Commentary

 

Do you practice as a team member? How is your team defined? Is it made up solely of physicians? Does it include mid-level providers? Does it extend to mental health and social service providers in your office? Do you consider nonproviders such as receptionists as team members? Do you consider the whole office “your team”? Or, is it a smaller team with just yourself and one or two other physicians along with a mid-level provider or two?

There has been a lot written about primary care teams as a natural consequence of the medical home model. In an article in AAP News, Gonzalo J. Paz-Soldán, MD, a member of the American Academy of Pediatrics Council on Community Pediatrics and regional executive medical director, pediatrics, at Reliant Medical Group, Worcester, Mass., suggests that pediatricians should be taking on leadership roles in directing these teams. He claims that in addition to improving the “quality, value, patient experience,” our leadership also will benefit “provider and staff wellness and engagement.” In other words, taking charge will return the joy of pediatrics, and make us more resilient in the face of burnout.

Copyright thinkstockphotos.com

It’s hard to argue with the notion that having more control improves our chances of satisfaction. Most of us who owned and ran our own small practices will tell you that when we were captains of the ship, those were our most rewarding and productive years.

However, assuming a leadership in a large multilevel team of providers and support staff is another story. As Dr. Paz-Soldán observes, most of us were not trained for leadership roles. I would add that the path to medical school does not select for those skills or interest. In addition to requiring a certain set of skill and aptitudes that we may not have, leadership demands a substantial time commitment.

Leading means attending what are often poorly conceived meetings (the topic for a future Letters from Maine), and receiving and writing emails – none of which involve actually taking care of patients. Like it or not, the ugly truth is that seeing patients is what generates our bottom lines. Time spent going to meetings and communicating with your teams members cannot be considered “billable hours.”

So here is our dilemma: Do we abandon the solo and small group practice model, sell out to large entities, lose control of our professional destiny, and spend our time grousing about it? Or do we attempt to regain some control of where our practices are going by giving up productive time with our patients and going to meetings?

There are a few saintly and gifted physicians who have the skills, energy, and commitment to become leaders and still spend enough time seeing patients to satisfy both their emotional and financial professional needs. However, in my experience, when physicians move into leadership roles, the additional responsibilities cannibalize their commitment to patient care and the skills that made them talented physicians.

Of course, one answer may be that we don’t all need to be leaders in the organizational sense that Dr. Paz-Soldán suggests. Personally, I prefer to lead by example. The problem is that the influence you can have when leading by example is limited to the small circle of people with first-hand knowledge of your activities.

Given my aversion to meetings and my disinterest in organization on a large scale, I think if I were a college student considering a career taking care of children, I would take a hard look at becoming a nurse practitioner or physician’s assistant. I might not make as much money, nor would my parents be able to introduce me as their “son the doctor.” But I would be content spending more time doing what I enjoyed.
 

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].

 

Do you practice as a team member? How is your team defined? Is it made up solely of physicians? Does it include mid-level providers? Does it extend to mental health and social service providers in your office? Do you consider nonproviders such as receptionists as team members? Do you consider the whole office “your team”? Or, is it a smaller team with just yourself and one or two other physicians along with a mid-level provider or two?

There has been a lot written about primary care teams as a natural consequence of the medical home model. In an article in AAP News, Gonzalo J. Paz-Soldán, MD, a member of the American Academy of Pediatrics Council on Community Pediatrics and regional executive medical director, pediatrics, at Reliant Medical Group, Worcester, Mass., suggests that pediatricians should be taking on leadership roles in directing these teams. He claims that in addition to improving the “quality, value, patient experience,” our leadership also will benefit “provider and staff wellness and engagement.” In other words, taking charge will return the joy of pediatrics, and make us more resilient in the face of burnout.

Copyright thinkstockphotos.com

It’s hard to argue with the notion that having more control improves our chances of satisfaction. Most of us who owned and ran our own small practices will tell you that when we were captains of the ship, those were our most rewarding and productive years.

However, assuming a leadership in a large multilevel team of providers and support staff is another story. As Dr. Paz-Soldán observes, most of us were not trained for leadership roles. I would add that the path to medical school does not select for those skills or interest. In addition to requiring a certain set of skill and aptitudes that we may not have, leadership demands a substantial time commitment.

Leading means attending what are often poorly conceived meetings (the topic for a future Letters from Maine), and receiving and writing emails – none of which involve actually taking care of patients. Like it or not, the ugly truth is that seeing patients is what generates our bottom lines. Time spent going to meetings and communicating with your teams members cannot be considered “billable hours.”

So here is our dilemma: Do we abandon the solo and small group practice model, sell out to large entities, lose control of our professional destiny, and spend our time grousing about it? Or do we attempt to regain some control of where our practices are going by giving up productive time with our patients and going to meetings?

There are a few saintly and gifted physicians who have the skills, energy, and commitment to become leaders and still spend enough time seeing patients to satisfy both their emotional and financial professional needs. However, in my experience, when physicians move into leadership roles, the additional responsibilities cannibalize their commitment to patient care and the skills that made them talented physicians.

Of course, one answer may be that we don’t all need to be leaders in the organizational sense that Dr. Paz-Soldán suggests. Personally, I prefer to lead by example. The problem is that the influence you can have when leading by example is limited to the small circle of people with first-hand knowledge of your activities.

Given my aversion to meetings and my disinterest in organization on a large scale, I think if I were a college student considering a career taking care of children, I would take a hard look at becoming a nurse practitioner or physician’s assistant. I might not make as much money, nor would my parents be able to introduce me as their “son the doctor.” But I would be content spending more time doing what I enjoyed.
 

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].

 

Do you practice as a team member? How is your team defined? Is it made up solely of physicians? Does it include mid-level providers? Does it extend to mental health and social service providers in your office? Do you consider nonproviders such as receptionists as team members? Do you consider the whole office “your team”? Or, is it a smaller team with just yourself and one or two other physicians along with a mid-level provider or two?

There has been a lot written about primary care teams as a natural consequence of the medical home model. In an article in AAP News, Gonzalo J. Paz-Soldán, MD, a member of the American Academy of Pediatrics Council on Community Pediatrics and regional executive medical director, pediatrics, at Reliant Medical Group, Worcester, Mass., suggests that pediatricians should be taking on leadership roles in directing these teams. He claims that in addition to improving the “quality, value, patient experience,” our leadership also will benefit “provider and staff wellness and engagement.” In other words, taking charge will return the joy of pediatrics, and make us more resilient in the face of burnout.

Copyright thinkstockphotos.com

It’s hard to argue with the notion that having more control improves our chances of satisfaction. Most of us who owned and ran our own small practices will tell you that when we were captains of the ship, those were our most rewarding and productive years.

However, assuming a leadership in a large multilevel team of providers and support staff is another story. As Dr. Paz-Soldán observes, most of us were not trained for leadership roles. I would add that the path to medical school does not select for those skills or interest. In addition to requiring a certain set of skill and aptitudes that we may not have, leadership demands a substantial time commitment.

Leading means attending what are often poorly conceived meetings (the topic for a future Letters from Maine), and receiving and writing emails – none of which involve actually taking care of patients. Like it or not, the ugly truth is that seeing patients is what generates our bottom lines. Time spent going to meetings and communicating with your teams members cannot be considered “billable hours.”

So here is our dilemma: Do we abandon the solo and small group practice model, sell out to large entities, lose control of our professional destiny, and spend our time grousing about it? Or do we attempt to regain some control of where our practices are going by giving up productive time with our patients and going to meetings?

There are a few saintly and gifted physicians who have the skills, energy, and commitment to become leaders and still spend enough time seeing patients to satisfy both their emotional and financial professional needs. However, in my experience, when physicians move into leadership roles, the additional responsibilities cannibalize their commitment to patient care and the skills that made them talented physicians.

Of course, one answer may be that we don’t all need to be leaders in the organizational sense that Dr. Paz-Soldán suggests. Personally, I prefer to lead by example. The problem is that the influence you can have when leading by example is limited to the small circle of people with first-hand knowledge of your activities.

Given my aversion to meetings and my disinterest in organization on a large scale, I think if I were a college student considering a career taking care of children, I would take a hard look at becoming a nurse practitioner or physician’s assistant. I might not make as much money, nor would my parents be able to introduce me as their “son the doctor.” But I would be content spending more time doing what I enjoyed.
 

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 Food and Drug Administration is concerned about incidents of overheating, fires, and explosions of e-cigarettes, or “vapes,” which in some cases have resulted in serious injuries. The agency is reviewing these types of incidents and has taken steps to protect the public.

The FDA recently developed resources for consumers, including tips to help avoid e-cigarette overheating and explosions, as well as social media tools to help spread the word about protective steps. The agency also has a reporting system to collect information about adverse experiences associated with e-cigarettes and other tobacco products. Comprehensive and accurate reports could provide evidence to help inform future actions to protect the public.

The FDA has provided tips that may help reduce the risk of e-cigarette overheating and explosions. The agency’s Center for Tobacco Products (CTP) encourages you to share these tips with patients who use or might use these tobacco products, as well as with health professionals, parents, and others who might pass along the tips.
 

For e-cigarette users: Tips to help prevent fires and explosions

Learn about your device.

The best protection against battery explosions may be knowing about your device and how to handle and charge its batteries appropriately. Read and follow the manufacturer’s use and care recommendations. If the e-cigarette did not come with instructions or you have additional questions, contact the manufacturer.

Consider using e-cigarettes with protective features.

Some e-cigarettes have features such as firing button locks, vent holes, and protection against overcharging. These features are designed to prevent battery overheating and explosions, so do not remove or disable them.

Choose batteries carefully and replace them if necessary:

• Use only the batteries recommended for your device. Do not mix different brands, different charge levels, or old and new batteries in the same device.

• Replace the batteries if they get damaged or wet. If your e-cigarette is damaged and the batteries are not replaceable, contact the manufacturer.

• Stop using the device under certain circumstances. Although battery explosions can occur with no warning, you should immediately stop using your e-cigarette and get a safe distance from it if you notice any of these during use or while charging: strange noises; unusual smells; a leaking battery; the e-cigarette becoming unusually hot; or the device beginning to smoke, spark, emit flashes, or catch fire.

Be aware when charging your e-cigarette:

• Use only the charger that came with your device, and never charge it with a phone or tablet charger.

• Charge the device on a clean, flat surface, in a place you can clearly see it, and away from anything that can easily catch fire. Do not leave the e-cigarette charging on a surface such as a couch or pillow, where it may be more likely to overheat or turn on unintentionally.

• Do not charge the device overnight or leave it charging unattended.

Know this about carrying and storing your e-cigarette:

• Keep your e-cigarette covered. If you are carrying it in your pocket, avoid having it come in contact with coins or loose batteries.

• Protect the e-cigarette from extreme temperatures. Do not leave it in direct sunlight or in your car in extremely cold or hot temperatures.

Report any problems.

If something goes wrong with an e-cigarette, please submit a report to https://www.safetyreporting.hhs.gov

To make it easy to share the FDA’s top tips, the agency has developed a 5 Tips to Help Avoid “Vape” Battery Explosion infographic.

This infographic and other public-health resources can be found on a dedicated CTP webpage, which offers shareable and downloadable content to help spread the word about e-cigarette battery issues, as well as a video on how to report adverse experiences related to tobacco products to the FDA.
 

When a fire or explosion does occur: The Safety Reporting Portal

The CTP identified 143 reported incidents of e-cigarette overheating, fires, and explosions during 2009-2015, and 20 additional reports during 2016. Based on the FDA’s experience with underreporting of adverse events for other regulated products, the number of actual events is probably higher.

The FDA is working to collect more information to identify the true number of events and why these incidents are occurring. The agency has a Safety Reporting Portal (SRP) dedicated to receiving reports of issues associated with FDA-regulated products, including e-cigarettes and other tobacco products.

The FDA strongly encourages any physicians, other health care professionals, or those with firsthand knowledge about an unexpected e-cigarette incident to report it through the SRP. Family physicians can play a valuable reporting role by informing patients about the reporting system, helping people submit complete information about incidents related to e-cigarettes, or providing information about an incident on a patient’s behalf.

To report an e-cigarette failure or other tobacco-related adverse event, please go to the SRP and follow the instructions in each section. Those unable to use the SRP to submit a report can call 877-CTP-1373 or email [email protected].

The more complete and accurate a report is, the more helpful it can be to the FDA and, in turn, to public health. When submitting a report about an e-cigarette, please include:

• E-cigarette manufacturer’s name.

• E-cigarette’s brand name, model, and serial number.

• Battery’s brand name and model.

• Place the e-cigarette was purchased.

• Whether, and how, the product was being used at the time of the incident.

• Whether the product was used differently than intended by the manufacturer.

• Whether the product was modified in any way.

To collect as much detail as possible, the FDA encourages those submitting reports to upload photos or other files, such as police or hospital reports. They also appreciate submission of contact information, such as a phone number or email address, which will help the agency follow up with any questions related to the report. Personal information will not be shared or used for any additional matter and is protected by security practices. The HHS Privacy Policy contains more information.
 

Ongoing public health protection efforts

The FDA continues to evaluate possible ways to protect the public from device-related fires and explosions. During a public workshop in April, the FDA heard from experts including scientists, engineers, and e-cigarette manufacturers and retailers, as well as from the general public, about hazards and possible solutions related to batteries in e-cigarettes and other electronic nicotine delivery systems. Also, the agency’s premarket review process for electronic nicotine delivery systems includes an assessment of device operation and any features that may reduce the risks associated with product use, including testing related to overheating and exploding batteries.

Through these and other measures, the FDA is committed to identifying and addressing factors leading to e-cigarette overheating and any subsequent injuries. Health care professionals can help by spreading the word about the agency’s user tips and reporting portal.

To learn more broadly about the FDA’s ongoing efforts to protect the public health by regulating the manufacture, marketing, and distribution of tobacco products, please visit the Center for Tobacco Products website.

Dr. Holman is director of the office of science at the FDA’s Center for Tobacco Products.

 

The Food and Drug Administration is concerned about incidents of overheating, fires, and explosions of e-cigarettes, or “vapes,” which in some cases have resulted in serious injuries. The agency is reviewing these types of incidents and has taken steps to protect the public.

The FDA recently developed resources for consumers, including tips to help avoid e-cigarette overheating and explosions, as well as social media tools to help spread the word about protective steps. The agency also has a reporting system to collect information about adverse experiences associated with e-cigarettes and other tobacco products. Comprehensive and accurate reports could provide evidence to help inform future actions to protect the public.

The FDA has provided tips that may help reduce the risk of e-cigarette overheating and explosions. The agency’s Center for Tobacco Products (CTP) encourages you to share these tips with patients who use or might use these tobacco products, as well as with health professionals, parents, and others who might pass along the tips.
 

For e-cigarette users: Tips to help prevent fires and explosions

Learn about your device.

The best protection against battery explosions may be knowing about your device and how to handle and charge its batteries appropriately. Read and follow the manufacturer’s use and care recommendations. If the e-cigarette did not come with instructions or you have additional questions, contact the manufacturer.

Consider using e-cigarettes with protective features.

Some e-cigarettes have features such as firing button locks, vent holes, and protection against overcharging. These features are designed to prevent battery overheating and explosions, so do not remove or disable them.

Choose batteries carefully and replace them if necessary:

• Use only the batteries recommended for your device. Do not mix different brands, different charge levels, or old and new batteries in the same device.

• Replace the batteries if they get damaged or wet. If your e-cigarette is damaged and the batteries are not replaceable, contact the manufacturer.

• Stop using the device under certain circumstances. Although battery explosions can occur with no warning, you should immediately stop using your e-cigarette and get a safe distance from it if you notice any of these during use or while charging: strange noises; unusual smells; a leaking battery; the e-cigarette becoming unusually hot; or the device beginning to smoke, spark, emit flashes, or catch fire.

Be aware when charging your e-cigarette:

• Use only the charger that came with your device, and never charge it with a phone or tablet charger.

• Charge the device on a clean, flat surface, in a place you can clearly see it, and away from anything that can easily catch fire. Do not leave the e-cigarette charging on a surface such as a couch or pillow, where it may be more likely to overheat or turn on unintentionally.

• Do not charge the device overnight or leave it charging unattended.

Know this about carrying and storing your e-cigarette:

• Keep your e-cigarette covered. If you are carrying it in your pocket, avoid having it come in contact with coins or loose batteries.

• Protect the e-cigarette from extreme temperatures. Do not leave it in direct sunlight or in your car in extremely cold or hot temperatures.

Report any problems.

If something goes wrong with an e-cigarette, please submit a report to https://www.safetyreporting.hhs.gov

To make it easy to share the FDA’s top tips, the agency has developed a 5 Tips to Help Avoid “Vape” Battery Explosion infographic.

This infographic and other public-health resources can be found on a dedicated CTP webpage, which offers shareable and downloadable content to help spread the word about e-cigarette battery issues, as well as a video on how to report adverse experiences related to tobacco products to the FDA.
 

When a fire or explosion does occur: The Safety Reporting Portal

The CTP identified 143 reported incidents of e-cigarette overheating, fires, and explosions during 2009-2015, and 20 additional reports during 2016. Based on the FDA’s experience with underreporting of adverse events for other regulated products, the number of actual events is probably higher.

The FDA is working to collect more information to identify the true number of events and why these incidents are occurring. The agency has a Safety Reporting Portal (SRP) dedicated to receiving reports of issues associated with FDA-regulated products, including e-cigarettes and other tobacco products.

The FDA strongly encourages any physicians, other health care professionals, or those with firsthand knowledge about an unexpected e-cigarette incident to report it through the SRP. Family physicians can play a valuable reporting role by informing patients about the reporting system, helping people submit complete information about incidents related to e-cigarettes, or providing information about an incident on a patient’s behalf.

To report an e-cigarette failure or other tobacco-related adverse event, please go to the SRP and follow the instructions in each section. Those unable to use the SRP to submit a report can call 877-CTP-1373 or email [email protected].

The more complete and accurate a report is, the more helpful it can be to the FDA and, in turn, to public health. When submitting a report about an e-cigarette, please include:

• E-cigarette manufacturer’s name.

• E-cigarette’s brand name, model, and serial number.

• Battery’s brand name and model.

• Place the e-cigarette was purchased.

• Whether, and how, the product was being used at the time of the incident.

• Whether the product was used differently than intended by the manufacturer.

• Whether the product was modified in any way.

To collect as much detail as possible, the FDA encourages those submitting reports to upload photos or other files, such as police or hospital reports. They also appreciate submission of contact information, such as a phone number or email address, which will help the agency follow up with any questions related to the report. Personal information will not be shared or used for any additional matter and is protected by security practices. The HHS Privacy Policy contains more information.
 

Ongoing public health protection efforts

The FDA continues to evaluate possible ways to protect the public from device-related fires and explosions. During a public workshop in April, the FDA heard from experts including scientists, engineers, and e-cigarette manufacturers and retailers, as well as from the general public, about hazards and possible solutions related to batteries in e-cigarettes and other electronic nicotine delivery systems. Also, the agency’s premarket review process for electronic nicotine delivery systems includes an assessment of device operation and any features that may reduce the risks associated with product use, including testing related to overheating and exploding batteries.

Through these and other measures, the FDA is committed to identifying and addressing factors leading to e-cigarette overheating and any subsequent injuries. Health care professionals can help by spreading the word about the agency’s user tips and reporting portal.

To learn more broadly about the FDA’s ongoing efforts to protect the public health by regulating the manufacture, marketing, and distribution of tobacco products, please visit the Center for Tobacco Products website.

Dr. Holman is director of the office of science at the FDA’s Center for Tobacco Products.

 

The Food and Drug Administration is concerned about incidents of overheating, fires, and explosions of e-cigarettes, or “vapes,” which in some cases have resulted in serious injuries. The agency is reviewing these types of incidents and has taken steps to protect the public.

The FDA recently developed resources for consumers, including tips to help avoid e-cigarette overheating and explosions, as well as social media tools to help spread the word about protective steps. The agency also has a reporting system to collect information about adverse experiences associated with e-cigarettes and other tobacco products. Comprehensive and accurate reports could provide evidence to help inform future actions to protect the public.

The FDA has provided tips that may help reduce the risk of e-cigarette overheating and explosions. The agency’s Center for Tobacco Products (CTP) encourages you to share these tips with patients who use or might use these tobacco products, as well as with health professionals, parents, and others who might pass along the tips.
 

For e-cigarette users: Tips to help prevent fires and explosions

Learn about your device.

The best protection against battery explosions may be knowing about your device and how to handle and charge its batteries appropriately. Read and follow the manufacturer’s use and care recommendations. If the e-cigarette did not come with instructions or you have additional questions, contact the manufacturer.

Consider using e-cigarettes with protective features.

Some e-cigarettes have features such as firing button locks, vent holes, and protection against overcharging. These features are designed to prevent battery overheating and explosions, so do not remove or disable them.

Choose batteries carefully and replace them if necessary:

• Use only the batteries recommended for your device. Do not mix different brands, different charge levels, or old and new batteries in the same device.

• Replace the batteries if they get damaged or wet. If your e-cigarette is damaged and the batteries are not replaceable, contact the manufacturer.

• Stop using the device under certain circumstances. Although battery explosions can occur with no warning, you should immediately stop using your e-cigarette and get a safe distance from it if you notice any of these during use or while charging: strange noises; unusual smells; a leaking battery; the e-cigarette becoming unusually hot; or the device beginning to smoke, spark, emit flashes, or catch fire.

Be aware when charging your e-cigarette:

• Use only the charger that came with your device, and never charge it with a phone or tablet charger.

• Charge the device on a clean, flat surface, in a place you can clearly see it, and away from anything that can easily catch fire. Do not leave the e-cigarette charging on a surface such as a couch or pillow, where it may be more likely to overheat or turn on unintentionally.

• Do not charge the device overnight or leave it charging unattended.

Know this about carrying and storing your e-cigarette:

• Keep your e-cigarette covered. If you are carrying it in your pocket, avoid having it come in contact with coins or loose batteries.

• Protect the e-cigarette from extreme temperatures. Do not leave it in direct sunlight or in your car in extremely cold or hot temperatures.

Report any problems.

If something goes wrong with an e-cigarette, please submit a report to https://www.safetyreporting.hhs.gov

To make it easy to share the FDA’s top tips, the agency has developed a 5 Tips to Help Avoid “Vape” Battery Explosion infographic.

This infographic and other public-health resources can be found on a dedicated CTP webpage, which offers shareable and downloadable content to help spread the word about e-cigarette battery issues, as well as a video on how to report adverse experiences related to tobacco products to the FDA.
 

When a fire or explosion does occur: The Safety Reporting Portal

The CTP identified 143 reported incidents of e-cigarette overheating, fires, and explosions during 2009-2015, and 20 additional reports during 2016. Based on the FDA’s experience with underreporting of adverse events for other regulated products, the number of actual events is probably higher.

The FDA is working to collect more information to identify the true number of events and why these incidents are occurring. The agency has a Safety Reporting Portal (SRP) dedicated to receiving reports of issues associated with FDA-regulated products, including e-cigarettes and other tobacco products.

The FDA strongly encourages any physicians, other health care professionals, or those with firsthand knowledge about an unexpected e-cigarette incident to report it through the SRP. Family physicians can play a valuable reporting role by informing patients about the reporting system, helping people submit complete information about incidents related to e-cigarettes, or providing information about an incident on a patient’s behalf.

To report an e-cigarette failure or other tobacco-related adverse event, please go to the SRP and follow the instructions in each section. Those unable to use the SRP to submit a report can call 877-CTP-1373 or email [email protected].

The more complete and accurate a report is, the more helpful it can be to the FDA and, in turn, to public health. When submitting a report about an e-cigarette, please include:

• E-cigarette manufacturer’s name.

• E-cigarette’s brand name, model, and serial number.

• Battery’s brand name and model.

• Place the e-cigarette was purchased.

• Whether, and how, the product was being used at the time of the incident.

• Whether the product was used differently than intended by the manufacturer.

• Whether the product was modified in any way.

To collect as much detail as possible, the FDA encourages those submitting reports to upload photos or other files, such as police or hospital reports. They also appreciate submission of contact information, such as a phone number or email address, which will help the agency follow up with any questions related to the report. Personal information will not be shared or used for any additional matter and is protected by security practices. The HHS Privacy Policy contains more information.
 

Ongoing public health protection efforts

The FDA continues to evaluate possible ways to protect the public from device-related fires and explosions. During a public workshop in April, the FDA heard from experts including scientists, engineers, and e-cigarette manufacturers and retailers, as well as from the general public, about hazards and possible solutions related to batteries in e-cigarettes and other electronic nicotine delivery systems. Also, the agency’s premarket review process for electronic nicotine delivery systems includes an assessment of device operation and any features that may reduce the risks associated with product use, including testing related to overheating and exploding batteries.

Through these and other measures, the FDA is committed to identifying and addressing factors leading to e-cigarette overheating and any subsequent injuries. Health care professionals can help by spreading the word about the agency’s user tips and reporting portal.

To learn more broadly about the FDA’s ongoing efforts to protect the public health by regulating the manufacture, marketing, and distribution of tobacco products, please visit the Center for Tobacco Products website.

Dr. Holman is director of the office of science at the FDA’s Center for Tobacco Products.

 

Sexual health screening and counseling is an important part of wellness care for all adolescents, and transgender and gender nonconforming (TGNC) youth are no exception. TGNC youth may avoid routine health visits and sexual health conversations because they fear discrimination in the health care setting and feel uncomfortable about physical exams.¹ Providers should be aware of the potential anxiety patients may feel during health care visits and work to establish an environment of respect and inclusiveness. Below are some tips to help provide care that is inclusive of the diverse gender and sexual identities of the patients we see.

JackF/Thinkstock

Obtaining a sexual history

1. Clearly explain the reasons for asking sexually explicit questions.

TGNC youth experiencing dysphoria may have heightened levels of anxiety when discussing sexuality. Before asking these questions, acknowledge the sensitivity of this topic and explain that this information is important for providers to know so that they can provide appropriate counseling and screening recommendations. This may alleviate some of their discomfort.

2. Ensure confidentiality.

When obtaining sexual health histories, it is crucial to ensure confidential patient encounters, as described by the American Academy of Pediatrics and Society for Adolescent Health and Medicine.^2,3 The Guttmacher Institute provides information about minors’ consent law in each state.⁴

3. Do not assume identity equals behavior.

Sexual and gender identity may not be predictive of sexual behaviors, and providers should not assume behaviors based on a patient’s identity.

Here are some sexual health questions you need to ask:

• Who are you attracted to? What is/are the gender(s) of your partner(s)?
• Have you ever had anal, genital, or oral sex? If yes:

Do you give, receive, or both?

When was the last time you had sex?

How many partners have you had in past 6 months?

Do you use barrier protection most of the time, some of the time, always, or never?

Do you have symptoms of an infection, such as burning when you pee, abnormal genital discharge, pain with sex, or irregular bleeding?

• Have you ever been forced/coerced into having sex?

Starting with open-ended questions about attraction can give patients an opportunity to describe their pattern of attraction. If needed, patients can be prompted with more specific questions about their partners’ genders. It is important to ask explicitly about genital, oral, and anal sex because patients sometimes do not realize that the term sex includes oral and anal sex. Patients also may not be aware that it is possible to spread infections through oral and anal sex.

4. Anatomy and behavior may change over time, and it is important to reassess sexually transmitted infection risk at each visit

Studies suggest that, as gender dysphoria decreases, sexual desires may increase; this is true for all adolescents but of particular interest with TGNC youth. This may affect behaviors.⁵ For youth on hormone therapy, testosterone can increase libido, whereas estrogen may decrease libido and affect sexual function.⁶
 

Physical exam

Dysphoria related to primary and secondary sex characteristics may make exams particularly distressing. Providers should clearly explain reasons for performing various parts of the physical exam. When performing the physical exam, providers should use a gender-affirming approach. This includes using the patient’s identified name and pronouns throughout the visit and asking patients preference for terminology when discussing body parts (some patients may prefer the use of the term “front hole” to vagina).^1,7,8 The exam and evaluation may need to be modified based on comfort. If a patient refuses a speculum exam after the need for the its use has been discussed, consider offering an external genital exam and bimanual exam instead. If a patient refuses to allow a provider to obtain a rectal or vaginal swab, consider allowing patients to self-swab. Providers also should consider whether genital exams can be deferred to subsequent visits. These techniques offer an opportunity to build trust and rapport with patients so that they remain engaged in care and may become comfortable with the necessary tests and procedures at future visits.

Sexual health counseling

Sexual health counseling should address reducing risk and optimizing physical and emotional satisfaction in relationships and encounters.⁹ In addition to assessing risky behaviors and screening for sexually transmitted infections, providers also should provide counseling on safer-sex practices. This includes the use of lubrication to reduce trauma to genital tissues, which can potentiate the spread of infections, and the use of barrier protection, such as external condoms (often referred to as male condoms), internal condoms (often referred to as female condoms), dental dams during oral sex, and gloves for digital penetration. Patients at risk for pregnancy should receive comprehensive contraceptive counseling. TGNC patients may be at increased risk of sexual victimization, and honest discussions about safety in relationships is important. The goal of sexual health counseling should be to promote safe, satisfying experiences for all patients.

 

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Email her at [email protected].

References

1. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, in Center of Excellence for Transgender Health, Department of Family and Community Medicine, 2nd ed. (San Francisco: University of California, 2016).

2. Pediatrics. 2008. doi: 10.1542/peds.2008-0694.

3. J Adol Health. 2004;35:160-7.

4. An Overview of Minors’ Consent Law: State Laws and Policies. 2017, by the Guttmacher Institute.

5. Eur J Endocrinol. 2011 Aug;165(2):331-7.

6. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.

7. Sex Roles. 2013 Jun 1;68(11-12):675-89.

8. J Midwifery Womens Health. 2008 Jul-Aug;53(4):331-7.

9. “The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health,” 2nd ed. (Philadelphia: American College of Physicians Press, 2008).

 

Sexual health screening and counseling is an important part of wellness care for all adolescents, and transgender and gender nonconforming (TGNC) youth are no exception. TGNC youth may avoid routine health visits and sexual health conversations because they fear discrimination in the health care setting and feel uncomfortable about physical exams.¹ Providers should be aware of the potential anxiety patients may feel during health care visits and work to establish an environment of respect and inclusiveness. Below are some tips to help provide care that is inclusive of the diverse gender and sexual identities of the patients we see.

JackF/Thinkstock

Obtaining a sexual history

1. Clearly explain the reasons for asking sexually explicit questions.

TGNC youth experiencing dysphoria may have heightened levels of anxiety when discussing sexuality. Before asking these questions, acknowledge the sensitivity of this topic and explain that this information is important for providers to know so that they can provide appropriate counseling and screening recommendations. This may alleviate some of their discomfort.

2. Ensure confidentiality.

When obtaining sexual health histories, it is crucial to ensure confidential patient encounters, as described by the American Academy of Pediatrics and Society for Adolescent Health and Medicine.^2,3 The Guttmacher Institute provides information about minors’ consent law in each state.⁴

3. Do not assume identity equals behavior.

Sexual and gender identity may not be predictive of sexual behaviors, and providers should not assume behaviors based on a patient’s identity.

Here are some sexual health questions you need to ask:

• Who are you attracted to? What is/are the gender(s) of your partner(s)?
• Have you ever had anal, genital, or oral sex? If yes:

Do you give, receive, or both?

When was the last time you had sex?

How many partners have you had in past 6 months?

Do you use barrier protection most of the time, some of the time, always, or never?

Do you have symptoms of an infection, such as burning when you pee, abnormal genital discharge, pain with sex, or irregular bleeding?

• Have you ever been forced/coerced into having sex?

Starting with open-ended questions about attraction can give patients an opportunity to describe their pattern of attraction. If needed, patients can be prompted with more specific questions about their partners’ genders. It is important to ask explicitly about genital, oral, and anal sex because patients sometimes do not realize that the term sex includes oral and anal sex. Patients also may not be aware that it is possible to spread infections through oral and anal sex.

4. Anatomy and behavior may change over time, and it is important to reassess sexually transmitted infection risk at each visit

Studies suggest that, as gender dysphoria decreases, sexual desires may increase; this is true for all adolescents but of particular interest with TGNC youth. This may affect behaviors.⁵ For youth on hormone therapy, testosterone can increase libido, whereas estrogen may decrease libido and affect sexual function.⁶
 

Physical exam

Dysphoria related to primary and secondary sex characteristics may make exams particularly distressing. Providers should clearly explain reasons for performing various parts of the physical exam. When performing the physical exam, providers should use a gender-affirming approach. This includes using the patient’s identified name and pronouns throughout the visit and asking patients preference for terminology when discussing body parts (some patients may prefer the use of the term “front hole” to vagina).^1,7,8 The exam and evaluation may need to be modified based on comfort. If a patient refuses a speculum exam after the need for the its use has been discussed, consider offering an external genital exam and bimanual exam instead. If a patient refuses to allow a provider to obtain a rectal or vaginal swab, consider allowing patients to self-swab. Providers also should consider whether genital exams can be deferred to subsequent visits. These techniques offer an opportunity to build trust and rapport with patients so that they remain engaged in care and may become comfortable with the necessary tests and procedures at future visits.

Sexual health counseling

Sexual health counseling should address reducing risk and optimizing physical and emotional satisfaction in relationships and encounters.⁹ In addition to assessing risky behaviors and screening for sexually transmitted infections, providers also should provide counseling on safer-sex practices. This includes the use of lubrication to reduce trauma to genital tissues, which can potentiate the spread of infections, and the use of barrier protection, such as external condoms (often referred to as male condoms), internal condoms (often referred to as female condoms), dental dams during oral sex, and gloves for digital penetration. Patients at risk for pregnancy should receive comprehensive contraceptive counseling. TGNC patients may be at increased risk of sexual victimization, and honest discussions about safety in relationships is important. The goal of sexual health counseling should be to promote safe, satisfying experiences for all patients.

 

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Email her at [email protected].

References

1. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, in Center of Excellence for Transgender Health, Department of Family and Community Medicine, 2nd ed. (San Francisco: University of California, 2016).

2. Pediatrics. 2008. doi: 10.1542/peds.2008-0694.

3. J Adol Health. 2004;35:160-7.

4. An Overview of Minors’ Consent Law: State Laws and Policies. 2017, by the Guttmacher Institute.

5. Eur J Endocrinol. 2011 Aug;165(2):331-7.

6. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.

7. Sex Roles. 2013 Jun 1;68(11-12):675-89.

8. J Midwifery Womens Health. 2008 Jul-Aug;53(4):331-7.

9. “The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health,” 2nd ed. (Philadelphia: American College of Physicians Press, 2008).

 

Sexual health screening and counseling is an important part of wellness care for all adolescents, and transgender and gender nonconforming (TGNC) youth are no exception. TGNC youth may avoid routine health visits and sexual health conversations because they fear discrimination in the health care setting and feel uncomfortable about physical exams.¹ Providers should be aware of the potential anxiety patients may feel during health care visits and work to establish an environment of respect and inclusiveness. Below are some tips to help provide care that is inclusive of the diverse gender and sexual identities of the patients we see.

JackF/Thinkstock

Obtaining a sexual history

1. Clearly explain the reasons for asking sexually explicit questions.

TGNC youth experiencing dysphoria may have heightened levels of anxiety when discussing sexuality. Before asking these questions, acknowledge the sensitivity of this topic and explain that this information is important for providers to know so that they can provide appropriate counseling and screening recommendations. This may alleviate some of their discomfort.

2. Ensure confidentiality.

When obtaining sexual health histories, it is crucial to ensure confidential patient encounters, as described by the American Academy of Pediatrics and Society for Adolescent Health and Medicine.^2,3 The Guttmacher Institute provides information about minors’ consent law in each state.⁴

3. Do not assume identity equals behavior.

Sexual and gender identity may not be predictive of sexual behaviors, and providers should not assume behaviors based on a patient’s identity.

Here are some sexual health questions you need to ask:

• Who are you attracted to? What is/are the gender(s) of your partner(s)?
• Have you ever had anal, genital, or oral sex? If yes:

Do you give, receive, or both?

When was the last time you had sex?

How many partners have you had in past 6 months?

Do you use barrier protection most of the time, some of the time, always, or never?

Do you have symptoms of an infection, such as burning when you pee, abnormal genital discharge, pain with sex, or irregular bleeding?

• Have you ever been forced/coerced into having sex?

Starting with open-ended questions about attraction can give patients an opportunity to describe their pattern of attraction. If needed, patients can be prompted with more specific questions about their partners’ genders. It is important to ask explicitly about genital, oral, and anal sex because patients sometimes do not realize that the term sex includes oral and anal sex. Patients also may not be aware that it is possible to spread infections through oral and anal sex.

4. Anatomy and behavior may change over time, and it is important to reassess sexually transmitted infection risk at each visit

Studies suggest that, as gender dysphoria decreases, sexual desires may increase; this is true for all adolescents but of particular interest with TGNC youth. This may affect behaviors.⁵ For youth on hormone therapy, testosterone can increase libido, whereas estrogen may decrease libido and affect sexual function.⁶
 

Physical exam

Dysphoria related to primary and secondary sex characteristics may make exams particularly distressing. Providers should clearly explain reasons for performing various parts of the physical exam. When performing the physical exam, providers should use a gender-affirming approach. This includes using the patient’s identified name and pronouns throughout the visit and asking patients preference for terminology when discussing body parts (some patients may prefer the use of the term “front hole” to vagina).^1,7,8 The exam and evaluation may need to be modified based on comfort. If a patient refuses a speculum exam after the need for the its use has been discussed, consider offering an external genital exam and bimanual exam instead. If a patient refuses to allow a provider to obtain a rectal or vaginal swab, consider allowing patients to self-swab. Providers also should consider whether genital exams can be deferred to subsequent visits. These techniques offer an opportunity to build trust and rapport with patients so that they remain engaged in care and may become comfortable with the necessary tests and procedures at future visits.

Sexual health counseling

Sexual health counseling should address reducing risk and optimizing physical and emotional satisfaction in relationships and encounters.⁹ In addition to assessing risky behaviors and screening for sexually transmitted infections, providers also should provide counseling on safer-sex practices. This includes the use of lubrication to reduce trauma to genital tissues, which can potentiate the spread of infections, and the use of barrier protection, such as external condoms (often referred to as male condoms), internal condoms (often referred to as female condoms), dental dams during oral sex, and gloves for digital penetration. Patients at risk for pregnancy should receive comprehensive contraceptive counseling. TGNC patients may be at increased risk of sexual victimization, and honest discussions about safety in relationships is important. The goal of sexual health counseling should be to promote safe, satisfying experiences for all patients.

 

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Email her at [email protected].

References

1. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, in Center of Excellence for Transgender Health, Department of Family and Community Medicine, 2nd ed. (San Francisco: University of California, 2016).

2. Pediatrics. 2008. doi: 10.1542/peds.2008-0694.

3. J Adol Health. 2004;35:160-7.

4. An Overview of Minors’ Consent Law: State Laws and Policies. 2017, by the Guttmacher Institute.

5. Eur J Endocrinol. 2011 Aug;165(2):331-7.

6. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.

7. Sex Roles. 2013 Jun 1;68(11-12):675-89.

8. J Midwifery Womens Health. 2008 Jul-Aug;53(4):331-7.

9. “The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health,” 2nd ed. (Philadelphia: American College of Physicians Press, 2008).

 

I recently received a group text from a friend voicing her frustration that her neighbor had acquired chickens, and she shared a photo of some roaming freely in the front yard. Naturally, my response was related to the potential infectious disease exposure and infections. Another friend chimed in “fresh eggs, and these are free range chickens. They don’t get sick. ... Many people in my area have chickens.” Unbeknownst to my friends, they had helped me select the ID Consult topic for this month.

Nontyphoidal Salmonella bacteria are associated with a wide spectrum of infections which range from asymptomatic gastrointestinal carriage to bacteremia, meningitis, osteomyelitis, and focal infections. Invasive disease is seen most often in children younger than 5 years of age, persons aged 65 years or older, and individuals with hemoglobinopathies including sickle cell disease and those with immunodeficiencies. Annually, the Centers for Disease Control and Prevention estimates that nontyphoidal salmonellosis is responsible for 1.2 million illnesses, 23,000 hospitalizations, and 450 deaths in the United States. Gastroenteritis is the most common manifestation of the disease and is characterized by abdominal cramps, diarrhea, and fever that develops 12-72 hours after exposure. It is usually self-limited. As previously reported in this column (June, 2017), Salmonella is one of the top two foodborne pathogens in the United States, and most outbreaks have been associated with consumption of contaminated food. But wait, contaminated food is not the only cause of some of our most recent outbreaks.

JasonJiron/Thinkstock

Salmonella is a zoonotic bacteria commonly found in the intestinal tract of several animals including poultry (chickens, ducks, geese, and turkeys), reptiles, and amphibians. Humans can acquire infection after both direct and indirect contact with infected animals. Most infected animals are asymptomatic and shed bacteria intermittently. Current U.S. outbreaks involve both pet turtles and poultry. Let’s stay focused on poultry.

Live poultry-associated salmonellosis (LPAS)

LPAS was first reported in the 1950s. More recent epidemiologic data was published by C. Basler et al. (Emerging Infect Dis. 2016;22[10]:1705-11). LPAS was defined as two or more culture confirmed human Salmonella infections with a combination of epidemiologic, laboratory, or traceback evidence linking illnesses to contact with live poultry. From 1990 to 2014, a total of 53 LPAS outbreaks in the United States were documented and associated with 2,630 illnesses, 387 hospitalizations, and 5 deaths. The median outbreak size involved 26 cases (range, 4-363) and 77% (41 of 53) were multistate. The median age of the patients was 9 years (range, less than 1 to 92 years), and 31% were aged 5 years or younger. Exposure to chicks and ducklings was reported in 85% and 38%, respectively. High-risk practices included keeping poultry inside of the home (46%), snuggling baby birds (49%), and kissing baby birds (13%). The median time from purchase of poultry to onset of illness was 17 days (range, 1-672), and 66% reported onset of illness less than 30 days after purchase. Almost 52% reported owning poultry for less than 1 year.

The number of outbreaks continued to increase. From 1990 to 2005, there were a total of 17 outbreaks, compared with 36 between 2006 and 2014. Historically, outbreaks occurred in children around Easter when brightly colored dyed chicks were purchased. In the above review, 80% of outbreaks began in February, March, or April with an average duration of 4.9 months (range, 1-12).

Salmonella isolates

Serotypes traditionally associated with foodborne outbreaks are not usually isolated in LPAS outbreaks. Most chicks are acquired from small mail order hatcheries that house multiple species, and the potential for comingling exists not only of birds but their pathogens. In contrast, commercial hatcheries typically are closed facilities with one breed. It is thought that this is one reason for multiple serotypes associated with backyard flock associated salmonellosis. In the 1990-2014 review, while S. montivideo was the most common serotype isolated (36%), 5 other serotypes also were reported.

Backyard flocks and LPAS

More recently outbreaks have been associated with backyard flocks occurring year round and affecting both adults and children in contrast to seasonal peaks. The first multistate backyard flock outbreak was documented in 2007. Currently, the CDC is investigating 10 separate multistate outbreaks that began on Jan. 4, 2017. It involves 48 states, 961 infected individuals, 215 hospitalizations, and 1 death. At least 5 salmonella serotypes have been isolated.

What about the hatcheries?

It’s estimated that 50 million live poultry are sold annually. Birds are shipped within 24 hours after hatching via the U.S. Postal Service in boxes containing up to 100 chicks. Delivery occurs within 72 hours of hatching. Approximately 20 mail order hatcheries provide the majority of poultry sold to the general public. The National Poultry Improvement Plan (NPIP) is a voluntary state and federal testing and certification program whose goal is to eliminate poultry disease from breeder flocks to prevent egg-transmitted and hatchery-disseminated diseases. All hatcheries may participate. They also may participate in the voluntary Salmonella monitoring program. Note participation is not mandatory.

Preventing future outbreaks: patient/parental education is mandatory

1. Make sure your parents know about the association of Salmonella and live poultry. Reinforce these are farm animals, not pets. Purchase birds from hatcheries that participate in NPIP and the Salmonella monitoring programs.

2. Chicks, ducklings, or other live poultry should not be taken to schools, day care facilities, or nursing homes. Poultry should not be allowed in the home or in areas where food or drink is being prepared or consumed.

3. Poultry should not be snuggled, kissed, or allowed to touch one’s mouth. Hand washing with soap and water should occur after touching live poultry or any object touched in areas where they live or roam.

4. Contact with live poultry should be avoided in those at risk for developing serious infections including persons aged 5 years or younger, 65 years or older, immunocompromised individuals, and those with hemoglobinopathies.

5. All equipment used to care for live birds should be washed outdoors. Owners should have designated shoes when caring for poultry which should never be worn inside the home.

Hopefully, the next time you see a patient with fever and diarrhea you will recall this topic and ask about their contact with live poultry.

Additional resources to facilitate discussions can be found at www.cdc.gov/salmonella.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures. Email her at [email protected].

 

I recently received a group text from a friend voicing her frustration that her neighbor had acquired chickens, and she shared a photo of some roaming freely in the front yard. Naturally, my response was related to the potential infectious disease exposure and infections. Another friend chimed in “fresh eggs, and these are free range chickens. They don’t get sick. ... Many people in my area have chickens.” Unbeknownst to my friends, they had helped me select the ID Consult topic for this month.

Nontyphoidal Salmonella bacteria are associated with a wide spectrum of infections which range from asymptomatic gastrointestinal carriage to bacteremia, meningitis, osteomyelitis, and focal infections. Invasive disease is seen most often in children younger than 5 years of age, persons aged 65 years or older, and individuals with hemoglobinopathies including sickle cell disease and those with immunodeficiencies. Annually, the Centers for Disease Control and Prevention estimates that nontyphoidal salmonellosis is responsible for 1.2 million illnesses, 23,000 hospitalizations, and 450 deaths in the United States. Gastroenteritis is the most common manifestation of the disease and is characterized by abdominal cramps, diarrhea, and fever that develops 12-72 hours after exposure. It is usually self-limited. As previously reported in this column (June, 2017), Salmonella is one of the top two foodborne pathogens in the United States, and most outbreaks have been associated with consumption of contaminated food. But wait, contaminated food is not the only cause of some of our most recent outbreaks.

JasonJiron/Thinkstock

Salmonella is a zoonotic bacteria commonly found in the intestinal tract of several animals including poultry (chickens, ducks, geese, and turkeys), reptiles, and amphibians. Humans can acquire infection after both direct and indirect contact with infected animals. Most infected animals are asymptomatic and shed bacteria intermittently. Current U.S. outbreaks involve both pet turtles and poultry. Let’s stay focused on poultry.

Live poultry-associated salmonellosis (LPAS)

LPAS was first reported in the 1950s. More recent epidemiologic data was published by C. Basler et al. (Emerging Infect Dis. 2016;22[10]:1705-11). LPAS was defined as two or more culture confirmed human Salmonella infections with a combination of epidemiologic, laboratory, or traceback evidence linking illnesses to contact with live poultry. From 1990 to 2014, a total of 53 LPAS outbreaks in the United States were documented and associated with 2,630 illnesses, 387 hospitalizations, and 5 deaths. The median outbreak size involved 26 cases (range, 4-363) and 77% (41 of 53) were multistate. The median age of the patients was 9 years (range, less than 1 to 92 years), and 31% were aged 5 years or younger. Exposure to chicks and ducklings was reported in 85% and 38%, respectively. High-risk practices included keeping poultry inside of the home (46%), snuggling baby birds (49%), and kissing baby birds (13%). The median time from purchase of poultry to onset of illness was 17 days (range, 1-672), and 66% reported onset of illness less than 30 days after purchase. Almost 52% reported owning poultry for less than 1 year.

The number of outbreaks continued to increase. From 1990 to 2005, there were a total of 17 outbreaks, compared with 36 between 2006 and 2014. Historically, outbreaks occurred in children around Easter when brightly colored dyed chicks were purchased. In the above review, 80% of outbreaks began in February, March, or April with an average duration of 4.9 months (range, 1-12).

Salmonella isolates

Serotypes traditionally associated with foodborne outbreaks are not usually isolated in LPAS outbreaks. Most chicks are acquired from small mail order hatcheries that house multiple species, and the potential for comingling exists not only of birds but their pathogens. In contrast, commercial hatcheries typically are closed facilities with one breed. It is thought that this is one reason for multiple serotypes associated with backyard flock associated salmonellosis. In the 1990-2014 review, while S. montivideo was the most common serotype isolated (36%), 5 other serotypes also were reported.

Backyard flocks and LPAS

More recently outbreaks have been associated with backyard flocks occurring year round and affecting both adults and children in contrast to seasonal peaks. The first multistate backyard flock outbreak was documented in 2007. Currently, the CDC is investigating 10 separate multistate outbreaks that began on Jan. 4, 2017. It involves 48 states, 961 infected individuals, 215 hospitalizations, and 1 death. At least 5 salmonella serotypes have been isolated.

What about the hatcheries?

It’s estimated that 50 million live poultry are sold annually. Birds are shipped within 24 hours after hatching via the U.S. Postal Service in boxes containing up to 100 chicks. Delivery occurs within 72 hours of hatching. Approximately 20 mail order hatcheries provide the majority of poultry sold to the general public. The National Poultry Improvement Plan (NPIP) is a voluntary state and federal testing and certification program whose goal is to eliminate poultry disease from breeder flocks to prevent egg-transmitted and hatchery-disseminated diseases. All hatcheries may participate. They also may participate in the voluntary Salmonella monitoring program. Note participation is not mandatory.

Preventing future outbreaks: patient/parental education is mandatory

1. Make sure your parents know about the association of Salmonella and live poultry. Reinforce these are farm animals, not pets. Purchase birds from hatcheries that participate in NPIP and the Salmonella monitoring programs.

2. Chicks, ducklings, or other live poultry should not be taken to schools, day care facilities, or nursing homes. Poultry should not be allowed in the home or in areas where food or drink is being prepared or consumed.

3. Poultry should not be snuggled, kissed, or allowed to touch one’s mouth. Hand washing with soap and water should occur after touching live poultry or any object touched in areas where they live or roam.

4. Contact with live poultry should be avoided in those at risk for developing serious infections including persons aged 5 years or younger, 65 years or older, immunocompromised individuals, and those with hemoglobinopathies.

5. All equipment used to care for live birds should be washed outdoors. Owners should have designated shoes when caring for poultry which should never be worn inside the home.

Hopefully, the next time you see a patient with fever and diarrhea you will recall this topic and ask about their contact with live poultry.

Additional resources to facilitate discussions can be found at www.cdc.gov/salmonella.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures. Email her at [email protected].

 

I recently received a group text from a friend voicing her frustration that her neighbor had acquired chickens, and she shared a photo of some roaming freely in the front yard. Naturally, my response was related to the potential infectious disease exposure and infections. Another friend chimed in “fresh eggs, and these are free range chickens. They don’t get sick. ... Many people in my area have chickens.” Unbeknownst to my friends, they had helped me select the ID Consult topic for this month.

Nontyphoidal Salmonella bacteria are associated with a wide spectrum of infections which range from asymptomatic gastrointestinal carriage to bacteremia, meningitis, osteomyelitis, and focal infections. Invasive disease is seen most often in children younger than 5 years of age, persons aged 65 years or older, and individuals with hemoglobinopathies including sickle cell disease and those with immunodeficiencies. Annually, the Centers for Disease Control and Prevention estimates that nontyphoidal salmonellosis is responsible for 1.2 million illnesses, 23,000 hospitalizations, and 450 deaths in the United States. Gastroenteritis is the most common manifestation of the disease and is characterized by abdominal cramps, diarrhea, and fever that develops 12-72 hours after exposure. It is usually self-limited. As previously reported in this column (June, 2017), Salmonella is one of the top two foodborne pathogens in the United States, and most outbreaks have been associated with consumption of contaminated food. But wait, contaminated food is not the only cause of some of our most recent outbreaks.

JasonJiron/Thinkstock

Salmonella is a zoonotic bacteria commonly found in the intestinal tract of several animals including poultry (chickens, ducks, geese, and turkeys), reptiles, and amphibians. Humans can acquire infection after both direct and indirect contact with infected animals. Most infected animals are asymptomatic and shed bacteria intermittently. Current U.S. outbreaks involve both pet turtles and poultry. Let’s stay focused on poultry.

Live poultry-associated salmonellosis (LPAS)

LPAS was first reported in the 1950s. More recent epidemiologic data was published by C. Basler et al. (Emerging Infect Dis. 2016;22[10]:1705-11). LPAS was defined as two or more culture confirmed human Salmonella infections with a combination of epidemiologic, laboratory, or traceback evidence linking illnesses to contact with live poultry. From 1990 to 2014, a total of 53 LPAS outbreaks in the United States were documented and associated with 2,630 illnesses, 387 hospitalizations, and 5 deaths. The median outbreak size involved 26 cases (range, 4-363) and 77% (41 of 53) were multistate. The median age of the patients was 9 years (range, less than 1 to 92 years), and 31% were aged 5 years or younger. Exposure to chicks and ducklings was reported in 85% and 38%, respectively. High-risk practices included keeping poultry inside of the home (46%), snuggling baby birds (49%), and kissing baby birds (13%). The median time from purchase of poultry to onset of illness was 17 days (range, 1-672), and 66% reported onset of illness less than 30 days after purchase. Almost 52% reported owning poultry for less than 1 year.

The number of outbreaks continued to increase. From 1990 to 2005, there were a total of 17 outbreaks, compared with 36 between 2006 and 2014. Historically, outbreaks occurred in children around Easter when brightly colored dyed chicks were purchased. In the above review, 80% of outbreaks began in February, March, or April with an average duration of 4.9 months (range, 1-12).

Salmonella isolates

Serotypes traditionally associated with foodborne outbreaks are not usually isolated in LPAS outbreaks. Most chicks are acquired from small mail order hatcheries that house multiple species, and the potential for comingling exists not only of birds but their pathogens. In contrast, commercial hatcheries typically are closed facilities with one breed. It is thought that this is one reason for multiple serotypes associated with backyard flock associated salmonellosis. In the 1990-2014 review, while S. montivideo was the most common serotype isolated (36%), 5 other serotypes also were reported.

Backyard flocks and LPAS

More recently outbreaks have been associated with backyard flocks occurring year round and affecting both adults and children in contrast to seasonal peaks. The first multistate backyard flock outbreak was documented in 2007. Currently, the CDC is investigating 10 separate multistate outbreaks that began on Jan. 4, 2017. It involves 48 states, 961 infected individuals, 215 hospitalizations, and 1 death. At least 5 salmonella serotypes have been isolated.

What about the hatcheries?

It’s estimated that 50 million live poultry are sold annually. Birds are shipped within 24 hours after hatching via the U.S. Postal Service in boxes containing up to 100 chicks. Delivery occurs within 72 hours of hatching. Approximately 20 mail order hatcheries provide the majority of poultry sold to the general public. The National Poultry Improvement Plan (NPIP) is a voluntary state and federal testing and certification program whose goal is to eliminate poultry disease from breeder flocks to prevent egg-transmitted and hatchery-disseminated diseases. All hatcheries may participate. They also may participate in the voluntary Salmonella monitoring program. Note participation is not mandatory.

Preventing future outbreaks: patient/parental education is mandatory

1. Make sure your parents know about the association of Salmonella and live poultry. Reinforce these are farm animals, not pets. Purchase birds from hatcheries that participate in NPIP and the Salmonella monitoring programs.

2. Chicks, ducklings, or other live poultry should not be taken to schools, day care facilities, or nursing homes. Poultry should not be allowed in the home or in areas where food or drink is being prepared or consumed.

3. Poultry should not be snuggled, kissed, or allowed to touch one’s mouth. Hand washing with soap and water should occur after touching live poultry or any object touched in areas where they live or roam.

4. Contact with live poultry should be avoided in those at risk for developing serious infections including persons aged 5 years or younger, 65 years or older, immunocompromised individuals, and those with hemoglobinopathies.

5. All equipment used to care for live birds should be washed outdoors. Owners should have designated shoes when caring for poultry which should never be worn inside the home.

Hopefully, the next time you see a patient with fever and diarrhea you will recall this topic and ask about their contact with live poultry.

Additional resources to facilitate discussions can be found at www.cdc.gov/salmonella.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures. Email her at [email protected].

Alternative therapies, from vitamins and supplements to meditation and acupuncture, have become increasingly popular treatments in the United States for many medical problems in the past few decades. In 2008, the National Institutes of Health reported that nearly 40% of adults and 12% of children had used “complementary or alternative medicine” (CAM) in the preceding year. Other surveys have suggested that closer to 30% of general pediatric patients and as many as 75% of adolescent patients have used CAM at least once. These treatments are especially popular for chronic conditions that are managed but not usually cured with current evidence-based treatments. Psychiatric conditions in childhood sometimes have a long course, and have effective but controversial treatments, as with stimulants for ADHD. Parents sometimes feel guilty about their child’s problem and want to use “natural” methods or deny the accepted understanding of their child’s illness. So it is not surprising that families may investigate alternative treatments, and such treatments have multiplied.

While there is evidence that parents and patients rarely discuss these treatments with their physicians, it is critical that you know what therapies your patients are using. The limited evidence, the potential impact of placebo effects, and the passion of parental beliefs can make alternative therapies a difficult area of practice. You should focus on tolerance in the context of protecting the child from harm and improving the child’s functioning. If you have ever recommended chicken soup for a cold, then you have prescribed complementary medicine, so it is not a stretch for you to offer some input about the other alternative therapies your patients may be considering.

Sally Kubetin/Frontline Medical News

The first step in helping families make smart choices about alternative therapies is to ask about them in a nonjudgmental way. “Have you found any remedies or strategies that have been helpful in managing ... ?” If you strike a posture that is genuinely curious and humble, it will be easier for your patients to consider your input. With adolescent patients, you should ask them without their parents present about supplements and alternative treatments (especially as many teenagers think of marijuana as “medicine”). If you aren’t familiar with what your patients describe (Ayurveda?), let them teach you and then do some research yourself.

It is important to note that rigorous, case-controlled studies of efficacy of most alternative therapies are few in number and usually small in size (so any evidence of efficacy is weaker), and that the products themselves are not regulated by the Food and Drug Administration or other public body. This means that the family (and you) will have to do some homework to ensure that the therapy they purchase comes from a reputable source and is what it purports to be.

Many of the alternative therapies patients are investigating will be herbs or supplements. Omega-3 fatty acids are critical to multiple essential body functions, and are taken in primarily via certain foods, primarily fish and certain seeds and nuts. A deficiency in certain omega-3 fatty acids can cause problems in infant neurological development and put one at risk for heart disease, rheumatologic illness, and depression. Supplementation with Omega-3 fatty acids (eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA], specifically) has a solid evidence base as an effective adjunctive treatment for depression and bipolar disorder in adults. In addition, randomized, placebo-controlled, double-blind studies have demonstrated efficacy in treatment of children with mild to moderate ADHD at doses of 1,200 mg/day. There are some studies that have demonstrated improvement in hyperactivity in children with autism with supplementation at similar doses. These supplements have very low risk of side effects. They are a reasonable recommendation to your patients whose children have mild to moderate ADHD, and they want to manage it without stimulants.

Another alternative first-line psychiatric treatment patients may ask about is St. John’s Wort. Studies have demonstrated its moderate efficacy in the treatment of mild depression, but not in adolescents. It is worth noting that this supplement also has demonstrated potentially serious interactions with other medicines, including raising the risk of serotonin syndrome when combined with SSRIs and decreasing the efficacy of birth control. Another supplement, SAM-e (s-adenosyl-l-methionine), has demonstrated modest efficacy in small open-label studies in the treatment of depression, and has fewer side effects than St. John’s Wort. But its efficacy is not as robust as traditional antidepressants. N-acetyl cysteine, a protein that people usually get from their diets, is the treatment for acetaminophen overdose and carbon monoxide poisoning, and has been used in the treatment of amyotrophic lateral sclerosis and Alzheimer’s disease. There is growing evidence of its efficacy as a treatment for trichotillomania, compulsive nail biting, and compulsive skin picking, often associated with severe anxiety disorders such as obsessive compulsive disorder. It also has demonstrated efficacy as part of treatment for marijuana dependence, alongside behavioral therapy. Myoinositol, a sugar alcohol which can be produced by the body and is found in many foods, has been used at higher doses as a supplement in children and adolescents with bipolar disorder, as an adjunct to treatment with some promising results. When families are considering adding one of these supplements to improve the efficacy of treatment of a complex psychiatric illness, you should feel comfortable referring their questions to their psychiatrist.

Families also may be considering physical or mechanical treatments. Acupuncture has demonstrated efficacy in the treatment of fatigue and pain, migraines, and addiction, although there are very few studies in children and adolescents. There is some evidence for its efficacy in treatment of mild to moderate depression and anxiety in adults, but again no research has been done in youth. Hypnotherapy has shown modest efficacy in treatment of anticipatory anxiety symptoms, headache, chronic pain, nausea and vomiting, migraines, hair-pulling and skin picking as well as compulsive eating and smoking cessation in adults. There is some clinical evidence for its efficacy in children and adolescents, and its safety is well established. Massage therapy has shown value in improving mood and behavior in children with ADHD, but not efficacy as a first-line treatment for ADHD symptoms. Chiropractic care, which is among the most commonly used alternative therapies, claims to be effective for the treatment of anxiety, depression, ADHD, behavioral problems of autism and even schizophrenia and bipolar disorder, but there is no significant scientific evidence to support these claims. And neurofeedback, which is a variant of biofeedback in which patients practice calming themselves or improving focus while watching an EEG has shown modest efficacy in the treatment of ADHD in children in early studies. It is worth noting that all of these therapies may be costly and not covered by insurance.

Perhaps the easiest alternative therapies to recommend are those with the lowest risk and lowest cost, which patients themselves learn to do and which have other health benefits. Exercise has a growing body of evidence for its concrete health benefits. Moderate exercise three times weekly has been shown to be as effective in treating mild to moderate depression in adults as SSRIs, and several smaller studies have demonstrated similar efficacy in adolescents with depression. In addition, exercise improves the quality and quantity of sleep and improves symptoms of anxiety. Along a similar vein, developing a regular meditation practice appears to improve the symptoms of multiple psychiatric conditions. One meta-analysis demonstrated that meditation had the same effect size for both anxiety disorders and depression in both adults and adolescents as antidepressants have. Studies of meditation also have shown promise in treating addiction and in improving measures of attention and concentration. Both exercise and meditation appear to improve health overall, are inexpensive, and have few if any negative side effects. Of course, helping a depressed patient find the motivation to begin and sustain a new practice is the main challenge. But if a family is considering alternative therapies that may be more passive, costly, and of uncertain benefit, it can be a wonderful opportunity to point out the effective, inexpensive alternative therapies immediately at their disposal.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

Additional readings

1. Child Adolesc Psychiatr Clin N Am. 2013 Jul;22(3):375-80.

2. J Am Acad Child Adolesc Psychiatry. 2008;47(4):364-8.

3. J Am Acad Child Adolesc Psychiatry. 2011;50(10):991-1000.

4. J Am Acad Child Adolesc Psychiatry. 2014 Jun; 53(6):658-66.

5. J Am Acad Child Adolesc Psychiatry. 2016 Oct;55(10):S168-9.

Alternative therapies, from vitamins and supplements to meditation and acupuncture, have become increasingly popular treatments in the United States for many medical problems in the past few decades. In 2008, the National Institutes of Health reported that nearly 40% of adults and 12% of children had used “complementary or alternative medicine” (CAM) in the preceding year. Other surveys have suggested that closer to 30% of general pediatric patients and as many as 75% of adolescent patients have used CAM at least once. These treatments are especially popular for chronic conditions that are managed but not usually cured with current evidence-based treatments. Psychiatric conditions in childhood sometimes have a long course, and have effective but controversial treatments, as with stimulants for ADHD. Parents sometimes feel guilty about their child’s problem and want to use “natural” methods or deny the accepted understanding of their child’s illness. So it is not surprising that families may investigate alternative treatments, and such treatments have multiplied.

While there is evidence that parents and patients rarely discuss these treatments with their physicians, it is critical that you know what therapies your patients are using. The limited evidence, the potential impact of placebo effects, and the passion of parental beliefs can make alternative therapies a difficult area of practice. You should focus on tolerance in the context of protecting the child from harm and improving the child’s functioning. If you have ever recommended chicken soup for a cold, then you have prescribed complementary medicine, so it is not a stretch for you to offer some input about the other alternative therapies your patients may be considering.

Sally Kubetin/Frontline Medical News

The first step in helping families make smart choices about alternative therapies is to ask about them in a nonjudgmental way. “Have you found any remedies or strategies that have been helpful in managing ... ?” If you strike a posture that is genuinely curious and humble, it will be easier for your patients to consider your input. With adolescent patients, you should ask them without their parents present about supplements and alternative treatments (especially as many teenagers think of marijuana as “medicine”). If you aren’t familiar with what your patients describe (Ayurveda?), let them teach you and then do some research yourself.

It is important to note that rigorous, case-controlled studies of efficacy of most alternative therapies are few in number and usually small in size (so any evidence of efficacy is weaker), and that the products themselves are not regulated by the Food and Drug Administration or other public body. This means that the family (and you) will have to do some homework to ensure that the therapy they purchase comes from a reputable source and is what it purports to be.

Many of the alternative therapies patients are investigating will be herbs or supplements. Omega-3 fatty acids are critical to multiple essential body functions, and are taken in primarily via certain foods, primarily fish and certain seeds and nuts. A deficiency in certain omega-3 fatty acids can cause problems in infant neurological development and put one at risk for heart disease, rheumatologic illness, and depression. Supplementation with Omega-3 fatty acids (eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA], specifically) has a solid evidence base as an effective adjunctive treatment for depression and bipolar disorder in adults. In addition, randomized, placebo-controlled, double-blind studies have demonstrated efficacy in treatment of children with mild to moderate ADHD at doses of 1,200 mg/day. There are some studies that have demonstrated improvement in hyperactivity in children with autism with supplementation at similar doses. These supplements have very low risk of side effects. They are a reasonable recommendation to your patients whose children have mild to moderate ADHD, and they want to manage it without stimulants.

Another alternative first-line psychiatric treatment patients may ask about is St. John’s Wort. Studies have demonstrated its moderate efficacy in the treatment of mild depression, but not in adolescents. It is worth noting that this supplement also has demonstrated potentially serious interactions with other medicines, including raising the risk of serotonin syndrome when combined with SSRIs and decreasing the efficacy of birth control. Another supplement, SAM-e (s-adenosyl-l-methionine), has demonstrated modest efficacy in small open-label studies in the treatment of depression, and has fewer side effects than St. John’s Wort. But its efficacy is not as robust as traditional antidepressants. N-acetyl cysteine, a protein that people usually get from their diets, is the treatment for acetaminophen overdose and carbon monoxide poisoning, and has been used in the treatment of amyotrophic lateral sclerosis and Alzheimer’s disease. There is growing evidence of its efficacy as a treatment for trichotillomania, compulsive nail biting, and compulsive skin picking, often associated with severe anxiety disorders such as obsessive compulsive disorder. It also has demonstrated efficacy as part of treatment for marijuana dependence, alongside behavioral therapy. Myoinositol, a sugar alcohol which can be produced by the body and is found in many foods, has been used at higher doses as a supplement in children and adolescents with bipolar disorder, as an adjunct to treatment with some promising results. When families are considering adding one of these supplements to improve the efficacy of treatment of a complex psychiatric illness, you should feel comfortable referring their questions to their psychiatrist.

Families also may be considering physical or mechanical treatments. Acupuncture has demonstrated efficacy in the treatment of fatigue and pain, migraines, and addiction, although there are very few studies in children and adolescents. There is some evidence for its efficacy in treatment of mild to moderate depression and anxiety in adults, but again no research has been done in youth. Hypnotherapy has shown modest efficacy in treatment of anticipatory anxiety symptoms, headache, chronic pain, nausea and vomiting, migraines, hair-pulling and skin picking as well as compulsive eating and smoking cessation in adults. There is some clinical evidence for its efficacy in children and adolescents, and its safety is well established. Massage therapy has shown value in improving mood and behavior in children with ADHD, but not efficacy as a first-line treatment for ADHD symptoms. Chiropractic care, which is among the most commonly used alternative therapies, claims to be effective for the treatment of anxiety, depression, ADHD, behavioral problems of autism and even schizophrenia and bipolar disorder, but there is no significant scientific evidence to support these claims. And neurofeedback, which is a variant of biofeedback in which patients practice calming themselves or improving focus while watching an EEG has shown modest efficacy in the treatment of ADHD in children in early studies. It is worth noting that all of these therapies may be costly and not covered by insurance.

Perhaps the easiest alternative therapies to recommend are those with the lowest risk and lowest cost, which patients themselves learn to do and which have other health benefits. Exercise has a growing body of evidence for its concrete health benefits. Moderate exercise three times weekly has been shown to be as effective in treating mild to moderate depression in adults as SSRIs, and several smaller studies have demonstrated similar efficacy in adolescents with depression. In addition, exercise improves the quality and quantity of sleep and improves symptoms of anxiety. Along a similar vein, developing a regular meditation practice appears to improve the symptoms of multiple psychiatric conditions. One meta-analysis demonstrated that meditation had the same effect size for both anxiety disorders and depression in both adults and adolescents as antidepressants have. Studies of meditation also have shown promise in treating addiction and in improving measures of attention and concentration. Both exercise and meditation appear to improve health overall, are inexpensive, and have few if any negative side effects. Of course, helping a depressed patient find the motivation to begin and sustain a new practice is the main challenge. But if a family is considering alternative therapies that may be more passive, costly, and of uncertain benefit, it can be a wonderful opportunity to point out the effective, inexpensive alternative therapies immediately at their disposal.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

Additional readings

1. Child Adolesc Psychiatr Clin N Am. 2013 Jul;22(3):375-80.

2. J Am Acad Child Adolesc Psychiatry. 2008;47(4):364-8.

3. J Am Acad Child Adolesc Psychiatry. 2011;50(10):991-1000.

4. J Am Acad Child Adolesc Psychiatry. 2014 Jun; 53(6):658-66.

5. J Am Acad Child Adolesc Psychiatry. 2016 Oct;55(10):S168-9.

Alternative therapies, from vitamins and supplements to meditation and acupuncture, have become increasingly popular treatments in the United States for many medical problems in the past few decades. In 2008, the National Institutes of Health reported that nearly 40% of adults and 12% of children had used “complementary or alternative medicine” (CAM) in the preceding year. Other surveys have suggested that closer to 30% of general pediatric patients and as many as 75% of adolescent patients have used CAM at least once. These treatments are especially popular for chronic conditions that are managed but not usually cured with current evidence-based treatments. Psychiatric conditions in childhood sometimes have a long course, and have effective but controversial treatments, as with stimulants for ADHD. Parents sometimes feel guilty about their child’s problem and want to use “natural” methods or deny the accepted understanding of their child’s illness. So it is not surprising that families may investigate alternative treatments, and such treatments have multiplied.

While there is evidence that parents and patients rarely discuss these treatments with their physicians, it is critical that you know what therapies your patients are using. The limited evidence, the potential impact of placebo effects, and the passion of parental beliefs can make alternative therapies a difficult area of practice. You should focus on tolerance in the context of protecting the child from harm and improving the child’s functioning. If you have ever recommended chicken soup for a cold, then you have prescribed complementary medicine, so it is not a stretch for you to offer some input about the other alternative therapies your patients may be considering.

Sally Kubetin/Frontline Medical News

The first step in helping families make smart choices about alternative therapies is to ask about them in a nonjudgmental way. “Have you found any remedies or strategies that have been helpful in managing ... ?” If you strike a posture that is genuinely curious and humble, it will be easier for your patients to consider your input. With adolescent patients, you should ask them without their parents present about supplements and alternative treatments (especially as many teenagers think of marijuana as “medicine”). If you aren’t familiar with what your patients describe (Ayurveda?), let them teach you and then do some research yourself.

It is important to note that rigorous, case-controlled studies of efficacy of most alternative therapies are few in number and usually small in size (so any evidence of efficacy is weaker), and that the products themselves are not regulated by the Food and Drug Administration or other public body. This means that the family (and you) will have to do some homework to ensure that the therapy they purchase comes from a reputable source and is what it purports to be.

Many of the alternative therapies patients are investigating will be herbs or supplements. Omega-3 fatty acids are critical to multiple essential body functions, and are taken in primarily via certain foods, primarily fish and certain seeds and nuts. A deficiency in certain omega-3 fatty acids can cause problems in infant neurological development and put one at risk for heart disease, rheumatologic illness, and depression. Supplementation with Omega-3 fatty acids (eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA], specifically) has a solid evidence base as an effective adjunctive treatment for depression and bipolar disorder in adults. In addition, randomized, placebo-controlled, double-blind studies have demonstrated efficacy in treatment of children with mild to moderate ADHD at doses of 1,200 mg/day. There are some studies that have demonstrated improvement in hyperactivity in children with autism with supplementation at similar doses. These supplements have very low risk of side effects. They are a reasonable recommendation to your patients whose children have mild to moderate ADHD, and they want to manage it without stimulants.

Another alternative first-line psychiatric treatment patients may ask about is St. John’s Wort. Studies have demonstrated its moderate efficacy in the treatment of mild depression, but not in adolescents. It is worth noting that this supplement also has demonstrated potentially serious interactions with other medicines, including raising the risk of serotonin syndrome when combined with SSRIs and decreasing the efficacy of birth control. Another supplement, SAM-e (s-adenosyl-l-methionine), has demonstrated modest efficacy in small open-label studies in the treatment of depression, and has fewer side effects than St. John’s Wort. But its efficacy is not as robust as traditional antidepressants. N-acetyl cysteine, a protein that people usually get from their diets, is the treatment for acetaminophen overdose and carbon monoxide poisoning, and has been used in the treatment of amyotrophic lateral sclerosis and Alzheimer’s disease. There is growing evidence of its efficacy as a treatment for trichotillomania, compulsive nail biting, and compulsive skin picking, often associated with severe anxiety disorders such as obsessive compulsive disorder. It also has demonstrated efficacy as part of treatment for marijuana dependence, alongside behavioral therapy. Myoinositol, a sugar alcohol which can be produced by the body and is found in many foods, has been used at higher doses as a supplement in children and adolescents with bipolar disorder, as an adjunct to treatment with some promising results. When families are considering adding one of these supplements to improve the efficacy of treatment of a complex psychiatric illness, you should feel comfortable referring their questions to their psychiatrist.

Families also may be considering physical or mechanical treatments. Acupuncture has demonstrated efficacy in the treatment of fatigue and pain, migraines, and addiction, although there are very few studies in children and adolescents. There is some evidence for its efficacy in treatment of mild to moderate depression and anxiety in adults, but again no research has been done in youth. Hypnotherapy has shown modest efficacy in treatment of anticipatory anxiety symptoms, headache, chronic pain, nausea and vomiting, migraines, hair-pulling and skin picking as well as compulsive eating and smoking cessation in adults. There is some clinical evidence for its efficacy in children and adolescents, and its safety is well established. Massage therapy has shown value in improving mood and behavior in children with ADHD, but not efficacy as a first-line treatment for ADHD symptoms. Chiropractic care, which is among the most commonly used alternative therapies, claims to be effective for the treatment of anxiety, depression, ADHD, behavioral problems of autism and even schizophrenia and bipolar disorder, but there is no significant scientific evidence to support these claims. And neurofeedback, which is a variant of biofeedback in which patients practice calming themselves or improving focus while watching an EEG has shown modest efficacy in the treatment of ADHD in children in early studies. It is worth noting that all of these therapies may be costly and not covered by insurance.

Perhaps the easiest alternative therapies to recommend are those with the lowest risk and lowest cost, which patients themselves learn to do and which have other health benefits. Exercise has a growing body of evidence for its concrete health benefits. Moderate exercise three times weekly has been shown to be as effective in treating mild to moderate depression in adults as SSRIs, and several smaller studies have demonstrated similar efficacy in adolescents with depression. In addition, exercise improves the quality and quantity of sleep and improves symptoms of anxiety. Along a similar vein, developing a regular meditation practice appears to improve the symptoms of multiple psychiatric conditions. One meta-analysis demonstrated that meditation had the same effect size for both anxiety disorders and depression in both adults and adolescents as antidepressants have. Studies of meditation also have shown promise in treating addiction and in improving measures of attention and concentration. Both exercise and meditation appear to improve health overall, are inexpensive, and have few if any negative side effects. Of course, helping a depressed patient find the motivation to begin and sustain a new practice is the main challenge. But if a family is considering alternative therapies that may be more passive, costly, and of uncertain benefit, it can be a wonderful opportunity to point out the effective, inexpensive alternative therapies immediately at their disposal.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

Additional readings

1. Child Adolesc Psychiatr Clin N Am. 2013 Jul;22(3):375-80.

2. J Am Acad Child Adolesc Psychiatry. 2008;47(4):364-8.

3. J Am Acad Child Adolesc Psychiatry. 2011;50(10):991-1000.

4. J Am Acad Child Adolesc Psychiatry. 2014 Jun; 53(6):658-66.

5. J Am Acad Child Adolesc Psychiatry. 2016 Oct;55(10):S168-9.

 

Is human behavior driven by innate biological forces or it is the product of our learning and the environment? This basic question has been debated at settings ranging from scientific conferences to dinner tables for many decades. The media also has covered it in forms ranging from documentaries to the popular comedy movie “Trading Places” (1983). Yet, despite so much attention and so much research devoted to resolving this timeless debate, the arguments continue to this day.

A lack of a clear answer, however, by no means implies that we have not made major advances in our understanding. This short review takes a look at the progression of this seemingly eternal question by categorizing the development of the nature versus nurture question into three main stages. While such a partitioning is somewhat oversimplified with regard to what the various positions on this issue have been at different times, it does illustrate the way that the debate has gradually evolved.
 

Part 1: Nature versus nurture

The origins of the nature versus nurture debate date back far beyond the past 50 years. The ancient Greek philosopher Galen postulated that personality traits were driven by the relative concentrations of four bodily fluids or “humours.” In 1874, Sir Francis Galton published “English Men of Science: Their Nature and Nurture,” in which he advanced his ideas about the dominance of hereditary factors in intelligence and character at the beginning of the eugenics movement.¹ These ideas were in stark opposition to the perspective of earlier scholars, such as the philosopher John Locke, who popularized the theory that children are born a “blank slate” and from there develop their traits and intellectual abilities through their environment and experiences.

lvcandy/Thinkstock

Fifty years ago, some of the same arguments were being heard and supported by early research. The behaviorism movement, started by people such as John Watson, PhD, was a prominent force at that time, with notable psychologists such as B.F. Skinner, PhD, showing evidence in many experiments with both animals and people regarding the importance of rewards and punishments in shaping behavior.

The other primary school of thought in the mid-1960s was psychoanalysis, which was based on the ideas of Sigmund Freud, MD. Psychoanalysis maintains that the way that unconscious sexual and aggressive drives were channeled through various defense mechanisms was of primary importance to the understanding of both psychopathology and typical human behavior.

While these two perspectives were often very much in opposition to each other, they shared in common the view that the environment and a person’s individual experiences, i.e. nurture, were the prevailing forces in development. In the background, more biologically oriented research and clinical work was slowly beginning to work its way into the field, especially at certain institutions, such as Washington University in St. Louis. Several medications of various types were then available, including chlorpromazine, imipramine, and diazepam.

Overall, however, it is probably fair to say that, 50 years ago, it was the nurture perspective that held the most sway since psychodynamic treatment and behaviorist research dominated, while the emerging fields of genetics and neuroscience were only beginning to take hold.
 

Part 2: Nature and nurture

From the 1970s to the end of the 20th century, a noticeable shift occurred as knowledge of the brain and genetics – supported by remarkable advances in research techniques – began to swing the pendulum back toward an increased appreciation of nature as a critical influence on a person’s thoughts, feelings, and behavior.

Researchers Stella Chess, MD, and Alexander Thomas, MD, for example, conducted the New York Longitudinal Study, in which they closely observed a group of young children over many years. Their studies compelled them to argue for the significance of more innate temperament traits as critical aspects of a youth’s overall adjustment.² The Human Genome Project was launched in 1990, and the entire decade was designated as the “Decade of the Brain.” During this time, neuroscience research exploded as techniques, such as MRI and PET, allowed scientists to view the living brain like never before.

The type of research investigation that perhaps was most directly relevant to the nature-nurture debate and that became quite popular during this time was the twin study. By comparing the relative similarities among monozygotic and dizygotic twins raised in the same household, it became possible to calculate directly the degree to which a variable of interest (intelligence, height, aggressive behavior) could be attributed to genetic versus environmental factors. When it came to behavioral variables, a repeated finding that emerged was that both genetic and environmental influences are important, often at close to a 50/50 split in terms of magnitude.^3,4 These studies were complemented by molecular genetic studies, which were beginning to be able to identify specific genes that conveyed usually small amounts of risk for a wide range of psychiatric disorders.

Yet, while twin studies and many other lines of research made it increasingly difficult to argue for the overwhelming supremacy of either nature or nurture, the two domains generally were treated as being independent of each other. Specific traits or symptoms in an individual often were thought of as being the result of either psychological (nurture) or biological (nature) causes. Terms such as “endogenous depression,” for example, were used to distinguish those who had symptoms that were thought generally to be out of reach for “psychological” treatments, such as psychotherapy. Looking back, it might be fair to say that one of the principle flaws in this perspective was the commonly held belief that, if something was brain based or biological, then it therefore implied a kind of automatic “wiring” of the brain that was generally driven by genes and beyond the influence of environmental factors.
 

 

Part 3: Nature is nurture (and vice versa)

As the science progressed, it became increasingly clear that the nature and nurture domains were hopelessly intertwined with one another. From early PET-scan studies showing that both medications and psychotherapy not only changed the brain but also did so in ways similar to behavioral-genetic studies showing how genetically influenced behaviors actually cause certain environmental events to be more likely to occur, research continued to demonstrate the bidirectional influences of genetic and environmental factors on development.^5,6 This appreciation rose to even greater heights with advances in the field of epigenetics, which was able to document some of the specific mechanisms through which environmental factors cause genes involved in regulating the plasticity of the brain to turn on and off.⁷

Given this modern understanding, the question of nature versus nurture ceases even to make sense in many ways. As an example, consider the developmental pathway a 10-year-old boy might have taken before eventually presenting to his pediatrician for severe general and social anxiety. He may have inherited a genetically based temperamental predisposition to being anxious from his parents, who also may struggle with anxiety. Then, those predispositions easily can evoke responses from his parents and teachers to shield and perhaps overprotect him, thereby limiting his opportunities to overcome his anxiety further. He selects friends and activities that match his more inhibited temperament. All of these environmental effects – some of which have been triggered by the boy’s genes – result in real changes with regard to his brain structure and epigenetic modifications, with the end result being an anxious child whose stress pathways in the brain have been reinforced while the circuits involved in emotional regulation are not as structurally or functionally strong as they otherwise would be.

In thinking through some of this complexity, however, it is important to remember the hopeful message that is contained in this rich understanding. All of these complicated, interacting genetic and environmental factors give us many avenues for positive intervention. Now we understand that not only might a medication help strengthen some of the brain connections needed to reduce and cope with that child’s anxiety, but so could mindfulness, exercise, and addressing his parents’ symptoms. When the families ask me whether their child’s struggles are behavioral or psychological, the answer I tend to give them is “yes.”
 

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington.

Email him at [email protected]. Follow him on Twitter @pedipsych.

References

1. “English Men of Science: Their Nature and Nurture” (London: MacMillan & Co., 1874)

2. “Temperament: Theory and Practice” (New York: Brunner/Mazel, 1996)

3. “Nature and Nurture during Infancy and Early Childhood” (New York: Cambridge University Press, 1988)

4. Nat Genet. 2015;47(7):702-9.

5. Arch Gen Psychiatry. 1992;49(9):681-9.

6. Dev Psychopathol. 1997 Spring;9(2):335-64.

7. JAMA Psychiatry. 2017;74(6):551-2.

 

Is human behavior driven by innate biological forces or it is the product of our learning and the environment? This basic question has been debated at settings ranging from scientific conferences to dinner tables for many decades. The media also has covered it in forms ranging from documentaries to the popular comedy movie “Trading Places” (1983). Yet, despite so much attention and so much research devoted to resolving this timeless debate, the arguments continue to this day.

A lack of a clear answer, however, by no means implies that we have not made major advances in our understanding. This short review takes a look at the progression of this seemingly eternal question by categorizing the development of the nature versus nurture question into three main stages. While such a partitioning is somewhat oversimplified with regard to what the various positions on this issue have been at different times, it does illustrate the way that the debate has gradually evolved.
 

Part 1: Nature versus nurture

The origins of the nature versus nurture debate date back far beyond the past 50 years. The ancient Greek philosopher Galen postulated that personality traits were driven by the relative concentrations of four bodily fluids or “humours.” In 1874, Sir Francis Galton published “English Men of Science: Their Nature and Nurture,” in which he advanced his ideas about the dominance of hereditary factors in intelligence and character at the beginning of the eugenics movement.¹ These ideas were in stark opposition to the perspective of earlier scholars, such as the philosopher John Locke, who popularized the theory that children are born a “blank slate” and from there develop their traits and intellectual abilities through their environment and experiences.

lvcandy/Thinkstock

Fifty years ago, some of the same arguments were being heard and supported by early research. The behaviorism movement, started by people such as John Watson, PhD, was a prominent force at that time, with notable psychologists such as B.F. Skinner, PhD, showing evidence in many experiments with both animals and people regarding the importance of rewards and punishments in shaping behavior.

The other primary school of thought in the mid-1960s was psychoanalysis, which was based on the ideas of Sigmund Freud, MD. Psychoanalysis maintains that the way that unconscious sexual and aggressive drives were channeled through various defense mechanisms was of primary importance to the understanding of both psychopathology and typical human behavior.

While these two perspectives were often very much in opposition to each other, they shared in common the view that the environment and a person’s individual experiences, i.e. nurture, were the prevailing forces in development. In the background, more biologically oriented research and clinical work was slowly beginning to work its way into the field, especially at certain institutions, such as Washington University in St. Louis. Several medications of various types were then available, including chlorpromazine, imipramine, and diazepam.

Overall, however, it is probably fair to say that, 50 years ago, it was the nurture perspective that held the most sway since psychodynamic treatment and behaviorist research dominated, while the emerging fields of genetics and neuroscience were only beginning to take hold.
 

Part 2: Nature and nurture

From the 1970s to the end of the 20th century, a noticeable shift occurred as knowledge of the brain and genetics – supported by remarkable advances in research techniques – began to swing the pendulum back toward an increased appreciation of nature as a critical influence on a person’s thoughts, feelings, and behavior.

Researchers Stella Chess, MD, and Alexander Thomas, MD, for example, conducted the New York Longitudinal Study, in which they closely observed a group of young children over many years. Their studies compelled them to argue for the significance of more innate temperament traits as critical aspects of a youth’s overall adjustment.² The Human Genome Project was launched in 1990, and the entire decade was designated as the “Decade of the Brain.” During this time, neuroscience research exploded as techniques, such as MRI and PET, allowed scientists to view the living brain like never before.

The type of research investigation that perhaps was most directly relevant to the nature-nurture debate and that became quite popular during this time was the twin study. By comparing the relative similarities among monozygotic and dizygotic twins raised in the same household, it became possible to calculate directly the degree to which a variable of interest (intelligence, height, aggressive behavior) could be attributed to genetic versus environmental factors. When it came to behavioral variables, a repeated finding that emerged was that both genetic and environmental influences are important, often at close to a 50/50 split in terms of magnitude.^3,4 These studies were complemented by molecular genetic studies, which were beginning to be able to identify specific genes that conveyed usually small amounts of risk for a wide range of psychiatric disorders.

Yet, while twin studies and many other lines of research made it increasingly difficult to argue for the overwhelming supremacy of either nature or nurture, the two domains generally were treated as being independent of each other. Specific traits or symptoms in an individual often were thought of as being the result of either psychological (nurture) or biological (nature) causes. Terms such as “endogenous depression,” for example, were used to distinguish those who had symptoms that were thought generally to be out of reach for “psychological” treatments, such as psychotherapy. Looking back, it might be fair to say that one of the principle flaws in this perspective was the commonly held belief that, if something was brain based or biological, then it therefore implied a kind of automatic “wiring” of the brain that was generally driven by genes and beyond the influence of environmental factors.
 

 

Part 3: Nature is nurture (and vice versa)

As the science progressed, it became increasingly clear that the nature and nurture domains were hopelessly intertwined with one another. From early PET-scan studies showing that both medications and psychotherapy not only changed the brain but also did so in ways similar to behavioral-genetic studies showing how genetically influenced behaviors actually cause certain environmental events to be more likely to occur, research continued to demonstrate the bidirectional influences of genetic and environmental factors on development.^5,6 This appreciation rose to even greater heights with advances in the field of epigenetics, which was able to document some of the specific mechanisms through which environmental factors cause genes involved in regulating the plasticity of the brain to turn on and off.⁷

Given this modern understanding, the question of nature versus nurture ceases even to make sense in many ways. As an example, consider the developmental pathway a 10-year-old boy might have taken before eventually presenting to his pediatrician for severe general and social anxiety. He may have inherited a genetically based temperamental predisposition to being anxious from his parents, who also may struggle with anxiety. Then, those predispositions easily can evoke responses from his parents and teachers to shield and perhaps overprotect him, thereby limiting his opportunities to overcome his anxiety further. He selects friends and activities that match his more inhibited temperament. All of these environmental effects – some of which have been triggered by the boy’s genes – result in real changes with regard to his brain structure and epigenetic modifications, with the end result being an anxious child whose stress pathways in the brain have been reinforced while the circuits involved in emotional regulation are not as structurally or functionally strong as they otherwise would be.

In thinking through some of this complexity, however, it is important to remember the hopeful message that is contained in this rich understanding. All of these complicated, interacting genetic and environmental factors give us many avenues for positive intervention. Now we understand that not only might a medication help strengthen some of the brain connections needed to reduce and cope with that child’s anxiety, but so could mindfulness, exercise, and addressing his parents’ symptoms. When the families ask me whether their child’s struggles are behavioral or psychological, the answer I tend to give them is “yes.”
 

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington.

Email him at [email protected]. Follow him on Twitter @pedipsych.

References

1. “English Men of Science: Their Nature and Nurture” (London: MacMillan & Co., 1874)

2. “Temperament: Theory and Practice” (New York: Brunner/Mazel, 1996)

3. “Nature and Nurture during Infancy and Early Childhood” (New York: Cambridge University Press, 1988)

4. Nat Genet. 2015;47(7):702-9.

5. Arch Gen Psychiatry. 1992;49(9):681-9.

6. Dev Psychopathol. 1997 Spring;9(2):335-64.

7. JAMA Psychiatry. 2017;74(6):551-2.

 

Is human behavior driven by innate biological forces or it is the product of our learning and the environment? This basic question has been debated at settings ranging from scientific conferences to dinner tables for many decades. The media also has covered it in forms ranging from documentaries to the popular comedy movie “Trading Places” (1983). Yet, despite so much attention and so much research devoted to resolving this timeless debate, the arguments continue to this day.

A lack of a clear answer, however, by no means implies that we have not made major advances in our understanding. This short review takes a look at the progression of this seemingly eternal question by categorizing the development of the nature versus nurture question into three main stages. While such a partitioning is somewhat oversimplified with regard to what the various positions on this issue have been at different times, it does illustrate the way that the debate has gradually evolved.
 

Part 1: Nature versus nurture

The origins of the nature versus nurture debate date back far beyond the past 50 years. The ancient Greek philosopher Galen postulated that personality traits were driven by the relative concentrations of four bodily fluids or “humours.” In 1874, Sir Francis Galton published “English Men of Science: Their Nature and Nurture,” in which he advanced his ideas about the dominance of hereditary factors in intelligence and character at the beginning of the eugenics movement.¹ These ideas were in stark opposition to the perspective of earlier scholars, such as the philosopher John Locke, who popularized the theory that children are born a “blank slate” and from there develop their traits and intellectual abilities through their environment and experiences.

lvcandy/Thinkstock

Fifty years ago, some of the same arguments were being heard and supported by early research. The behaviorism movement, started by people such as John Watson, PhD, was a prominent force at that time, with notable psychologists such as B.F. Skinner, PhD, showing evidence in many experiments with both animals and people regarding the importance of rewards and punishments in shaping behavior.

The other primary school of thought in the mid-1960s was psychoanalysis, which was based on the ideas of Sigmund Freud, MD. Psychoanalysis maintains that the way that unconscious sexual and aggressive drives were channeled through various defense mechanisms was of primary importance to the understanding of both psychopathology and typical human behavior.

While these two perspectives were often very much in opposition to each other, they shared in common the view that the environment and a person’s individual experiences, i.e. nurture, were the prevailing forces in development. In the background, more biologically oriented research and clinical work was slowly beginning to work its way into the field, especially at certain institutions, such as Washington University in St. Louis. Several medications of various types were then available, including chlorpromazine, imipramine, and diazepam.

Overall, however, it is probably fair to say that, 50 years ago, it was the nurture perspective that held the most sway since psychodynamic treatment and behaviorist research dominated, while the emerging fields of genetics and neuroscience were only beginning to take hold.
 

Part 2: Nature and nurture

From the 1970s to the end of the 20th century, a noticeable shift occurred as knowledge of the brain and genetics – supported by remarkable advances in research techniques – began to swing the pendulum back toward an increased appreciation of nature as a critical influence on a person’s thoughts, feelings, and behavior.

Researchers Stella Chess, MD, and Alexander Thomas, MD, for example, conducted the New York Longitudinal Study, in which they closely observed a group of young children over many years. Their studies compelled them to argue for the significance of more innate temperament traits as critical aspects of a youth’s overall adjustment.² The Human Genome Project was launched in 1990, and the entire decade was designated as the “Decade of the Brain.” During this time, neuroscience research exploded as techniques, such as MRI and PET, allowed scientists to view the living brain like never before.

The type of research investigation that perhaps was most directly relevant to the nature-nurture debate and that became quite popular during this time was the twin study. By comparing the relative similarities among monozygotic and dizygotic twins raised in the same household, it became possible to calculate directly the degree to which a variable of interest (intelligence, height, aggressive behavior) could be attributed to genetic versus environmental factors. When it came to behavioral variables, a repeated finding that emerged was that both genetic and environmental influences are important, often at close to a 50/50 split in terms of magnitude.^3,4 These studies were complemented by molecular genetic studies, which were beginning to be able to identify specific genes that conveyed usually small amounts of risk for a wide range of psychiatric disorders.

Yet, while twin studies and many other lines of research made it increasingly difficult to argue for the overwhelming supremacy of either nature or nurture, the two domains generally were treated as being independent of each other. Specific traits or symptoms in an individual often were thought of as being the result of either psychological (nurture) or biological (nature) causes. Terms such as “endogenous depression,” for example, were used to distinguish those who had symptoms that were thought generally to be out of reach for “psychological” treatments, such as psychotherapy. Looking back, it might be fair to say that one of the principle flaws in this perspective was the commonly held belief that, if something was brain based or biological, then it therefore implied a kind of automatic “wiring” of the brain that was generally driven by genes and beyond the influence of environmental factors.
 

 

Part 3: Nature is nurture (and vice versa)

As the science progressed, it became increasingly clear that the nature and nurture domains were hopelessly intertwined with one another. From early PET-scan studies showing that both medications and psychotherapy not only changed the brain but also did so in ways similar to behavioral-genetic studies showing how genetically influenced behaviors actually cause certain environmental events to be more likely to occur, research continued to demonstrate the bidirectional influences of genetic and environmental factors on development.^5,6 This appreciation rose to even greater heights with advances in the field of epigenetics, which was able to document some of the specific mechanisms through which environmental factors cause genes involved in regulating the plasticity of the brain to turn on and off.⁷

Given this modern understanding, the question of nature versus nurture ceases even to make sense in many ways. As an example, consider the developmental pathway a 10-year-old boy might have taken before eventually presenting to his pediatrician for severe general and social anxiety. He may have inherited a genetically based temperamental predisposition to being anxious from his parents, who also may struggle with anxiety. Then, those predispositions easily can evoke responses from his parents and teachers to shield and perhaps overprotect him, thereby limiting his opportunities to overcome his anxiety further. He selects friends and activities that match his more inhibited temperament. All of these environmental effects – some of which have been triggered by the boy’s genes – result in real changes with regard to his brain structure and epigenetic modifications, with the end result being an anxious child whose stress pathways in the brain have been reinforced while the circuits involved in emotional regulation are not as structurally or functionally strong as they otherwise would be.

In thinking through some of this complexity, however, it is important to remember the hopeful message that is contained in this rich understanding. All of these complicated, interacting genetic and environmental factors give us many avenues for positive intervention. Now we understand that not only might a medication help strengthen some of the brain connections needed to reduce and cope with that child’s anxiety, but so could mindfulness, exercise, and addressing his parents’ symptoms. When the families ask me whether their child’s struggles are behavioral or psychological, the answer I tend to give them is “yes.”
 

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington.

Email him at [email protected]. Follow him on Twitter @pedipsych.

References

1. “English Men of Science: Their Nature and Nurture” (London: MacMillan & Co., 1874)

2. “Temperament: Theory and Practice” (New York: Brunner/Mazel, 1996)

3. “Nature and Nurture during Infancy and Early Childhood” (New York: Cambridge University Press, 1988)

4. Nat Genet. 2015;47(7):702-9.

5. Arch Gen Psychiatry. 1992;49(9):681-9.

6. Dev Psychopathol. 1997 Spring;9(2):335-64.

7. JAMA Psychiatry. 2017;74(6):551-2.

 

Just as surgeons must maintain currency in their profession, the American Board of Surgery is doing the same: revising and reinventing the recertification process to better fulfill its mission. The ABS aims to make the recertification a lifelong learning activity that is more relevant to the way surgeons actually practice. The high-stakes exam taken every decade will be supplemented with other options for demonstrating competence and currency in various surgical specialties.

The ABS has appointed a new Executive Director, Jo Buyske, MD, FACS, who will take her position after Frank Lewis, MD, FACS, retires later this year. Dr. Buyske has served as the ABS associate director and director of evaluation since 2008. She remains an  adjunct professor at the Perelman  School of Medicine, University of Pennsylvania, where she was formerly chief of surgery and director of minimally invasive surgery at PennPresbyterian Medical Center.

Dr. Buyske will be the first woman to assume the role of Executive Director of the ABS, and she will take the lead in implementing the overhaul of recertification.

We asked Dr. Buyske to share with us some of her insights on the new direction of the ABS, the challenges ahead, and her plans to carry out the mission.

Surgery News: The recent ABS announcement regarding a new direction for the program of recertification has come at a time when many medical specialties are facing challenges in the means by which practitioners are required to demonstrate currency in their fields. Is this initiative a response to complaints from surgeons about the Maintenance of Certification (MOC)?

Dr. Buyske: The ABS has been looking at options for the initiation and maintenance of certification for over 10 years. This effort isn’t really reactive but an ongoing process in the works for some time. This initial statement is a first swing at an attempt to better serve the profession. We all understand that it is necessary to stay up to date and demonstrate mastery.

SN: What has been the response from the Diplomates to the announcement?

Dr. Buyske: We haven’t gotten formal feedback yet, but all the response has been quite positive and, rightfully, conservative. People say, “That sounds good, but what does it really mean?” This is an entirely legitimate question, because all we really said is that we are going to change the process, make it more practice focused and less onerous. That sounds good to many. Diplomates want to know the practical implications of this approach.

SN: What happens now in this process of overhauling the recertification process?

Dr. Buyske: We have a hardworking, fast-moving task force that is taking up all the information we have gathered over the past months and years. We did a survey at this time last year that gave us a lot of information about what the Diplomates want. The concerns were on a more practice-focused recertification process, and also one that is less onerous in terms of cost and time away from practice for study and travel.

Right now, the task force is fanning out across the country to talk to state and local societies, regional representatives, and nominating societies to ask for time on their programs to meet with their members and leadership. The objective is feedback and input to help us get a handle on what people’s practices are really about.

Mary Klingensmith, MD, FACS, the Mary Culver Distinguished Professor and the vice chair of education in the department of surgery at Washington University in St. Louis, has been elected as the chair of the ABS. She will be leading a town hall at the American College of Surgeons Clinical Congress in October to discuss the process and get input.

The communications division will be recruiting additional staff and will be undertaking another survey. We will be asking ABS directors to be a presence in their regional societies and to listen to their members on behalf of the ABS. We also hope the directors will participate in the ACS Communities and be a part of a discussion on recertification.

The task force timeline will be to have a basic structure for 2018, but this will not be a final project set in granite. We will have more options available in 2018, and we will continue to roll out ever more options. This is a moving target and needs to be continually reassessed as technology improves and practice needs change. And we will get better as time goes on at understanding what practices are about and what the needs of recertification are.
 

 

SN: Many of our readers are general surgeons. What do you think the new approach to recertification will mean to general surgeons?

Dr. Buyske: General surgery is a large umbrella. I have thought for years that the MOC is a general surgery exam. It covers the entire waterfront of surgery, but it doesn’t represent how people actually practice. But the new approach will apply to the many ways that people practice general surgery.

We know from our research that most general surgeons perform about 10 different operations, depending on where they live and what their interests are. And each general surgeon has a different list of operations. We want the recertification process to reflect and be relevant to each surgeon’s list of around 10, although it may be too high an expectation to have this ready by 2018. But we will begin, and we will roll out more options as time goes on.
 

SN: Anti-MOC legislation has been initiated in several states recently, some of which involved laws that prevent hospitals, licensing boards, insurance companies, and health systems from requiring MOC. How is the ABS responding to this trend?

Dr. Buyske: When ABS becomes aware of a particular legislative movement along these lines, we reach out to directors and senior directors and ask them to write to their state legislators and to testify. What we really want is to be allowed to continue to self-regulate our profession. We don’t want the government to intervene with the process that hospitals and insurance companies use to hire staff and compensate surgeons. For legislation to dictate how hospitals hire is a slippery slope. I feel strongly that it is incumbent that we police our own standards.

It is a fair expectation of our patients that physicians in our field keep up to date and demonstrate this. I have to dispute the argument that patients should “just trust us.” The whole argument that being up to date is unnecessary and insulting is just off base. People from all lines of work are required to demonstrate that they are up to date on their profession. You can argue that the methods used in the surgical profession are currently not the best, but not that the principle of maintenance of currency in our field is invalid. I continue to believe in the value of certification.
 

SN: What would you like to tell us about ABS that surgeons may be unaware of or may not have a the complete picture of?

Dr. Buyske: I would like your readers to get a sense of how much volunteer effort goes into the certification process. We have 30+ volunteer directors that give 30 days per year of time – an amazing commitment. We invite local surgeons to give examinations with us. We also have a 200+ pool of surgeons who write questions for the exams and another pool of 600 surgeons who help out in a variety of ways. We work to make sure there is a great diversity of people who take part – from all over the country, from different points in the surgical career, specialists, fellowship and nonfellowship surgeons, etc. We have people from rural practices, from the military, and some just 1 year out of training. We also have a “standard setting” meeting where we revisit and review questions to make sure they are pertinent and to evaluate their difficulty. We invite surgeons who have never done any work for the board to help us review our examinations. These can be daylong events or 4-day–long events, and most of the work is done by volunteer surgeons as a contribution to their profession.

SN: How would you describe your leadership style, and how do you think it will play out in the reinvention of the certification process?Dr. Buyske: My leadership mode is collaborative. When it comes to the new look of recertification, I have my opinions about what I want it to look like, and I think they are in line with ideas of other ABS leaders, but I don’t want to hamstring the task force in advance, before it has had a chance to do its work. I have ideas, but I consider it my job to be convincing and persuasive and listen to other very smart and committed people on the board, and they have the opportunity to try to convince me. I am grateful every day for the quality of the people I work with, both here in the office and the volunteer directors, the leaders in surgical societies, and ABS leaders.

SN: Is there something in particular you would like to say to Diplomates who are reading this?Dr. Buyske: I would say to them that I feel in my heart that we are all on the same side: We all want to take good care of the patients. The charge of the board is to protect the public and enhance the profession, and both of those things are of great importance to me. I still take care of patients, I go to the hospital, I put on scrubs, I train with residents, and I deal with the electronic medical record. I really honor the hard work required to take care of patients. And I understand the gravity of the charge of the board, which is to protect the public and enhance the profession. We all want that and we are all on the same side.

 

Just as surgeons must maintain currency in their profession, the American Board of Surgery is doing the same: revising and reinventing the recertification process to better fulfill its mission. The ABS aims to make the recertification a lifelong learning activity that is more relevant to the way surgeons actually practice. The high-stakes exam taken every decade will be supplemented with other options for demonstrating competence and currency in various surgical specialties.

The ABS has appointed a new Executive Director, Jo Buyske, MD, FACS, who will take her position after Frank Lewis, MD, FACS, retires later this year. Dr. Buyske has served as the ABS associate director and director of evaluation since 2008. She remains an  adjunct professor at the Perelman  School of Medicine, University of Pennsylvania, where she was formerly chief of surgery and director of minimally invasive surgery at PennPresbyterian Medical Center.

Dr. Buyske will be the first woman to assume the role of Executive Director of the ABS, and she will take the lead in implementing the overhaul of recertification.

We asked Dr. Buyske to share with us some of her insights on the new direction of the ABS, the challenges ahead, and her plans to carry out the mission.

Surgery News: The recent ABS announcement regarding a new direction for the program of recertification has come at a time when many medical specialties are facing challenges in the means by which practitioners are required to demonstrate currency in their fields. Is this initiative a response to complaints from surgeons about the Maintenance of Certification (MOC)?

Dr. Buyske: The ABS has been looking at options for the initiation and maintenance of certification for over 10 years. This effort isn’t really reactive but an ongoing process in the works for some time. This initial statement is a first swing at an attempt to better serve the profession. We all understand that it is necessary to stay up to date and demonstrate mastery.

SN: What has been the response from the Diplomates to the announcement?

Dr. Buyske: We haven’t gotten formal feedback yet, but all the response has been quite positive and, rightfully, conservative. People say, “That sounds good, but what does it really mean?” This is an entirely legitimate question, because all we really said is that we are going to change the process, make it more practice focused and less onerous. That sounds good to many. Diplomates want to know the practical implications of this approach.

SN: What happens now in this process of overhauling the recertification process?

Dr. Buyske: We have a hardworking, fast-moving task force that is taking up all the information we have gathered over the past months and years. We did a survey at this time last year that gave us a lot of information about what the Diplomates want. The concerns were on a more practice-focused recertification process, and also one that is less onerous in terms of cost and time away from practice for study and travel.

Right now, the task force is fanning out across the country to talk to state and local societies, regional representatives, and nominating societies to ask for time on their programs to meet with their members and leadership. The objective is feedback and input to help us get a handle on what people’s practices are really about.

Mary Klingensmith, MD, FACS, the Mary Culver Distinguished Professor and the vice chair of education in the department of surgery at Washington University in St. Louis, has been elected as the chair of the ABS. She will be leading a town hall at the American College of Surgeons Clinical Congress in October to discuss the process and get input.

The communications division will be recruiting additional staff and will be undertaking another survey. We will be asking ABS directors to be a presence in their regional societies and to listen to their members on behalf of the ABS. We also hope the directors will participate in the ACS Communities and be a part of a discussion on recertification.

The task force timeline will be to have a basic structure for 2018, but this will not be a final project set in granite. We will have more options available in 2018, and we will continue to roll out ever more options. This is a moving target and needs to be continually reassessed as technology improves and practice needs change. And we will get better as time goes on at understanding what practices are about and what the needs of recertification are.
 

 

SN: Many of our readers are general surgeons. What do you think the new approach to recertification will mean to general surgeons?

Dr. Buyske: General surgery is a large umbrella. I have thought for years that the MOC is a general surgery exam. It covers the entire waterfront of surgery, but it doesn’t represent how people actually practice. But the new approach will apply to the many ways that people practice general surgery.

We know from our research that most general surgeons perform about 10 different operations, depending on where they live and what their interests are. And each general surgeon has a different list of operations. We want the recertification process to reflect and be relevant to each surgeon’s list of around 10, although it may be too high an expectation to have this ready by 2018. But we will begin, and we will roll out more options as time goes on.
 

SN: Anti-MOC legislation has been initiated in several states recently, some of which involved laws that prevent hospitals, licensing boards, insurance companies, and health systems from requiring MOC. How is the ABS responding to this trend?

Dr. Buyske: When ABS becomes aware of a particular legislative movement along these lines, we reach out to directors and senior directors and ask them to write to their state legislators and to testify. What we really want is to be allowed to continue to self-regulate our profession. We don’t want the government to intervene with the process that hospitals and insurance companies use to hire staff and compensate surgeons. For legislation to dictate how hospitals hire is a slippery slope. I feel strongly that it is incumbent that we police our own standards.

It is a fair expectation of our patients that physicians in our field keep up to date and demonstrate this. I have to dispute the argument that patients should “just trust us.” The whole argument that being up to date is unnecessary and insulting is just off base. People from all lines of work are required to demonstrate that they are up to date on their profession. You can argue that the methods used in the surgical profession are currently not the best, but not that the principle of maintenance of currency in our field is invalid. I continue to believe in the value of certification.
 

SN: What would you like to tell us about ABS that surgeons may be unaware of or may not have a the complete picture of?

Dr. Buyske: I would like your readers to get a sense of how much volunteer effort goes into the certification process. We have 30+ volunteer directors that give 30 days per year of time – an amazing commitment. We invite local surgeons to give examinations with us. We also have a 200+ pool of surgeons who write questions for the exams and another pool of 600 surgeons who help out in a variety of ways. We work to make sure there is a great diversity of people who take part – from all over the country, from different points in the surgical career, specialists, fellowship and nonfellowship surgeons, etc. We have people from rural practices, from the military, and some just 1 year out of training. We also have a “standard setting” meeting where we revisit and review questions to make sure they are pertinent and to evaluate their difficulty. We invite surgeons who have never done any work for the board to help us review our examinations. These can be daylong events or 4-day–long events, and most of the work is done by volunteer surgeons as a contribution to their profession.

SN: How would you describe your leadership style, and how do you think it will play out in the reinvention of the certification process?Dr. Buyske: My leadership mode is collaborative. When it comes to the new look of recertification, I have my opinions about what I want it to look like, and I think they are in line with ideas of other ABS leaders, but I don’t want to hamstring the task force in advance, before it has had a chance to do its work. I have ideas, but I consider it my job to be convincing and persuasive and listen to other very smart and committed people on the board, and they have the opportunity to try to convince me. I am grateful every day for the quality of the people I work with, both here in the office and the volunteer directors, the leaders in surgical societies, and ABS leaders.

SN: Is there something in particular you would like to say to Diplomates who are reading this?Dr. Buyske: I would say to them that I feel in my heart that we are all on the same side: We all want to take good care of the patients. The charge of the board is to protect the public and enhance the profession, and both of those things are of great importance to me. I still take care of patients, I go to the hospital, I put on scrubs, I train with residents, and I deal with the electronic medical record. I really honor the hard work required to take care of patients. And I understand the gravity of the charge of the board, which is to protect the public and enhance the profession. We all want that and we are all on the same side.

 

Just as surgeons must maintain currency in their profession, the American Board of Surgery is doing the same: revising and reinventing the recertification process to better fulfill its mission. The ABS aims to make the recertification a lifelong learning activity that is more relevant to the way surgeons actually practice. The high-stakes exam taken every decade will be supplemented with other options for demonstrating competence and currency in various surgical specialties.

The ABS has appointed a new Executive Director, Jo Buyske, MD, FACS, who will take her position after Frank Lewis, MD, FACS, retires later this year. Dr. Buyske has served as the ABS associate director and director of evaluation since 2008. She remains an  adjunct professor at the Perelman  School of Medicine, University of Pennsylvania, where she was formerly chief of surgery and director of minimally invasive surgery at PennPresbyterian Medical Center.

Dr. Buyske will be the first woman to assume the role of Executive Director of the ABS, and she will take the lead in implementing the overhaul of recertification.

We asked Dr. Buyske to share with us some of her insights on the new direction of the ABS, the challenges ahead, and her plans to carry out the mission.

Surgery News: The recent ABS announcement regarding a new direction for the program of recertification has come at a time when many medical specialties are facing challenges in the means by which practitioners are required to demonstrate currency in their fields. Is this initiative a response to complaints from surgeons about the Maintenance of Certification (MOC)?

Dr. Buyske: The ABS has been looking at options for the initiation and maintenance of certification for over 10 years. This effort isn’t really reactive but an ongoing process in the works for some time. This initial statement is a first swing at an attempt to better serve the profession. We all understand that it is necessary to stay up to date and demonstrate mastery.

SN: What has been the response from the Diplomates to the announcement?

Dr. Buyske: We haven’t gotten formal feedback yet, but all the response has been quite positive and, rightfully, conservative. People say, “That sounds good, but what does it really mean?” This is an entirely legitimate question, because all we really said is that we are going to change the process, make it more practice focused and less onerous. That sounds good to many. Diplomates want to know the practical implications of this approach.

SN: What happens now in this process of overhauling the recertification process?

Dr. Buyske: We have a hardworking, fast-moving task force that is taking up all the information we have gathered over the past months and years. We did a survey at this time last year that gave us a lot of information about what the Diplomates want. The concerns were on a more practice-focused recertification process, and also one that is less onerous in terms of cost and time away from practice for study and travel.

Right now, the task force is fanning out across the country to talk to state and local societies, regional representatives, and nominating societies to ask for time on their programs to meet with their members and leadership. The objective is feedback and input to help us get a handle on what people’s practices are really about.

Mary Klingensmith, MD, FACS, the Mary Culver Distinguished Professor and the vice chair of education in the department of surgery at Washington University in St. Louis, has been elected as the chair of the ABS. She will be leading a town hall at the American College of Surgeons Clinical Congress in October to discuss the process and get input.

The communications division will be recruiting additional staff and will be undertaking another survey. We will be asking ABS directors to be a presence in their regional societies and to listen to their members on behalf of the ABS. We also hope the directors will participate in the ACS Communities and be a part of a discussion on recertification.

The task force timeline will be to have a basic structure for 2018, but this will not be a final project set in granite. We will have more options available in 2018, and we will continue to roll out ever more options. This is a moving target and needs to be continually reassessed as technology improves and practice needs change. And we will get better as time goes on at understanding what practices are about and what the needs of recertification are.
 

 

SN: Many of our readers are general surgeons. What do you think the new approach to recertification will mean to general surgeons?

Dr. Buyske: General surgery is a large umbrella. I have thought for years that the MOC is a general surgery exam. It covers the entire waterfront of surgery, but it doesn’t represent how people actually practice. But the new approach will apply to the many ways that people practice general surgery.

We know from our research that most general surgeons perform about 10 different operations, depending on where they live and what their interests are. And each general surgeon has a different list of operations. We want the recertification process to reflect and be relevant to each surgeon’s list of around 10, although it may be too high an expectation to have this ready by 2018. But we will begin, and we will roll out more options as time goes on.
 

SN: Anti-MOC legislation has been initiated in several states recently, some of which involved laws that prevent hospitals, licensing boards, insurance companies, and health systems from requiring MOC. How is the ABS responding to this trend?

Dr. Buyske: When ABS becomes aware of a particular legislative movement along these lines, we reach out to directors and senior directors and ask them to write to their state legislators and to testify. What we really want is to be allowed to continue to self-regulate our profession. We don’t want the government to intervene with the process that hospitals and insurance companies use to hire staff and compensate surgeons. For legislation to dictate how hospitals hire is a slippery slope. I feel strongly that it is incumbent that we police our own standards.

It is a fair expectation of our patients that physicians in our field keep up to date and demonstrate this. I have to dispute the argument that patients should “just trust us.” The whole argument that being up to date is unnecessary and insulting is just off base. People from all lines of work are required to demonstrate that they are up to date on their profession. You can argue that the methods used in the surgical profession are currently not the best, but not that the principle of maintenance of currency in our field is invalid. I continue to believe in the value of certification.
 

SN: What would you like to tell us about ABS that surgeons may be unaware of or may not have a the complete picture of?

Dr. Buyske: I would like your readers to get a sense of how much volunteer effort goes into the certification process. We have 30+ volunteer directors that give 30 days per year of time – an amazing commitment. We invite local surgeons to give examinations with us. We also have a 200+ pool of surgeons who write questions for the exams and another pool of 600 surgeons who help out in a variety of ways. We work to make sure there is a great diversity of people who take part – from all over the country, from different points in the surgical career, specialists, fellowship and nonfellowship surgeons, etc. We have people from rural practices, from the military, and some just 1 year out of training. We also have a “standard setting” meeting where we revisit and review questions to make sure they are pertinent and to evaluate their difficulty. We invite surgeons who have never done any work for the board to help us review our examinations. These can be daylong events or 4-day–long events, and most of the work is done by volunteer surgeons as a contribution to their profession.

SN: How would you describe your leadership style, and how do you think it will play out in the reinvention of the certification process?Dr. Buyske: My leadership mode is collaborative. When it comes to the new look of recertification, I have my opinions about what I want it to look like, and I think they are in line with ideas of other ABS leaders, but I don’t want to hamstring the task force in advance, before it has had a chance to do its work. I have ideas, but I consider it my job to be convincing and persuasive and listen to other very smart and committed people on the board, and they have the opportunity to try to convince me. I am grateful every day for the quality of the people I work with, both here in the office and the volunteer directors, the leaders in surgical societies, and ABS leaders.

SN: Is there something in particular you would like to say to Diplomates who are reading this?Dr. Buyske: I would say to them that I feel in my heart that we are all on the same side: We all want to take good care of the patients. The charge of the board is to protect the public and enhance the profession, and both of those things are of great importance to me. I still take care of patients, I go to the hospital, I put on scrubs, I train with residents, and I deal with the electronic medical record. I really honor the hard work required to take care of patients. And I understand the gravity of the charge of the board, which is to protect the public and enhance the profession. We all want that and we are all on the same side.

I have to give a talk. Get this – the topic is how to give a good talk. Very meta.

I’ve given a hundred or so presentations in my career, including a couple of TEDx talks. With each one, I try to get a little better. Effective speaking is always simple but never easy. Let me share with you a few things I’ve learned.

Even if you don’t want to become a TEDMED phenom, you should know a few fundamentals. Giving good talks enhances your reputation and can jump-start your practice or career. For any talk, you must master three things: preparation, content, and delivery.

First, prepare. Just as no football team, no matter how dominant, would play without exhaustive preparation, no presenter should speak without thoroughly preparing. No matter how slick your slides, if the audience is not interested, you’ll lose. The purpose of a presentation is to affect your audience – to teach them, to move them, to inspire them. Therefore, you must know your audience. A seasoned private practice dermatologist will care about different issues than a second-year resident or an academic psoriasis expert. Ask yourself, Who will attend? Why are they coming? What do they hope to get out of your lecture? Perusing the agenda and seeing other speakers’ topics can also help you understand your audience. These factors should help determine both your content and delivery style.

Just as we choose movies with actors we like, people choose speakers they want to see. Who you are matters. If you are introduced by an emcee, then be sure he or she bills you as a star. However, don’t try to be someone you aren’t – If I gave a talk on robotic prostate surgery, I’d be sure to lose no matter how witty I was. That’s why writing your own intro can sometimes be your best option.

Next up: content. It’s the king of speaking as well as marketing. Although you can pick up points for style, if you want to be remembered, you have to deliver something worth remembering. This starts with your preparation. Resist the temptation to focus exclusively on your slides. As in writing, it is best to brainstorm what you want to cover, then outline your ideas, then fill in content with slides.

Most presentations require visuals; however, there are times when you can do without. Go for it! Nothing is more freeing or more intimate than you one-on-one with your audience. If you must have slides, then follow the one-idea one-slide rule. Slides crammed with information actually detract from your presentation. Here’s a tip: Write only what you can fit with a marker on a Post-it pad. Then, laying out the Post-its, you can rearrange slides getting a feel for the flow or argument of the talk.

Did you ever wonder why headlines like, “Why I never use this suture” and “How I cut my EMR documentation time in half” work so well? They tap into a core human instinct: curiosity. Your opening should introduce some sense of wonder. What is she going to share? Really, how does he do that? Starting with a problem and taking them to a solution is also a great game plan that will often yield success.

When it comes to slides, be clean and concise. Taking a cue from wildly popular TED talks, use images and art instead of words. Use sentence fragments, not sentences, and limit content to the width of the slide (no easy feat). Sometimes you need the slide to prompt your talking point. Put only the data or fact you need and leave the rest at the bottom in your notes section.

Humor is almost always a good idea and more difficult to execute than most realize. Cartoons with captions don’t work. I know that’s hard for many of you to hear, but it’s true. Delete them from your decks. Go ahead, I’ll wait.

Instead, try finding something relevant to the audience that only they will find funny. Inside jokes not only have a higher chance of success, but will also help you bond with your audience. A joke about ICD10 as it relates to neurology is better than the funniest Calvin and Hobbes strip. Self-deprecating humor is always appreciated. I’m not among the gifted who can come up with a great one-liner on the spot. It’s OK to plan it ahead.

Once you’ve got your talk built, it’s time to run it. This is hard, as it requires planning to have your content done in time to rehearse. Find the discipline to do it. The first time you run it, you’ll likely realize that 1/3 of the content needs to be cut. Cut it. Indeed, plan to run 10% less than the time allotted. Leave your audience wanting for more rather than wishing for less.

As I’ve learned, your talking points and slides will always be most appreciated in your own head. Keeping to time shows your respect for your audience and makes you appear polished.

The day of, get to the venue well ahead of time and check the sound, lights, and temperature. All of your preparation will be for naught if they can’t hear you, see your slides, or feel their fingers due to the frigid AC.

One of the reasons I love giving talks is because they are live. You and your audience are intimately engaged, and like any conversation, you’ll sense how it’s going. Are they looking at you or at their phones? Do they seem bored? Do they laugh easily, even when you weren’t expecting them to? Observe what is happening and adjust your performance accordingly. Are you losing them? Pause. Let them catch up. Are you putting them to sleep? Pick up the pace. Try that bit of humor now.

Your delivery is critical to your success. If you’re on the dais and behind the podium of a large audience, then be big, Greek theatre big, which means bigger facial expressions and bigger arm and hand gestures. Vary the tone and pace of your voice. Speed it up to build excitement. Slow down and lower your pitch for gravity and authority. Pause for 3-4 seconds to create suspense and drama.

Leave time for discussion when possible. Invite the audience to engage by asking, What do you think? Finally, on the plane ride home, or even as you walk back from the auditorium to your clinic, think about your presentation: What worked? What fell flat? What roused the audience? How can you deliver it better next time?

Even if it didn’t go well, remember, there’s always next week. It’s on to Cincinnati.

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

I have to give a talk. Get this – the topic is how to give a good talk. Very meta.

I’ve given a hundred or so presentations in my career, including a couple of TEDx talks. With each one, I try to get a little better. Effective speaking is always simple but never easy. Let me share with you a few things I’ve learned.

Even if you don’t want to become a TEDMED phenom, you should know a few fundamentals. Giving good talks enhances your reputation and can jump-start your practice or career. For any talk, you must master three things: preparation, content, and delivery.

First, prepare. Just as no football team, no matter how dominant, would play without exhaustive preparation, no presenter should speak without thoroughly preparing. No matter how slick your slides, if the audience is not interested, you’ll lose. The purpose of a presentation is to affect your audience – to teach them, to move them, to inspire them. Therefore, you must know your audience. A seasoned private practice dermatologist will care about different issues than a second-year resident or an academic psoriasis expert. Ask yourself, Who will attend? Why are they coming? What do they hope to get out of your lecture? Perusing the agenda and seeing other speakers’ topics can also help you understand your audience. These factors should help determine both your content and delivery style.

Just as we choose movies with actors we like, people choose speakers they want to see. Who you are matters. If you are introduced by an emcee, then be sure he or she bills you as a star. However, don’t try to be someone you aren’t – If I gave a talk on robotic prostate surgery, I’d be sure to lose no matter how witty I was. That’s why writing your own intro can sometimes be your best option.

Next up: content. It’s the king of speaking as well as marketing. Although you can pick up points for style, if you want to be remembered, you have to deliver something worth remembering. This starts with your preparation. Resist the temptation to focus exclusively on your slides. As in writing, it is best to brainstorm what you want to cover, then outline your ideas, then fill in content with slides.

Most presentations require visuals; however, there are times when you can do without. Go for it! Nothing is more freeing or more intimate than you one-on-one with your audience. If you must have slides, then follow the one-idea one-slide rule. Slides crammed with information actually detract from your presentation. Here’s a tip: Write only what you can fit with a marker on a Post-it pad. Then, laying out the Post-its, you can rearrange slides getting a feel for the flow or argument of the talk.

Did you ever wonder why headlines like, “Why I never use this suture” and “How I cut my EMR documentation time in half” work so well? They tap into a core human instinct: curiosity. Your opening should introduce some sense of wonder. What is she going to share? Really, how does he do that? Starting with a problem and taking them to a solution is also a great game plan that will often yield success.

When it comes to slides, be clean and concise. Taking a cue from wildly popular TED talks, use images and art instead of words. Use sentence fragments, not sentences, and limit content to the width of the slide (no easy feat). Sometimes you need the slide to prompt your talking point. Put only the data or fact you need and leave the rest at the bottom in your notes section.

Humor is almost always a good idea and more difficult to execute than most realize. Cartoons with captions don’t work. I know that’s hard for many of you to hear, but it’s true. Delete them from your decks. Go ahead, I’ll wait.

Instead, try finding something relevant to the audience that only they will find funny. Inside jokes not only have a higher chance of success, but will also help you bond with your audience. A joke about ICD10 as it relates to neurology is better than the funniest Calvin and Hobbes strip. Self-deprecating humor is always appreciated. I’m not among the gifted who can come up with a great one-liner on the spot. It’s OK to plan it ahead.

Once you’ve got your talk built, it’s time to run it. This is hard, as it requires planning to have your content done in time to rehearse. Find the discipline to do it. The first time you run it, you’ll likely realize that 1/3 of the content needs to be cut. Cut it. Indeed, plan to run 10% less than the time allotted. Leave your audience wanting for more rather than wishing for less.

As I’ve learned, your talking points and slides will always be most appreciated in your own head. Keeping to time shows your respect for your audience and makes you appear polished.

The day of, get to the venue well ahead of time and check the sound, lights, and temperature. All of your preparation will be for naught if they can’t hear you, see your slides, or feel their fingers due to the frigid AC.

One of the reasons I love giving talks is because they are live. You and your audience are intimately engaged, and like any conversation, you’ll sense how it’s going. Are they looking at you or at their phones? Do they seem bored? Do they laugh easily, even when you weren’t expecting them to? Observe what is happening and adjust your performance accordingly. Are you losing them? Pause. Let them catch up. Are you putting them to sleep? Pick up the pace. Try that bit of humor now.

Your delivery is critical to your success. If you’re on the dais and behind the podium of a large audience, then be big, Greek theatre big, which means bigger facial expressions and bigger arm and hand gestures. Vary the tone and pace of your voice. Speed it up to build excitement. Slow down and lower your pitch for gravity and authority. Pause for 3-4 seconds to create suspense and drama.

Leave time for discussion when possible. Invite the audience to engage by asking, What do you think? Finally, on the plane ride home, or even as you walk back from the auditorium to your clinic, think about your presentation: What worked? What fell flat? What roused the audience? How can you deliver it better next time?

Even if it didn’t go well, remember, there’s always next week. It’s on to Cincinnati.

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

I have to give a talk. Get this – the topic is how to give a good talk. Very meta.

I’ve given a hundred or so presentations in my career, including a couple of TEDx talks. With each one, I try to get a little better. Effective speaking is always simple but never easy. Let me share with you a few things I’ve learned.

Even if you don’t want to become a TEDMED phenom, you should know a few fundamentals. Giving good talks enhances your reputation and can jump-start your practice or career. For any talk, you must master three things: preparation, content, and delivery.

First, prepare. Just as no football team, no matter how dominant, would play without exhaustive preparation, no presenter should speak without thoroughly preparing. No matter how slick your slides, if the audience is not interested, you’ll lose. The purpose of a presentation is to affect your audience – to teach them, to move them, to inspire them. Therefore, you must know your audience. A seasoned private practice dermatologist will care about different issues than a second-year resident or an academic psoriasis expert. Ask yourself, Who will attend? Why are they coming? What do they hope to get out of your lecture? Perusing the agenda and seeing other speakers’ topics can also help you understand your audience. These factors should help determine both your content and delivery style.

Just as we choose movies with actors we like, people choose speakers they want to see. Who you are matters. If you are introduced by an emcee, then be sure he or she bills you as a star. However, don’t try to be someone you aren’t – If I gave a talk on robotic prostate surgery, I’d be sure to lose no matter how witty I was. That’s why writing your own intro can sometimes be your best option.

Next up: content. It’s the king of speaking as well as marketing. Although you can pick up points for style, if you want to be remembered, you have to deliver something worth remembering. This starts with your preparation. Resist the temptation to focus exclusively on your slides. As in writing, it is best to brainstorm what you want to cover, then outline your ideas, then fill in content with slides.

Most presentations require visuals; however, there are times when you can do without. Go for it! Nothing is more freeing or more intimate than you one-on-one with your audience. If you must have slides, then follow the one-idea one-slide rule. Slides crammed with information actually detract from your presentation. Here’s a tip: Write only what you can fit with a marker on a Post-it pad. Then, laying out the Post-its, you can rearrange slides getting a feel for the flow or argument of the talk.

Did you ever wonder why headlines like, “Why I never use this suture” and “How I cut my EMR documentation time in half” work so well? They tap into a core human instinct: curiosity. Your opening should introduce some sense of wonder. What is she going to share? Really, how does he do that? Starting with a problem and taking them to a solution is also a great game plan that will often yield success.

When it comes to slides, be clean and concise. Taking a cue from wildly popular TED talks, use images and art instead of words. Use sentence fragments, not sentences, and limit content to the width of the slide (no easy feat). Sometimes you need the slide to prompt your talking point. Put only the data or fact you need and leave the rest at the bottom in your notes section.

Humor is almost always a good idea and more difficult to execute than most realize. Cartoons with captions don’t work. I know that’s hard for many of you to hear, but it’s true. Delete them from your decks. Go ahead, I’ll wait.

Instead, try finding something relevant to the audience that only they will find funny. Inside jokes not only have a higher chance of success, but will also help you bond with your audience. A joke about ICD10 as it relates to neurology is better than the funniest Calvin and Hobbes strip. Self-deprecating humor is always appreciated. I’m not among the gifted who can come up with a great one-liner on the spot. It’s OK to plan it ahead.

Once you’ve got your talk built, it’s time to run it. This is hard, as it requires planning to have your content done in time to rehearse. Find the discipline to do it. The first time you run it, you’ll likely realize that 1/3 of the content needs to be cut. Cut it. Indeed, plan to run 10% less than the time allotted. Leave your audience wanting for more rather than wishing for less.

As I’ve learned, your talking points and slides will always be most appreciated in your own head. Keeping to time shows your respect for your audience and makes you appear polished.

The day of, get to the venue well ahead of time and check the sound, lights, and temperature. All of your preparation will be for naught if they can’t hear you, see your slides, or feel their fingers due to the frigid AC.

One of the reasons I love giving talks is because they are live. You and your audience are intimately engaged, and like any conversation, you’ll sense how it’s going. Are they looking at you or at their phones? Do they seem bored? Do they laugh easily, even when you weren’t expecting them to? Observe what is happening and adjust your performance accordingly. Are you losing them? Pause. Let them catch up. Are you putting them to sleep? Pick up the pace. Try that bit of humor now.

Your delivery is critical to your success. If you’re on the dais and behind the podium of a large audience, then be big, Greek theatre big, which means bigger facial expressions and bigger arm and hand gestures. Vary the tone and pace of your voice. Speed it up to build excitement. Slow down and lower your pitch for gravity and authority. Pause for 3-4 seconds to create suspense and drama.

Leave time for discussion when possible. Invite the audience to engage by asking, What do you think? Finally, on the plane ride home, or even as you walk back from the auditorium to your clinic, think about your presentation: What worked? What fell flat? What roused the audience? How can you deliver it better next time?

Even if it didn’t go well, remember, there’s always next week. It’s on to Cincinnati.

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