Commentary

Clinicians who have attempted to perform an in-office procedure on infants or young children will recognize the difficulties that arise from the developmental inability to cooperate with procedures.¹ Potential problems mentioned in the literature include but are not limited to anxiety, which is identified in all age groups of patients undergoing dermatologic procedures²; limitation of pain control³; and poor outcomes due to movement by the patient.¹ In one author’s experience (N.B.S.), anxious and scared children can potentially cause injury to themselves, parents/guardians, and health care professionals by flailing and kicking; children are flexible and can wriggle out of even fine grips, and some children, especially toddlers, can be strong.

The usage of topical anesthetics can only give superficial anesthesia. They can ostensibly reduce pain and are useful for anesthesia of curettage, but their use is limited in infants and young children by the minimal amount of drug that is safe for application, as risks of absorption include methemoglobinemia and seizure activity, and especially by lack of cooperation by the child.⁴ Infiltrative anesthesia is needed for adequate pain control in addition to a topical anesthetic for many procedures.³

General anesthesia seems to be the best alternative due to associated amnesia of the events occurring including pain; immobilization and ability to produce more accurate biopsy sampling; better immobilization leading to superior cosmetic results; and reduced risk to patients, parents/guardians, and health care professionals from a flailing child. In the field of pediatric dermatology, general anesthesia often is used for excision of larger lesions and cosmetic repairs. Operating room privileges are not always easy to obtain, but many pediatric dermatologists take advantage of outpatient surgical centers associated with their medical center. A retrospective review of 226 children receiving 681 procedures at a single institution documented low rates of complications.¹

If it was that easy, most children would be anesthetized with general anesthesia. However, there are risks associated with general anesthesia. Parents/guardians often will do what they can to avoid risk and may therefore refuse general anesthesia, but it is not completely avoidable in complicated skin disease. Despite the risks, the benefit is present in a major anomaly correction such as a cleft palate in a 6-month-old but may not be there for the treatment of a wart. When procedures are nonessential or may be conducted without anesthesia, avoidance of general anesthesia is reasonable and a combination of topical and local infiltrative anesthesia can help. In the American Academy of Dermatology guidelines on in-office anesthesia, Kouba et al⁵ states: “Topical agents are recommended as a first-line method of anesthesia for the repair of dermal lacerations in children and for other minor dermatologic procedures, including curettage. For skin biopsy, excision, or other cases where topical agents alone are insufficient, adjunctive use of topical anesthesia to lessen the discomfort of infiltrative anesthetic should be considered.”

A new controversy recently has emerged concerning the potential risks of anesthesia on neurocognitive development in infants and young children. These concerns regardingthe labeling changes of anesthetic and sedation drugs by the US Food and Drug Administration (FDA) in December 2016 specifically focused on these risks in children younger than 3 years with prolonged (>3 hours) and repeated exposures; however, this kind of exposure is unlikely with standard pediatric dermatologic procedures.^6-9

There is compelling evidence from animal studies that exposure to all anesthetic agents in clinical use induces neurotoxicity and long-term adverse neurobehavioral deficits; however, whether these findings are applicable in human infants is unknown.^6-9 Most of the studies in humans showing adverse outcomes have been retrospective observational studies subject to multiple sources of bias. Two recent large clinical studies—the GAS (General Anaesthesia compared to Spinal anaesthesia) trial¹⁰ and the PANDA (Pediatric Anesthesia and Neurodevelopment Assessment) study¹¹—have shown no evidence of abnormal neurocognitive effects with a single brief exposure before 3 years of age (PANDA) or during infancy (GAS) in otherwise-healthy children.^10,11

It is important to note that the FDA labeling change warning specifically stated that “[c]onsistent with animal studies, recent human data suggest that a single, relatively short exposure to general anesthetic and sedation drugs in infants or toddlers is unlikely to have negative effects on behavior or learning.” Moreover, the FDA emphasized that “Surgeries or procedures in children younger than 3 years should not be delayed or avoided when medically necessary.”¹² Taking these points into consideration, we should offer our patients in-office care when possible and postpone elective procedures when advisable but proceed when necessary for our patients’ physical and emotional health.

Clinicians who have attempted to perform an in-office procedure on infants or young children will recognize the difficulties that arise from the developmental inability to cooperate with procedures.¹ Potential problems mentioned in the literature include but are not limited to anxiety, which is identified in all age groups of patients undergoing dermatologic procedures²; limitation of pain control³; and poor outcomes due to movement by the patient.¹ In one author’s experience (N.B.S.), anxious and scared children can potentially cause injury to themselves, parents/guardians, and health care professionals by flailing and kicking; children are flexible and can wriggle out of even fine grips, and some children, especially toddlers, can be strong.

The usage of topical anesthetics can only give superficial anesthesia. They can ostensibly reduce pain and are useful for anesthesia of curettage, but their use is limited in infants and young children by the minimal amount of drug that is safe for application, as risks of absorption include methemoglobinemia and seizure activity, and especially by lack of cooperation by the child.⁴ Infiltrative anesthesia is needed for adequate pain control in addition to a topical anesthetic for many procedures.³

General anesthesia seems to be the best alternative due to associated amnesia of the events occurring including pain; immobilization and ability to produce more accurate biopsy sampling; better immobilization leading to superior cosmetic results; and reduced risk to patients, parents/guardians, and health care professionals from a flailing child. In the field of pediatric dermatology, general anesthesia often is used for excision of larger lesions and cosmetic repairs. Operating room privileges are not always easy to obtain, but many pediatric dermatologists take advantage of outpatient surgical centers associated with their medical center. A retrospective review of 226 children receiving 681 procedures at a single institution documented low rates of complications.¹

If it was that easy, most children would be anesthetized with general anesthesia. However, there are risks associated with general anesthesia. Parents/guardians often will do what they can to avoid risk and may therefore refuse general anesthesia, but it is not completely avoidable in complicated skin disease. Despite the risks, the benefit is present in a major anomaly correction such as a cleft palate in a 6-month-old but may not be there for the treatment of a wart. When procedures are nonessential or may be conducted without anesthesia, avoidance of general anesthesia is reasonable and a combination of topical and local infiltrative anesthesia can help. In the American Academy of Dermatology guidelines on in-office anesthesia, Kouba et al⁵ states: “Topical agents are recommended as a first-line method of anesthesia for the repair of dermal lacerations in children and for other minor dermatologic procedures, including curettage. For skin biopsy, excision, or other cases where topical agents alone are insufficient, adjunctive use of topical anesthesia to lessen the discomfort of infiltrative anesthetic should be considered.”

A new controversy recently has emerged concerning the potential risks of anesthesia on neurocognitive development in infants and young children. These concerns regardingthe labeling changes of anesthetic and sedation drugs by the US Food and Drug Administration (FDA) in December 2016 specifically focused on these risks in children younger than 3 years with prolonged (>3 hours) and repeated exposures; however, this kind of exposure is unlikely with standard pediatric dermatologic procedures.^6-9

There is compelling evidence from animal studies that exposure to all anesthetic agents in clinical use induces neurotoxicity and long-term adverse neurobehavioral deficits; however, whether these findings are applicable in human infants is unknown.^6-9 Most of the studies in humans showing adverse outcomes have been retrospective observational studies subject to multiple sources of bias. Two recent large clinical studies—the GAS (General Anaesthesia compared to Spinal anaesthesia) trial¹⁰ and the PANDA (Pediatric Anesthesia and Neurodevelopment Assessment) study¹¹—have shown no evidence of abnormal neurocognitive effects with a single brief exposure before 3 years of age (PANDA) or during infancy (GAS) in otherwise-healthy children.^10,11

It is important to note that the FDA labeling change warning specifically stated that “[c]onsistent with animal studies, recent human data suggest that a single, relatively short exposure to general anesthetic and sedation drugs in infants or toddlers is unlikely to have negative effects on behavior or learning.” Moreover, the FDA emphasized that “Surgeries or procedures in children younger than 3 years should not be delayed or avoided when medically necessary.”¹² Taking these points into consideration, we should offer our patients in-office care when possible and postpone elective procedures when advisable but proceed when necessary for our patients’ physical and emotional health.

Clinicians who have attempted to perform an in-office procedure on infants or young children will recognize the difficulties that arise from the developmental inability to cooperate with procedures.¹ Potential problems mentioned in the literature include but are not limited to anxiety, which is identified in all age groups of patients undergoing dermatologic procedures²; limitation of pain control³; and poor outcomes due to movement by the patient.¹ In one author’s experience (N.B.S.), anxious and scared children can potentially cause injury to themselves, parents/guardians, and health care professionals by flailing and kicking; children are flexible and can wriggle out of even fine grips, and some children, especially toddlers, can be strong.

The usage of topical anesthetics can only give superficial anesthesia. They can ostensibly reduce pain and are useful for anesthesia of curettage, but their use is limited in infants and young children by the minimal amount of drug that is safe for application, as risks of absorption include methemoglobinemia and seizure activity, and especially by lack of cooperation by the child.⁴ Infiltrative anesthesia is needed for adequate pain control in addition to a topical anesthetic for many procedures.³

General anesthesia seems to be the best alternative due to associated amnesia of the events occurring including pain; immobilization and ability to produce more accurate biopsy sampling; better immobilization leading to superior cosmetic results; and reduced risk to patients, parents/guardians, and health care professionals from a flailing child. In the field of pediatric dermatology, general anesthesia often is used for excision of larger lesions and cosmetic repairs. Operating room privileges are not always easy to obtain, but many pediatric dermatologists take advantage of outpatient surgical centers associated with their medical center. A retrospective review of 226 children receiving 681 procedures at a single institution documented low rates of complications.¹

If it was that easy, most children would be anesthetized with general anesthesia. However, there are risks associated with general anesthesia. Parents/guardians often will do what they can to avoid risk and may therefore refuse general anesthesia, but it is not completely avoidable in complicated skin disease. Despite the risks, the benefit is present in a major anomaly correction such as a cleft palate in a 6-month-old but may not be there for the treatment of a wart. When procedures are nonessential or may be conducted without anesthesia, avoidance of general anesthesia is reasonable and a combination of topical and local infiltrative anesthesia can help. In the American Academy of Dermatology guidelines on in-office anesthesia, Kouba et al⁵ states: “Topical agents are recommended as a first-line method of anesthesia for the repair of dermal lacerations in children and for other minor dermatologic procedures, including curettage. For skin biopsy, excision, or other cases where topical agents alone are insufficient, adjunctive use of topical anesthesia to lessen the discomfort of infiltrative anesthetic should be considered.”

A new controversy recently has emerged concerning the potential risks of anesthesia on neurocognitive development in infants and young children. These concerns regardingthe labeling changes of anesthetic and sedation drugs by the US Food and Drug Administration (FDA) in December 2016 specifically focused on these risks in children younger than 3 years with prolonged (>3 hours) and repeated exposures; however, this kind of exposure is unlikely with standard pediatric dermatologic procedures.^6-9

There is compelling evidence from animal studies that exposure to all anesthetic agents in clinical use induces neurotoxicity and long-term adverse neurobehavioral deficits; however, whether these findings are applicable in human infants is unknown.^6-9 Most of the studies in humans showing adverse outcomes have been retrospective observational studies subject to multiple sources of bias. Two recent large clinical studies—the GAS (General Anaesthesia compared to Spinal anaesthesia) trial¹⁰ and the PANDA (Pediatric Anesthesia and Neurodevelopment Assessment) study¹¹—have shown no evidence of abnormal neurocognitive effects with a single brief exposure before 3 years of age (PANDA) or during infancy (GAS) in otherwise-healthy children.^10,11

It is important to note that the FDA labeling change warning specifically stated that “[c]onsistent with animal studies, recent human data suggest that a single, relatively short exposure to general anesthetic and sedation drugs in infants or toddlers is unlikely to have negative effects on behavior or learning.” Moreover, the FDA emphasized that “Surgeries or procedures in children younger than 3 years should not be delayed or avoided when medically necessary.”¹² Taking these points into consideration, we should offer our patients in-office care when possible and postpone elective procedures when advisable but proceed when necessary for our patients’ physical and emotional health.

Some of you who are reading this column likely are military brats from one branch or another. Many of us felt the call to give back by either joining the military, PHS, or working in organizations like the VA, treating former service members. That certainly was a huge motivation for me to become a VA physician. I always felt more welcomed, even felt at home, at the VA or at a military hospital than I did at any civilian health care facility. And many of my colleagues feel the same way. Other brats have never interacted much with the military except for their being raised by family members in the armed forces; yet this designation is still a part of their identity, one that is especially important as the number of Americans with a military connection continues to decline.

The percentage of adults > 50 years old who have an immediate family member who served in the military is 77%; the percentage of those aged 30 to 49 years is 57%; and aged < 30 years, only 33%.¹ Almost 5% of adult Americans are military brats. This demographic trend brings with it an increasing chance that current and former service members may feel socially isolated and that many health care professionals will struggle to relate to, and appreciate, their unique cultural background.

Authors always should acknowledge any material conflict of interest, and as a double Army brat, I am far from objective on this subject. I was born and raised on an army base. My father was a career military physician, and my mother, albeit briefly, was an army nurse. Some of my earliest memories are of being with my father and driving around Fort Sam Houston when everyone and everything stopped upon hearing the sound of a bugle (at the time, it was still a real bugle). My father and I would get out of the car. He would salute, and I would stand as still as a small active child can while we turned toward the flag being lowered over the base.

In reading about army brats, this memory seems to be a common one. Many individuals have commented on how this repeated experience from their youth instilled in them a sense of respect for our flag and country and an appreciation of order and discipline that stayed with them long after they became adults.

Obviously, while those of us claiming this identity use it positively as a phrase of winsome nostalgia and civic pride, in everyday language a brat is a pejorative reference. The online magazine Military Brat Life, defines the term as “someone, who, as a child, grows up in a family where one or more parents are ‘career’ military, and where the children move from base to base, experiencing life in several different places and possibly different countries.”² The phrase denotes an individual whose parents at some point served full-time in the military, no duration is specified or whether the parents had to be active duty, reserve or National Guard members. The prefix for the label comes from the military branch in which the parents primarily served, though like hyphenated names some younger generations will introduce themselves as a Navy-Air Force brat. Other sites suggest that it doesn’t refer to a spoiled child at all but actually is yet another of the acronyms that proliferate in military environments. Although after I read these possible theories, many seemed retrospective attempts to jettison the negative connotations.

I learned that like others sharing similar formative experiences, military brats are considered a subculture or a third culture, in some of the literature. There is a dearth of scholarly data about the phenomenology and social psychology of adults who spent some of their formative years under the auspices of military culture. As in any foray into cultural competence, avoiding stereotypes is crucial. However, research has shown that the experience of growing up in the military is one that bestows resilience and risk.³ It is also an important piece of a patient’s narrative that health care professionals in and out of the federal system should consider to provide patient-centered care.

A childhood in a military environment is often romanticized as shaping an adult who is worldly, cosmopolitan, resilient, and tolerant. Although these are adaptive traits that children of military personnel develop, there also is a far darker side emerging in the research.⁴ We are all too aware of the epidemic of suicide, opioid use, and posttraumatic stress disorder that has developed in the wake of our country’s latest and lasting conflicts. The reverberations of these mental health problems are felt by the children who lived through them or who lost loved ones to war or suicide. The DoD has begun recognizing this collateral damage and is developing innovative programs to help children and adolescents.

We need to do more though, not just in this arena when the wounds occur, but also later when those wounded come to nurse practitioners and psychologists, social workers, and physicians. Our growing number of community partners through Choice and other programs also need to be aware of the potential mental health impacts of being a military brat or family member.

In the introduction to one of the best books written on the subject, Military Brats: Legacies of Childhood Inside the Fortress, author Pat Conroy wrote, “I thought I was singular in all this, one of a kind.... I discovered that I speak in the multitongued, deep-throated voice of my tribe. It’s a language I was not even aware I spoke... a secret family I did not know I had.... Military brats, my lost tribe, spent their entire youth in service to this country, and no one even knew we were there.”⁵

Some of you who are reading this column likely are military brats from one branch or another. Many of us felt the call to give back by either joining the military, PHS, or working in organizations like the VA, treating former service members. That certainly was a huge motivation for me to become a VA physician. I always felt more welcomed, even felt at home, at the VA or at a military hospital than I did at any civilian health care facility. And many of my colleagues feel the same way. Other brats have never interacted much with the military except for their being raised by family members in the armed forces; yet this designation is still a part of their identity, one that is especially important as the number of Americans with a military connection continues to decline.

The percentage of adults > 50 years old who have an immediate family member who served in the military is 77%; the percentage of those aged 30 to 49 years is 57%; and aged < 30 years, only 33%.¹ Almost 5% of adult Americans are military brats. This demographic trend brings with it an increasing chance that current and former service members may feel socially isolated and that many health care professionals will struggle to relate to, and appreciate, their unique cultural background.

Authors always should acknowledge any material conflict of interest, and as a double Army brat, I am far from objective on this subject. I was born and raised on an army base. My father was a career military physician, and my mother, albeit briefly, was an army nurse. Some of my earliest memories are of being with my father and driving around Fort Sam Houston when everyone and everything stopped upon hearing the sound of a bugle (at the time, it was still a real bugle). My father and I would get out of the car. He would salute, and I would stand as still as a small active child can while we turned toward the flag being lowered over the base.

In reading about army brats, this memory seems to be a common one. Many individuals have commented on how this repeated experience from their youth instilled in them a sense of respect for our flag and country and an appreciation of order and discipline that stayed with them long after they became adults.

Obviously, while those of us claiming this identity use it positively as a phrase of winsome nostalgia and civic pride, in everyday language a brat is a pejorative reference. The online magazine Military Brat Life, defines the term as “someone, who, as a child, grows up in a family where one or more parents are ‘career’ military, and where the children move from base to base, experiencing life in several different places and possibly different countries.”² The phrase denotes an individual whose parents at some point served full-time in the military, no duration is specified or whether the parents had to be active duty, reserve or National Guard members. The prefix for the label comes from the military branch in which the parents primarily served, though like hyphenated names some younger generations will introduce themselves as a Navy-Air Force brat. Other sites suggest that it doesn’t refer to a spoiled child at all but actually is yet another of the acronyms that proliferate in military environments. Although after I read these possible theories, many seemed retrospective attempts to jettison the negative connotations.

I learned that like others sharing similar formative experiences, military brats are considered a subculture or a third culture, in some of the literature. There is a dearth of scholarly data about the phenomenology and social psychology of adults who spent some of their formative years under the auspices of military culture. As in any foray into cultural competence, avoiding stereotypes is crucial. However, research has shown that the experience of growing up in the military is one that bestows resilience and risk.³ It is also an important piece of a patient’s narrative that health care professionals in and out of the federal system should consider to provide patient-centered care.

A childhood in a military environment is often romanticized as shaping an adult who is worldly, cosmopolitan, resilient, and tolerant. Although these are adaptive traits that children of military personnel develop, there also is a far darker side emerging in the research.⁴ We are all too aware of the epidemic of suicide, opioid use, and posttraumatic stress disorder that has developed in the wake of our country’s latest and lasting conflicts. The reverberations of these mental health problems are felt by the children who lived through them or who lost loved ones to war or suicide. The DoD has begun recognizing this collateral damage and is developing innovative programs to help children and adolescents.

We need to do more though, not just in this arena when the wounds occur, but also later when those wounded come to nurse practitioners and psychologists, social workers, and physicians. Our growing number of community partners through Choice and other programs also need to be aware of the potential mental health impacts of being a military brat or family member.

In the introduction to one of the best books written on the subject, Military Brats: Legacies of Childhood Inside the Fortress, author Pat Conroy wrote, “I thought I was singular in all this, one of a kind.... I discovered that I speak in the multitongued, deep-throated voice of my tribe. It’s a language I was not even aware I spoke... a secret family I did not know I had.... Military brats, my lost tribe, spent their entire youth in service to this country, and no one even knew we were there.”⁵

Some of you who are reading this column likely are military brats from one branch or another. Many of us felt the call to give back by either joining the military, PHS, or working in organizations like the VA, treating former service members. That certainly was a huge motivation for me to become a VA physician. I always felt more welcomed, even felt at home, at the VA or at a military hospital than I did at any civilian health care facility. And many of my colleagues feel the same way. Other brats have never interacted much with the military except for their being raised by family members in the armed forces; yet this designation is still a part of their identity, one that is especially important as the number of Americans with a military connection continues to decline.

The percentage of adults > 50 years old who have an immediate family member who served in the military is 77%; the percentage of those aged 30 to 49 years is 57%; and aged < 30 years, only 33%.¹ Almost 5% of adult Americans are military brats. This demographic trend brings with it an increasing chance that current and former service members may feel socially isolated and that many health care professionals will struggle to relate to, and appreciate, their unique cultural background.

Authors always should acknowledge any material conflict of interest, and as a double Army brat, I am far from objective on this subject. I was born and raised on an army base. My father was a career military physician, and my mother, albeit briefly, was an army nurse. Some of my earliest memories are of being with my father and driving around Fort Sam Houston when everyone and everything stopped upon hearing the sound of a bugle (at the time, it was still a real bugle). My father and I would get out of the car. He would salute, and I would stand as still as a small active child can while we turned toward the flag being lowered over the base.

In reading about army brats, this memory seems to be a common one. Many individuals have commented on how this repeated experience from their youth instilled in them a sense of respect for our flag and country and an appreciation of order and discipline that stayed with them long after they became adults.

Obviously, while those of us claiming this identity use it positively as a phrase of winsome nostalgia and civic pride, in everyday language a brat is a pejorative reference. The online magazine Military Brat Life, defines the term as “someone, who, as a child, grows up in a family where one or more parents are ‘career’ military, and where the children move from base to base, experiencing life in several different places and possibly different countries.”² The phrase denotes an individual whose parents at some point served full-time in the military, no duration is specified or whether the parents had to be active duty, reserve or National Guard members. The prefix for the label comes from the military branch in which the parents primarily served, though like hyphenated names some younger generations will introduce themselves as a Navy-Air Force brat. Other sites suggest that it doesn’t refer to a spoiled child at all but actually is yet another of the acronyms that proliferate in military environments. Although after I read these possible theories, many seemed retrospective attempts to jettison the negative connotations.

I learned that like others sharing similar formative experiences, military brats are considered a subculture or a third culture, in some of the literature. There is a dearth of scholarly data about the phenomenology and social psychology of adults who spent some of their formative years under the auspices of military culture. As in any foray into cultural competence, avoiding stereotypes is crucial. However, research has shown that the experience of growing up in the military is one that bestows resilience and risk.³ It is also an important piece of a patient’s narrative that health care professionals in and out of the federal system should consider to provide patient-centered care.

A childhood in a military environment is often romanticized as shaping an adult who is worldly, cosmopolitan, resilient, and tolerant. Although these are adaptive traits that children of military personnel develop, there also is a far darker side emerging in the research.⁴ We are all too aware of the epidemic of suicide, opioid use, and posttraumatic stress disorder that has developed in the wake of our country’s latest and lasting conflicts. The reverberations of these mental health problems are felt by the children who lived through them or who lost loved ones to war or suicide. The DoD has begun recognizing this collateral damage and is developing innovative programs to help children and adolescents.

We need to do more though, not just in this arena when the wounds occur, but also later when those wounded come to nurse practitioners and psychologists, social workers, and physicians. Our growing number of community partners through Choice and other programs also need to be aware of the potential mental health impacts of being a military brat or family member.

In the introduction to one of the best books written on the subject, Military Brats: Legacies of Childhood Inside the Fortress, author Pat Conroy wrote, “I thought I was singular in all this, one of a kind.... I discovered that I speak in the multitongued, deep-throated voice of my tribe. It’s a language I was not even aware I spoke... a secret family I did not know I had.... Military brats, my lost tribe, spent their entire youth in service to this country, and no one even knew we were there.”⁵

Although the concept of the living will was first proposed in 1969,¹ the idea caught on slowly. In fact, the first scholarly article discussing the topic didn’t appear until 16 years later.²

In contrast, an informal search of PubMed reveals that at least 38 articles on advance directives and end-of-life care have been published during the first 7 months of 2017. And a feature article in this month’s issue of JFP makes one more. Why is there such strong interest now in an issue that seldom arose when I began practice in 1978?

More complex, less personalized medicine. As medical care has become more sophisticated, there is a great deal more we can do to keep people alive as they approach the end of life, and a great many more decisions to be made.

Now, most dying hospitalized patients are cared for by hospitalists who may be meeting the patient for the first time.

Additionally, people are much less likely today to be cared for in their dying days by a family physician who knows them, their wishes, and their family well. In my early years in small-town practice, I was present when my patients were dying, and I usually knew their family members. Family meetings were easy to arrange, and we quickly came to a consensus about what to do and what not to do. If I was not available, one of my practice partners was. We cared for our patients in the office, nursing home, and hospital. Now, most dying hospitalized patients are cared for by hospitalists who may be meeting the patient for the first time.

Getting more people to participate. Consequently, it is important to understand patients’ wishes for end-of-life care and to document those wishes in writing, using things like a POLST (Physician Orders for Life-Sustaining Treatment) form. Although randomized trials support the value of advance care planning, especially in primary care settings,^3,4 two-thirds of Americans have not completed an advance directive.⁵ Rolnick suggests we “delegalize” the process to remove barriers and make it easier for people to execute such documents and integrate them into health care systems.⁶

Make it part of your office routine. A 70-year-old patient of mine with advanced COPD arrived at his office visit last month with advance directive and POLST forms in hand. We had an excellent, frank conversation, spiced with humor that he supplied, about his wishes for end-of-life care. Just like so many other tasks that we must squeeze into our busy schedules, this is one that we should hard-wire into our office systems and routines.

Although the concept of the living will was first proposed in 1969,¹ the idea caught on slowly. In fact, the first scholarly article discussing the topic didn’t appear until 16 years later.²

In contrast, an informal search of PubMed reveals that at least 38 articles on advance directives and end-of-life care have been published during the first 7 months of 2017. And a feature article in this month’s issue of JFP makes one more. Why is there such strong interest now in an issue that seldom arose when I began practice in 1978?

More complex, less personalized medicine. As medical care has become more sophisticated, there is a great deal more we can do to keep people alive as they approach the end of life, and a great many more decisions to be made.

Now, most dying hospitalized patients are cared for by hospitalists who may be meeting the patient for the first time.

Additionally, people are much less likely today to be cared for in their dying days by a family physician who knows them, their wishes, and their family well. In my early years in small-town practice, I was present when my patients were dying, and I usually knew their family members. Family meetings were easy to arrange, and we quickly came to a consensus about what to do and what not to do. If I was not available, one of my practice partners was. We cared for our patients in the office, nursing home, and hospital. Now, most dying hospitalized patients are cared for by hospitalists who may be meeting the patient for the first time.

Getting more people to participate. Consequently, it is important to understand patients’ wishes for end-of-life care and to document those wishes in writing, using things like a POLST (Physician Orders for Life-Sustaining Treatment) form. Although randomized trials support the value of advance care planning, especially in primary care settings,^3,4 two-thirds of Americans have not completed an advance directive.⁵ Rolnick suggests we “delegalize” the process to remove barriers and make it easier for people to execute such documents and integrate them into health care systems.⁶

Make it part of your office routine. A 70-year-old patient of mine with advanced COPD arrived at his office visit last month with advance directive and POLST forms in hand. We had an excellent, frank conversation, spiced with humor that he supplied, about his wishes for end-of-life care. Just like so many other tasks that we must squeeze into our busy schedules, this is one that we should hard-wire into our office systems and routines.

Although the concept of the living will was first proposed in 1969,¹ the idea caught on slowly. In fact, the first scholarly article discussing the topic didn’t appear until 16 years later.²

In contrast, an informal search of PubMed reveals that at least 38 articles on advance directives and end-of-life care have been published during the first 7 months of 2017. And a feature article in this month’s issue of JFP makes one more. Why is there such strong interest now in an issue that seldom arose when I began practice in 1978?

More complex, less personalized medicine. As medical care has become more sophisticated, there is a great deal more we can do to keep people alive as they approach the end of life, and a great many more decisions to be made.

Now, most dying hospitalized patients are cared for by hospitalists who may be meeting the patient for the first time.

Additionally, people are much less likely today to be cared for in their dying days by a family physician who knows them, their wishes, and their family well. In my early years in small-town practice, I was present when my patients were dying, and I usually knew their family members. Family meetings were easy to arrange, and we quickly came to a consensus about what to do and what not to do. If I was not available, one of my practice partners was. We cared for our patients in the office, nursing home, and hospital. Now, most dying hospitalized patients are cared for by hospitalists who may be meeting the patient for the first time.

Getting more people to participate. Consequently, it is important to understand patients’ wishes for end-of-life care and to document those wishes in writing, using things like a POLST (Physician Orders for Life-Sustaining Treatment) form. Although randomized trials support the value of advance care planning, especially in primary care settings,^3,4 two-thirds of Americans have not completed an advance directive.⁵ Rolnick suggests we “delegalize” the process to remove barriers and make it easier for people to execute such documents and integrate them into health care systems.⁶

Make it part of your office routine. A 70-year-old patient of mine with advanced COPD arrived at his office visit last month with advance directive and POLST forms in hand. We had an excellent, frank conversation, spiced with humor that he supplied, about his wishes for end-of-life care. Just like so many other tasks that we must squeeze into our busy schedules, this is one that we should hard-wire into our office systems and routines.

The staff are the ones who answer patient questions the most. The more we can educate them on how to answer the questions, the more effective they will be in helping us be more efficient with our time. I asked my staff to put together a list of the most common patient skin care questions. This column can be used as a guide for your staff when answering questions about skin care.

Q: Should my sunscreen be applied first or last?

A: The best way to remember is that medications should be applied closest to the skin and sunscreen should be applied closest to the sun. I recommend that morning skin care be applied in the following order:

Step 1. Facial cleanser

Step 2. Eye products (protect the delicate eye area from the medication)

Step 3. Treatment product (medications, or the most important active ingredients)

Step 4. Moisturizer (if needed)

Step 5. Sunscreen

Q: When can I restart my normal skin care regimen after receiving dermal fillers?

A: The morning after receiving dermal fillers, you can resume your normal facial skin care regimen.

masterzphotois/Thinkstock

Q: How do I treat my skin after receiving cosmetic injections such as Botox?

A: After you are injected with dermal fillers, keep the Arnica gel, Arnica pads, or post procedure product on your face until bedtime. Prior to bed, wash your face with a gentle cleanser and lukewarm water. Do not use any scrubs, facial brushes, or hydroxy acids. Apply a soothing gel or soothing moisturizer. Do not use hot water on the face for 48 hours. Avoid hot showers, saunas, facial steaming, facial massage, and exercise for 48 hours. If you must exercise, try to keep the face cool with an ice filled bottle of water. Heat makes you more likely to bruise.

Q: Will retinol make my skin sun sensitive?

A: Retinol breaks down upon sun exposure so it should only be used at night. It is a myth that retinol makes your skin sun sensitive. Retinol is a form of vitamin A that helps protect your skin from sun damage by reducing levels of an enzyme called collagenase that is produced after sun exposure. For this and other reasons, retinol can help protect your skin from sun damage. However, if your skin gets irritated from the retinol and you go into the sun, you can develop postinflammatory hyperpigmentation – or dark patches on the skin. It is a good idea to always wear sunscreen in the morning every day whether you are using retinol or not.

Q: What do I do to treat the dark circles under my eyes?

A: Dark circles can be caused by sluggish blood flow around the eyes leading to deposition of a pigment found in blood called hemosiderin. Dark circles around the eyes also can be caused by an increased amount of the pigment melanin that occurs from sun exposure, heat, estrogen, and stress. Treatments include lifestyle habits that increase blood circulation, such as smoking cessation and exercise. Supplements such as horse chestnut may help improve circulation. Ingredients such as the tyrosinase inhibitors ascorbic acid, kojic acid, arbutin, and hydroquinone will help decrease melanin production, and may improve dark circles caused by increased melanin. Wearing a daily sunscreen around the eyes is a very important part of improving the appearance of dark circles under the eyes.

Q: Do I need an eye cream?

A: Most people need an eye product whether it is a serum, gel, or cream. Eye treatment products are usually one of the first skin care products that male patients purchase. The most common indications for eye treatment products are dark circles under the eyes, puffy eyes, dryness, fine lines, or redness. Each one of these indications requires very different ingredients; therefore, most people need more than one eye product depending on what eye issues they are experiencing. Eye treatment products can protect the delicate eye area from medications such as tretinoin that gets on the pillowcase and is transferred to the eye area at night. Eye products that have humectants, such as heparan sulfate or hyaluronic acid, should be used to treat fines lines and dryness, but these may make eyes puffy. For those with dry and puffy eyes, a second eye product with vasoconstrictive ingredients should be used in the daytime while the hydrating one is used at night. Antiaging eye products with retinol and hydroxy acids may irritate sensitive skin types so they can be paired with a soothing eye product. Consider using different eye products for the morning and evening depending on what eye issues need to be treated.

Q: Will moisturizer make my acne worse?

A: Noncomedogenic moisturizers can help improve acne and speed recovery. Using the proper cleanser and moisturizer will make acne medications more tolerable. Many patients cannot tolerate their acne medications every day. The bacteria that cause acne reproduce every 12 hours. For this reason, acne medications must be used consistently twice a day. Using the proper cleanser and moisturizer makes this possible in most patients. Avoid moisturizers with coconut oil, isopropyl myristate, and other ingredients known to cause acne.

Q: Why does my face get so red after washing it?

A: Rosacea-prone skin types get red from the friction of washing the face – even if just using water. If this occurs, use skin care products with anti-inflammatory ingredients such as argan oil, green tea, fever few, chamomile, caffeine, resveratrol, and niacinamide to sooth the skin. These can be paired with prescription rosacea medications such as Rhofade (oxymetazoline hydrochloride) to reduce facial redness. People with rosacea-prone skin types should avoid facial brushes, scrubs, and vigorous exfoliation.

Q: Why is my melasma not getting better on skin lighteners?

Educating our staff on the basics of skin care can make our office much more efficient. If you liked the format of this column or have questions that you hear often from patients, please email me at [email protected].
 

Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, Aclaris, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.

The staff are the ones who answer patient questions the most. The more we can educate them on how to answer the questions, the more effective they will be in helping us be more efficient with our time. I asked my staff to put together a list of the most common patient skin care questions. This column can be used as a guide for your staff when answering questions about skin care.

Q: Should my sunscreen be applied first or last?

A: The best way to remember is that medications should be applied closest to the skin and sunscreen should be applied closest to the sun. I recommend that morning skin care be applied in the following order:

Step 1. Facial cleanser

Step 2. Eye products (protect the delicate eye area from the medication)

Step 3. Treatment product (medications, or the most important active ingredients)

Step 4. Moisturizer (if needed)

Step 5. Sunscreen

Q: When can I restart my normal skin care regimen after receiving dermal fillers?

A: The morning after receiving dermal fillers, you can resume your normal facial skin care regimen.

masterzphotois/Thinkstock

Q: How do I treat my skin after receiving cosmetic injections such as Botox?

A: After you are injected with dermal fillers, keep the Arnica gel, Arnica pads, or post procedure product on your face until bedtime. Prior to bed, wash your face with a gentle cleanser and lukewarm water. Do not use any scrubs, facial brushes, or hydroxy acids. Apply a soothing gel or soothing moisturizer. Do not use hot water on the face for 48 hours. Avoid hot showers, saunas, facial steaming, facial massage, and exercise for 48 hours. If you must exercise, try to keep the face cool with an ice filled bottle of water. Heat makes you more likely to bruise.

Q: Will retinol make my skin sun sensitive?

A: Retinol breaks down upon sun exposure so it should only be used at night. It is a myth that retinol makes your skin sun sensitive. Retinol is a form of vitamin A that helps protect your skin from sun damage by reducing levels of an enzyme called collagenase that is produced after sun exposure. For this and other reasons, retinol can help protect your skin from sun damage. However, if your skin gets irritated from the retinol and you go into the sun, you can develop postinflammatory hyperpigmentation – or dark patches on the skin. It is a good idea to always wear sunscreen in the morning every day whether you are using retinol or not.

Q: What do I do to treat the dark circles under my eyes?

A: Dark circles can be caused by sluggish blood flow around the eyes leading to deposition of a pigment found in blood called hemosiderin. Dark circles around the eyes also can be caused by an increased amount of the pigment melanin that occurs from sun exposure, heat, estrogen, and stress. Treatments include lifestyle habits that increase blood circulation, such as smoking cessation and exercise. Supplements such as horse chestnut may help improve circulation. Ingredients such as the tyrosinase inhibitors ascorbic acid, kojic acid, arbutin, and hydroquinone will help decrease melanin production, and may improve dark circles caused by increased melanin. Wearing a daily sunscreen around the eyes is a very important part of improving the appearance of dark circles under the eyes.

Q: Do I need an eye cream?

A: Most people need an eye product whether it is a serum, gel, or cream. Eye treatment products are usually one of the first skin care products that male patients purchase. The most common indications for eye treatment products are dark circles under the eyes, puffy eyes, dryness, fine lines, or redness. Each one of these indications requires very different ingredients; therefore, most people need more than one eye product depending on what eye issues they are experiencing. Eye treatment products can protect the delicate eye area from medications such as tretinoin that gets on the pillowcase and is transferred to the eye area at night. Eye products that have humectants, such as heparan sulfate or hyaluronic acid, should be used to treat fines lines and dryness, but these may make eyes puffy. For those with dry and puffy eyes, a second eye product with vasoconstrictive ingredients should be used in the daytime while the hydrating one is used at night. Antiaging eye products with retinol and hydroxy acids may irritate sensitive skin types so they can be paired with a soothing eye product. Consider using different eye products for the morning and evening depending on what eye issues need to be treated.

Q: Will moisturizer make my acne worse?

A: Noncomedogenic moisturizers can help improve acne and speed recovery. Using the proper cleanser and moisturizer will make acne medications more tolerable. Many patients cannot tolerate their acne medications every day. The bacteria that cause acne reproduce every 12 hours. For this reason, acne medications must be used consistently twice a day. Using the proper cleanser and moisturizer makes this possible in most patients. Avoid moisturizers with coconut oil, isopropyl myristate, and other ingredients known to cause acne.

Q: Why does my face get so red after washing it?

A: Rosacea-prone skin types get red from the friction of washing the face – even if just using water. If this occurs, use skin care products with anti-inflammatory ingredients such as argan oil, green tea, fever few, chamomile, caffeine, resveratrol, and niacinamide to sooth the skin. These can be paired with prescription rosacea medications such as Rhofade (oxymetazoline hydrochloride) to reduce facial redness. People with rosacea-prone skin types should avoid facial brushes, scrubs, and vigorous exfoliation.

Q: Why is my melasma not getting better on skin lighteners?

Educating our staff on the basics of skin care can make our office much more efficient. If you liked the format of this column or have questions that you hear often from patients, please email me at [email protected].
 

Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, Aclaris, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.

The staff are the ones who answer patient questions the most. The more we can educate them on how to answer the questions, the more effective they will be in helping us be more efficient with our time. I asked my staff to put together a list of the most common patient skin care questions. This column can be used as a guide for your staff when answering questions about skin care.

Q: Should my sunscreen be applied first or last?

A: The best way to remember is that medications should be applied closest to the skin and sunscreen should be applied closest to the sun. I recommend that morning skin care be applied in the following order:

Step 1. Facial cleanser

Step 2. Eye products (protect the delicate eye area from the medication)

Step 3. Treatment product (medications, or the most important active ingredients)

Step 4. Moisturizer (if needed)

Step 5. Sunscreen

Q: When can I restart my normal skin care regimen after receiving dermal fillers?

A: The morning after receiving dermal fillers, you can resume your normal facial skin care regimen.

masterzphotois/Thinkstock

Q: How do I treat my skin after receiving cosmetic injections such as Botox?

A: After you are injected with dermal fillers, keep the Arnica gel, Arnica pads, or post procedure product on your face until bedtime. Prior to bed, wash your face with a gentle cleanser and lukewarm water. Do not use any scrubs, facial brushes, or hydroxy acids. Apply a soothing gel or soothing moisturizer. Do not use hot water on the face for 48 hours. Avoid hot showers, saunas, facial steaming, facial massage, and exercise for 48 hours. If you must exercise, try to keep the face cool with an ice filled bottle of water. Heat makes you more likely to bruise.

Q: Will retinol make my skin sun sensitive?

A: Retinol breaks down upon sun exposure so it should only be used at night. It is a myth that retinol makes your skin sun sensitive. Retinol is a form of vitamin A that helps protect your skin from sun damage by reducing levels of an enzyme called collagenase that is produced after sun exposure. For this and other reasons, retinol can help protect your skin from sun damage. However, if your skin gets irritated from the retinol and you go into the sun, you can develop postinflammatory hyperpigmentation – or dark patches on the skin. It is a good idea to always wear sunscreen in the morning every day whether you are using retinol or not.

Q: What do I do to treat the dark circles under my eyes?

A: Dark circles can be caused by sluggish blood flow around the eyes leading to deposition of a pigment found in blood called hemosiderin. Dark circles around the eyes also can be caused by an increased amount of the pigment melanin that occurs from sun exposure, heat, estrogen, and stress. Treatments include lifestyle habits that increase blood circulation, such as smoking cessation and exercise. Supplements such as horse chestnut may help improve circulation. Ingredients such as the tyrosinase inhibitors ascorbic acid, kojic acid, arbutin, and hydroquinone will help decrease melanin production, and may improve dark circles caused by increased melanin. Wearing a daily sunscreen around the eyes is a very important part of improving the appearance of dark circles under the eyes.

Q: Do I need an eye cream?

A: Most people need an eye product whether it is a serum, gel, or cream. Eye treatment products are usually one of the first skin care products that male patients purchase. The most common indications for eye treatment products are dark circles under the eyes, puffy eyes, dryness, fine lines, or redness. Each one of these indications requires very different ingredients; therefore, most people need more than one eye product depending on what eye issues they are experiencing. Eye treatment products can protect the delicate eye area from medications such as tretinoin that gets on the pillowcase and is transferred to the eye area at night. Eye products that have humectants, such as heparan sulfate or hyaluronic acid, should be used to treat fines lines and dryness, but these may make eyes puffy. For those with dry and puffy eyes, a second eye product with vasoconstrictive ingredients should be used in the daytime while the hydrating one is used at night. Antiaging eye products with retinol and hydroxy acids may irritate sensitive skin types so they can be paired with a soothing eye product. Consider using different eye products for the morning and evening depending on what eye issues need to be treated.

Q: Will moisturizer make my acne worse?

A: Noncomedogenic moisturizers can help improve acne and speed recovery. Using the proper cleanser and moisturizer will make acne medications more tolerable. Many patients cannot tolerate their acne medications every day. The bacteria that cause acne reproduce every 12 hours. For this reason, acne medications must be used consistently twice a day. Using the proper cleanser and moisturizer makes this possible in most patients. Avoid moisturizers with coconut oil, isopropyl myristate, and other ingredients known to cause acne.

Q: Why does my face get so red after washing it?

A: Rosacea-prone skin types get red from the friction of washing the face – even if just using water. If this occurs, use skin care products with anti-inflammatory ingredients such as argan oil, green tea, fever few, chamomile, caffeine, resveratrol, and niacinamide to sooth the skin. These can be paired with prescription rosacea medications such as Rhofade (oxymetazoline hydrochloride) to reduce facial redness. People with rosacea-prone skin types should avoid facial brushes, scrubs, and vigorous exfoliation.

Q: Why is my melasma not getting better on skin lighteners?

Educating our staff on the basics of skin care can make our office much more efficient. If you liked the format of this column or have questions that you hear often from patients, please email me at [email protected].
 

Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, Aclaris, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.

As a physician or a patient, you probably have noticed that the quality of health care is better when there is a continuous relationship between the physician and the patient. Discontinuity can make doctor-patient communication less fluid, but familiarity can breed comfort and confidence. Patients often complain when they see a different physician at every visit. And physicians know they are less efficient when they are seeing a patient they have never seen before.

Tomwang112/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

As a physician or a patient, you probably have noticed that the quality of health care is better when there is a continuous relationship between the physician and the patient. Discontinuity can make doctor-patient communication less fluid, but familiarity can breed comfort and confidence. Patients often complain when they see a different physician at every visit. And physicians know they are less efficient when they are seeing a patient they have never seen before.

Tomwang112/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

As a physician or a patient, you probably have noticed that the quality of health care is better when there is a continuous relationship between the physician and the patient. Discontinuity can make doctor-patient communication less fluid, but familiarity can breed comfort and confidence. Patients often complain when they see a different physician at every visit. And physicians know they are less efficient when they are seeing a patient they have never seen before.

Tomwang112/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

As physicians, we know, and have been taught, that success comes from being smart and answering questions correctly. By doing so, we excelled in school, scored high on standardized tests, and confidently raised our hands in class. As a result, we were chosen for plum assignments like class officer, yearbook editor, and team captain. Success bred success and we were initiated into honor societies, accepted into prestigious internships, and allowed to work on important research projects.

These achievements guaranteed further success in medical school where the tradition of competition continued as we positioned for the attention of those who would someday write our letters of recommendation. This model of individual success served us very well until we joined a hematology group to begin our practice.

When we join a group of physicians, we join a team. The team might organize around diagnoses, laboratories, or geographic location, but it is a team nonetheless. The team, of course, includes more than just physicians. As a team member, we are expected to fulfill a role that advances the mission of the team and the larger organization. That mission may include some combination of academic, educational, and clinical productivity.

As physicians trained to compete with other individuals, teamwork does not come naturally. We might think that so long as the team consists of more and mor

Nick Youngson/thebluediamondgallery.com/CC BY SA 3.0 nyphotographic.com/thebluediamondgallery.com/CC BY-SA 3.0

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

As physicians, we know, and have been taught, that success comes from being smart and answering questions correctly. By doing so, we excelled in school, scored high on standardized tests, and confidently raised our hands in class. As a result, we were chosen for plum assignments like class officer, yearbook editor, and team captain. Success bred success and we were initiated into honor societies, accepted into prestigious internships, and allowed to work on important research projects.

These achievements guaranteed further success in medical school where the tradition of competition continued as we positioned for the attention of those who would someday write our letters of recommendation. This model of individual success served us very well until we joined a hematology group to begin our practice.

When we join a group of physicians, we join a team. The team might organize around diagnoses, laboratories, or geographic location, but it is a team nonetheless. The team, of course, includes more than just physicians. As a team member, we are expected to fulfill a role that advances the mission of the team and the larger organization. That mission may include some combination of academic, educational, and clinical productivity.

As physicians trained to compete with other individuals, teamwork does not come naturally. We might think that so long as the team consists of more and mor

Nick Youngson/thebluediamondgallery.com/CC BY SA 3.0 nyphotographic.com/thebluediamondgallery.com/CC BY-SA 3.0

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

As physicians, we know, and have been taught, that success comes from being smart and answering questions correctly. By doing so, we excelled in school, scored high on standardized tests, and confidently raised our hands in class. As a result, we were chosen for plum assignments like class officer, yearbook editor, and team captain. Success bred success and we were initiated into honor societies, accepted into prestigious internships, and allowed to work on important research projects.

These achievements guaranteed further success in medical school where the tradition of competition continued as we positioned for the attention of those who would someday write our letters of recommendation. This model of individual success served us very well until we joined a hematology group to begin our practice.

When we join a group of physicians, we join a team. The team might organize around diagnoses, laboratories, or geographic location, but it is a team nonetheless. The team, of course, includes more than just physicians. As a team member, we are expected to fulfill a role that advances the mission of the team and the larger organization. That mission may include some combination of academic, educational, and clinical productivity.

As physicians trained to compete with other individuals, teamwork does not come naturally. We might think that so long as the team consists of more and mor

Nick Youngson/thebluediamondgallery.com/CC BY SA 3.0 nyphotographic.com/thebluediamondgallery.com/CC BY-SA 3.0

Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

In the Journal of Child and Adolescent Psychopharmacology’s July 2017 issue, a group of respected individuals representing diverse expertise published “guidelines” to support clinical management of pediatric acute-onset neuropsychiatric syndrome (PANS) and its subclass PANDAS (those associated with streptococcal infection). PANS represents an enigmatic clinical syndrome that includes abrupt onset of obsessive-compulsive disorder (OCD) or eating restriction in combination with anxiety, attention deficit, hyperkinesia, emotional lability, irritability, aggressive or oppositional behavior, or academic decline. Neurologic findings also may be present; these are most often motor or vocal tics, but choreiform movements of the finger (repetitive motions that are rapid, jerky, and involuntary), deteriorating penmanship, sleep disruptions, or urinary frequency also may be present. The clinical course most often is relapsing and remitting with overall improvement over months or years.

CDC/ Melissa Brower

Proposed criteria for documenting GAS infection in PANS pediatric patients

• A rise in serial antibody level, regardless of rapid test or culture result. This definition does not require clinical pharyngitis.
• Acute pharyngitis with a positive GAS throat culture, with or without a rising antibody level.
• Pharyngitis with characteristic palatal petechiae.
• Pharyngitis with a characteristic scarlatiniform rash.
• Pharyngitis without a throat swab or serology, but intimate (usually household) exposure to a proven GAS case.
• Asymptomatic pharyngeal colonization documented after an intimate exposure.
• Asymptomatic pharyngeal colonization after a negative throat swab documented within the prior 3-4 months.
• Single ASO or ADB antibody level within 6 months after the initial onset of neuropsychiatric symptoms may be accepted as positive if it is more than 95th percentile, using the laboratory’s normal standard for children of comparable age, or provisionally ASO greater than or equal to 1:480 or ADB greater than or equal to 1:1280.
• Both ASO and ADB are elevated at more than 80% percentile for age in the same serum sample within 6 months after the initial onset of neuropsychiatric symptoms.
• Culture-documented streptococcal dermatitis.

Source: J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0151.

Dr. Pelton is chief of pediatric infectious disease and coordinator of the maternal-child HIV program at Boston Medical Center. Dr. Pelton said he had no relevant financial disclosures. Email him at [email protected].

In the Journal of Child and Adolescent Psychopharmacology’s July 2017 issue, a group of respected individuals representing diverse expertise published “guidelines” to support clinical management of pediatric acute-onset neuropsychiatric syndrome (PANS) and its subclass PANDAS (those associated with streptococcal infection). PANS represents an enigmatic clinical syndrome that includes abrupt onset of obsessive-compulsive disorder (OCD) or eating restriction in combination with anxiety, attention deficit, hyperkinesia, emotional lability, irritability, aggressive or oppositional behavior, or academic decline. Neurologic findings also may be present; these are most often motor or vocal tics, but choreiform movements of the finger (repetitive motions that are rapid, jerky, and involuntary), deteriorating penmanship, sleep disruptions, or urinary frequency also may be present. The clinical course most often is relapsing and remitting with overall improvement over months or years.

CDC/ Melissa Brower

Proposed criteria for documenting GAS infection in PANS pediatric patients

• A rise in serial antibody level, regardless of rapid test or culture result. This definition does not require clinical pharyngitis.
• Acute pharyngitis with a positive GAS throat culture, with or without a rising antibody level.
• Pharyngitis with characteristic palatal petechiae.
• Pharyngitis with a characteristic scarlatiniform rash.
• Pharyngitis without a throat swab or serology, but intimate (usually household) exposure to a proven GAS case.
• Asymptomatic pharyngeal colonization documented after an intimate exposure.
• Asymptomatic pharyngeal colonization after a negative throat swab documented within the prior 3-4 months.
• Single ASO or ADB antibody level within 6 months after the initial onset of neuropsychiatric symptoms may be accepted as positive if it is more than 95th percentile, using the laboratory’s normal standard for children of comparable age, or provisionally ASO greater than or equal to 1:480 or ADB greater than or equal to 1:1280.
• Both ASO and ADB are elevated at more than 80% percentile for age in the same serum sample within 6 months after the initial onset of neuropsychiatric symptoms.
• Culture-documented streptococcal dermatitis.

Source: J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0151.

Dr. Pelton is chief of pediatric infectious disease and coordinator of the maternal-child HIV program at Boston Medical Center. Dr. Pelton said he had no relevant financial disclosures. Email him at [email protected].

In the Journal of Child and Adolescent Psychopharmacology’s July 2017 issue, a group of respected individuals representing diverse expertise published “guidelines” to support clinical management of pediatric acute-onset neuropsychiatric syndrome (PANS) and its subclass PANDAS (those associated with streptococcal infection). PANS represents an enigmatic clinical syndrome that includes abrupt onset of obsessive-compulsive disorder (OCD) or eating restriction in combination with anxiety, attention deficit, hyperkinesia, emotional lability, irritability, aggressive or oppositional behavior, or academic decline. Neurologic findings also may be present; these are most often motor or vocal tics, but choreiform movements of the finger (repetitive motions that are rapid, jerky, and involuntary), deteriorating penmanship, sleep disruptions, or urinary frequency also may be present. The clinical course most often is relapsing and remitting with overall improvement over months or years.

CDC/ Melissa Brower

Proposed criteria for documenting GAS infection in PANS pediatric patients

• A rise in serial antibody level, regardless of rapid test or culture result. This definition does not require clinical pharyngitis.
• Acute pharyngitis with a positive GAS throat culture, with or without a rising antibody level.
• Pharyngitis with characteristic palatal petechiae.
• Pharyngitis with a characteristic scarlatiniform rash.
• Pharyngitis without a throat swab or serology, but intimate (usually household) exposure to a proven GAS case.
• Asymptomatic pharyngeal colonization documented after an intimate exposure.
• Asymptomatic pharyngeal colonization after a negative throat swab documented within the prior 3-4 months.
• Single ASO or ADB antibody level within 6 months after the initial onset of neuropsychiatric symptoms may be accepted as positive if it is more than 95th percentile, using the laboratory’s normal standard for children of comparable age, or provisionally ASO greater than or equal to 1:480 or ADB greater than or equal to 1:1280.
• Both ASO and ADB are elevated at more than 80% percentile for age in the same serum sample within 6 months after the initial onset of neuropsychiatric symptoms.
• Culture-documented streptococcal dermatitis.

Source: J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0151.

Dr. Pelton is chief of pediatric infectious disease and coordinator of the maternal-child HIV program at Boston Medical Center. Dr. Pelton said he had no relevant financial disclosures. Email him at [email protected].

JB is a 15-year-old female who presents to your office for a wellness check. Mom is concerned because she has seemed more depressed and withdrawn over the past few months. During the confidential portion of your visit, JB discloses that, while she has had boyfriends in the past, she is realizing that she is romantically and sexually attracted to females. Many members of her religious faith, which she is strongly connected to, believe that homosexuality is a sin. She has been secretly researching therapies to help her “not be gay” and asks you for advice.

Adolescence is a time of rapid growth and development. Two important developmental tasks of adolescence are to establish key aspects of identity and identify meaningful moral standards, values, and belief systems.¹ For some LGBTQ adolescents, these tasks can become more complicated when the value system or religious faith in which they were raised views homosexuality or gender nonconformity as a sin.

Design Pics/Thinkstock

• Identifying as lesbian, gay, bisexual, or transgender is normal, just different.
• LGBT people exist in almost every faith group across the country.
• Many religious groups have wrestled with homosexuality, gender identity, and religion and decided to be more welcoming to LGBT communities.
• Within most faiths, there are many interpretations of religious texts, such as the Bible and the Koran, on all issues, including homosexuality.
• While every religion has different teachings, almost all religions advocate love and compassion.
• Clergy and other faith leaders can be a source of support. However, every faith community is different and may not always be supportive. Safely investigate your individual community’s approach. You have the right to question and explore your faith, sexuality, and/or gender identity and reconcile these in a way that is true to you.
• Remember this is your journey. You get to decide the path and the pace.
• Recognize that this may involve working for change within your community or it may mean leaving it.
• Referral for “conversion” or “reparative therapy” is never indicated. Such therapy is not effective and may be harmful to LGBTQ individuals by increasing internalized stigma, distress, and depression.

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. She has no relevant financial disclosures. Email her at [email protected].

Spirituality resources

• LGBTQ and Religion: Your Relationship with Religion is Completely Up to You, the FAQ Page by the Trevor Project, a national organization that provides crisis intervention and suicide prevention resources to LGBTQ young people ages 13-24 years. www.thetrevorproject.org/pages/lgbtq-and-religion
• Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality, a resource from PFLAG (Parents, Families, and Friends of Lesbians and Gays). www.pflag.org/sites/default/files/Faith%20In%20Our%20Families.pdf
• LGBT Center UNC Chapel Hill: Religion and Spirituality, a page with a link to nondenominational and denomination-specific resources with various religious and spiritual communities’ beliefs regarding faith and LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual). lgbtq.unc.edu/resources/exploring-identities/religion-and-spirituality
• HRC: Explore Religion and Faith, a Human Rights Campaign page containing links to resources on religion and faith. It also has links to the Coming Home Series, guides aimed at those who hope to lead their faith communities toward a more welcoming stance and those seeking a path back to beloved traditions. www.hrc.org/explore/topic/religion-faith

References

1. Raising teens: A synthesis or research and a foundation for action. (Boston: Center for Health Communication, Harvard School of Public Health, 2001).

2. Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality (Washington, D.C.: Parents, Families and Friends of Lesbians and Gays, 1997)

3. Pediatrics. 2013 Jul;132(1):198-203.

4. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011)

5. Coming Home: To Faith, to Spirit, to Self. Pamphlet by the Human Rights Campaign.

JB is a 15-year-old female who presents to your office for a wellness check. Mom is concerned because she has seemed more depressed and withdrawn over the past few months. During the confidential portion of your visit, JB discloses that, while she has had boyfriends in the past, she is realizing that she is romantically and sexually attracted to females. Many members of her religious faith, which she is strongly connected to, believe that homosexuality is a sin. She has been secretly researching therapies to help her “not be gay” and asks you for advice.

Adolescence is a time of rapid growth and development. Two important developmental tasks of adolescence are to establish key aspects of identity and identify meaningful moral standards, values, and belief systems.¹ For some LGBTQ adolescents, these tasks can become more complicated when the value system or religious faith in which they were raised views homosexuality or gender nonconformity as a sin.

Design Pics/Thinkstock

• Identifying as lesbian, gay, bisexual, or transgender is normal, just different.
• LGBT people exist in almost every faith group across the country.
• Many religious groups have wrestled with homosexuality, gender identity, and religion and decided to be more welcoming to LGBT communities.
• Within most faiths, there are many interpretations of religious texts, such as the Bible and the Koran, on all issues, including homosexuality.
• While every religion has different teachings, almost all religions advocate love and compassion.
• Clergy and other faith leaders can be a source of support. However, every faith community is different and may not always be supportive. Safely investigate your individual community’s approach. You have the right to question and explore your faith, sexuality, and/or gender identity and reconcile these in a way that is true to you.
• Remember this is your journey. You get to decide the path and the pace.
• Recognize that this may involve working for change within your community or it may mean leaving it.
• Referral for “conversion” or “reparative therapy” is never indicated. Such therapy is not effective and may be harmful to LGBTQ individuals by increasing internalized stigma, distress, and depression.

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. She has no relevant financial disclosures. Email her at [email protected].

Spirituality resources

• LGBTQ and Religion: Your Relationship with Religion is Completely Up to You, the FAQ Page by the Trevor Project, a national organization that provides crisis intervention and suicide prevention resources to LGBTQ young people ages 13-24 years. www.thetrevorproject.org/pages/lgbtq-and-religion
• Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality, a resource from PFLAG (Parents, Families, and Friends of Lesbians and Gays). www.pflag.org/sites/default/files/Faith%20In%20Our%20Families.pdf
• LGBT Center UNC Chapel Hill: Religion and Spirituality, a page with a link to nondenominational and denomination-specific resources with various religious and spiritual communities’ beliefs regarding faith and LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual). lgbtq.unc.edu/resources/exploring-identities/religion-and-spirituality
• HRC: Explore Religion and Faith, a Human Rights Campaign page containing links to resources on religion and faith. It also has links to the Coming Home Series, guides aimed at those who hope to lead their faith communities toward a more welcoming stance and those seeking a path back to beloved traditions. www.hrc.org/explore/topic/religion-faith

References

1. Raising teens: A synthesis or research and a foundation for action. (Boston: Center for Health Communication, Harvard School of Public Health, 2001).

2. Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality (Washington, D.C.: Parents, Families and Friends of Lesbians and Gays, 1997)

3. Pediatrics. 2013 Jul;132(1):198-203.

4. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011)

5. Coming Home: To Faith, to Spirit, to Self. Pamphlet by the Human Rights Campaign.

JB is a 15-year-old female who presents to your office for a wellness check. Mom is concerned because she has seemed more depressed and withdrawn over the past few months. During the confidential portion of your visit, JB discloses that, while she has had boyfriends in the past, she is realizing that she is romantically and sexually attracted to females. Many members of her religious faith, which she is strongly connected to, believe that homosexuality is a sin. She has been secretly researching therapies to help her “not be gay” and asks you for advice.

Adolescence is a time of rapid growth and development. Two important developmental tasks of adolescence are to establish key aspects of identity and identify meaningful moral standards, values, and belief systems.¹ For some LGBTQ adolescents, these tasks can become more complicated when the value system or religious faith in which they were raised views homosexuality or gender nonconformity as a sin.

Design Pics/Thinkstock

• Identifying as lesbian, gay, bisexual, or transgender is normal, just different.
• LGBT people exist in almost every faith group across the country.
• Many religious groups have wrestled with homosexuality, gender identity, and religion and decided to be more welcoming to LGBT communities.
• Within most faiths, there are many interpretations of religious texts, such as the Bible and the Koran, on all issues, including homosexuality.
• While every religion has different teachings, almost all religions advocate love and compassion.
• Clergy and other faith leaders can be a source of support. However, every faith community is different and may not always be supportive. Safely investigate your individual community’s approach. You have the right to question and explore your faith, sexuality, and/or gender identity and reconcile these in a way that is true to you.
• Remember this is your journey. You get to decide the path and the pace.
• Recognize that this may involve working for change within your community or it may mean leaving it.
• Referral for “conversion” or “reparative therapy” is never indicated. Such therapy is not effective and may be harmful to LGBTQ individuals by increasing internalized stigma, distress, and depression.

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. She has no relevant financial disclosures. Email her at [email protected].

Spirituality resources

• LGBTQ and Religion: Your Relationship with Religion is Completely Up to You, the FAQ Page by the Trevor Project, a national organization that provides crisis intervention and suicide prevention resources to LGBTQ young people ages 13-24 years. www.thetrevorproject.org/pages/lgbtq-and-religion
• Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality, a resource from PFLAG (Parents, Families, and Friends of Lesbians and Gays). www.pflag.org/sites/default/files/Faith%20In%20Our%20Families.pdf
• LGBT Center UNC Chapel Hill: Religion and Spirituality, a page with a link to nondenominational and denomination-specific resources with various religious and spiritual communities’ beliefs regarding faith and LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual). lgbtq.unc.edu/resources/exploring-identities/religion-and-spirituality
• HRC: Explore Religion and Faith, a Human Rights Campaign page containing links to resources on religion and faith. It also has links to the Coming Home Series, guides aimed at those who hope to lead their faith communities toward a more welcoming stance and those seeking a path back to beloved traditions. www.hrc.org/explore/topic/religion-faith

References

1. Raising teens: A synthesis or research and a foundation for action. (Boston: Center for Health Communication, Harvard School of Public Health, 2001).

2. Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality (Washington, D.C.: Parents, Families and Friends of Lesbians and Gays, 1997)

3. Pediatrics. 2013 Jul;132(1):198-203.

4. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011)

5. Coming Home: To Faith, to Spirit, to Self. Pamphlet by the Human Rights Campaign.

Do you talk about marijuana with your patients?

In medical school, I had a roommate. He was a smart law school graduate, good looking, outgoing, had lots of friends, was funny, and he was a great cook.

[polldaddy:9796432]

Throughout my journey in the psychiatric world (studying and working on three different continents) another typical marijuana user is the patient living with chronic mental illness. My Israeli mentor often complained about not having a single “clean” patient with schizophrenia anymore. I now see the same phenomena in Philadelphia and was also exposed to the same reality in Europe during medical school.

As physicians, and especially as psychiatrists, I believe we are obligated to educate our patients by telling them about the risks in their behaviors. Educating patients about marijuana in today’s atmosphere can be a very important preventive measure, and awareness is an important step toward change.

The current generation of psychiatrists is dealing with an opioid epidemic. Let’s educate ourselves and our patients so this current epidemic won’t be followed by another, severe cannabis epidemic.

Dr. Shilo is a second-year PGY in the department of psychiatry at Einstein Medical Center, Philadelphia.

Do you talk about marijuana with your patients?

In medical school, I had a roommate. He was a smart law school graduate, good looking, outgoing, had lots of friends, was funny, and he was a great cook.

[polldaddy:9796432]

Throughout my journey in the psychiatric world (studying and working on three different continents) another typical marijuana user is the patient living with chronic mental illness. My Israeli mentor often complained about not having a single “clean” patient with schizophrenia anymore. I now see the same phenomena in Philadelphia and was also exposed to the same reality in Europe during medical school.

As physicians, and especially as psychiatrists, I believe we are obligated to educate our patients by telling them about the risks in their behaviors. Educating patients about marijuana in today’s atmosphere can be a very important preventive measure, and awareness is an important step toward change.

The current generation of psychiatrists is dealing with an opioid epidemic. Let’s educate ourselves and our patients so this current epidemic won’t be followed by another, severe cannabis epidemic.

Dr. Shilo is a second-year PGY in the department of psychiatry at Einstein Medical Center, Philadelphia.

Do you talk about marijuana with your patients?

In medical school, I had a roommate. He was a smart law school graduate, good looking, outgoing, had lots of friends, was funny, and he was a great cook.

[polldaddy:9796432]

Throughout my journey in the psychiatric world (studying and working on three different continents) another typical marijuana user is the patient living with chronic mental illness. My Israeli mentor often complained about not having a single “clean” patient with schizophrenia anymore. I now see the same phenomena in Philadelphia and was also exposed to the same reality in Europe during medical school.

As physicians, and especially as psychiatrists, I believe we are obligated to educate our patients by telling them about the risks in their behaviors. Educating patients about marijuana in today’s atmosphere can be a very important preventive measure, and awareness is an important step toward change.

The current generation of psychiatrists is dealing with an opioid epidemic. Let’s educate ourselves and our patients so this current epidemic won’t be followed by another, severe cannabis epidemic.

Dr. Shilo is a second-year PGY in the department of psychiatry at Einstein Medical Center, Philadelphia.