Commentary

Is dementia a diagnosis?

I use it myself, although I find that some neurologists consider this blasphemy.

alexdans/Thinkstock

The problem is that there aren’t many terms to cover cognitive disorders beyond mild cognitive impairment (MCI). Phrases like “cortical degeneration” and “frontotemporal disorder” are difficult for families and patients. They aren’t medically trained and want something easy to write down.

“Alzheimer’s,” or – as one patient’s family member says, “the A-word” – is often more accurate, but has stigma attached to it that many don’t want, especially at a first visit. It also immediately conjures up feared images of nursing homes, wheelchairs, and bed-bound people.

So I use a diagnosis of dementia with many families, at least initially. Since, with occasional exceptions, we tend to perform a work-up of all cognitive disorders the same way, I don’t have a problem with using a more generic blanket term. As I sometimes try to simplify things, I’ll say, “It’s like squares and rectangles. Alzheimer’s disease is a dementia, but not all dementias are Alzheimer’s disease.”

I don’t do this to avoid confrontation, be dishonest, mislead patients and families, or avoid telling the truth. I still make it very clear that this is a progressive neurologic illness that will cause worsening cognitive problems over time. But many times families aren’t ready for “the A-word” early on, or there’s a concern the patient will harm themselves while they still have that capacity. Sometimes, it’s better to use a different phrase.

It may all be semantics, but on a personal level, a word can make a huge difference.

So I say dementia. In spite of some editorials I’ve seen saying we should retire the phrase, I argue that in many circumstances it’s still valid and useful.

It may not be a final, or even specific, diagnosis, but it is often the best and most socially acceptable one at the beginning of the doctor-patient-family relationship. When you’re trying to build rapport with them, that’s equally critical when you know what’s to come down the road.

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

Is dementia a diagnosis?

I use it myself, although I find that some neurologists consider this blasphemy.

alexdans/Thinkstock

The problem is that there aren’t many terms to cover cognitive disorders beyond mild cognitive impairment (MCI). Phrases like “cortical degeneration” and “frontotemporal disorder” are difficult for families and patients. They aren’t medically trained and want something easy to write down.

“Alzheimer’s,” or – as one patient’s family member says, “the A-word” – is often more accurate, but has stigma attached to it that many don’t want, especially at a first visit. It also immediately conjures up feared images of nursing homes, wheelchairs, and bed-bound people.

So I use a diagnosis of dementia with many families, at least initially. Since, with occasional exceptions, we tend to perform a work-up of all cognitive disorders the same way, I don’t have a problem with using a more generic blanket term. As I sometimes try to simplify things, I’ll say, “It’s like squares and rectangles. Alzheimer’s disease is a dementia, but not all dementias are Alzheimer’s disease.”

I don’t do this to avoid confrontation, be dishonest, mislead patients and families, or avoid telling the truth. I still make it very clear that this is a progressive neurologic illness that will cause worsening cognitive problems over time. But many times families aren’t ready for “the A-word” early on, or there’s a concern the patient will harm themselves while they still have that capacity. Sometimes, it’s better to use a different phrase.

It may all be semantics, but on a personal level, a word can make a huge difference.

So I say dementia. In spite of some editorials I’ve seen saying we should retire the phrase, I argue that in many circumstances it’s still valid and useful.

It may not be a final, or even specific, diagnosis, but it is often the best and most socially acceptable one at the beginning of the doctor-patient-family relationship. When you’re trying to build rapport with them, that’s equally critical when you know what’s to come down the road.

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

Is dementia a diagnosis?

I use it myself, although I find that some neurologists consider this blasphemy.

alexdans/Thinkstock

The problem is that there aren’t many terms to cover cognitive disorders beyond mild cognitive impairment (MCI). Phrases like “cortical degeneration” and “frontotemporal disorder” are difficult for families and patients. They aren’t medically trained and want something easy to write down.

“Alzheimer’s,” or – as one patient’s family member says, “the A-word” – is often more accurate, but has stigma attached to it that many don’t want, especially at a first visit. It also immediately conjures up feared images of nursing homes, wheelchairs, and bed-bound people.

So I use a diagnosis of dementia with many families, at least initially. Since, with occasional exceptions, we tend to perform a work-up of all cognitive disorders the same way, I don’t have a problem with using a more generic blanket term. As I sometimes try to simplify things, I’ll say, “It’s like squares and rectangles. Alzheimer’s disease is a dementia, but not all dementias are Alzheimer’s disease.”

I don’t do this to avoid confrontation, be dishonest, mislead patients and families, or avoid telling the truth. I still make it very clear that this is a progressive neurologic illness that will cause worsening cognitive problems over time. But many times families aren’t ready for “the A-word” early on, or there’s a concern the patient will harm themselves while they still have that capacity. Sometimes, it’s better to use a different phrase.

It may all be semantics, but on a personal level, a word can make a huge difference.

So I say dementia. In spite of some editorials I’ve seen saying we should retire the phrase, I argue that in many circumstances it’s still valid and useful.

It may not be a final, or even specific, diagnosis, but it is often the best and most socially acceptable one at the beginning of the doctor-patient-family relationship. When you’re trying to build rapport with them, that’s equally critical when you know what’s to come down the road.

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

In a recent article on this website, Jake Remaly reports on a study suggesting that maternal migraine is associated with infant colic. In a presentation at the annual meeting of the American Headache Society, Amy Gelfand, MD, a neurologist at the University of California, San Francisco, reported the results of a national survey of more than 1,400 parents (827 mothers, 592 fathers) collected via social media. She and her colleagues found that mothers with migraine were more likely to have an infant with colic, with an odds ratio of 1.7 that increased to 2.5 for mothers with more frequent migraine. Fathers with migraine were no more likely to have an infant with colic.

AntonioGuillem/Gety Images

In a video clip included in the article, Dr. Gelfand discusses the possibilities that she and her group considered as they attempted to explain the study’s findings. Are there such things as “migraine genes?” If so, the failure to discover a paternal association might suggest that these would be mitochondrial genes. The researchers wondered if a substance in breast milk was acting as trigger, but they found that the association between colic and migraine was unrelated to whether the baby was fed by breast or bottle.

In full disclosure, I was not one of the investigators. Neither my wife nor I have migraine, and although our children cried as infants, they wouldn’t have qualified as having colic. However, I spent more than 40 years immersed in more than 300,000 patient encounters and can claim membership in the International Brother/Sisterhood of Anecdotal Observers. And, as such will offer up my explanation for Dr. Gelfand’s findings.

It is clear to me that most, if not all, children with migraine have their headaches when they are sleep deprived. While my sample size is smaller, I believe the same association also is true for many of the adults I know who have migraine. At least in children, restorative sleep ends the migraine much as it does for an epileptic seizure.

Traditionally, colic has been thought to be somehow related to a gastrointestinal phenomenon by many extended family members and some physicians. However, in my experience, it is usually a symptom of sleep deprivation compounded by the failure of those around the children to realize the obvious and take appropriate action. Of course, some babies are reacting to sore tummies, but my guess is that most are having headaches. We may never know. Dr. Gelfand also shares my observation that colicky crying is more likely to occur “at the end of the day,” a time when we are tired and are less tolerant of overstimulation.

For decades, I have been convinced that migraine and colic are the same pathophysiologic process. However, the presentation varies depending on the age of the patients. Remember, infants can’t talk. It already has been shown that adults with migraine often were more likely to have been colicky infants. (Dr. Gelfand mentions this as well.) These unfortunate individuals probably have inherited a vulnerability to sleep deprivation that manifests itself as a headache. I hope to live long enough to be around when someone discovers the wrinkle in the genome that creates this vulnerability.

So, why did the researchers fail to find an association between fathers and colic? The answer is simple. We fathers are beginning to take on a larger role in parenting of infants and like to complain about how difficult it is. However, it is mothers who still have the lioness’ share of the work. They lose the most sleep and are starting off parenthood with 9 months of less than optimal sleep followed by who knows how many hours of energy-sapping labor. It’s surprising they all don’t have migraines.
 

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].

In a recent article on this website, Jake Remaly reports on a study suggesting that maternal migraine is associated with infant colic. In a presentation at the annual meeting of the American Headache Society, Amy Gelfand, MD, a neurologist at the University of California, San Francisco, reported the results of a national survey of more than 1,400 parents (827 mothers, 592 fathers) collected via social media. She and her colleagues found that mothers with migraine were more likely to have an infant with colic, with an odds ratio of 1.7 that increased to 2.5 for mothers with more frequent migraine. Fathers with migraine were no more likely to have an infant with colic.

AntonioGuillem/Gety Images

In a video clip included in the article, Dr. Gelfand discusses the possibilities that she and her group considered as they attempted to explain the study’s findings. Are there such things as “migraine genes?” If so, the failure to discover a paternal association might suggest that these would be mitochondrial genes. The researchers wondered if a substance in breast milk was acting as trigger, but they found that the association between colic and migraine was unrelated to whether the baby was fed by breast or bottle.

In full disclosure, I was not one of the investigators. Neither my wife nor I have migraine, and although our children cried as infants, they wouldn’t have qualified as having colic. However, I spent more than 40 years immersed in more than 300,000 patient encounters and can claim membership in the International Brother/Sisterhood of Anecdotal Observers. And, as such will offer up my explanation for Dr. Gelfand’s findings.

It is clear to me that most, if not all, children with migraine have their headaches when they are sleep deprived. While my sample size is smaller, I believe the same association also is true for many of the adults I know who have migraine. At least in children, restorative sleep ends the migraine much as it does for an epileptic seizure.

Traditionally, colic has been thought to be somehow related to a gastrointestinal phenomenon by many extended family members and some physicians. However, in my experience, it is usually a symptom of sleep deprivation compounded by the failure of those around the children to realize the obvious and take appropriate action. Of course, some babies are reacting to sore tummies, but my guess is that most are having headaches. We may never know. Dr. Gelfand also shares my observation that colicky crying is more likely to occur “at the end of the day,” a time when we are tired and are less tolerant of overstimulation.

For decades, I have been convinced that migraine and colic are the same pathophysiologic process. However, the presentation varies depending on the age of the patients. Remember, infants can’t talk. It already has been shown that adults with migraine often were more likely to have been colicky infants. (Dr. Gelfand mentions this as well.) These unfortunate individuals probably have inherited a vulnerability to sleep deprivation that manifests itself as a headache. I hope to live long enough to be around when someone discovers the wrinkle in the genome that creates this vulnerability.

So, why did the researchers fail to find an association between fathers and colic? The answer is simple. We fathers are beginning to take on a larger role in parenting of infants and like to complain about how difficult it is. However, it is mothers who still have the lioness’ share of the work. They lose the most sleep and are starting off parenthood with 9 months of less than optimal sleep followed by who knows how many hours of energy-sapping labor. It’s surprising they all don’t have migraines.
 

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].

In a recent article on this website, Jake Remaly reports on a study suggesting that maternal migraine is associated with infant colic. In a presentation at the annual meeting of the American Headache Society, Amy Gelfand, MD, a neurologist at the University of California, San Francisco, reported the results of a national survey of more than 1,400 parents (827 mothers, 592 fathers) collected via social media. She and her colleagues found that mothers with migraine were more likely to have an infant with colic, with an odds ratio of 1.7 that increased to 2.5 for mothers with more frequent migraine. Fathers with migraine were no more likely to have an infant with colic.

AntonioGuillem/Gety Images

In a video clip included in the article, Dr. Gelfand discusses the possibilities that she and her group considered as they attempted to explain the study’s findings. Are there such things as “migraine genes?” If so, the failure to discover a paternal association might suggest that these would be mitochondrial genes. The researchers wondered if a substance in breast milk was acting as trigger, but they found that the association between colic and migraine was unrelated to whether the baby was fed by breast or bottle.

In full disclosure, I was not one of the investigators. Neither my wife nor I have migraine, and although our children cried as infants, they wouldn’t have qualified as having colic. However, I spent more than 40 years immersed in more than 300,000 patient encounters and can claim membership in the International Brother/Sisterhood of Anecdotal Observers. And, as such will offer up my explanation for Dr. Gelfand’s findings.

It is clear to me that most, if not all, children with migraine have their headaches when they are sleep deprived. While my sample size is smaller, I believe the same association also is true for many of the adults I know who have migraine. At least in children, restorative sleep ends the migraine much as it does for an epileptic seizure.

Traditionally, colic has been thought to be somehow related to a gastrointestinal phenomenon by many extended family members and some physicians. However, in my experience, it is usually a symptom of sleep deprivation compounded by the failure of those around the children to realize the obvious and take appropriate action. Of course, some babies are reacting to sore tummies, but my guess is that most are having headaches. We may never know. Dr. Gelfand also shares my observation that colicky crying is more likely to occur “at the end of the day,” a time when we are tired and are less tolerant of overstimulation.

For decades, I have been convinced that migraine and colic are the same pathophysiologic process. However, the presentation varies depending on the age of the patients. Remember, infants can’t talk. It already has been shown that adults with migraine often were more likely to have been colicky infants. (Dr. Gelfand mentions this as well.) These unfortunate individuals probably have inherited a vulnerability to sleep deprivation that manifests itself as a headache. I hope to live long enough to be around when someone discovers the wrinkle in the genome that creates this vulnerability.

So, why did the researchers fail to find an association between fathers and colic? The answer is simple. We fathers are beginning to take on a larger role in parenting of infants and like to complain about how difficult it is. However, it is mothers who still have the lioness’ share of the work. They lose the most sleep and are starting off parenthood with 9 months of less than optimal sleep followed by who knows how many hours of energy-sapping labor. It’s surprising they all don’t have migraines.
 

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].

In October 2018 the US Food and Drug Administration expanded the approved use of the human papillomavirus (HPV) vaccine (Gardasil 9) to adults aged 27 through 45.¹ In June 2019, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) voted to extend catch-up HPV vaccination to include all individuals through age 26 and to catch-up HPV vaccination, based on shared clinical decision making, for all adults aged 27 through 45.² HPV viruses are associated with cervical cancer, as well as several other forms of cancer that affect both women and men. Approval for the expanded use of the HPV vaccine was based on data of the vaccine’s use in women.^1,3

Unfortunately, adult immunization rates, including among pregnant women, do not equal the higher rates in childhood vaccine uptake, according to Kevin A. Ault, MD, and colleagues. Less than half of women (46.6%) receive influenza vaccination prior to and during pregnancy, for instance.⁴ Dr. Ault has identified the need for an “immunization champion”—someone who can manage one-on-one conversations with patients in the office setting to enhance the acceptance and uptake of adult and maternal vaccines. OBG Management recently asked Dr. Ault how ObGyn practices could successfully implement such a champion and for his tips on communicating with patients about vaccination, particularly the maternal influenza vaccine.

OBG Management: How would you advise ObGyns to develop and execute an immunization champion position?

Dr. Kevin A. Ault, MD: The main thing a practice needs to do is to identify someone who is interested, and this person does not have to be a physician. In fact, he or she can frequently be a member of your nursing staff or office staff. And the word “champion” involves a lot of nuts and bolts: such details as how do you store the vaccine, how do you keep track of it, where are the vaccine information statements filed, where can the provider get more information if there is a question about contraindications? One person should organize all these details. The mechanics of vaccine administration are important as well, as the research shows that the more automated the process is, the better and more smoothly it is carried out. There is certainly a role for “standing orders” for adult vaccines.

OBG Management: What communication approach do you take with patients to enhance vaccination acceptance and uptake?

Dr. Ault: There are multiple research studies that show that provider recommendation is the most important way to get both nonpregnant and pregnant adults to receive vaccinations. Take the pertussis vaccine (the whooping cough booster) as an example. It is a relatively new vaccine recommendation during pregnancy. Your approach is relatively straightforward when explaining it to pregnant women. Make the point that we do not want your newborn to have whooping cough in those first few months of life before the newborn or infant vaccine becomes effective. Most people know they had a whooping cough, or pertussis, vaccine when they were younger, and the concept of the booster is well-known to patients. You should explain that the maternal antibodies pass through the placenta to the fetus, and they provide benefit for the first few months of life after birth.

The pertussis vaccine does not have all the “baggage” of the influenza vaccine. Talking with patients about the flu vaccine may present more challenges. Typically, each fall there is a popular press publication that explains “the 10, or 20, most common myths about influenza vaccine.” Every fall I try to find one of those articles, print it out, and even carry it in my jacket pocket and talk about all the myths. For example, there is a myth that “I always get sick when I get the flu shot.” Obstetricians should be giving patients an inactivated vaccine that does not contain any live flu virus. We should be able to explain to patients, your arm will be sore, and you may have some muscle aches, but you will not have the flu from your flu vaccine.

I think another reason that pregnant women do not always take the flu vaccine is that we do not yet have normalized influenza vaccination in the adult population. Women in their twenties and thirties are generally very healthy and have other concerns when they are pregnant, and they perhaps do not realize that they are more vulnerable to devastating effects of influenza while pregnant. Additionally, maternal influenza vaccination does protect the newborn from flu for the first few months. It is vital that those patients who are due during the dark winter months, when the flu is in season, get vaccinated.

Combat the myths and tell your patients the reasons for flu vaccination. Also tell them that you got your flu shot, like most health care professionals do every fall. You should be prepared to talk about safety. There are wonderful safety data, even some published in 2017 and 2018, about pertussis vaccine safety during pregnancy, and it is very reassuring to patients. For flu, the idea of vaccinating women against influenza has been around for decades, and so we have reliable information about that as well. Certainly, the risks are very minor, and the benefits are potentially huge for the pregnant woman and for the newborn.
 

OBG Management: When do you recommend that ObGyns administer the flu vaccine for pregnant women?

Dr. Ault: There are 2 issues to this question: when throughout the year and when during the pregnancy to administer the vaccine. First, you want to give the flu vaccine during the usual influenza season during the fall. As soon as the vaccine is available, you will recommend that pregnant women, even in their late pregnancy, get vaccinated so that their newborns who are 3 and 4 months old in the peak flu season are protected. The patients who deliver over the summer, who are coming in for their postpartum visit during the fall, should be getting vaccinated as well, because they are still vulnerable to influenza and pneumonia for several months postpartum.

If you have patients that come in for preconception visits, you could say: “Let’s get this out of the way. You could be pregnant by the time flu season really gets cranked up.”

Because we see patients 10 or 12 times during pregnancy, we certainly have plenty of opportunities to educate patients about and administer the flu vaccine. There are older data that demonstrate if patients do not get the flu vaccine done during early pregnancy, the opportunity may be lost. It is different now because there is more emphasis on vaccinating all adults. Your patients certainly can get their vaccine at the pharmacy or at their primary care doctor; however, delaying until later pregnancy usually means not getting the vaccine.

I would like to address one recent study from Donahue and colleagues that showed a potentially increased risk of miscarriage with flu vaccination.⁵ That study was an anomaly, as there are many other studies into the issue. Yes, there are not a lot of first trimester data, but there are other studies, including studies by the same authors, that did not find this to be the case.^6-10

The 2017 study by Donahue and colleagues was an anomaly because the group of women they were vaccinating were already at high risk for miscarriage. The women were older, had diabetes, or a history of miscarriages. There is selection bias in the study because the pregnant women who were vaccinated were already at higher risk for miscarriage. The Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists are not going to change any of their recommendations based on a single study that is different than our previous data.¹¹

In October 2018 the US Food and Drug Administration expanded the approved use of the human papillomavirus (HPV) vaccine (Gardasil 9) to adults aged 27 through 45.¹ In June 2019, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) voted to extend catch-up HPV vaccination to include all individuals through age 26 and to catch-up HPV vaccination, based on shared clinical decision making, for all adults aged 27 through 45.² HPV viruses are associated with cervical cancer, as well as several other forms of cancer that affect both women and men. Approval for the expanded use of the HPV vaccine was based on data of the vaccine’s use in women.^1,3

Unfortunately, adult immunization rates, including among pregnant women, do not equal the higher rates in childhood vaccine uptake, according to Kevin A. Ault, MD, and colleagues. Less than half of women (46.6%) receive influenza vaccination prior to and during pregnancy, for instance.⁴ Dr. Ault has identified the need for an “immunization champion”—someone who can manage one-on-one conversations with patients in the office setting to enhance the acceptance and uptake of adult and maternal vaccines. OBG Management recently asked Dr. Ault how ObGyn practices could successfully implement such a champion and for his tips on communicating with patients about vaccination, particularly the maternal influenza vaccine.

OBG Management: How would you advise ObGyns to develop and execute an immunization champion position?

Dr. Kevin A. Ault, MD: The main thing a practice needs to do is to identify someone who is interested, and this person does not have to be a physician. In fact, he or she can frequently be a member of your nursing staff or office staff. And the word “champion” involves a lot of nuts and bolts: such details as how do you store the vaccine, how do you keep track of it, where are the vaccine information statements filed, where can the provider get more information if there is a question about contraindications? One person should organize all these details. The mechanics of vaccine administration are important as well, as the research shows that the more automated the process is, the better and more smoothly it is carried out. There is certainly a role for “standing orders” for adult vaccines.

OBG Management: What communication approach do you take with patients to enhance vaccination acceptance and uptake?

Dr. Ault: There are multiple research studies that show that provider recommendation is the most important way to get both nonpregnant and pregnant adults to receive vaccinations. Take the pertussis vaccine (the whooping cough booster) as an example. It is a relatively new vaccine recommendation during pregnancy. Your approach is relatively straightforward when explaining it to pregnant women. Make the point that we do not want your newborn to have whooping cough in those first few months of life before the newborn or infant vaccine becomes effective. Most people know they had a whooping cough, or pertussis, vaccine when they were younger, and the concept of the booster is well-known to patients. You should explain that the maternal antibodies pass through the placenta to the fetus, and they provide benefit for the first few months of life after birth.

The pertussis vaccine does not have all the “baggage” of the influenza vaccine. Talking with patients about the flu vaccine may present more challenges. Typically, each fall there is a popular press publication that explains “the 10, or 20, most common myths about influenza vaccine.” Every fall I try to find one of those articles, print it out, and even carry it in my jacket pocket and talk about all the myths. For example, there is a myth that “I always get sick when I get the flu shot.” Obstetricians should be giving patients an inactivated vaccine that does not contain any live flu virus. We should be able to explain to patients, your arm will be sore, and you may have some muscle aches, but you will not have the flu from your flu vaccine.

I think another reason that pregnant women do not always take the flu vaccine is that we do not yet have normalized influenza vaccination in the adult population. Women in their twenties and thirties are generally very healthy and have other concerns when they are pregnant, and they perhaps do not realize that they are more vulnerable to devastating effects of influenza while pregnant. Additionally, maternal influenza vaccination does protect the newborn from flu for the first few months. It is vital that those patients who are due during the dark winter months, when the flu is in season, get vaccinated.

Combat the myths and tell your patients the reasons for flu vaccination. Also tell them that you got your flu shot, like most health care professionals do every fall. You should be prepared to talk about safety. There are wonderful safety data, even some published in 2017 and 2018, about pertussis vaccine safety during pregnancy, and it is very reassuring to patients. For flu, the idea of vaccinating women against influenza has been around for decades, and so we have reliable information about that as well. Certainly, the risks are very minor, and the benefits are potentially huge for the pregnant woman and for the newborn.
 

OBG Management: When do you recommend that ObGyns administer the flu vaccine for pregnant women?

Dr. Ault: There are 2 issues to this question: when throughout the year and when during the pregnancy to administer the vaccine. First, you want to give the flu vaccine during the usual influenza season during the fall. As soon as the vaccine is available, you will recommend that pregnant women, even in their late pregnancy, get vaccinated so that their newborns who are 3 and 4 months old in the peak flu season are protected. The patients who deliver over the summer, who are coming in for their postpartum visit during the fall, should be getting vaccinated as well, because they are still vulnerable to influenza and pneumonia for several months postpartum.

If you have patients that come in for preconception visits, you could say: “Let’s get this out of the way. You could be pregnant by the time flu season really gets cranked up.”

Because we see patients 10 or 12 times during pregnancy, we certainly have plenty of opportunities to educate patients about and administer the flu vaccine. There are older data that demonstrate if patients do not get the flu vaccine done during early pregnancy, the opportunity may be lost. It is different now because there is more emphasis on vaccinating all adults. Your patients certainly can get their vaccine at the pharmacy or at their primary care doctor; however, delaying until later pregnancy usually means not getting the vaccine.

I would like to address one recent study from Donahue and colleagues that showed a potentially increased risk of miscarriage with flu vaccination.⁵ That study was an anomaly, as there are many other studies into the issue. Yes, there are not a lot of first trimester data, but there are other studies, including studies by the same authors, that did not find this to be the case.^6-10

The 2017 study by Donahue and colleagues was an anomaly because the group of women they were vaccinating were already at high risk for miscarriage. The women were older, had diabetes, or a history of miscarriages. There is selection bias in the study because the pregnant women who were vaccinated were already at higher risk for miscarriage. The Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists are not going to change any of their recommendations based on a single study that is different than our previous data.¹¹

In October 2018 the US Food and Drug Administration expanded the approved use of the human papillomavirus (HPV) vaccine (Gardasil 9) to adults aged 27 through 45.¹ In June 2019, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) voted to extend catch-up HPV vaccination to include all individuals through age 26 and to catch-up HPV vaccination, based on shared clinical decision making, for all adults aged 27 through 45.² HPV viruses are associated with cervical cancer, as well as several other forms of cancer that affect both women and men. Approval for the expanded use of the HPV vaccine was based on data of the vaccine’s use in women.^1,3

Unfortunately, adult immunization rates, including among pregnant women, do not equal the higher rates in childhood vaccine uptake, according to Kevin A. Ault, MD, and colleagues. Less than half of women (46.6%) receive influenza vaccination prior to and during pregnancy, for instance.⁴ Dr. Ault has identified the need for an “immunization champion”—someone who can manage one-on-one conversations with patients in the office setting to enhance the acceptance and uptake of adult and maternal vaccines. OBG Management recently asked Dr. Ault how ObGyn practices could successfully implement such a champion and for his tips on communicating with patients about vaccination, particularly the maternal influenza vaccine.

OBG Management: How would you advise ObGyns to develop and execute an immunization champion position?

Dr. Kevin A. Ault, MD: The main thing a practice needs to do is to identify someone who is interested, and this person does not have to be a physician. In fact, he or she can frequently be a member of your nursing staff or office staff. And the word “champion” involves a lot of nuts and bolts: such details as how do you store the vaccine, how do you keep track of it, where are the vaccine information statements filed, where can the provider get more information if there is a question about contraindications? One person should organize all these details. The mechanics of vaccine administration are important as well, as the research shows that the more automated the process is, the better and more smoothly it is carried out. There is certainly a role for “standing orders” for adult vaccines.

OBG Management: What communication approach do you take with patients to enhance vaccination acceptance and uptake?

Dr. Ault: There are multiple research studies that show that provider recommendation is the most important way to get both nonpregnant and pregnant adults to receive vaccinations. Take the pertussis vaccine (the whooping cough booster) as an example. It is a relatively new vaccine recommendation during pregnancy. Your approach is relatively straightforward when explaining it to pregnant women. Make the point that we do not want your newborn to have whooping cough in those first few months of life before the newborn or infant vaccine becomes effective. Most people know they had a whooping cough, or pertussis, vaccine when they were younger, and the concept of the booster is well-known to patients. You should explain that the maternal antibodies pass through the placenta to the fetus, and they provide benefit for the first few months of life after birth.

The pertussis vaccine does not have all the “baggage” of the influenza vaccine. Talking with patients about the flu vaccine may present more challenges. Typically, each fall there is a popular press publication that explains “the 10, or 20, most common myths about influenza vaccine.” Every fall I try to find one of those articles, print it out, and even carry it in my jacket pocket and talk about all the myths. For example, there is a myth that “I always get sick when I get the flu shot.” Obstetricians should be giving patients an inactivated vaccine that does not contain any live flu virus. We should be able to explain to patients, your arm will be sore, and you may have some muscle aches, but you will not have the flu from your flu vaccine.

I think another reason that pregnant women do not always take the flu vaccine is that we do not yet have normalized influenza vaccination in the adult population. Women in their twenties and thirties are generally very healthy and have other concerns when they are pregnant, and they perhaps do not realize that they are more vulnerable to devastating effects of influenza while pregnant. Additionally, maternal influenza vaccination does protect the newborn from flu for the first few months. It is vital that those patients who are due during the dark winter months, when the flu is in season, get vaccinated.

Combat the myths and tell your patients the reasons for flu vaccination. Also tell them that you got your flu shot, like most health care professionals do every fall. You should be prepared to talk about safety. There are wonderful safety data, even some published in 2017 and 2018, about pertussis vaccine safety during pregnancy, and it is very reassuring to patients. For flu, the idea of vaccinating women against influenza has been around for decades, and so we have reliable information about that as well. Certainly, the risks are very minor, and the benefits are potentially huge for the pregnant woman and for the newborn.
 

OBG Management: When do you recommend that ObGyns administer the flu vaccine for pregnant women?

Dr. Ault: There are 2 issues to this question: when throughout the year and when during the pregnancy to administer the vaccine. First, you want to give the flu vaccine during the usual influenza season during the fall. As soon as the vaccine is available, you will recommend that pregnant women, even in their late pregnancy, get vaccinated so that their newborns who are 3 and 4 months old in the peak flu season are protected. The patients who deliver over the summer, who are coming in for their postpartum visit during the fall, should be getting vaccinated as well, because they are still vulnerable to influenza and pneumonia for several months postpartum.

If you have patients that come in for preconception visits, you could say: “Let’s get this out of the way. You could be pregnant by the time flu season really gets cranked up.”

Because we see patients 10 or 12 times during pregnancy, we certainly have plenty of opportunities to educate patients about and administer the flu vaccine. There are older data that demonstrate if patients do not get the flu vaccine done during early pregnancy, the opportunity may be lost. It is different now because there is more emphasis on vaccinating all adults. Your patients certainly can get their vaccine at the pharmacy or at their primary care doctor; however, delaying until later pregnancy usually means not getting the vaccine.

I would like to address one recent study from Donahue and colleagues that showed a potentially increased risk of miscarriage with flu vaccination.⁵ That study was an anomaly, as there are many other studies into the issue. Yes, there are not a lot of first trimester data, but there are other studies, including studies by the same authors, that did not find this to be the case.^6-10

The 2017 study by Donahue and colleagues was an anomaly because the group of women they were vaccinating were already at high risk for miscarriage. The women were older, had diabetes, or a history of miscarriages. There is selection bias in the study because the pregnant women who were vaccinated were already at higher risk for miscarriage. The Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists are not going to change any of their recommendations based on a single study that is different than our previous data.¹¹

Carla is an otherwise-healthy 14-year-old female followed by her pediatrician for symptoms of depression and anxiety that have worsened over the past 8 months. Anhedonia, irritability, poor concentration, fatigue, hypersomnolence, and significant weight gain have increasingly led to further dysphoria, social isolation, and obsessive rumination, all of which now contribute to more dysfunction in both her home and school life. Based on Carla’s apprehension over “taking pills,” she was referred for outpatient therapy 5 months ago but because of difficulty maintaining weekly appointments, she stopped attending after 6 weeks, citing difficulty aligning with her therapist.

Carla was seen in an urgent, unscheduled follow-up appointment 2 months prior to address increased thoughts of wishing to be dead. She had neither a plan nor a desire to act on these ideations. During an interview, she was distant with poor eye contact, and her affect was notably blunted. Her mother, who had accompanied her in the waiting room, expressed frustration to the nurse about discovering that Carla was using cannabis, that she often appeared aloof and unmotivated to do much of anything but “sit in her room and play on her phone for hours on end.” She compared Carla with her ex-husband, who had similar mood swings that often led to erratic and violent outbursts towards Carla and her mother, behaviors that ultimately led them to leave him when Carla was 6 years old.

After a discussion over the risks and benefits of various treatment options, Carla was started on low-dose fluoxetine with a plan to titrate the medication after 2 weeks. A referral for outpatient substance use treatment also was initiated. Carla’s mother telephoned 10 days later in an update that things have drastically improved in Carla’s mood and activity. The following week her mother called back again with concerns that Carla is no longer sleeping, appears restless, impulsive, and disinhibited.

Discussion

Carla’s initial presentation is common to primary care settings. Based on her earliest reported symptoms, she would qualify for a diagnosis of major depression. Decisions regarding initial treatment for children and adolescents must take into account the severity of symptoms, risks, autonomy of the patient and family, as well as available evidence. Her response to outpatient therapy is not an anomaly. With an ever-increasing demand on mental health services, the availability of consistent, quality outpatient therapy for this population is not always easy to secure.^1,2 Combining targeted therapy with pharmacologic interventions for major depression appear to have the most effective outcomes.³

Carla’s progression also illustrates the challenges and potential pitfalls of attempting to understand and address her symptoms according to a single nosology. Depression is a like a fever. It can be caused by a myriad of factors and, left to linger, may lead to further residual complications. Focusing attention to her symptoms also may lead to a differential including adjustment problems, social anxiety, effects of trauma, surreptitious substance use, or even bipolar depression. Understanding Carla’s (or anyone else’s) unique predispositions to illness will better optimize the course of treatment.

To begin with, a clear delineation of Carla’s historic symptoms and any possible medical contributions to her presentation are necessary to investigate. Specific inquiries into past episodes of activation including hyperarousal, impulsivity, restlessness, and insomnia should be elucidated prior to consideration of medication selection.⁴ Considering Carla’s age and the known association between antidepressant-induced manic conversion among children aged 10-14 years,⁵ any pharmacologic intervention will benefit from the maxim “start low and go slow.” Her symptoms of activation arise within the setting of titration of an antidepressant. This may raise considerations to her specific metabolism and physiological concentrations of the medication as well as cumulative day exposure.

Complementary to Carla’s own history is that of family members. Often obtaining a reliable family psychiatric history is an exercise fraught with bias, vagueness, and generalizations.⁶ However, given the known heritability of bipolar disorders and the implications for treating depression in such individuals, compared with unipolar depressive symptoms, clarifying the nature of family illness may elucidate potential susceptibilities previously unconsidered.⁷ In this case, descriptions of Carla’s father’s behavior raise concerns for underlying bipolar disorder, as do the accounts of traumatic stress exposure and their compounded preponderance for increased suicide risk.⁸

Unfortunately, Carla’s current environmental cues and maladaptive behaviors may be perpetuating her symptoms and possibly placing her on a trajectory for further illness. Exploration of her relationship with her caregivers regarding the interpretation of her symptoms, and need for treatment should be undertaken so as to expand supportive roles. Education regarding cannabis use among adolescents and age-specific risks for later depression, anxiety, and suicide is warranted in a climate when accessibility is on the rise.⁹ Whether or not cannabis use itself leads to amotivation is the subject of current debate.¹⁰ A growing body of evidence is clearly illustrating that Carla’s sedentary behaviors and perceived loneliness likely exacerbate her mental well-being. Such patterns indicate the need for environmental intervention to change such cycles.

Finally, Carla’s progression through treatment speak to the need for open and honest discussions regarding realistic benefits as well potential risks. Progressive symptoms of depression left untreated can be life-threatening themselves, just as effects of activation as described in the vignette above can easily and quickly progress into situations that pose safety concerns. Amidst such periods of intervention, close communication and follow up with patients and their supports ameliorate potential adverse events and lead to better outcomes.

Outcome

Carla’s mother was advised to discontinue the medication, closely monitor Carla’s behavior and sleep, and schedule an emergent follow-up appointment for the next day. A safety plan indicating circumstances in which Carla would require closer medical supervision for safety was reviewed with her mother. Carla was later initiated on lamotrigine and restarted interpersonal therapy.

References

1. N Engl J Med. 2015 May 21;372(21):2029-38.

2. J Pediatr. 2010 Nov;157(5):848-51.

3. Arch Gen Psychiatry. 2007 Oct;64(10):1132-43.

4. Curr Probl Pediatr Adolesc Health Care. 2018 Feb;48(2):50-62.

5. Arch Pediatr Adolesc Med. 2004 Aug;158(8):773-80.

6. Can J Psychiatry. 1993 Nov;38(9):590-4.

7. Appl Clin Genet. 2014 Feb 12;7:33-42.

8. J Am Acad Child Adolesc Psychiatry. 2017 Dec;56(12):1073-1080.

9. JAMA Psychiatry. 2019;76(4):426-34.

10. Subst Use Misuse. 2018 Jun 7;53(7):1158-69.

Carla is an otherwise-healthy 14-year-old female followed by her pediatrician for symptoms of depression and anxiety that have worsened over the past 8 months. Anhedonia, irritability, poor concentration, fatigue, hypersomnolence, and significant weight gain have increasingly led to further dysphoria, social isolation, and obsessive rumination, all of which now contribute to more dysfunction in both her home and school life. Based on Carla’s apprehension over “taking pills,” she was referred for outpatient therapy 5 months ago but because of difficulty maintaining weekly appointments, she stopped attending after 6 weeks, citing difficulty aligning with her therapist.

Carla was seen in an urgent, unscheduled follow-up appointment 2 months prior to address increased thoughts of wishing to be dead. She had neither a plan nor a desire to act on these ideations. During an interview, she was distant with poor eye contact, and her affect was notably blunted. Her mother, who had accompanied her in the waiting room, expressed frustration to the nurse about discovering that Carla was using cannabis, that she often appeared aloof and unmotivated to do much of anything but “sit in her room and play on her phone for hours on end.” She compared Carla with her ex-husband, who had similar mood swings that often led to erratic and violent outbursts towards Carla and her mother, behaviors that ultimately led them to leave him when Carla was 6 years old.

After a discussion over the risks and benefits of various treatment options, Carla was started on low-dose fluoxetine with a plan to titrate the medication after 2 weeks. A referral for outpatient substance use treatment also was initiated. Carla’s mother telephoned 10 days later in an update that things have drastically improved in Carla’s mood and activity. The following week her mother called back again with concerns that Carla is no longer sleeping, appears restless, impulsive, and disinhibited.

Discussion

Carla’s initial presentation is common to primary care settings. Based on her earliest reported symptoms, she would qualify for a diagnosis of major depression. Decisions regarding initial treatment for children and adolescents must take into account the severity of symptoms, risks, autonomy of the patient and family, as well as available evidence. Her response to outpatient therapy is not an anomaly. With an ever-increasing demand on mental health services, the availability of consistent, quality outpatient therapy for this population is not always easy to secure.^1,2 Combining targeted therapy with pharmacologic interventions for major depression appear to have the most effective outcomes.³

Carla’s progression also illustrates the challenges and potential pitfalls of attempting to understand and address her symptoms according to a single nosology. Depression is a like a fever. It can be caused by a myriad of factors and, left to linger, may lead to further residual complications. Focusing attention to her symptoms also may lead to a differential including adjustment problems, social anxiety, effects of trauma, surreptitious substance use, or even bipolar depression. Understanding Carla’s (or anyone else’s) unique predispositions to illness will better optimize the course of treatment.

To begin with, a clear delineation of Carla’s historic symptoms and any possible medical contributions to her presentation are necessary to investigate. Specific inquiries into past episodes of activation including hyperarousal, impulsivity, restlessness, and insomnia should be elucidated prior to consideration of medication selection.⁴ Considering Carla’s age and the known association between antidepressant-induced manic conversion among children aged 10-14 years,⁵ any pharmacologic intervention will benefit from the maxim “start low and go slow.” Her symptoms of activation arise within the setting of titration of an antidepressant. This may raise considerations to her specific metabolism and physiological concentrations of the medication as well as cumulative day exposure.

Complementary to Carla’s own history is that of family members. Often obtaining a reliable family psychiatric history is an exercise fraught with bias, vagueness, and generalizations.⁶ However, given the known heritability of bipolar disorders and the implications for treating depression in such individuals, compared with unipolar depressive symptoms, clarifying the nature of family illness may elucidate potential susceptibilities previously unconsidered.⁷ In this case, descriptions of Carla’s father’s behavior raise concerns for underlying bipolar disorder, as do the accounts of traumatic stress exposure and their compounded preponderance for increased suicide risk.⁸

Unfortunately, Carla’s current environmental cues and maladaptive behaviors may be perpetuating her symptoms and possibly placing her on a trajectory for further illness. Exploration of her relationship with her caregivers regarding the interpretation of her symptoms, and need for treatment should be undertaken so as to expand supportive roles. Education regarding cannabis use among adolescents and age-specific risks for later depression, anxiety, and suicide is warranted in a climate when accessibility is on the rise.⁹ Whether or not cannabis use itself leads to amotivation is the subject of current debate.¹⁰ A growing body of evidence is clearly illustrating that Carla’s sedentary behaviors and perceived loneliness likely exacerbate her mental well-being. Such patterns indicate the need for environmental intervention to change such cycles.

Finally, Carla’s progression through treatment speak to the need for open and honest discussions regarding realistic benefits as well potential risks. Progressive symptoms of depression left untreated can be life-threatening themselves, just as effects of activation as described in the vignette above can easily and quickly progress into situations that pose safety concerns. Amidst such periods of intervention, close communication and follow up with patients and their supports ameliorate potential adverse events and lead to better outcomes.

Outcome

Carla’s mother was advised to discontinue the medication, closely monitor Carla’s behavior and sleep, and schedule an emergent follow-up appointment for the next day. A safety plan indicating circumstances in which Carla would require closer medical supervision for safety was reviewed with her mother. Carla was later initiated on lamotrigine and restarted interpersonal therapy.

References

1. N Engl J Med. 2015 May 21;372(21):2029-38.

2. J Pediatr. 2010 Nov;157(5):848-51.

3. Arch Gen Psychiatry. 2007 Oct;64(10):1132-43.

4. Curr Probl Pediatr Adolesc Health Care. 2018 Feb;48(2):50-62.

5. Arch Pediatr Adolesc Med. 2004 Aug;158(8):773-80.

6. Can J Psychiatry. 1993 Nov;38(9):590-4.

7. Appl Clin Genet. 2014 Feb 12;7:33-42.

8. J Am Acad Child Adolesc Psychiatry. 2017 Dec;56(12):1073-1080.

9. JAMA Psychiatry. 2019;76(4):426-34.

10. Subst Use Misuse. 2018 Jun 7;53(7):1158-69.

Carla is an otherwise-healthy 14-year-old female followed by her pediatrician for symptoms of depression and anxiety that have worsened over the past 8 months. Anhedonia, irritability, poor concentration, fatigue, hypersomnolence, and significant weight gain have increasingly led to further dysphoria, social isolation, and obsessive rumination, all of which now contribute to more dysfunction in both her home and school life. Based on Carla’s apprehension over “taking pills,” she was referred for outpatient therapy 5 months ago but because of difficulty maintaining weekly appointments, she stopped attending after 6 weeks, citing difficulty aligning with her therapist.

Carla was seen in an urgent, unscheduled follow-up appointment 2 months prior to address increased thoughts of wishing to be dead. She had neither a plan nor a desire to act on these ideations. During an interview, she was distant with poor eye contact, and her affect was notably blunted. Her mother, who had accompanied her in the waiting room, expressed frustration to the nurse about discovering that Carla was using cannabis, that she often appeared aloof and unmotivated to do much of anything but “sit in her room and play on her phone for hours on end.” She compared Carla with her ex-husband, who had similar mood swings that often led to erratic and violent outbursts towards Carla and her mother, behaviors that ultimately led them to leave him when Carla was 6 years old.

After a discussion over the risks and benefits of various treatment options, Carla was started on low-dose fluoxetine with a plan to titrate the medication after 2 weeks. A referral for outpatient substance use treatment also was initiated. Carla’s mother telephoned 10 days later in an update that things have drastically improved in Carla’s mood and activity. The following week her mother called back again with concerns that Carla is no longer sleeping, appears restless, impulsive, and disinhibited.

Discussion

Carla’s initial presentation is common to primary care settings. Based on her earliest reported symptoms, she would qualify for a diagnosis of major depression. Decisions regarding initial treatment for children and adolescents must take into account the severity of symptoms, risks, autonomy of the patient and family, as well as available evidence. Her response to outpatient therapy is not an anomaly. With an ever-increasing demand on mental health services, the availability of consistent, quality outpatient therapy for this population is not always easy to secure.^1,2 Combining targeted therapy with pharmacologic interventions for major depression appear to have the most effective outcomes.³

Carla’s progression also illustrates the challenges and potential pitfalls of attempting to understand and address her symptoms according to a single nosology. Depression is a like a fever. It can be caused by a myriad of factors and, left to linger, may lead to further residual complications. Focusing attention to her symptoms also may lead to a differential including adjustment problems, social anxiety, effects of trauma, surreptitious substance use, or even bipolar depression. Understanding Carla’s (or anyone else’s) unique predispositions to illness will better optimize the course of treatment.

To begin with, a clear delineation of Carla’s historic symptoms and any possible medical contributions to her presentation are necessary to investigate. Specific inquiries into past episodes of activation including hyperarousal, impulsivity, restlessness, and insomnia should be elucidated prior to consideration of medication selection.⁴ Considering Carla’s age and the known association between antidepressant-induced manic conversion among children aged 10-14 years,⁵ any pharmacologic intervention will benefit from the maxim “start low and go slow.” Her symptoms of activation arise within the setting of titration of an antidepressant. This may raise considerations to her specific metabolism and physiological concentrations of the medication as well as cumulative day exposure.

Complementary to Carla’s own history is that of family members. Often obtaining a reliable family psychiatric history is an exercise fraught with bias, vagueness, and generalizations.⁶ However, given the known heritability of bipolar disorders and the implications for treating depression in such individuals, compared with unipolar depressive symptoms, clarifying the nature of family illness may elucidate potential susceptibilities previously unconsidered.⁷ In this case, descriptions of Carla’s father’s behavior raise concerns for underlying bipolar disorder, as do the accounts of traumatic stress exposure and their compounded preponderance for increased suicide risk.⁸

Unfortunately, Carla’s current environmental cues and maladaptive behaviors may be perpetuating her symptoms and possibly placing her on a trajectory for further illness. Exploration of her relationship with her caregivers regarding the interpretation of her symptoms, and need for treatment should be undertaken so as to expand supportive roles. Education regarding cannabis use among adolescents and age-specific risks for later depression, anxiety, and suicide is warranted in a climate when accessibility is on the rise.⁹ Whether or not cannabis use itself leads to amotivation is the subject of current debate.¹⁰ A growing body of evidence is clearly illustrating that Carla’s sedentary behaviors and perceived loneliness likely exacerbate her mental well-being. Such patterns indicate the need for environmental intervention to change such cycles.

Finally, Carla’s progression through treatment speak to the need for open and honest discussions regarding realistic benefits as well potential risks. Progressive symptoms of depression left untreated can be life-threatening themselves, just as effects of activation as described in the vignette above can easily and quickly progress into situations that pose safety concerns. Amidst such periods of intervention, close communication and follow up with patients and their supports ameliorate potential adverse events and lead to better outcomes.

Outcome

Carla’s mother was advised to discontinue the medication, closely monitor Carla’s behavior and sleep, and schedule an emergent follow-up appointment for the next day. A safety plan indicating circumstances in which Carla would require closer medical supervision for safety was reviewed with her mother. Carla was later initiated on lamotrigine and restarted interpersonal therapy.

References

1. N Engl J Med. 2015 May 21;372(21):2029-38.

2. J Pediatr. 2010 Nov;157(5):848-51.

3. Arch Gen Psychiatry. 2007 Oct;64(10):1132-43.

4. Curr Probl Pediatr Adolesc Health Care. 2018 Feb;48(2):50-62.

5. Arch Pediatr Adolesc Med. 2004 Aug;158(8):773-80.

6. Can J Psychiatry. 1993 Nov;38(9):590-4.

7. Appl Clin Genet. 2014 Feb 12;7:33-42.

8. J Am Acad Child Adolesc Psychiatry. 2017 Dec;56(12):1073-1080.

9. JAMA Psychiatry. 2019;76(4):426-34.

10. Subst Use Misuse. 2018 Jun 7;53(7):1158-69.

Question: A patient died unexpectedly during hospitalization for a diabetic foot infection. The autopsy revealed the presence of a large saddle pulmonary embolus. The hospital’s peer review committee met to determine if care was suboptimal and whether prophylactic anticoagulation should have been used. When the attending doctor was subsequently sued for malpractice, the plaintiff’s attorney sought to subpoena all of the medical records, including the minutes of the peer review committee. Given this hypothetical scenario, which of the following can occur?

A. “Discovery” is the legal term given to the process during the pretrial phase for amassing relevant documents and other information.

B. A subpoena duces tecum, which is a court order for the production of relevant documents and one that should normally be obeyed, may be issued.

C. The hospital declines to hand over certain types of hospital records, such as peer review minutes, which in this case are statutorily protected from discovery.

D. The plaintiff attorney goes to the judge for an order to compel production and may or may not be successful.

E. All are correct.
 

Answer: E. Physicians and other participants regularly meet, under strict confidential conditions, to discuss adverse events that occur in their institution. Congress and state legislatures have enacted laws to ensure the confidentiality of medical peer review, incident reports, and patient safety work products. Such records are protected from “discovery,” which is a pretrial procedure for collecting evidence in preparation for trial. The rationale for keeping these records beyond the reach of the discovery process is to encourage participants to engage in candid and free-rein analysis of adverse medical events so as to avoid future mishaps. If the content and nature of these discussions were freely available to parties in litigation, there would be a natural reluctance to express one’s viewpoints in a forthright manner.

Any given state’s statute on discovery requires careful reading because it could differ from another state’s directive – with important legal consequences. As an example, Hawaii’s statute¹ contains several inclusions and exclusions and reads in part: “... the information and data protected shall include proceedings and records of a peer review committee, hospital quality assurance committee, or health care review organization that include recordings, transcripts, minutes, and summaries of meetings, conversations, notes, materials, or reports created for, by, or at the direction of a peer review committee, quality assurance committee, or a health care review organization when related to a medical error reporting system. ... Information and data protected from discovery shall not include incident reports, occurrence reports, statements, or similar reports that state facts concerning a specific situation and shall not include records made in the regular course of business by a hospital ... including patient medical records. Original sources of information ... shall not be construed as being immune from discovery ... merely because they were reviewed ... or were in fact submitted to, a health care review organization.”

Predictably, plaintiff attorneys in a medical malpractice lawsuit will attempt to discover information regarding adverse events, hoping to learn about potential errors and judgment lapses, and thus gain an advantage over the defendant doctor and/or hospital. Several recent court cases highlight the contentious nature regarding whether a particular hospital report is to be deemed discoverable. Organized medicine, led by the American Medical Association, has mounted a vigorous response in arguing against the release of peer review and patient safety documents.

The AMA² recently weighed in on the case of Daley v. Teruel and Ingalls Memorial Hospital. In 2013, a renal failure patient died in an Illinois hospital from injuries that arose from prolonged hypoglycemia. She had received insulin, but when her blood glucose dropped to 16 mg/dl, the treatment team was not alerted and she was later found unresponsive with irreversible brain damage. The issue was whether incident reports from the case that were submitted to a certified PSO (patient safety organization) could be discovered. The Federal Patient Safety and Quality Improvement Act (PSQIA) had created PSOs to aggregate data from multiple sources to reduce adverse events and errors and improve medication safety.

An Illinois lower court ruled that, as part of the discovery process, the hospital had to turn over the report. However, the Illinois Appellate Court ruled in favor of the hospital, holding that the PSQIA protects the report because it is a “patient safety work product.”³ The AMA amicus brief had emphasized that Congress created a safeguarded patient safety process under the PSQIA to encourage hospitals to submit patient safety outcomes without fear of increased liability risk and that “these voluntarily created materials should be used for their intended purpose, not as a roadmap for litigation.”

New Jersey has also ruled against the discovery of a hospital’s self-critical report of a patient’s care, prepared in accordance with New Jersey’s Patient Safety Act.⁴ The plaintiff alleged that, when she reported to the emergency room at Chilton Medical Center complaining of persistent abdominal pain, fever, body aches, weakness, and a phlegmatic cough, she was incorrectly diagnosed as having pneumonia. In fact, she had appendicitis and a pelvic abscess. The New Jersey Supreme Court affirmed the panel’s order shielding the redacted document from discovery, but it reversed the judgment to the extent it ended the defendants’ discovery obligation with respect to this dispute, requiring instead that the lower court address, through current discovery rules, the proper balancing of interests between requesting and responding parties.

In a recent Michigan case,⁵ the trial court had earlier ruled that peer review documents at issue were in fact discoverable. Like similar statutes elsewhere, Michigan’s peer review privileges serve to encourage participation to improve on patient morbidity and mortality. The case centered on a court order compelling a Michigan hospital to release a physician’s credentialing file in a medical liability lawsuit on the narrow basis that the nondiscoverability privilege applied only to peer review deliberations and was inapplicable in the case. The trial judge had opined that, if all materials viewed by peer review committees were deemed undiscoverable, a hospital could never be held accountable for any negligent act within the purview of the committee. In its amicus brief in support of the hospital, the AMA argued that Michigan’s peer review privilege has historically spanned the bounds of the actual peer review process, and it countered that hospitals can be held liable – and are regularly held liable – without opening up these documents and that plaintiffs can use the same discovery mechanisms generally available to plaintiffs in other lawsuits.⁶ The case is currently under appeal.

In contrast, at least two state supreme courts have ruled to limit protections from discovery. The Florida Supreme Court has held that the federal law was intended to improve overall health care rather than to act as a shield to providers. In a case of alleged malpractice with severe neurological injuries, the court took a restrictive interpretation of the PSQIA as it relates to Florida’s risk-management and discovery laws, holding that patient safety work and related reports, when required by state law, do not come under the definition of patient safety work product and were therefore discoverable.⁷

The Pennsylvania Supreme Court has likewise ruled that documents generated by a hospital’s outside contractor are not protected from discovery under the state’s Peer Review Protection Act. It agreed with a lower-court ruling that Monongahela Valley Hospital could not claim privilege for a performance file on an emergency department physician employed by the hospital’s contractor University of Pittsburgh Medical Center Emergency Medicine.⁸ The case alleged that the plaintiff’s chest and back pain was misdiagnosed as reflux disease when in fact it was a myocardial infarct.

Dr. Tan is professor of medicine and former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].

References

1. Hawaii Revised Statutes §624-25.5 (2012).

2. AMA fights to protect patient-safety work from legal discovery. AMA Morning Rounds. 2018 Aug 1.
 

3. Daley v. Teruel and Ingalls Memorial Hospital, 2018 Ill. App. LEXIS 440 (Ill. App. Ct. 2018).

4. Brugaletta v. Garcia, 190 A.3d 419 (NJ. 2018).

5. Dwyer v. Ascension Crittenton Hospital. Michigan Supreme Court SC: 158668, 919 N.W.2d 407 (Mi. 2018).

6. Appellate court case puts peer-review protections in danger. AMA Morning Rounds. 2019 Mar 29.

7. Charles v. Southern Baptist Hospital of Florida, Inc., 2017 Fla. LEXIS 231 (Fla. Jan. 31, 2017).

8. Reginelli v. Boggs, 2018 Pa. LEXIS 1503 (Pa. 2018).

Question: A patient died unexpectedly during hospitalization for a diabetic foot infection. The autopsy revealed the presence of a large saddle pulmonary embolus. The hospital’s peer review committee met to determine if care was suboptimal and whether prophylactic anticoagulation should have been used. When the attending doctor was subsequently sued for malpractice, the plaintiff’s attorney sought to subpoena all of the medical records, including the minutes of the peer review committee. Given this hypothetical scenario, which of the following can occur?

A. “Discovery” is the legal term given to the process during the pretrial phase for amassing relevant documents and other information.

B. A subpoena duces tecum, which is a court order for the production of relevant documents and one that should normally be obeyed, may be issued.

C. The hospital declines to hand over certain types of hospital records, such as peer review minutes, which in this case are statutorily protected from discovery.

D. The plaintiff attorney goes to the judge for an order to compel production and may or may not be successful.

E. All are correct.
 

Answer: E. Physicians and other participants regularly meet, under strict confidential conditions, to discuss adverse events that occur in their institution. Congress and state legislatures have enacted laws to ensure the confidentiality of medical peer review, incident reports, and patient safety work products. Such records are protected from “discovery,” which is a pretrial procedure for collecting evidence in preparation for trial. The rationale for keeping these records beyond the reach of the discovery process is to encourage participants to engage in candid and free-rein analysis of adverse medical events so as to avoid future mishaps. If the content and nature of these discussions were freely available to parties in litigation, there would be a natural reluctance to express one’s viewpoints in a forthright manner.

Any given state’s statute on discovery requires careful reading because it could differ from another state’s directive – with important legal consequences. As an example, Hawaii’s statute¹ contains several inclusions and exclusions and reads in part: “... the information and data protected shall include proceedings and records of a peer review committee, hospital quality assurance committee, or health care review organization that include recordings, transcripts, minutes, and summaries of meetings, conversations, notes, materials, or reports created for, by, or at the direction of a peer review committee, quality assurance committee, or a health care review organization when related to a medical error reporting system. ... Information and data protected from discovery shall not include incident reports, occurrence reports, statements, or similar reports that state facts concerning a specific situation and shall not include records made in the regular course of business by a hospital ... including patient medical records. Original sources of information ... shall not be construed as being immune from discovery ... merely because they were reviewed ... or were in fact submitted to, a health care review organization.”

Predictably, plaintiff attorneys in a medical malpractice lawsuit will attempt to discover information regarding adverse events, hoping to learn about potential errors and judgment lapses, and thus gain an advantage over the defendant doctor and/or hospital. Several recent court cases highlight the contentious nature regarding whether a particular hospital report is to be deemed discoverable. Organized medicine, led by the American Medical Association, has mounted a vigorous response in arguing against the release of peer review and patient safety documents.

The AMA² recently weighed in on the case of Daley v. Teruel and Ingalls Memorial Hospital. In 2013, a renal failure patient died in an Illinois hospital from injuries that arose from prolonged hypoglycemia. She had received insulin, but when her blood glucose dropped to 16 mg/dl, the treatment team was not alerted and she was later found unresponsive with irreversible brain damage. The issue was whether incident reports from the case that were submitted to a certified PSO (patient safety organization) could be discovered. The Federal Patient Safety and Quality Improvement Act (PSQIA) had created PSOs to aggregate data from multiple sources to reduce adverse events and errors and improve medication safety.

An Illinois lower court ruled that, as part of the discovery process, the hospital had to turn over the report. However, the Illinois Appellate Court ruled in favor of the hospital, holding that the PSQIA protects the report because it is a “patient safety work product.”³ The AMA amicus brief had emphasized that Congress created a safeguarded patient safety process under the PSQIA to encourage hospitals to submit patient safety outcomes without fear of increased liability risk and that “these voluntarily created materials should be used for their intended purpose, not as a roadmap for litigation.”

New Jersey has also ruled against the discovery of a hospital’s self-critical report of a patient’s care, prepared in accordance with New Jersey’s Patient Safety Act.⁴ The plaintiff alleged that, when she reported to the emergency room at Chilton Medical Center complaining of persistent abdominal pain, fever, body aches, weakness, and a phlegmatic cough, she was incorrectly diagnosed as having pneumonia. In fact, she had appendicitis and a pelvic abscess. The New Jersey Supreme Court affirmed the panel’s order shielding the redacted document from discovery, but it reversed the judgment to the extent it ended the defendants’ discovery obligation with respect to this dispute, requiring instead that the lower court address, through current discovery rules, the proper balancing of interests between requesting and responding parties.

In a recent Michigan case,⁵ the trial court had earlier ruled that peer review documents at issue were in fact discoverable. Like similar statutes elsewhere, Michigan’s peer review privileges serve to encourage participation to improve on patient morbidity and mortality. The case centered on a court order compelling a Michigan hospital to release a physician’s credentialing file in a medical liability lawsuit on the narrow basis that the nondiscoverability privilege applied only to peer review deliberations and was inapplicable in the case. The trial judge had opined that, if all materials viewed by peer review committees were deemed undiscoverable, a hospital could never be held accountable for any negligent act within the purview of the committee. In its amicus brief in support of the hospital, the AMA argued that Michigan’s peer review privilege has historically spanned the bounds of the actual peer review process, and it countered that hospitals can be held liable – and are regularly held liable – without opening up these documents and that plaintiffs can use the same discovery mechanisms generally available to plaintiffs in other lawsuits.⁶ The case is currently under appeal.

In contrast, at least two state supreme courts have ruled to limit protections from discovery. The Florida Supreme Court has held that the federal law was intended to improve overall health care rather than to act as a shield to providers. In a case of alleged malpractice with severe neurological injuries, the court took a restrictive interpretation of the PSQIA as it relates to Florida’s risk-management and discovery laws, holding that patient safety work and related reports, when required by state law, do not come under the definition of patient safety work product and were therefore discoverable.⁷

The Pennsylvania Supreme Court has likewise ruled that documents generated by a hospital’s outside contractor are not protected from discovery under the state’s Peer Review Protection Act. It agreed with a lower-court ruling that Monongahela Valley Hospital could not claim privilege for a performance file on an emergency department physician employed by the hospital’s contractor University of Pittsburgh Medical Center Emergency Medicine.⁸ The case alleged that the plaintiff’s chest and back pain was misdiagnosed as reflux disease when in fact it was a myocardial infarct.

Dr. Tan is professor of medicine and former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].

References

1. Hawaii Revised Statutes §624-25.5 (2012).

2. AMA fights to protect patient-safety work from legal discovery. AMA Morning Rounds. 2018 Aug 1.
 

3. Daley v. Teruel and Ingalls Memorial Hospital, 2018 Ill. App. LEXIS 440 (Ill. App. Ct. 2018).

4. Brugaletta v. Garcia, 190 A.3d 419 (NJ. 2018).

5. Dwyer v. Ascension Crittenton Hospital. Michigan Supreme Court SC: 158668, 919 N.W.2d 407 (Mi. 2018).

6. Appellate court case puts peer-review protections in danger. AMA Morning Rounds. 2019 Mar 29.

7. Charles v. Southern Baptist Hospital of Florida, Inc., 2017 Fla. LEXIS 231 (Fla. Jan. 31, 2017).

8. Reginelli v. Boggs, 2018 Pa. LEXIS 1503 (Pa. 2018).

Question: A patient died unexpectedly during hospitalization for a diabetic foot infection. The autopsy revealed the presence of a large saddle pulmonary embolus. The hospital’s peer review committee met to determine if care was suboptimal and whether prophylactic anticoagulation should have been used. When the attending doctor was subsequently sued for malpractice, the plaintiff’s attorney sought to subpoena all of the medical records, including the minutes of the peer review committee. Given this hypothetical scenario, which of the following can occur?

A. “Discovery” is the legal term given to the process during the pretrial phase for amassing relevant documents and other information.

B. A subpoena duces tecum, which is a court order for the production of relevant documents and one that should normally be obeyed, may be issued.

C. The hospital declines to hand over certain types of hospital records, such as peer review minutes, which in this case are statutorily protected from discovery.

D. The plaintiff attorney goes to the judge for an order to compel production and may or may not be successful.

E. All are correct.
 

Answer: E. Physicians and other participants regularly meet, under strict confidential conditions, to discuss adverse events that occur in their institution. Congress and state legislatures have enacted laws to ensure the confidentiality of medical peer review, incident reports, and patient safety work products. Such records are protected from “discovery,” which is a pretrial procedure for collecting evidence in preparation for trial. The rationale for keeping these records beyond the reach of the discovery process is to encourage participants to engage in candid and free-rein analysis of adverse medical events so as to avoid future mishaps. If the content and nature of these discussions were freely available to parties in litigation, there would be a natural reluctance to express one’s viewpoints in a forthright manner.

Any given state’s statute on discovery requires careful reading because it could differ from another state’s directive – with important legal consequences. As an example, Hawaii’s statute¹ contains several inclusions and exclusions and reads in part: “... the information and data protected shall include proceedings and records of a peer review committee, hospital quality assurance committee, or health care review organization that include recordings, transcripts, minutes, and summaries of meetings, conversations, notes, materials, or reports created for, by, or at the direction of a peer review committee, quality assurance committee, or a health care review organization when related to a medical error reporting system. ... Information and data protected from discovery shall not include incident reports, occurrence reports, statements, or similar reports that state facts concerning a specific situation and shall not include records made in the regular course of business by a hospital ... including patient medical records. Original sources of information ... shall not be construed as being immune from discovery ... merely because they were reviewed ... or were in fact submitted to, a health care review organization.”

Predictably, plaintiff attorneys in a medical malpractice lawsuit will attempt to discover information regarding adverse events, hoping to learn about potential errors and judgment lapses, and thus gain an advantage over the defendant doctor and/or hospital. Several recent court cases highlight the contentious nature regarding whether a particular hospital report is to be deemed discoverable. Organized medicine, led by the American Medical Association, has mounted a vigorous response in arguing against the release of peer review and patient safety documents.

The AMA² recently weighed in on the case of Daley v. Teruel and Ingalls Memorial Hospital. In 2013, a renal failure patient died in an Illinois hospital from injuries that arose from prolonged hypoglycemia. She had received insulin, but when her blood glucose dropped to 16 mg/dl, the treatment team was not alerted and she was later found unresponsive with irreversible brain damage. The issue was whether incident reports from the case that were submitted to a certified PSO (patient safety organization) could be discovered. The Federal Patient Safety and Quality Improvement Act (PSQIA) had created PSOs to aggregate data from multiple sources to reduce adverse events and errors and improve medication safety.

An Illinois lower court ruled that, as part of the discovery process, the hospital had to turn over the report. However, the Illinois Appellate Court ruled in favor of the hospital, holding that the PSQIA protects the report because it is a “patient safety work product.”³ The AMA amicus brief had emphasized that Congress created a safeguarded patient safety process under the PSQIA to encourage hospitals to submit patient safety outcomes without fear of increased liability risk and that “these voluntarily created materials should be used for their intended purpose, not as a roadmap for litigation.”

New Jersey has also ruled against the discovery of a hospital’s self-critical report of a patient’s care, prepared in accordance with New Jersey’s Patient Safety Act.⁴ The plaintiff alleged that, when she reported to the emergency room at Chilton Medical Center complaining of persistent abdominal pain, fever, body aches, weakness, and a phlegmatic cough, she was incorrectly diagnosed as having pneumonia. In fact, she had appendicitis and a pelvic abscess. The New Jersey Supreme Court affirmed the panel’s order shielding the redacted document from discovery, but it reversed the judgment to the extent it ended the defendants’ discovery obligation with respect to this dispute, requiring instead that the lower court address, through current discovery rules, the proper balancing of interests between requesting and responding parties.

In a recent Michigan case,⁵ the trial court had earlier ruled that peer review documents at issue were in fact discoverable. Like similar statutes elsewhere, Michigan’s peer review privileges serve to encourage participation to improve on patient morbidity and mortality. The case centered on a court order compelling a Michigan hospital to release a physician’s credentialing file in a medical liability lawsuit on the narrow basis that the nondiscoverability privilege applied only to peer review deliberations and was inapplicable in the case. The trial judge had opined that, if all materials viewed by peer review committees were deemed undiscoverable, a hospital could never be held accountable for any negligent act within the purview of the committee. In its amicus brief in support of the hospital, the AMA argued that Michigan’s peer review privilege has historically spanned the bounds of the actual peer review process, and it countered that hospitals can be held liable – and are regularly held liable – without opening up these documents and that plaintiffs can use the same discovery mechanisms generally available to plaintiffs in other lawsuits.⁶ The case is currently under appeal.

In contrast, at least two state supreme courts have ruled to limit protections from discovery. The Florida Supreme Court has held that the federal law was intended to improve overall health care rather than to act as a shield to providers. In a case of alleged malpractice with severe neurological injuries, the court took a restrictive interpretation of the PSQIA as it relates to Florida’s risk-management and discovery laws, holding that patient safety work and related reports, when required by state law, do not come under the definition of patient safety work product and were therefore discoverable.⁷

The Pennsylvania Supreme Court has likewise ruled that documents generated by a hospital’s outside contractor are not protected from discovery under the state’s Peer Review Protection Act. It agreed with a lower-court ruling that Monongahela Valley Hospital could not claim privilege for a performance file on an emergency department physician employed by the hospital’s contractor University of Pittsburgh Medical Center Emergency Medicine.⁸ The case alleged that the plaintiff’s chest and back pain was misdiagnosed as reflux disease when in fact it was a myocardial infarct.

Dr. Tan is professor of medicine and former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].

References

1. Hawaii Revised Statutes §624-25.5 (2012).

2. AMA fights to protect patient-safety work from legal discovery. AMA Morning Rounds. 2018 Aug 1.
 

3. Daley v. Teruel and Ingalls Memorial Hospital, 2018 Ill. App. LEXIS 440 (Ill. App. Ct. 2018).

4. Brugaletta v. Garcia, 190 A.3d 419 (NJ. 2018).

5. Dwyer v. Ascension Crittenton Hospital. Michigan Supreme Court SC: 158668, 919 N.W.2d 407 (Mi. 2018).

6. Appellate court case puts peer-review protections in danger. AMA Morning Rounds. 2019 Mar 29.

7. Charles v. Southern Baptist Hospital of Florida, Inc., 2017 Fla. LEXIS 231 (Fla. Jan. 31, 2017).

8. Reginelli v. Boggs, 2018 Pa. LEXIS 1503 (Pa. 2018).

When you fly as a physician, there’s always a chance you’ll get a free drink. It’s not free, of course. For at least a few minutes, you worked. “Is there a physician onboard? – Ah, just how badly do you want that vodka tonic?

I ring my call button, as I’m sure you do. (It’s worth it to see the flight attendant’s face when I reply: “I’m a dermatologist.”) Last time it was for a 68-year-old man who was vomiting. There was no rash.

I responded along with a pediatrician and an ER nurse – gratitude is an ER nurse at 38,000 feet. The patient had chemotherapy-induced nausea. We three managed to get him well enough to finish the flight. Our ER nurse team member ran the show; she was excellent. She asked all the right questions and helped us all make good decisions. Unlike in clinic, I wasn’t an expert here despite my MD.

Several weeks ago, I saw a patient in the office with severe psoriasis. She stood before me erythrodermic. As I was adjusting her orders, I stepped out of the office to call one of my partners for her opinion. She examined the patient and declared: “I don’t think it’s psoriasis. Despite that biopsy, I think this is chronic eczema.” Brilliant.

In contrast to the former story, I was an expert in my office. And yet, success depended in both instances on my recognizing a cognitive bias: I don’t know everything, and worse, I sometimes don’t realize what I don’t know.

There are several biases of overconfidence. One is the expert trap: You believe you are an expert or correct, but you are wrong and you don’t see it. It’s a common mistake and manifests as overconfidence in our own abilities. For example, what decade did Hawaii join the union? Who is on the 20-dollar bill? Which is the farthest planet? You might be 90% confident of your answers, but most of us are more confident than we ought to be. Chances are you’ll be wrong on one. Recognizing this is hard. And yet, it’s what separates the good from the great clinicians.

Short of having your medical assistant whisper in your ear each day “Memento stultus” (remember you’re stupid), avoiding this bias is difficult. Signs that you might be trapped in an expert mindset are: 1. You believe your patients’ failure to improve is due to lack of adherence to your plan. 2. You cannot recall the last time you tried a new treatment. 3. You never ask others for second opinions. 4. Your colleagues stop asking for your opinion. 5. A flight attendant asks if you would mind returning to your seat rather than help with a medical situation.

If you want to be a better doctor, try working on your sense of self-importance. Remember your limitations and those of medicine. Be methodical in questioning your assumptions. Could you be wrong? Could the data you have be misleading? What are you missing? Ask a colleague to review some of your charts or spend time with you during procedures. Join (or start!) a journal club. Share your difficult cases with others and take note of how their advice differs from your approach.

By recognizing when you might be wrong and humbly stepping aside or taking the time to learn, you might just earn that free drink.

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

When you fly as a physician, there’s always a chance you’ll get a free drink. It’s not free, of course. For at least a few minutes, you worked. “Is there a physician onboard? – Ah, just how badly do you want that vodka tonic?

I ring my call button, as I’m sure you do. (It’s worth it to see the flight attendant’s face when I reply: “I’m a dermatologist.”) Last time it was for a 68-year-old man who was vomiting. There was no rash.

I responded along with a pediatrician and an ER nurse – gratitude is an ER nurse at 38,000 feet. The patient had chemotherapy-induced nausea. We three managed to get him well enough to finish the flight. Our ER nurse team member ran the show; she was excellent. She asked all the right questions and helped us all make good decisions. Unlike in clinic, I wasn’t an expert here despite my MD.

Several weeks ago, I saw a patient in the office with severe psoriasis. She stood before me erythrodermic. As I was adjusting her orders, I stepped out of the office to call one of my partners for her opinion. She examined the patient and declared: “I don’t think it’s psoriasis. Despite that biopsy, I think this is chronic eczema.” Brilliant.

In contrast to the former story, I was an expert in my office. And yet, success depended in both instances on my recognizing a cognitive bias: I don’t know everything, and worse, I sometimes don’t realize what I don’t know.

There are several biases of overconfidence. One is the expert trap: You believe you are an expert or correct, but you are wrong and you don’t see it. It’s a common mistake and manifests as overconfidence in our own abilities. For example, what decade did Hawaii join the union? Who is on the 20-dollar bill? Which is the farthest planet? You might be 90% confident of your answers, but most of us are more confident than we ought to be. Chances are you’ll be wrong on one. Recognizing this is hard. And yet, it’s what separates the good from the great clinicians.

Short of having your medical assistant whisper in your ear each day “Memento stultus” (remember you’re stupid), avoiding this bias is difficult. Signs that you might be trapped in an expert mindset are: 1. You believe your patients’ failure to improve is due to lack of adherence to your plan. 2. You cannot recall the last time you tried a new treatment. 3. You never ask others for second opinions. 4. Your colleagues stop asking for your opinion. 5. A flight attendant asks if you would mind returning to your seat rather than help with a medical situation.

If you want to be a better doctor, try working on your sense of self-importance. Remember your limitations and those of medicine. Be methodical in questioning your assumptions. Could you be wrong? Could the data you have be misleading? What are you missing? Ask a colleague to review some of your charts or spend time with you during procedures. Join (or start!) a journal club. Share your difficult cases with others and take note of how their advice differs from your approach.

By recognizing when you might be wrong and humbly stepping aside or taking the time to learn, you might just earn that free drink.

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

When you fly as a physician, there’s always a chance you’ll get a free drink. It’s not free, of course. For at least a few minutes, you worked. “Is there a physician onboard? – Ah, just how badly do you want that vodka tonic?

I ring my call button, as I’m sure you do. (It’s worth it to see the flight attendant’s face when I reply: “I’m a dermatologist.”) Last time it was for a 68-year-old man who was vomiting. There was no rash.

I responded along with a pediatrician and an ER nurse – gratitude is an ER nurse at 38,000 feet. The patient had chemotherapy-induced nausea. We three managed to get him well enough to finish the flight. Our ER nurse team member ran the show; she was excellent. She asked all the right questions and helped us all make good decisions. Unlike in clinic, I wasn’t an expert here despite my MD.

Several weeks ago, I saw a patient in the office with severe psoriasis. She stood before me erythrodermic. As I was adjusting her orders, I stepped out of the office to call one of my partners for her opinion. She examined the patient and declared: “I don’t think it’s psoriasis. Despite that biopsy, I think this is chronic eczema.” Brilliant.

In contrast to the former story, I was an expert in my office. And yet, success depended in both instances on my recognizing a cognitive bias: I don’t know everything, and worse, I sometimes don’t realize what I don’t know.

There are several biases of overconfidence. One is the expert trap: You believe you are an expert or correct, but you are wrong and you don’t see it. It’s a common mistake and manifests as overconfidence in our own abilities. For example, what decade did Hawaii join the union? Who is on the 20-dollar bill? Which is the farthest planet? You might be 90% confident of your answers, but most of us are more confident than we ought to be. Chances are you’ll be wrong on one. Recognizing this is hard. And yet, it’s what separates the good from the great clinicians.

Short of having your medical assistant whisper in your ear each day “Memento stultus” (remember you’re stupid), avoiding this bias is difficult. Signs that you might be trapped in an expert mindset are: 1. You believe your patients’ failure to improve is due to lack of adherence to your plan. 2. You cannot recall the last time you tried a new treatment. 3. You never ask others for second opinions. 4. Your colleagues stop asking for your opinion. 5. A flight attendant asks if you would mind returning to your seat rather than help with a medical situation.

If you want to be a better doctor, try working on your sense of self-importance. Remember your limitations and those of medicine. Be methodical in questioning your assumptions. Could you be wrong? Could the data you have be misleading? What are you missing? Ask a colleague to review some of your charts or spend time with you during procedures. Join (or start!) a journal club. Share your difficult cases with others and take note of how their advice differs from your approach.

By recognizing when you might be wrong and humbly stepping aside or taking the time to learn, you might just earn that free drink.

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

Intuitively, we have come to believe that adding more to each family members’ schedule – a lesson, an activity, more homework time – is more enriching or meaningful than is a family dinner, which appears to have less direct impact. However, there is a growing body of evidence that, when an entire family eats dinner together 5 or more nights weekly, the emotional health and well-being of all family members is improved. Not only is their health improved, as there is a greater likelihood of eating nutritious food, but so are a child’s school performance and emotional well-being. As the frequency of eating dinner with parents goes up, the rates of mood and anxiety disorders and high-risk behaviors in teenagers go down.

Wavebreakmedia/Thinkstock

But less than 60% of children eat five or more meals with their parents each week (National Center on Addiction and Substance Abuse [CASA], 2012). Few people would suggest that encouraging families to eat dinner together is a bad idea, but time is the ultimate scarce resource. Preparing food and eating together takes time, and parents and children have many demands on that time that feel nonnegotiable, such as homework, exercise, team practice, or work obligations. When you meet with your patients and explain the tremendous health benefits of eating dinner together, you help your patients and their parents make informed decisions about how to rebalance time to prioritize family dinners that have real but fewer obvious impacts then do a piano lesson or dance class.

Of course, children who eat regular family dinners eat more fruits and vegetables and fewer fried foods and soft drinks than do their peers who eat dinner with their families less often. They are less likely to become obese in youth and more likely to eat healthily and maintain a healthy weight once they live on their own as adults.

It is important to set the framework for what really matters in a family dinner so that your patients can enjoy all of these benefits. Parents may assume that the meal must be prepared from scratch with only fresh, local, or organic ingredients. But what matters most is that the food is delicious and nutritious, and that the time spent eating (and preparing it) is fun, and promotes conversation and connection. Homemade food usually is more nutritious and will bring more of the physical health benefits, but many store-bought ingredients or even take-out options can be healthy and can promote time for the family to sit together and connect. If parents enjoy preparing food, then it’s worthwhile! And they should not worry about having every member of the family together at every meal. Even if only one parent and child are present for a dinner, they each will enjoy the benefits.

Offer some ideas about how to facilitate conversations. Asking about how a child’s day went may spark conversations sometimes, but usually people benefit from specific questions. What made you really laugh today? What did you have for lunch? Whom did you sit next to on the bus? If a parent starts by telling a story about his or her day, even better! This is especially potent if a parent talks about something embarrassing or challenging, or mentions a failure. Young children will have plenty of these stories, and adolescents build resilience by internalizing the idea that setbacks and difficulties are a normal, healthy part of every day. This is a great time to talk about current events, whether in the news, entertainment, or sports. And telling stories about when children were younger, when the parents were children, or even about grandparents or more distant ancestors is a wonderful way to engage children in the greater story of their family narrative, and is always engaging and memorable.

At a deeper level, the family dinner is a time that recognizes each person’s contribution to a discussion, and facilitates a calm discussion of the families’ history and values. There is connection, communication, and building of trust. Families that cannot schedule a minimum number of dinners or that have dinners filled with tension and conflict, are very likely to have children at risk. For those conflicted and often unhappy families, a pediatrician’s early recognition and intervention could make a meaningful difference.

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

References

1. J Adolesc Health. 2006;39(3):337-45.

2. J Adolesc. 2010;33(1):187-96.

3. J Adolesc Health. 2009;44(5):431-6.

4. Health Psychol. 2008;27(Suppl 2):s109-17.

5. J Adolesc Health. 2009;45(4):389-95.

6. Pediatrics. 2019 Jul 8. doi: 10.1542/peds.2018-945.

7. Arch Pediatr Adolesc Med. 2004;158(8):792-6.

8. Prev Med. 2018;113:7-12.

Intuitively, we have come to believe that adding more to each family members’ schedule – a lesson, an activity, more homework time – is more enriching or meaningful than is a family dinner, which appears to have less direct impact. However, there is a growing body of evidence that, when an entire family eats dinner together 5 or more nights weekly, the emotional health and well-being of all family members is improved. Not only is their health improved, as there is a greater likelihood of eating nutritious food, but so are a child’s school performance and emotional well-being. As the frequency of eating dinner with parents goes up, the rates of mood and anxiety disorders and high-risk behaviors in teenagers go down.

Wavebreakmedia/Thinkstock

But less than 60% of children eat five or more meals with their parents each week (National Center on Addiction and Substance Abuse [CASA], 2012). Few people would suggest that encouraging families to eat dinner together is a bad idea, but time is the ultimate scarce resource. Preparing food and eating together takes time, and parents and children have many demands on that time that feel nonnegotiable, such as homework, exercise, team practice, or work obligations. When you meet with your patients and explain the tremendous health benefits of eating dinner together, you help your patients and their parents make informed decisions about how to rebalance time to prioritize family dinners that have real but fewer obvious impacts then do a piano lesson or dance class.

Of course, children who eat regular family dinners eat more fruits and vegetables and fewer fried foods and soft drinks than do their peers who eat dinner with their families less often. They are less likely to become obese in youth and more likely to eat healthily and maintain a healthy weight once they live on their own as adults.

It is important to set the framework for what really matters in a family dinner so that your patients can enjoy all of these benefits. Parents may assume that the meal must be prepared from scratch with only fresh, local, or organic ingredients. But what matters most is that the food is delicious and nutritious, and that the time spent eating (and preparing it) is fun, and promotes conversation and connection. Homemade food usually is more nutritious and will bring more of the physical health benefits, but many store-bought ingredients or even take-out options can be healthy and can promote time for the family to sit together and connect. If parents enjoy preparing food, then it’s worthwhile! And they should not worry about having every member of the family together at every meal. Even if only one parent and child are present for a dinner, they each will enjoy the benefits.

Offer some ideas about how to facilitate conversations. Asking about how a child’s day went may spark conversations sometimes, but usually people benefit from specific questions. What made you really laugh today? What did you have for lunch? Whom did you sit next to on the bus? If a parent starts by telling a story about his or her day, even better! This is especially potent if a parent talks about something embarrassing or challenging, or mentions a failure. Young children will have plenty of these stories, and adolescents build resilience by internalizing the idea that setbacks and difficulties are a normal, healthy part of every day. This is a great time to talk about current events, whether in the news, entertainment, or sports. And telling stories about when children were younger, when the parents were children, or even about grandparents or more distant ancestors is a wonderful way to engage children in the greater story of their family narrative, and is always engaging and memorable.

At a deeper level, the family dinner is a time that recognizes each person’s contribution to a discussion, and facilitates a calm discussion of the families’ history and values. There is connection, communication, and building of trust. Families that cannot schedule a minimum number of dinners or that have dinners filled with tension and conflict, are very likely to have children at risk. For those conflicted and often unhappy families, a pediatrician’s early recognition and intervention could make a meaningful difference.

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

References

1. J Adolesc Health. 2006;39(3):337-45.

2. J Adolesc. 2010;33(1):187-96.

3. J Adolesc Health. 2009;44(5):431-6.

4. Health Psychol. 2008;27(Suppl 2):s109-17.

5. J Adolesc Health. 2009;45(4):389-95.

6. Pediatrics. 2019 Jul 8. doi: 10.1542/peds.2018-945.

7. Arch Pediatr Adolesc Med. 2004;158(8):792-6.

8. Prev Med. 2018;113:7-12.

Intuitively, we have come to believe that adding more to each family members’ schedule – a lesson, an activity, more homework time – is more enriching or meaningful than is a family dinner, which appears to have less direct impact. However, there is a growing body of evidence that, when an entire family eats dinner together 5 or more nights weekly, the emotional health and well-being of all family members is improved. Not only is their health improved, as there is a greater likelihood of eating nutritious food, but so are a child’s school performance and emotional well-being. As the frequency of eating dinner with parents goes up, the rates of mood and anxiety disorders and high-risk behaviors in teenagers go down.

Wavebreakmedia/Thinkstock

But less than 60% of children eat five or more meals with their parents each week (National Center on Addiction and Substance Abuse [CASA], 2012). Few people would suggest that encouraging families to eat dinner together is a bad idea, but time is the ultimate scarce resource. Preparing food and eating together takes time, and parents and children have many demands on that time that feel nonnegotiable, such as homework, exercise, team practice, or work obligations. When you meet with your patients and explain the tremendous health benefits of eating dinner together, you help your patients and their parents make informed decisions about how to rebalance time to prioritize family dinners that have real but fewer obvious impacts then do a piano lesson or dance class.

Of course, children who eat regular family dinners eat more fruits and vegetables and fewer fried foods and soft drinks than do their peers who eat dinner with their families less often. They are less likely to become obese in youth and more likely to eat healthily and maintain a healthy weight once they live on their own as adults.

It is important to set the framework for what really matters in a family dinner so that your patients can enjoy all of these benefits. Parents may assume that the meal must be prepared from scratch with only fresh, local, or organic ingredients. But what matters most is that the food is delicious and nutritious, and that the time spent eating (and preparing it) is fun, and promotes conversation and connection. Homemade food usually is more nutritious and will bring more of the physical health benefits, but many store-bought ingredients or even take-out options can be healthy and can promote time for the family to sit together and connect. If parents enjoy preparing food, then it’s worthwhile! And they should not worry about having every member of the family together at every meal. Even if only one parent and child are present for a dinner, they each will enjoy the benefits.

Offer some ideas about how to facilitate conversations. Asking about how a child’s day went may spark conversations sometimes, but usually people benefit from specific questions. What made you really laugh today? What did you have for lunch? Whom did you sit next to on the bus? If a parent starts by telling a story about his or her day, even better! This is especially potent if a parent talks about something embarrassing or challenging, or mentions a failure. Young children will have plenty of these stories, and adolescents build resilience by internalizing the idea that setbacks and difficulties are a normal, healthy part of every day. This is a great time to talk about current events, whether in the news, entertainment, or sports. And telling stories about when children were younger, when the parents were children, or even about grandparents or more distant ancestors is a wonderful way to engage children in the greater story of their family narrative, and is always engaging and memorable.

At a deeper level, the family dinner is a time that recognizes each person’s contribution to a discussion, and facilitates a calm discussion of the families’ history and values. There is connection, communication, and building of trust. Families that cannot schedule a minimum number of dinners or that have dinners filled with tension and conflict, are very likely to have children at risk. For those conflicted and often unhappy families, a pediatrician’s early recognition and intervention could make a meaningful difference.

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

References

1. J Adolesc Health. 2006;39(3):337-45.

2. J Adolesc. 2010;33(1):187-96.

3. J Adolesc Health. 2009;44(5):431-6.

4. Health Psychol. 2008;27(Suppl 2):s109-17.

5. J Adolesc Health. 2009;45(4):389-95.

6. Pediatrics. 2019 Jul 8. doi: 10.1542/peds.2018-945.

7. Arch Pediatr Adolesc Med. 2004;158(8):792-6.

8. Prev Med. 2018;113:7-12.

Long-acting injectables (LAIs) continue to be underused for patients with chronic diseases such as schizophrenia and bipolar disorder. However, in my practice, I have found the use of those medications to be useful for promoting adherence, and I wonder why they are not used more often – in light of their effectiveness. Specifically, among individuals with schizophrenia, LAIs can lead to significant improvements in symptom control, quality of life, and overall functioning.¹

The following three cases illustrate the power of LAIs:

Case 1: A male patient with schizoaffective diagnosis had been admitted several times to the inpatient psychiatric unit and had poor compliance to medications by mouth. He had multiple emergency department visits besides having community health behavioral support. After various medication trials by mouth, he responded to LAIs. He was able to function in the community for longer periods of time and required far fewer ED visits. He followed up with his outpatient psychiatric support regularly.

Case 2: A female patient with schizoaffective disorder had psychosis of a persecutory nature and paranoia. She was unable to function in the community and struggled with delusional thoughts leading to anger outbursts in the community. She continually refused medicines by mouth in the outpatient unit. Upon involuntary inpatient management as per court order, the patient responded to LAIs. Her insight improved, and she displayed better judgment in the future.

Case 3: A female patient with bipolar I was impulsive and promiscuous, and routinely entered into high-risk situations. She was not able to negotiate safely in the community, and was shuttling from shelter to shelter. She was losing her medications time and again during her transition in the community. She responded well to LAIs, however, and was able to keep herself out of the inpatient hospital for longer periods of time. She said she felt relieved about not depending on daily oral medications. She also reported not self medicating with street substances.

A recent retrospective study of more than 3,600 patients showed that those who initiate LAIs versus oral antipsychotics have greater reductions in the number of hospitalizations.² Furthermore, treatment with LAIs might be more cost-effective than oral medications, and might reduce the risk of suicide and the propensity to violence in at least a subset of individuals with psychotic illnesses and comorbid substance use disorders.^3,4

References

1. Kaplan G et al. Impact of long-acting injectable antipsychotics on medication adherence and clinical, functional, and economic outcomes of schizophrenia. Patient Prefer Adherence. 2013;13:1171-80.

2. Brissos S et al. The role of long-acting injectable antipsychotics in schizophrenia: a critical appraisal. Therapeutic advances in psychopharmacology. 2014 Oct;4(5):198-219.

3. Ravasio R et al. Analisi di costo-efficacia dello switch da un antipsicotico orale a risperidone a rilascio prolungato nel trattamento dei pazienti affetti da schizofrenia. Giorn Ital Health Technol Ass. 2019;2:1-8.

4. Reichhart T and W Kissling. Societal costs of nonadherence in schizophrenia: homicide/suicide. Mind & Brain, J Psychiatry. 2010 Aug 1(2):29-32.

5. Offord S et al. Health care resource usage of schizophrenia patients initiating long-acting injectable antipsychotics vs oral. J Med Econ. 2013;16:231-9.

6. Matthias J and W Rossler. Attitudes toward long-acting depot antipsychotics: a survey of patients, relatives and psychiatrists. Psychiatry Res. 2010 Jan 30;175(1-2):58-62.

Dr. Lamba, a psychiatrist and medical director at BayRidge Hospital in Lynn, Mass., has no disclosures. He changed key facts about the patients discussed to protect their confidentiality.

Long-acting injectables (LAIs) continue to be underused for patients with chronic diseases such as schizophrenia and bipolar disorder. However, in my practice, I have found the use of those medications to be useful for promoting adherence, and I wonder why they are not used more often – in light of their effectiveness. Specifically, among individuals with schizophrenia, LAIs can lead to significant improvements in symptom control, quality of life, and overall functioning.¹

The following three cases illustrate the power of LAIs:

Case 1: A male patient with schizoaffective diagnosis had been admitted several times to the inpatient psychiatric unit and had poor compliance to medications by mouth. He had multiple emergency department visits besides having community health behavioral support. After various medication trials by mouth, he responded to LAIs. He was able to function in the community for longer periods of time and required far fewer ED visits. He followed up with his outpatient psychiatric support regularly.

Case 2: A female patient with schizoaffective disorder had psychosis of a persecutory nature and paranoia. She was unable to function in the community and struggled with delusional thoughts leading to anger outbursts in the community. She continually refused medicines by mouth in the outpatient unit. Upon involuntary inpatient management as per court order, the patient responded to LAIs. Her insight improved, and she displayed better judgment in the future.

Case 3: A female patient with bipolar I was impulsive and promiscuous, and routinely entered into high-risk situations. She was not able to negotiate safely in the community, and was shuttling from shelter to shelter. She was losing her medications time and again during her transition in the community. She responded well to LAIs, however, and was able to keep herself out of the inpatient hospital for longer periods of time. She said she felt relieved about not depending on daily oral medications. She also reported not self medicating with street substances.

A recent retrospective study of more than 3,600 patients showed that those who initiate LAIs versus oral antipsychotics have greater reductions in the number of hospitalizations.² Furthermore, treatment with LAIs might be more cost-effective than oral medications, and might reduce the risk of suicide and the propensity to violence in at least a subset of individuals with psychotic illnesses and comorbid substance use disorders.^3,4

References

1. Kaplan G et al. Impact of long-acting injectable antipsychotics on medication adherence and clinical, functional, and economic outcomes of schizophrenia. Patient Prefer Adherence. 2013;13:1171-80.

2. Brissos S et al. The role of long-acting injectable antipsychotics in schizophrenia: a critical appraisal. Therapeutic advances in psychopharmacology. 2014 Oct;4(5):198-219.

3. Ravasio R et al. Analisi di costo-efficacia dello switch da un antipsicotico orale a risperidone a rilascio prolungato nel trattamento dei pazienti affetti da schizofrenia. Giorn Ital Health Technol Ass. 2019;2:1-8.

4. Reichhart T and W Kissling. Societal costs of nonadherence in schizophrenia: homicide/suicide. Mind & Brain, J Psychiatry. 2010 Aug 1(2):29-32.

5. Offord S et al. Health care resource usage of schizophrenia patients initiating long-acting injectable antipsychotics vs oral. J Med Econ. 2013;16:231-9.

6. Matthias J and W Rossler. Attitudes toward long-acting depot antipsychotics: a survey of patients, relatives and psychiatrists. Psychiatry Res. 2010 Jan 30;175(1-2):58-62.

Dr. Lamba, a psychiatrist and medical director at BayRidge Hospital in Lynn, Mass., has no disclosures. He changed key facts about the patients discussed to protect their confidentiality.

Long-acting injectables (LAIs) continue to be underused for patients with chronic diseases such as schizophrenia and bipolar disorder. However, in my practice, I have found the use of those medications to be useful for promoting adherence, and I wonder why they are not used more often – in light of their effectiveness. Specifically, among individuals with schizophrenia, LAIs can lead to significant improvements in symptom control, quality of life, and overall functioning.¹

The following three cases illustrate the power of LAIs:

Case 1: A male patient with schizoaffective diagnosis had been admitted several times to the inpatient psychiatric unit and had poor compliance to medications by mouth. He had multiple emergency department visits besides having community health behavioral support. After various medication trials by mouth, he responded to LAIs. He was able to function in the community for longer periods of time and required far fewer ED visits. He followed up with his outpatient psychiatric support regularly.

Case 2: A female patient with schizoaffective disorder had psychosis of a persecutory nature and paranoia. She was unable to function in the community and struggled with delusional thoughts leading to anger outbursts in the community. She continually refused medicines by mouth in the outpatient unit. Upon involuntary inpatient management as per court order, the patient responded to LAIs. Her insight improved, and she displayed better judgment in the future.

Case 3: A female patient with bipolar I was impulsive and promiscuous, and routinely entered into high-risk situations. She was not able to negotiate safely in the community, and was shuttling from shelter to shelter. She was losing her medications time and again during her transition in the community. She responded well to LAIs, however, and was able to keep herself out of the inpatient hospital for longer periods of time. She said she felt relieved about not depending on daily oral medications. She also reported not self medicating with street substances.

A recent retrospective study of more than 3,600 patients showed that those who initiate LAIs versus oral antipsychotics have greater reductions in the number of hospitalizations.² Furthermore, treatment with LAIs might be more cost-effective than oral medications, and might reduce the risk of suicide and the propensity to violence in at least a subset of individuals with psychotic illnesses and comorbid substance use disorders.^3,4

References

1. Kaplan G et al. Impact of long-acting injectable antipsychotics on medication adherence and clinical, functional, and economic outcomes of schizophrenia. Patient Prefer Adherence. 2013;13:1171-80.

2. Brissos S et al. The role of long-acting injectable antipsychotics in schizophrenia: a critical appraisal. Therapeutic advances in psychopharmacology. 2014 Oct;4(5):198-219.

3. Ravasio R et al. Analisi di costo-efficacia dello switch da un antipsicotico orale a risperidone a rilascio prolungato nel trattamento dei pazienti affetti da schizofrenia. Giorn Ital Health Technol Ass. 2019;2:1-8.

4. Reichhart T and W Kissling. Societal costs of nonadherence in schizophrenia: homicide/suicide. Mind & Brain, J Psychiatry. 2010 Aug 1(2):29-32.

5. Offord S et al. Health care resource usage of schizophrenia patients initiating long-acting injectable antipsychotics vs oral. J Med Econ. 2013;16:231-9.

6. Matthias J and W Rossler. Attitudes toward long-acting depot antipsychotics: a survey of patients, relatives and psychiatrists. Psychiatry Res. 2010 Jan 30;175(1-2):58-62.

Dr. Lamba, a psychiatrist and medical director at BayRidge Hospital in Lynn, Mass., has no disclosures. He changed key facts about the patients discussed to protect their confidentiality.

Many of the personnel questions I receive concern the dreaded “marginal employee” – a person who has never done anything truly heinous to merit firing, but neither anything special to merit continued employment. I advise getting rid of such people and then changing the hiring criteria that bring you marginal employees in the first place.

katleho Seisa/Getty Images

Most bad hires come about because employers do not have a clear vision of the kind of employee they want. Many office manuals do not contain detailed job descriptions. If you don’t know exactly what you are looking for, your entire selection process will be inadequate from initial screening of applicants through assessments of their skills and personalities. Many physicians compound the problem with poor interview techniques and inadequate verification.

So now is the time, before a job vacancy occurs, to reevaluate your entire hiring process.. Take a hard look at your job descriptions, and update them if necessary. A good job description lists the major responsibilities of the position, with the relative importance of each duty and the critical knowledge, skills, and education levels necessary for each function. In other words, it describes, accurately and in detail, exactly what you expect from the employee you will hire to perform that job.

Once you have a clear job description in mind (and in print), take all the time you need to find the best possible match for it. This is not a place to cut corners. Screen your candidates carefully and avoid lowering your expectations. This is the point at which it might be tempting to settle for a marginal candidate, just to get the process over with.

It also is tempting to hire the candidate that you have the “best feeling” about, even though he or she is a poor match for the job, and then try to mold the job to that person. Every doctor knows that hunches are no substitute for hard data.


Be alert for red flags in résumés: significant time gaps between jobs; positions at companies that are no longer in business, or are otherwise impossible to verify; job titles that don’t make sense, given the applicant’s qualifications.

Background checks are a dicey subject, but publicly available information can be found, cheaply or free, on multiple websites created for that purpose. Be sure to tell applicants that you will be verifying facts in their résumés; it’s usually wise to get their written consent to do so.

Many employers skip the essential step of verification; many applicants know that. (I once actually overheard a new hire say, “I won’t be here long if they check my references.” And by golly, she was right!) If a reference is reluctant to tell you anything substantive, ask, “Would you hire this person again?” You can interpret a lot from the answer – or lack of one.

Interviews often get short shrift as well. Many doctors tend to do all the talking. The purpose of an interview is to allow you to size up the prospective employee, not to deliver a lecture on the sterling attributes of your office. Important interview topics include educational background, skills, experience, and unrelated job history.

By law, you cannot ask an applicant’s age, date of birth, sex, creed, color, religion, or national origin. Other forbidden subjects include disabilities, marital status, military record, number of children (or who cares for them), addiction history, citizenship, criminal record, psychiatric history, absenteeism, or workers’ compensation.

There are acceptable alternatives to some of those questions, however: You can ask if applicants have ever gone by another name (for your background check), for example. You can ask if they are legally authorized to work in this country, and whether they will be physically able to perform the duties specified in the job description. While past addictions are off limits, you do have a right to know about current addictions to illegal substances.

Once you have hired people whose skills and personalities best fit your needs, train them well, and then give them the opportunity to succeed. “The best executive,” wrote Theodore Roosevelt, “is the one who has sense enough to pick good [people] to do what he [or she] wants done, and self-restraint enough to keep from meddling with them while they do it.”
 

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].

Many of the personnel questions I receive concern the dreaded “marginal employee” – a person who has never done anything truly heinous to merit firing, but neither anything special to merit continued employment. I advise getting rid of such people and then changing the hiring criteria that bring you marginal employees in the first place.

katleho Seisa/Getty Images

Most bad hires come about because employers do not have a clear vision of the kind of employee they want. Many office manuals do not contain detailed job descriptions. If you don’t know exactly what you are looking for, your entire selection process will be inadequate from initial screening of applicants through assessments of their skills and personalities. Many physicians compound the problem with poor interview techniques and inadequate verification.

So now is the time, before a job vacancy occurs, to reevaluate your entire hiring process.. Take a hard look at your job descriptions, and update them if necessary. A good job description lists the major responsibilities of the position, with the relative importance of each duty and the critical knowledge, skills, and education levels necessary for each function. In other words, it describes, accurately and in detail, exactly what you expect from the employee you will hire to perform that job.

Once you have a clear job description in mind (and in print), take all the time you need to find the best possible match for it. This is not a place to cut corners. Screen your candidates carefully and avoid lowering your expectations. This is the point at which it might be tempting to settle for a marginal candidate, just to get the process over with.

It also is tempting to hire the candidate that you have the “best feeling” about, even though he or she is a poor match for the job, and then try to mold the job to that person. Every doctor knows that hunches are no substitute for hard data.


Be alert for red flags in résumés: significant time gaps between jobs; positions at companies that are no longer in business, or are otherwise impossible to verify; job titles that don’t make sense, given the applicant’s qualifications.

Background checks are a dicey subject, but publicly available information can be found, cheaply or free, on multiple websites created for that purpose. Be sure to tell applicants that you will be verifying facts in their résumés; it’s usually wise to get their written consent to do so.

Many employers skip the essential step of verification; many applicants know that. (I once actually overheard a new hire say, “I won’t be here long if they check my references.” And by golly, she was right!) If a reference is reluctant to tell you anything substantive, ask, “Would you hire this person again?” You can interpret a lot from the answer – or lack of one.

Interviews often get short shrift as well. Many doctors tend to do all the talking. The purpose of an interview is to allow you to size up the prospective employee, not to deliver a lecture on the sterling attributes of your office. Important interview topics include educational background, skills, experience, and unrelated job history.

By law, you cannot ask an applicant’s age, date of birth, sex, creed, color, religion, or national origin. Other forbidden subjects include disabilities, marital status, military record, number of children (or who cares for them), addiction history, citizenship, criminal record, psychiatric history, absenteeism, or workers’ compensation.

There are acceptable alternatives to some of those questions, however: You can ask if applicants have ever gone by another name (for your background check), for example. You can ask if they are legally authorized to work in this country, and whether they will be physically able to perform the duties specified in the job description. While past addictions are off limits, you do have a right to know about current addictions to illegal substances.

Once you have hired people whose skills and personalities best fit your needs, train them well, and then give them the opportunity to succeed. “The best executive,” wrote Theodore Roosevelt, “is the one who has sense enough to pick good [people] to do what he [or she] wants done, and self-restraint enough to keep from meddling with them while they do it.”
 

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].

Many of the personnel questions I receive concern the dreaded “marginal employee” – a person who has never done anything truly heinous to merit firing, but neither anything special to merit continued employment. I advise getting rid of such people and then changing the hiring criteria that bring you marginal employees in the first place.

katleho Seisa/Getty Images

Most bad hires come about because employers do not have a clear vision of the kind of employee they want. Many office manuals do not contain detailed job descriptions. If you don’t know exactly what you are looking for, your entire selection process will be inadequate from initial screening of applicants through assessments of their skills and personalities. Many physicians compound the problem with poor interview techniques and inadequate verification.

So now is the time, before a job vacancy occurs, to reevaluate your entire hiring process.. Take a hard look at your job descriptions, and update them if necessary. A good job description lists the major responsibilities of the position, with the relative importance of each duty and the critical knowledge, skills, and education levels necessary for each function. In other words, it describes, accurately and in detail, exactly what you expect from the employee you will hire to perform that job.

Once you have a clear job description in mind (and in print), take all the time you need to find the best possible match for it. This is not a place to cut corners. Screen your candidates carefully and avoid lowering your expectations. This is the point at which it might be tempting to settle for a marginal candidate, just to get the process over with.

It also is tempting to hire the candidate that you have the “best feeling” about, even though he or she is a poor match for the job, and then try to mold the job to that person. Every doctor knows that hunches are no substitute for hard data.


Be alert for red flags in résumés: significant time gaps between jobs; positions at companies that are no longer in business, or are otherwise impossible to verify; job titles that don’t make sense, given the applicant’s qualifications.

Background checks are a dicey subject, but publicly available information can be found, cheaply or free, on multiple websites created for that purpose. Be sure to tell applicants that you will be verifying facts in their résumés; it’s usually wise to get their written consent to do so.

Many employers skip the essential step of verification; many applicants know that. (I once actually overheard a new hire say, “I won’t be here long if they check my references.” And by golly, she was right!) If a reference is reluctant to tell you anything substantive, ask, “Would you hire this person again?” You can interpret a lot from the answer – or lack of one.

Interviews often get short shrift as well. Many doctors tend to do all the talking. The purpose of an interview is to allow you to size up the prospective employee, not to deliver a lecture on the sterling attributes of your office. Important interview topics include educational background, skills, experience, and unrelated job history.

By law, you cannot ask an applicant’s age, date of birth, sex, creed, color, religion, or national origin. Other forbidden subjects include disabilities, marital status, military record, number of children (or who cares for them), addiction history, citizenship, criminal record, psychiatric history, absenteeism, or workers’ compensation.

There are acceptable alternatives to some of those questions, however: You can ask if applicants have ever gone by another name (for your background check), for example. You can ask if they are legally authorized to work in this country, and whether they will be physically able to perform the duties specified in the job description. While past addictions are off limits, you do have a right to know about current addictions to illegal substances.

Once you have hired people whose skills and personalities best fit your needs, train them well, and then give them the opportunity to succeed. “The best executive,” wrote Theodore Roosevelt, “is the one who has sense enough to pick good [people] to do what he [or she] wants done, and self-restraint enough to keep from meddling with them while they do it.”
 

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].