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Puerto Rico after Maria: Trauma team returns
Ten months after Hurricane Maria pummeled into the island of Puerto Rico, things have begun to get better.
Despite some signs of recovery, mental – and physical – health problems are ongoing. The official death toll was recorded at 64, but a recent study by the Harvard School of Public Health estimates that it is closer to 5,000 (N Engl J Med. 2018 May 28. doi: 10.1056/NEJMsa1803972). Some reports show that the suicide rate on the island has soared by nearly 30%. Other reports show that unemployment has increased as has crime, and some estimates show that up to 200,000 people have left the island. As of this writing, thousands of people still are without power. And the hurricane season has begun yet again.
Week-long training gets underway
A few weeks ago, I joined a team of mental health professionals affiliated with the International Center for Psychosocial Trauma at the University of Missouri–Columbia (UMICPT) that went to Puerto Rico for a week. Under the leadership of UMICPT founder Syed Arshad Husain, MD, our goals were train our colleagues and teachers how to help children suffering from posttraumatic stress disorder after Maria. Several months earlier, our team had traveled to the island to train doctors, psychologists, social workers, and other mental health workers in San Juan and Ponce, and we were eager to return to continue our work.
Carlos Sellas, PsyD, a faculty member and supervisor of child and adolescent mental health clinics at Ponce Health Sciences University, attended the training. Dr. Sellas reported that somatic symptoms among the children had escalated after the hurricane. One child, whose grandfather suffered a myocardial infarction after Maria, repeatedly complains of chest pain. Pseudoseizures also have been observed.
Dr. Sellas said he also is seeing increased suicidal ideation and behavior in children and adolescents. In addition, some children are reporting auditory and visual hallucinations, and phobic reaction to rainstorms and lightening – in addition to fears of the dark.
Regressive behaviors cited
Laura Deliz, PsyD, director of the Autism Center at Ponce Health Sciences University, also attended the training. She reported that some of the autistic children under her care are manifesting regressive behaviors and are losing learned skills. They are more insecure, cling to transitional objects, and complain of pains, sleep problems, and show signs of having eating disorders. “Little things bother them more,” Dr. Deliz said. They cry more frequently, display more problems with concentration and attention, and are having more tantrums.
Comorbid with PTSD, symptoms of depression, anxiety disorders, conduct disorders, attention deficit disorders, and substance use disorders also are being encountered. Substance abuse more often is a comorbid condition in adolescents, but clinicians also are seeing this in children. Impulsive behaviors, self-destructive behaviors, and feelings of guilt also are being observed.
Compassion fatigue
Many trainees also are reporting symptoms of secondary traumatization and compassion fatigue. One trainee who lives in a mountain area had no electricity until 3 weeks before the training. Access to clean water has been sporadic, because power is required to pump the water.
Efforts to obtain gasoline has entailed waiting in line for 5 hours, sometimes only to have the supply run out upon reaching the pump. Puerto Rico continues to experience rolling blackouts. The island’s power company has lacked the proper materials to fix the problems. The elderly seem to be the main victims of this failing. Many of the elderly in the mountain areas, for example, still have no clean drinking water or electricity. Many of them live alone, and the churches are trying to help them.
Another trainee from the north coast, where the primary source of work is the dairy industry, reported that, when the power went off, the electric fences failed – and the cows wandered. Many became ill and died. An entire herd perished when an electric wire fell into nearby water.
Meanwhile, another trainee reported seeing a lot of anxiety and fear in the faces of the people waiting in long lines in the supermarkets trying to buy water, food that did not require refrigeration or cooking, and among people waiting in long lines at gas stations. Some people were sociable and supportive to one another; others were encouraging and telling stories. But there also were reports of fights breaking out. People were feeling frustrated because they could not get their basic needs met.
Among the adults, according to one observer, a sense of hopelessness and sadness prevailed. In the first weeks after the hurricane, just trying to communicate with other family members was a struggle because of the absence of cell phone service. In some ways, the children seemed more resilient, because they still managed to find ways to engage in play.
Compassion fatigue also is being experienced by many of the teachers on the island, our team learned. Many of them do not know whether they will have jobs at the beginning of the new school year. The public education system, already hit hard by a decade-long recession that preceded Maria, remains challenged. Of the 1,113 public schools, only 828 will remain operational, according to the Orlando Sentinel. Meanwhile, the psychosocial environment in many of the schools is not healthy, “not when you have students who are hungry and emotionally hurting,” according to one of our students.
UMICPT curriculum
When our team travels to a traumatized area, we use the model of “training the trainers.” We teach local mental health professionals and teachers how to recognize some of the negative sequelae of trauma in children, including PTSD, complex traumatic grief, depression, and phobias. It is our aim to train them, so they can train others to recognize these conditions, and provide evidence-based interventions, which in turn can help to alleviate symptoms and promote healing.
Our students already have some training in mental health. We seek to use their training and their experiences in our exercises. They learn from us, and we also learn much from them. When they share their experiences with us, we learn about their cultural values, which in turn enables us to provide culturally sensitive training. Skills for recovering from trauma include psychoeducation, relaxation and visualization training, dialectical behavioral therapy strategies for stress reduction, art therapy, narrative therapy, mindfulness training, and group therapy.
Future plans
UMICPT plans to make two more trips to Puerto Rico. A group of trainees will be further trained to serve as trainers to others in some of the techniques they have been taught. There is a plan to conduct a needs assessment in the schools and train teachers during the visit. Trained teachers would then have the option of introducing a weekly mental hygiene hour into the schools, with the aim of providing some relief to the children suffering from PTSD and other psychiatric problems.
Judith R. Milner, MD, MEd, SpecEd, is a general, child, and adolescent psychiatrist in private practice in Everett, Wash. She has traveled with various groups over the years in an effort to alleviate some of the suffering caused by war and natural disaster. Her predominant association has been with the International Center for Psychosocial Trauma. She also has worked with Step Up Rwanda Women and Pygmy Survival Alliance, as well as on the Committee for Women at the American Psychiatric Association and the Consumer Issues Committee, the Committee on Diversity and Culture, and the Membership Committee for the American Academy of Child and Adolescent Psychiatry.
Ten months after Hurricane Maria pummeled into the island of Puerto Rico, things have begun to get better.
Despite some signs of recovery, mental – and physical – health problems are ongoing. The official death toll was recorded at 64, but a recent study by the Harvard School of Public Health estimates that it is closer to 5,000 (N Engl J Med. 2018 May 28. doi: 10.1056/NEJMsa1803972). Some reports show that the suicide rate on the island has soared by nearly 30%. Other reports show that unemployment has increased as has crime, and some estimates show that up to 200,000 people have left the island. As of this writing, thousands of people still are without power. And the hurricane season has begun yet again.
Week-long training gets underway
A few weeks ago, I joined a team of mental health professionals affiliated with the International Center for Psychosocial Trauma at the University of Missouri–Columbia (UMICPT) that went to Puerto Rico for a week. Under the leadership of UMICPT founder Syed Arshad Husain, MD, our goals were train our colleagues and teachers how to help children suffering from posttraumatic stress disorder after Maria. Several months earlier, our team had traveled to the island to train doctors, psychologists, social workers, and other mental health workers in San Juan and Ponce, and we were eager to return to continue our work.
Carlos Sellas, PsyD, a faculty member and supervisor of child and adolescent mental health clinics at Ponce Health Sciences University, attended the training. Dr. Sellas reported that somatic symptoms among the children had escalated after the hurricane. One child, whose grandfather suffered a myocardial infarction after Maria, repeatedly complains of chest pain. Pseudoseizures also have been observed.
Dr. Sellas said he also is seeing increased suicidal ideation and behavior in children and adolescents. In addition, some children are reporting auditory and visual hallucinations, and phobic reaction to rainstorms and lightening – in addition to fears of the dark.
Regressive behaviors cited
Laura Deliz, PsyD, director of the Autism Center at Ponce Health Sciences University, also attended the training. She reported that some of the autistic children under her care are manifesting regressive behaviors and are losing learned skills. They are more insecure, cling to transitional objects, and complain of pains, sleep problems, and show signs of having eating disorders. “Little things bother them more,” Dr. Deliz said. They cry more frequently, display more problems with concentration and attention, and are having more tantrums.
Comorbid with PTSD, symptoms of depression, anxiety disorders, conduct disorders, attention deficit disorders, and substance use disorders also are being encountered. Substance abuse more often is a comorbid condition in adolescents, but clinicians also are seeing this in children. Impulsive behaviors, self-destructive behaviors, and feelings of guilt also are being observed.
Compassion fatigue
Many trainees also are reporting symptoms of secondary traumatization and compassion fatigue. One trainee who lives in a mountain area had no electricity until 3 weeks before the training. Access to clean water has been sporadic, because power is required to pump the water.
Efforts to obtain gasoline has entailed waiting in line for 5 hours, sometimes only to have the supply run out upon reaching the pump. Puerto Rico continues to experience rolling blackouts. The island’s power company has lacked the proper materials to fix the problems. The elderly seem to be the main victims of this failing. Many of the elderly in the mountain areas, for example, still have no clean drinking water or electricity. Many of them live alone, and the churches are trying to help them.
Another trainee from the north coast, where the primary source of work is the dairy industry, reported that, when the power went off, the electric fences failed – and the cows wandered. Many became ill and died. An entire herd perished when an electric wire fell into nearby water.
Meanwhile, another trainee reported seeing a lot of anxiety and fear in the faces of the people waiting in long lines in the supermarkets trying to buy water, food that did not require refrigeration or cooking, and among people waiting in long lines at gas stations. Some people were sociable and supportive to one another; others were encouraging and telling stories. But there also were reports of fights breaking out. People were feeling frustrated because they could not get their basic needs met.
Among the adults, according to one observer, a sense of hopelessness and sadness prevailed. In the first weeks after the hurricane, just trying to communicate with other family members was a struggle because of the absence of cell phone service. In some ways, the children seemed more resilient, because they still managed to find ways to engage in play.
Compassion fatigue also is being experienced by many of the teachers on the island, our team learned. Many of them do not know whether they will have jobs at the beginning of the new school year. The public education system, already hit hard by a decade-long recession that preceded Maria, remains challenged. Of the 1,113 public schools, only 828 will remain operational, according to the Orlando Sentinel. Meanwhile, the psychosocial environment in many of the schools is not healthy, “not when you have students who are hungry and emotionally hurting,” according to one of our students.
UMICPT curriculum
When our team travels to a traumatized area, we use the model of “training the trainers.” We teach local mental health professionals and teachers how to recognize some of the negative sequelae of trauma in children, including PTSD, complex traumatic grief, depression, and phobias. It is our aim to train them, so they can train others to recognize these conditions, and provide evidence-based interventions, which in turn can help to alleviate symptoms and promote healing.
Our students already have some training in mental health. We seek to use their training and their experiences in our exercises. They learn from us, and we also learn much from them. When they share their experiences with us, we learn about their cultural values, which in turn enables us to provide culturally sensitive training. Skills for recovering from trauma include psychoeducation, relaxation and visualization training, dialectical behavioral therapy strategies for stress reduction, art therapy, narrative therapy, mindfulness training, and group therapy.
Future plans
UMICPT plans to make two more trips to Puerto Rico. A group of trainees will be further trained to serve as trainers to others in some of the techniques they have been taught. There is a plan to conduct a needs assessment in the schools and train teachers during the visit. Trained teachers would then have the option of introducing a weekly mental hygiene hour into the schools, with the aim of providing some relief to the children suffering from PTSD and other psychiatric problems.
Judith R. Milner, MD, MEd, SpecEd, is a general, child, and adolescent psychiatrist in private practice in Everett, Wash. She has traveled with various groups over the years in an effort to alleviate some of the suffering caused by war and natural disaster. Her predominant association has been with the International Center for Psychosocial Trauma. She also has worked with Step Up Rwanda Women and Pygmy Survival Alliance, as well as on the Committee for Women at the American Psychiatric Association and the Consumer Issues Committee, the Committee on Diversity and Culture, and the Membership Committee for the American Academy of Child and Adolescent Psychiatry.
Ten months after Hurricane Maria pummeled into the island of Puerto Rico, things have begun to get better.
Despite some signs of recovery, mental – and physical – health problems are ongoing. The official death toll was recorded at 64, but a recent study by the Harvard School of Public Health estimates that it is closer to 5,000 (N Engl J Med. 2018 May 28. doi: 10.1056/NEJMsa1803972). Some reports show that the suicide rate on the island has soared by nearly 30%. Other reports show that unemployment has increased as has crime, and some estimates show that up to 200,000 people have left the island. As of this writing, thousands of people still are without power. And the hurricane season has begun yet again.
Week-long training gets underway
A few weeks ago, I joined a team of mental health professionals affiliated with the International Center for Psychosocial Trauma at the University of Missouri–Columbia (UMICPT) that went to Puerto Rico for a week. Under the leadership of UMICPT founder Syed Arshad Husain, MD, our goals were train our colleagues and teachers how to help children suffering from posttraumatic stress disorder after Maria. Several months earlier, our team had traveled to the island to train doctors, psychologists, social workers, and other mental health workers in San Juan and Ponce, and we were eager to return to continue our work.
Carlos Sellas, PsyD, a faculty member and supervisor of child and adolescent mental health clinics at Ponce Health Sciences University, attended the training. Dr. Sellas reported that somatic symptoms among the children had escalated after the hurricane. One child, whose grandfather suffered a myocardial infarction after Maria, repeatedly complains of chest pain. Pseudoseizures also have been observed.
Dr. Sellas said he also is seeing increased suicidal ideation and behavior in children and adolescents. In addition, some children are reporting auditory and visual hallucinations, and phobic reaction to rainstorms and lightening – in addition to fears of the dark.
Regressive behaviors cited
Laura Deliz, PsyD, director of the Autism Center at Ponce Health Sciences University, also attended the training. She reported that some of the autistic children under her care are manifesting regressive behaviors and are losing learned skills. They are more insecure, cling to transitional objects, and complain of pains, sleep problems, and show signs of having eating disorders. “Little things bother them more,” Dr. Deliz said. They cry more frequently, display more problems with concentration and attention, and are having more tantrums.
Comorbid with PTSD, symptoms of depression, anxiety disorders, conduct disorders, attention deficit disorders, and substance use disorders also are being encountered. Substance abuse more often is a comorbid condition in adolescents, but clinicians also are seeing this in children. Impulsive behaviors, self-destructive behaviors, and feelings of guilt also are being observed.
Compassion fatigue
Many trainees also are reporting symptoms of secondary traumatization and compassion fatigue. One trainee who lives in a mountain area had no electricity until 3 weeks before the training. Access to clean water has been sporadic, because power is required to pump the water.
Efforts to obtain gasoline has entailed waiting in line for 5 hours, sometimes only to have the supply run out upon reaching the pump. Puerto Rico continues to experience rolling blackouts. The island’s power company has lacked the proper materials to fix the problems. The elderly seem to be the main victims of this failing. Many of the elderly in the mountain areas, for example, still have no clean drinking water or electricity. Many of them live alone, and the churches are trying to help them.
Another trainee from the north coast, where the primary source of work is the dairy industry, reported that, when the power went off, the electric fences failed – and the cows wandered. Many became ill and died. An entire herd perished when an electric wire fell into nearby water.
Meanwhile, another trainee reported seeing a lot of anxiety and fear in the faces of the people waiting in long lines in the supermarkets trying to buy water, food that did not require refrigeration or cooking, and among people waiting in long lines at gas stations. Some people were sociable and supportive to one another; others were encouraging and telling stories. But there also were reports of fights breaking out. People were feeling frustrated because they could not get their basic needs met.
Among the adults, according to one observer, a sense of hopelessness and sadness prevailed. In the first weeks after the hurricane, just trying to communicate with other family members was a struggle because of the absence of cell phone service. In some ways, the children seemed more resilient, because they still managed to find ways to engage in play.
Compassion fatigue also is being experienced by many of the teachers on the island, our team learned. Many of them do not know whether they will have jobs at the beginning of the new school year. The public education system, already hit hard by a decade-long recession that preceded Maria, remains challenged. Of the 1,113 public schools, only 828 will remain operational, according to the Orlando Sentinel. Meanwhile, the psychosocial environment in many of the schools is not healthy, “not when you have students who are hungry and emotionally hurting,” according to one of our students.
UMICPT curriculum
When our team travels to a traumatized area, we use the model of “training the trainers.” We teach local mental health professionals and teachers how to recognize some of the negative sequelae of trauma in children, including PTSD, complex traumatic grief, depression, and phobias. It is our aim to train them, so they can train others to recognize these conditions, and provide evidence-based interventions, which in turn can help to alleviate symptoms and promote healing.
Our students already have some training in mental health. We seek to use their training and their experiences in our exercises. They learn from us, and we also learn much from them. When they share their experiences with us, we learn about their cultural values, which in turn enables us to provide culturally sensitive training. Skills for recovering from trauma include psychoeducation, relaxation and visualization training, dialectical behavioral therapy strategies for stress reduction, art therapy, narrative therapy, mindfulness training, and group therapy.
Future plans
UMICPT plans to make two more trips to Puerto Rico. A group of trainees will be further trained to serve as trainers to others in some of the techniques they have been taught. There is a plan to conduct a needs assessment in the schools and train teachers during the visit. Trained teachers would then have the option of introducing a weekly mental hygiene hour into the schools, with the aim of providing some relief to the children suffering from PTSD and other psychiatric problems.
Judith R. Milner, MD, MEd, SpecEd, is a general, child, and adolescent psychiatrist in private practice in Everett, Wash. She has traveled with various groups over the years in an effort to alleviate some of the suffering caused by war and natural disaster. Her predominant association has been with the International Center for Psychosocial Trauma. She also has worked with Step Up Rwanda Women and Pygmy Survival Alliance, as well as on the Committee for Women at the American Psychiatric Association and the Consumer Issues Committee, the Committee on Diversity and Culture, and the Membership Committee for the American Academy of Child and Adolescent Psychiatry.
Fish pedicures
A letter published in JAMA Dermatology describes an otherwise healthy woman in her 20s who experienced nail abnormalities some months after having a fish pedicure. Onychomadesis, or transverse splitting of the nail plate, occurs when the nail matrix has arrested in producing the nail plate. It can be thought of as more severe form of Beau’s lines, in which the nail itself actually breaks and separates from the proximal nail plate and eventually sheds.
Fish pedicures have a long-standing history in Mediterranean and Middle Eastern cultures for aiding such skin conditions as psoriasis and helping to remove scaly skin. The Garra rufa fish are nonmigratory freshwater fish native to the Persian Gulf and Eastern Mediterranean. Suction allows them to attach to rocks and eat plankton. These “doctor fish,” as they are nicknamed, when placed in a warm bath of 25°C to 30°C, will also eat human skin when starved of their natural food source. As the JAMA Dermatology letter mentions, this was demonstrated in a study in Kangal, Turkey, where Garra rufa fish were used to improve psoriasis by feeding on psoriasis plaques but not normal skin. After 3 weeks of therapy with Garra rufa in 67 patients, there was a 72% reduction in the Psoriasis Area and Severity Index (PASI) score from baseline (Evid Based Complement Alternat Med. 2006 Dec;3[4]:483-8).
Popular in the United States and Europe about a decade ago, fish pedicures have now been banned in 10 U.S. states and in some parts of Europe. While the trend in the United States has waned, fish pedicures have recently become more popular in vacation destinations, such as the Caribbean. The inherent concern of fish pedicures is risk of infection as the same fish are used successively and cannot be adequately sanitized between people.
Two cases of staphylococcus infections and one of Mycobacterium marinum have been reported after fish pedicures. Whether these infections were caused by the fish or the water source, however, remains to be determined. If the fish were transmitting infections, it seems that more infections would likely have been reported, considering the widespread popularity in the past. I, like Antonella Tosti, MD, who commented in a CNN report on the JAMA Dermatology case, also doubt that the fish pedicure alone caused onychomadesis in this woman. In order for onychomadesis to occur, there would have had to have been significant trauma to all 10 nails at the matrix. Would the fish been able to have caused the same amount of trauma to all 10 nails in one setting? While it is possible, I believe a more likely explanation would be an alternate endogenous or exogenous source.
Traditional medicine has been used to enhance beauty and cure ailments for thousands of years before the advent of modern medicine as demonstrated by the Kangal study. Before discounting fish pedicures completely, perhaps some thought should also be given to how this practice affects wildlife and the fish. The CNN report refers to a 2011 investigation by the U.K.’s Fish Health Inspectorate, which “found a bacterial outbreak among thousands of these fish, which had been transported from Indonesia to the United Kingdom pedicure spas. Fish were found with bulging eyes, many hemorrhaging around the gills and mouth. The culprit was found to be a streptococcal bacteria, a strain that is associated with fish like tilapia, according to David Verner-Jeffreys, a senior microbiologist at the Centre for Environment, Fisheries and Aquaculture Science in the U.K.”
Whether or not these fish would pose any risk to humans is unknown, but certainly, this practice adversely affects the welfare of the fish and their environment. The overharvesting of these fish has led the Turkish government to introduce legal protections for the country’s Garra rufa in an attempt to combat overfishing and exploitation.
Perhaps fish pedicures solely for aesthetic reasons should not be practiced because of the potential infection risk – as well as the harm (to both humans and fish) and overharvesting of the fish. If used properly, these fish, however, could be an aid in treating certain skin pathologies.
Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
A letter published in JAMA Dermatology describes an otherwise healthy woman in her 20s who experienced nail abnormalities some months after having a fish pedicure. Onychomadesis, or transverse splitting of the nail plate, occurs when the nail matrix has arrested in producing the nail plate. It can be thought of as more severe form of Beau’s lines, in which the nail itself actually breaks and separates from the proximal nail plate and eventually sheds.
Fish pedicures have a long-standing history in Mediterranean and Middle Eastern cultures for aiding such skin conditions as psoriasis and helping to remove scaly skin. The Garra rufa fish are nonmigratory freshwater fish native to the Persian Gulf and Eastern Mediterranean. Suction allows them to attach to rocks and eat plankton. These “doctor fish,” as they are nicknamed, when placed in a warm bath of 25°C to 30°C, will also eat human skin when starved of their natural food source. As the JAMA Dermatology letter mentions, this was demonstrated in a study in Kangal, Turkey, where Garra rufa fish were used to improve psoriasis by feeding on psoriasis plaques but not normal skin. After 3 weeks of therapy with Garra rufa in 67 patients, there was a 72% reduction in the Psoriasis Area and Severity Index (PASI) score from baseline (Evid Based Complement Alternat Med. 2006 Dec;3[4]:483-8).
Popular in the United States and Europe about a decade ago, fish pedicures have now been banned in 10 U.S. states and in some parts of Europe. While the trend in the United States has waned, fish pedicures have recently become more popular in vacation destinations, such as the Caribbean. The inherent concern of fish pedicures is risk of infection as the same fish are used successively and cannot be adequately sanitized between people.
Two cases of staphylococcus infections and one of Mycobacterium marinum have been reported after fish pedicures. Whether these infections were caused by the fish or the water source, however, remains to be determined. If the fish were transmitting infections, it seems that more infections would likely have been reported, considering the widespread popularity in the past. I, like Antonella Tosti, MD, who commented in a CNN report on the JAMA Dermatology case, also doubt that the fish pedicure alone caused onychomadesis in this woman. In order for onychomadesis to occur, there would have had to have been significant trauma to all 10 nails at the matrix. Would the fish been able to have caused the same amount of trauma to all 10 nails in one setting? While it is possible, I believe a more likely explanation would be an alternate endogenous or exogenous source.
Traditional medicine has been used to enhance beauty and cure ailments for thousands of years before the advent of modern medicine as demonstrated by the Kangal study. Before discounting fish pedicures completely, perhaps some thought should also be given to how this practice affects wildlife and the fish. The CNN report refers to a 2011 investigation by the U.K.’s Fish Health Inspectorate, which “found a bacterial outbreak among thousands of these fish, which had been transported from Indonesia to the United Kingdom pedicure spas. Fish were found with bulging eyes, many hemorrhaging around the gills and mouth. The culprit was found to be a streptococcal bacteria, a strain that is associated with fish like tilapia, according to David Verner-Jeffreys, a senior microbiologist at the Centre for Environment, Fisheries and Aquaculture Science in the U.K.”
Whether or not these fish would pose any risk to humans is unknown, but certainly, this practice adversely affects the welfare of the fish and their environment. The overharvesting of these fish has led the Turkish government to introduce legal protections for the country’s Garra rufa in an attempt to combat overfishing and exploitation.
Perhaps fish pedicures solely for aesthetic reasons should not be practiced because of the potential infection risk – as well as the harm (to both humans and fish) and overharvesting of the fish. If used properly, these fish, however, could be an aid in treating certain skin pathologies.
Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
A letter published in JAMA Dermatology describes an otherwise healthy woman in her 20s who experienced nail abnormalities some months after having a fish pedicure. Onychomadesis, or transverse splitting of the nail plate, occurs when the nail matrix has arrested in producing the nail plate. It can be thought of as more severe form of Beau’s lines, in which the nail itself actually breaks and separates from the proximal nail plate and eventually sheds.
Fish pedicures have a long-standing history in Mediterranean and Middle Eastern cultures for aiding such skin conditions as psoriasis and helping to remove scaly skin. The Garra rufa fish are nonmigratory freshwater fish native to the Persian Gulf and Eastern Mediterranean. Suction allows them to attach to rocks and eat plankton. These “doctor fish,” as they are nicknamed, when placed in a warm bath of 25°C to 30°C, will also eat human skin when starved of their natural food source. As the JAMA Dermatology letter mentions, this was demonstrated in a study in Kangal, Turkey, where Garra rufa fish were used to improve psoriasis by feeding on psoriasis plaques but not normal skin. After 3 weeks of therapy with Garra rufa in 67 patients, there was a 72% reduction in the Psoriasis Area and Severity Index (PASI) score from baseline (Evid Based Complement Alternat Med. 2006 Dec;3[4]:483-8).
Popular in the United States and Europe about a decade ago, fish pedicures have now been banned in 10 U.S. states and in some parts of Europe. While the trend in the United States has waned, fish pedicures have recently become more popular in vacation destinations, such as the Caribbean. The inherent concern of fish pedicures is risk of infection as the same fish are used successively and cannot be adequately sanitized between people.
Two cases of staphylococcus infections and one of Mycobacterium marinum have been reported after fish pedicures. Whether these infections were caused by the fish or the water source, however, remains to be determined. If the fish were transmitting infections, it seems that more infections would likely have been reported, considering the widespread popularity in the past. I, like Antonella Tosti, MD, who commented in a CNN report on the JAMA Dermatology case, also doubt that the fish pedicure alone caused onychomadesis in this woman. In order for onychomadesis to occur, there would have had to have been significant trauma to all 10 nails at the matrix. Would the fish been able to have caused the same amount of trauma to all 10 nails in one setting? While it is possible, I believe a more likely explanation would be an alternate endogenous or exogenous source.
Traditional medicine has been used to enhance beauty and cure ailments for thousands of years before the advent of modern medicine as demonstrated by the Kangal study. Before discounting fish pedicures completely, perhaps some thought should also be given to how this practice affects wildlife and the fish. The CNN report refers to a 2011 investigation by the U.K.’s Fish Health Inspectorate, which “found a bacterial outbreak among thousands of these fish, which had been transported from Indonesia to the United Kingdom pedicure spas. Fish were found with bulging eyes, many hemorrhaging around the gills and mouth. The culprit was found to be a streptococcal bacteria, a strain that is associated with fish like tilapia, according to David Verner-Jeffreys, a senior microbiologist at the Centre for Environment, Fisheries and Aquaculture Science in the U.K.”
Whether or not these fish would pose any risk to humans is unknown, but certainly, this practice adversely affects the welfare of the fish and their environment. The overharvesting of these fish has led the Turkish government to introduce legal protections for the country’s Garra rufa in an attempt to combat overfishing and exploitation.
Perhaps fish pedicures solely for aesthetic reasons should not be practiced because of the potential infection risk – as well as the harm (to both humans and fish) and overharvesting of the fish. If used properly, these fish, however, could be an aid in treating certain skin pathologies.
Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
Behavioral sleep interventions can work – if done
Sleep has begun to emerge from the shadows to gain its rightful place in the health pantheon. With this emergence has come a motley group of physicians and self-proclaimed experts (myself included) eager to share their anecdotal evidence and opinions on how new parents can shorten the inevitable and often painfully slow process of settling in.
A study in the May 2018 Journal of Pediatrics is an attempt to provide some data-driven guidance for sleep-deprived parents and their physician-advisors (“Real-World Implementation of Infant Behavioral Sleep Interventions: Results of a Parental Survey”). Using the responses from 652 parents who participated in a Facebook peer support group, the investigators created four categories of behavior sleep intervention for the parents of infants a mean age of 6 months: Modified extinction in which parents left the room and returned to briefly reassure the infant at intervals ranging from 5 to 25 minutes; unmodified extinction in which the parents let the infant cry it out; parental presence with support in which the parents remained in the room and interacted with the child; and parental presence without support. Extinction, both modified and unmodified (50% and 35%), was far and away the most frequently used method.
There was little difference in the effectiveness of the four strategies. By 2 weeks, 79% of the parents reported success, and the interventions were successfully discontinued in a mean and mode of 7 days. Not surprisingly, with success came reduced parental stress, as well as more consistent bedtime routines and smoother transitions to sleep.
When choosing a behavioral sleep intervention to suggest, I have tried to consider what I have learned about each family’s personality in the few months I have gotten to know them. But I have always been a big fan of extinction. And I suspect that my bias is simply a reflection of my no-nonsense, let’s-get-it-done-now personality. The results of this new study suggests that my poorly disguised pessimism about parental presence strategies may have discouraged some parents from trying an intervention that might have been successful for them.
The good news is that all four strategies can be successful. The problem is helping parents find the time and energy required to make any intervention successful. In the short term, extinction or parental presence is likely to mean less sleep for the parents. If work schedules and other family stressors already have drained a family’s energy reserves, it may not be the right time to try an intervention. When it becomes clear that there is never going to be right time, it is time for a frank discussion with the family about rearranging their priorities.
Behavioral sleep interventions require consistency and a family must be prepared to commit at least a week of uninterrupted evenings to get the job done. Business trips, visitors, and social engagements must take a back seat.
Extinction strategies are going to involve some crying, and while as pediatricians, we have developed the ability to buffer ourselves from crying (ignore really isn’t the right word), we must accept that listening to one’s child is too painful for some parents. When only one parent can’t tolerate the crying, the solution may be having that parent leave the home on the intervention evenings. When both parents share the vulnerability, the better answer is a parental presence strategy.
Although this study was small with a self-selected group of parents, the good news is that behavioral sleep intervention can work. We need to share the news with young families and encourage them to just do it.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Is My Child Overtired?: The Sleep Solution for Raising Happier, Healthier Children.” Email him at [email protected].
Sleep has begun to emerge from the shadows to gain its rightful place in the health pantheon. With this emergence has come a motley group of physicians and self-proclaimed experts (myself included) eager to share their anecdotal evidence and opinions on how new parents can shorten the inevitable and often painfully slow process of settling in.
A study in the May 2018 Journal of Pediatrics is an attempt to provide some data-driven guidance for sleep-deprived parents and their physician-advisors (“Real-World Implementation of Infant Behavioral Sleep Interventions: Results of a Parental Survey”). Using the responses from 652 parents who participated in a Facebook peer support group, the investigators created four categories of behavior sleep intervention for the parents of infants a mean age of 6 months: Modified extinction in which parents left the room and returned to briefly reassure the infant at intervals ranging from 5 to 25 minutes; unmodified extinction in which the parents let the infant cry it out; parental presence with support in which the parents remained in the room and interacted with the child; and parental presence without support. Extinction, both modified and unmodified (50% and 35%), was far and away the most frequently used method.
There was little difference in the effectiveness of the four strategies. By 2 weeks, 79% of the parents reported success, and the interventions were successfully discontinued in a mean and mode of 7 days. Not surprisingly, with success came reduced parental stress, as well as more consistent bedtime routines and smoother transitions to sleep.
When choosing a behavioral sleep intervention to suggest, I have tried to consider what I have learned about each family’s personality in the few months I have gotten to know them. But I have always been a big fan of extinction. And I suspect that my bias is simply a reflection of my no-nonsense, let’s-get-it-done-now personality. The results of this new study suggests that my poorly disguised pessimism about parental presence strategies may have discouraged some parents from trying an intervention that might have been successful for them.
The good news is that all four strategies can be successful. The problem is helping parents find the time and energy required to make any intervention successful. In the short term, extinction or parental presence is likely to mean less sleep for the parents. If work schedules and other family stressors already have drained a family’s energy reserves, it may not be the right time to try an intervention. When it becomes clear that there is never going to be right time, it is time for a frank discussion with the family about rearranging their priorities.
Behavioral sleep interventions require consistency and a family must be prepared to commit at least a week of uninterrupted evenings to get the job done. Business trips, visitors, and social engagements must take a back seat.
Extinction strategies are going to involve some crying, and while as pediatricians, we have developed the ability to buffer ourselves from crying (ignore really isn’t the right word), we must accept that listening to one’s child is too painful for some parents. When only one parent can’t tolerate the crying, the solution may be having that parent leave the home on the intervention evenings. When both parents share the vulnerability, the better answer is a parental presence strategy.
Although this study was small with a self-selected group of parents, the good news is that behavioral sleep intervention can work. We need to share the news with young families and encourage them to just do it.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Is My Child Overtired?: The Sleep Solution for Raising Happier, Healthier Children.” Email him at [email protected].
Sleep has begun to emerge from the shadows to gain its rightful place in the health pantheon. With this emergence has come a motley group of physicians and self-proclaimed experts (myself included) eager to share their anecdotal evidence and opinions on how new parents can shorten the inevitable and often painfully slow process of settling in.
A study in the May 2018 Journal of Pediatrics is an attempt to provide some data-driven guidance for sleep-deprived parents and their physician-advisors (“Real-World Implementation of Infant Behavioral Sleep Interventions: Results of a Parental Survey”). Using the responses from 652 parents who participated in a Facebook peer support group, the investigators created four categories of behavior sleep intervention for the parents of infants a mean age of 6 months: Modified extinction in which parents left the room and returned to briefly reassure the infant at intervals ranging from 5 to 25 minutes; unmodified extinction in which the parents let the infant cry it out; parental presence with support in which the parents remained in the room and interacted with the child; and parental presence without support. Extinction, both modified and unmodified (50% and 35%), was far and away the most frequently used method.
There was little difference in the effectiveness of the four strategies. By 2 weeks, 79% of the parents reported success, and the interventions were successfully discontinued in a mean and mode of 7 days. Not surprisingly, with success came reduced parental stress, as well as more consistent bedtime routines and smoother transitions to sleep.
When choosing a behavioral sleep intervention to suggest, I have tried to consider what I have learned about each family’s personality in the few months I have gotten to know them. But I have always been a big fan of extinction. And I suspect that my bias is simply a reflection of my no-nonsense, let’s-get-it-done-now personality. The results of this new study suggests that my poorly disguised pessimism about parental presence strategies may have discouraged some parents from trying an intervention that might have been successful for them.
The good news is that all four strategies can be successful. The problem is helping parents find the time and energy required to make any intervention successful. In the short term, extinction or parental presence is likely to mean less sleep for the parents. If work schedules and other family stressors already have drained a family’s energy reserves, it may not be the right time to try an intervention. When it becomes clear that there is never going to be right time, it is time for a frank discussion with the family about rearranging their priorities.
Behavioral sleep interventions require consistency and a family must be prepared to commit at least a week of uninterrupted evenings to get the job done. Business trips, visitors, and social engagements must take a back seat.
Extinction strategies are going to involve some crying, and while as pediatricians, we have developed the ability to buffer ourselves from crying (ignore really isn’t the right word), we must accept that listening to one’s child is too painful for some parents. When only one parent can’t tolerate the crying, the solution may be having that parent leave the home on the intervention evenings. When both parents share the vulnerability, the better answer is a parental presence strategy.
Although this study was small with a self-selected group of parents, the good news is that behavioral sleep intervention can work. We need to share the news with young families and encourage them to just do it.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Is My Child Overtired?: The Sleep Solution for Raising Happier, Healthier Children.” Email him at [email protected].
Malpractice and pain management
Question: A new patient with severe back pain sought treatment at the Ease-Your-Pain Clinic, a facility run by medical specialists. Following a history and physical, he was given a prescription for high-dose oxycodone. Shortly after filing the prescription, he became unresponsive, and toxicology studies postmortem revealed elevated blood levels.
In a wrongful death lawsuit against the doctor and clinic, which of the following statements is best?
A. A wrongful death lawsuit deals with a special type of malpractice in which criminal sanctions are likely.
B. The facts here fall within the domain of common knowledge, or res ipsa loquitur; so the case will not have to depend on an expert witness.
C. Substandard care is clearly evident from the fact that this opioid-naive patient was prescribed a much higher than usual starting dose of the drug.
D. The elevated blood levels indicate that the cause of death was an opioid overdose.
E. To prevail, the plaintiff has the burden of proving, by a preponderance of evidence and through expert testimony, that the defendant’s breach of duty of due care legally caused the patient’s death.
Answer: E. Criminal prosecution for homicide is quite different from a civil lawsuit for wrongful death, requiring state action with proof beyond reasonable doubt and a showing of intent. It is rare in medical malpractice cases, which require expert testimony to prove breach of duty and causation.
Choices C and D are incorrect, as the facts given are deliberately brief and vague. For example, the medical history may have revealed this patient to be a chronic user of opioid drugs rather than being opioid naive, thus the need for higher dosing. In addition, we cannot be certain of the actual cause of death; opioid levels obtained in body fluids postmortem may be difficult to interpret and are apt to be higher in chronic users (see Dallier v. Hsu, discussed below).
We are currently in the throes of an epidemic of opioid deaths involving both illicit street drugs such as heroin and synthetic fentanyl, as well as FDA-approved controlled substances such as morphine and codeine derivatives. Overdose now exceeds motor vehicle accidents as the leading cause of injury-related deaths, with nearly 100 Americans dying every day from an opioid overdose.
In an earlier column, we drew attention to physician and manufacturer criminality associated with opioid prescription deaths.1 In this article, we will focus on the civil liability facing doctors who treat patients afflicted with pain.
The onslaught of warnings, caution, and threats of criminal prosecution has prompted Medicare and pharmacy chains to impose restrictions on opioid prescriptions. Even more troubling, doctors are increasingly cutting back or stopping entirely their prescriptions. As a result, some patients may resort to desperate measures to obtain their drugs.
A recent article in the Washington Post draws attention to this situation.2 It tells the story of a 49-year-old trucker who had been taking large amounts of prescription opioids ever since hip surgery left him with nerve damage. Because no doctor nearby would write an opioid prescription, he had to drive 367 miles to his old pain clinic each month for a refill. According to the article, chronic pain patients may turn to unregulated alternatives such as kratom, and some have threatened suicide.
Citing data from the IQVIA Institute for Human Data Science, the article reported that the annual volume of prescription opioids shrank 29% between 2011 and 2017, even as the number of overdose deaths climbed ever higher. The drop in prescriptions was greatest for patients receiving high doses, most of whom had chronic pain.
Failure to treat pain can constitute substandard care. In Bergman v. Eden Medical Center, an Alameda County jury in California turned in a verdict against an internist charged with elder abuse and reckless negligence for failing to give enough pain medication to a patient dying of cancer.3 William Bergman was an 85-year-old retired railroad worker who complained of severe back pain. During his 6-day stay at the hospital, nurses consistently charted his pain in the 7-10 range, and on the day of discharge, his pain was at level 10. He died at home shortly thereafter.
After 4 days of deliberation, the jury, in a 9-3 vote, entered a guilty verdict, and awarded $1.5 million in general damages. That amount was subsequently reduced to $250,000 because of California’s cap on noneconomic damages. The Bergman case is notable for being the first of its kind, and it squarely put physicians on notice regarding their duty to adequately provide pain relief.
At the same time, prescribing opioid drugs that result in harm can be the basis of a successful claim – if the plaintiff can prove the tort elements of negligence. However, this may be harder than it looks.
For example, a Connecticut malpractice case alleging negligent opioid prescriptions resulted in a judgment in favor of the defendant.4 The patient had a congenital skeletal deformity called Madelung’s disease, and she suffered from many years of severe pain requiring chronic opioids such as oxycodone, methadone, morphine, fentanyl, and hydrocodone, in combination and with other types of medications for anxiety, sleep problems, and depression. She was not a compliant patient and had a history of inconsistent pill counts and urine tests, and a history of stockpiling and hoarding pills.
Following a recent fracture of her right arm and shoulder, she visited several doctors for narcotic prescriptions before consulting the defendant doctor, who concluded that hers was an emergency and urgent situation. He believed that if he did not prescribe medications to address her pain, she would engage in unsafe drug-seeking behaviors. Accordingly, the doctor prescribed the following: methadone, 40 mg, 4 pills per day; extended-release morphine sulfate, 60 mg, 2 per day; alprazolam, 1 mg, 3 per day. Within hours of filing her prescription, she began to stumble, developed slurred speech, and then became unresponsive and died.
The court was unpersuaded that the requisite standard of care was to contact the patient’s prior treaters or pharmacy, or to obtain her current records to determine her level of drug naiveté or tolerance, or that the defendant should have initiated treatment with starting doses of drugs. It held that that reflected “a narrow textbook approach to the practice of pain management and ignores the role of patient-physician interaction.”
Based on all the evidence, the patient’s tolerance for opiates had greatly escalated, and her level of pain remained at 10 on a scale of 10. The defendant had independently assessed the patient, determined her needs, and ruled out that she was opiate naive. Based on all the circumstances, he prescribed morphine, methadone, and alprazolam. The morphine prescription of 60 mg extended release every 12 hours was not lethal to her and was not her first opioid analgesic. The court ruled that the plaintiff had failed to sustain the burden of proving causation, there being no finding that the patient took more medications than prescribed or overdosed. It was unimpressed by the various calculations offered by the experts on postmortem drug levels and causation.
A recent report from the Doctor’s Company, a major malpractice carrier, reviewed 1,770 claims closed between 2007 and 2015 in which patient harm involved medication factors.5 In 272 of those claims (15%), the medications were narcotic analgesics, most often prescribed in the outpatient setting and involving methadone and oxycodone. The Centers for Disease Control and Prevention has recently published treatment guidelines noting that long-term opioid use among patients with chronic pain increased the likelihood of addiction and overdose and had uncertain benefits. They discouraged doses higher than the equivalent of 90 mg of morphine.6
While it is true that opioid-related malpractice lawsuits are not infrequent, stopping entirely the prescribing of controlled narcotic analgesics in the name of “first do no harm” is simplistic and misguided.
It is better to adopt widely recommended strategies in opioid prescribing, recognizing that, as Howard Marcus, MD, chair of the Texas Alliance for Patient Access, has said, “It is possible to prescribe opioids responsibly and safely for patients with chronic pain who do not obtain sufficient relief and reasonable function with nonopioid treatment. However, to do so, it is necessary to have adequate knowledge of the pharmacology of opioids, risk factors, and side effects. Safe opioid prescribing requires thorough patient evaluation, attention to detail, and familiarity with guidelines and regulations.”7
To this might be added the suggestion that, in tough cases, one should make a referral to a pain specialist skilled in the use of such drugs.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].
References
1. “Physician liability in opioid deaths.” Internal Medicine News, July 13, 2017.
2. “Unintended consequences: Inside the fallout of America’s crackdown on opioids.” Washington Post, May 31, 2018.
3. Bergman v. Eden Medical Center, No. H205732-1 (Sup. Ct. Alameda Co., Cal., June 13, 2001).
4. Dallaire v. Hsu, CV 07-5004043 (Conn. Sup. Ct., May 18, 2010).
5. “Prescription opioid abuse epidemic: analysis of medication-related claims.” The Doctor’s Advocate, first quarter 2017.
6. N Engl J Med. 2016 Apr 21;374(16):1501-4.
7. “Prescribing opioids safely.” The Doctor’s Advocate, second quarter 2017.
Question: A new patient with severe back pain sought treatment at the Ease-Your-Pain Clinic, a facility run by medical specialists. Following a history and physical, he was given a prescription for high-dose oxycodone. Shortly after filing the prescription, he became unresponsive, and toxicology studies postmortem revealed elevated blood levels.
In a wrongful death lawsuit against the doctor and clinic, which of the following statements is best?
A. A wrongful death lawsuit deals with a special type of malpractice in which criminal sanctions are likely.
B. The facts here fall within the domain of common knowledge, or res ipsa loquitur; so the case will not have to depend on an expert witness.
C. Substandard care is clearly evident from the fact that this opioid-naive patient was prescribed a much higher than usual starting dose of the drug.
D. The elevated blood levels indicate that the cause of death was an opioid overdose.
E. To prevail, the plaintiff has the burden of proving, by a preponderance of evidence and through expert testimony, that the defendant’s breach of duty of due care legally caused the patient’s death.
Answer: E. Criminal prosecution for homicide is quite different from a civil lawsuit for wrongful death, requiring state action with proof beyond reasonable doubt and a showing of intent. It is rare in medical malpractice cases, which require expert testimony to prove breach of duty and causation.
Choices C and D are incorrect, as the facts given are deliberately brief and vague. For example, the medical history may have revealed this patient to be a chronic user of opioid drugs rather than being opioid naive, thus the need for higher dosing. In addition, we cannot be certain of the actual cause of death; opioid levels obtained in body fluids postmortem may be difficult to interpret and are apt to be higher in chronic users (see Dallier v. Hsu, discussed below).
We are currently in the throes of an epidemic of opioid deaths involving both illicit street drugs such as heroin and synthetic fentanyl, as well as FDA-approved controlled substances such as morphine and codeine derivatives. Overdose now exceeds motor vehicle accidents as the leading cause of injury-related deaths, with nearly 100 Americans dying every day from an opioid overdose.
In an earlier column, we drew attention to physician and manufacturer criminality associated with opioid prescription deaths.1 In this article, we will focus on the civil liability facing doctors who treat patients afflicted with pain.
The onslaught of warnings, caution, and threats of criminal prosecution has prompted Medicare and pharmacy chains to impose restrictions on opioid prescriptions. Even more troubling, doctors are increasingly cutting back or stopping entirely their prescriptions. As a result, some patients may resort to desperate measures to obtain their drugs.
A recent article in the Washington Post draws attention to this situation.2 It tells the story of a 49-year-old trucker who had been taking large amounts of prescription opioids ever since hip surgery left him with nerve damage. Because no doctor nearby would write an opioid prescription, he had to drive 367 miles to his old pain clinic each month for a refill. According to the article, chronic pain patients may turn to unregulated alternatives such as kratom, and some have threatened suicide.
Citing data from the IQVIA Institute for Human Data Science, the article reported that the annual volume of prescription opioids shrank 29% between 2011 and 2017, even as the number of overdose deaths climbed ever higher. The drop in prescriptions was greatest for patients receiving high doses, most of whom had chronic pain.
Failure to treat pain can constitute substandard care. In Bergman v. Eden Medical Center, an Alameda County jury in California turned in a verdict against an internist charged with elder abuse and reckless negligence for failing to give enough pain medication to a patient dying of cancer.3 William Bergman was an 85-year-old retired railroad worker who complained of severe back pain. During his 6-day stay at the hospital, nurses consistently charted his pain in the 7-10 range, and on the day of discharge, his pain was at level 10. He died at home shortly thereafter.
After 4 days of deliberation, the jury, in a 9-3 vote, entered a guilty verdict, and awarded $1.5 million in general damages. That amount was subsequently reduced to $250,000 because of California’s cap on noneconomic damages. The Bergman case is notable for being the first of its kind, and it squarely put physicians on notice regarding their duty to adequately provide pain relief.
At the same time, prescribing opioid drugs that result in harm can be the basis of a successful claim – if the plaintiff can prove the tort elements of negligence. However, this may be harder than it looks.
For example, a Connecticut malpractice case alleging negligent opioid prescriptions resulted in a judgment in favor of the defendant.4 The patient had a congenital skeletal deformity called Madelung’s disease, and she suffered from many years of severe pain requiring chronic opioids such as oxycodone, methadone, morphine, fentanyl, and hydrocodone, in combination and with other types of medications for anxiety, sleep problems, and depression. She was not a compliant patient and had a history of inconsistent pill counts and urine tests, and a history of stockpiling and hoarding pills.
Following a recent fracture of her right arm and shoulder, she visited several doctors for narcotic prescriptions before consulting the defendant doctor, who concluded that hers was an emergency and urgent situation. He believed that if he did not prescribe medications to address her pain, she would engage in unsafe drug-seeking behaviors. Accordingly, the doctor prescribed the following: methadone, 40 mg, 4 pills per day; extended-release morphine sulfate, 60 mg, 2 per day; alprazolam, 1 mg, 3 per day. Within hours of filing her prescription, she began to stumble, developed slurred speech, and then became unresponsive and died.
The court was unpersuaded that the requisite standard of care was to contact the patient’s prior treaters or pharmacy, or to obtain her current records to determine her level of drug naiveté or tolerance, or that the defendant should have initiated treatment with starting doses of drugs. It held that that reflected “a narrow textbook approach to the practice of pain management and ignores the role of patient-physician interaction.”
Based on all the evidence, the patient’s tolerance for opiates had greatly escalated, and her level of pain remained at 10 on a scale of 10. The defendant had independently assessed the patient, determined her needs, and ruled out that she was opiate naive. Based on all the circumstances, he prescribed morphine, methadone, and alprazolam. The morphine prescription of 60 mg extended release every 12 hours was not lethal to her and was not her first opioid analgesic. The court ruled that the plaintiff had failed to sustain the burden of proving causation, there being no finding that the patient took more medications than prescribed or overdosed. It was unimpressed by the various calculations offered by the experts on postmortem drug levels and causation.
A recent report from the Doctor’s Company, a major malpractice carrier, reviewed 1,770 claims closed between 2007 and 2015 in which patient harm involved medication factors.5 In 272 of those claims (15%), the medications were narcotic analgesics, most often prescribed in the outpatient setting and involving methadone and oxycodone. The Centers for Disease Control and Prevention has recently published treatment guidelines noting that long-term opioid use among patients with chronic pain increased the likelihood of addiction and overdose and had uncertain benefits. They discouraged doses higher than the equivalent of 90 mg of morphine.6
While it is true that opioid-related malpractice lawsuits are not infrequent, stopping entirely the prescribing of controlled narcotic analgesics in the name of “first do no harm” is simplistic and misguided.
It is better to adopt widely recommended strategies in opioid prescribing, recognizing that, as Howard Marcus, MD, chair of the Texas Alliance for Patient Access, has said, “It is possible to prescribe opioids responsibly and safely for patients with chronic pain who do not obtain sufficient relief and reasonable function with nonopioid treatment. However, to do so, it is necessary to have adequate knowledge of the pharmacology of opioids, risk factors, and side effects. Safe opioid prescribing requires thorough patient evaluation, attention to detail, and familiarity with guidelines and regulations.”7
To this might be added the suggestion that, in tough cases, one should make a referral to a pain specialist skilled in the use of such drugs.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].
References
1. “Physician liability in opioid deaths.” Internal Medicine News, July 13, 2017.
2. “Unintended consequences: Inside the fallout of America’s crackdown on opioids.” Washington Post, May 31, 2018.
3. Bergman v. Eden Medical Center, No. H205732-1 (Sup. Ct. Alameda Co., Cal., June 13, 2001).
4. Dallaire v. Hsu, CV 07-5004043 (Conn. Sup. Ct., May 18, 2010).
5. “Prescription opioid abuse epidemic: analysis of medication-related claims.” The Doctor’s Advocate, first quarter 2017.
6. N Engl J Med. 2016 Apr 21;374(16):1501-4.
7. “Prescribing opioids safely.” The Doctor’s Advocate, second quarter 2017.
Question: A new patient with severe back pain sought treatment at the Ease-Your-Pain Clinic, a facility run by medical specialists. Following a history and physical, he was given a prescription for high-dose oxycodone. Shortly after filing the prescription, he became unresponsive, and toxicology studies postmortem revealed elevated blood levels.
In a wrongful death lawsuit against the doctor and clinic, which of the following statements is best?
A. A wrongful death lawsuit deals with a special type of malpractice in which criminal sanctions are likely.
B. The facts here fall within the domain of common knowledge, or res ipsa loquitur; so the case will not have to depend on an expert witness.
C. Substandard care is clearly evident from the fact that this opioid-naive patient was prescribed a much higher than usual starting dose of the drug.
D. The elevated blood levels indicate that the cause of death was an opioid overdose.
E. To prevail, the plaintiff has the burden of proving, by a preponderance of evidence and through expert testimony, that the defendant’s breach of duty of due care legally caused the patient’s death.
Answer: E. Criminal prosecution for homicide is quite different from a civil lawsuit for wrongful death, requiring state action with proof beyond reasonable doubt and a showing of intent. It is rare in medical malpractice cases, which require expert testimony to prove breach of duty and causation.
Choices C and D are incorrect, as the facts given are deliberately brief and vague. For example, the medical history may have revealed this patient to be a chronic user of opioid drugs rather than being opioid naive, thus the need for higher dosing. In addition, we cannot be certain of the actual cause of death; opioid levels obtained in body fluids postmortem may be difficult to interpret and are apt to be higher in chronic users (see Dallier v. Hsu, discussed below).
We are currently in the throes of an epidemic of opioid deaths involving both illicit street drugs such as heroin and synthetic fentanyl, as well as FDA-approved controlled substances such as morphine and codeine derivatives. Overdose now exceeds motor vehicle accidents as the leading cause of injury-related deaths, with nearly 100 Americans dying every day from an opioid overdose.
In an earlier column, we drew attention to physician and manufacturer criminality associated with opioid prescription deaths.1 In this article, we will focus on the civil liability facing doctors who treat patients afflicted with pain.
The onslaught of warnings, caution, and threats of criminal prosecution has prompted Medicare and pharmacy chains to impose restrictions on opioid prescriptions. Even more troubling, doctors are increasingly cutting back or stopping entirely their prescriptions. As a result, some patients may resort to desperate measures to obtain their drugs.
A recent article in the Washington Post draws attention to this situation.2 It tells the story of a 49-year-old trucker who had been taking large amounts of prescription opioids ever since hip surgery left him with nerve damage. Because no doctor nearby would write an opioid prescription, he had to drive 367 miles to his old pain clinic each month for a refill. According to the article, chronic pain patients may turn to unregulated alternatives such as kratom, and some have threatened suicide.
Citing data from the IQVIA Institute for Human Data Science, the article reported that the annual volume of prescription opioids shrank 29% between 2011 and 2017, even as the number of overdose deaths climbed ever higher. The drop in prescriptions was greatest for patients receiving high doses, most of whom had chronic pain.
Failure to treat pain can constitute substandard care. In Bergman v. Eden Medical Center, an Alameda County jury in California turned in a verdict against an internist charged with elder abuse and reckless negligence for failing to give enough pain medication to a patient dying of cancer.3 William Bergman was an 85-year-old retired railroad worker who complained of severe back pain. During his 6-day stay at the hospital, nurses consistently charted his pain in the 7-10 range, and on the day of discharge, his pain was at level 10. He died at home shortly thereafter.
After 4 days of deliberation, the jury, in a 9-3 vote, entered a guilty verdict, and awarded $1.5 million in general damages. That amount was subsequently reduced to $250,000 because of California’s cap on noneconomic damages. The Bergman case is notable for being the first of its kind, and it squarely put physicians on notice regarding their duty to adequately provide pain relief.
At the same time, prescribing opioid drugs that result in harm can be the basis of a successful claim – if the plaintiff can prove the tort elements of negligence. However, this may be harder than it looks.
For example, a Connecticut malpractice case alleging negligent opioid prescriptions resulted in a judgment in favor of the defendant.4 The patient had a congenital skeletal deformity called Madelung’s disease, and she suffered from many years of severe pain requiring chronic opioids such as oxycodone, methadone, morphine, fentanyl, and hydrocodone, in combination and with other types of medications for anxiety, sleep problems, and depression. She was not a compliant patient and had a history of inconsistent pill counts and urine tests, and a history of stockpiling and hoarding pills.
Following a recent fracture of her right arm and shoulder, she visited several doctors for narcotic prescriptions before consulting the defendant doctor, who concluded that hers was an emergency and urgent situation. He believed that if he did not prescribe medications to address her pain, she would engage in unsafe drug-seeking behaviors. Accordingly, the doctor prescribed the following: methadone, 40 mg, 4 pills per day; extended-release morphine sulfate, 60 mg, 2 per day; alprazolam, 1 mg, 3 per day. Within hours of filing her prescription, she began to stumble, developed slurred speech, and then became unresponsive and died.
The court was unpersuaded that the requisite standard of care was to contact the patient’s prior treaters or pharmacy, or to obtain her current records to determine her level of drug naiveté or tolerance, or that the defendant should have initiated treatment with starting doses of drugs. It held that that reflected “a narrow textbook approach to the practice of pain management and ignores the role of patient-physician interaction.”
Based on all the evidence, the patient’s tolerance for opiates had greatly escalated, and her level of pain remained at 10 on a scale of 10. The defendant had independently assessed the patient, determined her needs, and ruled out that she was opiate naive. Based on all the circumstances, he prescribed morphine, methadone, and alprazolam. The morphine prescription of 60 mg extended release every 12 hours was not lethal to her and was not her first opioid analgesic. The court ruled that the plaintiff had failed to sustain the burden of proving causation, there being no finding that the patient took more medications than prescribed or overdosed. It was unimpressed by the various calculations offered by the experts on postmortem drug levels and causation.
A recent report from the Doctor’s Company, a major malpractice carrier, reviewed 1,770 claims closed between 2007 and 2015 in which patient harm involved medication factors.5 In 272 of those claims (15%), the medications were narcotic analgesics, most often prescribed in the outpatient setting and involving methadone and oxycodone. The Centers for Disease Control and Prevention has recently published treatment guidelines noting that long-term opioid use among patients with chronic pain increased the likelihood of addiction and overdose and had uncertain benefits. They discouraged doses higher than the equivalent of 90 mg of morphine.6
While it is true that opioid-related malpractice lawsuits are not infrequent, stopping entirely the prescribing of controlled narcotic analgesics in the name of “first do no harm” is simplistic and misguided.
It is better to adopt widely recommended strategies in opioid prescribing, recognizing that, as Howard Marcus, MD, chair of the Texas Alliance for Patient Access, has said, “It is possible to prescribe opioids responsibly and safely for patients with chronic pain who do not obtain sufficient relief and reasonable function with nonopioid treatment. However, to do so, it is necessary to have adequate knowledge of the pharmacology of opioids, risk factors, and side effects. Safe opioid prescribing requires thorough patient evaluation, attention to detail, and familiarity with guidelines and regulations.”7
To this might be added the suggestion that, in tough cases, one should make a referral to a pain specialist skilled in the use of such drugs.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].
References
1. “Physician liability in opioid deaths.” Internal Medicine News, July 13, 2017.
2. “Unintended consequences: Inside the fallout of America’s crackdown on opioids.” Washington Post, May 31, 2018.
3. Bergman v. Eden Medical Center, No. H205732-1 (Sup. Ct. Alameda Co., Cal., June 13, 2001).
4. Dallaire v. Hsu, CV 07-5004043 (Conn. Sup. Ct., May 18, 2010).
5. “Prescription opioid abuse epidemic: analysis of medication-related claims.” The Doctor’s Advocate, first quarter 2017.
6. N Engl J Med. 2016 Apr 21;374(16):1501-4.
7. “Prescribing opioids safely.” The Doctor’s Advocate, second quarter 2017.
Tabata training
I’m in really good shape. Well, more like really not bad shape. I eat healthy food (see my previous column on diet) and work out nearly every day. I have done so for years. I’ve learned that working out doesn’t make much difference with my weight, but it makes a huge difference with my mood, even more so than meditating. That’s why I’ll never give it up.
My approach is to vary my routine, typically by month. I’ve done “BUD/S qualification” months where I do only push-ups, sit-ups, pull-ups, and runs to meet the minimum requirements for the Navy Seal Training. (It’s not as hard as you might think, although I’m pretty lenient on form.)
When I have an hour to exercise and I’m deep into a podcast, then I’ll just keep going. If I’m trying to work out a piece I’m writing, like this one, then I’ll go for a run along the harbor here in San Diego. If I have to catch an early flight or drive to LA for the day, then I might have only 15 minutes. In that instance, I do high-intensity sprints, also known as high-intensity interval training (HIIT). Although it’s hard to break a good sweat, these workouts are both challenging and rewarding.
Recently, I participated in a wonderful physician wellness program at Kaiser Permanente, San Diego, where, over several weeks, we learned about nutrition, practiced meditation, and did Tabatas. What’s a Tabata you ask? It’s a kick in the butt.
. Yup, it’s a 4-minute workout that consists of 20 seconds of all-out, maximum effort, followed by 10 seconds of rest. The specific move you do for Tabatas is up to you, but it’s recommended that it be the same move for all 4 minutes. I like burpees which work your entire body – you jump, you drop into a push-up position, you pull your feet back in, and jump again. (Check out a video on YouTube.)
When we started the class, I thought Tabatas would be too easy for a gym rat like me. Plus, there were pediatricians, and even radiologists there, so how hard could they be? Let’s just say I couldn’t sit for 2 days after my first session: That’s how hard.
Tabatas are also a quick way to torch calories. A study published in the Journal of Sports Science and Medicine in 2013 found subjects who performed a 20-minute Tabata session experienced improved cardiorespiratory endurance and increased calorie burn (J Sports Sci Med. 2013 Sep;12[3]: 612-3).
Sometimes on a Monday, which is typically my difficult day, I’ll break out a few burpees in my office between patients. The energy jolt is real, and unlike caffeine, doesn’t leave me shaky. Because Tabatas require physical and mental focus, they’re an effective way to clear your mind after a grueling patient visit or if you’re feeling distracted. You simply can’t be thinking about that late patient or angry email when you’re jumping and lunging at full speed.
All the physicians in our program liked the Tabatas; many were even better than me. (Turns out we have pediatricians and radiologists who do things like run the Boston marathon and win Spartan races).
And if you start doing Tabatas, feel free to email me if you need a recommendation for a standing desk – you might not be able to sit as much afterward.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
I’m in really good shape. Well, more like really not bad shape. I eat healthy food (see my previous column on diet) and work out nearly every day. I have done so for years. I’ve learned that working out doesn’t make much difference with my weight, but it makes a huge difference with my mood, even more so than meditating. That’s why I’ll never give it up.
My approach is to vary my routine, typically by month. I’ve done “BUD/S qualification” months where I do only push-ups, sit-ups, pull-ups, and runs to meet the minimum requirements for the Navy Seal Training. (It’s not as hard as you might think, although I’m pretty lenient on form.)
When I have an hour to exercise and I’m deep into a podcast, then I’ll just keep going. If I’m trying to work out a piece I’m writing, like this one, then I’ll go for a run along the harbor here in San Diego. If I have to catch an early flight or drive to LA for the day, then I might have only 15 minutes. In that instance, I do high-intensity sprints, also known as high-intensity interval training (HIIT). Although it’s hard to break a good sweat, these workouts are both challenging and rewarding.
Recently, I participated in a wonderful physician wellness program at Kaiser Permanente, San Diego, where, over several weeks, we learned about nutrition, practiced meditation, and did Tabatas. What’s a Tabata you ask? It’s a kick in the butt.
. Yup, it’s a 4-minute workout that consists of 20 seconds of all-out, maximum effort, followed by 10 seconds of rest. The specific move you do for Tabatas is up to you, but it’s recommended that it be the same move for all 4 minutes. I like burpees which work your entire body – you jump, you drop into a push-up position, you pull your feet back in, and jump again. (Check out a video on YouTube.)
When we started the class, I thought Tabatas would be too easy for a gym rat like me. Plus, there were pediatricians, and even radiologists there, so how hard could they be? Let’s just say I couldn’t sit for 2 days after my first session: That’s how hard.
Tabatas are also a quick way to torch calories. A study published in the Journal of Sports Science and Medicine in 2013 found subjects who performed a 20-minute Tabata session experienced improved cardiorespiratory endurance and increased calorie burn (J Sports Sci Med. 2013 Sep;12[3]: 612-3).
Sometimes on a Monday, which is typically my difficult day, I’ll break out a few burpees in my office between patients. The energy jolt is real, and unlike caffeine, doesn’t leave me shaky. Because Tabatas require physical and mental focus, they’re an effective way to clear your mind after a grueling patient visit or if you’re feeling distracted. You simply can’t be thinking about that late patient or angry email when you’re jumping and lunging at full speed.
All the physicians in our program liked the Tabatas; many were even better than me. (Turns out we have pediatricians and radiologists who do things like run the Boston marathon and win Spartan races).
And if you start doing Tabatas, feel free to email me if you need a recommendation for a standing desk – you might not be able to sit as much afterward.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
I’m in really good shape. Well, more like really not bad shape. I eat healthy food (see my previous column on diet) and work out nearly every day. I have done so for years. I’ve learned that working out doesn’t make much difference with my weight, but it makes a huge difference with my mood, even more so than meditating. That’s why I’ll never give it up.
My approach is to vary my routine, typically by month. I’ve done “BUD/S qualification” months where I do only push-ups, sit-ups, pull-ups, and runs to meet the minimum requirements for the Navy Seal Training. (It’s not as hard as you might think, although I’m pretty lenient on form.)
When I have an hour to exercise and I’m deep into a podcast, then I’ll just keep going. If I’m trying to work out a piece I’m writing, like this one, then I’ll go for a run along the harbor here in San Diego. If I have to catch an early flight or drive to LA for the day, then I might have only 15 minutes. In that instance, I do high-intensity sprints, also known as high-intensity interval training (HIIT). Although it’s hard to break a good sweat, these workouts are both challenging and rewarding.
Recently, I participated in a wonderful physician wellness program at Kaiser Permanente, San Diego, where, over several weeks, we learned about nutrition, practiced meditation, and did Tabatas. What’s a Tabata you ask? It’s a kick in the butt.
. Yup, it’s a 4-minute workout that consists of 20 seconds of all-out, maximum effort, followed by 10 seconds of rest. The specific move you do for Tabatas is up to you, but it’s recommended that it be the same move for all 4 minutes. I like burpees which work your entire body – you jump, you drop into a push-up position, you pull your feet back in, and jump again. (Check out a video on YouTube.)
When we started the class, I thought Tabatas would be too easy for a gym rat like me. Plus, there were pediatricians, and even radiologists there, so how hard could they be? Let’s just say I couldn’t sit for 2 days after my first session: That’s how hard.
Tabatas are also a quick way to torch calories. A study published in the Journal of Sports Science and Medicine in 2013 found subjects who performed a 20-minute Tabata session experienced improved cardiorespiratory endurance and increased calorie burn (J Sports Sci Med. 2013 Sep;12[3]: 612-3).
Sometimes on a Monday, which is typically my difficult day, I’ll break out a few burpees in my office between patients. The energy jolt is real, and unlike caffeine, doesn’t leave me shaky. Because Tabatas require physical and mental focus, they’re an effective way to clear your mind after a grueling patient visit or if you’re feeling distracted. You simply can’t be thinking about that late patient or angry email when you’re jumping and lunging at full speed.
All the physicians in our program liked the Tabatas; many were even better than me. (Turns out we have pediatricians and radiologists who do things like run the Boston marathon and win Spartan races).
And if you start doing Tabatas, feel free to email me if you need a recommendation for a standing desk – you might not be able to sit as much afterward.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Maternal lifestyle affects child obesity
A study published in the British Medical Journal found that women who practiced five healthy habits had children who when they reached adolescence were 75% less likely to be overweight, compared with women who practiced none of the those healthy habits.
The healthy habits were maintaining a healthy weight, eating a nutritious diet, exercising regularly, not smoking, and consuming no more than a moderate amount of alcohol (BMJ 2018;362:k2486). I suspect you aren’t surprised by the core finding of this study of 16,945 female nurses and their 24,289 children. You’ve seen it scores of times. Mothers who lead unhealthy lifestyles seem to have children who are more likely to be obese. Now you have some numbers to support your decades of anecdotal observations. But the question is, what are we supposed to do with this new data? When and with whom should we share this unfortunate truth?
Evidence from previous studies makes it clear that by the time a child enters grade school the die is cast. Baby fat is neither cute nor temporary. This means that our target audience must be mothers-to-be and women whose children are infants and toddlers. On the other hand, telling the mother of an overweight teenager that her own unhealthy habits have probably contributed to her child’s weight problem is cruel and a waste of time. The mother already may have suspected her culpability. She also may feel that it is too late to do anything about it. While there have been some studies looking for an association between paternal body mass index and offspring BMI, I was unable to find any addressing paternal lifestyle and adolescent obesity.
This new study doesn’t address the unusual situation in which a mother of a teenager sheds all five of her unhealthy habits. I guess there may be examples in which a mother’s positive lifestyle change has helped reverse her adolescent child’s path to obesity. But I suspect these cases are rare.
So on one hand but on the other we must be careful to avoid playing the blame game and giving other mothers a one-way ticket on the guilt train. This is just one more example of the tightrope that we have been walking for generations. Every day in our offices we see children whose health is endangered by their parents’ behaviors and lifestyles. In cases in which the parental behavior is creating a serious short-term risk, such as failing to use an appropriate motor vehicle safety restraint system, we have no qualms about speaking out. We aren’t afraid to do a little shaming in hopes of sparing a family a serious guilt trip. When the threat to the child is more abstract and less dramatic – such as vaccine refusal – shaming and education don’t seem to be effective in changing parental behavior.
Obesity presents its own collection of complexities. It is like a car wreck seen in slow motion as the plots on the growth chart accumulate pound by pound. Unfortunately, parents often are among the last to notice or accept the reality. This new study doesn’t tell us whether we can make a difference. But it does suggest that when we first see the warning signs on the growth chart that we should engage the parents in a discussion of their lifestyle and its possible association with the child’s weight gain. The challenge, of course, is how one can cast the discussion without sounding judgmental.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
A study published in the British Medical Journal found that women who practiced five healthy habits had children who when they reached adolescence were 75% less likely to be overweight, compared with women who practiced none of the those healthy habits.
The healthy habits were maintaining a healthy weight, eating a nutritious diet, exercising regularly, not smoking, and consuming no more than a moderate amount of alcohol (BMJ 2018;362:k2486). I suspect you aren’t surprised by the core finding of this study of 16,945 female nurses and their 24,289 children. You’ve seen it scores of times. Mothers who lead unhealthy lifestyles seem to have children who are more likely to be obese. Now you have some numbers to support your decades of anecdotal observations. But the question is, what are we supposed to do with this new data? When and with whom should we share this unfortunate truth?
Evidence from previous studies makes it clear that by the time a child enters grade school the die is cast. Baby fat is neither cute nor temporary. This means that our target audience must be mothers-to-be and women whose children are infants and toddlers. On the other hand, telling the mother of an overweight teenager that her own unhealthy habits have probably contributed to her child’s weight problem is cruel and a waste of time. The mother already may have suspected her culpability. She also may feel that it is too late to do anything about it. While there have been some studies looking for an association between paternal body mass index and offspring BMI, I was unable to find any addressing paternal lifestyle and adolescent obesity.
This new study doesn’t address the unusual situation in which a mother of a teenager sheds all five of her unhealthy habits. I guess there may be examples in which a mother’s positive lifestyle change has helped reverse her adolescent child’s path to obesity. But I suspect these cases are rare.
So on one hand but on the other we must be careful to avoid playing the blame game and giving other mothers a one-way ticket on the guilt train. This is just one more example of the tightrope that we have been walking for generations. Every day in our offices we see children whose health is endangered by their parents’ behaviors and lifestyles. In cases in which the parental behavior is creating a serious short-term risk, such as failing to use an appropriate motor vehicle safety restraint system, we have no qualms about speaking out. We aren’t afraid to do a little shaming in hopes of sparing a family a serious guilt trip. When the threat to the child is more abstract and less dramatic – such as vaccine refusal – shaming and education don’t seem to be effective in changing parental behavior.
Obesity presents its own collection of complexities. It is like a car wreck seen in slow motion as the plots on the growth chart accumulate pound by pound. Unfortunately, parents often are among the last to notice or accept the reality. This new study doesn’t tell us whether we can make a difference. But it does suggest that when we first see the warning signs on the growth chart that we should engage the parents in a discussion of their lifestyle and its possible association with the child’s weight gain. The challenge, of course, is how one can cast the discussion without sounding judgmental.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
A study published in the British Medical Journal found that women who practiced five healthy habits had children who when they reached adolescence were 75% less likely to be overweight, compared with women who practiced none of the those healthy habits.
The healthy habits were maintaining a healthy weight, eating a nutritious diet, exercising regularly, not smoking, and consuming no more than a moderate amount of alcohol (BMJ 2018;362:k2486). I suspect you aren’t surprised by the core finding of this study of 16,945 female nurses and their 24,289 children. You’ve seen it scores of times. Mothers who lead unhealthy lifestyles seem to have children who are more likely to be obese. Now you have some numbers to support your decades of anecdotal observations. But the question is, what are we supposed to do with this new data? When and with whom should we share this unfortunate truth?
Evidence from previous studies makes it clear that by the time a child enters grade school the die is cast. Baby fat is neither cute nor temporary. This means that our target audience must be mothers-to-be and women whose children are infants and toddlers. On the other hand, telling the mother of an overweight teenager that her own unhealthy habits have probably contributed to her child’s weight problem is cruel and a waste of time. The mother already may have suspected her culpability. She also may feel that it is too late to do anything about it. While there have been some studies looking for an association between paternal body mass index and offspring BMI, I was unable to find any addressing paternal lifestyle and adolescent obesity.
This new study doesn’t address the unusual situation in which a mother of a teenager sheds all five of her unhealthy habits. I guess there may be examples in which a mother’s positive lifestyle change has helped reverse her adolescent child’s path to obesity. But I suspect these cases are rare.
So on one hand but on the other we must be careful to avoid playing the blame game and giving other mothers a one-way ticket on the guilt train. This is just one more example of the tightrope that we have been walking for generations. Every day in our offices we see children whose health is endangered by their parents’ behaviors and lifestyles. In cases in which the parental behavior is creating a serious short-term risk, such as failing to use an appropriate motor vehicle safety restraint system, we have no qualms about speaking out. We aren’t afraid to do a little shaming in hopes of sparing a family a serious guilt trip. When the threat to the child is more abstract and less dramatic – such as vaccine refusal – shaming and education don’t seem to be effective in changing parental behavior.
Obesity presents its own collection of complexities. It is like a car wreck seen in slow motion as the plots on the growth chart accumulate pound by pound. Unfortunately, parents often are among the last to notice or accept the reality. This new study doesn’t tell us whether we can make a difference. But it does suggest that when we first see the warning signs on the growth chart that we should engage the parents in a discussion of their lifestyle and its possible association with the child’s weight gain. The challenge, of course, is how one can cast the discussion without sounding judgmental.
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].
Credit cards FAQ
After my last column on credit cards, I was (as usual) inundated with questions, comments, and requests for copies of the letter we give to patients explaining our credit card policy.
at www.mdedge.com/edermatologynews. If you have a question not addressed here, feel free to ask, either on the website or via email ([email protected]).
How do you safeguard the credit information you keep on file?
The same way we do medical information; it’s all covered by the same HIPAA rules. If you have an EHR, it can go in the chart with everything else; if not, I suggest a separate portable file that can be locked up each night.
How do you keep the info current, as cards do expire?
We check expiration dates at each visit, and ask for a new number or date if the card has expired or is close.
Don’t your patients object to signing, in effect, a blank check?
They’re not “signing a blank check.” All credit card contracts give cardholders the right to challenge any charge against their account.
There were some initial objections, mostly from devotees of the financial “old school.” But when we explain that we’re doing nothing different than a hotel does at each check-in, and that it will work to their advantage as well, by decreasing the bills they will receive and the checks they must write, most come around.
How do you handle patients who refuse to hand over a number, particularly those who say they have no credit cards?
We used to let refusers slide, but now we’ve made the policy mandatory. Patients who refuse without a good reason are asked, like any patient who refuses to cooperate with any standard office policy, to go elsewhere. Life’s too short. And “I don’t have any credit cards” does not count as a good reason. Nearly everyone has credit cards in this day and age. For the occasional patient who does not have a credit card, my office manager does have authority to make exceptions on a case-by-case basis, however.
One cosmetic surgeon I know asks “no credit card” patients to pay a lawyer-style “retainer,” which is held in escrow, and used to pay receivable amounts as they come due. When presented with that alternative, he told me, most of them suddenly remember that they do have a credit card after all.
What’s the difference between this and “balance billing”?
All the difference in the world. “Balance billing” is billing patients for the difference between your normal fee and the insurer’s authorized payment. If your office has contracted to accept that particular insurance, you can’t do that; but you can bill for the portion of the insurer-determined payment not paid by the insurer. (Many contracts stipulate that you must do so.) For example, your normal fee is $200; the insurer approves $100, and pays 80% of that. The other $20 is the patient’s responsibility, and that is what you charge to the credit card – instead of sending out a statement for that amount.
Since we instituted this policy, one patient has called to ask if it is legal, and one insurance company has inquired about it. How do you respond to such queries?
Of course it’s legal; you are entitled to collect what is owed to you. Ask those patients if they question the legality every time they check into a hotel or rent a car.
We have had no inquiries from insurers, but my response would be that it’s none of their business. Again, you have every right to bill for the patient-owed portion of your fees – in fact, Medicare and many private insurers consider it an illegal “inducement” if you don’t – and third parties have no right to dictate how you can or cannot collect it.
In the past, another popular practice management columnist advised against adopting this policy.
Despite multiple requests from me and others, that columnist – who owns a medical billing company – has never, to my knowledge, offered a single convincing argument in support of that position.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
After my last column on credit cards, I was (as usual) inundated with questions, comments, and requests for copies of the letter we give to patients explaining our credit card policy.
at www.mdedge.com/edermatologynews. If you have a question not addressed here, feel free to ask, either on the website or via email ([email protected]).
How do you safeguard the credit information you keep on file?
The same way we do medical information; it’s all covered by the same HIPAA rules. If you have an EHR, it can go in the chart with everything else; if not, I suggest a separate portable file that can be locked up each night.
How do you keep the info current, as cards do expire?
We check expiration dates at each visit, and ask for a new number or date if the card has expired or is close.
Don’t your patients object to signing, in effect, a blank check?
They’re not “signing a blank check.” All credit card contracts give cardholders the right to challenge any charge against their account.
There were some initial objections, mostly from devotees of the financial “old school.” But when we explain that we’re doing nothing different than a hotel does at each check-in, and that it will work to their advantage as well, by decreasing the bills they will receive and the checks they must write, most come around.
How do you handle patients who refuse to hand over a number, particularly those who say they have no credit cards?
We used to let refusers slide, but now we’ve made the policy mandatory. Patients who refuse without a good reason are asked, like any patient who refuses to cooperate with any standard office policy, to go elsewhere. Life’s too short. And “I don’t have any credit cards” does not count as a good reason. Nearly everyone has credit cards in this day and age. For the occasional patient who does not have a credit card, my office manager does have authority to make exceptions on a case-by-case basis, however.
One cosmetic surgeon I know asks “no credit card” patients to pay a lawyer-style “retainer,” which is held in escrow, and used to pay receivable amounts as they come due. When presented with that alternative, he told me, most of them suddenly remember that they do have a credit card after all.
What’s the difference between this and “balance billing”?
All the difference in the world. “Balance billing” is billing patients for the difference between your normal fee and the insurer’s authorized payment. If your office has contracted to accept that particular insurance, you can’t do that; but you can bill for the portion of the insurer-determined payment not paid by the insurer. (Many contracts stipulate that you must do so.) For example, your normal fee is $200; the insurer approves $100, and pays 80% of that. The other $20 is the patient’s responsibility, and that is what you charge to the credit card – instead of sending out a statement for that amount.
Since we instituted this policy, one patient has called to ask if it is legal, and one insurance company has inquired about it. How do you respond to such queries?
Of course it’s legal; you are entitled to collect what is owed to you. Ask those patients if they question the legality every time they check into a hotel or rent a car.
We have had no inquiries from insurers, but my response would be that it’s none of their business. Again, you have every right to bill for the patient-owed portion of your fees – in fact, Medicare and many private insurers consider it an illegal “inducement” if you don’t – and third parties have no right to dictate how you can or cannot collect it.
In the past, another popular practice management columnist advised against adopting this policy.
Despite multiple requests from me and others, that columnist – who owns a medical billing company – has never, to my knowledge, offered a single convincing argument in support of that position.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
After my last column on credit cards, I was (as usual) inundated with questions, comments, and requests for copies of the letter we give to patients explaining our credit card policy.
at www.mdedge.com/edermatologynews. If you have a question not addressed here, feel free to ask, either on the website or via email ([email protected]).
How do you safeguard the credit information you keep on file?
The same way we do medical information; it’s all covered by the same HIPAA rules. If you have an EHR, it can go in the chart with everything else; if not, I suggest a separate portable file that can be locked up each night.
How do you keep the info current, as cards do expire?
We check expiration dates at each visit, and ask for a new number or date if the card has expired or is close.
Don’t your patients object to signing, in effect, a blank check?
They’re not “signing a blank check.” All credit card contracts give cardholders the right to challenge any charge against their account.
There were some initial objections, mostly from devotees of the financial “old school.” But when we explain that we’re doing nothing different than a hotel does at each check-in, and that it will work to their advantage as well, by decreasing the bills they will receive and the checks they must write, most come around.
How do you handle patients who refuse to hand over a number, particularly those who say they have no credit cards?
We used to let refusers slide, but now we’ve made the policy mandatory. Patients who refuse without a good reason are asked, like any patient who refuses to cooperate with any standard office policy, to go elsewhere. Life’s too short. And “I don’t have any credit cards” does not count as a good reason. Nearly everyone has credit cards in this day and age. For the occasional patient who does not have a credit card, my office manager does have authority to make exceptions on a case-by-case basis, however.
One cosmetic surgeon I know asks “no credit card” patients to pay a lawyer-style “retainer,” which is held in escrow, and used to pay receivable amounts as they come due. When presented with that alternative, he told me, most of them suddenly remember that they do have a credit card after all.
What’s the difference between this and “balance billing”?
All the difference in the world. “Balance billing” is billing patients for the difference between your normal fee and the insurer’s authorized payment. If your office has contracted to accept that particular insurance, you can’t do that; but you can bill for the portion of the insurer-determined payment not paid by the insurer. (Many contracts stipulate that you must do so.) For example, your normal fee is $200; the insurer approves $100, and pays 80% of that. The other $20 is the patient’s responsibility, and that is what you charge to the credit card – instead of sending out a statement for that amount.
Since we instituted this policy, one patient has called to ask if it is legal, and one insurance company has inquired about it. How do you respond to such queries?
Of course it’s legal; you are entitled to collect what is owed to you. Ask those patients if they question the legality every time they check into a hotel or rent a car.
We have had no inquiries from insurers, but my response would be that it’s none of their business. Again, you have every right to bill for the patient-owed portion of your fees – in fact, Medicare and many private insurers consider it an illegal “inducement” if you don’t – and third parties have no right to dictate how you can or cannot collect it.
In the past, another popular practice management columnist advised against adopting this policy.
Despite multiple requests from me and others, that columnist – who owns a medical billing company – has never, to my knowledge, offered a single convincing argument in support of that position.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
PNPs integrate behavioral, mental health in PC practice
Concerns about mental health (MH) care delivery for children are repeatedly identified by health care providers, described in the literature, and addressed through advocacy. Unfortunately, health inequities continue to exist, including the social stigma of an MH diagnosis, lower reimbursement for MH compared with medical care, and poor access to expert pediatric behavioral health providers. This is especially true for families living below the poverty line, who are more likely to have MH problems.1
An estimated 50% of primary care (PC) pediatric visits involve an MH or behavioral problem, yet only about 20% of these patients receive services.2 According to the Centers for Disease Control and Prevention, one out of seven children aged 2-8 years has a developmental or behavioral disorder.3 In children aged 3-17 years, 7% have ADHD, 2% have depressive disorders, and 3% have anxiety.3 In the 2015 National Youth Risk Behavior Surveillance survey, more than 29% of high school respondents stated that they felt so sad or hopeless during the past 12 months that they had stopped some of their usual activities, and 18% considered suicide.4 The incidence of violent acts committed by and affecting teens adds a critical need for creative provision of pediatric MH care.
MH integration in pediatric PC, supported by the National Association of Pediatric Nurse Practitioners, American Academy of Pediatrics, American Psychological Association, and many others is an avenue to provide quality MH services for children.5,6,7 In a coordinated or colocated model, a behavioral health specialist works with a pediatric provider either in consultation with the practice (coordinated) or in the same practice site where patients are referred (colocated).7 The collaborative care model places pediatric medical providers with care managers or behavioral health specialists to deliver care in one practice setting.
The use of pediatric nurse practitioners (PNPs) with advanced training in MH care is described in the literature as a different type of collaborative care model.8,9,10 PNPs assess, diagnose, and treat using pharmacologic and nonpharmacologic therapies. PNPs may offer evidence-based psychotherapy or refer for psychotherapy or parenting skills development. Those who have added knowledge and skills in MH care may seek validation of these competencies through completion of added certification as pediatric PC MH specialists (PMHS).11 Since 2011, there are more than 400 PMHSs certified in the United States. We share examples of services provided by PNPs across the United States.
At a federally qualified health center
Dawn Garzon Maaks, PhD, CPNP-PC, the current president of the National Association of Pediatric Nurse Practitioners, is certified as a PMHS and works in a federally-qualified health center in southwest Washington State. This center provides lifespan services for patients, with separate office spaces for MH/psychiatric care and PC. Within this colocated environment, Dr. Garzon Maaks spends about 75% of her time caring for children with developmental, behavioral, and MH problems in the MH clinic and 25% in the PC office, providing health maintenance and acute episodic care. She collaborates with psychiatrists and psychiatric mental health nurse practitioners by adding pediatric developmental and medical expertise and is welcomed by providers who have limited experience caring for children. While providing PC, she educates about issues such as resiliency, screening for substance abuse, and treatment of common pediatric mood disorders and ADHD. Her expertise also allows for MH care integration into PC visits, taking away the “stigma” which still is pervasive for patients referred to MH providers.
“What my position has taught me is that when primary and mental health care providers work closely, it improves outcomes for all patients seen. Through frequent consultation, our primary care physicians have increasing skills in caring for children with mild mental health issues, thus freeing up the mental health people to deal with the more significant cases. On the other hand, our mental health providers benefit from having the primary care expertise in diagnosing and treating common conditions that mimic mental health issues. This integration also significantly reduces stigma because families see their mental health professional in the primary care setting,” Dr. Garzon Maaks said.
At an urban/suburban PC practice
Another PNP MH expert, Dr. Susan Van Cleve, is certified as a PMHS and works as a subspecialist within an urban/suburban pediatric PC practice. Her team is composed of two PNPs and one registered nurse who is designated as the full time MH coordinator. This team cares for children and teens with mild to moderate MH disorders from within the practice. The registered nurse performs intake interviews, schedules patients, and sends out screening tools before visits and is available to families and providers in the practice on a dedicated phone line. She refers complex patients to local providers for more comprehensive care and follows them to ensure that appointments and referrals are made. Scheduling with the PNPs allows for longer appointments, comprehensive treatment including medication management if warranted, and close follow-up care. Patient types seen include those with concerns about developmental delays, autism spectrum disorder, disruptive behavior, ADHD, anxiety, and depression. Children or teens with more severe disorders are referred to colleagues in psychiatry or counseling services, or to pediatric or adolescent subspecialists in the community.
“The children and families I see seem to feel comfortable because our behavioral team is embedded in the pediatric practice, and we use the same office space. Families have easy access to our full-time registered nurse who is available to answer questions, provide resources and advice, lend support, or assist navigating the health system. This type of system increases access, enables us to provide comprehensive family-centered care, and supports the child and family,” said Dr. Van Cleve, clinical professor and primary care pediatric nurse practitioner program director at the University of Iowa College of Nursing, Iowa City.
As an educator
Naomi A. Schapiro, PhD, CPNP, is a professor of nursing at the University of California, San Francisco, and a PNP at a school-based health center with an integrated behavioral health model, managed by a federally qualified health center in a medically underserved area. She is the principle investigator of an Advanced Nursing Education Health Resources Service Administration grant supporting interprofessional training and practice collaboration to improve care and reduce health inequities for disadvantaged children and adolescents coping with both behavioral health conditions and chronic physical conditions, including obesity.11
Dr. Schapiro collaborates with a multidisciplinary, multi-university team, a local children’s hospital, a social work training program, and the county health care services agency to develop and implement a training program for pediatric PC providers to increase skills and self-confidence implementing American Academy of Pediatrics guidelines assessing and treating depression, ADHD, anxiety and trauma-related symptoms; triaging patients with nonsuicidal self-injury and suicidal ideation; and recognizing and referring patients with bipolar disorder and psychosis. These training modules are currently being recorded for online posting. As part of this interprofessional collaboration, Dr. Schapiro and her colleagues developed a “warmline” for decision support, staffed by a psychiatrist and two nurse practitioners available to PC providers in a network of 29 school-based health centers and two pediatric practices for complex decision making about medications or diagnostic dilemmas. Efforts are underway to continue and expand this program.
“As a faculty teaching PNP students enhanced behavioral health assessment skills, I have been proudest when students have been able to apply and disseminate these skills,” Dr. Schapiro said. “One of our recent PNP graduates was in a community primary care practicum when an adolescent thinking about suicide walked into the clinic with her father. Her preceptor wasn’t sure how to proceed, when the student said, ‘Wait! We just practiced this in class.’ The student pulled up her course website, and she and her preceptor walked through the assessment together, developed a safety plan with the teen and her father, and connected the teen with a therapist, avoiding an unnecessary ER visit and potential fragmentation of care.”
The need and expectation that pediatric PC providers incorporate MH services is well documented.2,12,13 PNPs who have additional training and expertise in assessing, diagnosing, and managing MH care are an excellent solution for addressing this problem. The benefits of this team-based approach to the pediatric health care home include decreasing stigma, increasing access, and providing comprehensive MH care to children and their families.
Dr. Haut works at Beacon Pediatrics, a large primary care practice in Rehoboth Beach, Del. She works part-time for Pediatrix Medical Group, serving the Pediatric Intensive Care Unit medical team at the Herman & Walter Samuelson Children’s Hospital at Sinai in Baltimore, and she serves as adjunct faculty at the University of Maryland School of Nursing, also in Baltimore. Other contributors to this article were Dawn Garzon Maaks, PhD, CPNP, PMHS; Naomi Schapiro, PhD, CPNP; Susan Van Cleve, DNP, RN, CPNP-PC, PMHS; and Laura Searcy, MN, APRN, PPCNP-BC. Ms. Searcy is on the medical staff at WellStar Kennestone Regional Medical Center in Marietta, Ga., delivering care to newborns. Dr. Haut and Ms. Searcy are members of the Pediatric News Consultant Advisory Board. Email them at [email protected].
References
1. “Best principles for integration of child psychiatry into the pediatric health home,” AACAP Executive Summary,2012, pages 1-13.
2. Pediatrics. 2009 Apr;123(4):1248-51.
3. Center for Disease Control and Prevention: Children’s Mental Health Data and Statistics.
4. MMWR Surveill Summ, 2016. doi:10.15585/mmwr.ss6506a1.
5. Pediatrics. 2015;135(5):909-17.
6. JAMA Pediatr. 2015;169(10):929-37.
7. “Integrating child psychology services into primary care,” by Tynan D, Woods K, and Carpenter J. American Psychological Association, 2014.
8. J Am Psychiatr Nurses Assoc. 2005;11(5): 276-82.
9. J Nurse Pract. 2013;9(4):243-8.
10. J Pediatr Health Care. 2013; 27(3):162-3.
11. Advanced Nursing Education Health Resources Service Administration grant (#D09HP26958).
12. J Nurse Pract. 2013:9(3):142-8.
13. Pediatrics. 2018;141(3):e20174082
Concerns about mental health (MH) care delivery for children are repeatedly identified by health care providers, described in the literature, and addressed through advocacy. Unfortunately, health inequities continue to exist, including the social stigma of an MH diagnosis, lower reimbursement for MH compared with medical care, and poor access to expert pediatric behavioral health providers. This is especially true for families living below the poverty line, who are more likely to have MH problems.1
An estimated 50% of primary care (PC) pediatric visits involve an MH or behavioral problem, yet only about 20% of these patients receive services.2 According to the Centers for Disease Control and Prevention, one out of seven children aged 2-8 years has a developmental or behavioral disorder.3 In children aged 3-17 years, 7% have ADHD, 2% have depressive disorders, and 3% have anxiety.3 In the 2015 National Youth Risk Behavior Surveillance survey, more than 29% of high school respondents stated that they felt so sad or hopeless during the past 12 months that they had stopped some of their usual activities, and 18% considered suicide.4 The incidence of violent acts committed by and affecting teens adds a critical need for creative provision of pediatric MH care.
MH integration in pediatric PC, supported by the National Association of Pediatric Nurse Practitioners, American Academy of Pediatrics, American Psychological Association, and many others is an avenue to provide quality MH services for children.5,6,7 In a coordinated or colocated model, a behavioral health specialist works with a pediatric provider either in consultation with the practice (coordinated) or in the same practice site where patients are referred (colocated).7 The collaborative care model places pediatric medical providers with care managers or behavioral health specialists to deliver care in one practice setting.
The use of pediatric nurse practitioners (PNPs) with advanced training in MH care is described in the literature as a different type of collaborative care model.8,9,10 PNPs assess, diagnose, and treat using pharmacologic and nonpharmacologic therapies. PNPs may offer evidence-based psychotherapy or refer for psychotherapy or parenting skills development. Those who have added knowledge and skills in MH care may seek validation of these competencies through completion of added certification as pediatric PC MH specialists (PMHS).11 Since 2011, there are more than 400 PMHSs certified in the United States. We share examples of services provided by PNPs across the United States.
At a federally qualified health center
Dawn Garzon Maaks, PhD, CPNP-PC, the current president of the National Association of Pediatric Nurse Practitioners, is certified as a PMHS and works in a federally-qualified health center in southwest Washington State. This center provides lifespan services for patients, with separate office spaces for MH/psychiatric care and PC. Within this colocated environment, Dr. Garzon Maaks spends about 75% of her time caring for children with developmental, behavioral, and MH problems in the MH clinic and 25% in the PC office, providing health maintenance and acute episodic care. She collaborates with psychiatrists and psychiatric mental health nurse practitioners by adding pediatric developmental and medical expertise and is welcomed by providers who have limited experience caring for children. While providing PC, she educates about issues such as resiliency, screening for substance abuse, and treatment of common pediatric mood disorders and ADHD. Her expertise also allows for MH care integration into PC visits, taking away the “stigma” which still is pervasive for patients referred to MH providers.
“What my position has taught me is that when primary and mental health care providers work closely, it improves outcomes for all patients seen. Through frequent consultation, our primary care physicians have increasing skills in caring for children with mild mental health issues, thus freeing up the mental health people to deal with the more significant cases. On the other hand, our mental health providers benefit from having the primary care expertise in diagnosing and treating common conditions that mimic mental health issues. This integration also significantly reduces stigma because families see their mental health professional in the primary care setting,” Dr. Garzon Maaks said.
At an urban/suburban PC practice
Another PNP MH expert, Dr. Susan Van Cleve, is certified as a PMHS and works as a subspecialist within an urban/suburban pediatric PC practice. Her team is composed of two PNPs and one registered nurse who is designated as the full time MH coordinator. This team cares for children and teens with mild to moderate MH disorders from within the practice. The registered nurse performs intake interviews, schedules patients, and sends out screening tools before visits and is available to families and providers in the practice on a dedicated phone line. She refers complex patients to local providers for more comprehensive care and follows them to ensure that appointments and referrals are made. Scheduling with the PNPs allows for longer appointments, comprehensive treatment including medication management if warranted, and close follow-up care. Patient types seen include those with concerns about developmental delays, autism spectrum disorder, disruptive behavior, ADHD, anxiety, and depression. Children or teens with more severe disorders are referred to colleagues in psychiatry or counseling services, or to pediatric or adolescent subspecialists in the community.
“The children and families I see seem to feel comfortable because our behavioral team is embedded in the pediatric practice, and we use the same office space. Families have easy access to our full-time registered nurse who is available to answer questions, provide resources and advice, lend support, or assist navigating the health system. This type of system increases access, enables us to provide comprehensive family-centered care, and supports the child and family,” said Dr. Van Cleve, clinical professor and primary care pediatric nurse practitioner program director at the University of Iowa College of Nursing, Iowa City.
As an educator
Naomi A. Schapiro, PhD, CPNP, is a professor of nursing at the University of California, San Francisco, and a PNP at a school-based health center with an integrated behavioral health model, managed by a federally qualified health center in a medically underserved area. She is the principle investigator of an Advanced Nursing Education Health Resources Service Administration grant supporting interprofessional training and practice collaboration to improve care and reduce health inequities for disadvantaged children and adolescents coping with both behavioral health conditions and chronic physical conditions, including obesity.11
Dr. Schapiro collaborates with a multidisciplinary, multi-university team, a local children’s hospital, a social work training program, and the county health care services agency to develop and implement a training program for pediatric PC providers to increase skills and self-confidence implementing American Academy of Pediatrics guidelines assessing and treating depression, ADHD, anxiety and trauma-related symptoms; triaging patients with nonsuicidal self-injury and suicidal ideation; and recognizing and referring patients with bipolar disorder and psychosis. These training modules are currently being recorded for online posting. As part of this interprofessional collaboration, Dr. Schapiro and her colleagues developed a “warmline” for decision support, staffed by a psychiatrist and two nurse practitioners available to PC providers in a network of 29 school-based health centers and two pediatric practices for complex decision making about medications or diagnostic dilemmas. Efforts are underway to continue and expand this program.
“As a faculty teaching PNP students enhanced behavioral health assessment skills, I have been proudest when students have been able to apply and disseminate these skills,” Dr. Schapiro said. “One of our recent PNP graduates was in a community primary care practicum when an adolescent thinking about suicide walked into the clinic with her father. Her preceptor wasn’t sure how to proceed, when the student said, ‘Wait! We just practiced this in class.’ The student pulled up her course website, and she and her preceptor walked through the assessment together, developed a safety plan with the teen and her father, and connected the teen with a therapist, avoiding an unnecessary ER visit and potential fragmentation of care.”
The need and expectation that pediatric PC providers incorporate MH services is well documented.2,12,13 PNPs who have additional training and expertise in assessing, diagnosing, and managing MH care are an excellent solution for addressing this problem. The benefits of this team-based approach to the pediatric health care home include decreasing stigma, increasing access, and providing comprehensive MH care to children and their families.
Dr. Haut works at Beacon Pediatrics, a large primary care practice in Rehoboth Beach, Del. She works part-time for Pediatrix Medical Group, serving the Pediatric Intensive Care Unit medical team at the Herman & Walter Samuelson Children’s Hospital at Sinai in Baltimore, and she serves as adjunct faculty at the University of Maryland School of Nursing, also in Baltimore. Other contributors to this article were Dawn Garzon Maaks, PhD, CPNP, PMHS; Naomi Schapiro, PhD, CPNP; Susan Van Cleve, DNP, RN, CPNP-PC, PMHS; and Laura Searcy, MN, APRN, PPCNP-BC. Ms. Searcy is on the medical staff at WellStar Kennestone Regional Medical Center in Marietta, Ga., delivering care to newborns. Dr. Haut and Ms. Searcy are members of the Pediatric News Consultant Advisory Board. Email them at [email protected].
References
1. “Best principles for integration of child psychiatry into the pediatric health home,” AACAP Executive Summary,2012, pages 1-13.
2. Pediatrics. 2009 Apr;123(4):1248-51.
3. Center for Disease Control and Prevention: Children’s Mental Health Data and Statistics.
4. MMWR Surveill Summ, 2016. doi:10.15585/mmwr.ss6506a1.
5. Pediatrics. 2015;135(5):909-17.
6. JAMA Pediatr. 2015;169(10):929-37.
7. “Integrating child psychology services into primary care,” by Tynan D, Woods K, and Carpenter J. American Psychological Association, 2014.
8. J Am Psychiatr Nurses Assoc. 2005;11(5): 276-82.
9. J Nurse Pract. 2013;9(4):243-8.
10. J Pediatr Health Care. 2013; 27(3):162-3.
11. Advanced Nursing Education Health Resources Service Administration grant (#D09HP26958).
12. J Nurse Pract. 2013:9(3):142-8.
13. Pediatrics. 2018;141(3):e20174082
Concerns about mental health (MH) care delivery for children are repeatedly identified by health care providers, described in the literature, and addressed through advocacy. Unfortunately, health inequities continue to exist, including the social stigma of an MH diagnosis, lower reimbursement for MH compared with medical care, and poor access to expert pediatric behavioral health providers. This is especially true for families living below the poverty line, who are more likely to have MH problems.1
An estimated 50% of primary care (PC) pediatric visits involve an MH or behavioral problem, yet only about 20% of these patients receive services.2 According to the Centers for Disease Control and Prevention, one out of seven children aged 2-8 years has a developmental or behavioral disorder.3 In children aged 3-17 years, 7% have ADHD, 2% have depressive disorders, and 3% have anxiety.3 In the 2015 National Youth Risk Behavior Surveillance survey, more than 29% of high school respondents stated that they felt so sad or hopeless during the past 12 months that they had stopped some of their usual activities, and 18% considered suicide.4 The incidence of violent acts committed by and affecting teens adds a critical need for creative provision of pediatric MH care.
MH integration in pediatric PC, supported by the National Association of Pediatric Nurse Practitioners, American Academy of Pediatrics, American Psychological Association, and many others is an avenue to provide quality MH services for children.5,6,7 In a coordinated or colocated model, a behavioral health specialist works with a pediatric provider either in consultation with the practice (coordinated) or in the same practice site where patients are referred (colocated).7 The collaborative care model places pediatric medical providers with care managers or behavioral health specialists to deliver care in one practice setting.
The use of pediatric nurse practitioners (PNPs) with advanced training in MH care is described in the literature as a different type of collaborative care model.8,9,10 PNPs assess, diagnose, and treat using pharmacologic and nonpharmacologic therapies. PNPs may offer evidence-based psychotherapy or refer for psychotherapy or parenting skills development. Those who have added knowledge and skills in MH care may seek validation of these competencies through completion of added certification as pediatric PC MH specialists (PMHS).11 Since 2011, there are more than 400 PMHSs certified in the United States. We share examples of services provided by PNPs across the United States.
At a federally qualified health center
Dawn Garzon Maaks, PhD, CPNP-PC, the current president of the National Association of Pediatric Nurse Practitioners, is certified as a PMHS and works in a federally-qualified health center in southwest Washington State. This center provides lifespan services for patients, with separate office spaces for MH/psychiatric care and PC. Within this colocated environment, Dr. Garzon Maaks spends about 75% of her time caring for children with developmental, behavioral, and MH problems in the MH clinic and 25% in the PC office, providing health maintenance and acute episodic care. She collaborates with psychiatrists and psychiatric mental health nurse practitioners by adding pediatric developmental and medical expertise and is welcomed by providers who have limited experience caring for children. While providing PC, she educates about issues such as resiliency, screening for substance abuse, and treatment of common pediatric mood disorders and ADHD. Her expertise also allows for MH care integration into PC visits, taking away the “stigma” which still is pervasive for patients referred to MH providers.
“What my position has taught me is that when primary and mental health care providers work closely, it improves outcomes for all patients seen. Through frequent consultation, our primary care physicians have increasing skills in caring for children with mild mental health issues, thus freeing up the mental health people to deal with the more significant cases. On the other hand, our mental health providers benefit from having the primary care expertise in diagnosing and treating common conditions that mimic mental health issues. This integration also significantly reduces stigma because families see their mental health professional in the primary care setting,” Dr. Garzon Maaks said.
At an urban/suburban PC practice
Another PNP MH expert, Dr. Susan Van Cleve, is certified as a PMHS and works as a subspecialist within an urban/suburban pediatric PC practice. Her team is composed of two PNPs and one registered nurse who is designated as the full time MH coordinator. This team cares for children and teens with mild to moderate MH disorders from within the practice. The registered nurse performs intake interviews, schedules patients, and sends out screening tools before visits and is available to families and providers in the practice on a dedicated phone line. She refers complex patients to local providers for more comprehensive care and follows them to ensure that appointments and referrals are made. Scheduling with the PNPs allows for longer appointments, comprehensive treatment including medication management if warranted, and close follow-up care. Patient types seen include those with concerns about developmental delays, autism spectrum disorder, disruptive behavior, ADHD, anxiety, and depression. Children or teens with more severe disorders are referred to colleagues in psychiatry or counseling services, or to pediatric or adolescent subspecialists in the community.
“The children and families I see seem to feel comfortable because our behavioral team is embedded in the pediatric practice, and we use the same office space. Families have easy access to our full-time registered nurse who is available to answer questions, provide resources and advice, lend support, or assist navigating the health system. This type of system increases access, enables us to provide comprehensive family-centered care, and supports the child and family,” said Dr. Van Cleve, clinical professor and primary care pediatric nurse practitioner program director at the University of Iowa College of Nursing, Iowa City.
As an educator
Naomi A. Schapiro, PhD, CPNP, is a professor of nursing at the University of California, San Francisco, and a PNP at a school-based health center with an integrated behavioral health model, managed by a federally qualified health center in a medically underserved area. She is the principle investigator of an Advanced Nursing Education Health Resources Service Administration grant supporting interprofessional training and practice collaboration to improve care and reduce health inequities for disadvantaged children and adolescents coping with both behavioral health conditions and chronic physical conditions, including obesity.11
Dr. Schapiro collaborates with a multidisciplinary, multi-university team, a local children’s hospital, a social work training program, and the county health care services agency to develop and implement a training program for pediatric PC providers to increase skills and self-confidence implementing American Academy of Pediatrics guidelines assessing and treating depression, ADHD, anxiety and trauma-related symptoms; triaging patients with nonsuicidal self-injury and suicidal ideation; and recognizing and referring patients with bipolar disorder and psychosis. These training modules are currently being recorded for online posting. As part of this interprofessional collaboration, Dr. Schapiro and her colleagues developed a “warmline” for decision support, staffed by a psychiatrist and two nurse practitioners available to PC providers in a network of 29 school-based health centers and two pediatric practices for complex decision making about medications or diagnostic dilemmas. Efforts are underway to continue and expand this program.
“As a faculty teaching PNP students enhanced behavioral health assessment skills, I have been proudest when students have been able to apply and disseminate these skills,” Dr. Schapiro said. “One of our recent PNP graduates was in a community primary care practicum when an adolescent thinking about suicide walked into the clinic with her father. Her preceptor wasn’t sure how to proceed, when the student said, ‘Wait! We just practiced this in class.’ The student pulled up her course website, and she and her preceptor walked through the assessment together, developed a safety plan with the teen and her father, and connected the teen with a therapist, avoiding an unnecessary ER visit and potential fragmentation of care.”
The need and expectation that pediatric PC providers incorporate MH services is well documented.2,12,13 PNPs who have additional training and expertise in assessing, diagnosing, and managing MH care are an excellent solution for addressing this problem. The benefits of this team-based approach to the pediatric health care home include decreasing stigma, increasing access, and providing comprehensive MH care to children and their families.
Dr. Haut works at Beacon Pediatrics, a large primary care practice in Rehoboth Beach, Del. She works part-time for Pediatrix Medical Group, serving the Pediatric Intensive Care Unit medical team at the Herman & Walter Samuelson Children’s Hospital at Sinai in Baltimore, and she serves as adjunct faculty at the University of Maryland School of Nursing, also in Baltimore. Other contributors to this article were Dawn Garzon Maaks, PhD, CPNP, PMHS; Naomi Schapiro, PhD, CPNP; Susan Van Cleve, DNP, RN, CPNP-PC, PMHS; and Laura Searcy, MN, APRN, PPCNP-BC. Ms. Searcy is on the medical staff at WellStar Kennestone Regional Medical Center in Marietta, Ga., delivering care to newborns. Dr. Haut and Ms. Searcy are members of the Pediatric News Consultant Advisory Board. Email them at [email protected].
References
1. “Best principles for integration of child psychiatry into the pediatric health home,” AACAP Executive Summary,2012, pages 1-13.
2. Pediatrics. 2009 Apr;123(4):1248-51.
3. Center for Disease Control and Prevention: Children’s Mental Health Data and Statistics.
4. MMWR Surveill Summ, 2016. doi:10.15585/mmwr.ss6506a1.
5. Pediatrics. 2015;135(5):909-17.
6. JAMA Pediatr. 2015;169(10):929-37.
7. “Integrating child psychology services into primary care,” by Tynan D, Woods K, and Carpenter J. American Psychological Association, 2014.
8. J Am Psychiatr Nurses Assoc. 2005;11(5): 276-82.
9. J Nurse Pract. 2013;9(4):243-8.
10. J Pediatr Health Care. 2013; 27(3):162-3.
11. Advanced Nursing Education Health Resources Service Administration grant (#D09HP26958).
12. J Nurse Pract. 2013:9(3):142-8.
13. Pediatrics. 2018;141(3):e20174082
Examining developmental monitoring and screening in LMICs
Over the last decade, three series published in the Lancet on child development have increased global awareness of the importance of early brain development and highlighted the critical role nurturing care plays in the first 3 years of a child’s life. Yet, as practitioners and policy makers in low- and middle-income countries increasingly acknowledge the influence early development has on later developmental, educational, and socioeconomic trajectories, there has been less agreement regarding the most appropriate methods and measures for screening and monitoring child development over time.
In an article published in Developmental Medicine & Child Neurology, we and our colleagues, Emily Vargas-Barón, PhD, of RISE Institute, Washington, and Kevin P. Marks, MD, of PeaceHealth Medical Group in Eugene, Ore., countered some of the concerns raised about translating and adapting screening measures developed in HICs. In the paper, we documented the translation, cultural adaptation, and implementation of the Ages and Stages Questionnaires (ASQ) in LMICs based on a critical examination of 53 studies published in a variety of peer-reviewed journals.
We used a consensus rating procedure to classify the articles into one of four categories: feasibility study, psychometric study, prevalence study, or research study. In total, we identified 8 feasibility studies, 12 psychometric studies, and 9 prevalence studies. The main objectives of these studies varied by economy and region.
Overall, the review revealed that the ASQ is already being used broadly in a range of countries, cultures, and linguistic contexts. As of 2017, the ASQ has been used in 23 LMICs distributed across all world regions and has been translated into at least 16 languages for use in these countries. Over half of the studies reported that parents filled out the ASQ, a finding that runs contrary to recent misconceptions about the use of developmental screeners in LMICs.
Additionally, we found that adaptation and use of the ASQ in LMICs often followed one of two paths. The first path involved engagement in a systematic translation and adaptation process, collection of evidence to support reliability and validity, completion of prevalence studies, and use in research or practice. This first path resulted in higher rates of parent completion and, in general, closer adherence to the administration procedures recommended by the ASQ development team. In contrast, a second path utilized the ASQ solely for research purposes. This path tended to result in more frequent deviations from recommended procedures for adaptation and translation (for example, on-the-fly translation or administration by assessors) and may be fueling some of the misunderstandings associated with developmental screening in LMICs.
As countries begin to develop and scale up Early Childhood Development and Early Childhood Intervention systems and services worldwide, it is vitally important that properly standardized developmental screening measures with strong evidence of reliability and validity are available for parents and practitioners. Regardless of whether researchers develop these measures locally or adapt them from measures developed in HICs, it is imperative that decision makers step back, compile available psychometric and feasibility information across the studies that have been conducted for a given measure, and draw their own conclusions.
Finally, given that some LMICs may have fewer early intervention resources and may face more barriers to ensuring service follow-up, it would be ideal if evidence-based developmental promotion (for example, early literacy promotion, positive parenting tips, or resiliency counseling) is incorporated into the process of developmental screening. In theory, this would make the screening process more effective and parent-centered.
Mr. Small is with the Oregon Research Institute, Eugene. Dr. Hix-Small is with Portland (Ore.) State University. The authors have stated that they had no interests that might be perceived as posing a conflict or bias. Dr. Hix-Small has worked as a paid ASQ trainer. Email them at [email protected].
Over the last decade, three series published in the Lancet on child development have increased global awareness of the importance of early brain development and highlighted the critical role nurturing care plays in the first 3 years of a child’s life. Yet, as practitioners and policy makers in low- and middle-income countries increasingly acknowledge the influence early development has on later developmental, educational, and socioeconomic trajectories, there has been less agreement regarding the most appropriate methods and measures for screening and monitoring child development over time.
In an article published in Developmental Medicine & Child Neurology, we and our colleagues, Emily Vargas-Barón, PhD, of RISE Institute, Washington, and Kevin P. Marks, MD, of PeaceHealth Medical Group in Eugene, Ore., countered some of the concerns raised about translating and adapting screening measures developed in HICs. In the paper, we documented the translation, cultural adaptation, and implementation of the Ages and Stages Questionnaires (ASQ) in LMICs based on a critical examination of 53 studies published in a variety of peer-reviewed journals.
We used a consensus rating procedure to classify the articles into one of four categories: feasibility study, psychometric study, prevalence study, or research study. In total, we identified 8 feasibility studies, 12 psychometric studies, and 9 prevalence studies. The main objectives of these studies varied by economy and region.
Overall, the review revealed that the ASQ is already being used broadly in a range of countries, cultures, and linguistic contexts. As of 2017, the ASQ has been used in 23 LMICs distributed across all world regions and has been translated into at least 16 languages for use in these countries. Over half of the studies reported that parents filled out the ASQ, a finding that runs contrary to recent misconceptions about the use of developmental screeners in LMICs.
Additionally, we found that adaptation and use of the ASQ in LMICs often followed one of two paths. The first path involved engagement in a systematic translation and adaptation process, collection of evidence to support reliability and validity, completion of prevalence studies, and use in research or practice. This first path resulted in higher rates of parent completion and, in general, closer adherence to the administration procedures recommended by the ASQ development team. In contrast, a second path utilized the ASQ solely for research purposes. This path tended to result in more frequent deviations from recommended procedures for adaptation and translation (for example, on-the-fly translation or administration by assessors) and may be fueling some of the misunderstandings associated with developmental screening in LMICs.
As countries begin to develop and scale up Early Childhood Development and Early Childhood Intervention systems and services worldwide, it is vitally important that properly standardized developmental screening measures with strong evidence of reliability and validity are available for parents and practitioners. Regardless of whether researchers develop these measures locally or adapt them from measures developed in HICs, it is imperative that decision makers step back, compile available psychometric and feasibility information across the studies that have been conducted for a given measure, and draw their own conclusions.
Finally, given that some LMICs may have fewer early intervention resources and may face more barriers to ensuring service follow-up, it would be ideal if evidence-based developmental promotion (for example, early literacy promotion, positive parenting tips, or resiliency counseling) is incorporated into the process of developmental screening. In theory, this would make the screening process more effective and parent-centered.
Mr. Small is with the Oregon Research Institute, Eugene. Dr. Hix-Small is with Portland (Ore.) State University. The authors have stated that they had no interests that might be perceived as posing a conflict or bias. Dr. Hix-Small has worked as a paid ASQ trainer. Email them at [email protected].
Over the last decade, three series published in the Lancet on child development have increased global awareness of the importance of early brain development and highlighted the critical role nurturing care plays in the first 3 years of a child’s life. Yet, as practitioners and policy makers in low- and middle-income countries increasingly acknowledge the influence early development has on later developmental, educational, and socioeconomic trajectories, there has been less agreement regarding the most appropriate methods and measures for screening and monitoring child development over time.
In an article published in Developmental Medicine & Child Neurology, we and our colleagues, Emily Vargas-Barón, PhD, of RISE Institute, Washington, and Kevin P. Marks, MD, of PeaceHealth Medical Group in Eugene, Ore., countered some of the concerns raised about translating and adapting screening measures developed in HICs. In the paper, we documented the translation, cultural adaptation, and implementation of the Ages and Stages Questionnaires (ASQ) in LMICs based on a critical examination of 53 studies published in a variety of peer-reviewed journals.
We used a consensus rating procedure to classify the articles into one of four categories: feasibility study, psychometric study, prevalence study, or research study. In total, we identified 8 feasibility studies, 12 psychometric studies, and 9 prevalence studies. The main objectives of these studies varied by economy and region.
Overall, the review revealed that the ASQ is already being used broadly in a range of countries, cultures, and linguistic contexts. As of 2017, the ASQ has been used in 23 LMICs distributed across all world regions and has been translated into at least 16 languages for use in these countries. Over half of the studies reported that parents filled out the ASQ, a finding that runs contrary to recent misconceptions about the use of developmental screeners in LMICs.
Additionally, we found that adaptation and use of the ASQ in LMICs often followed one of two paths. The first path involved engagement in a systematic translation and adaptation process, collection of evidence to support reliability and validity, completion of prevalence studies, and use in research or practice. This first path resulted in higher rates of parent completion and, in general, closer adherence to the administration procedures recommended by the ASQ development team. In contrast, a second path utilized the ASQ solely for research purposes. This path tended to result in more frequent deviations from recommended procedures for adaptation and translation (for example, on-the-fly translation or administration by assessors) and may be fueling some of the misunderstandings associated with developmental screening in LMICs.
As countries begin to develop and scale up Early Childhood Development and Early Childhood Intervention systems and services worldwide, it is vitally important that properly standardized developmental screening measures with strong evidence of reliability and validity are available for parents and practitioners. Regardless of whether researchers develop these measures locally or adapt them from measures developed in HICs, it is imperative that decision makers step back, compile available psychometric and feasibility information across the studies that have been conducted for a given measure, and draw their own conclusions.
Finally, given that some LMICs may have fewer early intervention resources and may face more barriers to ensuring service follow-up, it would be ideal if evidence-based developmental promotion (for example, early literacy promotion, positive parenting tips, or resiliency counseling) is incorporated into the process of developmental screening. In theory, this would make the screening process more effective and parent-centered.
Mr. Small is with the Oregon Research Institute, Eugene. Dr. Hix-Small is with Portland (Ore.) State University. The authors have stated that they had no interests that might be perceived as posing a conflict or bias. Dr. Hix-Small has worked as a paid ASQ trainer. Email them at [email protected].
Looking at study results with a critical eye
As a physician you are the embodiment of delayed gratification. You spent more than 20 years in school before you earned a degree that then allowed you spend another 3-plus years in training before anyone would consider you a “real” doctor. Somewhere along that long and shallow trajectory someone may have said, “You must have done really well on the marshmallow test.”
That is, until this year, when an attempt to replicate the initial study by Shoda et al. failed to find that the associations between delayed gratification and adolescent achievement were anywhere near as significant as those reported in the 1990 study (Psychol Sci. 2018 May. doi: 10.1177/0956797618761661). Watts et al. suggest that the discrepancy may be explained in part by a failure to adequately control for family background, home environment, and early cognitive ability in the initial experimental design.
Is there a message here? Should we stop wasting our time reading papers from the developmental psychology literature? Not just yet. There are more papers coming out in which the authors attempt to replicate other landmark studies, often without success (“Undergrads Can Improve Psychology,” by Russel T. Warne and Jordan Wagge, The Wall Street Journal, June 20, 2018). Let’s wait and see how much more debunking there is going to be before we throw the baby out with the bath water.
regardless of how prestigious the institution of origin and regardless of how much it appeals to our common sense. Our intuition can be a powerful tool when we are looking for answers, but it can lead us astray if we take it too seriously.
It is often said that a good experiment is one that raises more questions than it answers. You don’t have to remember all that stuff you learned when you studied statistics to be able to question the results of a study you read in a peer-reviewed journal. I find that in many of the papers I read I have serious concerns about how well the authors have controlled for the not-so-obvious variables.
So where does this failed attempt at replicating the original marshmallow test study leave us? It is still very likely given your aptitude for delayed gratification that had you been given the test as a preschooler you would not have even touched the marshmallow until the experimenter re-entered the room to end the test and then ... you probably would have offered to share it with her.
But these new results suggest that your ability to delay gratification was not some skill with which you were born. You may have been born smarter than the average child, but your skill at delaying gratification may have been one you learned from your parents and assimilated from the home environment in which your grew up. This may be one of those nature-or-nurture skirmishes in which nurture wins. And, it may be another good example of the importance of the first 3 or 4 years in a child’s emotional and psychological development.
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].
As a physician you are the embodiment of delayed gratification. You spent more than 20 years in school before you earned a degree that then allowed you spend another 3-plus years in training before anyone would consider you a “real” doctor. Somewhere along that long and shallow trajectory someone may have said, “You must have done really well on the marshmallow test.”
That is, until this year, when an attempt to replicate the initial study by Shoda et al. failed to find that the associations between delayed gratification and adolescent achievement were anywhere near as significant as those reported in the 1990 study (Psychol Sci. 2018 May. doi: 10.1177/0956797618761661). Watts et al. suggest that the discrepancy may be explained in part by a failure to adequately control for family background, home environment, and early cognitive ability in the initial experimental design.
Is there a message here? Should we stop wasting our time reading papers from the developmental psychology literature? Not just yet. There are more papers coming out in which the authors attempt to replicate other landmark studies, often without success (“Undergrads Can Improve Psychology,” by Russel T. Warne and Jordan Wagge, The Wall Street Journal, June 20, 2018). Let’s wait and see how much more debunking there is going to be before we throw the baby out with the bath water.
regardless of how prestigious the institution of origin and regardless of how much it appeals to our common sense. Our intuition can be a powerful tool when we are looking for answers, but it can lead us astray if we take it too seriously.
It is often said that a good experiment is one that raises more questions than it answers. You don’t have to remember all that stuff you learned when you studied statistics to be able to question the results of a study you read in a peer-reviewed journal. I find that in many of the papers I read I have serious concerns about how well the authors have controlled for the not-so-obvious variables.
So where does this failed attempt at replicating the original marshmallow test study leave us? It is still very likely given your aptitude for delayed gratification that had you been given the test as a preschooler you would not have even touched the marshmallow until the experimenter re-entered the room to end the test and then ... you probably would have offered to share it with her.
But these new results suggest that your ability to delay gratification was not some skill with which you were born. You may have been born smarter than the average child, but your skill at delaying gratification may have been one you learned from your parents and assimilated from the home environment in which your grew up. This may be one of those nature-or-nurture skirmishes in which nurture wins. And, it may be another good example of the importance of the first 3 or 4 years in a child’s emotional and psychological development.
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].
As a physician you are the embodiment of delayed gratification. You spent more than 20 years in school before you earned a degree that then allowed you spend another 3-plus years in training before anyone would consider you a “real” doctor. Somewhere along that long and shallow trajectory someone may have said, “You must have done really well on the marshmallow test.”
That is, until this year, when an attempt to replicate the initial study by Shoda et al. failed to find that the associations between delayed gratification and adolescent achievement were anywhere near as significant as those reported in the 1990 study (Psychol Sci. 2018 May. doi: 10.1177/0956797618761661). Watts et al. suggest that the discrepancy may be explained in part by a failure to adequately control for family background, home environment, and early cognitive ability in the initial experimental design.
Is there a message here? Should we stop wasting our time reading papers from the developmental psychology literature? Not just yet. There are more papers coming out in which the authors attempt to replicate other landmark studies, often without success (“Undergrads Can Improve Psychology,” by Russel T. Warne and Jordan Wagge, The Wall Street Journal, June 20, 2018). Let’s wait and see how much more debunking there is going to be before we throw the baby out with the bath water.
regardless of how prestigious the institution of origin and regardless of how much it appeals to our common sense. Our intuition can be a powerful tool when we are looking for answers, but it can lead us astray if we take it too seriously.
It is often said that a good experiment is one that raises more questions than it answers. You don’t have to remember all that stuff you learned when you studied statistics to be able to question the results of a study you read in a peer-reviewed journal. I find that in many of the papers I read I have serious concerns about how well the authors have controlled for the not-so-obvious variables.
So where does this failed attempt at replicating the original marshmallow test study leave us? It is still very likely given your aptitude for delayed gratification that had you been given the test as a preschooler you would not have even touched the marshmallow until the experimenter re-entered the room to end the test and then ... you probably would have offered to share it with her.
But these new results suggest that your ability to delay gratification was not some skill with which you were born. You may have been born smarter than the average child, but your skill at delaying gratification may have been one you learned from your parents and assimilated from the home environment in which your grew up. This may be one of those nature-or-nurture skirmishes in which nurture wins. And, it may be another good example of the importance of the first 3 or 4 years in a child’s emotional and psychological development.
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].