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Consider the siblings
Robert is a 5-year-old boy who presents for an autism diagnostic evaluation accompanied by his parents, who report longstanding concerns about their son’s communication difficulties. Robert has an older brother who has been diagnosed with an autism spectrum disorder (ASD). Robert’s caregivers have noticed his tendency to “copy cat” others and often repeat phrases from television or movies. Robert and his family provided additional history and, after a multidisciplinary evaluation, he was diagnosed as fitting the criteria for ASD. Our team spoke with Robert’s parents about their impressions and recommendations and further explored the family history and ways in which the family functions. Robert lives with his parents and four siblings (one older and three younger, including a set of fraternal twins), most of whom display language impairments and difficulties with emotional regulation, as well. Robert’s mother also discloses that she is pregnant again. “Where do we go from here?” Robert’s mother wonders. “Our family is already so affected by autism, should I be worried about the other children?”
Discussion
It’s well established that genetic factors play a significant role in the etiology of autism spectrum disorders, other neurodevelopmental disorders, and a vast array of mental health problems. Although quite complicated and multifactorial, heritability estimates garnered from twin studies for autism range up to well above 50%1, and although finding specific genetic causes of nonsyndromic autism is the exception to the rule, chromosomal microarray analysis (CMA) is recommended as a first-line genetic test for those with autism. Recent literature has shown that molecular diagnoses of ASD are found in about 9% of the population studied2, and families should be aware that genetic testing can potentially help make decisions about clinical management and can inform discussions about recurrence risk.
Families should be made aware that sibling recurrence rates of autism have been found to be around 20 times higher than the prevalence within the general population3. Certainly having one child with autism can afford a significant risk for parents having another child with the same disorder, and researchers are learning more about the influence of gender on such risk4. Curiously, siblings born after an older sister with autism seem to have a higher risk of ASD than if they were born after an older brother with autism. The authors of this study note, however, that even for those with the highest risk (younger brothers with an older sister with autism had about a 17% probability of recurrence), odds are they will be unaffected by autism. Complicating matters is the notion of the broad autism phenotype (BAP – denoting those who may have features of autism but do not reach diagnostic threshold) with literature indicating at least one BAP trait was found in about 50% of family members of those with ASD5.
In addition, autism also may share genetic vulnerabilities with other conditions – parental psychiatric diagnoses have been found to increase the risk for ASD in their children, and ASD frequently co-occurs with a constellation of other disorders – including anxiety disorders, intellectual disabilities, ADHD, and learning problems. This information can be helpful to clinicians when they speak with parents about the complicated nature of psychiatric and developmental disorders, and how such disorders can affect the family not only biologically, but through dynamic environmental means, as well. , including parents and siblings6. Data clearly indicate that, if a child carries an autism diagnosis, engaging family in family-based treatment, prevention, surveillance/screening, and general supportive interventions are critical in promoting positive outcomes.
Children and adolescents with ASD are a remarkably heterogeneous group with variable family dynamics; clinically, it’s not uncommon to meet parents from all backgrounds who speak eloquently about the stress they face raising a child with any neurodevelopmental disorder. This stress has been well documented in several scientific articles over the past decade (for mothers more so than fathers) but other family members (for example, typically developing siblings) undoubtedly experience similar stress, but this has been less robustly researched. Literature has, in fact, revealed that children who develop typically and who reside with a sibling who has a disability are more likely (compared with siblings living with other typically developing siblings) to have problems related to interpersonal relationships, school functioning, and use of leisure time7. Undeniably, complicated interactions with one’s functional profile, the quality of a sibling’s symptoms, parental stress, and other variables (parental marital status, birth order, presence of parental depression, available sources of support, etc.) are noted, and clearly, autism’s effects can extend far beyond the “identified patient.”
It’s important to note, however, that not all effects are negative. Siblings can demonstrate positive adjustments when growing up with a brother or sister who has autism. While siblings encounter unique demands (missing out on certain outings, feeling embarrassed by a brother’s social behaviors, having to “take care” of their brother, “why can’t we be a normal family?”), these demands can produce benefits, and parents should be aware that negative effects on siblings are far from inevitable. Siblings actually may show increased empathy, more sophisticated coping skills, and an advanced appreciation for those with developmental challenges, compared with most of their peers. Typically developing siblings can serve not only as a social and play partner for their family member with ASD (fostering social competencies), but also the individual with ASD can serve a positive role in influencing the development of those without ASD8.
All things considered, talking with families about the impact of autism on parents and siblings can be complicated but should focus on the positives while being realistic about potential challenges. It is important to inform families about the risk of recurrence and about the stress that autism can create on siblings while you are assessing a family’s functioning and care-giving burdens. Ultimately, this can help you determine how to offer them the most appropriate, evidence-based, and family-focused care.
Dr. Dickerson, a child and adolescent psychiatrist, is an assistant professor of psychiatry at the University of Vermont, Burlington, where he is director of the autism diagnostic clinic. Email him at [email protected].
References
1. J Child Psychol Psychiatry. 2016 May;57(5):585-95.
2. JAMA. 2015;314(9):895-903.
3. Child Adolesc Psychiatr Clin N Am. 2017 Jul;26(3):555-70.
4. (JAMA Pediatr. 2017 Sep 25. doi: 10.1001/jamapediatrics.2017.2832).
5. J Autism Dev Disord. 2007 Mar; 37(3):523-36.
6. JAMA Psychiatry. 2016;73(6):622-9.
7. Pediatrics. 2013. doi: 10.1542/peds.2013-0644.
Robert is a 5-year-old boy who presents for an autism diagnostic evaluation accompanied by his parents, who report longstanding concerns about their son’s communication difficulties. Robert has an older brother who has been diagnosed with an autism spectrum disorder (ASD). Robert’s caregivers have noticed his tendency to “copy cat” others and often repeat phrases from television or movies. Robert and his family provided additional history and, after a multidisciplinary evaluation, he was diagnosed as fitting the criteria for ASD. Our team spoke with Robert’s parents about their impressions and recommendations and further explored the family history and ways in which the family functions. Robert lives with his parents and four siblings (one older and three younger, including a set of fraternal twins), most of whom display language impairments and difficulties with emotional regulation, as well. Robert’s mother also discloses that she is pregnant again. “Where do we go from here?” Robert’s mother wonders. “Our family is already so affected by autism, should I be worried about the other children?”
Discussion
It’s well established that genetic factors play a significant role in the etiology of autism spectrum disorders, other neurodevelopmental disorders, and a vast array of mental health problems. Although quite complicated and multifactorial, heritability estimates garnered from twin studies for autism range up to well above 50%1, and although finding specific genetic causes of nonsyndromic autism is the exception to the rule, chromosomal microarray analysis (CMA) is recommended as a first-line genetic test for those with autism. Recent literature has shown that molecular diagnoses of ASD are found in about 9% of the population studied2, and families should be aware that genetic testing can potentially help make decisions about clinical management and can inform discussions about recurrence risk.
Families should be made aware that sibling recurrence rates of autism have been found to be around 20 times higher than the prevalence within the general population3. Certainly having one child with autism can afford a significant risk for parents having another child with the same disorder, and researchers are learning more about the influence of gender on such risk4. Curiously, siblings born after an older sister with autism seem to have a higher risk of ASD than if they were born after an older brother with autism. The authors of this study note, however, that even for those with the highest risk (younger brothers with an older sister with autism had about a 17% probability of recurrence), odds are they will be unaffected by autism. Complicating matters is the notion of the broad autism phenotype (BAP – denoting those who may have features of autism but do not reach diagnostic threshold) with literature indicating at least one BAP trait was found in about 50% of family members of those with ASD5.
In addition, autism also may share genetic vulnerabilities with other conditions – parental psychiatric diagnoses have been found to increase the risk for ASD in their children, and ASD frequently co-occurs with a constellation of other disorders – including anxiety disorders, intellectual disabilities, ADHD, and learning problems. This information can be helpful to clinicians when they speak with parents about the complicated nature of psychiatric and developmental disorders, and how such disorders can affect the family not only biologically, but through dynamic environmental means, as well. , including parents and siblings6. Data clearly indicate that, if a child carries an autism diagnosis, engaging family in family-based treatment, prevention, surveillance/screening, and general supportive interventions are critical in promoting positive outcomes.
Children and adolescents with ASD are a remarkably heterogeneous group with variable family dynamics; clinically, it’s not uncommon to meet parents from all backgrounds who speak eloquently about the stress they face raising a child with any neurodevelopmental disorder. This stress has been well documented in several scientific articles over the past decade (for mothers more so than fathers) but other family members (for example, typically developing siblings) undoubtedly experience similar stress, but this has been less robustly researched. Literature has, in fact, revealed that children who develop typically and who reside with a sibling who has a disability are more likely (compared with siblings living with other typically developing siblings) to have problems related to interpersonal relationships, school functioning, and use of leisure time7. Undeniably, complicated interactions with one’s functional profile, the quality of a sibling’s symptoms, parental stress, and other variables (parental marital status, birth order, presence of parental depression, available sources of support, etc.) are noted, and clearly, autism’s effects can extend far beyond the “identified patient.”
It’s important to note, however, that not all effects are negative. Siblings can demonstrate positive adjustments when growing up with a brother or sister who has autism. While siblings encounter unique demands (missing out on certain outings, feeling embarrassed by a brother’s social behaviors, having to “take care” of their brother, “why can’t we be a normal family?”), these demands can produce benefits, and parents should be aware that negative effects on siblings are far from inevitable. Siblings actually may show increased empathy, more sophisticated coping skills, and an advanced appreciation for those with developmental challenges, compared with most of their peers. Typically developing siblings can serve not only as a social and play partner for their family member with ASD (fostering social competencies), but also the individual with ASD can serve a positive role in influencing the development of those without ASD8.
All things considered, talking with families about the impact of autism on parents and siblings can be complicated but should focus on the positives while being realistic about potential challenges. It is important to inform families about the risk of recurrence and about the stress that autism can create on siblings while you are assessing a family’s functioning and care-giving burdens. Ultimately, this can help you determine how to offer them the most appropriate, evidence-based, and family-focused care.
Dr. Dickerson, a child and adolescent psychiatrist, is an assistant professor of psychiatry at the University of Vermont, Burlington, where he is director of the autism diagnostic clinic. Email him at [email protected].
References
1. J Child Psychol Psychiatry. 2016 May;57(5):585-95.
2. JAMA. 2015;314(9):895-903.
3. Child Adolesc Psychiatr Clin N Am. 2017 Jul;26(3):555-70.
4. (JAMA Pediatr. 2017 Sep 25. doi: 10.1001/jamapediatrics.2017.2832).
5. J Autism Dev Disord. 2007 Mar; 37(3):523-36.
6. JAMA Psychiatry. 2016;73(6):622-9.
7. Pediatrics. 2013. doi: 10.1542/peds.2013-0644.
Robert is a 5-year-old boy who presents for an autism diagnostic evaluation accompanied by his parents, who report longstanding concerns about their son’s communication difficulties. Robert has an older brother who has been diagnosed with an autism spectrum disorder (ASD). Robert’s caregivers have noticed his tendency to “copy cat” others and often repeat phrases from television or movies. Robert and his family provided additional history and, after a multidisciplinary evaluation, he was diagnosed as fitting the criteria for ASD. Our team spoke with Robert’s parents about their impressions and recommendations and further explored the family history and ways in which the family functions. Robert lives with his parents and four siblings (one older and three younger, including a set of fraternal twins), most of whom display language impairments and difficulties with emotional regulation, as well. Robert’s mother also discloses that she is pregnant again. “Where do we go from here?” Robert’s mother wonders. “Our family is already so affected by autism, should I be worried about the other children?”
Discussion
It’s well established that genetic factors play a significant role in the etiology of autism spectrum disorders, other neurodevelopmental disorders, and a vast array of mental health problems. Although quite complicated and multifactorial, heritability estimates garnered from twin studies for autism range up to well above 50%1, and although finding specific genetic causes of nonsyndromic autism is the exception to the rule, chromosomal microarray analysis (CMA) is recommended as a first-line genetic test for those with autism. Recent literature has shown that molecular diagnoses of ASD are found in about 9% of the population studied2, and families should be aware that genetic testing can potentially help make decisions about clinical management and can inform discussions about recurrence risk.
Families should be made aware that sibling recurrence rates of autism have been found to be around 20 times higher than the prevalence within the general population3. Certainly having one child with autism can afford a significant risk for parents having another child with the same disorder, and researchers are learning more about the influence of gender on such risk4. Curiously, siblings born after an older sister with autism seem to have a higher risk of ASD than if they were born after an older brother with autism. The authors of this study note, however, that even for those with the highest risk (younger brothers with an older sister with autism had about a 17% probability of recurrence), odds are they will be unaffected by autism. Complicating matters is the notion of the broad autism phenotype (BAP – denoting those who may have features of autism but do not reach diagnostic threshold) with literature indicating at least one BAP trait was found in about 50% of family members of those with ASD5.
In addition, autism also may share genetic vulnerabilities with other conditions – parental psychiatric diagnoses have been found to increase the risk for ASD in their children, and ASD frequently co-occurs with a constellation of other disorders – including anxiety disorders, intellectual disabilities, ADHD, and learning problems. This information can be helpful to clinicians when they speak with parents about the complicated nature of psychiatric and developmental disorders, and how such disorders can affect the family not only biologically, but through dynamic environmental means, as well. , including parents and siblings6. Data clearly indicate that, if a child carries an autism diagnosis, engaging family in family-based treatment, prevention, surveillance/screening, and general supportive interventions are critical in promoting positive outcomes.
Children and adolescents with ASD are a remarkably heterogeneous group with variable family dynamics; clinically, it’s not uncommon to meet parents from all backgrounds who speak eloquently about the stress they face raising a child with any neurodevelopmental disorder. This stress has been well documented in several scientific articles over the past decade (for mothers more so than fathers) but other family members (for example, typically developing siblings) undoubtedly experience similar stress, but this has been less robustly researched. Literature has, in fact, revealed that children who develop typically and who reside with a sibling who has a disability are more likely (compared with siblings living with other typically developing siblings) to have problems related to interpersonal relationships, school functioning, and use of leisure time7. Undeniably, complicated interactions with one’s functional profile, the quality of a sibling’s symptoms, parental stress, and other variables (parental marital status, birth order, presence of parental depression, available sources of support, etc.) are noted, and clearly, autism’s effects can extend far beyond the “identified patient.”
It’s important to note, however, that not all effects are negative. Siblings can demonstrate positive adjustments when growing up with a brother or sister who has autism. While siblings encounter unique demands (missing out on certain outings, feeling embarrassed by a brother’s social behaviors, having to “take care” of their brother, “why can’t we be a normal family?”), these demands can produce benefits, and parents should be aware that negative effects on siblings are far from inevitable. Siblings actually may show increased empathy, more sophisticated coping skills, and an advanced appreciation for those with developmental challenges, compared with most of their peers. Typically developing siblings can serve not only as a social and play partner for their family member with ASD (fostering social competencies), but also the individual with ASD can serve a positive role in influencing the development of those without ASD8.
All things considered, talking with families about the impact of autism on parents and siblings can be complicated but should focus on the positives while being realistic about potential challenges. It is important to inform families about the risk of recurrence and about the stress that autism can create on siblings while you are assessing a family’s functioning and care-giving burdens. Ultimately, this can help you determine how to offer them the most appropriate, evidence-based, and family-focused care.
Dr. Dickerson, a child and adolescent psychiatrist, is an assistant professor of psychiatry at the University of Vermont, Burlington, where he is director of the autism diagnostic clinic. Email him at [email protected].
References
1. J Child Psychol Psychiatry. 2016 May;57(5):585-95.
2. JAMA. 2015;314(9):895-903.
3. Child Adolesc Psychiatr Clin N Am. 2017 Jul;26(3):555-70.
4. (JAMA Pediatr. 2017 Sep 25. doi: 10.1001/jamapediatrics.2017.2832).
5. J Autism Dev Disord. 2007 Mar; 37(3):523-36.
6. JAMA Psychiatry. 2016;73(6):622-9.
7. Pediatrics. 2013. doi: 10.1542/peds.2013-0644.
AHRQ Practice Toolbox: Team-based care
This is the third in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.
Primary care clinicians increasingly recognize the benefits of team-based care, in which providers with complementary strengths join to the betterment of patient care. Care teams are groups of primary care staff members who collectively take responsibility for a set of patients. These teams blend multidisciplinary skills, focusing several people’s insights, rather than a single provider’s, on each patient’s problems. The composition of a care team depends on the size and resources of the practice and the needs of the patient population. Teams are generally organized around a primary care provider (for example, physician, advanced practice nurse, physician assistant) and the patient. Nurses, pharmacists, nutritionists, social workers, educators, and care coordinators also may be part of the care team. In smaller practices, care teams have fewer members, requiring creative team-based solutions. Such practices also may build virtual teams by linking themselves and their patients to providers and services in their communities. Team-based care is especially important when addressing the needs of patients with multiple chronic conditions.
AHRQ recognizes the importance that creating a team-based patient-centered culture in primary care has on improving patient outcomes. “Creating Patient-Centered Team-Based Care” is a white paper that proposes a conceptual framework to facilitate the integration of team-based care and patient-centered care in primary care settings and offers some practical strategies to support the implementation of patient-centered team-based primary care. In addition, the white paper identifies strategies that can serve as a starting point for investigations into the effectiveness of interventions to provide patient-centered team-based primary care.
One such strategy is an evidence-based teamwork practice improvement program jointly developed by AHRQ and the Department of Defense called Team Strategies & Tools to Enhance Performance and Patient Safety, better known as TeamSTEPPS. “TeamSTEPPS for Office-Based Care Version” adapts the core concepts of 20 years of evidence in the application of teamwork principles to building high-functioning teams specifically in office-based settings. The examples, discussions, videos, and exercises are tailored to the primary care environment to help any practice begin or expand its team-based care efforts.
Links from the NCEPCR site:
Tools and Resources for Research, Quality Improvement, and Practice: https://www.ahrq.gov/ncepcr/research-qi-practice/index.html
Creating Patient-Centered Team-Based Care: https://www.pcmh.ahrq.gov/page/creating-patient-centered-team-based-primary-care
TeamSTEPPS for Office-Based Care Version: https://www.ahrq.gov/teamstepps/officebasedcare/index.html
Dr. Ricciardi is director of the Division of Practice Improvement at the AHRQ. Dr. Ganiats is director of the National Center for Excellence in Primary Care Research at the AHRQ.
This is the third in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.
Primary care clinicians increasingly recognize the benefits of team-based care, in which providers with complementary strengths join to the betterment of patient care. Care teams are groups of primary care staff members who collectively take responsibility for a set of patients. These teams blend multidisciplinary skills, focusing several people’s insights, rather than a single provider’s, on each patient’s problems. The composition of a care team depends on the size and resources of the practice and the needs of the patient population. Teams are generally organized around a primary care provider (for example, physician, advanced practice nurse, physician assistant) and the patient. Nurses, pharmacists, nutritionists, social workers, educators, and care coordinators also may be part of the care team. In smaller practices, care teams have fewer members, requiring creative team-based solutions. Such practices also may build virtual teams by linking themselves and their patients to providers and services in their communities. Team-based care is especially important when addressing the needs of patients with multiple chronic conditions.
AHRQ recognizes the importance that creating a team-based patient-centered culture in primary care has on improving patient outcomes. “Creating Patient-Centered Team-Based Care” is a white paper that proposes a conceptual framework to facilitate the integration of team-based care and patient-centered care in primary care settings and offers some practical strategies to support the implementation of patient-centered team-based primary care. In addition, the white paper identifies strategies that can serve as a starting point for investigations into the effectiveness of interventions to provide patient-centered team-based primary care.
One such strategy is an evidence-based teamwork practice improvement program jointly developed by AHRQ and the Department of Defense called Team Strategies & Tools to Enhance Performance and Patient Safety, better known as TeamSTEPPS. “TeamSTEPPS for Office-Based Care Version” adapts the core concepts of 20 years of evidence in the application of teamwork principles to building high-functioning teams specifically in office-based settings. The examples, discussions, videos, and exercises are tailored to the primary care environment to help any practice begin or expand its team-based care efforts.
Links from the NCEPCR site:
Tools and Resources for Research, Quality Improvement, and Practice: https://www.ahrq.gov/ncepcr/research-qi-practice/index.html
Creating Patient-Centered Team-Based Care: https://www.pcmh.ahrq.gov/page/creating-patient-centered-team-based-primary-care
TeamSTEPPS for Office-Based Care Version: https://www.ahrq.gov/teamstepps/officebasedcare/index.html
Dr. Ricciardi is director of the Division of Practice Improvement at the AHRQ. Dr. Ganiats is director of the National Center for Excellence in Primary Care Research at the AHRQ.
This is the third in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.
Primary care clinicians increasingly recognize the benefits of team-based care, in which providers with complementary strengths join to the betterment of patient care. Care teams are groups of primary care staff members who collectively take responsibility for a set of patients. These teams blend multidisciplinary skills, focusing several people’s insights, rather than a single provider’s, on each patient’s problems. The composition of a care team depends on the size and resources of the practice and the needs of the patient population. Teams are generally organized around a primary care provider (for example, physician, advanced practice nurse, physician assistant) and the patient. Nurses, pharmacists, nutritionists, social workers, educators, and care coordinators also may be part of the care team. In smaller practices, care teams have fewer members, requiring creative team-based solutions. Such practices also may build virtual teams by linking themselves and their patients to providers and services in their communities. Team-based care is especially important when addressing the needs of patients with multiple chronic conditions.
AHRQ recognizes the importance that creating a team-based patient-centered culture in primary care has on improving patient outcomes. “Creating Patient-Centered Team-Based Care” is a white paper that proposes a conceptual framework to facilitate the integration of team-based care and patient-centered care in primary care settings and offers some practical strategies to support the implementation of patient-centered team-based primary care. In addition, the white paper identifies strategies that can serve as a starting point for investigations into the effectiveness of interventions to provide patient-centered team-based primary care.
One such strategy is an evidence-based teamwork practice improvement program jointly developed by AHRQ and the Department of Defense called Team Strategies & Tools to Enhance Performance and Patient Safety, better known as TeamSTEPPS. “TeamSTEPPS for Office-Based Care Version” adapts the core concepts of 20 years of evidence in the application of teamwork principles to building high-functioning teams specifically in office-based settings. The examples, discussions, videos, and exercises are tailored to the primary care environment to help any practice begin or expand its team-based care efforts.
Links from the NCEPCR site:
Tools and Resources for Research, Quality Improvement, and Practice: https://www.ahrq.gov/ncepcr/research-qi-practice/index.html
Creating Patient-Centered Team-Based Care: https://www.pcmh.ahrq.gov/page/creating-patient-centered-team-based-primary-care
TeamSTEPPS for Office-Based Care Version: https://www.ahrq.gov/teamstepps/officebasedcare/index.html
Dr. Ricciardi is director of the Division of Practice Improvement at the AHRQ. Dr. Ganiats is director of the National Center for Excellence in Primary Care Research at the AHRQ.
“I’m sorry, doctor, I’m afraid I can’t do that”
In “2001: A Space Odyssey,” the epic 1968 film by Stanley Kubrick and Arthur C. Clarke, humanity makes first contact with an alien intelligence, and the course of history is irreversibly altered. Hailed as a watershed moment in science fiction, “2001” was considered way ahead of its time and raised a number of philosophical questions about what would happen if we ever encountered another form of life. Interestingly, the most noteworthy character in the film isn’t human or alien, but instead a new form of life altogether: an artificial intelligence (AI) known as the Heuristically programmed ALgorithmic computer 9000. HAL (as he is known colloquially) operates the Discovery One spacecraft, ferrying several scientists bound for Jupiter on a mission of exploration. Stating that he is “foolproof and incapable of error,” HAL’s superiority complex leads him to become the film’s antagonist, as he believes that human error is the cause of the difficulties they encounter. He eventually concludes that the best way to complete the mission is to eliminate human interference. When asked by scientist Dr. David Bowman to perform a simple function essential to the survival of the crew, HAL simply states “I’m sorry, Dave, I’m afraid I can’t do that.” Bowman is forced to disconnect HAL’s higher intellectual capabilities, reverting the computer to its most basic functions to ensure human survival.
Kubrick and Clarke may have been overly ambitious in predicting the progress of human space flight, but their call for concern over the risks of artificial intelligence seems quite prescient. Recently, billionaire entrepreneur Elon Musk (CEO of Tesla Motors and SpaceX) raised his concerns about AI, warning that, left unchecked, AI could be mankind’s final invention – one that could eventually destroy us. Other giants of the tech industry, including Bill Gates and Mark Zuckerberg, disagree. They believe AI represents tremendous promise for humanity and could usher in innovations unlike any we have ever seen.
A few weeks ago, we attended a national electronic health records conference where a well-known EHR vendor unveiled the new features in the upcoming release of their software. One of the most noteworthy additions was an intelligent virtual assistant, designed to help providers care for patients. While this is not the first time AI has ventured into health care (see IBM’s “Watson”), it is the first time the idea has become mainstream and fully integrated into physician workflow. Much like the virtual assistants mentioned above, this one can use voice or mouse/keyboard interaction to find clinical information, simplify common tasks, and help with medical decision-making.
While exciting at first, the idea of artificially intelligent EHRs may sound terrifying to some who aren’t yet ready to trust any patient care to machines. Reassuringly, while the integrated virtual assistant mentioned above can make suggestions to guide physicians to the right data or offer decision support when available, it is primarily focused on interface enhancement to improve work flow. It is not yet capable of making true clinical decisions that remove the physician from care delivery, but computers that do the diagnostic work of physicians may be closer than you think.
Research done at Jefferson University in Philadelphia and published in the August 2017 edition of Radiology1 investigated the ability of deep-learning algorithms to interpret chest radiographs for the diagnosis of tuberculosis. The computers achieved an impressive reliability of 99%. While at first radiograph interpretation seems quite different than the diagnostic decision-making done in primary care, the fundamental skill required for both is similar: pattern recognition. To build those patterns, artificial intelligence requires an enormous number of data points, but that’s hardly a problem thanks to the continual collection of patient data through electronic health records. The amount of raw information available to these algorithms is growing exponentially by the day, and with time their predictive ability will be unmatched. So where will that leave us, the physicians, entrusted for generations with the responsibility of diagnosis? Possibly more satisfied than we are today.
There was a time – not long ago – when the body of available medical knowledge was incredibly limited. Diagnostic testing was primitive and often inaccurate, and the treatment provided by physicians was focused on supporting, communicating, and genuinely caring for patients and their families. In the past 50 years, medical knowledge has exploded, and diagnostic testing has become incredibly advanced. Sadly, at the same time physicians have begun to feel more like clerical workers: entering data, writing prescriptions, and filling out forms. As artificial intelligence assumes some of this busywork and takes much of the guesswork out of diagnosis, physicians may find greater job satisfaction as they provide the skills a computer never can: a human touch, a personal and reflective interpretation of a patient’s diagnosis, and a true emotional connection. Ask this of a computer, and the response will always be the same: “I’m sorry, doctor, I’m afraid I can’t do that.”
Reference
1. Lakhani, Paras & Sundaram, Baskaran, “Deep Learning at Chest Radiography: Automated Classification of Pulmonary Tuberculosis by Using Convolutional Neural Networks,” Radiology. 2017 Aug;284:574-82.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health.
In “2001: A Space Odyssey,” the epic 1968 film by Stanley Kubrick and Arthur C. Clarke, humanity makes first contact with an alien intelligence, and the course of history is irreversibly altered. Hailed as a watershed moment in science fiction, “2001” was considered way ahead of its time and raised a number of philosophical questions about what would happen if we ever encountered another form of life. Interestingly, the most noteworthy character in the film isn’t human or alien, but instead a new form of life altogether: an artificial intelligence (AI) known as the Heuristically programmed ALgorithmic computer 9000. HAL (as he is known colloquially) operates the Discovery One spacecraft, ferrying several scientists bound for Jupiter on a mission of exploration. Stating that he is “foolproof and incapable of error,” HAL’s superiority complex leads him to become the film’s antagonist, as he believes that human error is the cause of the difficulties they encounter. He eventually concludes that the best way to complete the mission is to eliminate human interference. When asked by scientist Dr. David Bowman to perform a simple function essential to the survival of the crew, HAL simply states “I’m sorry, Dave, I’m afraid I can’t do that.” Bowman is forced to disconnect HAL’s higher intellectual capabilities, reverting the computer to its most basic functions to ensure human survival.
Kubrick and Clarke may have been overly ambitious in predicting the progress of human space flight, but their call for concern over the risks of artificial intelligence seems quite prescient. Recently, billionaire entrepreneur Elon Musk (CEO of Tesla Motors and SpaceX) raised his concerns about AI, warning that, left unchecked, AI could be mankind’s final invention – one that could eventually destroy us. Other giants of the tech industry, including Bill Gates and Mark Zuckerberg, disagree. They believe AI represents tremendous promise for humanity and could usher in innovations unlike any we have ever seen.
A few weeks ago, we attended a national electronic health records conference where a well-known EHR vendor unveiled the new features in the upcoming release of their software. One of the most noteworthy additions was an intelligent virtual assistant, designed to help providers care for patients. While this is not the first time AI has ventured into health care (see IBM’s “Watson”), it is the first time the idea has become mainstream and fully integrated into physician workflow. Much like the virtual assistants mentioned above, this one can use voice or mouse/keyboard interaction to find clinical information, simplify common tasks, and help with medical decision-making.
While exciting at first, the idea of artificially intelligent EHRs may sound terrifying to some who aren’t yet ready to trust any patient care to machines. Reassuringly, while the integrated virtual assistant mentioned above can make suggestions to guide physicians to the right data or offer decision support when available, it is primarily focused on interface enhancement to improve work flow. It is not yet capable of making true clinical decisions that remove the physician from care delivery, but computers that do the diagnostic work of physicians may be closer than you think.
Research done at Jefferson University in Philadelphia and published in the August 2017 edition of Radiology1 investigated the ability of deep-learning algorithms to interpret chest radiographs for the diagnosis of tuberculosis. The computers achieved an impressive reliability of 99%. While at first radiograph interpretation seems quite different than the diagnostic decision-making done in primary care, the fundamental skill required for both is similar: pattern recognition. To build those patterns, artificial intelligence requires an enormous number of data points, but that’s hardly a problem thanks to the continual collection of patient data through electronic health records. The amount of raw information available to these algorithms is growing exponentially by the day, and with time their predictive ability will be unmatched. So where will that leave us, the physicians, entrusted for generations with the responsibility of diagnosis? Possibly more satisfied than we are today.
There was a time – not long ago – when the body of available medical knowledge was incredibly limited. Diagnostic testing was primitive and often inaccurate, and the treatment provided by physicians was focused on supporting, communicating, and genuinely caring for patients and their families. In the past 50 years, medical knowledge has exploded, and diagnostic testing has become incredibly advanced. Sadly, at the same time physicians have begun to feel more like clerical workers: entering data, writing prescriptions, and filling out forms. As artificial intelligence assumes some of this busywork and takes much of the guesswork out of diagnosis, physicians may find greater job satisfaction as they provide the skills a computer never can: a human touch, a personal and reflective interpretation of a patient’s diagnosis, and a true emotional connection. Ask this of a computer, and the response will always be the same: “I’m sorry, doctor, I’m afraid I can’t do that.”
Reference
1. Lakhani, Paras & Sundaram, Baskaran, “Deep Learning at Chest Radiography: Automated Classification of Pulmonary Tuberculosis by Using Convolutional Neural Networks,” Radiology. 2017 Aug;284:574-82.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health.
In “2001: A Space Odyssey,” the epic 1968 film by Stanley Kubrick and Arthur C. Clarke, humanity makes first contact with an alien intelligence, and the course of history is irreversibly altered. Hailed as a watershed moment in science fiction, “2001” was considered way ahead of its time and raised a number of philosophical questions about what would happen if we ever encountered another form of life. Interestingly, the most noteworthy character in the film isn’t human or alien, but instead a new form of life altogether: an artificial intelligence (AI) known as the Heuristically programmed ALgorithmic computer 9000. HAL (as he is known colloquially) operates the Discovery One spacecraft, ferrying several scientists bound for Jupiter on a mission of exploration. Stating that he is “foolproof and incapable of error,” HAL’s superiority complex leads him to become the film’s antagonist, as he believes that human error is the cause of the difficulties they encounter. He eventually concludes that the best way to complete the mission is to eliminate human interference. When asked by scientist Dr. David Bowman to perform a simple function essential to the survival of the crew, HAL simply states “I’m sorry, Dave, I’m afraid I can’t do that.” Bowman is forced to disconnect HAL’s higher intellectual capabilities, reverting the computer to its most basic functions to ensure human survival.
Kubrick and Clarke may have been overly ambitious in predicting the progress of human space flight, but their call for concern over the risks of artificial intelligence seems quite prescient. Recently, billionaire entrepreneur Elon Musk (CEO of Tesla Motors and SpaceX) raised his concerns about AI, warning that, left unchecked, AI could be mankind’s final invention – one that could eventually destroy us. Other giants of the tech industry, including Bill Gates and Mark Zuckerberg, disagree. They believe AI represents tremendous promise for humanity and could usher in innovations unlike any we have ever seen.
A few weeks ago, we attended a national electronic health records conference where a well-known EHR vendor unveiled the new features in the upcoming release of their software. One of the most noteworthy additions was an intelligent virtual assistant, designed to help providers care for patients. While this is not the first time AI has ventured into health care (see IBM’s “Watson”), it is the first time the idea has become mainstream and fully integrated into physician workflow. Much like the virtual assistants mentioned above, this one can use voice or mouse/keyboard interaction to find clinical information, simplify common tasks, and help with medical decision-making.
While exciting at first, the idea of artificially intelligent EHRs may sound terrifying to some who aren’t yet ready to trust any patient care to machines. Reassuringly, while the integrated virtual assistant mentioned above can make suggestions to guide physicians to the right data or offer decision support when available, it is primarily focused on interface enhancement to improve work flow. It is not yet capable of making true clinical decisions that remove the physician from care delivery, but computers that do the diagnostic work of physicians may be closer than you think.
Research done at Jefferson University in Philadelphia and published in the August 2017 edition of Radiology1 investigated the ability of deep-learning algorithms to interpret chest radiographs for the diagnosis of tuberculosis. The computers achieved an impressive reliability of 99%. While at first radiograph interpretation seems quite different than the diagnostic decision-making done in primary care, the fundamental skill required for both is similar: pattern recognition. To build those patterns, artificial intelligence requires an enormous number of data points, but that’s hardly a problem thanks to the continual collection of patient data through electronic health records. The amount of raw information available to these algorithms is growing exponentially by the day, and with time their predictive ability will be unmatched. So where will that leave us, the physicians, entrusted for generations with the responsibility of diagnosis? Possibly more satisfied than we are today.
There was a time – not long ago – when the body of available medical knowledge was incredibly limited. Diagnostic testing was primitive and often inaccurate, and the treatment provided by physicians was focused on supporting, communicating, and genuinely caring for patients and their families. In the past 50 years, medical knowledge has exploded, and diagnostic testing has become incredibly advanced. Sadly, at the same time physicians have begun to feel more like clerical workers: entering data, writing prescriptions, and filling out forms. As artificial intelligence assumes some of this busywork and takes much of the guesswork out of diagnosis, physicians may find greater job satisfaction as they provide the skills a computer never can: a human touch, a personal and reflective interpretation of a patient’s diagnosis, and a true emotional connection. Ask this of a computer, and the response will always be the same: “I’m sorry, doctor, I’m afraid I can’t do that.”
Reference
1. Lakhani, Paras & Sundaram, Baskaran, “Deep Learning at Chest Radiography: Automated Classification of Pulmonary Tuberculosis by Using Convolutional Neural Networks,” Radiology. 2017 Aug;284:574-82.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health.
Flu shots and persuasion
Compliant patients are all alike; every noncompliant patient is obstinate in his or her own way. Because of this, persuading patients to make good choices is rarely easy and never universal.
At Kaiser Permanente, we have begun in earnest providing flu shots. Every department participates (even dermatology) with a goal of vaccinating every eligible patient. Most patients want their shot. When patients decline, it’s game on. A rare few decline for justifiable reasons such as an allergy. Most say “no” for flawed reasons: “I never get the flu,” “The shot always gives me the flu,” and “I don’t believe in vaccines,” are common ones.
Fortunately, we can help them. Here are techniques I learned while working on my MBA that I’ve found useful in persuading patients to make better choices:
- The “everyone is doing it” technique. At KP, we’ve put up boards with the iconic goal thermometer showing how many flu shots we need to reach our objective. When patients see we’ve given over 1,000 shots in dermatology in just 2 weeks, this technique helps convince them. Patients prefer to be like others rather than to stand out, particularly when there is uncertainty.
- The “this is who you are technique.” Patients hate to be seen as inconsistent. In fact, we are all more likely to make a choice seen as consistent with who we are rather than change our mind, even if doing so is a better choice. Highlight how they have previously shown good decision making and healthy behaviors and point out how getting vaccinated is consonant with who they are. For example: “Being a vegan, you are clearly someone who takes care of her health. Getting the vaccine is similar to choosing to eat plants. It’s what healthy people like you do.”
- The “well, that’s not like you” technique. Here, you point out how their choice is inconsistent with their previous choices. You might say, “Why would you get the hepatitis A vaccine last week and not the flu shot today?” Like the previous technique, this creates cognitive dissonance. You might soften the approach by saying, “You might have thought this,” or “I’m sure you didn’t realize.”
- The emotional decision approach. Making the risk seem real and imminent can combat future discounting. One example might be: “We have had several people hospitalized and one death from the flu in San Diego already.” Use stories and descriptive language to make the risk salient.
- The use your authority approach. The long coat does matter. A more modern version of the paternalistic physician is referred to as “asymmetric” or “light paternalism,” and we should recognize that it might be used to save a life. One example is: “I advise you to get the flu shot because I care about you, and I’m worried you might end up in the hospital or worse if you don’t get it.” There’s a reason why tobacco companies once used doctors in white coats to sell cigarettes – we can be quite persuasive.
“A great deal of literature has been distributed, casting discredit upon the value of vaccination ... I do not see how any one ... who is familiar with the history of the subject, and who has any capacity left for clear judgment, can doubt its value.” – William Osler
Dr. Benabio is director of health care 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].
Compliant patients are all alike; every noncompliant patient is obstinate in his or her own way. Because of this, persuading patients to make good choices is rarely easy and never universal.
At Kaiser Permanente, we have begun in earnest providing flu shots. Every department participates (even dermatology) with a goal of vaccinating every eligible patient. Most patients want their shot. When patients decline, it’s game on. A rare few decline for justifiable reasons such as an allergy. Most say “no” for flawed reasons: “I never get the flu,” “The shot always gives me the flu,” and “I don’t believe in vaccines,” are common ones.
Fortunately, we can help them. Here are techniques I learned while working on my MBA that I’ve found useful in persuading patients to make better choices:
- The “everyone is doing it” technique. At KP, we’ve put up boards with the iconic goal thermometer showing how many flu shots we need to reach our objective. When patients see we’ve given over 1,000 shots in dermatology in just 2 weeks, this technique helps convince them. Patients prefer to be like others rather than to stand out, particularly when there is uncertainty.
- The “this is who you are technique.” Patients hate to be seen as inconsistent. In fact, we are all more likely to make a choice seen as consistent with who we are rather than change our mind, even if doing so is a better choice. Highlight how they have previously shown good decision making and healthy behaviors and point out how getting vaccinated is consonant with who they are. For example: “Being a vegan, you are clearly someone who takes care of her health. Getting the vaccine is similar to choosing to eat plants. It’s what healthy people like you do.”
- The “well, that’s not like you” technique. Here, you point out how their choice is inconsistent with their previous choices. You might say, “Why would you get the hepatitis A vaccine last week and not the flu shot today?” Like the previous technique, this creates cognitive dissonance. You might soften the approach by saying, “You might have thought this,” or “I’m sure you didn’t realize.”
- The emotional decision approach. Making the risk seem real and imminent can combat future discounting. One example might be: “We have had several people hospitalized and one death from the flu in San Diego already.” Use stories and descriptive language to make the risk salient.
- The use your authority approach. The long coat does matter. A more modern version of the paternalistic physician is referred to as “asymmetric” or “light paternalism,” and we should recognize that it might be used to save a life. One example is: “I advise you to get the flu shot because I care about you, and I’m worried you might end up in the hospital or worse if you don’t get it.” There’s a reason why tobacco companies once used doctors in white coats to sell cigarettes – we can be quite persuasive.
“A great deal of literature has been distributed, casting discredit upon the value of vaccination ... I do not see how any one ... who is familiar with the history of the subject, and who has any capacity left for clear judgment, can doubt its value.” – William Osler
Dr. Benabio is director of health care 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].
Compliant patients are all alike; every noncompliant patient is obstinate in his or her own way. Because of this, persuading patients to make good choices is rarely easy and never universal.
At Kaiser Permanente, we have begun in earnest providing flu shots. Every department participates (even dermatology) with a goal of vaccinating every eligible patient. Most patients want their shot. When patients decline, it’s game on. A rare few decline for justifiable reasons such as an allergy. Most say “no” for flawed reasons: “I never get the flu,” “The shot always gives me the flu,” and “I don’t believe in vaccines,” are common ones.
Fortunately, we can help them. Here are techniques I learned while working on my MBA that I’ve found useful in persuading patients to make better choices:
- The “everyone is doing it” technique. At KP, we’ve put up boards with the iconic goal thermometer showing how many flu shots we need to reach our objective. When patients see we’ve given over 1,000 shots in dermatology in just 2 weeks, this technique helps convince them. Patients prefer to be like others rather than to stand out, particularly when there is uncertainty.
- The “this is who you are technique.” Patients hate to be seen as inconsistent. In fact, we are all more likely to make a choice seen as consistent with who we are rather than change our mind, even if doing so is a better choice. Highlight how they have previously shown good decision making and healthy behaviors and point out how getting vaccinated is consonant with who they are. For example: “Being a vegan, you are clearly someone who takes care of her health. Getting the vaccine is similar to choosing to eat plants. It’s what healthy people like you do.”
- The “well, that’s not like you” technique. Here, you point out how their choice is inconsistent with their previous choices. You might say, “Why would you get the hepatitis A vaccine last week and not the flu shot today?” Like the previous technique, this creates cognitive dissonance. You might soften the approach by saying, “You might have thought this,” or “I’m sure you didn’t realize.”
- The emotional decision approach. Making the risk seem real and imminent can combat future discounting. One example might be: “We have had several people hospitalized and one death from the flu in San Diego already.” Use stories and descriptive language to make the risk salient.
- The use your authority approach. The long coat does matter. A more modern version of the paternalistic physician is referred to as “asymmetric” or “light paternalism,” and we should recognize that it might be used to save a life. One example is: “I advise you to get the flu shot because I care about you, and I’m worried you might end up in the hospital or worse if you don’t get it.” There’s a reason why tobacco companies once used doctors in white coats to sell cigarettes – we can be quite persuasive.
“A great deal of literature has been distributed, casting discredit upon the value of vaccination ... I do not see how any one ... who is familiar with the history of the subject, and who has any capacity left for clear judgment, can doubt its value.” – William Osler
Dr. Benabio is director of health care transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
When is technology ready for mainstream use for mental health care?
It is a daunting task for mental health providers to stay abreast with the current technology options available for mental health treatment. The past decade has seen the rise of multiple technology platforms with applications in mental health treatment (e.g., videoconferencing, mobile phones, web, patient-portals) along with specific interventions tailored to these platforms.
Traditional mechanisms for providers and mental health organizations, such as research papers and educational trainings, are unable to keep pace with both the technology available for providers and the technology being used by patients. How does a busy individual provider or mental health organization assess whether a technology is at a point to be considered a mainstream intervention and should be considered for routine use in clinical practice?
I proffer here the “middle caribou theory” for adapting “new” treatments and interventions. In a migrating caribou herd, animals leading the pack risk breaking through thin ice or getting pushed off unexpected cliffs by the masses behind them before the herd can institute a course correction. The caribou at the back of the herd are vulnerable to predation from wolves. The astute provider, like the caribou in the middle of the herd, has allowed others to test the path ahead and is less likely to be put at risk from antiquated methodologies found at the back of the herd.
There are now “base” technologies that every mental health provider and organization should be proficient in using and incorporating into clinical services where appropriate. These include email, videoconferencing, web-based technologies (e.g., patient education, patient portals) electronic medical records, and mobile phone-based applications. These are technologies that are relatively mature, and have reasonable track records in administrative and clinical psychiatry, in addition to growing or developed scientific literature supporting their use. “Emergent” technologies are those being deployed in clinical practice that have not reached widespread use and have underdeveloped literature and track records for their use. Examples of these include texting, virtual reality, and location technologies.1
Base vs. emergent technologies offer a framework for providers to determine which technologies they should be using in their practices. Often, it’s difficult to pinpoint when a technology has reached a “tipping point” into becoming a base/standard technology in the field and should be carefully considered by the middle caribou. Arguably, this occurs when a combination of a growing body of scientific evidence supporting a technology is coupled with wide adoption, although these two factors are not necessarily correlated. There are many examples in psychiatry of treatments coming into widespread practice with limited scientific support as well as scientifically robust treatments not being used in practice. Funding and reimbursement structures also play a role in facilitating and encouraging deployment and adoption of technology in mental health – and are not always driven by scientific best practices.
Finally, the temperament of individual providers and organizations determines when and how adoption might occur. Risk tolerance, novelty seeking, and capacity affect whether someone is an early or late adopter of an innovation.
Ultimately, clinical necessity drives the use of technologies in practice. Often, technology that has proved useful in other medical fields or in general use is translated into mental health, rather than being de novo developed for specific mental health treatments. This type of cross-pollination is not negative. Instead, it carries the risk of an initial “halo effect” where the promise of a technology used in other settings creates an unrealistic set of expectations about its potential in mental health treatments. This can lead to premature use and wider adoption that outpaces supporting scientific evidence.
So what should psychiatric providers and organizations consider in approaching these issues?
• Be proficient in base technologies, and stay up to date in their evolving uses and refinement.
• Stay informed about developing technologies, particularly those gaining broader use.
• Before considering adapting a new technology into clinical practice, make sure one is up to date on the scientific evidence supporting the technology. Providers should consider specialized training and orientation before piloting a new technology within a clinical setting.
• Take advantage of, and follow guidance of, reviews and best practices for assessing technology fit.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also serves as associate professor of psychiatry at the university.
References
1 Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals Arlington, Va.: American Psychiatric Association Publishing, 2017.
2 Telemed J E Health. 2015;21(12):1038-41.
3 Mil Med. 2014 Aug;179(8):865-78.
It is a daunting task for mental health providers to stay abreast with the current technology options available for mental health treatment. The past decade has seen the rise of multiple technology platforms with applications in mental health treatment (e.g., videoconferencing, mobile phones, web, patient-portals) along with specific interventions tailored to these platforms.
Traditional mechanisms for providers and mental health organizations, such as research papers and educational trainings, are unable to keep pace with both the technology available for providers and the technology being used by patients. How does a busy individual provider or mental health organization assess whether a technology is at a point to be considered a mainstream intervention and should be considered for routine use in clinical practice?
I proffer here the “middle caribou theory” for adapting “new” treatments and interventions. In a migrating caribou herd, animals leading the pack risk breaking through thin ice or getting pushed off unexpected cliffs by the masses behind them before the herd can institute a course correction. The caribou at the back of the herd are vulnerable to predation from wolves. The astute provider, like the caribou in the middle of the herd, has allowed others to test the path ahead and is less likely to be put at risk from antiquated methodologies found at the back of the herd.
There are now “base” technologies that every mental health provider and organization should be proficient in using and incorporating into clinical services where appropriate. These include email, videoconferencing, web-based technologies (e.g., patient education, patient portals) electronic medical records, and mobile phone-based applications. These are technologies that are relatively mature, and have reasonable track records in administrative and clinical psychiatry, in addition to growing or developed scientific literature supporting their use. “Emergent” technologies are those being deployed in clinical practice that have not reached widespread use and have underdeveloped literature and track records for their use. Examples of these include texting, virtual reality, and location technologies.1
Base vs. emergent technologies offer a framework for providers to determine which technologies they should be using in their practices. Often, it’s difficult to pinpoint when a technology has reached a “tipping point” into becoming a base/standard technology in the field and should be carefully considered by the middle caribou. Arguably, this occurs when a combination of a growing body of scientific evidence supporting a technology is coupled with wide adoption, although these two factors are not necessarily correlated. There are many examples in psychiatry of treatments coming into widespread practice with limited scientific support as well as scientifically robust treatments not being used in practice. Funding and reimbursement structures also play a role in facilitating and encouraging deployment and adoption of technology in mental health – and are not always driven by scientific best practices.
Finally, the temperament of individual providers and organizations determines when and how adoption might occur. Risk tolerance, novelty seeking, and capacity affect whether someone is an early or late adopter of an innovation.
Ultimately, clinical necessity drives the use of technologies in practice. Often, technology that has proved useful in other medical fields or in general use is translated into mental health, rather than being de novo developed for specific mental health treatments. This type of cross-pollination is not negative. Instead, it carries the risk of an initial “halo effect” where the promise of a technology used in other settings creates an unrealistic set of expectations about its potential in mental health treatments. This can lead to premature use and wider adoption that outpaces supporting scientific evidence.
So what should psychiatric providers and organizations consider in approaching these issues?
• Be proficient in base technologies, and stay up to date in their evolving uses and refinement.
• Stay informed about developing technologies, particularly those gaining broader use.
• Before considering adapting a new technology into clinical practice, make sure one is up to date on the scientific evidence supporting the technology. Providers should consider specialized training and orientation before piloting a new technology within a clinical setting.
• Take advantage of, and follow guidance of, reviews and best practices for assessing technology fit.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also serves as associate professor of psychiatry at the university.
References
1 Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals Arlington, Va.: American Psychiatric Association Publishing, 2017.
2 Telemed J E Health. 2015;21(12):1038-41.
3 Mil Med. 2014 Aug;179(8):865-78.
It is a daunting task for mental health providers to stay abreast with the current technology options available for mental health treatment. The past decade has seen the rise of multiple technology platforms with applications in mental health treatment (e.g., videoconferencing, mobile phones, web, patient-portals) along with specific interventions tailored to these platforms.
Traditional mechanisms for providers and mental health organizations, such as research papers and educational trainings, are unable to keep pace with both the technology available for providers and the technology being used by patients. How does a busy individual provider or mental health organization assess whether a technology is at a point to be considered a mainstream intervention and should be considered for routine use in clinical practice?
I proffer here the “middle caribou theory” for adapting “new” treatments and interventions. In a migrating caribou herd, animals leading the pack risk breaking through thin ice or getting pushed off unexpected cliffs by the masses behind them before the herd can institute a course correction. The caribou at the back of the herd are vulnerable to predation from wolves. The astute provider, like the caribou in the middle of the herd, has allowed others to test the path ahead and is less likely to be put at risk from antiquated methodologies found at the back of the herd.
There are now “base” technologies that every mental health provider and organization should be proficient in using and incorporating into clinical services where appropriate. These include email, videoconferencing, web-based technologies (e.g., patient education, patient portals) electronic medical records, and mobile phone-based applications. These are technologies that are relatively mature, and have reasonable track records in administrative and clinical psychiatry, in addition to growing or developed scientific literature supporting their use. “Emergent” technologies are those being deployed in clinical practice that have not reached widespread use and have underdeveloped literature and track records for their use. Examples of these include texting, virtual reality, and location technologies.1
Base vs. emergent technologies offer a framework for providers to determine which technologies they should be using in their practices. Often, it’s difficult to pinpoint when a technology has reached a “tipping point” into becoming a base/standard technology in the field and should be carefully considered by the middle caribou. Arguably, this occurs when a combination of a growing body of scientific evidence supporting a technology is coupled with wide adoption, although these two factors are not necessarily correlated. There are many examples in psychiatry of treatments coming into widespread practice with limited scientific support as well as scientifically robust treatments not being used in practice. Funding and reimbursement structures also play a role in facilitating and encouraging deployment and adoption of technology in mental health – and are not always driven by scientific best practices.
Finally, the temperament of individual providers and organizations determines when and how adoption might occur. Risk tolerance, novelty seeking, and capacity affect whether someone is an early or late adopter of an innovation.
Ultimately, clinical necessity drives the use of technologies in practice. Often, technology that has proved useful in other medical fields or in general use is translated into mental health, rather than being de novo developed for specific mental health treatments. This type of cross-pollination is not negative. Instead, it carries the risk of an initial “halo effect” where the promise of a technology used in other settings creates an unrealistic set of expectations about its potential in mental health treatments. This can lead to premature use and wider adoption that outpaces supporting scientific evidence.
So what should psychiatric providers and organizations consider in approaching these issues?
• Be proficient in base technologies, and stay up to date in their evolving uses and refinement.
• Stay informed about developing technologies, particularly those gaining broader use.
• Before considering adapting a new technology into clinical practice, make sure one is up to date on the scientific evidence supporting the technology. Providers should consider specialized training and orientation before piloting a new technology within a clinical setting.
• Take advantage of, and follow guidance of, reviews and best practices for assessing technology fit.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also serves as associate professor of psychiatry at the university.
References
1 Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals Arlington, Va.: American Psychiatric Association Publishing, 2017.
2 Telemed J E Health. 2015;21(12):1038-41.
3 Mil Med. 2014 Aug;179(8):865-78.
Good for something, or an American tragedy
The headline in the Oct. 13, 2017, Portland (Maine) Press Herald hinted that I was about to read a sad story: “New Hampshire doctor, 85, may lose practice because she doesn’t use computer.” Anna Konopka, MD, who has a 300-patient practice in New London, doesn’t use a computer in her office, and as a consequence can’t participate in her state’s mandated prescription drug monitoring program. She has appealed to the governor, but if her appeal is denied she will be forced to close her office.
The closure will present a hardship for the residents of this small New Hampshire town, who will have to replace their obviously committed physician who has served them for more than 30 years. And I am sure that Dr. Konopka would have preferred to end her professional career on her own terms. It isn’t going to be easy to give up that positive feedback from her patients that every primary care physician enjoys even on her worst day.
I wouldn’t be surprised to learn that Dr. Konopka has listened to other physicians in her community complain about the cost and time-gobbling inefficiencies of their EHRs. She may have been put off by her own experiences as a patient whose physician spends too much time looking at his computer screen and fails to engage with her. Or she may have simply done the math and come up with the obvious answer that a computer system would be a bad investment for her small practice.
I suspect that there are days that you wish you had followed this wise older physician’s lead and never plugged into that “good-for-nothing piece of junk” sitting on the desk in your exam room. The sadness in this story is that the computer and the Internet are (or at least could be) good for some things, including the statewide prescription drug monitoring program that Dr. Konopka can’t participate in. Immunization data banks, prescribing programs that minimize physician error, and systems for storing and plotting your patient’s lab work and metrics are just a few of the things that a good computer system is good for. And, of course, there is the real-time access to the vast store of medical and research knowledge that has made textbooks obsolete.
I’m not sure where we can go from here without throwing out the baby with the bathwater and starting from scratch. We have computer scientists and physicians who I am sure could create a patient- and physician-friendly system that could cover the whole country. The trick will be keeping the politicians out of the room.
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].
The headline in the Oct. 13, 2017, Portland (Maine) Press Herald hinted that I was about to read a sad story: “New Hampshire doctor, 85, may lose practice because she doesn’t use computer.” Anna Konopka, MD, who has a 300-patient practice in New London, doesn’t use a computer in her office, and as a consequence can’t participate in her state’s mandated prescription drug monitoring program. She has appealed to the governor, but if her appeal is denied she will be forced to close her office.
The closure will present a hardship for the residents of this small New Hampshire town, who will have to replace their obviously committed physician who has served them for more than 30 years. And I am sure that Dr. Konopka would have preferred to end her professional career on her own terms. It isn’t going to be easy to give up that positive feedback from her patients that every primary care physician enjoys even on her worst day.
I wouldn’t be surprised to learn that Dr. Konopka has listened to other physicians in her community complain about the cost and time-gobbling inefficiencies of their EHRs. She may have been put off by her own experiences as a patient whose physician spends too much time looking at his computer screen and fails to engage with her. Or she may have simply done the math and come up with the obvious answer that a computer system would be a bad investment for her small practice.
I suspect that there are days that you wish you had followed this wise older physician’s lead and never plugged into that “good-for-nothing piece of junk” sitting on the desk in your exam room. The sadness in this story is that the computer and the Internet are (or at least could be) good for some things, including the statewide prescription drug monitoring program that Dr. Konopka can’t participate in. Immunization data banks, prescribing programs that minimize physician error, and systems for storing and plotting your patient’s lab work and metrics are just a few of the things that a good computer system is good for. And, of course, there is the real-time access to the vast store of medical and research knowledge that has made textbooks obsolete.
I’m not sure where we can go from here without throwing out the baby with the bathwater and starting from scratch. We have computer scientists and physicians who I am sure could create a patient- and physician-friendly system that could cover the whole country. The trick will be keeping the politicians out of the room.
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].
The headline in the Oct. 13, 2017, Portland (Maine) Press Herald hinted that I was about to read a sad story: “New Hampshire doctor, 85, may lose practice because she doesn’t use computer.” Anna Konopka, MD, who has a 300-patient practice in New London, doesn’t use a computer in her office, and as a consequence can’t participate in her state’s mandated prescription drug monitoring program. She has appealed to the governor, but if her appeal is denied she will be forced to close her office.
The closure will present a hardship for the residents of this small New Hampshire town, who will have to replace their obviously committed physician who has served them for more than 30 years. And I am sure that Dr. Konopka would have preferred to end her professional career on her own terms. It isn’t going to be easy to give up that positive feedback from her patients that every primary care physician enjoys even on her worst day.
I wouldn’t be surprised to learn that Dr. Konopka has listened to other physicians in her community complain about the cost and time-gobbling inefficiencies of their EHRs. She may have been put off by her own experiences as a patient whose physician spends too much time looking at his computer screen and fails to engage with her. Or she may have simply done the math and come up with the obvious answer that a computer system would be a bad investment for her small practice.
I suspect that there are days that you wish you had followed this wise older physician’s lead and never plugged into that “good-for-nothing piece of junk” sitting on the desk in your exam room. The sadness in this story is that the computer and the Internet are (or at least could be) good for some things, including the statewide prescription drug monitoring program that Dr. Konopka can’t participate in. Immunization data banks, prescribing programs that minimize physician error, and systems for storing and plotting your patient’s lab work and metrics are just a few of the things that a good computer system is good for. And, of course, there is the real-time access to the vast store of medical and research knowledge that has made textbooks obsolete.
I’m not sure where we can go from here without throwing out the baby with the bathwater and starting from scratch. We have computer scientists and physicians who I am sure could create a patient- and physician-friendly system that could cover the whole country. The trick will be keeping the politicians out of the room.
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].
The cost of conflation: Avoiding loose talk about the duty to warn
The campaign, election, and administration of President Donald Trump have reinvigorated debate over rule 7.3 of the American Psychiatric Association (APA) code of ethics. Known as the Goldwater Rule for its historical roots in a magazine profile and subsequent libel suit by the 1964 Republican presidential nominee,1 this standard deems it unethical for a psychiatrist to offer a professional opinion of a public figure without conducting an examination and obtaining authorization.2 The American Psychological Association similarly provides that assessments must be based on adequate examination of the individual.3
Growing controversy
Shortly after President Trump’s inauguration, a group of 35 mental health professionals penned a letter in the New York Times stating that he was “incapable of serving safely as president.” Importantly, the writers couched their conclusions in professional expertise and specifically criticized the Goldwater Rule as having subjected their colleagues to self-imposed silence.4 A prominent psychiatrist, Allen J. Frances, MD, responded the following day to caution against “psychiatric name-calling” as a substitute for political action.5
Since then, psychiatrists classifying the APA ethics position as a “gag rule” preventing them from performing a public service have garnered considerable press coverage. When the American Psychoanalytic Association (APsaA) reiterated this summer that only APA members are bound by the Goldwater Rule, Boston Globe Media’s STAT news outlet misreported it as a license for psychiatrists to disregard the standard. Amid the ensuing media storm, the APsaA was forced to clarify that it was not countenancing defiance of psychiatry’s flagship organization and that its own longstanding policy remained unchanged.
Among those chafing against the Goldwater Rule in the current political environment, a call to arms has been the profession’s supposed “duty to warn” the public of the president’s mental health. This rationale was made explicit in an eponymous online movement and town hall forum hosted by Bandy X. Lee, MD, MDiv, a member of Yale University’s psychiatry faculty. According to these critics, an inherent tension exists between the Goldwater Rule’s prohibition on volunteering professional opinions from afar and the imperative to warn about the dangers posed by a leader with mental illness.
The duty to warn
Clinicians’ obligation to warn third parties when patients make credible threats or pose a high risk of harm emanates from various state laws, court decisions, and professional ethics rules. In the seminal Tarasoff case, a patient divulged in the course of psychotherapy his plan to murder a fellow student who had rejected his romantic overtures; campus police were alerted, but the intended victim was not. After the plan came to fruition, the California Supreme Court held that therapists must exercise reasonable care to protect “foreseeable victims” where they know or should know that a patient poses a serious danger.6
Although a controversial and massive expansion of tort liability 40 years ago, the basic tenets of Tarasoff have since been adopted by numerous courts, state legislatures, and professional organizations. The American Medical Association (AMA) recognizes an exception to confidentiality to mitigate serious threats of harm to the patient or other identifiable individuals.7 To enable health care professionals to operate in a way that is consistent with these standards, the HIPAA Privacy Rule expressly permits doctors to disclose protected health information, including psychotherapy notes, if the disclosure “is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.”8
In terms of both professional ethics and privacy law, the duty to warn is framed as a limited and enumerated exception to the general rule that patient communications must be kept in confidence. In the absence of a clinician’s being privy to personal details about a patient via interview and examination, the duty to warn loses all coherence. It is precisely the intimacy of the doctor-patient relationship that gives rise to the fiduciary duty of confidentiality, which in turn must yield to public safety in rare situations where a credible threat is issued against an identifiable victim.
Origins of a misconception
Unlike the duty to warn, the Goldwater Rule is neither premised on nor a departure from the dictates of confidentiality. The rule is codified under the section of the APA ethics standards dealing with community and public health activities, not patient privacy. In nearly all cases where the Goldwater Rule could be invoked, the fundamental issue is that no examination has occurred. If it had, informed consent would be required for treatment, and appropriate authorization would be required for disclosure. Moreover, talking with the media – as opposed to alerting law enforcement, family members, or the subject of a threat – would almost never qualify as an appropriate outlet for discharging a physician’s duty to warn.
Whatever its merits, the Goldwater Rule is intended to distinguish between educational activities – in which psychiatrists share their expertise with the public and shed light on mental illness – and professional opinion wherein psychiatrists offer diagnoses or prognoses unsolicited by the individual.9
The APA has since clarified that the Goldwater Rule does not prohibit “psychologically informed leadership studies” so long as they maintain scholarly standards and do not specify a clinical diagnosis. When appropriately conducted as academic research, including acknowledgment of inherent limitations, psychological profiles do not implicate the Goldwater Rule by drawing clinical conclusions outside clinical practice.
Ultimately, the debate over the Goldwater Rule pits concerns over professional standards and respect for persons against the ability of psychiatrists to apply the expertise and language of their profession according to their own best judgment, without running afoul of an ethical norm. The premise that the Tarasoff principle overrides the Goldwater Rule is a red herring that does a disservice to both. There may be valid reasons to reevaluate the Goldwater Rule, but the duty to warn is not one of them.
Lt. Col. Charles G. Kels practices health and disability law in the U.S. Air Force. Dr. Lori H. Kels teaches and practices psychiatry at the University of the Incarnate Word School of Osteopathic Medicine in San Antonio. Opinions expressed in this article are those of the authors alone and do not necessarily reflect those of the Air Force or Department of Defense.
References
1. Goldwater v. Ginzburg, 414 F2d 324 (2d Cir 1969), cert denied, 396 US 1049 (1970).
2. APA Principles of Medical Ethics, 2013 ed. [7.3].
3. American Psychological Association Ethical Principles of Psychologists and Code of Ethics, 2016 ed. [9.01b].
4. The New York Times. Feb. 14, 2017.
5. The New York Times. Feb. 15, 2017.
6. Tarasoff v. Regents of University of California, 551 P2d 334 (Cal. 1976).
7. AMA Code of Medical Ethics, 2017 ed. [3.2.1(e) Confidentiality].
8. 45 Code of Federal Regulations 164.512(j)
9. JAMA. 2008;300(11):1348-50.
10. Psychiatr Clin North Am. 2002;25(3):A635-A46.
11. APA Opinions of the Ethics Committee, 2017 ed. [Q.7.a].
The campaign, election, and administration of President Donald Trump have reinvigorated debate over rule 7.3 of the American Psychiatric Association (APA) code of ethics. Known as the Goldwater Rule for its historical roots in a magazine profile and subsequent libel suit by the 1964 Republican presidential nominee,1 this standard deems it unethical for a psychiatrist to offer a professional opinion of a public figure without conducting an examination and obtaining authorization.2 The American Psychological Association similarly provides that assessments must be based on adequate examination of the individual.3
Growing controversy
Shortly after President Trump’s inauguration, a group of 35 mental health professionals penned a letter in the New York Times stating that he was “incapable of serving safely as president.” Importantly, the writers couched their conclusions in professional expertise and specifically criticized the Goldwater Rule as having subjected their colleagues to self-imposed silence.4 A prominent psychiatrist, Allen J. Frances, MD, responded the following day to caution against “psychiatric name-calling” as a substitute for political action.5
Since then, psychiatrists classifying the APA ethics position as a “gag rule” preventing them from performing a public service have garnered considerable press coverage. When the American Psychoanalytic Association (APsaA) reiterated this summer that only APA members are bound by the Goldwater Rule, Boston Globe Media’s STAT news outlet misreported it as a license for psychiatrists to disregard the standard. Amid the ensuing media storm, the APsaA was forced to clarify that it was not countenancing defiance of psychiatry’s flagship organization and that its own longstanding policy remained unchanged.
Among those chafing against the Goldwater Rule in the current political environment, a call to arms has been the profession’s supposed “duty to warn” the public of the president’s mental health. This rationale was made explicit in an eponymous online movement and town hall forum hosted by Bandy X. Lee, MD, MDiv, a member of Yale University’s psychiatry faculty. According to these critics, an inherent tension exists between the Goldwater Rule’s prohibition on volunteering professional opinions from afar and the imperative to warn about the dangers posed by a leader with mental illness.
The duty to warn
Clinicians’ obligation to warn third parties when patients make credible threats or pose a high risk of harm emanates from various state laws, court decisions, and professional ethics rules. In the seminal Tarasoff case, a patient divulged in the course of psychotherapy his plan to murder a fellow student who had rejected his romantic overtures; campus police were alerted, but the intended victim was not. After the plan came to fruition, the California Supreme Court held that therapists must exercise reasonable care to protect “foreseeable victims” where they know or should know that a patient poses a serious danger.6
Although a controversial and massive expansion of tort liability 40 years ago, the basic tenets of Tarasoff have since been adopted by numerous courts, state legislatures, and professional organizations. The American Medical Association (AMA) recognizes an exception to confidentiality to mitigate serious threats of harm to the patient or other identifiable individuals.7 To enable health care professionals to operate in a way that is consistent with these standards, the HIPAA Privacy Rule expressly permits doctors to disclose protected health information, including psychotherapy notes, if the disclosure “is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.”8
In terms of both professional ethics and privacy law, the duty to warn is framed as a limited and enumerated exception to the general rule that patient communications must be kept in confidence. In the absence of a clinician’s being privy to personal details about a patient via interview and examination, the duty to warn loses all coherence. It is precisely the intimacy of the doctor-patient relationship that gives rise to the fiduciary duty of confidentiality, which in turn must yield to public safety in rare situations where a credible threat is issued against an identifiable victim.
Origins of a misconception
Unlike the duty to warn, the Goldwater Rule is neither premised on nor a departure from the dictates of confidentiality. The rule is codified under the section of the APA ethics standards dealing with community and public health activities, not patient privacy. In nearly all cases where the Goldwater Rule could be invoked, the fundamental issue is that no examination has occurred. If it had, informed consent would be required for treatment, and appropriate authorization would be required for disclosure. Moreover, talking with the media – as opposed to alerting law enforcement, family members, or the subject of a threat – would almost never qualify as an appropriate outlet for discharging a physician’s duty to warn.
Whatever its merits, the Goldwater Rule is intended to distinguish between educational activities – in which psychiatrists share their expertise with the public and shed light on mental illness – and professional opinion wherein psychiatrists offer diagnoses or prognoses unsolicited by the individual.9
The APA has since clarified that the Goldwater Rule does not prohibit “psychologically informed leadership studies” so long as they maintain scholarly standards and do not specify a clinical diagnosis. When appropriately conducted as academic research, including acknowledgment of inherent limitations, psychological profiles do not implicate the Goldwater Rule by drawing clinical conclusions outside clinical practice.
Ultimately, the debate over the Goldwater Rule pits concerns over professional standards and respect for persons against the ability of psychiatrists to apply the expertise and language of their profession according to their own best judgment, without running afoul of an ethical norm. The premise that the Tarasoff principle overrides the Goldwater Rule is a red herring that does a disservice to both. There may be valid reasons to reevaluate the Goldwater Rule, but the duty to warn is not one of them.
Lt. Col. Charles G. Kels practices health and disability law in the U.S. Air Force. Dr. Lori H. Kels teaches and practices psychiatry at the University of the Incarnate Word School of Osteopathic Medicine in San Antonio. Opinions expressed in this article are those of the authors alone and do not necessarily reflect those of the Air Force or Department of Defense.
References
1. Goldwater v. Ginzburg, 414 F2d 324 (2d Cir 1969), cert denied, 396 US 1049 (1970).
2. APA Principles of Medical Ethics, 2013 ed. [7.3].
3. American Psychological Association Ethical Principles of Psychologists and Code of Ethics, 2016 ed. [9.01b].
4. The New York Times. Feb. 14, 2017.
5. The New York Times. Feb. 15, 2017.
6. Tarasoff v. Regents of University of California, 551 P2d 334 (Cal. 1976).
7. AMA Code of Medical Ethics, 2017 ed. [3.2.1(e) Confidentiality].
8. 45 Code of Federal Regulations 164.512(j)
9. JAMA. 2008;300(11):1348-50.
10. Psychiatr Clin North Am. 2002;25(3):A635-A46.
11. APA Opinions of the Ethics Committee, 2017 ed. [Q.7.a].
The campaign, election, and administration of President Donald Trump have reinvigorated debate over rule 7.3 of the American Psychiatric Association (APA) code of ethics. Known as the Goldwater Rule for its historical roots in a magazine profile and subsequent libel suit by the 1964 Republican presidential nominee,1 this standard deems it unethical for a psychiatrist to offer a professional opinion of a public figure without conducting an examination and obtaining authorization.2 The American Psychological Association similarly provides that assessments must be based on adequate examination of the individual.3
Growing controversy
Shortly after President Trump’s inauguration, a group of 35 mental health professionals penned a letter in the New York Times stating that he was “incapable of serving safely as president.” Importantly, the writers couched their conclusions in professional expertise and specifically criticized the Goldwater Rule as having subjected their colleagues to self-imposed silence.4 A prominent psychiatrist, Allen J. Frances, MD, responded the following day to caution against “psychiatric name-calling” as a substitute for political action.5
Since then, psychiatrists classifying the APA ethics position as a “gag rule” preventing them from performing a public service have garnered considerable press coverage. When the American Psychoanalytic Association (APsaA) reiterated this summer that only APA members are bound by the Goldwater Rule, Boston Globe Media’s STAT news outlet misreported it as a license for psychiatrists to disregard the standard. Amid the ensuing media storm, the APsaA was forced to clarify that it was not countenancing defiance of psychiatry’s flagship organization and that its own longstanding policy remained unchanged.
Among those chafing against the Goldwater Rule in the current political environment, a call to arms has been the profession’s supposed “duty to warn” the public of the president’s mental health. This rationale was made explicit in an eponymous online movement and town hall forum hosted by Bandy X. Lee, MD, MDiv, a member of Yale University’s psychiatry faculty. According to these critics, an inherent tension exists between the Goldwater Rule’s prohibition on volunteering professional opinions from afar and the imperative to warn about the dangers posed by a leader with mental illness.
The duty to warn
Clinicians’ obligation to warn third parties when patients make credible threats or pose a high risk of harm emanates from various state laws, court decisions, and professional ethics rules. In the seminal Tarasoff case, a patient divulged in the course of psychotherapy his plan to murder a fellow student who had rejected his romantic overtures; campus police were alerted, but the intended victim was not. After the plan came to fruition, the California Supreme Court held that therapists must exercise reasonable care to protect “foreseeable victims” where they know or should know that a patient poses a serious danger.6
Although a controversial and massive expansion of tort liability 40 years ago, the basic tenets of Tarasoff have since been adopted by numerous courts, state legislatures, and professional organizations. The American Medical Association (AMA) recognizes an exception to confidentiality to mitigate serious threats of harm to the patient or other identifiable individuals.7 To enable health care professionals to operate in a way that is consistent with these standards, the HIPAA Privacy Rule expressly permits doctors to disclose protected health information, including psychotherapy notes, if the disclosure “is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.”8
In terms of both professional ethics and privacy law, the duty to warn is framed as a limited and enumerated exception to the general rule that patient communications must be kept in confidence. In the absence of a clinician’s being privy to personal details about a patient via interview and examination, the duty to warn loses all coherence. It is precisely the intimacy of the doctor-patient relationship that gives rise to the fiduciary duty of confidentiality, which in turn must yield to public safety in rare situations where a credible threat is issued against an identifiable victim.
Origins of a misconception
Unlike the duty to warn, the Goldwater Rule is neither premised on nor a departure from the dictates of confidentiality. The rule is codified under the section of the APA ethics standards dealing with community and public health activities, not patient privacy. In nearly all cases where the Goldwater Rule could be invoked, the fundamental issue is that no examination has occurred. If it had, informed consent would be required for treatment, and appropriate authorization would be required for disclosure. Moreover, talking with the media – as opposed to alerting law enforcement, family members, or the subject of a threat – would almost never qualify as an appropriate outlet for discharging a physician’s duty to warn.
Whatever its merits, the Goldwater Rule is intended to distinguish between educational activities – in which psychiatrists share their expertise with the public and shed light on mental illness – and professional opinion wherein psychiatrists offer diagnoses or prognoses unsolicited by the individual.9
The APA has since clarified that the Goldwater Rule does not prohibit “psychologically informed leadership studies” so long as they maintain scholarly standards and do not specify a clinical diagnosis. When appropriately conducted as academic research, including acknowledgment of inherent limitations, psychological profiles do not implicate the Goldwater Rule by drawing clinical conclusions outside clinical practice.
Ultimately, the debate over the Goldwater Rule pits concerns over professional standards and respect for persons against the ability of psychiatrists to apply the expertise and language of their profession according to their own best judgment, without running afoul of an ethical norm. The premise that the Tarasoff principle overrides the Goldwater Rule is a red herring that does a disservice to both. There may be valid reasons to reevaluate the Goldwater Rule, but the duty to warn is not one of them.
Lt. Col. Charles G. Kels practices health and disability law in the U.S. Air Force. Dr. Lori H. Kels teaches and practices psychiatry at the University of the Incarnate Word School of Osteopathic Medicine in San Antonio. Opinions expressed in this article are those of the authors alone and do not necessarily reflect those of the Air Force or Department of Defense.
References
1. Goldwater v. Ginzburg, 414 F2d 324 (2d Cir 1969), cert denied, 396 US 1049 (1970).
2. APA Principles of Medical Ethics, 2013 ed. [7.3].
3. American Psychological Association Ethical Principles of Psychologists and Code of Ethics, 2016 ed. [9.01b].
4. The New York Times. Feb. 14, 2017.
5. The New York Times. Feb. 15, 2017.
6. Tarasoff v. Regents of University of California, 551 P2d 334 (Cal. 1976).
7. AMA Code of Medical Ethics, 2017 ed. [3.2.1(e) Confidentiality].
8. 45 Code of Federal Regulations 164.512(j)
9. JAMA. 2008;300(11):1348-50.
10. Psychiatr Clin North Am. 2002;25(3):A635-A46.
11. APA Opinions of the Ethics Committee, 2017 ed. [Q.7.a].
The electronic elephant
Five years ago, while I still was actively practicing primary care pediatrics, I did a rough calculation that the EHR the practice had purchased was adding an hour to my workday. We were not computer neophytes. This was our third EHR system in 10 years. Not a single minute of that extra time included face-to-face interaction with my patients. In the ensuing years, I have been listening to former colleagues and reading emails from readers of this column. It is clear that my unfortunate experience with our new EHR in 2012 was just a hint at how bad things would get for primary care physicians indentured to EHRs. The short learning curve that was promised has not flattened out, and my rough calculation of an hour at the computer was clearly an underestimate. Most physicians I hear from feel they are spending significantly more than an hour scrolling and clicking.
Although I frequently have used this column to grumble about EHRs, I have been hesitant to launch into a vein-popping tirade because my evidence has been primarily anecdotal. However, a few weeks ago a friend shared a link to a study that provided some startling figures that went beyond my expectation (“Tethered to the EHR: Primary care physician workload assessment using EHR event log data and time motion observations,” Ann Fam Med. 2017;15[5]:419-26).
Let that sentence sink in for a moment. How do those numbers compare with your own practice experience? Has anyone in your clinic or hospital taken the time to collect the data? I suspect that your time expenditure on the EHR is similar. Are you or anyone else in your group doing anything more than grumbling to one another about this situation?
Isn’t it time for us to do more than just grouse about this electronic elephant in the room? How many successful businesses would tolerate a situation in which the employees responsible for producing the company’s signature product are allowed to spend half of their time idle? From a purely business perspective, the current EHR/provider interface makes no sense.
Although the cost of physician productivity misdirected to EHRs is probably less than the billions of dollars lost to overpriced medication in this country, this is a topic that deserves a spotlight in ongoing discussions of the Affordable Care Act. At a time when the adequacy of our physician workforce is being questioned, we must take seriously the anecdotal evidence that frustration with EHRs is driving older and experienced physicians into early retirement.
Our patients can be our best allies because most of them don’t like us looking at our computer screens when we should be looking them in the eye … and listening. Like it or not, we now have a president who is a disruptor of the status quo. Maybe it’s time for us to follow his example and begin making some real noise about the personal and financial cost of EHRs. Talk to your legislators, practice administrators, the American Academy of Pediatrics, anyone … even if they don’t seem to be listening.
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].
Five years ago, while I still was actively practicing primary care pediatrics, I did a rough calculation that the EHR the practice had purchased was adding an hour to my workday. We were not computer neophytes. This was our third EHR system in 10 years. Not a single minute of that extra time included face-to-face interaction with my patients. In the ensuing years, I have been listening to former colleagues and reading emails from readers of this column. It is clear that my unfortunate experience with our new EHR in 2012 was just a hint at how bad things would get for primary care physicians indentured to EHRs. The short learning curve that was promised has not flattened out, and my rough calculation of an hour at the computer was clearly an underestimate. Most physicians I hear from feel they are spending significantly more than an hour scrolling and clicking.
Although I frequently have used this column to grumble about EHRs, I have been hesitant to launch into a vein-popping tirade because my evidence has been primarily anecdotal. However, a few weeks ago a friend shared a link to a study that provided some startling figures that went beyond my expectation (“Tethered to the EHR: Primary care physician workload assessment using EHR event log data and time motion observations,” Ann Fam Med. 2017;15[5]:419-26).
Let that sentence sink in for a moment. How do those numbers compare with your own practice experience? Has anyone in your clinic or hospital taken the time to collect the data? I suspect that your time expenditure on the EHR is similar. Are you or anyone else in your group doing anything more than grumbling to one another about this situation?
Isn’t it time for us to do more than just grouse about this electronic elephant in the room? How many successful businesses would tolerate a situation in which the employees responsible for producing the company’s signature product are allowed to spend half of their time idle? From a purely business perspective, the current EHR/provider interface makes no sense.
Although the cost of physician productivity misdirected to EHRs is probably less than the billions of dollars lost to overpriced medication in this country, this is a topic that deserves a spotlight in ongoing discussions of the Affordable Care Act. At a time when the adequacy of our physician workforce is being questioned, we must take seriously the anecdotal evidence that frustration with EHRs is driving older and experienced physicians into early retirement.
Our patients can be our best allies because most of them don’t like us looking at our computer screens when we should be looking them in the eye … and listening. Like it or not, we now have a president who is a disruptor of the status quo. Maybe it’s time for us to follow his example and begin making some real noise about the personal and financial cost of EHRs. Talk to your legislators, practice administrators, the American Academy of Pediatrics, anyone … even if they don’t seem to be listening.
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].
Five years ago, while I still was actively practicing primary care pediatrics, I did a rough calculation that the EHR the practice had purchased was adding an hour to my workday. We were not computer neophytes. This was our third EHR system in 10 years. Not a single minute of that extra time included face-to-face interaction with my patients. In the ensuing years, I have been listening to former colleagues and reading emails from readers of this column. It is clear that my unfortunate experience with our new EHR in 2012 was just a hint at how bad things would get for primary care physicians indentured to EHRs. The short learning curve that was promised has not flattened out, and my rough calculation of an hour at the computer was clearly an underestimate. Most physicians I hear from feel they are spending significantly more than an hour scrolling and clicking.
Although I frequently have used this column to grumble about EHRs, I have been hesitant to launch into a vein-popping tirade because my evidence has been primarily anecdotal. However, a few weeks ago a friend shared a link to a study that provided some startling figures that went beyond my expectation (“Tethered to the EHR: Primary care physician workload assessment using EHR event log data and time motion observations,” Ann Fam Med. 2017;15[5]:419-26).
Let that sentence sink in for a moment. How do those numbers compare with your own practice experience? Has anyone in your clinic or hospital taken the time to collect the data? I suspect that your time expenditure on the EHR is similar. Are you or anyone else in your group doing anything more than grumbling to one another about this situation?
Isn’t it time for us to do more than just grouse about this electronic elephant in the room? How many successful businesses would tolerate a situation in which the employees responsible for producing the company’s signature product are allowed to spend half of their time idle? From a purely business perspective, the current EHR/provider interface makes no sense.
Although the cost of physician productivity misdirected to EHRs is probably less than the billions of dollars lost to overpriced medication in this country, this is a topic that deserves a spotlight in ongoing discussions of the Affordable Care Act. At a time when the adequacy of our physician workforce is being questioned, we must take seriously the anecdotal evidence that frustration with EHRs is driving older and experienced physicians into early retirement.
Our patients can be our best allies because most of them don’t like us looking at our computer screens when we should be looking them in the eye … and listening. Like it or not, we now have a president who is a disruptor of the status quo. Maybe it’s time for us to follow his example and begin making some real noise about the personal and financial cost of EHRs. Talk to your legislators, practice administrators, the American Academy of Pediatrics, anyone … even if they don’t seem to be listening.
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].
Contraception coverage rollback is discriminatory
On Oct. 6, the Trump administration rolled back a crucial piece of the Affordable Care Act so that any employer can now claim a moral or religious objection to providing contraception coverage, thus denying their employees access to critical health care – contraception.
Nearly all women – 99% – who have had sex have used some form of contraception at some point during their reproductive lives, regardless of faith or religion (National health statistics reports. 2013 Feb 14[62]). Most women spend the majority of their fertile life span, approximately 35-40 years, avoiding pregnancy, and only a few years actively trying to become pregnant. A desired pregnancy is a gift, but unplanned pregnancies may have a negative impact on women, families, and society.
In the United States, our rising maternal mortality ratio is currently at 26.4 per 100,000 live births (Lancet. 2016 Oct 8;388[10053]:1775-812). Given the risks of pregnancy, especially to those with medical conditions that make pregnancy more dangerous, women need access to methods to avoid pregnancy until they actively seek it. If employers of for-profit businesses now choose to claim a moral or religious objection to providing coverage for contraception, millions of women could become unable to access affordable, effective contraception.
Since the Affordable Care Act mandate that provided coverage for contraceptive methods with no cost-sharing, thousands of women have had improved access to contraception, including IUDs and contraceptive implants, the most effective and longest-lasting reversible methods available. Since President Trump took office, many women have presented to clinics across the country to get long-acting contraception, like an IUD or implant, before the Trump administration could pull the plug on the contraceptive mandate. That scenario has now occurred, leaving millions of women up in the air about the future of their contraceptive coverage.
By allowing employers to deny coverage of contraception, the Trump administration is demonstrating its lack of concern for women’s health and its denial of the most fundamental principles of public health.
Rolling back the contraceptive mandate is rolling back on vital women’s preventive health services. It is counter to society’s interest in public health and is discriminatory against women.
Dr. Prager is associate professor of obstetrics and gynecology at the University of Washington, Seattle. She is also the director of the family planning division and family planning fellowship. Dr. Prager is an unpaid trainer for Nexplanon (Merck). Dr. Espey is professor and chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque. Dr. Espey reported having no relevant disclosures.
On Oct. 6, the Trump administration rolled back a crucial piece of the Affordable Care Act so that any employer can now claim a moral or religious objection to providing contraception coverage, thus denying their employees access to critical health care – contraception.
Nearly all women – 99% – who have had sex have used some form of contraception at some point during their reproductive lives, regardless of faith or religion (National health statistics reports. 2013 Feb 14[62]). Most women spend the majority of their fertile life span, approximately 35-40 years, avoiding pregnancy, and only a few years actively trying to become pregnant. A desired pregnancy is a gift, but unplanned pregnancies may have a negative impact on women, families, and society.
In the United States, our rising maternal mortality ratio is currently at 26.4 per 100,000 live births (Lancet. 2016 Oct 8;388[10053]:1775-812). Given the risks of pregnancy, especially to those with medical conditions that make pregnancy more dangerous, women need access to methods to avoid pregnancy until they actively seek it. If employers of for-profit businesses now choose to claim a moral or religious objection to providing coverage for contraception, millions of women could become unable to access affordable, effective contraception.
Since the Affordable Care Act mandate that provided coverage for contraceptive methods with no cost-sharing, thousands of women have had improved access to contraception, including IUDs and contraceptive implants, the most effective and longest-lasting reversible methods available. Since President Trump took office, many women have presented to clinics across the country to get long-acting contraception, like an IUD or implant, before the Trump administration could pull the plug on the contraceptive mandate. That scenario has now occurred, leaving millions of women up in the air about the future of their contraceptive coverage.
By allowing employers to deny coverage of contraception, the Trump administration is demonstrating its lack of concern for women’s health and its denial of the most fundamental principles of public health.
Rolling back the contraceptive mandate is rolling back on vital women’s preventive health services. It is counter to society’s interest in public health and is discriminatory against women.
Dr. Prager is associate professor of obstetrics and gynecology at the University of Washington, Seattle. She is also the director of the family planning division and family planning fellowship. Dr. Prager is an unpaid trainer for Nexplanon (Merck). Dr. Espey is professor and chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque. Dr. Espey reported having no relevant disclosures.
On Oct. 6, the Trump administration rolled back a crucial piece of the Affordable Care Act so that any employer can now claim a moral or religious objection to providing contraception coverage, thus denying their employees access to critical health care – contraception.
Nearly all women – 99% – who have had sex have used some form of contraception at some point during their reproductive lives, regardless of faith or religion (National health statistics reports. 2013 Feb 14[62]). Most women spend the majority of their fertile life span, approximately 35-40 years, avoiding pregnancy, and only a few years actively trying to become pregnant. A desired pregnancy is a gift, but unplanned pregnancies may have a negative impact on women, families, and society.
In the United States, our rising maternal mortality ratio is currently at 26.4 per 100,000 live births (Lancet. 2016 Oct 8;388[10053]:1775-812). Given the risks of pregnancy, especially to those with medical conditions that make pregnancy more dangerous, women need access to methods to avoid pregnancy until they actively seek it. If employers of for-profit businesses now choose to claim a moral or religious objection to providing coverage for contraception, millions of women could become unable to access affordable, effective contraception.
Since the Affordable Care Act mandate that provided coverage for contraceptive methods with no cost-sharing, thousands of women have had improved access to contraception, including IUDs and contraceptive implants, the most effective and longest-lasting reversible methods available. Since President Trump took office, many women have presented to clinics across the country to get long-acting contraception, like an IUD or implant, before the Trump administration could pull the plug on the contraceptive mandate. That scenario has now occurred, leaving millions of women up in the air about the future of their contraceptive coverage.
By allowing employers to deny coverage of contraception, the Trump administration is demonstrating its lack of concern for women’s health and its denial of the most fundamental principles of public health.
Rolling back the contraceptive mandate is rolling back on vital women’s preventive health services. It is counter to society’s interest in public health and is discriminatory against women.
Dr. Prager is associate professor of obstetrics and gynecology at the University of Washington, Seattle. She is also the director of the family planning division and family planning fellowship. Dr. Prager is an unpaid trainer for Nexplanon (Merck). Dr. Espey is professor and chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque. Dr. Espey reported having no relevant disclosures.
Don't just blame Facebook for fake news: It's us, too
Critics such as Zeynep Tufekci are quite right to take Facebook and Twitter to task for allowing nefarious and hostile actors, likely including the Russian state, to hold sway on social media (“Facebook’s Ad Scandal Isn’t a ‘Fail,’ It’s a Feature,” New York Times, Sept. 23, 2017).
These actors must be reined in online, for the very simple reason that so many of us are immersed in our news feeds and Twitter streams, and thus susceptible to whatever toxins are allowed to proliferate there.
Some have called apps, including social media, “the race to the bottom of the brainstem.” The most primitive parts of our brain, responsible for fight-flight and survival, are always on the lookout for perceived threats. In our restless, clicking and scrolling state, we are often naturally attracted to and activated by tantalizing, titillating, and emotionally charged posts that are lacking in reason, but are inflammatory and viscerally captivating. Viral news, click bait, gossip, rumors, and scandals get a disproportionate share of our attention. And since we become what we do, our reason is overwhelmed by reaction. In fact, a recent 60 Minutes segment demonstrated how President Trump’s political operatives optimized Facebook ads for reaction, not thought. As we engage in social media, we may become less reasonable, and prone to reacting out of our most base and primal fears.
The late neurologist and psychiatrist Viktor E. Frankl pointed out our freedom lies in our ability to put space between stimulus and response. In this space lies our freedom to choose, he wrote. Online, this inner life can shrink. Our wandering minds look for cheap thrills and anything that confirms our biases of threat. We reduce the world to simplistic one-size-fits-all narratives, and heap blame on our usual suspects. I call the Internet the angernet. Anger is the most viral and contagious emotion on social networks, and as we use social media, we deepen the groove of anger – making our anger more likely and the most readily shared.
But we’ve been racing to the bottom of the brainstem, where fear, anger, hatred, and reactivity reside, for decades in this country. Again, we can’t simply blame social media. Trust has been eroding for decades, for many reasons. No matter the generation, only a minority of us trust each other, according to the Pew Research Center’s surveys. Millennials are the least trusting of all: Only 19% of them agree that “generally speaking, people are to be trusted.” Any scroll of the news feed quickly confirms this dangerous bias to mistrust, as we are besieged by a near cataclysmic barrage of traumatic events. We are also more polarized than ever, with a great percentage of partisans believing that the other side aims at the destruction of all they hold dear in America. As we feel more vulnerable, we are more likely to mistrust and become further polarized, and the cycle continues.
More importantly, as we flee real-world relationships and interaction for the ease and seeming reach of the online world, we lose subtle cues and important connections that would normally soothe our reactivity. Humanity has evolved and progressed precisely because of our social connections. We are who happens to us, and what we make of the happening. When we connect in more superficial ways, we endanger our very identities. As a nation, we are having an identity crisis: We have not worked out who we are in relation to one another, and to ourselves. This is expressed politically, and in our confused and fearful opinions and appraisals of each other and government. Without the good graces that come out of shared presence in real-world relationships, we are more likely to think badly of each other. We are more likely to retreat into narrow and tribal identities where we think safety resides, and deemphasize communal identity. In this space of narrow identity, ideological self-righteousness and dogma prevail, and we are less likely to listen and cultivate curiosity, understanding, and empathy for others. One example lies in how representatives and senators spend less time socializing with each other than in years past, and are thus less likely to forge compromise. Online, we are all refugees from the real world, and we fall to building our own personal walls and exiling those with whom we disagree – who then become those we hate, fear, blame, and fight.
We have met the enemy, and it is us.
The antidote to mistrust is in cultivating the top of our nervous systems, where long-term planning and positive emotions reside. We can only do this through real-world relationships. Social media will not ultimately take us to a feeling of society. It might provide a glimmer of connection, but its inherent vectors of disconnection and division are proving deadly, from Internet radicalization, to the increased levels of depression, anxiety, loneliness, and suicidality noted with increasing Internet and social media use.
We each have incredible human possibilities, but to reach them, we have to transcend the biases and reactivity of our habitually and usually unconsciously self-centered egos. We can start with awareness of what the Internet siren is doing to us and steer our ships in a more fruitful direction. Toward home, toward our hearts, and toward each other.
Dr. Chandra is a psychiatrist and writer in San Francisco. He is the author of Facebuddha: Transcendence in the Age of Social Networks (Pacific Heart Books, 2017).
Critics such as Zeynep Tufekci are quite right to take Facebook and Twitter to task for allowing nefarious and hostile actors, likely including the Russian state, to hold sway on social media (“Facebook’s Ad Scandal Isn’t a ‘Fail,’ It’s a Feature,” New York Times, Sept. 23, 2017).
These actors must be reined in online, for the very simple reason that so many of us are immersed in our news feeds and Twitter streams, and thus susceptible to whatever toxins are allowed to proliferate there.
Some have called apps, including social media, “the race to the bottom of the brainstem.” The most primitive parts of our brain, responsible for fight-flight and survival, are always on the lookout for perceived threats. In our restless, clicking and scrolling state, we are often naturally attracted to and activated by tantalizing, titillating, and emotionally charged posts that are lacking in reason, but are inflammatory and viscerally captivating. Viral news, click bait, gossip, rumors, and scandals get a disproportionate share of our attention. And since we become what we do, our reason is overwhelmed by reaction. In fact, a recent 60 Minutes segment demonstrated how President Trump’s political operatives optimized Facebook ads for reaction, not thought. As we engage in social media, we may become less reasonable, and prone to reacting out of our most base and primal fears.
The late neurologist and psychiatrist Viktor E. Frankl pointed out our freedom lies in our ability to put space between stimulus and response. In this space lies our freedom to choose, he wrote. Online, this inner life can shrink. Our wandering minds look for cheap thrills and anything that confirms our biases of threat. We reduce the world to simplistic one-size-fits-all narratives, and heap blame on our usual suspects. I call the Internet the angernet. Anger is the most viral and contagious emotion on social networks, and as we use social media, we deepen the groove of anger – making our anger more likely and the most readily shared.
But we’ve been racing to the bottom of the brainstem, where fear, anger, hatred, and reactivity reside, for decades in this country. Again, we can’t simply blame social media. Trust has been eroding for decades, for many reasons. No matter the generation, only a minority of us trust each other, according to the Pew Research Center’s surveys. Millennials are the least trusting of all: Only 19% of them agree that “generally speaking, people are to be trusted.” Any scroll of the news feed quickly confirms this dangerous bias to mistrust, as we are besieged by a near cataclysmic barrage of traumatic events. We are also more polarized than ever, with a great percentage of partisans believing that the other side aims at the destruction of all they hold dear in America. As we feel more vulnerable, we are more likely to mistrust and become further polarized, and the cycle continues.
More importantly, as we flee real-world relationships and interaction for the ease and seeming reach of the online world, we lose subtle cues and important connections that would normally soothe our reactivity. Humanity has evolved and progressed precisely because of our social connections. We are who happens to us, and what we make of the happening. When we connect in more superficial ways, we endanger our very identities. As a nation, we are having an identity crisis: We have not worked out who we are in relation to one another, and to ourselves. This is expressed politically, and in our confused and fearful opinions and appraisals of each other and government. Without the good graces that come out of shared presence in real-world relationships, we are more likely to think badly of each other. We are more likely to retreat into narrow and tribal identities where we think safety resides, and deemphasize communal identity. In this space of narrow identity, ideological self-righteousness and dogma prevail, and we are less likely to listen and cultivate curiosity, understanding, and empathy for others. One example lies in how representatives and senators spend less time socializing with each other than in years past, and are thus less likely to forge compromise. Online, we are all refugees from the real world, and we fall to building our own personal walls and exiling those with whom we disagree – who then become those we hate, fear, blame, and fight.
We have met the enemy, and it is us.
The antidote to mistrust is in cultivating the top of our nervous systems, where long-term planning and positive emotions reside. We can only do this through real-world relationships. Social media will not ultimately take us to a feeling of society. It might provide a glimmer of connection, but its inherent vectors of disconnection and division are proving deadly, from Internet radicalization, to the increased levels of depression, anxiety, loneliness, and suicidality noted with increasing Internet and social media use.
We each have incredible human possibilities, but to reach them, we have to transcend the biases and reactivity of our habitually and usually unconsciously self-centered egos. We can start with awareness of what the Internet siren is doing to us and steer our ships in a more fruitful direction. Toward home, toward our hearts, and toward each other.
Dr. Chandra is a psychiatrist and writer in San Francisco. He is the author of Facebuddha: Transcendence in the Age of Social Networks (Pacific Heart Books, 2017).
Critics such as Zeynep Tufekci are quite right to take Facebook and Twitter to task for allowing nefarious and hostile actors, likely including the Russian state, to hold sway on social media (“Facebook’s Ad Scandal Isn’t a ‘Fail,’ It’s a Feature,” New York Times, Sept. 23, 2017).
These actors must be reined in online, for the very simple reason that so many of us are immersed in our news feeds and Twitter streams, and thus susceptible to whatever toxins are allowed to proliferate there.
Some have called apps, including social media, “the race to the bottom of the brainstem.” The most primitive parts of our brain, responsible for fight-flight and survival, are always on the lookout for perceived threats. In our restless, clicking and scrolling state, we are often naturally attracted to and activated by tantalizing, titillating, and emotionally charged posts that are lacking in reason, but are inflammatory and viscerally captivating. Viral news, click bait, gossip, rumors, and scandals get a disproportionate share of our attention. And since we become what we do, our reason is overwhelmed by reaction. In fact, a recent 60 Minutes segment demonstrated how President Trump’s political operatives optimized Facebook ads for reaction, not thought. As we engage in social media, we may become less reasonable, and prone to reacting out of our most base and primal fears.
The late neurologist and psychiatrist Viktor E. Frankl pointed out our freedom lies in our ability to put space between stimulus and response. In this space lies our freedom to choose, he wrote. Online, this inner life can shrink. Our wandering minds look for cheap thrills and anything that confirms our biases of threat. We reduce the world to simplistic one-size-fits-all narratives, and heap blame on our usual suspects. I call the Internet the angernet. Anger is the most viral and contagious emotion on social networks, and as we use social media, we deepen the groove of anger – making our anger more likely and the most readily shared.
But we’ve been racing to the bottom of the brainstem, where fear, anger, hatred, and reactivity reside, for decades in this country. Again, we can’t simply blame social media. Trust has been eroding for decades, for many reasons. No matter the generation, only a minority of us trust each other, according to the Pew Research Center’s surveys. Millennials are the least trusting of all: Only 19% of them agree that “generally speaking, people are to be trusted.” Any scroll of the news feed quickly confirms this dangerous bias to mistrust, as we are besieged by a near cataclysmic barrage of traumatic events. We are also more polarized than ever, with a great percentage of partisans believing that the other side aims at the destruction of all they hold dear in America. As we feel more vulnerable, we are more likely to mistrust and become further polarized, and the cycle continues.
More importantly, as we flee real-world relationships and interaction for the ease and seeming reach of the online world, we lose subtle cues and important connections that would normally soothe our reactivity. Humanity has evolved and progressed precisely because of our social connections. We are who happens to us, and what we make of the happening. When we connect in more superficial ways, we endanger our very identities. As a nation, we are having an identity crisis: We have not worked out who we are in relation to one another, and to ourselves. This is expressed politically, and in our confused and fearful opinions and appraisals of each other and government. Without the good graces that come out of shared presence in real-world relationships, we are more likely to think badly of each other. We are more likely to retreat into narrow and tribal identities where we think safety resides, and deemphasize communal identity. In this space of narrow identity, ideological self-righteousness and dogma prevail, and we are less likely to listen and cultivate curiosity, understanding, and empathy for others. One example lies in how representatives and senators spend less time socializing with each other than in years past, and are thus less likely to forge compromise. Online, we are all refugees from the real world, and we fall to building our own personal walls and exiling those with whom we disagree – who then become those we hate, fear, blame, and fight.
We have met the enemy, and it is us.
The antidote to mistrust is in cultivating the top of our nervous systems, where long-term planning and positive emotions reside. We can only do this through real-world relationships. Social media will not ultimately take us to a feeling of society. It might provide a glimmer of connection, but its inherent vectors of disconnection and division are proving deadly, from Internet radicalization, to the increased levels of depression, anxiety, loneliness, and suicidality noted with increasing Internet and social media use.
We each have incredible human possibilities, but to reach them, we have to transcend the biases and reactivity of our habitually and usually unconsciously self-centered egos. We can start with awareness of what the Internet siren is doing to us and steer our ships in a more fruitful direction. Toward home, toward our hearts, and toward each other.
Dr. Chandra is a psychiatrist and writer in San Francisco. He is the author of Facebuddha: Transcendence in the Age of Social Networks (Pacific Heart Books, 2017).