol. 2014 Dec;211(6):695.e1-7.
Cannabis and prenatal care
We know that the environment significantly impacts our health. People who live in areas prone to industrial waste, poor air or water quality, and crime have higher risks for cardiovascular disease, severe asthma, and stress-induced illnesses. Children who grow up under these conditions can experience a failure to thrive.
As ob.gyns., we also recognize that the intrauterine environment plays a key role in influencing embryonic and fetal development. For this reason, we counsel our pregnant patients to eat well-balanced diets, drink healthy amounts of water, get plenty of rest, and incorporate physical activity into their daily routines. Indeed, the seminal work by Sir David Barker demonstrated that the roots of chronic diseases – including hypertension, stroke, and type 2 diabetes – begin in utero. We truly are where we live – from before birth up through adulthood.
Because the womb environment, where we spend the first critical 9 months of life, dramatically affects our lifelong health, we advise against the use of certain medications and other substances during pregnancy. Some of these recommendations seem clear-cut: Don’t smoke and significantly reduce or abstain from alcohol consumption; illicit drugs – such as cocaine or heroin – should never be used. However, gray areas exist. For example, although anticonvulsants carry higher risks for congenital malformations, patients who experience seizures may need to continue taking antiepileptic drugs during pregnancy, especially those with long safety records.
One of the newer challenges the medical community in general must face is the broadened use and wider societal acceptance of cannabis. Currently legal in 33 U.S. states and Washington, D.C., medical marijuana now is viewed as another legitimate tool in the health care arsenal, rather than the off-limits, off-label substance it was less than a generation ago.
Although proponents may tout the health benefits of cannabis and related products like cannabidiol, it remains unclear what the long-term effects of routine use may have on development, especially fetal development. However, how we as ob.gyns. navigate conversations with our patients around substance use remains crucial to our delivery of the best possible prenatal care.
We have invited Katrina S. Mark, MD, associate professor of obstetrics, gynecology, and reproductive sciences at the University of Maryland School of Medicine, to examine use of cannabis in pregnancy and the need for maintaining trust in the patient-practitioner relationship when discussing substance use during prenatal counseling.
Dr. Reece, who specializes in maternal-fetal medicine, is executive vice president for medical affairs at the University of Maryland School of Medicine as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. He is the medical editor of this column. He said he had no relevant financial disclosures. Contact him at [email protected].
We know that the environment significantly impacts our health. People who live in areas prone to industrial waste, poor air or water quality, and crime have higher risks for cardiovascular disease, severe asthma, and stress-induced illnesses. Children who grow up under these conditions can experience a failure to thrive.
As ob.gyns., we also recognize that the intrauterine environment plays a key role in influencing embryonic and fetal development. For this reason, we counsel our pregnant patients to eat well-balanced diets, drink healthy amounts of water, get plenty of rest, and incorporate physical activity into their daily routines. Indeed, the seminal work by Sir David Barker demonstrated that the roots of chronic diseases – including hypertension, stroke, and type 2 diabetes – begin in utero. We truly are where we live – from before birth up through adulthood.
Because the womb environment, where we spend the first critical 9 months of life, dramatically affects our lifelong health, we advise against the use of certain medications and other substances during pregnancy. Some of these recommendations seem clear-cut: Don’t smoke and significantly reduce or abstain from alcohol consumption; illicit drugs – such as cocaine or heroin – should never be used. However, gray areas exist. For example, although anticonvulsants carry higher risks for congenital malformations, patients who experience seizures may need to continue taking antiepileptic drugs during pregnancy, especially those with long safety records.
One of the newer challenges the medical community in general must face is the broadened use and wider societal acceptance of cannabis. Currently legal in 33 U.S. states and Washington, D.C., medical marijuana now is viewed as another legitimate tool in the health care arsenal, rather than the off-limits, off-label substance it was less than a generation ago.
Although proponents may tout the health benefits of cannabis and related products like cannabidiol, it remains unclear what the long-term effects of routine use may have on development, especially fetal development. However, how we as ob.gyns. navigate conversations with our patients around substance use remains crucial to our delivery of the best possible prenatal care.
We have invited Katrina S. Mark, MD, associate professor of obstetrics, gynecology, and reproductive sciences at the University of Maryland School of Medicine, to examine use of cannabis in pregnancy and the need for maintaining trust in the patient-practitioner relationship when discussing substance use during prenatal counseling.
Dr. Reece, who specializes in maternal-fetal medicine, is executive vice president for medical affairs at the University of Maryland School of Medicine as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. He is the medical editor of this column. He said he had no relevant financial disclosures. Contact him at [email protected].
We know that the environment significantly impacts our health. People who live in areas prone to industrial waste, poor air or water quality, and crime have higher risks for cardiovascular disease, severe asthma, and stress-induced illnesses. Children who grow up under these conditions can experience a failure to thrive.
As ob.gyns., we also recognize that the intrauterine environment plays a key role in influencing embryonic and fetal development. For this reason, we counsel our pregnant patients to eat well-balanced diets, drink healthy amounts of water, get plenty of rest, and incorporate physical activity into their daily routines. Indeed, the seminal work by Sir David Barker demonstrated that the roots of chronic diseases – including hypertension, stroke, and type 2 diabetes – begin in utero. We truly are where we live – from before birth up through adulthood.
Because the womb environment, where we spend the first critical 9 months of life, dramatically affects our lifelong health, we advise against the use of certain medications and other substances during pregnancy. Some of these recommendations seem clear-cut: Don’t smoke and significantly reduce or abstain from alcohol consumption; illicit drugs – such as cocaine or heroin – should never be used. However, gray areas exist. For example, although anticonvulsants carry higher risks for congenital malformations, patients who experience seizures may need to continue taking antiepileptic drugs during pregnancy, especially those with long safety records.
One of the newer challenges the medical community in general must face is the broadened use and wider societal acceptance of cannabis. Currently legal in 33 U.S. states and Washington, D.C., medical marijuana now is viewed as another legitimate tool in the health care arsenal, rather than the off-limits, off-label substance it was less than a generation ago.
Although proponents may tout the health benefits of cannabis and related products like cannabidiol, it remains unclear what the long-term effects of routine use may have on development, especially fetal development. However, how we as ob.gyns. navigate conversations with our patients around substance use remains crucial to our delivery of the best possible prenatal care.
We have invited Katrina S. Mark, MD, associate professor of obstetrics, gynecology, and reproductive sciences at the University of Maryland School of Medicine, to examine use of cannabis in pregnancy and the need for maintaining trust in the patient-practitioner relationship when discussing substance use during prenatal counseling.
Dr. Reece, who specializes in maternal-fetal medicine, is executive vice president for medical affairs at the University of Maryland School of Medicine as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. He is the medical editor of this column. He said he had no relevant financial disclosures. Contact him at [email protected].
Counseling on cannabis use in pregnancy
A flurry of research papers published this year has simultaneously documented a rise in the use of cannabis during pregnancy and offered more data about its potential harms. This confluence of findings is concerning and highlights the importance of screening our patients for cannabis use and engaging with them in a way in which we can maintain their trust and their commitment to prenatal care.
A retrospective cohort study involving 661,617 women in Ontario found a significant association between self-reported cannabis use in pregnancy and an increased risk of preterm birth (relative risk, 1.41), as well as a greater likelihood of small-for-gestational-age babies (RR, 1.53), placental abruption (RR, 1.72), and transfer to neonatal intensive care (RR, 1.40).1 The study, reported in JAMA in July 2019, carefully matched users with nonusers who had the same characteristics – for example, tobacco use or not.
This new information builds upon other meta-analyses that have demonstrated a decrease in birth weight and greater admittance to the neonatal ICU associated with cannabis use in pregnancy – and it supplements what some research suggests about long-term neurologic development and a potentially increased risk of attention and behavioral problems. Other outcomes that have been noted in long-term neurologic studies of children who were exposed to cannabis in utero include impaired visual acuity, verbal reasoning and comprehension, and short-term memory.2
Increases in use were recently documented in two studies. One, an analysis of data from the National Survey on Drug Use and Health (NSDUH) published in JAMA in June 2019, showed that, between 2002-2003 and 2016-2017, the use of cannabis “in the past month” increased from 3.4% to 7.0% among pregnant women overall, and from 6% to 12% during the first trimester.3
The use of cannabis on a daily or near-daily basis, moreover, increased from 0.9% to 3% among pregnant women overall and from 2% to 5% during the first trimester. The data were collected during face-to-face interviews and were adjusted for age, race/ethnicity, and family income.
In the second study – a cross-sectional study of 367,403 pregnancies among women who filled out a questionnaire on cannabis use during standard prenatal care at Kaiser Permanente Northern California – the adjusted prevalence of use in the year before pregnancy increased from 7% in 2009 to 13% in 2017, and the adjusted prevalence during pregnancy increased from 2% to 3%.4
As in the NSDUH analysis, daily use increased most rapidly (compared with weekly or monthly) such that, by 2017, 25% of those who reported using cannabis in the year before pregnancy – and 21% of those who used cannabis during pregnancy – were daily users. It is notable that Kaiser’s population is diverse in all respects, and that the annual relative rates of increase in cannabis use before and during pregnancy (at each level of frequency) were consistent across racial/ethnic and household income groups.
It’s also worth noting that, in earlier research covering a similar time period (2009-2016), the investigators found significant increases in use via urine toxicology testing that occurs at the first prenatal visit at Kaiser. The increase found through questionnaires, therefore, reflects more than a greater willingness to self-report.
Choosing a screening tool
Universal prenatal substance use screening is recommended by the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention, but we don’t have any specific recommendations on what this means. Who should be screening, and what should that screening look like? Should we use a biologic screen, a standardized screening tool, or simply ask patients whether they use illicit substances?
Screening tools seem advantageous in that they are low cost, noninvasive, potentially comprehensive, and not subject to false-positive results as biologic screens can be – but which tool or tools are best? There are several validated screening tools that can be used outside of pregnancy to determine an individual’s use of illicit substances and whether or not that use is problematic, but previous studies have not used biologic markers to validate substance use screeners in pregnancy. Nor have studies compared screeners in pregnancy.
In our prenatal population in Baltimore, we have not been getting the answers we want using various nonvalidated screening tools. Approximately 30% of patients are positive for cannabis by urine screen, but only half tell us about their use.
Through research in our two prenatal care practices (one serving mostly privately insured and the other serving primarily Medicaid-eligible patients), we assessed both the accuracy and the acceptability of three substance use screening tools that are brief and that have been validated (for the general population) by the World Health Organization for screening of multiple substances: the 4P’s Plus (Parents, Partner, Past, and Pregnancy), the National Institute on Drug Abuse Quick Screen–ASSIST (Modified Alcohol, Smoking and Substance Involvement Screening Test), and the SURP-P (Substance Use Risk Profile–Pregnancy) scale.
In one study, published in May 2019 in Obstetrics & Gynecology, we recruited 500 pregnant women and administered these three tests to each of them.5 We then compared results with those of urine and hair drug testing, and checked the test-retest reliability of each test by readministering them (albeit by telephone) a week later. Although hair testing is not an indicator of current substance use, we used it to validate the screening tools on less-recent use.
The tests with the highest sensitivity and negative predictive values – the qualities we most want for screening – were the SURP-P and the 4P’s Plus (sensitivity of 92.4% and 90.2%, respectively). Overall they were highly sensitive screening tools across all trimesters, races, and age groups, making them more ideal screening tests than the NIDA Quick Screen–ASSIST.
Of the two tests, the 4P’s Plus screening tool was the one preferred by staff from both practices. In a companion qualitative study, we conducted focus-group discussions with 40 practice staff who were responsible for administering or overseeing patient screening.6 The staff, who were unaware of the sensitivity findings, were asked what they thought about the acceptability to patients of each of the three tools and their usability in practice.
Most of the participating staff preferred the 4P’s Plus screening tool for several reasons: It is easy to understand, is brief and to the point, and it has nonjudgmental language and tone. The screener first asks the patient about her parents’ and her partner’s use of alcohol and drugs, and then asks the patient about her own use of alcohol and tobacco. Affirmative responses to these questions lead to additional questions.
The premise is that one’s genetics, history, and current exposures – as well as one’s own use of tobacco and alcohol – are significantly associated with the use of illicit substances. If the patient reports no parental history or partner usage, and has never drank or smoked before, it’s extremely unlikely that she is using other drugs. The progression of questions does indeed seem less judgmental than immediately asking: “Do you use drugs?”
For us, the insight from this staff perception study combined with the findings on accuracy mean that the 4P’s Plus may be the most useful and acceptable screening tool for routine use in prenatal care.
Talking with our patients
The increase in the use of cannabis before and after pregnancy parallels the movement toward state legalization and decriminalization. Historically, clinicians often have relied on illegality as their main focus of counseling when giving recommendations for cessation and abstinence in pregnancy.2 This approach not only leads to punitive counseling, which can fracture the doctor-patient relationship, but increasingly it is no longer valid. In our changing legal climate, we need to provide medically based counseling and be very clear with our patients that legalization does not equate to safety.
It is important that we neither minimize nor overstate the risks. The evidence base for adverse birth outcomes of cannabis use in pregnancy is quite robust, but the associations can be subtle and are moderated by other behaviors and environmental factors that continue to challenge researchers.
As with alcohol, there likely are dose-or trimester-dependent differences in perinatal outcomes, and it’s quite possible that different cannabis products and routes of consumption have different effects. At this point, however, we don’t know the full story, nor do we know the extent to which the literature is biased toward positive correlations – the reporting of adverse effects – compared with negative findings. It is our job as medical care providers to be comfortable in that gray area and to still counsel patients on what we do know, providing the best-possible medical advice based on the information available to us.
In talking with patients, I explain that cannabis may cause a spectrum of problems and that there certainly are risks. I also tell them that we’re uncertain about the conditions and magnitude of that risk and that some babies who are exposed to cannabis in utero may have no perceivable consequences. Such honesty is important for maintaining trust, especially as some patients may see friends and relatives who also are cannabis users have normal pregnancy outcomes.
Much of my concern about cannabis in pregnancy centers on its effect on the developing brain and on long-term neurologic development. I share this with patients – I tell them that cannabis crosses the placenta and may well affect their baby’s brain as it is developing. I explain that I do not know whether this effect would be big or small, but that it’s not a chance I’m willing to take for their baby.
It is also important to educate patients that cannabis products are untested and unregulated and that they may be contaminated with heavy metals, pesticides, and other toxins that may be harmful to themselves and their babies. Patients also should know that the potency of cannabis has been dramatically increasing; research shows that the tetrahydrocannabinol – the psychoactive component – concentration has tripled over the past 2 decades.7
Research tells us that women who use illicit drugs and alcohol categorically engage in some form of harm reduction once they learn they are pregnant, and the same is true for cannabis. This is seen in dramatically different rates of first- and third-trimester use in the new analysis of NSDUH data; third-trimester use is approximately halved.
Some women will not be able to discontinue use, however, or they may try to quit and fail in their attempts. As we should with substance use more broadly, we must meet patients where they are, view cannabis use as a chronic medical problem, offer our assistance in helping them reduce harms of their use, and understand that quitting is a process.
Screening for mental health disorders and trauma is, of course, especially important in patients who use cannabis and other substances recreationally. In cases of medical marijuana usage, I recommend, as ACOG and other have done, that we discuss the risks and benefits of continuing cannabis versus shifting to alternative medications if options exist.
All patients should be welcomed, congratulated on their pregnancy and on coming for prenatal care, and engaged in the overall process of optimizing their health and the health of their baby. Like any other health issue during pregnancy, cannabis use needs to be screened for and treated in an evidence-based manner, but it does not define the trajectory or success of a woman’s pregnancy or her ability to be a successful parent.
Dr. Mark is associate professor of obstetrics, gynecology, and reproductive sciences at the University of Maryland School of Medicine.
References
1. JAMA. 2019 Jul 9;322(2):145-52.
2. Preventive Medicine 2017 May 18;104:46-9.
3. JAMA. 2019 Jul 9;322(2):167-9.
4. JAMA Netw Open. 2019 Jul 3;2(7):e196471.
5. Obstet Gynecol. 2019 May;133(5):952-61.
6. J. Addict Med. 2019 May 10. doi: 10.1097/ADM.0000000000000543.
7. Biol Psychiatry. 2016 Apr 1;79(7):613-9.
A flurry of research papers published this year has simultaneously documented a rise in the use of cannabis during pregnancy and offered more data about its potential harms. This confluence of findings is concerning and highlights the importance of screening our patients for cannabis use and engaging with them in a way in which we can maintain their trust and their commitment to prenatal care.
A retrospective cohort study involving 661,617 women in Ontario found a significant association between self-reported cannabis use in pregnancy and an increased risk of preterm birth (relative risk, 1.41), as well as a greater likelihood of small-for-gestational-age babies (RR, 1.53), placental abruption (RR, 1.72), and transfer to neonatal intensive care (RR, 1.40).1 The study, reported in JAMA in July 2019, carefully matched users with nonusers who had the same characteristics – for example, tobacco use or not.
This new information builds upon other meta-analyses that have demonstrated a decrease in birth weight and greater admittance to the neonatal ICU associated with cannabis use in pregnancy – and it supplements what some research suggests about long-term neurologic development and a potentially increased risk of attention and behavioral problems. Other outcomes that have been noted in long-term neurologic studies of children who were exposed to cannabis in utero include impaired visual acuity, verbal reasoning and comprehension, and short-term memory.2
Increases in use were recently documented in two studies. One, an analysis of data from the National Survey on Drug Use and Health (NSDUH) published in JAMA in June 2019, showed that, between 2002-2003 and 2016-2017, the use of cannabis “in the past month” increased from 3.4% to 7.0% among pregnant women overall, and from 6% to 12% during the first trimester.3
The use of cannabis on a daily or near-daily basis, moreover, increased from 0.9% to 3% among pregnant women overall and from 2% to 5% during the first trimester. The data were collected during face-to-face interviews and were adjusted for age, race/ethnicity, and family income.
In the second study – a cross-sectional study of 367,403 pregnancies among women who filled out a questionnaire on cannabis use during standard prenatal care at Kaiser Permanente Northern California – the adjusted prevalence of use in the year before pregnancy increased from 7% in 2009 to 13% in 2017, and the adjusted prevalence during pregnancy increased from 2% to 3%.4
As in the NSDUH analysis, daily use increased most rapidly (compared with weekly or monthly) such that, by 2017, 25% of those who reported using cannabis in the year before pregnancy – and 21% of those who used cannabis during pregnancy – were daily users. It is notable that Kaiser’s population is diverse in all respects, and that the annual relative rates of increase in cannabis use before and during pregnancy (at each level of frequency) were consistent across racial/ethnic and household income groups.
It’s also worth noting that, in earlier research covering a similar time period (2009-2016), the investigators found significant increases in use via urine toxicology testing that occurs at the first prenatal visit at Kaiser. The increase found through questionnaires, therefore, reflects more than a greater willingness to self-report.
Choosing a screening tool
Universal prenatal substance use screening is recommended by the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention, but we don’t have any specific recommendations on what this means. Who should be screening, and what should that screening look like? Should we use a biologic screen, a standardized screening tool, or simply ask patients whether they use illicit substances?
Screening tools seem advantageous in that they are low cost, noninvasive, potentially comprehensive, and not subject to false-positive results as biologic screens can be – but which tool or tools are best? There are several validated screening tools that can be used outside of pregnancy to determine an individual’s use of illicit substances and whether or not that use is problematic, but previous studies have not used biologic markers to validate substance use screeners in pregnancy. Nor have studies compared screeners in pregnancy.
In our prenatal population in Baltimore, we have not been getting the answers we want using various nonvalidated screening tools. Approximately 30% of patients are positive for cannabis by urine screen, but only half tell us about their use.
Through research in our two prenatal care practices (one serving mostly privately insured and the other serving primarily Medicaid-eligible patients), we assessed both the accuracy and the acceptability of three substance use screening tools that are brief and that have been validated (for the general population) by the World Health Organization for screening of multiple substances: the 4P’s Plus (Parents, Partner, Past, and Pregnancy), the National Institute on Drug Abuse Quick Screen–ASSIST (Modified Alcohol, Smoking and Substance Involvement Screening Test), and the SURP-P (Substance Use Risk Profile–Pregnancy) scale.
In one study, published in May 2019 in Obstetrics & Gynecology, we recruited 500 pregnant women and administered these three tests to each of them.5 We then compared results with those of urine and hair drug testing, and checked the test-retest reliability of each test by readministering them (albeit by telephone) a week later. Although hair testing is not an indicator of current substance use, we used it to validate the screening tools on less-recent use.
The tests with the highest sensitivity and negative predictive values – the qualities we most want for screening – were the SURP-P and the 4P’s Plus (sensitivity of 92.4% and 90.2%, respectively). Overall they were highly sensitive screening tools across all trimesters, races, and age groups, making them more ideal screening tests than the NIDA Quick Screen–ASSIST.
Of the two tests, the 4P’s Plus screening tool was the one preferred by staff from both practices. In a companion qualitative study, we conducted focus-group discussions with 40 practice staff who were responsible for administering or overseeing patient screening.6 The staff, who were unaware of the sensitivity findings, were asked what they thought about the acceptability to patients of each of the three tools and their usability in practice.
Most of the participating staff preferred the 4P’s Plus screening tool for several reasons: It is easy to understand, is brief and to the point, and it has nonjudgmental language and tone. The screener first asks the patient about her parents’ and her partner’s use of alcohol and drugs, and then asks the patient about her own use of alcohol and tobacco. Affirmative responses to these questions lead to additional questions.
The premise is that one’s genetics, history, and current exposures – as well as one’s own use of tobacco and alcohol – are significantly associated with the use of illicit substances. If the patient reports no parental history or partner usage, and has never drank or smoked before, it’s extremely unlikely that she is using other drugs. The progression of questions does indeed seem less judgmental than immediately asking: “Do you use drugs?”
For us, the insight from this staff perception study combined with the findings on accuracy mean that the 4P’s Plus may be the most useful and acceptable screening tool for routine use in prenatal care.
Talking with our patients
The increase in the use of cannabis before and after pregnancy parallels the movement toward state legalization and decriminalization. Historically, clinicians often have relied on illegality as their main focus of counseling when giving recommendations for cessation and abstinence in pregnancy.2 This approach not only leads to punitive counseling, which can fracture the doctor-patient relationship, but increasingly it is no longer valid. In our changing legal climate, we need to provide medically based counseling and be very clear with our patients that legalization does not equate to safety.
It is important that we neither minimize nor overstate the risks. The evidence base for adverse birth outcomes of cannabis use in pregnancy is quite robust, but the associations can be subtle and are moderated by other behaviors and environmental factors that continue to challenge researchers.
As with alcohol, there likely are dose-or trimester-dependent differences in perinatal outcomes, and it’s quite possible that different cannabis products and routes of consumption have different effects. At this point, however, we don’t know the full story, nor do we know the extent to which the literature is biased toward positive correlations – the reporting of adverse effects – compared with negative findings. It is our job as medical care providers to be comfortable in that gray area and to still counsel patients on what we do know, providing the best-possible medical advice based on the information available to us.
In talking with patients, I explain that cannabis may cause a spectrum of problems and that there certainly are risks. I also tell them that we’re uncertain about the conditions and magnitude of that risk and that some babies who are exposed to cannabis in utero may have no perceivable consequences. Such honesty is important for maintaining trust, especially as some patients may see friends and relatives who also are cannabis users have normal pregnancy outcomes.
Much of my concern about cannabis in pregnancy centers on its effect on the developing brain and on long-term neurologic development. I share this with patients – I tell them that cannabis crosses the placenta and may well affect their baby’s brain as it is developing. I explain that I do not know whether this effect would be big or small, but that it’s not a chance I’m willing to take for their baby.
It is also important to educate patients that cannabis products are untested and unregulated and that they may be contaminated with heavy metals, pesticides, and other toxins that may be harmful to themselves and their babies. Patients also should know that the potency of cannabis has been dramatically increasing; research shows that the tetrahydrocannabinol – the psychoactive component – concentration has tripled over the past 2 decades.7
Research tells us that women who use illicit drugs and alcohol categorically engage in some form of harm reduction once they learn they are pregnant, and the same is true for cannabis. This is seen in dramatically different rates of first- and third-trimester use in the new analysis of NSDUH data; third-trimester use is approximately halved.
Some women will not be able to discontinue use, however, or they may try to quit and fail in their attempts. As we should with substance use more broadly, we must meet patients where they are, view cannabis use as a chronic medical problem, offer our assistance in helping them reduce harms of their use, and understand that quitting is a process.
Screening for mental health disorders and trauma is, of course, especially important in patients who use cannabis and other substances recreationally. In cases of medical marijuana usage, I recommend, as ACOG and other have done, that we discuss the risks and benefits of continuing cannabis versus shifting to alternative medications if options exist.
All patients should be welcomed, congratulated on their pregnancy and on coming for prenatal care, and engaged in the overall process of optimizing their health and the health of their baby. Like any other health issue during pregnancy, cannabis use needs to be screened for and treated in an evidence-based manner, but it does not define the trajectory or success of a woman’s pregnancy or her ability to be a successful parent.
Dr. Mark is associate professor of obstetrics, gynecology, and reproductive sciences at the University of Maryland School of Medicine.
References
1. JAMA. 2019 Jul 9;322(2):145-52.
2. Preventive Medicine 2017 May 18;104:46-9.
3. JAMA. 2019 Jul 9;322(2):167-9.
4. JAMA Netw Open. 2019 Jul 3;2(7):e196471.
5. Obstet Gynecol. 2019 May;133(5):952-61.
6. J. Addict Med. 2019 May 10. doi: 10.1097/ADM.0000000000000543.
7. Biol Psychiatry. 2016 Apr 1;79(7):613-9.
A flurry of research papers published this year has simultaneously documented a rise in the use of cannabis during pregnancy and offered more data about its potential harms. This confluence of findings is concerning and highlights the importance of screening our patients for cannabis use and engaging with them in a way in which we can maintain their trust and their commitment to prenatal care.
A retrospective cohort study involving 661,617 women in Ontario found a significant association between self-reported cannabis use in pregnancy and an increased risk of preterm birth (relative risk, 1.41), as well as a greater likelihood of small-for-gestational-age babies (RR, 1.53), placental abruption (RR, 1.72), and transfer to neonatal intensive care (RR, 1.40).1 The study, reported in JAMA in July 2019, carefully matched users with nonusers who had the same characteristics – for example, tobacco use or not.
This new information builds upon other meta-analyses that have demonstrated a decrease in birth weight and greater admittance to the neonatal ICU associated with cannabis use in pregnancy – and it supplements what some research suggests about long-term neurologic development and a potentially increased risk of attention and behavioral problems. Other outcomes that have been noted in long-term neurologic studies of children who were exposed to cannabis in utero include impaired visual acuity, verbal reasoning and comprehension, and short-term memory.2
Increases in use were recently documented in two studies. One, an analysis of data from the National Survey on Drug Use and Health (NSDUH) published in JAMA in June 2019, showed that, between 2002-2003 and 2016-2017, the use of cannabis “in the past month” increased from 3.4% to 7.0% among pregnant women overall, and from 6% to 12% during the first trimester.3
The use of cannabis on a daily or near-daily basis, moreover, increased from 0.9% to 3% among pregnant women overall and from 2% to 5% during the first trimester. The data were collected during face-to-face interviews and were adjusted for age, race/ethnicity, and family income.
In the second study – a cross-sectional study of 367,403 pregnancies among women who filled out a questionnaire on cannabis use during standard prenatal care at Kaiser Permanente Northern California – the adjusted prevalence of use in the year before pregnancy increased from 7% in 2009 to 13% in 2017, and the adjusted prevalence during pregnancy increased from 2% to 3%.4
As in the NSDUH analysis, daily use increased most rapidly (compared with weekly or monthly) such that, by 2017, 25% of those who reported using cannabis in the year before pregnancy – and 21% of those who used cannabis during pregnancy – were daily users. It is notable that Kaiser’s population is diverse in all respects, and that the annual relative rates of increase in cannabis use before and during pregnancy (at each level of frequency) were consistent across racial/ethnic and household income groups.
It’s also worth noting that, in earlier research covering a similar time period (2009-2016), the investigators found significant increases in use via urine toxicology testing that occurs at the first prenatal visit at Kaiser. The increase found through questionnaires, therefore, reflects more than a greater willingness to self-report.
Choosing a screening tool
Universal prenatal substance use screening is recommended by the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention, but we don’t have any specific recommendations on what this means. Who should be screening, and what should that screening look like? Should we use a biologic screen, a standardized screening tool, or simply ask patients whether they use illicit substances?
Screening tools seem advantageous in that they are low cost, noninvasive, potentially comprehensive, and not subject to false-positive results as biologic screens can be – but which tool or tools are best? There are several validated screening tools that can be used outside of pregnancy to determine an individual’s use of illicit substances and whether or not that use is problematic, but previous studies have not used biologic markers to validate substance use screeners in pregnancy. Nor have studies compared screeners in pregnancy.
In our prenatal population in Baltimore, we have not been getting the answers we want using various nonvalidated screening tools. Approximately 30% of patients are positive for cannabis by urine screen, but only half tell us about their use.
Through research in our two prenatal care practices (one serving mostly privately insured and the other serving primarily Medicaid-eligible patients), we assessed both the accuracy and the acceptability of three substance use screening tools that are brief and that have been validated (for the general population) by the World Health Organization for screening of multiple substances: the 4P’s Plus (Parents, Partner, Past, and Pregnancy), the National Institute on Drug Abuse Quick Screen–ASSIST (Modified Alcohol, Smoking and Substance Involvement Screening Test), and the SURP-P (Substance Use Risk Profile–Pregnancy) scale.
In one study, published in May 2019 in Obstetrics & Gynecology, we recruited 500 pregnant women and administered these three tests to each of them.5 We then compared results with those of urine and hair drug testing, and checked the test-retest reliability of each test by readministering them (albeit by telephone) a week later. Although hair testing is not an indicator of current substance use, we used it to validate the screening tools on less-recent use.
The tests with the highest sensitivity and negative predictive values – the qualities we most want for screening – were the SURP-P and the 4P’s Plus (sensitivity of 92.4% and 90.2%, respectively). Overall they were highly sensitive screening tools across all trimesters, races, and age groups, making them more ideal screening tests than the NIDA Quick Screen–ASSIST.
Of the two tests, the 4P’s Plus screening tool was the one preferred by staff from both practices. In a companion qualitative study, we conducted focus-group discussions with 40 practice staff who were responsible for administering or overseeing patient screening.6 The staff, who were unaware of the sensitivity findings, were asked what they thought about the acceptability to patients of each of the three tools and their usability in practice.
Most of the participating staff preferred the 4P’s Plus screening tool for several reasons: It is easy to understand, is brief and to the point, and it has nonjudgmental language and tone. The screener first asks the patient about her parents’ and her partner’s use of alcohol and drugs, and then asks the patient about her own use of alcohol and tobacco. Affirmative responses to these questions lead to additional questions.
The premise is that one’s genetics, history, and current exposures – as well as one’s own use of tobacco and alcohol – are significantly associated with the use of illicit substances. If the patient reports no parental history or partner usage, and has never drank or smoked before, it’s extremely unlikely that she is using other drugs. The progression of questions does indeed seem less judgmental than immediately asking: “Do you use drugs?”
For us, the insight from this staff perception study combined with the findings on accuracy mean that the 4P’s Plus may be the most useful and acceptable screening tool for routine use in prenatal care.
Talking with our patients
The increase in the use of cannabis before and after pregnancy parallels the movement toward state legalization and decriminalization. Historically, clinicians often have relied on illegality as their main focus of counseling when giving recommendations for cessation and abstinence in pregnancy.2 This approach not only leads to punitive counseling, which can fracture the doctor-patient relationship, but increasingly it is no longer valid. In our changing legal climate, we need to provide medically based counseling and be very clear with our patients that legalization does not equate to safety.
It is important that we neither minimize nor overstate the risks. The evidence base for adverse birth outcomes of cannabis use in pregnancy is quite robust, but the associations can be subtle and are moderated by other behaviors and environmental factors that continue to challenge researchers.
As with alcohol, there likely are dose-or trimester-dependent differences in perinatal outcomes, and it’s quite possible that different cannabis products and routes of consumption have different effects. At this point, however, we don’t know the full story, nor do we know the extent to which the literature is biased toward positive correlations – the reporting of adverse effects – compared with negative findings. It is our job as medical care providers to be comfortable in that gray area and to still counsel patients on what we do know, providing the best-possible medical advice based on the information available to us.
In talking with patients, I explain that cannabis may cause a spectrum of problems and that there certainly are risks. I also tell them that we’re uncertain about the conditions and magnitude of that risk and that some babies who are exposed to cannabis in utero may have no perceivable consequences. Such honesty is important for maintaining trust, especially as some patients may see friends and relatives who also are cannabis users have normal pregnancy outcomes.
Much of my concern about cannabis in pregnancy centers on its effect on the developing brain and on long-term neurologic development. I share this with patients – I tell them that cannabis crosses the placenta and may well affect their baby’s brain as it is developing. I explain that I do not know whether this effect would be big or small, but that it’s not a chance I’m willing to take for their baby.
It is also important to educate patients that cannabis products are untested and unregulated and that they may be contaminated with heavy metals, pesticides, and other toxins that may be harmful to themselves and their babies. Patients also should know that the potency of cannabis has been dramatically increasing; research shows that the tetrahydrocannabinol – the psychoactive component – concentration has tripled over the past 2 decades.7
Research tells us that women who use illicit drugs and alcohol categorically engage in some form of harm reduction once they learn they are pregnant, and the same is true for cannabis. This is seen in dramatically different rates of first- and third-trimester use in the new analysis of NSDUH data; third-trimester use is approximately halved.
Some women will not be able to discontinue use, however, or they may try to quit and fail in their attempts. As we should with substance use more broadly, we must meet patients where they are, view cannabis use as a chronic medical problem, offer our assistance in helping them reduce harms of their use, and understand that quitting is a process.
Screening for mental health disorders and trauma is, of course, especially important in patients who use cannabis and other substances recreationally. In cases of medical marijuana usage, I recommend, as ACOG and other have done, that we discuss the risks and benefits of continuing cannabis versus shifting to alternative medications if options exist.
All patients should be welcomed, congratulated on their pregnancy and on coming for prenatal care, and engaged in the overall process of optimizing their health and the health of their baby. Like any other health issue during pregnancy, cannabis use needs to be screened for and treated in an evidence-based manner, but it does not define the trajectory or success of a woman’s pregnancy or her ability to be a successful parent.
Dr. Mark is associate professor of obstetrics, gynecology, and reproductive sciences at the University of Maryland School of Medicine.
References
1. JAMA. 2019 Jul 9;322(2):145-52.
2. Preventive Medicine 2017 May 18;104:46-9.
3. JAMA. 2019 Jul 9;322(2):167-9.
4. JAMA Netw Open. 2019 Jul 3;2(7):e196471.
5. Obstet Gynecol. 2019 May;133(5):952-61.
6. J. Addict Med. 2019 May 10. doi: 10.1097/ADM.0000000000000543.
7. Biol Psychiatry. 2016 Apr 1;79(7):613-9.