Commentary

We are in the middle of flu season, and many of our patients are coughing. Is it the flu or might the child have a secondary bacterial pneumonia? Let’s start with the history for a tip off. The course of flu and respiratory viral infections in general involves a typical pattern of timing for fever and cough.

DavidWhalen/Thinkstock

A late-developing fever or fever that subsides then recurs should raise concern. A prolonged cough or cough that subsides then recurs also should raise concern. The respiratory rate and chest retractions are key physical findings that can aid in distinguishing children with bacterial pneumonia. Rales and decreased breath sounds in lung segments are best heard with deep breaths.

What diagnostic laboratory and imaging tests should be used

Fortunately, rapid tests to detect influenza are available, and many providers have added those to their laboratory evaluation. A complete blood count and differential may be helpful. If a pulse oximeter is available, checking oxygen saturation might be helpful. The American Academy of Pediatrics community pneumonia guideline states that routine chest radiographs are not necessary for the confirmation of suspected community-acquired pneumonia (CAP) in patients well enough to be treated in the outpatient setting (Clin Inf Dis. 2011 Oct;53[7]:e25–e76). Blood cultures should not be performed routinely in nontoxic, fully immunized children with CAP managed in the outpatient setting.

What antibiotic should be used

Antimicrobial therapy is not routinely required for preschool-aged children with cough, even cough caused by CAP, because viral pathogens are responsible for the great majority of clinical disease. If the diagnosis of CAP is made, the AAP endorses amoxicillin as first-line therapy for previously healthy, appropriately immunized infants and preschool children with mild to moderate CAP suspected to be of bacterial origin. For previously healthy, appropriately immunized school-aged children and adolescents with mild to moderate CAP, amoxicillin is recommended for treatment of Streptococcus pneumoniae, the most prominent invasive bacterial pathogen.

However, the treatment paradigm is complicated because Mycoplasma pneumoniae also should be considered in management decisions. Children with signs and symptoms suspicious for M. pneumoniae should be tested to help guide antibiotic selection. This may be a simple bedside cold agglutinin test. The highest incidence of Mycoplasma pneumonia is in 5- to 20-year-olds (51% in 5- to 9-year-olds, 74% in 9- to 15-year-olds, and 3%-18% in adults with pneumonia), but 9% of CAP occurs in patients younger than 5 years old. The clinical features of Mycoplasma pneumonia resemble influenza: The patient has gradual onset of headache, malaise, fever, sore throat, and cough. Mycoplasma pneumonia has a similar incidence of productive cough, rales, and diarrhea as pneumococcal CAP, but with more frequent upper respiratory symptoms and a normal leukocyte count. Mycoplasma bronchopneumonia occurs 30 times more frequently than Mycoplasma lobar pneumonia. The radiologic features of Mycoplasma is typical of a bronchopneumonia, usually involving a single lobe, subsegmental atelectasis, peribronchial thickening, and streaky interstitial densities. While Mycoplasma pneumonia is usually self-limited, the duration of illness is shortened by oral treatment with doxycycline, erythromycin, clarithromycin, or azithromycin.
 

What is the appropriate duration of antimicrobial therapy

Recommendations by the AAP for CAP note that treatment courses of 10 days have been best studied, although shorter courses may be just as effective, particularly for mild disease managed on an outpatient basis.

When should children be hospitalized

Dr. Pichichero is a specialist in pediatric infectious diseases and director of the Research Institute at Rochester (N.Y.) General Hospital. He had no conflicts to declare. Email him at [email protected].

We are in the middle of flu season, and many of our patients are coughing. Is it the flu or might the child have a secondary bacterial pneumonia? Let’s start with the history for a tip off. The course of flu and respiratory viral infections in general involves a typical pattern of timing for fever and cough.

DavidWhalen/Thinkstock

A late-developing fever or fever that subsides then recurs should raise concern. A prolonged cough or cough that subsides then recurs also should raise concern. The respiratory rate and chest retractions are key physical findings that can aid in distinguishing children with bacterial pneumonia. Rales and decreased breath sounds in lung segments are best heard with deep breaths.

What diagnostic laboratory and imaging tests should be used

Fortunately, rapid tests to detect influenza are available, and many providers have added those to their laboratory evaluation. A complete blood count and differential may be helpful. If a pulse oximeter is available, checking oxygen saturation might be helpful. The American Academy of Pediatrics community pneumonia guideline states that routine chest radiographs are not necessary for the confirmation of suspected community-acquired pneumonia (CAP) in patients well enough to be treated in the outpatient setting (Clin Inf Dis. 2011 Oct;53[7]:e25–e76). Blood cultures should not be performed routinely in nontoxic, fully immunized children with CAP managed in the outpatient setting.

What antibiotic should be used

Antimicrobial therapy is not routinely required for preschool-aged children with cough, even cough caused by CAP, because viral pathogens are responsible for the great majority of clinical disease. If the diagnosis of CAP is made, the AAP endorses amoxicillin as first-line therapy for previously healthy, appropriately immunized infants and preschool children with mild to moderate CAP suspected to be of bacterial origin. For previously healthy, appropriately immunized school-aged children and adolescents with mild to moderate CAP, amoxicillin is recommended for treatment of Streptococcus pneumoniae, the most prominent invasive bacterial pathogen.

However, the treatment paradigm is complicated because Mycoplasma pneumoniae also should be considered in management decisions. Children with signs and symptoms suspicious for M. pneumoniae should be tested to help guide antibiotic selection. This may be a simple bedside cold agglutinin test. The highest incidence of Mycoplasma pneumonia is in 5- to 20-year-olds (51% in 5- to 9-year-olds, 74% in 9- to 15-year-olds, and 3%-18% in adults with pneumonia), but 9% of CAP occurs in patients younger than 5 years old. The clinical features of Mycoplasma pneumonia resemble influenza: The patient has gradual onset of headache, malaise, fever, sore throat, and cough. Mycoplasma pneumonia has a similar incidence of productive cough, rales, and diarrhea as pneumococcal CAP, but with more frequent upper respiratory symptoms and a normal leukocyte count. Mycoplasma bronchopneumonia occurs 30 times more frequently than Mycoplasma lobar pneumonia. The radiologic features of Mycoplasma is typical of a bronchopneumonia, usually involving a single lobe, subsegmental atelectasis, peribronchial thickening, and streaky interstitial densities. While Mycoplasma pneumonia is usually self-limited, the duration of illness is shortened by oral treatment with doxycycline, erythromycin, clarithromycin, or azithromycin.
 

What is the appropriate duration of antimicrobial therapy

Recommendations by the AAP for CAP note that treatment courses of 10 days have been best studied, although shorter courses may be just as effective, particularly for mild disease managed on an outpatient basis.

When should children be hospitalized

Dr. Pichichero is a specialist in pediatric infectious diseases and director of the Research Institute at Rochester (N.Y.) General Hospital. He had no conflicts to declare. Email him at [email protected].

We are in the middle of flu season, and many of our patients are coughing. Is it the flu or might the child have a secondary bacterial pneumonia? Let’s start with the history for a tip off. The course of flu and respiratory viral infections in general involves a typical pattern of timing for fever and cough.

DavidWhalen/Thinkstock

A late-developing fever or fever that subsides then recurs should raise concern. A prolonged cough or cough that subsides then recurs also should raise concern. The respiratory rate and chest retractions are key physical findings that can aid in distinguishing children with bacterial pneumonia. Rales and decreased breath sounds in lung segments are best heard with deep breaths.

What diagnostic laboratory and imaging tests should be used

Fortunately, rapid tests to detect influenza are available, and many providers have added those to their laboratory evaluation. A complete blood count and differential may be helpful. If a pulse oximeter is available, checking oxygen saturation might be helpful. The American Academy of Pediatrics community pneumonia guideline states that routine chest radiographs are not necessary for the confirmation of suspected community-acquired pneumonia (CAP) in patients well enough to be treated in the outpatient setting (Clin Inf Dis. 2011 Oct;53[7]:e25–e76). Blood cultures should not be performed routinely in nontoxic, fully immunized children with CAP managed in the outpatient setting.

What antibiotic should be used

Antimicrobial therapy is not routinely required for preschool-aged children with cough, even cough caused by CAP, because viral pathogens are responsible for the great majority of clinical disease. If the diagnosis of CAP is made, the AAP endorses amoxicillin as first-line therapy for previously healthy, appropriately immunized infants and preschool children with mild to moderate CAP suspected to be of bacterial origin. For previously healthy, appropriately immunized school-aged children and adolescents with mild to moderate CAP, amoxicillin is recommended for treatment of Streptococcus pneumoniae, the most prominent invasive bacterial pathogen.

However, the treatment paradigm is complicated because Mycoplasma pneumoniae also should be considered in management decisions. Children with signs and symptoms suspicious for M. pneumoniae should be tested to help guide antibiotic selection. This may be a simple bedside cold agglutinin test. The highest incidence of Mycoplasma pneumonia is in 5- to 20-year-olds (51% in 5- to 9-year-olds, 74% in 9- to 15-year-olds, and 3%-18% in adults with pneumonia), but 9% of CAP occurs in patients younger than 5 years old. The clinical features of Mycoplasma pneumonia resemble influenza: The patient has gradual onset of headache, malaise, fever, sore throat, and cough. Mycoplasma pneumonia has a similar incidence of productive cough, rales, and diarrhea as pneumococcal CAP, but with more frequent upper respiratory symptoms and a normal leukocyte count. Mycoplasma bronchopneumonia occurs 30 times more frequently than Mycoplasma lobar pneumonia. The radiologic features of Mycoplasma is typical of a bronchopneumonia, usually involving a single lobe, subsegmental atelectasis, peribronchial thickening, and streaky interstitial densities. While Mycoplasma pneumonia is usually self-limited, the duration of illness is shortened by oral treatment with doxycycline, erythromycin, clarithromycin, or azithromycin.
 

What is the appropriate duration of antimicrobial therapy

Recommendations by the AAP for CAP note that treatment courses of 10 days have been best studied, although shorter courses may be just as effective, particularly for mild disease managed on an outpatient basis.

When should children be hospitalized

Dr. Pichichero is a specialist in pediatric infectious diseases and director of the Research Institute at Rochester (N.Y.) General Hospital. He had no conflicts to declare. Email him at [email protected].

During the holiday break I took some time to organize a lot of old family pictures: deleting duplicates, merging those I pulled off my dad’s computer when he died (which was over 5 years ago), importing ones I took with old digital cameras that were in separate folders ... a bunch of stuff. Some were even childhood pics of me that had been scanned into digital formats. Lots of gigabytes. Lots of time spent watching the little “importing” wheel spin.

Jokic/iStock/Getty Images Plus

As I scrolled through them – literally 5,891 pics and 679 videos – I watched as it became more than a bunch of photos. I watched myself grow up, go through medical school, get married, raise a family. My hair went from brown to gray and receding. My kids went from toddlers to young adults about to leave for college.

It was the story of my life. Without meaning to, it’s what the pictures had become.

It was late at night, but I kept scrolling back and forth. My parents, wife, and others aged in front of me.

Looking in the mirror, or seeing others each day, we never notice the slow changes that time brings. You don’t really see it just thumbing through old photos, either.

But here, in the photos app (something entirely undreamed of in my childhood), I was watching it like it was a movie. Even childhood pictures of my parents. Them dating and getting married. Holding me after bringing me home from the hospital.

I’m certainly not the first to have these thoughts, nor will I be the last. We all go through life in a somewhat organized yet haphazard way, and only when looking backward do we really see how far we’ve come ... often realizing we’re past the halfway point.

Not that this is a bad thing. I mean, that’s life on Earth. It has its good and bad, and aging is part of the rules for all of us.

I suppose you could look at this in terms of our profession. We all (or at least most of us) start out as hospital patients. As we get older and become doctors, hopefully we need to see our own kind less often while at the same time seeing others as patients. As time goes by, most of us start to need to see doctors again, and as we retire and stop practicing medicine, we move back toward being patients ourselves.

For me, the pictures bring back memories and strike emotions in the way hearing or reading stories never can. They give new life to long-forgotten thoughts. Happy and sad, but overall a feeling of contentment that, so far, I feel like I’ve done more good than bad, more right than wrong.

I hope I always feel that way.

I hope everyone else does, too.

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

During the holiday break I took some time to organize a lot of old family pictures: deleting duplicates, merging those I pulled off my dad’s computer when he died (which was over 5 years ago), importing ones I took with old digital cameras that were in separate folders ... a bunch of stuff. Some were even childhood pics of me that had been scanned into digital formats. Lots of gigabytes. Lots of time spent watching the little “importing” wheel spin.

Jokic/iStock/Getty Images Plus

As I scrolled through them – literally 5,891 pics and 679 videos – I watched as it became more than a bunch of photos. I watched myself grow up, go through medical school, get married, raise a family. My hair went from brown to gray and receding. My kids went from toddlers to young adults about to leave for college.

It was the story of my life. Without meaning to, it’s what the pictures had become.

It was late at night, but I kept scrolling back and forth. My parents, wife, and others aged in front of me.

Looking in the mirror, or seeing others each day, we never notice the slow changes that time brings. You don’t really see it just thumbing through old photos, either.

But here, in the photos app (something entirely undreamed of in my childhood), I was watching it like it was a movie. Even childhood pictures of my parents. Them dating and getting married. Holding me after bringing me home from the hospital.

I’m certainly not the first to have these thoughts, nor will I be the last. We all go through life in a somewhat organized yet haphazard way, and only when looking backward do we really see how far we’ve come ... often realizing we’re past the halfway point.

Not that this is a bad thing. I mean, that’s life on Earth. It has its good and bad, and aging is part of the rules for all of us.

I suppose you could look at this in terms of our profession. We all (or at least most of us) start out as hospital patients. As we get older and become doctors, hopefully we need to see our own kind less often while at the same time seeing others as patients. As time goes by, most of us start to need to see doctors again, and as we retire and stop practicing medicine, we move back toward being patients ourselves.

For me, the pictures bring back memories and strike emotions in the way hearing or reading stories never can. They give new life to long-forgotten thoughts. Happy and sad, but overall a feeling of contentment that, so far, I feel like I’ve done more good than bad, more right than wrong.

I hope I always feel that way.

I hope everyone else does, too.

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

During the holiday break I took some time to organize a lot of old family pictures: deleting duplicates, merging those I pulled off my dad’s computer when he died (which was over 5 years ago), importing ones I took with old digital cameras that were in separate folders ... a bunch of stuff. Some were even childhood pics of me that had been scanned into digital formats. Lots of gigabytes. Lots of time spent watching the little “importing” wheel spin.

Jokic/iStock/Getty Images Plus

As I scrolled through them – literally 5,891 pics and 679 videos – I watched as it became more than a bunch of photos. I watched myself grow up, go through medical school, get married, raise a family. My hair went from brown to gray and receding. My kids went from toddlers to young adults about to leave for college.

It was the story of my life. Without meaning to, it’s what the pictures had become.

It was late at night, but I kept scrolling back and forth. My parents, wife, and others aged in front of me.

Looking in the mirror, or seeing others each day, we never notice the slow changes that time brings. You don’t really see it just thumbing through old photos, either.

But here, in the photos app (something entirely undreamed of in my childhood), I was watching it like it was a movie. Even childhood pictures of my parents. Them dating and getting married. Holding me after bringing me home from the hospital.

I’m certainly not the first to have these thoughts, nor will I be the last. We all go through life in a somewhat organized yet haphazard way, and only when looking backward do we really see how far we’ve come ... often realizing we’re past the halfway point.

Not that this is a bad thing. I mean, that’s life on Earth. It has its good and bad, and aging is part of the rules for all of us.

I suppose you could look at this in terms of our profession. We all (or at least most of us) start out as hospital patients. As we get older and become doctors, hopefully we need to see our own kind less often while at the same time seeing others as patients. As time goes by, most of us start to need to see doctors again, and as we retire and stop practicing medicine, we move back toward being patients ourselves.

For me, the pictures bring back memories and strike emotions in the way hearing or reading stories never can. They give new life to long-forgotten thoughts. Happy and sad, but overall a feeling of contentment that, so far, I feel like I’ve done more good than bad, more right than wrong.

I hope I always feel that way.

I hope everyone else does, too.

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

“Parenthood in the United States has become much more demanding than it used to be.” It is hard to argue with this opening sentence in Clair Cain Miller’s op-ed piece titled “The Relentlessness of Modern Parenting,” published in the Dec. 25, 2018, electronic edition of the New York Times. But just in case you don’t agree with her premise, she lays out her case with evidence that parents in this country are investing more time, attention, and money into raising their children than was the norm several decades ago. She goes on to describe how this “intensive parenting” is taking its toll on parents on both sides of our nation’s widening economic divide. I’m sure you have seen it in your office in the tired faces and stooped shoulders of your patients’ parents. You may even be struggling yourself to find the time and energy to be the parent you believe your children need and deserve.

ftwitty/Getty Images

While there is debate on whether “parent” is inherently a verb or a noun (“Parent is a Noun, Not a Verb,” Cliff Price, the Australian Family Association; “Parent is a Verb – and we All do it,” Zaeli Kane, mother.ly), it is clear that “parenting” used as a verb has become one of the hot topics in pediatrics over the last quarter century and with it an epidemic of parental anxiety. What are the driving forces behind this shift in attitude? How has a relatively relaxed nature-will-take-its-course philosophy become an anxiety-provoking, stress-inducing phenomenon that will inevitably result in a disturbed and disappointed adult without a parent’s relentless attention to creating a nurturing and optimally stimulating environment?

Of course, parents have always worried about the health of their children and hope that they will be successful, regardless of how one defines success. But this natural parental concern seems to have gotten out of hand.

Is it because North Americans are having fewer children? Is it because in smaller families children become adults with little or no practical experience with hands-on child rearing? Are parents reacting to the predictions that the next generation may not be able to earn enough to match their parents’ lifestyle?

How much blame should fall on those of us who market ourselves as child health experts? Have we failed to put the research supporting the importance of early life experiences in the proper perspective? Are our recommendations creating unrealistic goals for parents? The American Academy of Pediatrics advice on breastfeeding duration and room sharing come to mind immediately. How realistic is it for parents to coview the majority of television shows their children are watching?

On one hand, we are beginning to realize that free play is important, but for years pediatricians have been one of the loudest voices supporting playground and toy safety. These two initiatives can certainly coexist, but I fear that at times we have begun to sound a bit like that annoying parent who is constantly warning his or her child, “Don’t do that, you’ll hurt yourself?”

Have we become the worry merchants? As a marketing strategy it seems to be working well. If we generate enough advice that supports an intensive parenting style, we can fill our waiting rooms with families struggling to meet the expectations we have been promoting.

A child can thrive without intensive parenting as long as he feels loved and he has been provided an environment with sensible limits to keep him safe. It is our job to help parents create that child-friendly discipline structure and then encourage them to step back.

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].

“Parenthood in the United States has become much more demanding than it used to be.” It is hard to argue with this opening sentence in Clair Cain Miller’s op-ed piece titled “The Relentlessness of Modern Parenting,” published in the Dec. 25, 2018, electronic edition of the New York Times. But just in case you don’t agree with her premise, she lays out her case with evidence that parents in this country are investing more time, attention, and money into raising their children than was the norm several decades ago. She goes on to describe how this “intensive parenting” is taking its toll on parents on both sides of our nation’s widening economic divide. I’m sure you have seen it in your office in the tired faces and stooped shoulders of your patients’ parents. You may even be struggling yourself to find the time and energy to be the parent you believe your children need and deserve.

ftwitty/Getty Images

While there is debate on whether “parent” is inherently a verb or a noun (“Parent is a Noun, Not a Verb,” Cliff Price, the Australian Family Association; “Parent is a Verb – and we All do it,” Zaeli Kane, mother.ly), it is clear that “parenting” used as a verb has become one of the hot topics in pediatrics over the last quarter century and with it an epidemic of parental anxiety. What are the driving forces behind this shift in attitude? How has a relatively relaxed nature-will-take-its-course philosophy become an anxiety-provoking, stress-inducing phenomenon that will inevitably result in a disturbed and disappointed adult without a parent’s relentless attention to creating a nurturing and optimally stimulating environment?

Of course, parents have always worried about the health of their children and hope that they will be successful, regardless of how one defines success. But this natural parental concern seems to have gotten out of hand.

Is it because North Americans are having fewer children? Is it because in smaller families children become adults with little or no practical experience with hands-on child rearing? Are parents reacting to the predictions that the next generation may not be able to earn enough to match their parents’ lifestyle?

How much blame should fall on those of us who market ourselves as child health experts? Have we failed to put the research supporting the importance of early life experiences in the proper perspective? Are our recommendations creating unrealistic goals for parents? The American Academy of Pediatrics advice on breastfeeding duration and room sharing come to mind immediately. How realistic is it for parents to coview the majority of television shows their children are watching?

On one hand, we are beginning to realize that free play is important, but for years pediatricians have been one of the loudest voices supporting playground and toy safety. These two initiatives can certainly coexist, but I fear that at times we have begun to sound a bit like that annoying parent who is constantly warning his or her child, “Don’t do that, you’ll hurt yourself?”

Have we become the worry merchants? As a marketing strategy it seems to be working well. If we generate enough advice that supports an intensive parenting style, we can fill our waiting rooms with families struggling to meet the expectations we have been promoting.

A child can thrive without intensive parenting as long as he feels loved and he has been provided an environment with sensible limits to keep him safe. It is our job to help parents create that child-friendly discipline structure and then encourage them to step back.

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].

“Parenthood in the United States has become much more demanding than it used to be.” It is hard to argue with this opening sentence in Clair Cain Miller’s op-ed piece titled “The Relentlessness of Modern Parenting,” published in the Dec. 25, 2018, electronic edition of the New York Times. But just in case you don’t agree with her premise, she lays out her case with evidence that parents in this country are investing more time, attention, and money into raising their children than was the norm several decades ago. She goes on to describe how this “intensive parenting” is taking its toll on parents on both sides of our nation’s widening economic divide. I’m sure you have seen it in your office in the tired faces and stooped shoulders of your patients’ parents. You may even be struggling yourself to find the time and energy to be the parent you believe your children need and deserve.

ftwitty/Getty Images

While there is debate on whether “parent” is inherently a verb or a noun (“Parent is a Noun, Not a Verb,” Cliff Price, the Australian Family Association; “Parent is a Verb – and we All do it,” Zaeli Kane, mother.ly), it is clear that “parenting” used as a verb has become one of the hot topics in pediatrics over the last quarter century and with it an epidemic of parental anxiety. What are the driving forces behind this shift in attitude? How has a relatively relaxed nature-will-take-its-course philosophy become an anxiety-provoking, stress-inducing phenomenon that will inevitably result in a disturbed and disappointed adult without a parent’s relentless attention to creating a nurturing and optimally stimulating environment?

Of course, parents have always worried about the health of their children and hope that they will be successful, regardless of how one defines success. But this natural parental concern seems to have gotten out of hand.

Is it because North Americans are having fewer children? Is it because in smaller families children become adults with little or no practical experience with hands-on child rearing? Are parents reacting to the predictions that the next generation may not be able to earn enough to match their parents’ lifestyle?

How much blame should fall on those of us who market ourselves as child health experts? Have we failed to put the research supporting the importance of early life experiences in the proper perspective? Are our recommendations creating unrealistic goals for parents? The American Academy of Pediatrics advice on breastfeeding duration and room sharing come to mind immediately. How realistic is it for parents to coview the majority of television shows their children are watching?

On one hand, we are beginning to realize that free play is important, but for years pediatricians have been one of the loudest voices supporting playground and toy safety. These two initiatives can certainly coexist, but I fear that at times we have begun to sound a bit like that annoying parent who is constantly warning his or her child, “Don’t do that, you’ll hurt yourself?”

Have we become the worry merchants? As a marketing strategy it seems to be working well. If we generate enough advice that supports an intensive parenting style, we can fill our waiting rooms with families struggling to meet the expectations we have been promoting.

A child can thrive without intensive parenting as long as he feels loved and he has been provided an environment with sensible limits to keep him safe. It is our job to help parents create that child-friendly discipline structure and then encourage them to step back.

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 2016, Swapnil Gupta, MD, and John Daniel Cahill, MD, PhD, challenged the field of psychiatry to reexamine our prescribing patterns. They warned against our use of polypharmacy when not attached to improvement in functioning for our patients.¹ They were concerned about the lack of evidence for those treatment regimens and for our diagnostic criteria. In their inspiring article, they described how psychiatrists might proceed in the process of “deprescribing” – which they define as a process of pharmacologic regimen optimization through reducing or ending medications for which “benefits no longer outweigh risks.”¹

In my practice, I routinely confront medication regimens that I have never encountered in the literature. The evidence for two psychotropics is limited but certainly available, in particular adjunct treatment of antidepressants² and mood stabilizers.³ The evidence supporting the use of more than two psychotropics, however, is quite sparse. Yet, patients often enter my office on more than five psychotropics. I am also confronted with poorly defined diagnostic labels – which present more as means to justify polypharmacy than a thorough review of the patient’s current state.

Dr. Gupta and Dr. Cahill recommend a series of steps aimed at attempting the deprescription of psychotropics. Those steps include timeliness, knowledge of the patient’s current regimen, discussion about the risk of prescriptions, discussion about deprescribing, choosing the right medications to stop, a plan for describing, and monitoring. In the case presented below, I used some of those steps in an effort to provide the best care for the patient. Key details of the case have been changed, including the name, to protect the patient’s confidentiality.
 

Overview of the case

Rosalie Bertin is a 54-year-old female who has been treated for depression by a variety of primary care physicians for the better part of the last 30 years. She had tried an array of antidepressants, including sertraline, citalopram, duloxetine, and mirtazapine, over that time. Each seemed to provide some benefit when reviewing the notes, but there is no mention of why she was continued on those medications despite the absence of continuing symptoms. Occasionally, Rosalie would present to her clinician tearful and endorsing sadness, though the record did not comment on reports of energy, concentration, sleep, appetite, and interest.

In 2014, Rosalie’s husband passed away from lung cancer. His death was fairly quick, and initially, Rosalie did not mention any significant emotional complaints. However, when visiting her primary care physician 4 months later, she was noted to experience auditory hallucinations. “Sometimes I hear my husband when I am alone in my home,” she said. Rosalie was referred to a psychiatrist with a diagnosis of “psychosis not otherwise specified.”

When discussing her condition with the psychiatrist, Rosalie mentioned experiencing low mood, and having diminished interest in engaging in activities. “I miss Marc when I go places; I used to do everything with him.” She reported hearing him often but only when at her home. He would say things like, “I miss you,” or ask her about her day. She was diagnosed with “major depressive disorder with psychotic features.” Risperidone was added to the escitalopram, buspirone, and gabapentin that had been started by her primary care physician.

After several months of psychotropic management, the dose of risperidone was titrated to 8 mg per day. Her mood symptoms were unchanged, but she now was complaining of poor concentration and memory. The psychiatrist performed a Mini-Mental State Examination (MMSE). It was noted that taking the MMSE engendered significant anxiety for the patient. Rosalie received a score suggesting mild cognitive impairment. She was started on donepezil for the memory complaint, quetiapine for the continued voices, and recommended for disability.

Once on short-term disability, the patient relocated to live closer to her mother in San Diego and subsequently contacted me about continuing psychiatric care.
 

Initial visit

Rosalie is a petite white woman, raised in the Midwest, who married her high school sweetheart, and subsequently became an administrative assistant. Rosalie and Marc were unable to have children. Marc was an engineer, and a longtime smoker. She describes their lives as simple – “few friends, few vacations, few problems, few regrets.” She states she misses her husband and often cries when thinking about him.

When asked about psychiatric diagnoses, she answered: “I have psychosis. … My doctor said maybe schizophrenia, but he is not sure yet.” She described schizophrenia as hearing voices. Rosalie also mentioned having memory problems: “They cannot tell if it is Alzheimer’s disease until I die and they look at my brain, but the medication should delay the progression.”

She reported no significant effect from her prior antidepressant trials: “I am not sure if or how they helped.” When asked why she had tried several different antidepressants, she answered: “Every time something difficult in my life happened, Dr. M gave me a new medication.” Rosalie could not explain the role of the medication. “I take medications as prescribed by my doctor,” she said.

When discussing her antipsychotics, she mentioned: “Those are strong medications; it is hard for me to stay awake with them.” She declared having had no changes in the voices while on the risperidone but said they went away since also being on the quetiapine: “I wonder if the combination of the two really fixed my brain imbalance.”

Assessment

I admit that I have a critical bias against the overuse of psychotropics, and this might have painted how I interpreted Rosalie’s story. Nonetheless, I was honest with her and told her of my concerns. I informed her that her diagnosis was not consistent with my understanding of mood and thought disorders. Her initial reports of depression neither met the DSM criteria for depression nor felt consistent with my conceptualization of the illness. She had retained appropriate functioning and seemed to be responding with the sadness expected when facing difficult challenges like grief.

Her subsequent reports of auditory hallucinations were not associated with delusions or forms of disorganization that I would expect in someone with a thought disorder. Furthermore, the context of the onset gave me the impression that this was part of her process of grief. Her poor result in the dementia screen was most surprising and inconsistent with my evaluation. I told her that I suspected that she was not suffering from Alzheimer’s but from being overmedicated and from anxiety at the time of the testing.

She was excited and hesitant about my report. She was surprised by the length of our visit and interested in hearing more from me. Strangely, I wished she had challenged my different approach. I think that I was hoping she would question my conceptualization, the way I hoped she would have done with her prior clinicians. Nonetheless, she agreed to make a plan with me.

Treatment plan

We decided to review each of her medications and discuss their benefits and risks over a couple of visits. She was most eager to discontinue the donepezil, which had caused diarrhea. She was concerned when I informed her of the potential side effects of antipsychotics. “My doctor asked me if I had any side effects at each visit; I answered that I felt nothing wrong; I had not realized that side effects could appear later.”

She was adamant about staying on buspirone, as she felt it helped her the most with her anxiety at social events. She voiced concern about discontinuing the antipsychotics despite being unsettled by my review of their risks. She asked that we taper them slowly.

In regard to receiving psychosocial support throughout this period of deprescribing, Rosalie declined weekly psychotherapy. She reported having a good social network in San Diego that she wanted to rely on.
 

Outcome

I often worry about consequences of stopping a medication, especially when I was not present at the time of its initiation. I agonize that the patient might relapse from my need to carry out my agenda on deprescribing. I try to remind myself that the evidence supports my decision making. The risks of psychotropics often are slow to show up, making the benefit of deprescribing less tangible. However, this case was straightforward.

Rosalie quickly improved. Tapering the antipsychotics was astonishing to her: “I can think clearly again.” Within 6 months, she was on buspirone only – though willing to discuss its discontinuation. She had a lead for a job and was hoping to return to work soon. Rosalie continued to miss her husband but had not heard him in some time. She has not had symptoms of psychosis or depression. Her cognition and mood were intact on my clinical assessment.
 

Discussion

Sadly and shockingly, cases like that of Rosalie are common. In my practice, I routinely see patients on multiple psychotropics – often on more than one antipsychotic. Their diagnoses are vague and dubious, and include diagnoses such as “unspecified psychosis” and “cognitive impairments.” Clinicians occasionally worry about relapse and promote a narrative that treatment must be not only long term but lifelong.⁴ There is some evidence for this perspective in a research context, but the clinical world also is filled with patients like Rosalie.

Her reports of auditory hallucinations were better explained by her grief than by a psychotic process.⁵ Her memory complaints were better explained by anxiety at the time of her testing while suffering from the side effects from her numerous psychotropics.⁶ Her depressive complaints were better explained by appropriate sadness in response to stressors. Several months later with fewer diagnoses and far fewer psychotropics, she is functioning better.
 

Take-home points

• Polypharmacy can lead to psychiatric symptoms and functional impairment.
• Patients often are unaware of the complete risks of psychotropics.
• Psychiatric symptoms are not always associated with a psychiatric disorder.
• Deprescribing can be performed safely and effectively.
• Deprescribing can be performed with the patient’s informed consent and agreement.

References

1. Psychiatr Serv. 2016 Aug 1;67(8):904-7.

2. Focus. 2016 Apr 13; doi: 10.1176/appi.focus.20150041.

3. Bipolar Disord. 2016 Dec;18(8):684-91.

4. Am J Psychiatry. 2017 Sep 1;174(9):840-9.

5. World Psychiatry. 2009 Jun;8(2):67-74.

6. Hosp Community Psychiatry. 1983 Sep;34(9):830-5.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).

*This column was updated 1/11/2019.

In 2016, Swapnil Gupta, MD, and John Daniel Cahill, MD, PhD, challenged the field of psychiatry to reexamine our prescribing patterns. They warned against our use of polypharmacy when not attached to improvement in functioning for our patients.¹ They were concerned about the lack of evidence for those treatment regimens and for our diagnostic criteria. In their inspiring article, they described how psychiatrists might proceed in the process of “deprescribing” – which they define as a process of pharmacologic regimen optimization through reducing or ending medications for which “benefits no longer outweigh risks.”¹

In my practice, I routinely confront medication regimens that I have never encountered in the literature. The evidence for two psychotropics is limited but certainly available, in particular adjunct treatment of antidepressants² and mood stabilizers.³ The evidence supporting the use of more than two psychotropics, however, is quite sparse. Yet, patients often enter my office on more than five psychotropics. I am also confronted with poorly defined diagnostic labels – which present more as means to justify polypharmacy than a thorough review of the patient’s current state.

Dr. Gupta and Dr. Cahill recommend a series of steps aimed at attempting the deprescription of psychotropics. Those steps include timeliness, knowledge of the patient’s current regimen, discussion about the risk of prescriptions, discussion about deprescribing, choosing the right medications to stop, a plan for describing, and monitoring. In the case presented below, I used some of those steps in an effort to provide the best care for the patient. Key details of the case have been changed, including the name, to protect the patient’s confidentiality.
 

Overview of the case

Rosalie Bertin is a 54-year-old female who has been treated for depression by a variety of primary care physicians for the better part of the last 30 years. She had tried an array of antidepressants, including sertraline, citalopram, duloxetine, and mirtazapine, over that time. Each seemed to provide some benefit when reviewing the notes, but there is no mention of why she was continued on those medications despite the absence of continuing symptoms. Occasionally, Rosalie would present to her clinician tearful and endorsing sadness, though the record did not comment on reports of energy, concentration, sleep, appetite, and interest.

In 2014, Rosalie’s husband passed away from lung cancer. His death was fairly quick, and initially, Rosalie did not mention any significant emotional complaints. However, when visiting her primary care physician 4 months later, she was noted to experience auditory hallucinations. “Sometimes I hear my husband when I am alone in my home,” she said. Rosalie was referred to a psychiatrist with a diagnosis of “psychosis not otherwise specified.”

When discussing her condition with the psychiatrist, Rosalie mentioned experiencing low mood, and having diminished interest in engaging in activities. “I miss Marc when I go places; I used to do everything with him.” She reported hearing him often but only when at her home. He would say things like, “I miss you,” or ask her about her day. She was diagnosed with “major depressive disorder with psychotic features.” Risperidone was added to the escitalopram, buspirone, and gabapentin that had been started by her primary care physician.

After several months of psychotropic management, the dose of risperidone was titrated to 8 mg per day. Her mood symptoms were unchanged, but she now was complaining of poor concentration and memory. The psychiatrist performed a Mini-Mental State Examination (MMSE). It was noted that taking the MMSE engendered significant anxiety for the patient. Rosalie received a score suggesting mild cognitive impairment. She was started on donepezil for the memory complaint, quetiapine for the continued voices, and recommended for disability.

Once on short-term disability, the patient relocated to live closer to her mother in San Diego and subsequently contacted me about continuing psychiatric care.
 

Initial visit

Rosalie is a petite white woman, raised in the Midwest, who married her high school sweetheart, and subsequently became an administrative assistant. Rosalie and Marc were unable to have children. Marc was an engineer, and a longtime smoker. She describes their lives as simple – “few friends, few vacations, few problems, few regrets.” She states she misses her husband and often cries when thinking about him.

When asked about psychiatric diagnoses, she answered: “I have psychosis. … My doctor said maybe schizophrenia, but he is not sure yet.” She described schizophrenia as hearing voices. Rosalie also mentioned having memory problems: “They cannot tell if it is Alzheimer’s disease until I die and they look at my brain, but the medication should delay the progression.”

She reported no significant effect from her prior antidepressant trials: “I am not sure if or how they helped.” When asked why she had tried several different antidepressants, she answered: “Every time something difficult in my life happened, Dr. M gave me a new medication.” Rosalie could not explain the role of the medication. “I take medications as prescribed by my doctor,” she said.

When discussing her antipsychotics, she mentioned: “Those are strong medications; it is hard for me to stay awake with them.” She declared having had no changes in the voices while on the risperidone but said they went away since also being on the quetiapine: “I wonder if the combination of the two really fixed my brain imbalance.”

Assessment

I admit that I have a critical bias against the overuse of psychotropics, and this might have painted how I interpreted Rosalie’s story. Nonetheless, I was honest with her and told her of my concerns. I informed her that her diagnosis was not consistent with my understanding of mood and thought disorders. Her initial reports of depression neither met the DSM criteria for depression nor felt consistent with my conceptualization of the illness. She had retained appropriate functioning and seemed to be responding with the sadness expected when facing difficult challenges like grief.

Her subsequent reports of auditory hallucinations were not associated with delusions or forms of disorganization that I would expect in someone with a thought disorder. Furthermore, the context of the onset gave me the impression that this was part of her process of grief. Her poor result in the dementia screen was most surprising and inconsistent with my evaluation. I told her that I suspected that she was not suffering from Alzheimer’s but from being overmedicated and from anxiety at the time of the testing.

She was excited and hesitant about my report. She was surprised by the length of our visit and interested in hearing more from me. Strangely, I wished she had challenged my different approach. I think that I was hoping she would question my conceptualization, the way I hoped she would have done with her prior clinicians. Nonetheless, she agreed to make a plan with me.

Treatment plan

We decided to review each of her medications and discuss their benefits and risks over a couple of visits. She was most eager to discontinue the donepezil, which had caused diarrhea. She was concerned when I informed her of the potential side effects of antipsychotics. “My doctor asked me if I had any side effects at each visit; I answered that I felt nothing wrong; I had not realized that side effects could appear later.”

She was adamant about staying on buspirone, as she felt it helped her the most with her anxiety at social events. She voiced concern about discontinuing the antipsychotics despite being unsettled by my review of their risks. She asked that we taper them slowly.

In regard to receiving psychosocial support throughout this period of deprescribing, Rosalie declined weekly psychotherapy. She reported having a good social network in San Diego that she wanted to rely on.
 

Outcome

I often worry about consequences of stopping a medication, especially when I was not present at the time of its initiation. I agonize that the patient might relapse from my need to carry out my agenda on deprescribing. I try to remind myself that the evidence supports my decision making. The risks of psychotropics often are slow to show up, making the benefit of deprescribing less tangible. However, this case was straightforward.

Rosalie quickly improved. Tapering the antipsychotics was astonishing to her: “I can think clearly again.” Within 6 months, she was on buspirone only – though willing to discuss its discontinuation. She had a lead for a job and was hoping to return to work soon. Rosalie continued to miss her husband but had not heard him in some time. She has not had symptoms of psychosis or depression. Her cognition and mood were intact on my clinical assessment.
 

Discussion

Sadly and shockingly, cases like that of Rosalie are common. In my practice, I routinely see patients on multiple psychotropics – often on more than one antipsychotic. Their diagnoses are vague and dubious, and include diagnoses such as “unspecified psychosis” and “cognitive impairments.” Clinicians occasionally worry about relapse and promote a narrative that treatment must be not only long term but lifelong.⁴ There is some evidence for this perspective in a research context, but the clinical world also is filled with patients like Rosalie.

Her reports of auditory hallucinations were better explained by her grief than by a psychotic process.⁵ Her memory complaints were better explained by anxiety at the time of her testing while suffering from the side effects from her numerous psychotropics.⁶ Her depressive complaints were better explained by appropriate sadness in response to stressors. Several months later with fewer diagnoses and far fewer psychotropics, she is functioning better.
 

Take-home points

• Polypharmacy can lead to psychiatric symptoms and functional impairment.
• Patients often are unaware of the complete risks of psychotropics.
• Psychiatric symptoms are not always associated with a psychiatric disorder.
• Deprescribing can be performed safely and effectively.
• Deprescribing can be performed with the patient’s informed consent and agreement.

References

1. Psychiatr Serv. 2016 Aug 1;67(8):904-7.

2. Focus. 2016 Apr 13; doi: 10.1176/appi.focus.20150041.

3. Bipolar Disord. 2016 Dec;18(8):684-91.

4. Am J Psychiatry. 2017 Sep 1;174(9):840-9.

5. World Psychiatry. 2009 Jun;8(2):67-74.

6. Hosp Community Psychiatry. 1983 Sep;34(9):830-5.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).

*This column was updated 1/11/2019.

In 2016, Swapnil Gupta, MD, and John Daniel Cahill, MD, PhD, challenged the field of psychiatry to reexamine our prescribing patterns. They warned against our use of polypharmacy when not attached to improvement in functioning for our patients.¹ They were concerned about the lack of evidence for those treatment regimens and for our diagnostic criteria. In their inspiring article, they described how psychiatrists might proceed in the process of “deprescribing” – which they define as a process of pharmacologic regimen optimization through reducing or ending medications for which “benefits no longer outweigh risks.”¹

In my practice, I routinely confront medication regimens that I have never encountered in the literature. The evidence for two psychotropics is limited but certainly available, in particular adjunct treatment of antidepressants² and mood stabilizers.³ The evidence supporting the use of more than two psychotropics, however, is quite sparse. Yet, patients often enter my office on more than five psychotropics. I am also confronted with poorly defined diagnostic labels – which present more as means to justify polypharmacy than a thorough review of the patient’s current state.

Dr. Gupta and Dr. Cahill recommend a series of steps aimed at attempting the deprescription of psychotropics. Those steps include timeliness, knowledge of the patient’s current regimen, discussion about the risk of prescriptions, discussion about deprescribing, choosing the right medications to stop, a plan for describing, and monitoring. In the case presented below, I used some of those steps in an effort to provide the best care for the patient. Key details of the case have been changed, including the name, to protect the patient’s confidentiality.
 

Overview of the case

Rosalie Bertin is a 54-year-old female who has been treated for depression by a variety of primary care physicians for the better part of the last 30 years. She had tried an array of antidepressants, including sertraline, citalopram, duloxetine, and mirtazapine, over that time. Each seemed to provide some benefit when reviewing the notes, but there is no mention of why she was continued on those medications despite the absence of continuing symptoms. Occasionally, Rosalie would present to her clinician tearful and endorsing sadness, though the record did not comment on reports of energy, concentration, sleep, appetite, and interest.

In 2014, Rosalie’s husband passed away from lung cancer. His death was fairly quick, and initially, Rosalie did not mention any significant emotional complaints. However, when visiting her primary care physician 4 months later, she was noted to experience auditory hallucinations. “Sometimes I hear my husband when I am alone in my home,” she said. Rosalie was referred to a psychiatrist with a diagnosis of “psychosis not otherwise specified.”

When discussing her condition with the psychiatrist, Rosalie mentioned experiencing low mood, and having diminished interest in engaging in activities. “I miss Marc when I go places; I used to do everything with him.” She reported hearing him often but only when at her home. He would say things like, “I miss you,” or ask her about her day. She was diagnosed with “major depressive disorder with psychotic features.” Risperidone was added to the escitalopram, buspirone, and gabapentin that had been started by her primary care physician.

After several months of psychotropic management, the dose of risperidone was titrated to 8 mg per day. Her mood symptoms were unchanged, but she now was complaining of poor concentration and memory. The psychiatrist performed a Mini-Mental State Examination (MMSE). It was noted that taking the MMSE engendered significant anxiety for the patient. Rosalie received a score suggesting mild cognitive impairment. She was started on donepezil for the memory complaint, quetiapine for the continued voices, and recommended for disability.

Once on short-term disability, the patient relocated to live closer to her mother in San Diego and subsequently contacted me about continuing psychiatric care.
 

Initial visit

Rosalie is a petite white woman, raised in the Midwest, who married her high school sweetheart, and subsequently became an administrative assistant. Rosalie and Marc were unable to have children. Marc was an engineer, and a longtime smoker. She describes their lives as simple – “few friends, few vacations, few problems, few regrets.” She states she misses her husband and often cries when thinking about him.

When asked about psychiatric diagnoses, she answered: “I have psychosis. … My doctor said maybe schizophrenia, but he is not sure yet.” She described schizophrenia as hearing voices. Rosalie also mentioned having memory problems: “They cannot tell if it is Alzheimer’s disease until I die and they look at my brain, but the medication should delay the progression.”

She reported no significant effect from her prior antidepressant trials: “I am not sure if or how they helped.” When asked why she had tried several different antidepressants, she answered: “Every time something difficult in my life happened, Dr. M gave me a new medication.” Rosalie could not explain the role of the medication. “I take medications as prescribed by my doctor,” she said.

When discussing her antipsychotics, she mentioned: “Those are strong medications; it is hard for me to stay awake with them.” She declared having had no changes in the voices while on the risperidone but said they went away since also being on the quetiapine: “I wonder if the combination of the two really fixed my brain imbalance.”

Assessment

I admit that I have a critical bias against the overuse of psychotropics, and this might have painted how I interpreted Rosalie’s story. Nonetheless, I was honest with her and told her of my concerns. I informed her that her diagnosis was not consistent with my understanding of mood and thought disorders. Her initial reports of depression neither met the DSM criteria for depression nor felt consistent with my conceptualization of the illness. She had retained appropriate functioning and seemed to be responding with the sadness expected when facing difficult challenges like grief.

Her subsequent reports of auditory hallucinations were not associated with delusions or forms of disorganization that I would expect in someone with a thought disorder. Furthermore, the context of the onset gave me the impression that this was part of her process of grief. Her poor result in the dementia screen was most surprising and inconsistent with my evaluation. I told her that I suspected that she was not suffering from Alzheimer’s but from being overmedicated and from anxiety at the time of the testing.

She was excited and hesitant about my report. She was surprised by the length of our visit and interested in hearing more from me. Strangely, I wished she had challenged my different approach. I think that I was hoping she would question my conceptualization, the way I hoped she would have done with her prior clinicians. Nonetheless, she agreed to make a plan with me.

Treatment plan

We decided to review each of her medications and discuss their benefits and risks over a couple of visits. She was most eager to discontinue the donepezil, which had caused diarrhea. She was concerned when I informed her of the potential side effects of antipsychotics. “My doctor asked me if I had any side effects at each visit; I answered that I felt nothing wrong; I had not realized that side effects could appear later.”

She was adamant about staying on buspirone, as she felt it helped her the most with her anxiety at social events. She voiced concern about discontinuing the antipsychotics despite being unsettled by my review of their risks. She asked that we taper them slowly.

In regard to receiving psychosocial support throughout this period of deprescribing, Rosalie declined weekly psychotherapy. She reported having a good social network in San Diego that she wanted to rely on.
 

Outcome

I often worry about consequences of stopping a medication, especially when I was not present at the time of its initiation. I agonize that the patient might relapse from my need to carry out my agenda on deprescribing. I try to remind myself that the evidence supports my decision making. The risks of psychotropics often are slow to show up, making the benefit of deprescribing less tangible. However, this case was straightforward.

Rosalie quickly improved. Tapering the antipsychotics was astonishing to her: “I can think clearly again.” Within 6 months, she was on buspirone only – though willing to discuss its discontinuation. She had a lead for a job and was hoping to return to work soon. Rosalie continued to miss her husband but had not heard him in some time. She has not had symptoms of psychosis or depression. Her cognition and mood were intact on my clinical assessment.
 

Discussion

Sadly and shockingly, cases like that of Rosalie are common. In my practice, I routinely see patients on multiple psychotropics – often on more than one antipsychotic. Their diagnoses are vague and dubious, and include diagnoses such as “unspecified psychosis” and “cognitive impairments.” Clinicians occasionally worry about relapse and promote a narrative that treatment must be not only long term but lifelong.⁴ There is some evidence for this perspective in a research context, but the clinical world also is filled with patients like Rosalie.

Her reports of auditory hallucinations were better explained by her grief than by a psychotic process.⁵ Her memory complaints were better explained by anxiety at the time of her testing while suffering from the side effects from her numerous psychotropics.⁶ Her depressive complaints were better explained by appropriate sadness in response to stressors. Several months later with fewer diagnoses and far fewer psychotropics, she is functioning better.
 

Take-home points

• Polypharmacy can lead to psychiatric symptoms and functional impairment.
• Patients often are unaware of the complete risks of psychotropics.
• Psychiatric symptoms are not always associated with a psychiatric disorder.
• Deprescribing can be performed safely and effectively.
• Deprescribing can be performed with the patient’s informed consent and agreement.

References

1. Psychiatr Serv. 2016 Aug 1;67(8):904-7.

2. Focus. 2016 Apr 13; doi: 10.1176/appi.focus.20150041.

3. Bipolar Disord. 2016 Dec;18(8):684-91.

4. Am J Psychiatry. 2017 Sep 1;174(9):840-9.

5. World Psychiatry. 2009 Jun;8(2):67-74.

6. Hosp Community Psychiatry. 1983 Sep;34(9):830-5.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).

*This column was updated 1/11/2019.

The Uniformed Services University of the Health Sciences (USU) was established by Congress in 1972 under the Uniformed Services Health Professions Revitalization Act. The only medical school administered by the federal government, “America’s Medical School” as it is affectionately known, has a mission to educate, train, and comprehensively prepare uniformed services health professionals to support the US military and public health system.

The USU School of Medicine (SOM) matriculates about 170 students each year. Although the majority of the medical students receive commissions in the US Army, Navy, or Air Force and serve as military physicians in the Department of Defense (DoD), a small number of students each year are commissioned as officers in the US Public Health Service Commissioned Corps (PHS). The PHS is a uniformed service within the US Department of Health and Human Services (HHS) whose officers serve nationwide in more than 30 government agencies. However, unlike its sister DoD services, the PHS does not participate in the Health Professions Scholarship Program, so admission to USU represents the only direct accession to the PHS Commissioned Corps for prospective physicians.

Beginning with the first graduating class, more than 160 PHS physician officers have now been trained under agreements with PHS agencies and SOM, and numerous others have received training and experience from the other academic programs and research centers within USU. Ten of those graduates achieved the rank of Rear Admiral, the general officer or “flag” position of the PHS.

The benefits of the partnerships between USU, PHS, and the agencies served by PHS to public health outcomes are many. Specifically, investment in PHS students at the SOM has served to ease disparities experienced by American Indians and Alaskan Natives (AI/AN), combat the shortage of primary care physicians (PCPs), generate exceptional clinical researchers, and train health care professionals to be prepared and ready to respond to emerging threats to public health.

Addressing Health Care Disparities Experienced by AI/AN

Through numerous treaties, laws, court cases, and Executive Orders—and most recently reaffirmed by the reauthorization of the Indian Health Care Improvement Act as part of the Patient Protection and Affordable Care Act (2010)–the US federal government holds responsibility for the provision of medical services to AI/AN. The Indian Health Service (IHS) is the principal federal provider of health care services for the AI/AN population. The mission of the IHS is to raise the physical, mental, social, and spiritual health of the AI/AN population to the highest level. It seeks to accomplish this mission by assuring that comprehensive, culturally acceptable personal and public health services are available and accessible to all AI/AN people.

Agency partnerships at USU, like the one between the school and IHS, sponsor medical students to become PHS physicians who can combat health disparities, especially those experienced by AI/AN. AI/AN continue to be subjected to disparities in health status across a wide array of chronic conditions, with significantly higher mortality rates than those of white populations.¹ These trends are driven by multifactorial etiologies, including social determinants of health,² obesity and the metabolic syndrome,³ high rates of tobacco and alcohol use,⁴ and limited access to medical care.⁵

Recruitment and retention of health care providers (HCPs) has long been a challenge for the IHS.⁶ Despite many attractive factors, providing care in a setting of otherwise limited resources and the relative remoteness of most facilities may prove to be deterring factors to prospective applicants. Furthermore, promotion of quality providers to administrative roles and high turnover rates of contractors or temporary staff contribute to poor continuity of care in certain locations. Consequently, efforts are under way to increase provider retention and continuity of care for patients.

This effort is augmented by training officers for a career of service to the IHS within the PHS. After completion of medical school and a residency in primary care, IHS-sponsored graduates from USU serve as officers in the PHS, stationed at an IHS-designated high-priority site for 10 years.⁷ However, many stay with the IHS for much longer, like IHS Chief Medical Officer, RADM Michael Toedt (USU 1995). In fact, nearly all the officers commissioned in the past 20 years are still on active duty. Within the IHS, physicians focus on community-oriented practice and improving the health of small-town and rural residents at tribal or federally operated clinics and community hospitals. In addition to performing clinical duties, graduates frequently become leaders within the IHS, advocating for systemwide improvements, performing practice-based research, and improving the overall well-being of AI/AN communities.

Combating the PCP Shortage

It has been well documented that primary care is essential for the prevention and control of chronic disease.⁸ However, fewer US medical school graduates are choosing to practice in primary care specialties, and the number of PCPs is forecasted to be insufficient for the needs of the American population in the coming years.^9,10 This deficit is predicted to be especially pronounced in rural and underserved communities.¹¹

Training PHS officers at the USU can fill this growing need by cultivating PCPs committed to a career of service in areas of high need. PHS medical students who are sponsored to attend USU by the IHS select from 1 of 7 approved primary care residencies: emergency medicine, family medicine, general pediatrics, general internal medicine, general psychiatry, obstetrics/gynecology, and general surgery.⁷ PHS students are permitted to train at military or civilian graduate medical education programs; permission to pursue combination programs is granted on a case-by-case basis, with consideration for the needs of the agency. Previously, such authorizations have included internal medicine/pediatrics, internal medicine/psychiatry, and family medicine/preventive medicine. This requirement, understood at the time of matriculation, selects for students who are passionate about primary care and are willing to live and practice in rural, underserved areas during their 10-year service commitment to the agency.

During medical school, USU students participate in numerous training activities that prepare doctors for practice in isolated or resource-poor settings, including point-of-care ultrasonography and field exercises in stabilization and transport of critically ill patients. The motto of the SOM, “Learning to Care for Those in Harm’s Way,” thereby applies not only to battlefield medicine, but to those who practice medicine in austere environments of all kinds.

Generating Clinical Researchers

Although IHS currently funds most PHS students, sponsorship also is available through the National Institute of Allergy and Infectious Diseases (NIAID), one of the institutes of the National Institutes of Health (NIH) in Bethesda, Maryland. Students selected for this competitive program complete a residency in either internal medicine or pediatrics, then complete an NIH-sponsored fellowship in either infectious diseases or allergy and immunology. Similar to their IHS counterparts, they incur a debt of service—10 years in the PHS Commissioned Corps; however, their service obligation is served at NIH. This track supports the creation of the next generation of clinical researchers and physician-scientists, critical in this time of ever-increasing threats to public health and national security, like emerging infectious diseases and bioterrorism.

Emergency Response Preparations

Combined training with experts from DoD and HHS prepares junior medical officers to serve as leaders in responding to large-scale emergencies and disasters. According to a memorandum of December 11, 1981, then Surgeon General C. Everett Koop described the importance of this skill set, saying that USU students are “ready for instant mobilization to meet military [needs] and [respond to] national disasters.” He continued, “Students are taught the necessary leadership and management skills to command medical units and organizations in the delivery of health services...They are exposed to the problems of dealing with national medical emergencies such as floods, earthquakes, and mass immigrations to this country.”¹² Fittingly, physician graduates of USU have recently led disaster response efforts for Hurricanes Harvey, Irma, and Maria and Typhoon Yutu.

Traditional medical school didactic coursework is supplemented by lectures on disaster response, emergency preparedness, and global health engagement. As training progresses, students translate their knowledge into action with practical fieldwork exercises in mass casualty triage, erection of field hospitals using preventive medicine principles, and containment of infectious disease outbreaks among displaced persons—under the close observation and guidance of military and public health subject matter experts from across the country. Medical students complete their clinical training at military treatment facilities around the country and have elective clerkship opportunities in operational medicine nationally and internationally. PHS graduates of USU are well prepared to interface with their military colleagues, building effective joint mission capacity.

Additional Training Opportunities

In addition to the 4-year, tuition-free MD program, the university offers 7 graduate degree programs in public health and residency programs in preventive medicine specialty areas. Continuing education opportunities and graduate certificates are available in global health, tropical medicine and hygiene, travelers’ health, international and domestic disaster response, and other fields of interest to any public health professional, military or civilian. Many programs are available to federal or uniformed service members at no cost, some incur a degree of service commitment. Furthermore, the university is home to multiple research centers, including the National Center for Disaster Medicine and Public Health, which strive to improve public health through research efforts and education.

Conclusion

Though the emerging public health needs of the nation are both varied and daunting, the USU/PHS partnership trains providers that will heed the call and face the modern public health needs head-on. USU remains an important source for commissioning PHS physicians and producing career officers. The unique training provided at USU educates and enables PHS physicians to ease disparities experienced by AI/AN, combat the shortage of PCPs, generate exceptional clinical researchers, and be prepared and ready to respond to emerging threats to public health.

The Uniformed Services University of the Health Sciences (USU) was established by Congress in 1972 under the Uniformed Services Health Professions Revitalization Act. The only medical school administered by the federal government, “America’s Medical School” as it is affectionately known, has a mission to educate, train, and comprehensively prepare uniformed services health professionals to support the US military and public health system.

The USU School of Medicine (SOM) matriculates about 170 students each year. Although the majority of the medical students receive commissions in the US Army, Navy, or Air Force and serve as military physicians in the Department of Defense (DoD), a small number of students each year are commissioned as officers in the US Public Health Service Commissioned Corps (PHS). The PHS is a uniformed service within the US Department of Health and Human Services (HHS) whose officers serve nationwide in more than 30 government agencies. However, unlike its sister DoD services, the PHS does not participate in the Health Professions Scholarship Program, so admission to USU represents the only direct accession to the PHS Commissioned Corps for prospective physicians.

Beginning with the first graduating class, more than 160 PHS physician officers have now been trained under agreements with PHS agencies and SOM, and numerous others have received training and experience from the other academic programs and research centers within USU. Ten of those graduates achieved the rank of Rear Admiral, the general officer or “flag” position of the PHS.

The benefits of the partnerships between USU, PHS, and the agencies served by PHS to public health outcomes are many. Specifically, investment in PHS students at the SOM has served to ease disparities experienced by American Indians and Alaskan Natives (AI/AN), combat the shortage of primary care physicians (PCPs), generate exceptional clinical researchers, and train health care professionals to be prepared and ready to respond to emerging threats to public health.

Addressing Health Care Disparities Experienced by AI/AN

Through numerous treaties, laws, court cases, and Executive Orders—and most recently reaffirmed by the reauthorization of the Indian Health Care Improvement Act as part of the Patient Protection and Affordable Care Act (2010)–the US federal government holds responsibility for the provision of medical services to AI/AN. The Indian Health Service (IHS) is the principal federal provider of health care services for the AI/AN population. The mission of the IHS is to raise the physical, mental, social, and spiritual health of the AI/AN population to the highest level. It seeks to accomplish this mission by assuring that comprehensive, culturally acceptable personal and public health services are available and accessible to all AI/AN people.

Agency partnerships at USU, like the one between the school and IHS, sponsor medical students to become PHS physicians who can combat health disparities, especially those experienced by AI/AN. AI/AN continue to be subjected to disparities in health status across a wide array of chronic conditions, with significantly higher mortality rates than those of white populations.¹ These trends are driven by multifactorial etiologies, including social determinants of health,² obesity and the metabolic syndrome,³ high rates of tobacco and alcohol use,⁴ and limited access to medical care.⁵

Recruitment and retention of health care providers (HCPs) has long been a challenge for the IHS.⁶ Despite many attractive factors, providing care in a setting of otherwise limited resources and the relative remoteness of most facilities may prove to be deterring factors to prospective applicants. Furthermore, promotion of quality providers to administrative roles and high turnover rates of contractors or temporary staff contribute to poor continuity of care in certain locations. Consequently, efforts are under way to increase provider retention and continuity of care for patients.

This effort is augmented by training officers for a career of service to the IHS within the PHS. After completion of medical school and a residency in primary care, IHS-sponsored graduates from USU serve as officers in the PHS, stationed at an IHS-designated high-priority site for 10 years.⁷ However, many stay with the IHS for much longer, like IHS Chief Medical Officer, RADM Michael Toedt (USU 1995). In fact, nearly all the officers commissioned in the past 20 years are still on active duty. Within the IHS, physicians focus on community-oriented practice and improving the health of small-town and rural residents at tribal or federally operated clinics and community hospitals. In addition to performing clinical duties, graduates frequently become leaders within the IHS, advocating for systemwide improvements, performing practice-based research, and improving the overall well-being of AI/AN communities.

Combating the PCP Shortage

It has been well documented that primary care is essential for the prevention and control of chronic disease.⁸ However, fewer US medical school graduates are choosing to practice in primary care specialties, and the number of PCPs is forecasted to be insufficient for the needs of the American population in the coming years.^9,10 This deficit is predicted to be especially pronounced in rural and underserved communities.¹¹

Training PHS officers at the USU can fill this growing need by cultivating PCPs committed to a career of service in areas of high need. PHS medical students who are sponsored to attend USU by the IHS select from 1 of 7 approved primary care residencies: emergency medicine, family medicine, general pediatrics, general internal medicine, general psychiatry, obstetrics/gynecology, and general surgery.⁷ PHS students are permitted to train at military or civilian graduate medical education programs; permission to pursue combination programs is granted on a case-by-case basis, with consideration for the needs of the agency. Previously, such authorizations have included internal medicine/pediatrics, internal medicine/psychiatry, and family medicine/preventive medicine. This requirement, understood at the time of matriculation, selects for students who are passionate about primary care and are willing to live and practice in rural, underserved areas during their 10-year service commitment to the agency.

During medical school, USU students participate in numerous training activities that prepare doctors for practice in isolated or resource-poor settings, including point-of-care ultrasonography and field exercises in stabilization and transport of critically ill patients. The motto of the SOM, “Learning to Care for Those in Harm’s Way,” thereby applies not only to battlefield medicine, but to those who practice medicine in austere environments of all kinds.

Generating Clinical Researchers

Although IHS currently funds most PHS students, sponsorship also is available through the National Institute of Allergy and Infectious Diseases (NIAID), one of the institutes of the National Institutes of Health (NIH) in Bethesda, Maryland. Students selected for this competitive program complete a residency in either internal medicine or pediatrics, then complete an NIH-sponsored fellowship in either infectious diseases or allergy and immunology. Similar to their IHS counterparts, they incur a debt of service—10 years in the PHS Commissioned Corps; however, their service obligation is served at NIH. This track supports the creation of the next generation of clinical researchers and physician-scientists, critical in this time of ever-increasing threats to public health and national security, like emerging infectious diseases and bioterrorism.

Emergency Response Preparations

Combined training with experts from DoD and HHS prepares junior medical officers to serve as leaders in responding to large-scale emergencies and disasters. According to a memorandum of December 11, 1981, then Surgeon General C. Everett Koop described the importance of this skill set, saying that USU students are “ready for instant mobilization to meet military [needs] and [respond to] national disasters.” He continued, “Students are taught the necessary leadership and management skills to command medical units and organizations in the delivery of health services...They are exposed to the problems of dealing with national medical emergencies such as floods, earthquakes, and mass immigrations to this country.”¹² Fittingly, physician graduates of USU have recently led disaster response efforts for Hurricanes Harvey, Irma, and Maria and Typhoon Yutu.

Traditional medical school didactic coursework is supplemented by lectures on disaster response, emergency preparedness, and global health engagement. As training progresses, students translate their knowledge into action with practical fieldwork exercises in mass casualty triage, erection of field hospitals using preventive medicine principles, and containment of infectious disease outbreaks among displaced persons—under the close observation and guidance of military and public health subject matter experts from across the country. Medical students complete their clinical training at military treatment facilities around the country and have elective clerkship opportunities in operational medicine nationally and internationally. PHS graduates of USU are well prepared to interface with their military colleagues, building effective joint mission capacity.

Additional Training Opportunities

In addition to the 4-year, tuition-free MD program, the university offers 7 graduate degree programs in public health and residency programs in preventive medicine specialty areas. Continuing education opportunities and graduate certificates are available in global health, tropical medicine and hygiene, travelers’ health, international and domestic disaster response, and other fields of interest to any public health professional, military or civilian. Many programs are available to federal or uniformed service members at no cost, some incur a degree of service commitment. Furthermore, the university is home to multiple research centers, including the National Center for Disaster Medicine and Public Health, which strive to improve public health through research efforts and education.

Conclusion

Though the emerging public health needs of the nation are both varied and daunting, the USU/PHS partnership trains providers that will heed the call and face the modern public health needs head-on. USU remains an important source for commissioning PHS physicians and producing career officers. The unique training provided at USU educates and enables PHS physicians to ease disparities experienced by AI/AN, combat the shortage of PCPs, generate exceptional clinical researchers, and be prepared and ready to respond to emerging threats to public health.

The Uniformed Services University of the Health Sciences (USU) was established by Congress in 1972 under the Uniformed Services Health Professions Revitalization Act. The only medical school administered by the federal government, “America’s Medical School” as it is affectionately known, has a mission to educate, train, and comprehensively prepare uniformed services health professionals to support the US military and public health system.

The USU School of Medicine (SOM) matriculates about 170 students each year. Although the majority of the medical students receive commissions in the US Army, Navy, or Air Force and serve as military physicians in the Department of Defense (DoD), a small number of students each year are commissioned as officers in the US Public Health Service Commissioned Corps (PHS). The PHS is a uniformed service within the US Department of Health and Human Services (HHS) whose officers serve nationwide in more than 30 government agencies. However, unlike its sister DoD services, the PHS does not participate in the Health Professions Scholarship Program, so admission to USU represents the only direct accession to the PHS Commissioned Corps for prospective physicians.

Beginning with the first graduating class, more than 160 PHS physician officers have now been trained under agreements with PHS agencies and SOM, and numerous others have received training and experience from the other academic programs and research centers within USU. Ten of those graduates achieved the rank of Rear Admiral, the general officer or “flag” position of the PHS.

The benefits of the partnerships between USU, PHS, and the agencies served by PHS to public health outcomes are many. Specifically, investment in PHS students at the SOM has served to ease disparities experienced by American Indians and Alaskan Natives (AI/AN), combat the shortage of primary care physicians (PCPs), generate exceptional clinical researchers, and train health care professionals to be prepared and ready to respond to emerging threats to public health.

Addressing Health Care Disparities Experienced by AI/AN

Through numerous treaties, laws, court cases, and Executive Orders—and most recently reaffirmed by the reauthorization of the Indian Health Care Improvement Act as part of the Patient Protection and Affordable Care Act (2010)–the US federal government holds responsibility for the provision of medical services to AI/AN. The Indian Health Service (IHS) is the principal federal provider of health care services for the AI/AN population. The mission of the IHS is to raise the physical, mental, social, and spiritual health of the AI/AN population to the highest level. It seeks to accomplish this mission by assuring that comprehensive, culturally acceptable personal and public health services are available and accessible to all AI/AN people.

Agency partnerships at USU, like the one between the school and IHS, sponsor medical students to become PHS physicians who can combat health disparities, especially those experienced by AI/AN. AI/AN continue to be subjected to disparities in health status across a wide array of chronic conditions, with significantly higher mortality rates than those of white populations.¹ These trends are driven by multifactorial etiologies, including social determinants of health,² obesity and the metabolic syndrome,³ high rates of tobacco and alcohol use,⁴ and limited access to medical care.⁵

Recruitment and retention of health care providers (HCPs) has long been a challenge for the IHS.⁶ Despite many attractive factors, providing care in a setting of otherwise limited resources and the relative remoteness of most facilities may prove to be deterring factors to prospective applicants. Furthermore, promotion of quality providers to administrative roles and high turnover rates of contractors or temporary staff contribute to poor continuity of care in certain locations. Consequently, efforts are under way to increase provider retention and continuity of care for patients.

This effort is augmented by training officers for a career of service to the IHS within the PHS. After completion of medical school and a residency in primary care, IHS-sponsored graduates from USU serve as officers in the PHS, stationed at an IHS-designated high-priority site for 10 years.⁷ However, many stay with the IHS for much longer, like IHS Chief Medical Officer, RADM Michael Toedt (USU 1995). In fact, nearly all the officers commissioned in the past 20 years are still on active duty. Within the IHS, physicians focus on community-oriented practice and improving the health of small-town and rural residents at tribal or federally operated clinics and community hospitals. In addition to performing clinical duties, graduates frequently become leaders within the IHS, advocating for systemwide improvements, performing practice-based research, and improving the overall well-being of AI/AN communities.

Combating the PCP Shortage

It has been well documented that primary care is essential for the prevention and control of chronic disease.⁸ However, fewer US medical school graduates are choosing to practice in primary care specialties, and the number of PCPs is forecasted to be insufficient for the needs of the American population in the coming years.^9,10 This deficit is predicted to be especially pronounced in rural and underserved communities.¹¹

Training PHS officers at the USU can fill this growing need by cultivating PCPs committed to a career of service in areas of high need. PHS medical students who are sponsored to attend USU by the IHS select from 1 of 7 approved primary care residencies: emergency medicine, family medicine, general pediatrics, general internal medicine, general psychiatry, obstetrics/gynecology, and general surgery.⁷ PHS students are permitted to train at military or civilian graduate medical education programs; permission to pursue combination programs is granted on a case-by-case basis, with consideration for the needs of the agency. Previously, such authorizations have included internal medicine/pediatrics, internal medicine/psychiatry, and family medicine/preventive medicine. This requirement, understood at the time of matriculation, selects for students who are passionate about primary care and are willing to live and practice in rural, underserved areas during their 10-year service commitment to the agency.

During medical school, USU students participate in numerous training activities that prepare doctors for practice in isolated or resource-poor settings, including point-of-care ultrasonography and field exercises in stabilization and transport of critically ill patients. The motto of the SOM, “Learning to Care for Those in Harm’s Way,” thereby applies not only to battlefield medicine, but to those who practice medicine in austere environments of all kinds.

Generating Clinical Researchers

Although IHS currently funds most PHS students, sponsorship also is available through the National Institute of Allergy and Infectious Diseases (NIAID), one of the institutes of the National Institutes of Health (NIH) in Bethesda, Maryland. Students selected for this competitive program complete a residency in either internal medicine or pediatrics, then complete an NIH-sponsored fellowship in either infectious diseases or allergy and immunology. Similar to their IHS counterparts, they incur a debt of service—10 years in the PHS Commissioned Corps; however, their service obligation is served at NIH. This track supports the creation of the next generation of clinical researchers and physician-scientists, critical in this time of ever-increasing threats to public health and national security, like emerging infectious diseases and bioterrorism.

Emergency Response Preparations

Combined training with experts from DoD and HHS prepares junior medical officers to serve as leaders in responding to large-scale emergencies and disasters. According to a memorandum of December 11, 1981, then Surgeon General C. Everett Koop described the importance of this skill set, saying that USU students are “ready for instant mobilization to meet military [needs] and [respond to] national disasters.” He continued, “Students are taught the necessary leadership and management skills to command medical units and organizations in the delivery of health services...They are exposed to the problems of dealing with national medical emergencies such as floods, earthquakes, and mass immigrations to this country.”¹² Fittingly, physician graduates of USU have recently led disaster response efforts for Hurricanes Harvey, Irma, and Maria and Typhoon Yutu.

Traditional medical school didactic coursework is supplemented by lectures on disaster response, emergency preparedness, and global health engagement. As training progresses, students translate their knowledge into action with practical fieldwork exercises in mass casualty triage, erection of field hospitals using preventive medicine principles, and containment of infectious disease outbreaks among displaced persons—under the close observation and guidance of military and public health subject matter experts from across the country. Medical students complete their clinical training at military treatment facilities around the country and have elective clerkship opportunities in operational medicine nationally and internationally. PHS graduates of USU are well prepared to interface with their military colleagues, building effective joint mission capacity.

Additional Training Opportunities

In addition to the 4-year, tuition-free MD program, the university offers 7 graduate degree programs in public health and residency programs in preventive medicine specialty areas. Continuing education opportunities and graduate certificates are available in global health, tropical medicine and hygiene, travelers’ health, international and domestic disaster response, and other fields of interest to any public health professional, military or civilian. Many programs are available to federal or uniformed service members at no cost, some incur a degree of service commitment. Furthermore, the university is home to multiple research centers, including the National Center for Disaster Medicine and Public Health, which strive to improve public health through research efforts and education.

Conclusion

Though the emerging public health needs of the nation are both varied and daunting, the USU/PHS partnership trains providers that will heed the call and face the modern public health needs head-on. USU remains an important source for commissioning PHS physicians and producing career officers. The unique training provided at USU educates and enables PHS physicians to ease disparities experienced by AI/AN, combat the shortage of PCPs, generate exceptional clinical researchers, and be prepared and ready to respond to emerging threats to public health.

Eucalyptus eulogy

(“Taps” quietly plays in the background ... ) In some sad news, Quincy the diabetic koala has passed on to that great eucalyptus tree in the sky. The furry type 1 diabetic lived in San Diego, where he was recently fitted with a cutting-edge continuous glucose monitor (CGM). This allowed Quincy more time for his favorite activities (chewing and sleeping) and less time spent with pesky skin pricks.

Courtesy San Diego Zoo

Quincy died of pneumonia, and it is unclear whether his death was diabetes related. All we know is that he will be missed greatly. He was beloved by those with diabetes everywhere, animal or otherwise. Quincy’s successful CGM procedure also gives endocrinologists hope that the technology could eventually be used for similarly fragile humans, like babies. R.I.P., Quincy; we loved you. In lieu of flowers, donations may be made to his favorite charity, the Drop Bear Awareness Association.
 

What’s Latin for ‘poop’?

The study of the human microbiota has become incredibly important in recent years, but there’s no getting away from the fact that it entails experimenting on poop. Remarkably, no one’s come up with a proper technical name for this unsavory activity. However, thanks to a collaboration between a gastroenterologist and a classics professor at the University of North Carolina, that deficiency is no more. You’ve met the in vivo and in vitro study. Now, please welcome the “in vimo” study!

ventdusud/iStock/Getty Images Plus

Why in vimo? The term fecal or “in feco” might seem obvious. But the Latin root word never referred to poop, and if there’s one thing scientists can’t have, it’s improper Latin usage. The Romans, it turns out, had lots of words for poop. The root word of laetamen referred to fertility, richness, and happiness – a tempting prospect – but was mostly used to refer to farm animal dung. Merda mostly referred to smell or stench, and stercus shared the same root word as scatology, which refers to obscene literature. Fimus, which specifically refers to manure, was thus the most precise, and it was used by literary giants such as Livy, Virgil, and Tacitus. A clear winner, and the in vimo study flushed the rest of the competition away.

And just in case you think these researchers are no fun, the name they chose for the active enzymes collected from their in vimo samples? Poopernatants. Yes, even doctors enjoy a good poop joke.
 

The new Breakfast Club

Researchers at the University of Illinois and the University of Texas have collaborated to study something that most of us fear greatly: high school cliques. The researchers, who may or may not have peaked in high school, took a look at high school peer crowds and influences that form those tight-knit bonds that last all of 4 years.

monkeybusinessimages/iStock/Getty Images Plus

The study found that most of the classic cliques – the jocks, the popular crowd, the brains, the stoners, the loners – are still alive and well in today’s American school system. However, at least one new group has emerged in the last decade: the “anime/manga fans.” Researchers noted that although schools have become much more diverse, racial and ethnic stereotypes are alive and well. Thank God we only have to do high school once.
 

Resistance is fecal

And now, just in case you were wondering how long it would take to put our newfound knowledge of “in vimo” to use, here comes a study that has “in vimo” written all over it (metaphorically speaking, of course).

Researchers in Sweden and Finland decided to take a look at antibiotic resistance genes in sewage, because “antibiotics consumed by humans and animals are released into the environment in urine and fecal material contained in treated wastewaters and sludge applied to land.” Then they compared the abundance of the mobile antibiotic resistance genes with the abundance of a human fecal pollution marker.

SutidaS/iStock/Getty Images Plus

That marker – a virus that infects bacteria in human feces but is rare in other animals – was “highly correlated to the abundance of antibiotic resistance genes in environmental samples,” they said in a separate written statement, which “indicates that fecal pollution can largely explain the increase in resistant bacteria often found in human-impacted environments.” The name of that marker, the virus found in feces, happens to be “crAssphage.” And yes, the A really is capitalized. Really. We are not making this up.
 

Gout wins a Golden Globe

Gout has a new poster girl: Great Britain’s Queen Anne. She’s been dead for more than 4 centuries, but a Hollywood version of this stout monarch is turning a famously royal affliction into the disease of the moment.

The credit goes to actress Olivia Colman, who just won a Golden Globe award for her brilliant performance in the earthy comedy “The Favourite.” Ms. Colman transforms the pain-wracked Queen Anne into a needy, manipulative, and loopy monarch who still manages to draw our sympathy.

Besides flummoxing American spell-checkers with its title, The Favourite glories in stretching the truth about the queen’s private life. But she really does seem to have had the “disease of kings,” which has long been linked to the rich, fatty diets enjoyed by blue bloods.

Now, there’s talk that high-protein, meat-friendly keto and paleo diets are boosting rates among the young. This theory got an airing last week in a New York Magazine article titled “Why Gout Is Making a Comeback.”

The truth may be more complicated. Over the last few years, researchers have cast doubt on the keto-leads-to-gout theory and suggested that fructose in sugar may be the real culprit. According to this hypothesis, gout afflicted British royals as they developed a communal sweet tooth during the early days of the sugar trade. Gout then spread to the general population as sugar became more accessible.

The gout debate will continue. As for Olivia Colman, she will soon grace smaller screens with her performance as Queen Elizabeth II in Netflix’s series “The Crown.”

QE II isn’t known for having suffered from any major diseases. But at her next checkup, we do think she should have that stiff upper lip looked at.

[email protected]

Eucalyptus eulogy

(“Taps” quietly plays in the background ... ) In some sad news, Quincy the diabetic koala has passed on to that great eucalyptus tree in the sky. The furry type 1 diabetic lived in San Diego, where he was recently fitted with a cutting-edge continuous glucose monitor (CGM). This allowed Quincy more time for his favorite activities (chewing and sleeping) and less time spent with pesky skin pricks.

Courtesy San Diego Zoo

Quincy died of pneumonia, and it is unclear whether his death was diabetes related. All we know is that he will be missed greatly. He was beloved by those with diabetes everywhere, animal or otherwise. Quincy’s successful CGM procedure also gives endocrinologists hope that the technology could eventually be used for similarly fragile humans, like babies. R.I.P., Quincy; we loved you. In lieu of flowers, donations may be made to his favorite charity, the Drop Bear Awareness Association.
 

What’s Latin for ‘poop’?

The study of the human microbiota has become incredibly important in recent years, but there’s no getting away from the fact that it entails experimenting on poop. Remarkably, no one’s come up with a proper technical name for this unsavory activity. However, thanks to a collaboration between a gastroenterologist and a classics professor at the University of North Carolina, that deficiency is no more. You’ve met the in vivo and in vitro study. Now, please welcome the “in vimo” study!

ventdusud/iStock/Getty Images Plus

Why in vimo? The term fecal or “in feco” might seem obvious. But the Latin root word never referred to poop, and if there’s one thing scientists can’t have, it’s improper Latin usage. The Romans, it turns out, had lots of words for poop. The root word of laetamen referred to fertility, richness, and happiness – a tempting prospect – but was mostly used to refer to farm animal dung. Merda mostly referred to smell or stench, and stercus shared the same root word as scatology, which refers to obscene literature. Fimus, which specifically refers to manure, was thus the most precise, and it was used by literary giants such as Livy, Virgil, and Tacitus. A clear winner, and the in vimo study flushed the rest of the competition away.

And just in case you think these researchers are no fun, the name they chose for the active enzymes collected from their in vimo samples? Poopernatants. Yes, even doctors enjoy a good poop joke.
 

The new Breakfast Club

Researchers at the University of Illinois and the University of Texas have collaborated to study something that most of us fear greatly: high school cliques. The researchers, who may or may not have peaked in high school, took a look at high school peer crowds and influences that form those tight-knit bonds that last all of 4 years.

monkeybusinessimages/iStock/Getty Images Plus

The study found that most of the classic cliques – the jocks, the popular crowd, the brains, the stoners, the loners – are still alive and well in today’s American school system. However, at least one new group has emerged in the last decade: the “anime/manga fans.” Researchers noted that although schools have become much more diverse, racial and ethnic stereotypes are alive and well. Thank God we only have to do high school once.
 

Resistance is fecal

And now, just in case you were wondering how long it would take to put our newfound knowledge of “in vimo” to use, here comes a study that has “in vimo” written all over it (metaphorically speaking, of course).

Researchers in Sweden and Finland decided to take a look at antibiotic resistance genes in sewage, because “antibiotics consumed by humans and animals are released into the environment in urine and fecal material contained in treated wastewaters and sludge applied to land.” Then they compared the abundance of the mobile antibiotic resistance genes with the abundance of a human fecal pollution marker.

SutidaS/iStock/Getty Images Plus

That marker – a virus that infects bacteria in human feces but is rare in other animals – was “highly correlated to the abundance of antibiotic resistance genes in environmental samples,” they said in a separate written statement, which “indicates that fecal pollution can largely explain the increase in resistant bacteria often found in human-impacted environments.” The name of that marker, the virus found in feces, happens to be “crAssphage.” And yes, the A really is capitalized. Really. We are not making this up.
 

Gout wins a Golden Globe

Gout has a new poster girl: Great Britain’s Queen Anne. She’s been dead for more than 4 centuries, but a Hollywood version of this stout monarch is turning a famously royal affliction into the disease of the moment.

The credit goes to actress Olivia Colman, who just won a Golden Globe award for her brilliant performance in the earthy comedy “The Favourite.” Ms. Colman transforms the pain-wracked Queen Anne into a needy, manipulative, and loopy monarch who still manages to draw our sympathy.

Besides flummoxing American spell-checkers with its title, The Favourite glories in stretching the truth about the queen’s private life. But she really does seem to have had the “disease of kings,” which has long been linked to the rich, fatty diets enjoyed by blue bloods.

Now, there’s talk that high-protein, meat-friendly keto and paleo diets are boosting rates among the young. This theory got an airing last week in a New York Magazine article titled “Why Gout Is Making a Comeback.”

The truth may be more complicated. Over the last few years, researchers have cast doubt on the keto-leads-to-gout theory and suggested that fructose in sugar may be the real culprit. According to this hypothesis, gout afflicted British royals as they developed a communal sweet tooth during the early days of the sugar trade. Gout then spread to the general population as sugar became more accessible.

The gout debate will continue. As for Olivia Colman, she will soon grace smaller screens with her performance as Queen Elizabeth II in Netflix’s series “The Crown.”

QE II isn’t known for having suffered from any major diseases. But at her next checkup, we do think she should have that stiff upper lip looked at.

[email protected]

Eucalyptus eulogy

(“Taps” quietly plays in the background ... ) In some sad news, Quincy the diabetic koala has passed on to that great eucalyptus tree in the sky. The furry type 1 diabetic lived in San Diego, where he was recently fitted with a cutting-edge continuous glucose monitor (CGM). This allowed Quincy more time for his favorite activities (chewing and sleeping) and less time spent with pesky skin pricks.

Courtesy San Diego Zoo

Quincy died of pneumonia, and it is unclear whether his death was diabetes related. All we know is that he will be missed greatly. He was beloved by those with diabetes everywhere, animal or otherwise. Quincy’s successful CGM procedure also gives endocrinologists hope that the technology could eventually be used for similarly fragile humans, like babies. R.I.P., Quincy; we loved you. In lieu of flowers, donations may be made to his favorite charity, the Drop Bear Awareness Association.
 

What’s Latin for ‘poop’?

The study of the human microbiota has become incredibly important in recent years, but there’s no getting away from the fact that it entails experimenting on poop. Remarkably, no one’s come up with a proper technical name for this unsavory activity. However, thanks to a collaboration between a gastroenterologist and a classics professor at the University of North Carolina, that deficiency is no more. You’ve met the in vivo and in vitro study. Now, please welcome the “in vimo” study!

ventdusud/iStock/Getty Images Plus

Why in vimo? The term fecal or “in feco” might seem obvious. But the Latin root word never referred to poop, and if there’s one thing scientists can’t have, it’s improper Latin usage. The Romans, it turns out, had lots of words for poop. The root word of laetamen referred to fertility, richness, and happiness – a tempting prospect – but was mostly used to refer to farm animal dung. Merda mostly referred to smell or stench, and stercus shared the same root word as scatology, which refers to obscene literature. Fimus, which specifically refers to manure, was thus the most precise, and it was used by literary giants such as Livy, Virgil, and Tacitus. A clear winner, and the in vimo study flushed the rest of the competition away.

And just in case you think these researchers are no fun, the name they chose for the active enzymes collected from their in vimo samples? Poopernatants. Yes, even doctors enjoy a good poop joke.
 

The new Breakfast Club

Researchers at the University of Illinois and the University of Texas have collaborated to study something that most of us fear greatly: high school cliques. The researchers, who may or may not have peaked in high school, took a look at high school peer crowds and influences that form those tight-knit bonds that last all of 4 years.

monkeybusinessimages/iStock/Getty Images Plus

The study found that most of the classic cliques – the jocks, the popular crowd, the brains, the stoners, the loners – are still alive and well in today’s American school system. However, at least one new group has emerged in the last decade: the “anime/manga fans.” Researchers noted that although schools have become much more diverse, racial and ethnic stereotypes are alive and well. Thank God we only have to do high school once.
 

Resistance is fecal

And now, just in case you were wondering how long it would take to put our newfound knowledge of “in vimo” to use, here comes a study that has “in vimo” written all over it (metaphorically speaking, of course).

Researchers in Sweden and Finland decided to take a look at antibiotic resistance genes in sewage, because “antibiotics consumed by humans and animals are released into the environment in urine and fecal material contained in treated wastewaters and sludge applied to land.” Then they compared the abundance of the mobile antibiotic resistance genes with the abundance of a human fecal pollution marker.

SutidaS/iStock/Getty Images Plus

That marker – a virus that infects bacteria in human feces but is rare in other animals – was “highly correlated to the abundance of antibiotic resistance genes in environmental samples,” they said in a separate written statement, which “indicates that fecal pollution can largely explain the increase in resistant bacteria often found in human-impacted environments.” The name of that marker, the virus found in feces, happens to be “crAssphage.” And yes, the A really is capitalized. Really. We are not making this up.
 

Gout wins a Golden Globe

Gout has a new poster girl: Great Britain’s Queen Anne. She’s been dead for more than 4 centuries, but a Hollywood version of this stout monarch is turning a famously royal affliction into the disease of the moment.

The credit goes to actress Olivia Colman, who just won a Golden Globe award for her brilliant performance in the earthy comedy “The Favourite.” Ms. Colman transforms the pain-wracked Queen Anne into a needy, manipulative, and loopy monarch who still manages to draw our sympathy.

Besides flummoxing American spell-checkers with its title, The Favourite glories in stretching the truth about the queen’s private life. But she really does seem to have had the “disease of kings,” which has long been linked to the rich, fatty diets enjoyed by blue bloods.

Now, there’s talk that high-protein, meat-friendly keto and paleo diets are boosting rates among the young. This theory got an airing last week in a New York Magazine article titled “Why Gout Is Making a Comeback.”

The truth may be more complicated. Over the last few years, researchers have cast doubt on the keto-leads-to-gout theory and suggested that fructose in sugar may be the real culprit. According to this hypothesis, gout afflicted British royals as they developed a communal sweet tooth during the early days of the sugar trade. Gout then spread to the general population as sugar became more accessible.

The gout debate will continue. As for Olivia Colman, she will soon grace smaller screens with her performance as Queen Elizabeth II in Netflix’s series “The Crown.”

QE II isn’t known for having suffered from any major diseases. But at her next checkup, we do think she should have that stiff upper lip looked at.

[email protected]

Despite clinical practice guidelines,^1,2 the lack of informed providers remains the greatest barrier to optimal transgender medical care, notable even with improvement with regard to other barriers to care.³ Barriers accessing appropriate care play a significant role in the persistent health disparities experienced by transgender individuals, such as increased rates of certain cancers, substance abuse, mental health concerns, infections, and chronic diseases.

In the United States, transgender people make up an estimated 0.6% of the population.⁴ Transgender individuals have unique health needs. However, when surveyed, most members of the medical community report that they are not adequately trained to address those needs.⁵ There is a need for health care providers to be comfortable treating, as well as versed in the health needs of, transgender patients. Physicians and medical students report having knowledge gaps in transgender health care because of insufficient education and exposure.

For medical students, the Association of American Medical Colleges (AAMC) launched a guide for medical schools in 2014 regarding the integration of LGBT-related curricula. Still, in a survey of 4,262 medical students from 170 medical schools in Canada and the United States, 67% of students rated their LGBT-related curriculum as “very poor,” “poor,” or “fair.”⁶

Data that are transgender specific are scarce. In a transgender medicine education–specific survey done among 365 Canadian medical students attending English-language medical schools, only 24% of them reported that transgender health was proficiently taught and only 6% reported feeling sufficiently knowledgeable to care for transgender individuals.⁷ Additionally, a survey among 341 United States medical students at a single institution reported that knowledge of transgender health lagged behind knowledge of other LGB health.⁸

Park et al. reported on the expanded Boston University School of Medicine (BUSM) transgender medical education model which supplemented the AAMC framework with evidence based, transgender-specific medical–education integrated throughout the medical curriculum.⁹ Beyond the AAMC-suggested program, first-year BUSM students in physiology learn about the biologic evidence for gender identity.¹⁰ In the following year, BUSM students are taught both the classic treatment regimens and monitoring requirements for transgender hormone therapy as part of the standard endocrinology curriculum.¹¹ Following the first 2 years, students reported a significant increase in willingness to care for transgender patients and a 67% decrease in discomfort with providing care to transgender patients.

However, the relative comfort with transgender-specific care still lagged behind the comfort for LGB care in general. In 2014, BUSM expanded its transgender programming further to include an experiential component with a clinical elective for 4th-year medical students.⁹ The transgender medicine elective included direct patient care experiences with transgender individuals in adult primary care, pediatrics, endocrinology, and surgery. Direct patient contact has been demonstrated to facilitate greater confidence in providing transgender medical care for other medical trainees.¹²

A mechanism for the national adoption of the BUSM approach should be instituted for all medical schools. Such a move could easily result in a significant improvement in reported comfort among students. After that, the goal should be to leverage opportunities to mandate experiential components in transgender medical education.

While aspects of health care for transgender individuals have improved significantly, education among healthcare providers still lags and remains the largest barrier to care for transgender individuals. With the identified transgender population continuing to expand, the gap remains large in the production and training of sufficient numbers of providers proficient in transgender care. Although data for effectiveness are only short term, several interventions among medical students have been shown to be effective and seem logical to adopt universally.
 

Dr. Safer is executive director, Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine, New York.

References

1. Coleman E et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. Int J Transgend. 2012;13:165.

2. Hembree WC et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102:3869-903.

3. Safer JD et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016;23:168-71.

4. Flores AR et al. How many adults identify as transgender in the United States? The Williams Institute. 2017 Jun. Los Angeles, Calif. (Accessed on Oct. 30, 2018).

5. Irwig MS. Transgender care by endocrinologists in the United States. Endocr Pract. 2016 Jul;22:832-6.

6. White W et al. Lesbian, gay, bisexual, and transgender patient care: Medical students’ preparedness and comfort. Teach Learn Med. 2015 Jul 9;27:254-63.

7. Chan B et al. Gaps in transgender medicine content identified among Canadian medical school curricula. Transgend Health. 2016 Jul 1;1:142-50.

8. Liang JJ et al. Observed deficiencies in medical student knowledge of transgender and intersex health. Endocr Pract. 2017 Aug;23:897-906.

9. Park JA et al. Clinical exposure to transgender medicine improves students’ preparedness above levels seen with didactic teaching alone: A key addition to the Boston University model for teaching transgender healthcare. Transgend Health. 2018 Jan 1;3:10-6.

10. Eriksson SE et al. Evidence-based curricular content improves student knowledge and changes attitudes towards transgender medicine. Endocr Pract. 2016 Jul;22:837-41.

11. Safer JD et al. A simple curriculum content change increased medical student comfort with transgender medicine. Endocr Pract. 2013 Jul-Aug;19:633-7.

12. Morrison SD et al. Transgender-related education in plastic surgery and urology residency programs. J Grad Med Educ. 2017 Apr;9:178-83.

Despite clinical practice guidelines,^1,2 the lack of informed providers remains the greatest barrier to optimal transgender medical care, notable even with improvement with regard to other barriers to care.³ Barriers accessing appropriate care play a significant role in the persistent health disparities experienced by transgender individuals, such as increased rates of certain cancers, substance abuse, mental health concerns, infections, and chronic diseases.

In the United States, transgender people make up an estimated 0.6% of the population.⁴ Transgender individuals have unique health needs. However, when surveyed, most members of the medical community report that they are not adequately trained to address those needs.⁵ There is a need for health care providers to be comfortable treating, as well as versed in the health needs of, transgender patients. Physicians and medical students report having knowledge gaps in transgender health care because of insufficient education and exposure.

For medical students, the Association of American Medical Colleges (AAMC) launched a guide for medical schools in 2014 regarding the integration of LGBT-related curricula. Still, in a survey of 4,262 medical students from 170 medical schools in Canada and the United States, 67% of students rated their LGBT-related curriculum as “very poor,” “poor,” or “fair.”⁶

Data that are transgender specific are scarce. In a transgender medicine education–specific survey done among 365 Canadian medical students attending English-language medical schools, only 24% of them reported that transgender health was proficiently taught and only 6% reported feeling sufficiently knowledgeable to care for transgender individuals.⁷ Additionally, a survey among 341 United States medical students at a single institution reported that knowledge of transgender health lagged behind knowledge of other LGB health.⁸

Park et al. reported on the expanded Boston University School of Medicine (BUSM) transgender medical education model which supplemented the AAMC framework with evidence based, transgender-specific medical–education integrated throughout the medical curriculum.⁹ Beyond the AAMC-suggested program, first-year BUSM students in physiology learn about the biologic evidence for gender identity.¹⁰ In the following year, BUSM students are taught both the classic treatment regimens and monitoring requirements for transgender hormone therapy as part of the standard endocrinology curriculum.¹¹ Following the first 2 years, students reported a significant increase in willingness to care for transgender patients and a 67% decrease in discomfort with providing care to transgender patients.

However, the relative comfort with transgender-specific care still lagged behind the comfort for LGB care in general. In 2014, BUSM expanded its transgender programming further to include an experiential component with a clinical elective for 4th-year medical students.⁹ The transgender medicine elective included direct patient care experiences with transgender individuals in adult primary care, pediatrics, endocrinology, and surgery. Direct patient contact has been demonstrated to facilitate greater confidence in providing transgender medical care for other medical trainees.¹²

A mechanism for the national adoption of the BUSM approach should be instituted for all medical schools. Such a move could easily result in a significant improvement in reported comfort among students. After that, the goal should be to leverage opportunities to mandate experiential components in transgender medical education.

While aspects of health care for transgender individuals have improved significantly, education among healthcare providers still lags and remains the largest barrier to care for transgender individuals. With the identified transgender population continuing to expand, the gap remains large in the production and training of sufficient numbers of providers proficient in transgender care. Although data for effectiveness are only short term, several interventions among medical students have been shown to be effective and seem logical to adopt universally.
 

Dr. Safer is executive director, Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine, New York.

References

1. Coleman E et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. Int J Transgend. 2012;13:165.

2. Hembree WC et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102:3869-903.

3. Safer JD et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016;23:168-71.

4. Flores AR et al. How many adults identify as transgender in the United States? The Williams Institute. 2017 Jun. Los Angeles, Calif. (Accessed on Oct. 30, 2018).

5. Irwig MS. Transgender care by endocrinologists in the United States. Endocr Pract. 2016 Jul;22:832-6.

6. White W et al. Lesbian, gay, bisexual, and transgender patient care: Medical students’ preparedness and comfort. Teach Learn Med. 2015 Jul 9;27:254-63.

7. Chan B et al. Gaps in transgender medicine content identified among Canadian medical school curricula. Transgend Health. 2016 Jul 1;1:142-50.

8. Liang JJ et al. Observed deficiencies in medical student knowledge of transgender and intersex health. Endocr Pract. 2017 Aug;23:897-906.

9. Park JA et al. Clinical exposure to transgender medicine improves students’ preparedness above levels seen with didactic teaching alone: A key addition to the Boston University model for teaching transgender healthcare. Transgend Health. 2018 Jan 1;3:10-6.

10. Eriksson SE et al. Evidence-based curricular content improves student knowledge and changes attitudes towards transgender medicine. Endocr Pract. 2016 Jul;22:837-41.

11. Safer JD et al. A simple curriculum content change increased medical student comfort with transgender medicine. Endocr Pract. 2013 Jul-Aug;19:633-7.

12. Morrison SD et al. Transgender-related education in plastic surgery and urology residency programs. J Grad Med Educ. 2017 Apr;9:178-83.

Despite clinical practice guidelines,^1,2 the lack of informed providers remains the greatest barrier to optimal transgender medical care, notable even with improvement with regard to other barriers to care.³ Barriers accessing appropriate care play a significant role in the persistent health disparities experienced by transgender individuals, such as increased rates of certain cancers, substance abuse, mental health concerns, infections, and chronic diseases.

In the United States, transgender people make up an estimated 0.6% of the population.⁴ Transgender individuals have unique health needs. However, when surveyed, most members of the medical community report that they are not adequately trained to address those needs.⁵ There is a need for health care providers to be comfortable treating, as well as versed in the health needs of, transgender patients. Physicians and medical students report having knowledge gaps in transgender health care because of insufficient education and exposure.

For medical students, the Association of American Medical Colleges (AAMC) launched a guide for medical schools in 2014 regarding the integration of LGBT-related curricula. Still, in a survey of 4,262 medical students from 170 medical schools in Canada and the United States, 67% of students rated their LGBT-related curriculum as “very poor,” “poor,” or “fair.”⁶

Data that are transgender specific are scarce. In a transgender medicine education–specific survey done among 365 Canadian medical students attending English-language medical schools, only 24% of them reported that transgender health was proficiently taught and only 6% reported feeling sufficiently knowledgeable to care for transgender individuals.⁷ Additionally, a survey among 341 United States medical students at a single institution reported that knowledge of transgender health lagged behind knowledge of other LGB health.⁸

Park et al. reported on the expanded Boston University School of Medicine (BUSM) transgender medical education model which supplemented the AAMC framework with evidence based, transgender-specific medical–education integrated throughout the medical curriculum.⁹ Beyond the AAMC-suggested program, first-year BUSM students in physiology learn about the biologic evidence for gender identity.¹⁰ In the following year, BUSM students are taught both the classic treatment regimens and monitoring requirements for transgender hormone therapy as part of the standard endocrinology curriculum.¹¹ Following the first 2 years, students reported a significant increase in willingness to care for transgender patients and a 67% decrease in discomfort with providing care to transgender patients.

However, the relative comfort with transgender-specific care still lagged behind the comfort for LGB care in general. In 2014, BUSM expanded its transgender programming further to include an experiential component with a clinical elective for 4th-year medical students.⁹ The transgender medicine elective included direct patient care experiences with transgender individuals in adult primary care, pediatrics, endocrinology, and surgery. Direct patient contact has been demonstrated to facilitate greater confidence in providing transgender medical care for other medical trainees.¹²

A mechanism for the national adoption of the BUSM approach should be instituted for all medical schools. Such a move could easily result in a significant improvement in reported comfort among students. After that, the goal should be to leverage opportunities to mandate experiential components in transgender medical education.

While aspects of health care for transgender individuals have improved significantly, education among healthcare providers still lags and remains the largest barrier to care for transgender individuals. With the identified transgender population continuing to expand, the gap remains large in the production and training of sufficient numbers of providers proficient in transgender care. Although data for effectiveness are only short term, several interventions among medical students have been shown to be effective and seem logical to adopt universally.
 

Dr. Safer is executive director, Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine, New York.

References

1. Coleman E et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. Int J Transgend. 2012;13:165.

2. Hembree WC et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102:3869-903.

3. Safer JD et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016;23:168-71.

4. Flores AR et al. How many adults identify as transgender in the United States? The Williams Institute. 2017 Jun. Los Angeles, Calif. (Accessed on Oct. 30, 2018).

5. Irwig MS. Transgender care by endocrinologists in the United States. Endocr Pract. 2016 Jul;22:832-6.

6. White W et al. Lesbian, gay, bisexual, and transgender patient care: Medical students’ preparedness and comfort. Teach Learn Med. 2015 Jul 9;27:254-63.

7. Chan B et al. Gaps in transgender medicine content identified among Canadian medical school curricula. Transgend Health. 2016 Jul 1;1:142-50.

8. Liang JJ et al. Observed deficiencies in medical student knowledge of transgender and intersex health. Endocr Pract. 2017 Aug;23:897-906.

9. Park JA et al. Clinical exposure to transgender medicine improves students’ preparedness above levels seen with didactic teaching alone: A key addition to the Boston University model for teaching transgender healthcare. Transgend Health. 2018 Jan 1;3:10-6.

10. Eriksson SE et al. Evidence-based curricular content improves student knowledge and changes attitudes towards transgender medicine. Endocr Pract. 2016 Jul;22:837-41.

11. Safer JD et al. A simple curriculum content change increased medical student comfort with transgender medicine. Endocr Pract. 2013 Jul-Aug;19:633-7.

12. Morrison SD et al. Transgender-related education in plastic surgery and urology residency programs. J Grad Med Educ. 2017 Apr;9:178-83.

I’ll put up with a lot in this practice, but I will not tolerate mistreatment of my staff.

ALLVISIONN/Thinkstock

Rudeness, while never pleasant, is generally tolerated. Some people just have that sort of personality. Others may be having a crappy day for unrelated reasons. We all have those.

But those who are intentionally abusive of my hardworking assistants aren’t going to get very far here. I have no problem telling them to go elsewhere. (This doesn’t include those with neurologic reasons for such behavior.)

Some doctors are more willing to put up with this than I am. I once shared space with one who routinely told his staff to ignore abusive behaviors. He didn’t want to turn away any potential revenue or risk angering a referring doctor.

I take another view. Life is short, and medical practice is, by nature, hectic. I have little enough time to care for the patients who genuinely appreciate what my staff and I are trying to do for them. People who are abusive and belligerent can find another doctor who’s willing to put up with it. I won’t.

My staff and I don’t expect to be thanked. We all signed up to work here. But we also try to treat patients with concern and respect, and ask the same courtesy in return. Isn’t that the golden rule?

Abusive patients are difficult to deal with, time consuming, and contribute to staff burnout. The two awesome women who work here deserve better than that. If they’re not happy, I’m not happy. All it takes is one bad person to throw the day off kilter and sometimes affect the care of the next patient in line. That person deserves better, too.

Some will argue that, as a doctor, I should care for all who need my help. In the hospital, I do. I understand that people there generally are scared and hurting and do not want to be there. But in my office I expect at least some degree of civility. We have to be at our best for each person who comes in, and having patients we can work with on a polite level helps.

There’s enough insanity in this job on a good day. People who intentionally try to make it worse aren’t welcome in my little world.

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

I’ll put up with a lot in this practice, but I will not tolerate mistreatment of my staff.

ALLVISIONN/Thinkstock

Rudeness, while never pleasant, is generally tolerated. Some people just have that sort of personality. Others may be having a crappy day for unrelated reasons. We all have those.

But those who are intentionally abusive of my hardworking assistants aren’t going to get very far here. I have no problem telling them to go elsewhere. (This doesn’t include those with neurologic reasons for such behavior.)

Some doctors are more willing to put up with this than I am. I once shared space with one who routinely told his staff to ignore abusive behaviors. He didn’t want to turn away any potential revenue or risk angering a referring doctor.

I take another view. Life is short, and medical practice is, by nature, hectic. I have little enough time to care for the patients who genuinely appreciate what my staff and I are trying to do for them. People who are abusive and belligerent can find another doctor who’s willing to put up with it. I won’t.

My staff and I don’t expect to be thanked. We all signed up to work here. But we also try to treat patients with concern and respect, and ask the same courtesy in return. Isn’t that the golden rule?

Abusive patients are difficult to deal with, time consuming, and contribute to staff burnout. The two awesome women who work here deserve better than that. If they’re not happy, I’m not happy. All it takes is one bad person to throw the day off kilter and sometimes affect the care of the next patient in line. That person deserves better, too.

Some will argue that, as a doctor, I should care for all who need my help. In the hospital, I do. I understand that people there generally are scared and hurting and do not want to be there. But in my office I expect at least some degree of civility. We have to be at our best for each person who comes in, and having patients we can work with on a polite level helps.

There’s enough insanity in this job on a good day. People who intentionally try to make it worse aren’t welcome in my little world.

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

I’ll put up with a lot in this practice, but I will not tolerate mistreatment of my staff.

ALLVISIONN/Thinkstock

Rudeness, while never pleasant, is generally tolerated. Some people just have that sort of personality. Others may be having a crappy day for unrelated reasons. We all have those.

But those who are intentionally abusive of my hardworking assistants aren’t going to get very far here. I have no problem telling them to go elsewhere. (This doesn’t include those with neurologic reasons for such behavior.)

Some doctors are more willing to put up with this than I am. I once shared space with one who routinely told his staff to ignore abusive behaviors. He didn’t want to turn away any potential revenue or risk angering a referring doctor.

I take another view. Life is short, and medical practice is, by nature, hectic. I have little enough time to care for the patients who genuinely appreciate what my staff and I are trying to do for them. People who are abusive and belligerent can find another doctor who’s willing to put up with it. I won’t.

My staff and I don’t expect to be thanked. We all signed up to work here. But we also try to treat patients with concern and respect, and ask the same courtesy in return. Isn’t that the golden rule?

Abusive patients are difficult to deal with, time consuming, and contribute to staff burnout. The two awesome women who work here deserve better than that. If they’re not happy, I’m not happy. All it takes is one bad person to throw the day off kilter and sometimes affect the care of the next patient in line. That person deserves better, too.

Some will argue that, as a doctor, I should care for all who need my help. In the hospital, I do. I understand that people there generally are scared and hurting and do not want to be there. But in my office I expect at least some degree of civility. We have to be at our best for each person who comes in, and having patients we can work with on a polite level helps.

There’s enough insanity in this job on a good day. People who intentionally try to make it worse aren’t welcome in my little world.

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

The image of inhaling the vapor from electronic cigarettes – vaping – is presented by some as an innocuous substitute to smoking traditional cigarettes. It is true that vaping might pose less danger than cigarettes and can wean people off smoking, vaping can be addictive and, consequently, tough to quit.

6okean/iStock/Getty Images

“Oh man, [withdrawal] was hell,” said Andrea “Nick” Tattanelli, a 39-year-old mortgage banker who reported engaging in vaping for more than 20 years, in a USA Today article. Mr. Tattanelli said quitting left him depressed.

Malissa M. Barbosa, DO, an addiction medicine specialist, wonders whether vaping is the best way to get patients to stop smoking. “The thing is, the studies aren’t fully available around vaping, and I’m very conservative. This is new, and I say, ‘Why aren’t we thinking of traditional means of quitting?’ ”

Vaping is more addictive than smoking traditional cigarettes “because the concentrated liquid form is more quickly metabolized,” said Dr. Barbosa, area medical director of CleanSlate Outpatient Addiction Medicine in Orlando.

And as the number of vapers grows, evidence is mounting that, rather than using it as a stepping stone to becoming nicotine-free, vaping is increasingly being used by adolescents as a form of delivering nicotine.

“We know how hard it is to quit smoking,” said Michael J. Blaha, MD, MPH, a cardiologist who serves as director of clinical research at the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins University, Baltimore. “[With vaping], we’re really dealing with much of the same problem. Early on, there were some reports vaping was less addictive, but that’s still something that can be debated.”

In the United States, vapers include nearly 4 million middle and high school students. Surgeon General Jerome M. Adams, MD, MPH, has suggested raising prices as a strategy aimed at curbing adolescent use.
 

Impact of gratitude on the brain

The beginning of a new year can be a time for reflection that can include a sense of gratitude for a relatively happy and secure life. And, according to an article at theconversation.com, the ability to have a sense of gratitude is good for well-being.

“Not only does gratitude go along with more optimism, less anxiety and depression, and greater goal attainment, but it’s also associated with fewer symptoms of illness and other physical benefits;” wrote Christina Karns, PhD, research associate in psychology at the University of Oregon, Portland.

A feeling of gratitude stimulates a part of the brain that controls the release of neurochemicals that confer pleasure. The benefits of gratitude aren’t just between the ears. Feeling gratitude can motivate people to pay it forward as altruistic behavior that helps others. Put another way, feeling good about life can trigger kindness.

Research by Dr. Karns and her colleagues also has demonstrated that this link between personal good feeling and altruism can be learned and accentuated. “So in terms of the brain’s reward response, it really can be true that giving is better than receiving,” wrote Dr. Karns, who also is affiliated with the Center for Brain Injury Research and Training at the university.

Imagine if the recipients of such goodwill, in turn, did some good for others, and they for others, and so on.
 

Did talk radio host save a life?

Talk radio can be filled with acrimony and argument – but it also can save lives. As reported in the Guardian, a show hosted by British TV and radio personality Iain Lee is different in that Mr. Lee sometimes connects with his audience by riffing on his own struggles with depression. A recent show extended the audience connection in a lifesaving way.

Mr. Lee received a call from a listener who reported overdosing on drugs with the intent of suicide. In hearing of that intent, Mr. Lee kept the caller on the line for 30 minutes. At one point, he responded: “Shut up, man, I know you want to die, brother, but I love you. I love you. You may want to die, but we can talk about that tomorrow.”

The response got through to the caller, who reportedly lay on the pavement outside a nightclub. Meanwhile, the call was being traced, and emergency medical personnel responded.

When Mr. Lee learned that the caller had been located and was still alive, he broke down on air. Later, he tweeted: “Tonight we took a call from a man who had taken an overdose … Long periods of silence where I thought he’d died. That was intense and upsetting. Thanks for your kind words. I really hope he makes it.”
 

A trip to Walmart can include therapy

A Walmart in Carrollton, Tex., is trying out a new service for customers: It is including an on-site mental health clinic. As reported by the Dallas Morning News, the idea is to make mental health care convenient and bring people who otherwise might forgo help through the clinic door.

“Twenty years ago, we would never imagine going to a retail location for a flu shot. You’d make an appointment with your primary care,” said Russell Petrella, chief executive of Beacon Health Options, which runs the in-store clinic. “The idea of bringing these services to places where consumers – potential patients – are more comfortable is getting more and more accepted.”

Initially, therapy was $25 for a 45-minute session with an individual or family. Prices will rise to $110 for an individual and $125 for a family early in this year. Lower prices are available for people who demonstrate a financial need.

The location for this trial run was deliberate. Texas has a disproportionately large number of residents without mental health care, ranking 49th in the nation, according to a 2018 report by Mental Health America.

Greg Hansch, public policy director of the National Alliance on Mental Illness in Texas, said he is encouraged by novel types of care like the Walmart clinic. He would like to see further integration of mental health care into schools, workplaces, and other retailers. “You remove some of that stigma if you can make services part of a person’s everyday routine,” he said.


 

Smartphones and the teenage brain

milindri/Thinkstock

The explosion in smartphone use since 2012 has coincided with increased rates of depression in adolescents. Reduced sleep might be one reason. Teenagers in the United States routinely rack up 6 hours a day on social media, which includes texting and other online activities. “For teens in particular, it’s catnip,” said Jean M. Twenge, PhD, professor of psychology at San Diego State University and author of “I-Gen: Why Today’s Super-Connected Kids Are Growing Up Less Rebellious, More Tolerant, Less Happy – and Completely Unprepared for Adulthood” (Atria Books, 2017).

A smartphone is no substitute for face-to-face interactions, and offers little training in verbal communication and problem solving. A consequence of a smartphone-connected youth, according to Dr. Twenge, could be worsened mental health.

But there is some good news. Some teens are working to curb their smartphone use. Stopping the use of a smartphone as a relief for boredom, setting self-imposed time limits of phone use, and not succumbing to the wired world’s tendency to ratchet up anxiety are helpful strategies that can make smartphone use more productive.

The image of inhaling the vapor from electronic cigarettes – vaping – is presented by some as an innocuous substitute to smoking traditional cigarettes. It is true that vaping might pose less danger than cigarettes and can wean people off smoking, vaping can be addictive and, consequently, tough to quit.

6okean/iStock/Getty Images

“Oh man, [withdrawal] was hell,” said Andrea “Nick” Tattanelli, a 39-year-old mortgage banker who reported engaging in vaping for more than 20 years, in a USA Today article. Mr. Tattanelli said quitting left him depressed.

Malissa M. Barbosa, DO, an addiction medicine specialist, wonders whether vaping is the best way to get patients to stop smoking. “The thing is, the studies aren’t fully available around vaping, and I’m very conservative. This is new, and I say, ‘Why aren’t we thinking of traditional means of quitting?’ ”

Vaping is more addictive than smoking traditional cigarettes “because the concentrated liquid form is more quickly metabolized,” said Dr. Barbosa, area medical director of CleanSlate Outpatient Addiction Medicine in Orlando.

And as the number of vapers grows, evidence is mounting that, rather than using it as a stepping stone to becoming nicotine-free, vaping is increasingly being used by adolescents as a form of delivering nicotine.

“We know how hard it is to quit smoking,” said Michael J. Blaha, MD, MPH, a cardiologist who serves as director of clinical research at the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins University, Baltimore. “[With vaping], we’re really dealing with much of the same problem. Early on, there were some reports vaping was less addictive, but that’s still something that can be debated.”

In the United States, vapers include nearly 4 million middle and high school students. Surgeon General Jerome M. Adams, MD, MPH, has suggested raising prices as a strategy aimed at curbing adolescent use.
 

Impact of gratitude on the brain

The beginning of a new year can be a time for reflection that can include a sense of gratitude for a relatively happy and secure life. And, according to an article at theconversation.com, the ability to have a sense of gratitude is good for well-being.

“Not only does gratitude go along with more optimism, less anxiety and depression, and greater goal attainment, but it’s also associated with fewer symptoms of illness and other physical benefits;” wrote Christina Karns, PhD, research associate in psychology at the University of Oregon, Portland.

A feeling of gratitude stimulates a part of the brain that controls the release of neurochemicals that confer pleasure. The benefits of gratitude aren’t just between the ears. Feeling gratitude can motivate people to pay it forward as altruistic behavior that helps others. Put another way, feeling good about life can trigger kindness.

Research by Dr. Karns and her colleagues also has demonstrated that this link between personal good feeling and altruism can be learned and accentuated. “So in terms of the brain’s reward response, it really can be true that giving is better than receiving,” wrote Dr. Karns, who also is affiliated with the Center for Brain Injury Research and Training at the university.

Imagine if the recipients of such goodwill, in turn, did some good for others, and they for others, and so on.
 

Did talk radio host save a life?

Talk radio can be filled with acrimony and argument – but it also can save lives. As reported in the Guardian, a show hosted by British TV and radio personality Iain Lee is different in that Mr. Lee sometimes connects with his audience by riffing on his own struggles with depression. A recent show extended the audience connection in a lifesaving way.

Mr. Lee received a call from a listener who reported overdosing on drugs with the intent of suicide. In hearing of that intent, Mr. Lee kept the caller on the line for 30 minutes. At one point, he responded: “Shut up, man, I know you want to die, brother, but I love you. I love you. You may want to die, but we can talk about that tomorrow.”

The response got through to the caller, who reportedly lay on the pavement outside a nightclub. Meanwhile, the call was being traced, and emergency medical personnel responded.

When Mr. Lee learned that the caller had been located and was still alive, he broke down on air. Later, he tweeted: “Tonight we took a call from a man who had taken an overdose … Long periods of silence where I thought he’d died. That was intense and upsetting. Thanks for your kind words. I really hope he makes it.”
 

A trip to Walmart can include therapy

A Walmart in Carrollton, Tex., is trying out a new service for customers: It is including an on-site mental health clinic. As reported by the Dallas Morning News, the idea is to make mental health care convenient and bring people who otherwise might forgo help through the clinic door.

“Twenty years ago, we would never imagine going to a retail location for a flu shot. You’d make an appointment with your primary care,” said Russell Petrella, chief executive of Beacon Health Options, which runs the in-store clinic. “The idea of bringing these services to places where consumers – potential patients – are more comfortable is getting more and more accepted.”

Initially, therapy was $25 for a 45-minute session with an individual or family. Prices will rise to $110 for an individual and $125 for a family early in this year. Lower prices are available for people who demonstrate a financial need.

The location for this trial run was deliberate. Texas has a disproportionately large number of residents without mental health care, ranking 49th in the nation, according to a 2018 report by Mental Health America.

Greg Hansch, public policy director of the National Alliance on Mental Illness in Texas, said he is encouraged by novel types of care like the Walmart clinic. He would like to see further integration of mental health care into schools, workplaces, and other retailers. “You remove some of that stigma if you can make services part of a person’s everyday routine,” he said.


 

Smartphones and the teenage brain

milindri/Thinkstock

The explosion in smartphone use since 2012 has coincided with increased rates of depression in adolescents. Reduced sleep might be one reason. Teenagers in the United States routinely rack up 6 hours a day on social media, which includes texting and other online activities. “For teens in particular, it’s catnip,” said Jean M. Twenge, PhD, professor of psychology at San Diego State University and author of “I-Gen: Why Today’s Super-Connected Kids Are Growing Up Less Rebellious, More Tolerant, Less Happy – and Completely Unprepared for Adulthood” (Atria Books, 2017).

A smartphone is no substitute for face-to-face interactions, and offers little training in verbal communication and problem solving. A consequence of a smartphone-connected youth, according to Dr. Twenge, could be worsened mental health.

But there is some good news. Some teens are working to curb their smartphone use. Stopping the use of a smartphone as a relief for boredom, setting self-imposed time limits of phone use, and not succumbing to the wired world’s tendency to ratchet up anxiety are helpful strategies that can make smartphone use more productive.

The image of inhaling the vapor from electronic cigarettes – vaping – is presented by some as an innocuous substitute to smoking traditional cigarettes. It is true that vaping might pose less danger than cigarettes and can wean people off smoking, vaping can be addictive and, consequently, tough to quit.

6okean/iStock/Getty Images

“Oh man, [withdrawal] was hell,” said Andrea “Nick” Tattanelli, a 39-year-old mortgage banker who reported engaging in vaping for more than 20 years, in a USA Today article. Mr. Tattanelli said quitting left him depressed.

Malissa M. Barbosa, DO, an addiction medicine specialist, wonders whether vaping is the best way to get patients to stop smoking. “The thing is, the studies aren’t fully available around vaping, and I’m very conservative. This is new, and I say, ‘Why aren’t we thinking of traditional means of quitting?’ ”

Vaping is more addictive than smoking traditional cigarettes “because the concentrated liquid form is more quickly metabolized,” said Dr. Barbosa, area medical director of CleanSlate Outpatient Addiction Medicine in Orlando.

And as the number of vapers grows, evidence is mounting that, rather than using it as a stepping stone to becoming nicotine-free, vaping is increasingly being used by adolescents as a form of delivering nicotine.

“We know how hard it is to quit smoking,” said Michael J. Blaha, MD, MPH, a cardiologist who serves as director of clinical research at the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins University, Baltimore. “[With vaping], we’re really dealing with much of the same problem. Early on, there were some reports vaping was less addictive, but that’s still something that can be debated.”

In the United States, vapers include nearly 4 million middle and high school students. Surgeon General Jerome M. Adams, MD, MPH, has suggested raising prices as a strategy aimed at curbing adolescent use.
 

Impact of gratitude on the brain

The beginning of a new year can be a time for reflection that can include a sense of gratitude for a relatively happy and secure life. And, according to an article at theconversation.com, the ability to have a sense of gratitude is good for well-being.

“Not only does gratitude go along with more optimism, less anxiety and depression, and greater goal attainment, but it’s also associated with fewer symptoms of illness and other physical benefits;” wrote Christina Karns, PhD, research associate in psychology at the University of Oregon, Portland.

A feeling of gratitude stimulates a part of the brain that controls the release of neurochemicals that confer pleasure. The benefits of gratitude aren’t just between the ears. Feeling gratitude can motivate people to pay it forward as altruistic behavior that helps others. Put another way, feeling good about life can trigger kindness.

Research by Dr. Karns and her colleagues also has demonstrated that this link between personal good feeling and altruism can be learned and accentuated. “So in terms of the brain’s reward response, it really can be true that giving is better than receiving,” wrote Dr. Karns, who also is affiliated with the Center for Brain Injury Research and Training at the university.

Imagine if the recipients of such goodwill, in turn, did some good for others, and they for others, and so on.
 

Did talk radio host save a life?

Talk radio can be filled with acrimony and argument – but it also can save lives. As reported in the Guardian, a show hosted by British TV and radio personality Iain Lee is different in that Mr. Lee sometimes connects with his audience by riffing on his own struggles with depression. A recent show extended the audience connection in a lifesaving way.

Mr. Lee received a call from a listener who reported overdosing on drugs with the intent of suicide. In hearing of that intent, Mr. Lee kept the caller on the line for 30 minutes. At one point, he responded: “Shut up, man, I know you want to die, brother, but I love you. I love you. You may want to die, but we can talk about that tomorrow.”

The response got through to the caller, who reportedly lay on the pavement outside a nightclub. Meanwhile, the call was being traced, and emergency medical personnel responded.

When Mr. Lee learned that the caller had been located and was still alive, he broke down on air. Later, he tweeted: “Tonight we took a call from a man who had taken an overdose … Long periods of silence where I thought he’d died. That was intense and upsetting. Thanks for your kind words. I really hope he makes it.”
 

A trip to Walmart can include therapy

A Walmart in Carrollton, Tex., is trying out a new service for customers: It is including an on-site mental health clinic. As reported by the Dallas Morning News, the idea is to make mental health care convenient and bring people who otherwise might forgo help through the clinic door.

“Twenty years ago, we would never imagine going to a retail location for a flu shot. You’d make an appointment with your primary care,” said Russell Petrella, chief executive of Beacon Health Options, which runs the in-store clinic. “The idea of bringing these services to places where consumers – potential patients – are more comfortable is getting more and more accepted.”

Initially, therapy was $25 for a 45-minute session with an individual or family. Prices will rise to $110 for an individual and $125 for a family early in this year. Lower prices are available for people who demonstrate a financial need.

The location for this trial run was deliberate. Texas has a disproportionately large number of residents without mental health care, ranking 49th in the nation, according to a 2018 report by Mental Health America.

Greg Hansch, public policy director of the National Alliance on Mental Illness in Texas, said he is encouraged by novel types of care like the Walmart clinic. He would like to see further integration of mental health care into schools, workplaces, and other retailers. “You remove some of that stigma if you can make services part of a person’s everyday routine,” he said.


 

Smartphones and the teenage brain

milindri/Thinkstock

The explosion in smartphone use since 2012 has coincided with increased rates of depression in adolescents. Reduced sleep might be one reason. Teenagers in the United States routinely rack up 6 hours a day on social media, which includes texting and other online activities. “For teens in particular, it’s catnip,” said Jean M. Twenge, PhD, professor of psychology at San Diego State University and author of “I-Gen: Why Today’s Super-Connected Kids Are Growing Up Less Rebellious, More Tolerant, Less Happy – and Completely Unprepared for Adulthood” (Atria Books, 2017).

A smartphone is no substitute for face-to-face interactions, and offers little training in verbal communication and problem solving. A consequence of a smartphone-connected youth, according to Dr. Twenge, could be worsened mental health.

But there is some good news. Some teens are working to curb their smartphone use. Stopping the use of a smartphone as a relief for boredom, setting self-imposed time limits of phone use, and not succumbing to the wired world’s tendency to ratchet up anxiety are helpful strategies that can make smartphone use more productive.

Every surgeon has experienced the anguish of an adverse outcome. The elective aneurysm that dies on the table, the asymptomatic carotid patient that has a stroke in the recovery room, the cosmetic varicose vein case that has a pulmonary embolus. Driving home alone, we tell ourselves that we did our “best,” but lingering in the dark shadows of our minds are the nagging questions: What should I have done differently? Am I really a safe surgeon? Should I quit and get a job with “industry”? What if I get sued? How should I deal with the family? Will I get fired?

Our houses are dark when we arrive home. We sit alone in living rooms silently mulling over the events of the day. Our spouses have seen this before and will offer sincere consolation, but will never really know how it feels. So we do what surgeons are trained to do – we suck it up and hide our feelings. As the Brits say: “Keep calm and carry on!”

A few years ago, I operated on a young woman with suspected median arcuate ligament syndrome. She had experienced temporary improvement after laparoscopic release of the median arcuate ligament at an outside hospital, but her symptoms returned after a few months.

Initially, I attempted to place a stent in the celiac artery from the groin but failed to establish a stable access sheath. Rather than choosing a brachial approach, I recommended open repair. The next day in the operating room, I was surprised to find a distinct blue tint to the adventitia of the celiac and hepatic arteries typical of dissection. After opening the common hepatic artery, I discovered that the dissection continued well into the bifurcation of the proper hepatic artery, forcing me to clamp the gastroduodenal artery, the primary collateral pathway to the liver. Within minutes, the liver turned a nauseating purple black.

I urgently constructed an aorto-hepatic bypass with vein using 8-0 suture to try to tack the dissection flap into place distally. I tried to ignore the dire appearance of the liver as I worked, but I was fearful that my distal anastomosis would be inadequate. When I took off the clamps, the liver improved slightly but remained bruised. The finding of a Doppler signal distal to my anastomosis gave me some hope but I remained fearful about the viability of the liver.

Postop, I found her husband in the waiting room with two small children. I explained the potentially catastrophic circumstances and prepared him for the possibility that she might need a liver transplant! He was stunned and angry but mostly silent. Her liver function tests (LFTs) deteriorated over the next 3 days, leaving me depressed, anxious, and sleepless. I hated making rounds on her. Her husband was invariably lying on a couch in her room, pictures of her children taped to her headboard. I reached out to hepatology and transplant surgery hoping for some encouragement. My partners patted me on the back and reminded me that they’d all been in similar binds. I swore to myself that I’d never do another operation on a patient with median arcuate ligament syndrome.

On the morning of the fourth postop day, her LFTs miraculously reversed course and she made an uneventful recovery. But I was scarred. To this day, when I see the diagnosis of median arcuate ligament syndrome on a chart in the office, I shudder. I remember the color of her liver – like the deep blackness of the abyss.

Some patients leave a scar on you. But how we, as surgeons, deal with adversity is largely unknown. Each of us has to discover through trial and error the most effective way to respond to unwanted outcomes. We model ourselves after our teachers, mentors, and chief residents. Some of us have enlightened, sympathetic partners to turn to for consolation, advice, and “competent critique.” But others may be isolated in solo practice or in shared-expense practice models where “partners” may actually be competitors.

John F Eidt, MD, is a vascular surgeon at Baylor Scott & White Heart and Vascular Hospital, Dallas.

Every surgeon has experienced the anguish of an adverse outcome. The elective aneurysm that dies on the table, the asymptomatic carotid patient that has a stroke in the recovery room, the cosmetic varicose vein case that has a pulmonary embolus. Driving home alone, we tell ourselves that we did our “best,” but lingering in the dark shadows of our minds are the nagging questions: What should I have done differently? Am I really a safe surgeon? Should I quit and get a job with “industry”? What if I get sued? How should I deal with the family? Will I get fired?

Our houses are dark when we arrive home. We sit alone in living rooms silently mulling over the events of the day. Our spouses have seen this before and will offer sincere consolation, but will never really know how it feels. So we do what surgeons are trained to do – we suck it up and hide our feelings. As the Brits say: “Keep calm and carry on!”

A few years ago, I operated on a young woman with suspected median arcuate ligament syndrome. She had experienced temporary improvement after laparoscopic release of the median arcuate ligament at an outside hospital, but her symptoms returned after a few months.

Initially, I attempted to place a stent in the celiac artery from the groin but failed to establish a stable access sheath. Rather than choosing a brachial approach, I recommended open repair. The next day in the operating room, I was surprised to find a distinct blue tint to the adventitia of the celiac and hepatic arteries typical of dissection. After opening the common hepatic artery, I discovered that the dissection continued well into the bifurcation of the proper hepatic artery, forcing me to clamp the gastroduodenal artery, the primary collateral pathway to the liver. Within minutes, the liver turned a nauseating purple black.

I urgently constructed an aorto-hepatic bypass with vein using 8-0 suture to try to tack the dissection flap into place distally. I tried to ignore the dire appearance of the liver as I worked, but I was fearful that my distal anastomosis would be inadequate. When I took off the clamps, the liver improved slightly but remained bruised. The finding of a Doppler signal distal to my anastomosis gave me some hope but I remained fearful about the viability of the liver.

Postop, I found her husband in the waiting room with two small children. I explained the potentially catastrophic circumstances and prepared him for the possibility that she might need a liver transplant! He was stunned and angry but mostly silent. Her liver function tests (LFTs) deteriorated over the next 3 days, leaving me depressed, anxious, and sleepless. I hated making rounds on her. Her husband was invariably lying on a couch in her room, pictures of her children taped to her headboard. I reached out to hepatology and transplant surgery hoping for some encouragement. My partners patted me on the back and reminded me that they’d all been in similar binds. I swore to myself that I’d never do another operation on a patient with median arcuate ligament syndrome.

On the morning of the fourth postop day, her LFTs miraculously reversed course and she made an uneventful recovery. But I was scarred. To this day, when I see the diagnosis of median arcuate ligament syndrome on a chart in the office, I shudder. I remember the color of her liver – like the deep blackness of the abyss.

Some patients leave a scar on you. But how we, as surgeons, deal with adversity is largely unknown. Each of us has to discover through trial and error the most effective way to respond to unwanted outcomes. We model ourselves after our teachers, mentors, and chief residents. Some of us have enlightened, sympathetic partners to turn to for consolation, advice, and “competent critique.” But others may be isolated in solo practice or in shared-expense practice models where “partners” may actually be competitors.

John F Eidt, MD, is a vascular surgeon at Baylor Scott & White Heart and Vascular Hospital, Dallas.

Every surgeon has experienced the anguish of an adverse outcome. The elective aneurysm that dies on the table, the asymptomatic carotid patient that has a stroke in the recovery room, the cosmetic varicose vein case that has a pulmonary embolus. Driving home alone, we tell ourselves that we did our “best,” but lingering in the dark shadows of our minds are the nagging questions: What should I have done differently? Am I really a safe surgeon? Should I quit and get a job with “industry”? What if I get sued? How should I deal with the family? Will I get fired?

Our houses are dark when we arrive home. We sit alone in living rooms silently mulling over the events of the day. Our spouses have seen this before and will offer sincere consolation, but will never really know how it feels. So we do what surgeons are trained to do – we suck it up and hide our feelings. As the Brits say: “Keep calm and carry on!”

A few years ago, I operated on a young woman with suspected median arcuate ligament syndrome. She had experienced temporary improvement after laparoscopic release of the median arcuate ligament at an outside hospital, but her symptoms returned after a few months.

Initially, I attempted to place a stent in the celiac artery from the groin but failed to establish a stable access sheath. Rather than choosing a brachial approach, I recommended open repair. The next day in the operating room, I was surprised to find a distinct blue tint to the adventitia of the celiac and hepatic arteries typical of dissection. After opening the common hepatic artery, I discovered that the dissection continued well into the bifurcation of the proper hepatic artery, forcing me to clamp the gastroduodenal artery, the primary collateral pathway to the liver. Within minutes, the liver turned a nauseating purple black.

I urgently constructed an aorto-hepatic bypass with vein using 8-0 suture to try to tack the dissection flap into place distally. I tried to ignore the dire appearance of the liver as I worked, but I was fearful that my distal anastomosis would be inadequate. When I took off the clamps, the liver improved slightly but remained bruised. The finding of a Doppler signal distal to my anastomosis gave me some hope but I remained fearful about the viability of the liver.

Postop, I found her husband in the waiting room with two small children. I explained the potentially catastrophic circumstances and prepared him for the possibility that she might need a liver transplant! He was stunned and angry but mostly silent. Her liver function tests (LFTs) deteriorated over the next 3 days, leaving me depressed, anxious, and sleepless. I hated making rounds on her. Her husband was invariably lying on a couch in her room, pictures of her children taped to her headboard. I reached out to hepatology and transplant surgery hoping for some encouragement. My partners patted me on the back and reminded me that they’d all been in similar binds. I swore to myself that I’d never do another operation on a patient with median arcuate ligament syndrome.

On the morning of the fourth postop day, her LFTs miraculously reversed course and she made an uneventful recovery. But I was scarred. To this day, when I see the diagnosis of median arcuate ligament syndrome on a chart in the office, I shudder. I remember the color of her liver – like the deep blackness of the abyss.

Some patients leave a scar on you. But how we, as surgeons, deal with adversity is largely unknown. Each of us has to discover through trial and error the most effective way to respond to unwanted outcomes. We model ourselves after our teachers, mentors, and chief residents. Some of us have enlightened, sympathetic partners to turn to for consolation, advice, and “competent critique.” But others may be isolated in solo practice or in shared-expense practice models where “partners” may actually be competitors.

John F Eidt, MD, is a vascular surgeon at Baylor Scott & White Heart and Vascular Hospital, Dallas.