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Evolving practice in perinatal psychopharmacology: Lessons learned
Over the last 2 decades, there has been a growing interest in establishing a rich evidence base for treatment of psychiatric illness in pregnancy and the postpartum period. It seems as if a week does not go by when we don’t find multiple publications in the scientific literature describing a new finding or confirmation or inconsistency with existing data – whether it is a small prospective cohort study or an elegant analysis of a large administrative database. The goals of these reports center on refining our knowledge of safe treatments for perinatal psychiatric disorders.
Despite these strides, my colleagues and I frequently see a divergence between recommendations in the literature and what is done clinically by those who treat women around reproductive associated psychiatric disturbance – premenstrual dysphoric disorder or psychiatric disorder during pregnancy and the postpartum period. In some cases, scientific evidence has not filtered into day to day practice and some physicians continue to follow practices that, while outdated, make intuitive sense. In other clinical situations, limited evidence is being applied too broadly or data are too sparse to clearly inform practice. Regardless of the reason, we frequently see patients in clinical situations in which we are forced to rethink the clinical rationale for advice they have received or the clinical path taken.
Here is a sample of the clinical scenarios in which we have seen inconsistencies between current practice and the best evidence in perinatal psychiatry or situations in which data are too sparse to inform the clearest clinical path.
1. Discontinuation of antidepressants proximate to conception
Despite multiple studies supporting the high risk for relapse of major depression in women on maintenance antidepressant therapy with a history of recurrent depressive illness, it is still quite common for clinicians to routinely advise women to stop antidepressants while planning a pregnancy or after documentation of a pregnancy, regardless of the severity of the underlying illness. This runs counter to data showing high rates of relapse in women who stop antidepressants proximate to conception, the safety of antidepressants in pregnancy, and the harm to the mother and fetus when depression during pregnancy is untreated.
2. Use of a lower dose of antidepressants during pregnancy
It makes intuitive sense to use the smallest dose of medicine like antidepressant during pregnancy. However, multiple studies show that, at least in nonpregnant patients, the dose that gets patients well is typically the dose that keeps them well. One of the quickest paths to relapse in depression is a reduction in the antidepressant dose after someone has gotten well. This is even more relevant in pregnant patients because pregnancy itself dilutes the plasma level of the antidepressant given the rapidly expanding plasma volume seen in pregnancy. One can debate whether clinicians should empirically increase the dose of antidepressant during pregnancy to sustain plasma level of medication, but lowering the dose of this medication proximate or during pregnancy makes little sense.
3. A switch to sertraline in pregnancy/post partum
Another scenario that my colleagues and I often see is a pregnant patient whose depression was previously well controlled with a particular antidepressant, but whose physician, once she decides to conceive or becomes pregnant, switched her to sertraline.
The idea, which has been around for a long time, is that sertraline is the safest antidepressant for pregnant women because it has robust reproductive safety data and has particularly modest amounts of medication (if detected at all) in the plasma of infants of mothers who breastfeed while using the medicine. While we certainly have more safety data on SSRIs that were manufactured earlier, as compared with antidepressants that became available later, we have now accumulated data that fails to demonstrate a clear signal for teratogenicity across many antidepressants manufactured over the last 2 decades. Identifying an antidepressant for a given patient to which she will respond can be a challenging course for the patient. Achieving euthymia and subsequently switching to sertraline or another medication may only put her at risk for recurrence of depression and its attendant morbidity.
4. A change to a Category B label drug
This is another example of switching a patient to a potentially less effective drug in a somewhat misguided effort at finding a treatment that is safer in pregnancy. While the Food and Drug Administration’s drug category label system was a step forward, or at least a well intentioned effort to give women and their clinicians clearer insight into the reproductive safety of a medication, ultimately, the incomplete nature of the information caused the agency to transition to a new system (see the Pregnancy Labeling and Lactation Rule). Switching a woman to a category B medicine with sparse reproductive safety data instead of a category C medicine, which may not be unsafe but has raised some concerns in animal models, is not a better choice. The new labeling system is a step forward.
5. Discontinuation of lithium during pregnancy
Like discontinuation of antidepressants, the discontinuation of lithium during attempts to conceive in a woman whose illness has been well controlled, is associated with a high risk of relapse. In earlier work, it was sometimes recommended that discontinuation of lithium be considered after a long period of wellness. We have learned over time that this can be a risky move. Even women with a remote history of bipolar disorder appear to be at high risk of relapse when a mood stabilizer is stopped. Exquisite response to medicine does not imply less severe illness. Women who have bipolar disorder who have sustained euthymia on lithium should consider maintaining the safest possible regimen before, during, and after pregnancy despite the known small teratogenic risk associated with fetal exposure to this agent.
6. Try supplements or alternative therapies
Out of a desire to avoid any medication with incomplete reproductive safety data, some women and clinicians make the intuitive leap that “alternative treatments” can mitigate relapse in pregnancy, and they stop pharmacological treatments and switch to supplements or alternative therapies, including acupuncture, massage, or light therapy. Unfortunately, data supporting this clinical maneuver are sparse. Frequently, we see women with past histories of severe depression who have stopped antidepressants and who have started supplements as a substitute and who then relapse. Then, they try to restore euthymia with antidepressants and psychotherapy, and the road to restoration of well-being can be long.
Data on efficacy of alternative therapies continues to evolve and is an exciting and important area of research. However, where these treatments are best employed in the algorithm for treating depression in pregnancy, or at other times, has yet to be adequately defined.
7. Stop breastfeeding or defer antidepressant treatment
Many women continue to be counseled to either stop breastfeeding while using antidepressants or to defer treatment with antidepressants if they wish to breastfeed. Not uncommonly, we see women who are suffering from postpartum depression and who are engaged in psychotherapy but who have deferred treatment with antidepressants despite residual depressive symptoms that impair functioning. Clinicians should keep in mind that data supporting evidence of toxicity in newborns of women using antidepressants while breastfeeding are extremely sparse. Unfortunately, some women with postpartum depression are deferring treatment because they were counseled that it is not compatible with their desire to breastfeed.
8. Use of non-benzodiazepine sedative-hypnotics
Insomnia is a common problem in pregnancy, especially when coupled with comorbid anxiety, and, increasingly, it is being treated with non-benzodiazepine sedative-hypnotics. Clinicians should keep in mind that a known small risk may be better than an unknown risk. If a pregnant woman has severe insomnia, she may benefit from a low dose of a benzodiazepine, such as lorazepam or clonazepam, as opposed to a medication such as zolpidem for which reproductive safety data are particularly limited.
9. Pumping and dumping breast milk
Many women are advised to set an alarm to “pump and dump” their breast milk to minimize their baby’s exposure to antidepressants during breastfeeding. Early literature to pump and dump breast milk at peak antidepressant concentration was of great analytic and theoretical interest but has scant clinical application. As an author of many of those early publications, I can say that we never intended for women to sacrifice precious sleep to dump breast milk with the idea that limiting exposure to trace amounts of antidepressants would have beneficial effects over the long term.
10. Failure to bring up contraception use
We continue to see a 50% unplanned pregnancy rate across sociodemographic groups in the United States. This is a critical statistic because it may affect how treatment is managed. Bringing up the topic of reliable contraception prior to pregnancy allows for planned pregnancy and affords us the time to discuss treatment options and the ability to plot a more thoughtful and safe clinical course. However, often, contraception is not discussed.
One of our goals as clinicians is to, first, do no harm and that continues to be a challenge because the data in perinatal psychiatry is still inconsistent in some areas and there are evidence gaps in others. Nevertheless, our task is to take the best available data along with the patient’s wishes and knowledge of her past clinical history and to then translate that into the best care for the individual.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications.
Over the last 2 decades, there has been a growing interest in establishing a rich evidence base for treatment of psychiatric illness in pregnancy and the postpartum period. It seems as if a week does not go by when we don’t find multiple publications in the scientific literature describing a new finding or confirmation or inconsistency with existing data – whether it is a small prospective cohort study or an elegant analysis of a large administrative database. The goals of these reports center on refining our knowledge of safe treatments for perinatal psychiatric disorders.
Despite these strides, my colleagues and I frequently see a divergence between recommendations in the literature and what is done clinically by those who treat women around reproductive associated psychiatric disturbance – premenstrual dysphoric disorder or psychiatric disorder during pregnancy and the postpartum period. In some cases, scientific evidence has not filtered into day to day practice and some physicians continue to follow practices that, while outdated, make intuitive sense. In other clinical situations, limited evidence is being applied too broadly or data are too sparse to clearly inform practice. Regardless of the reason, we frequently see patients in clinical situations in which we are forced to rethink the clinical rationale for advice they have received or the clinical path taken.
Here is a sample of the clinical scenarios in which we have seen inconsistencies between current practice and the best evidence in perinatal psychiatry or situations in which data are too sparse to inform the clearest clinical path.
1. Discontinuation of antidepressants proximate to conception
Despite multiple studies supporting the high risk for relapse of major depression in women on maintenance antidepressant therapy with a history of recurrent depressive illness, it is still quite common for clinicians to routinely advise women to stop antidepressants while planning a pregnancy or after documentation of a pregnancy, regardless of the severity of the underlying illness. This runs counter to data showing high rates of relapse in women who stop antidepressants proximate to conception, the safety of antidepressants in pregnancy, and the harm to the mother and fetus when depression during pregnancy is untreated.
2. Use of a lower dose of antidepressants during pregnancy
It makes intuitive sense to use the smallest dose of medicine like antidepressant during pregnancy. However, multiple studies show that, at least in nonpregnant patients, the dose that gets patients well is typically the dose that keeps them well. One of the quickest paths to relapse in depression is a reduction in the antidepressant dose after someone has gotten well. This is even more relevant in pregnant patients because pregnancy itself dilutes the plasma level of the antidepressant given the rapidly expanding plasma volume seen in pregnancy. One can debate whether clinicians should empirically increase the dose of antidepressant during pregnancy to sustain plasma level of medication, but lowering the dose of this medication proximate or during pregnancy makes little sense.
3. A switch to sertraline in pregnancy/post partum
Another scenario that my colleagues and I often see is a pregnant patient whose depression was previously well controlled with a particular antidepressant, but whose physician, once she decides to conceive or becomes pregnant, switched her to sertraline.
The idea, which has been around for a long time, is that sertraline is the safest antidepressant for pregnant women because it has robust reproductive safety data and has particularly modest amounts of medication (if detected at all) in the plasma of infants of mothers who breastfeed while using the medicine. While we certainly have more safety data on SSRIs that were manufactured earlier, as compared with antidepressants that became available later, we have now accumulated data that fails to demonstrate a clear signal for teratogenicity across many antidepressants manufactured over the last 2 decades. Identifying an antidepressant for a given patient to which she will respond can be a challenging course for the patient. Achieving euthymia and subsequently switching to sertraline or another medication may only put her at risk for recurrence of depression and its attendant morbidity.
4. A change to a Category B label drug
This is another example of switching a patient to a potentially less effective drug in a somewhat misguided effort at finding a treatment that is safer in pregnancy. While the Food and Drug Administration’s drug category label system was a step forward, or at least a well intentioned effort to give women and their clinicians clearer insight into the reproductive safety of a medication, ultimately, the incomplete nature of the information caused the agency to transition to a new system (see the Pregnancy Labeling and Lactation Rule). Switching a woman to a category B medicine with sparse reproductive safety data instead of a category C medicine, which may not be unsafe but has raised some concerns in animal models, is not a better choice. The new labeling system is a step forward.
5. Discontinuation of lithium during pregnancy
Like discontinuation of antidepressants, the discontinuation of lithium during attempts to conceive in a woman whose illness has been well controlled, is associated with a high risk of relapse. In earlier work, it was sometimes recommended that discontinuation of lithium be considered after a long period of wellness. We have learned over time that this can be a risky move. Even women with a remote history of bipolar disorder appear to be at high risk of relapse when a mood stabilizer is stopped. Exquisite response to medicine does not imply less severe illness. Women who have bipolar disorder who have sustained euthymia on lithium should consider maintaining the safest possible regimen before, during, and after pregnancy despite the known small teratogenic risk associated with fetal exposure to this agent.
6. Try supplements or alternative therapies
Out of a desire to avoid any medication with incomplete reproductive safety data, some women and clinicians make the intuitive leap that “alternative treatments” can mitigate relapse in pregnancy, and they stop pharmacological treatments and switch to supplements or alternative therapies, including acupuncture, massage, or light therapy. Unfortunately, data supporting this clinical maneuver are sparse. Frequently, we see women with past histories of severe depression who have stopped antidepressants and who have started supplements as a substitute and who then relapse. Then, they try to restore euthymia with antidepressants and psychotherapy, and the road to restoration of well-being can be long.
Data on efficacy of alternative therapies continues to evolve and is an exciting and important area of research. However, where these treatments are best employed in the algorithm for treating depression in pregnancy, or at other times, has yet to be adequately defined.
7. Stop breastfeeding or defer antidepressant treatment
Many women continue to be counseled to either stop breastfeeding while using antidepressants or to defer treatment with antidepressants if they wish to breastfeed. Not uncommonly, we see women who are suffering from postpartum depression and who are engaged in psychotherapy but who have deferred treatment with antidepressants despite residual depressive symptoms that impair functioning. Clinicians should keep in mind that data supporting evidence of toxicity in newborns of women using antidepressants while breastfeeding are extremely sparse. Unfortunately, some women with postpartum depression are deferring treatment because they were counseled that it is not compatible with their desire to breastfeed.
8. Use of non-benzodiazepine sedative-hypnotics
Insomnia is a common problem in pregnancy, especially when coupled with comorbid anxiety, and, increasingly, it is being treated with non-benzodiazepine sedative-hypnotics. Clinicians should keep in mind that a known small risk may be better than an unknown risk. If a pregnant woman has severe insomnia, she may benefit from a low dose of a benzodiazepine, such as lorazepam or clonazepam, as opposed to a medication such as zolpidem for which reproductive safety data are particularly limited.
9. Pumping and dumping breast milk
Many women are advised to set an alarm to “pump and dump” their breast milk to minimize their baby’s exposure to antidepressants during breastfeeding. Early literature to pump and dump breast milk at peak antidepressant concentration was of great analytic and theoretical interest but has scant clinical application. As an author of many of those early publications, I can say that we never intended for women to sacrifice precious sleep to dump breast milk with the idea that limiting exposure to trace amounts of antidepressants would have beneficial effects over the long term.
10. Failure to bring up contraception use
We continue to see a 50% unplanned pregnancy rate across sociodemographic groups in the United States. This is a critical statistic because it may affect how treatment is managed. Bringing up the topic of reliable contraception prior to pregnancy allows for planned pregnancy and affords us the time to discuss treatment options and the ability to plot a more thoughtful and safe clinical course. However, often, contraception is not discussed.
One of our goals as clinicians is to, first, do no harm and that continues to be a challenge because the data in perinatal psychiatry is still inconsistent in some areas and there are evidence gaps in others. Nevertheless, our task is to take the best available data along with the patient’s wishes and knowledge of her past clinical history and to then translate that into the best care for the individual.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications.
Over the last 2 decades, there has been a growing interest in establishing a rich evidence base for treatment of psychiatric illness in pregnancy and the postpartum period. It seems as if a week does not go by when we don’t find multiple publications in the scientific literature describing a new finding or confirmation or inconsistency with existing data – whether it is a small prospective cohort study or an elegant analysis of a large administrative database. The goals of these reports center on refining our knowledge of safe treatments for perinatal psychiatric disorders.
Despite these strides, my colleagues and I frequently see a divergence between recommendations in the literature and what is done clinically by those who treat women around reproductive associated psychiatric disturbance – premenstrual dysphoric disorder or psychiatric disorder during pregnancy and the postpartum period. In some cases, scientific evidence has not filtered into day to day practice and some physicians continue to follow practices that, while outdated, make intuitive sense. In other clinical situations, limited evidence is being applied too broadly or data are too sparse to clearly inform practice. Regardless of the reason, we frequently see patients in clinical situations in which we are forced to rethink the clinical rationale for advice they have received or the clinical path taken.
Here is a sample of the clinical scenarios in which we have seen inconsistencies between current practice and the best evidence in perinatal psychiatry or situations in which data are too sparse to inform the clearest clinical path.
1. Discontinuation of antidepressants proximate to conception
Despite multiple studies supporting the high risk for relapse of major depression in women on maintenance antidepressant therapy with a history of recurrent depressive illness, it is still quite common for clinicians to routinely advise women to stop antidepressants while planning a pregnancy or after documentation of a pregnancy, regardless of the severity of the underlying illness. This runs counter to data showing high rates of relapse in women who stop antidepressants proximate to conception, the safety of antidepressants in pregnancy, and the harm to the mother and fetus when depression during pregnancy is untreated.
2. Use of a lower dose of antidepressants during pregnancy
It makes intuitive sense to use the smallest dose of medicine like antidepressant during pregnancy. However, multiple studies show that, at least in nonpregnant patients, the dose that gets patients well is typically the dose that keeps them well. One of the quickest paths to relapse in depression is a reduction in the antidepressant dose after someone has gotten well. This is even more relevant in pregnant patients because pregnancy itself dilutes the plasma level of the antidepressant given the rapidly expanding plasma volume seen in pregnancy. One can debate whether clinicians should empirically increase the dose of antidepressant during pregnancy to sustain plasma level of medication, but lowering the dose of this medication proximate or during pregnancy makes little sense.
3. A switch to sertraline in pregnancy/post partum
Another scenario that my colleagues and I often see is a pregnant patient whose depression was previously well controlled with a particular antidepressant, but whose physician, once she decides to conceive or becomes pregnant, switched her to sertraline.
The idea, which has been around for a long time, is that sertraline is the safest antidepressant for pregnant women because it has robust reproductive safety data and has particularly modest amounts of medication (if detected at all) in the plasma of infants of mothers who breastfeed while using the medicine. While we certainly have more safety data on SSRIs that were manufactured earlier, as compared with antidepressants that became available later, we have now accumulated data that fails to demonstrate a clear signal for teratogenicity across many antidepressants manufactured over the last 2 decades. Identifying an antidepressant for a given patient to which she will respond can be a challenging course for the patient. Achieving euthymia and subsequently switching to sertraline or another medication may only put her at risk for recurrence of depression and its attendant morbidity.
4. A change to a Category B label drug
This is another example of switching a patient to a potentially less effective drug in a somewhat misguided effort at finding a treatment that is safer in pregnancy. While the Food and Drug Administration’s drug category label system was a step forward, or at least a well intentioned effort to give women and their clinicians clearer insight into the reproductive safety of a medication, ultimately, the incomplete nature of the information caused the agency to transition to a new system (see the Pregnancy Labeling and Lactation Rule). Switching a woman to a category B medicine with sparse reproductive safety data instead of a category C medicine, which may not be unsafe but has raised some concerns in animal models, is not a better choice. The new labeling system is a step forward.
5. Discontinuation of lithium during pregnancy
Like discontinuation of antidepressants, the discontinuation of lithium during attempts to conceive in a woman whose illness has been well controlled, is associated with a high risk of relapse. In earlier work, it was sometimes recommended that discontinuation of lithium be considered after a long period of wellness. We have learned over time that this can be a risky move. Even women with a remote history of bipolar disorder appear to be at high risk of relapse when a mood stabilizer is stopped. Exquisite response to medicine does not imply less severe illness. Women who have bipolar disorder who have sustained euthymia on lithium should consider maintaining the safest possible regimen before, during, and after pregnancy despite the known small teratogenic risk associated with fetal exposure to this agent.
6. Try supplements or alternative therapies
Out of a desire to avoid any medication with incomplete reproductive safety data, some women and clinicians make the intuitive leap that “alternative treatments” can mitigate relapse in pregnancy, and they stop pharmacological treatments and switch to supplements or alternative therapies, including acupuncture, massage, or light therapy. Unfortunately, data supporting this clinical maneuver are sparse. Frequently, we see women with past histories of severe depression who have stopped antidepressants and who have started supplements as a substitute and who then relapse. Then, they try to restore euthymia with antidepressants and psychotherapy, and the road to restoration of well-being can be long.
Data on efficacy of alternative therapies continues to evolve and is an exciting and important area of research. However, where these treatments are best employed in the algorithm for treating depression in pregnancy, or at other times, has yet to be adequately defined.
7. Stop breastfeeding or defer antidepressant treatment
Many women continue to be counseled to either stop breastfeeding while using antidepressants or to defer treatment with antidepressants if they wish to breastfeed. Not uncommonly, we see women who are suffering from postpartum depression and who are engaged in psychotherapy but who have deferred treatment with antidepressants despite residual depressive symptoms that impair functioning. Clinicians should keep in mind that data supporting evidence of toxicity in newborns of women using antidepressants while breastfeeding are extremely sparse. Unfortunately, some women with postpartum depression are deferring treatment because they were counseled that it is not compatible with their desire to breastfeed.
8. Use of non-benzodiazepine sedative-hypnotics
Insomnia is a common problem in pregnancy, especially when coupled with comorbid anxiety, and, increasingly, it is being treated with non-benzodiazepine sedative-hypnotics. Clinicians should keep in mind that a known small risk may be better than an unknown risk. If a pregnant woman has severe insomnia, she may benefit from a low dose of a benzodiazepine, such as lorazepam or clonazepam, as opposed to a medication such as zolpidem for which reproductive safety data are particularly limited.
9. Pumping and dumping breast milk
Many women are advised to set an alarm to “pump and dump” their breast milk to minimize their baby’s exposure to antidepressants during breastfeeding. Early literature to pump and dump breast milk at peak antidepressant concentration was of great analytic and theoretical interest but has scant clinical application. As an author of many of those early publications, I can say that we never intended for women to sacrifice precious sleep to dump breast milk with the idea that limiting exposure to trace amounts of antidepressants would have beneficial effects over the long term.
10. Failure to bring up contraception use
We continue to see a 50% unplanned pregnancy rate across sociodemographic groups in the United States. This is a critical statistic because it may affect how treatment is managed. Bringing up the topic of reliable contraception prior to pregnancy allows for planned pregnancy and affords us the time to discuss treatment options and the ability to plot a more thoughtful and safe clinical course. However, often, contraception is not discussed.
One of our goals as clinicians is to, first, do no harm and that continues to be a challenge because the data in perinatal psychiatry is still inconsistent in some areas and there are evidence gaps in others. Nevertheless, our task is to take the best available data along with the patient’s wishes and knowledge of her past clinical history and to then translate that into the best care for the individual.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications.
Understanding the human papillomavirus
Human papillomavirus (HPV) is the most prevalent sexually transmitted disease globally. It is causally related to the development of several malignancies, including cervical, anal, and oropharyngeal ones, because of its integration and dysregulation of the genome of infected cells. Fortunately, vaccination is available to prevent development of HPV-related diseases. Understanding this virus, its carcinogenic role, and the importance of prevention through vaccination are critically important for ob.gyns. This column reviews the fundamentals of HPV biology, epidemiology, and carcinogenesis.
Viral anatomy
HPV are members of the A genus of the family Papovaviridae. They contain between 7,800 and 7,900 base pairs. They are nonenveloped, double-stranded DNA viruses with a circular structure. The viral DNA is contained within an icosahedral capsid that measures 45 nm-55 nm. The HPV genome has three critical regions: the long control region, otherwise known as the upstream regulatory region; the early region; and the late region.1
Capsid proteins are similar between groups. Therefore, HPV are categorized into “types” and “subtypes” based on the extent of DNA similarity. There are more than 100 types of HPV in humans.2 The type of HPV is determined by the gene sequences of E6/E7 and L1 and must show more than 10% difference between types. The gene sequences between different subtypes differ by 2%-5%.
Epidemiology of HPV infection
HPV are widely distributed among mammalian species but are species specific. Their tissue affinity varies by type. HPV types 1, 2, and 4 cause common or plantar warts. HPV types 6 and 11 cause condyloma acuminata (genital warts) and low grade dysplasia. HPV types 16 and 18 – in addition to 31 and 52 – are of particular interest to oncologists because they are associated with lower genital tract high grade dysplasia and invasive carcinoma. Infection with HPV 16 is present in about half of invasive cervical cancers, with HPV type 18 present in 20% of cervical cancers. Adenocarcinomas of the cervix are more commonly associated with HPV 18. Anal cancer and oropharyngeal cancer are more commonly associated with HPV 16.3
HPV infections are acquired through cutaneous touching (including hand to genital) and HPV positivity is most commonly present within the first 10 years after sexual debut.4 However, most individuals who acquire HPV do so as a transient infection, which is cleared without sequelae. Those who fail to rapidly clear HPV infection, and in whom it becomes chronic, face an increasing risk of development of dysplasia and invasive carcinoma. The incidence of HPV infection increases again at menopause, but, for these older women, the new finding of HPV detection may be related to reactivation of an earlier infection rather than exclusively new exposure to the virus.5
Diagnosis and testing
HPV infection can be detected through DNA testing, RNA testing, and cellular markers.6
HPV DNA testing was the original form of testing offered. It improved the sensitivity over cytology alone in the detection of precursors to malignancy but had relatively poor specificity, resulting in a high false positive rate and unnecessary referral to colposcopy. The various tests approved by the Food and Drug Administration – Hybrid Capture 2 (HC2), Cervista, and Cobas 4800 – differ in the number and nature of HPV types that they detect.
HPV RNA testing has developed and involves measuring the expression of E6 and E7 RNA. This testing is FDA approved and has the potential to improve upon the specificity of DNA testing procedures by decreasing false positives.
Measurement of cellular markers is currently considered experimental/exploratory and is not yet FDA approved for diagnostic purposes in screening or confirmation of HPV infection or coexisting dysplasia. It involves measuring the downstream cellular targets (such as p16) of E6 or E7 activity.
The mechanism of carcinogenesis
The early region of the HPV genome is downstream from the upstream regulatory region. It codes for proteins involved in viral infection and replication. The two most important genes in the early region are E6 and E7. When integrated into the human genome of the lower genital tract cell, the viral genes E6 and E7 negatively interfere with cell cycle control and mechanisms to halt dysregulation.7
E6 and E7 are considered oncogenes because they cause loss of function of the critical tumor suppressor proteins p53 and the retinoblastoma protein. The p53 protein is typically responsible for controlling cell cycling through the G0/G1 to S phases. It involves stalling cellular mitosis in order to facilitate DNA repair mechanisms in the case of damaged cells, thereby preventing replication of DNA aberrations. The retinoblastoma protein also functions to inhibit cells that have acquired DNA damage from cycling and induces apoptosis in DNA damaged cells. When protein products of E6 and E7 negatively interact with these two tumor suppressor proteins they overcome the cell’s safeguard arrest response.
In the presence of other carcinogens, such as products of tobacco exposure, the increased DNA damage sustained by the genital tract cell is allowed to go relatively unchecked by the HPV coinfection, which has disabled tumor suppressor function. This facilitates immortality of the damaged cell, amplification of additional DNA mutations, and unchecked cellular growth and dysplastic transformation. E6 and E7 are strongly expressed in invasive genital tract lesions to support its important role in carcinogenesis.
HIV coinfection is another factor that promotes carcinogenesis following HPV infection because it inhibits clearance of the virus through T-cell mediated immunosuppression and directly enhances expression of E6 and E7 proteins in the HIV and HPV coinfected cell.8 For these reasons, HIV-positive women are less likely to clear HPV infection and more likely to develop high grade dysplasia or invasive carcinomas.
Prevention and vaccination
HPV vaccinations utilize virus-like particles (VLPs). These VLPs are capsid particles generated from the L1 region of the HPV DNA. The capsid proteins coded for by L1 are highly immunogenic. VLPs are recombinant proteins created in benign biologic systems (such as yeast) and contain no inner DNA core (effectively empty viral capsids) and therefore are not infectious. The L1 gene is incorporated into a plasmid, which is inserted into the nucleus of a eukaryotic cell. Transcription and translation of the L1 gene takes place, creating capsid proteins that self-assemble into VLPs. These VLPs are retrieved and inoculated into candidate patients to illicit an immune response.
Quadrivalent, nine-valent, and bivalent vaccines are available worldwide. However, only the nine-valent vaccine – protective against types 6, 11, 16, 18, 31, 33, 45, 52, and 58 – is available in the United States. This theoretically provides more comprehensive coverage against cervical cancer–causing HPV types, as 70% of cervical cancer is attributable to HPV 16 and 18, but an additional 20% is attributable to HPV 31, 33, 45, 52, and 58. This vaccine also provides protection against the HPV strains that cause genital warts and low-grade dysplastic changes.9
HPV, in most instances, is a transient virus with no sequelae. However, if not cleared from the cells of the lower genital tract, anus, or oropharynx it can result in the breakdown of cellular correction strategies and culminate in invasive carcinoma. Fortunately, highly effective and safe vaccinations are available and should be broadly prescribed.
Dr. Rossi is an assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She reported having no relevant financial disclosures.
References
1. Cancer Epidemiol Biomarkers Prev. 1995 Jun;4(4):415-28.
2. Gynecol Oncol. 2011 Apr;121(1):32-42.
3. Cancer Epidemiol Biomarkers Prev. 2008 Jul;17(7):1611-22.
4. JAMA. 2007 Feb 28;297(8):813-9.
5. J Infect Dis. 2013; 207(2): 272-80.
6. J Natl Cancer Inst. 2011 Mar 2;103(5):368-83.
7. J Natl Cancer Inst. 2000 May 3;92(9):690-8.
8. Lancet. 2002 Jan 12;359(9301):108-13.
9. Obstet Gynecol 2017;129:e173–8.
Human papillomavirus (HPV) is the most prevalent sexually transmitted disease globally. It is causally related to the development of several malignancies, including cervical, anal, and oropharyngeal ones, because of its integration and dysregulation of the genome of infected cells. Fortunately, vaccination is available to prevent development of HPV-related diseases. Understanding this virus, its carcinogenic role, and the importance of prevention through vaccination are critically important for ob.gyns. This column reviews the fundamentals of HPV biology, epidemiology, and carcinogenesis.
Viral anatomy
HPV are members of the A genus of the family Papovaviridae. They contain between 7,800 and 7,900 base pairs. They are nonenveloped, double-stranded DNA viruses with a circular structure. The viral DNA is contained within an icosahedral capsid that measures 45 nm-55 nm. The HPV genome has three critical regions: the long control region, otherwise known as the upstream regulatory region; the early region; and the late region.1
Capsid proteins are similar between groups. Therefore, HPV are categorized into “types” and “subtypes” based on the extent of DNA similarity. There are more than 100 types of HPV in humans.2 The type of HPV is determined by the gene sequences of E6/E7 and L1 and must show more than 10% difference between types. The gene sequences between different subtypes differ by 2%-5%.
Epidemiology of HPV infection
HPV are widely distributed among mammalian species but are species specific. Their tissue affinity varies by type. HPV types 1, 2, and 4 cause common or plantar warts. HPV types 6 and 11 cause condyloma acuminata (genital warts) and low grade dysplasia. HPV types 16 and 18 – in addition to 31 and 52 – are of particular interest to oncologists because they are associated with lower genital tract high grade dysplasia and invasive carcinoma. Infection with HPV 16 is present in about half of invasive cervical cancers, with HPV type 18 present in 20% of cervical cancers. Adenocarcinomas of the cervix are more commonly associated with HPV 18. Anal cancer and oropharyngeal cancer are more commonly associated with HPV 16.3
HPV infections are acquired through cutaneous touching (including hand to genital) and HPV positivity is most commonly present within the first 10 years after sexual debut.4 However, most individuals who acquire HPV do so as a transient infection, which is cleared without sequelae. Those who fail to rapidly clear HPV infection, and in whom it becomes chronic, face an increasing risk of development of dysplasia and invasive carcinoma. The incidence of HPV infection increases again at menopause, but, for these older women, the new finding of HPV detection may be related to reactivation of an earlier infection rather than exclusively new exposure to the virus.5
Diagnosis and testing
HPV infection can be detected through DNA testing, RNA testing, and cellular markers.6
HPV DNA testing was the original form of testing offered. It improved the sensitivity over cytology alone in the detection of precursors to malignancy but had relatively poor specificity, resulting in a high false positive rate and unnecessary referral to colposcopy. The various tests approved by the Food and Drug Administration – Hybrid Capture 2 (HC2), Cervista, and Cobas 4800 – differ in the number and nature of HPV types that they detect.
HPV RNA testing has developed and involves measuring the expression of E6 and E7 RNA. This testing is FDA approved and has the potential to improve upon the specificity of DNA testing procedures by decreasing false positives.
Measurement of cellular markers is currently considered experimental/exploratory and is not yet FDA approved for diagnostic purposes in screening or confirmation of HPV infection or coexisting dysplasia. It involves measuring the downstream cellular targets (such as p16) of E6 or E7 activity.
The mechanism of carcinogenesis
The early region of the HPV genome is downstream from the upstream regulatory region. It codes for proteins involved in viral infection and replication. The two most important genes in the early region are E6 and E7. When integrated into the human genome of the lower genital tract cell, the viral genes E6 and E7 negatively interfere with cell cycle control and mechanisms to halt dysregulation.7
E6 and E7 are considered oncogenes because they cause loss of function of the critical tumor suppressor proteins p53 and the retinoblastoma protein. The p53 protein is typically responsible for controlling cell cycling through the G0/G1 to S phases. It involves stalling cellular mitosis in order to facilitate DNA repair mechanisms in the case of damaged cells, thereby preventing replication of DNA aberrations. The retinoblastoma protein also functions to inhibit cells that have acquired DNA damage from cycling and induces apoptosis in DNA damaged cells. When protein products of E6 and E7 negatively interact with these two tumor suppressor proteins they overcome the cell’s safeguard arrest response.
In the presence of other carcinogens, such as products of tobacco exposure, the increased DNA damage sustained by the genital tract cell is allowed to go relatively unchecked by the HPV coinfection, which has disabled tumor suppressor function. This facilitates immortality of the damaged cell, amplification of additional DNA mutations, and unchecked cellular growth and dysplastic transformation. E6 and E7 are strongly expressed in invasive genital tract lesions to support its important role in carcinogenesis.
HIV coinfection is another factor that promotes carcinogenesis following HPV infection because it inhibits clearance of the virus through T-cell mediated immunosuppression and directly enhances expression of E6 and E7 proteins in the HIV and HPV coinfected cell.8 For these reasons, HIV-positive women are less likely to clear HPV infection and more likely to develop high grade dysplasia or invasive carcinomas.
Prevention and vaccination
HPV vaccinations utilize virus-like particles (VLPs). These VLPs are capsid particles generated from the L1 region of the HPV DNA. The capsid proteins coded for by L1 are highly immunogenic. VLPs are recombinant proteins created in benign biologic systems (such as yeast) and contain no inner DNA core (effectively empty viral capsids) and therefore are not infectious. The L1 gene is incorporated into a plasmid, which is inserted into the nucleus of a eukaryotic cell. Transcription and translation of the L1 gene takes place, creating capsid proteins that self-assemble into VLPs. These VLPs are retrieved and inoculated into candidate patients to illicit an immune response.
Quadrivalent, nine-valent, and bivalent vaccines are available worldwide. However, only the nine-valent vaccine – protective against types 6, 11, 16, 18, 31, 33, 45, 52, and 58 – is available in the United States. This theoretically provides more comprehensive coverage against cervical cancer–causing HPV types, as 70% of cervical cancer is attributable to HPV 16 and 18, but an additional 20% is attributable to HPV 31, 33, 45, 52, and 58. This vaccine also provides protection against the HPV strains that cause genital warts and low-grade dysplastic changes.9
HPV, in most instances, is a transient virus with no sequelae. However, if not cleared from the cells of the lower genital tract, anus, or oropharynx it can result in the breakdown of cellular correction strategies and culminate in invasive carcinoma. Fortunately, highly effective and safe vaccinations are available and should be broadly prescribed.
Dr. Rossi is an assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She reported having no relevant financial disclosures.
References
1. Cancer Epidemiol Biomarkers Prev. 1995 Jun;4(4):415-28.
2. Gynecol Oncol. 2011 Apr;121(1):32-42.
3. Cancer Epidemiol Biomarkers Prev. 2008 Jul;17(7):1611-22.
4. JAMA. 2007 Feb 28;297(8):813-9.
5. J Infect Dis. 2013; 207(2): 272-80.
6. J Natl Cancer Inst. 2011 Mar 2;103(5):368-83.
7. J Natl Cancer Inst. 2000 May 3;92(9):690-8.
8. Lancet. 2002 Jan 12;359(9301):108-13.
9. Obstet Gynecol 2017;129:e173–8.
Human papillomavirus (HPV) is the most prevalent sexually transmitted disease globally. It is causally related to the development of several malignancies, including cervical, anal, and oropharyngeal ones, because of its integration and dysregulation of the genome of infected cells. Fortunately, vaccination is available to prevent development of HPV-related diseases. Understanding this virus, its carcinogenic role, and the importance of prevention through vaccination are critically important for ob.gyns. This column reviews the fundamentals of HPV biology, epidemiology, and carcinogenesis.
Viral anatomy
HPV are members of the A genus of the family Papovaviridae. They contain between 7,800 and 7,900 base pairs. They are nonenveloped, double-stranded DNA viruses with a circular structure. The viral DNA is contained within an icosahedral capsid that measures 45 nm-55 nm. The HPV genome has three critical regions: the long control region, otherwise known as the upstream regulatory region; the early region; and the late region.1
Capsid proteins are similar between groups. Therefore, HPV are categorized into “types” and “subtypes” based on the extent of DNA similarity. There are more than 100 types of HPV in humans.2 The type of HPV is determined by the gene sequences of E6/E7 and L1 and must show more than 10% difference between types. The gene sequences between different subtypes differ by 2%-5%.
Epidemiology of HPV infection
HPV are widely distributed among mammalian species but are species specific. Their tissue affinity varies by type. HPV types 1, 2, and 4 cause common or plantar warts. HPV types 6 and 11 cause condyloma acuminata (genital warts) and low grade dysplasia. HPV types 16 and 18 – in addition to 31 and 52 – are of particular interest to oncologists because they are associated with lower genital tract high grade dysplasia and invasive carcinoma. Infection with HPV 16 is present in about half of invasive cervical cancers, with HPV type 18 present in 20% of cervical cancers. Adenocarcinomas of the cervix are more commonly associated with HPV 18. Anal cancer and oropharyngeal cancer are more commonly associated with HPV 16.3
HPV infections are acquired through cutaneous touching (including hand to genital) and HPV positivity is most commonly present within the first 10 years after sexual debut.4 However, most individuals who acquire HPV do so as a transient infection, which is cleared without sequelae. Those who fail to rapidly clear HPV infection, and in whom it becomes chronic, face an increasing risk of development of dysplasia and invasive carcinoma. The incidence of HPV infection increases again at menopause, but, for these older women, the new finding of HPV detection may be related to reactivation of an earlier infection rather than exclusively new exposure to the virus.5
Diagnosis and testing
HPV infection can be detected through DNA testing, RNA testing, and cellular markers.6
HPV DNA testing was the original form of testing offered. It improved the sensitivity over cytology alone in the detection of precursors to malignancy but had relatively poor specificity, resulting in a high false positive rate and unnecessary referral to colposcopy. The various tests approved by the Food and Drug Administration – Hybrid Capture 2 (HC2), Cervista, and Cobas 4800 – differ in the number and nature of HPV types that they detect.
HPV RNA testing has developed and involves measuring the expression of E6 and E7 RNA. This testing is FDA approved and has the potential to improve upon the specificity of DNA testing procedures by decreasing false positives.
Measurement of cellular markers is currently considered experimental/exploratory and is not yet FDA approved for diagnostic purposes in screening or confirmation of HPV infection or coexisting dysplasia. It involves measuring the downstream cellular targets (such as p16) of E6 or E7 activity.
The mechanism of carcinogenesis
The early region of the HPV genome is downstream from the upstream regulatory region. It codes for proteins involved in viral infection and replication. The two most important genes in the early region are E6 and E7. When integrated into the human genome of the lower genital tract cell, the viral genes E6 and E7 negatively interfere with cell cycle control and mechanisms to halt dysregulation.7
E6 and E7 are considered oncogenes because they cause loss of function of the critical tumor suppressor proteins p53 and the retinoblastoma protein. The p53 protein is typically responsible for controlling cell cycling through the G0/G1 to S phases. It involves stalling cellular mitosis in order to facilitate DNA repair mechanisms in the case of damaged cells, thereby preventing replication of DNA aberrations. The retinoblastoma protein also functions to inhibit cells that have acquired DNA damage from cycling and induces apoptosis in DNA damaged cells. When protein products of E6 and E7 negatively interact with these two tumor suppressor proteins they overcome the cell’s safeguard arrest response.
In the presence of other carcinogens, such as products of tobacco exposure, the increased DNA damage sustained by the genital tract cell is allowed to go relatively unchecked by the HPV coinfection, which has disabled tumor suppressor function. This facilitates immortality of the damaged cell, amplification of additional DNA mutations, and unchecked cellular growth and dysplastic transformation. E6 and E7 are strongly expressed in invasive genital tract lesions to support its important role in carcinogenesis.
HIV coinfection is another factor that promotes carcinogenesis following HPV infection because it inhibits clearance of the virus through T-cell mediated immunosuppression and directly enhances expression of E6 and E7 proteins in the HIV and HPV coinfected cell.8 For these reasons, HIV-positive women are less likely to clear HPV infection and more likely to develop high grade dysplasia or invasive carcinomas.
Prevention and vaccination
HPV vaccinations utilize virus-like particles (VLPs). These VLPs are capsid particles generated from the L1 region of the HPV DNA. The capsid proteins coded for by L1 are highly immunogenic. VLPs are recombinant proteins created in benign biologic systems (such as yeast) and contain no inner DNA core (effectively empty viral capsids) and therefore are not infectious. The L1 gene is incorporated into a plasmid, which is inserted into the nucleus of a eukaryotic cell. Transcription and translation of the L1 gene takes place, creating capsid proteins that self-assemble into VLPs. These VLPs are retrieved and inoculated into candidate patients to illicit an immune response.
Quadrivalent, nine-valent, and bivalent vaccines are available worldwide. However, only the nine-valent vaccine – protective against types 6, 11, 16, 18, 31, 33, 45, 52, and 58 – is available in the United States. This theoretically provides more comprehensive coverage against cervical cancer–causing HPV types, as 70% of cervical cancer is attributable to HPV 16 and 18, but an additional 20% is attributable to HPV 31, 33, 45, 52, and 58. This vaccine also provides protection against the HPV strains that cause genital warts and low-grade dysplastic changes.9
HPV, in most instances, is a transient virus with no sequelae. However, if not cleared from the cells of the lower genital tract, anus, or oropharynx it can result in the breakdown of cellular correction strategies and culminate in invasive carcinoma. Fortunately, highly effective and safe vaccinations are available and should be broadly prescribed.
Dr. Rossi is an assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She reported having no relevant financial disclosures.
References
1. Cancer Epidemiol Biomarkers Prev. 1995 Jun;4(4):415-28.
2. Gynecol Oncol. 2011 Apr;121(1):32-42.
3. Cancer Epidemiol Biomarkers Prev. 2008 Jul;17(7):1611-22.
4. JAMA. 2007 Feb 28;297(8):813-9.
5. J Infect Dis. 2013; 207(2): 272-80.
6. J Natl Cancer Inst. 2011 Mar 2;103(5):368-83.
7. J Natl Cancer Inst. 2000 May 3;92(9):690-8.
8. Lancet. 2002 Jan 12;359(9301):108-13.
9. Obstet Gynecol 2017;129:e173–8.
Writing: Do Make a MEAL of It!
Writing for publication fulfills a professional obligation to contribute to the body of knowledge. In the past decade, we’ve seen increases in the number of journals and in the number of NPs and PAs—providing more publishing opportunities and more potential authors. Yet many of my colleagues have little interest in publishing; perhaps they fear the writing process or believe they lack the skills to compose a manuscript.
How, then, do we cajole them into sharing their expertise in written form? Much has been written about why you should write.1,2 What is needed is guidance on the process to help overcome the common barriers to success in publishing. If it’s been a long time since you were in school at all—or at least since you took English Composition 101—allow me to offer a solid starting point for the journey of writing.
A manuscript, in essence, is a collection of paragraphs that follow a traditional flow. But to be sufficiently developed, paragraphs must (1) contain a main idea, (2) be structurally coherent, and (3) maintain a sense of unity around the idea.3 Once authors master the composition of a strong paragraph, the development of the manuscript comes naturally. Here are seven tips—four on content development and three on form—for compiling a manuscript worthy of publication and personal pride.
1. Start strong. Everyone understands the importance of grabbing a reader’s attention right out of the gate, right? A strong topic sentence does more than introduce the subject; it sets the tone for those that follow. A short sentence at the beginning of a paragraph establishes an understanding that a discussion will follow—and offers a preview of what the discussion will entail. But writers need not be limited; a topic sentence can take the form of a question or be placed later in the paragraph. Less experienced authors may prefer to open the paragraph with the topic sentence, however, as this allows for a quick assessment of whether the subsequent sentences follow logically. In other words, start simple—there is room to grow as you gain confidence with writing.
2. Use the MEAL plan. A paragraph should extend from the topic sentence. Collectively, the paragraph’s sentences should follow the steps outlined in the “MEAL plan,” a valuable resource conceptualized by the Duke University Thompson Writing Program.4 The “M” stands for the main topic; “E,” for the evidence that supports or refutes the topic sentence; “A,” for analysis and its importance; and “L,” for the link back to the larger claim (ie, the overall topic of the paper).
Using the MEAL approach is relatively straightforward. Picture yourself as the sender of a message; the reader is your recipient. You need to convey the information to your reader so that he or she understands it.
Limiting the number of words in a sentence and the number of sentences in a paragraph may help. Exceedingly long sentences are cumbersome and threaten to muddle the author’s message. They also pose the risk for improper noun/verb agreement, irregular punctuation, and hindered readability. (But then, what are editors for?)
A paragraph presents a well-formulated argument; one that contains only two sentences is unlikely to support the author’s assertion. Novice writers, however, often go to the other extreme, which dilutes the point. As a rule of thumb, if you can speak the entire paragraph with a single breath, the length is adequate. Reading your work aloud also helps identify hidden hazards.
3. Make connections. The result would be confusing and nonsensical. Similarly, you wouldn’t conclude your paragraph before you’ve started it. Imagine if you tried to clean out a wound after applying a dressing. The key to a good paragraph is cohesion.
If you’re scratching your head at the previous paragraph, you take my next point: All sentences within a paragraph should have a natural flow. In a well-developed paragraph, each sentence directly relates to the one before and the one after; they work together to convey your point. If the topic sentence contains an assertion, the following sentences provide supporting evidence. In medical writing, this evidence comes from citations to published literature.
If you are using the MEAL plan, you have an outline for how to support your topic sentence in a logical manner. You can then link sentences by capitalizing on words or phrases to form bridges that carry the reader through the paragraph.5 These links are created through repetition of key words or through parallel grammatical forms.
4. Pump the brakes. No one likes an abrupt stop. When you’re winding down on a paragraph, you need to signal to the reader that you’re going to shift gears. The last sentence of a paragraph should serve as a natural transition to the next paragraph.6 Equally important is the transition line at the beginning of the next paragraph.
Regardless of where the transition occurs, the goal remains to help the reader follow your logic. A subsequent paragraph can extend or refute the argument that has been presented, or it can introduce an entirely new point. No matter what, you want the reader to be prepared for a change in focus and to stay with you through your transition to a new perspective or subtopic.
On the other hand, if the argument is exhausted—it stops. When your discussion is complete, the transition to the next paragraph is very different (eg, “In summary…”). This is an appropriate time to move to a new paragraph and new section.
Speaking of a new section, let’s switch our focus to form.
5. Take action. There are two types of “voice” in communication: active, in which the subject is taking some form of action (eg, You are reading this article), and passive, in which the action is performed upon the subject (eg, This article is being read by you). Active voice is preferred for several reasons—namely, clarity and space. An active sentence identifies who is doing what. The same conclusion may be reached through a passive sentence, with some effort on the reader’s part—but active sentences tend to be more concise. They also convey a sense of immediacy, hopefully drawing the reader into your article.
6. Punctuate like a pro. Punctuation is important! It provides structure, improving clarity and comprehension. Can you fathom the confusion that would occur if an author misused (or failed to use) appropriate punctuation?
Thankfully, rules regarding punctuation have not changed much over the past century. One notable exception is use of the serial (or “Oxford”) comma, which incites passionate debate among both amateur and professional linguists.7 (For the record, this publication uses the Oxford comma. Just ask the editors: Karen, Ann, and Amy.)
A full review of punctuation is beyond the scope of this article; however, be it known that the most problematic marks—the ones to double-check in your own writing—are the apostrophe (plural or singular possessive use), the semi-colon, the comma (or lack of), and quotation marks.8 To improve your punctuation, obtain a basic grammar handbook or search online.
7. Don’t volley with verbs. Verb tense should remain consistent throughout the paragraph.9 Paragraphs with multiple verb tenses bounce the reader’s mind back and forth. It’s like watching a ping pong match, but less enjoyable.
To check for consistency, print the manuscript and mix the order of the pages. Circle the verbs. Look at the circled words and assess the tense of each. Then, repair the damage.
It is easier to identify these types of problems with a manuscript when you’re reading the pages out of order. Editors will tell you that it is difficult to focus on particulars when you are distracted by the content of the paper. Out-of-order pages are harder to read for “sense,” so you can focus on tense, voice, and punctuation.
In conclusion, I hope I’ve helped you see that writing is a process—some say a craft—but it is one that anyone can tackle with the right mindset and preparation. Most authors have a key message; they may just need help expressing it. Starting with small elements, such as the paragraph, helps the author deliver the message clearly.
1. Danielsen RD. I’d like to write a medical article, but …. Clinician Reviews. 2013;23(12):11-12.
2. Onieal ME. Be the change you wish to see. Clinician Reviews. 2015;25(7):8-9.
3. Monmouth University Tutoring and Writing Services. Paragraphs. www.monmouth.edu/uploadedFiles/Resources_for_Writers/The_Writing_Process/Paragraphs2013.pdf. Accessed June 1, 2017.
4. Duke University Thompson Writing Program. Paragraphing: The MEAL Plan. https://twp.duke.edu/sites/twp.duke.edu/files/file-attachments/meal-plan.original.pdf. Accessed June 1, 2017.
5. Purdue Online Writing Lab. On paragraphs. https://owl.english.purdue.edu/owl/resource/606/01/. Accessed June 1, 2017.
6. The Writing Center at UNC–Chapel Hill. Transitions. http://writingcenter.unc.edu/handouts/transitions/. Accessed June 1, 2017.
7. Edwards A. What is the Oxford comma and why do people care so much about it? www.grammarly.com/blog/what-is-the-oxford-comma-and-why-do-people-care-so-much-about-it/. Accessed June 1, 2017.
8. Endpaper: the Paperblanks blog. Writing Wednesday: 3 most commonly misused punctuation marks. February 1, 2017. http://blog.paperblanks.com/2017/02/writing-wednesday-3-most-commonly-misused-punctuation-marks/. Accessed June 1, 2017.
9. Towson University Online Writing Support. Verb tense consistency. https://webapps.towson.edu/ows/tenseconsistency.htm. Accessed June 1, 2017.
Rodney W. Hicks is a Professor in the College of Graduate Nursing at Western University of Health Sciences Center in Pomona, California.
Rodney W. Hicks is a Professor in the College of Graduate Nursing at Western University of Health Sciences Center in Pomona, California.
Rodney W. Hicks is a Professor in the College of Graduate Nursing at Western University of Health Sciences Center in Pomona, California.
Writing for publication fulfills a professional obligation to contribute to the body of knowledge. In the past decade, we’ve seen increases in the number of journals and in the number of NPs and PAs—providing more publishing opportunities and more potential authors. Yet many of my colleagues have little interest in publishing; perhaps they fear the writing process or believe they lack the skills to compose a manuscript.
How, then, do we cajole them into sharing their expertise in written form? Much has been written about why you should write.1,2 What is needed is guidance on the process to help overcome the common barriers to success in publishing. If it’s been a long time since you were in school at all—or at least since you took English Composition 101—allow me to offer a solid starting point for the journey of writing.
A manuscript, in essence, is a collection of paragraphs that follow a traditional flow. But to be sufficiently developed, paragraphs must (1) contain a main idea, (2) be structurally coherent, and (3) maintain a sense of unity around the idea.3 Once authors master the composition of a strong paragraph, the development of the manuscript comes naturally. Here are seven tips—four on content development and three on form—for compiling a manuscript worthy of publication and personal pride.
1. Start strong. Everyone understands the importance of grabbing a reader’s attention right out of the gate, right? A strong topic sentence does more than introduce the subject; it sets the tone for those that follow. A short sentence at the beginning of a paragraph establishes an understanding that a discussion will follow—and offers a preview of what the discussion will entail. But writers need not be limited; a topic sentence can take the form of a question or be placed later in the paragraph. Less experienced authors may prefer to open the paragraph with the topic sentence, however, as this allows for a quick assessment of whether the subsequent sentences follow logically. In other words, start simple—there is room to grow as you gain confidence with writing.
2. Use the MEAL plan. A paragraph should extend from the topic sentence. Collectively, the paragraph’s sentences should follow the steps outlined in the “MEAL plan,” a valuable resource conceptualized by the Duke University Thompson Writing Program.4 The “M” stands for the main topic; “E,” for the evidence that supports or refutes the topic sentence; “A,” for analysis and its importance; and “L,” for the link back to the larger claim (ie, the overall topic of the paper).
Using the MEAL approach is relatively straightforward. Picture yourself as the sender of a message; the reader is your recipient. You need to convey the information to your reader so that he or she understands it.
Limiting the number of words in a sentence and the number of sentences in a paragraph may help. Exceedingly long sentences are cumbersome and threaten to muddle the author’s message. They also pose the risk for improper noun/verb agreement, irregular punctuation, and hindered readability. (But then, what are editors for?)
A paragraph presents a well-formulated argument; one that contains only two sentences is unlikely to support the author’s assertion. Novice writers, however, often go to the other extreme, which dilutes the point. As a rule of thumb, if you can speak the entire paragraph with a single breath, the length is adequate. Reading your work aloud also helps identify hidden hazards.
3. Make connections. The result would be confusing and nonsensical. Similarly, you wouldn’t conclude your paragraph before you’ve started it. Imagine if you tried to clean out a wound after applying a dressing. The key to a good paragraph is cohesion.
If you’re scratching your head at the previous paragraph, you take my next point: All sentences within a paragraph should have a natural flow. In a well-developed paragraph, each sentence directly relates to the one before and the one after; they work together to convey your point. If the topic sentence contains an assertion, the following sentences provide supporting evidence. In medical writing, this evidence comes from citations to published literature.
If you are using the MEAL plan, you have an outline for how to support your topic sentence in a logical manner. You can then link sentences by capitalizing on words or phrases to form bridges that carry the reader through the paragraph.5 These links are created through repetition of key words or through parallel grammatical forms.
4. Pump the brakes. No one likes an abrupt stop. When you’re winding down on a paragraph, you need to signal to the reader that you’re going to shift gears. The last sentence of a paragraph should serve as a natural transition to the next paragraph.6 Equally important is the transition line at the beginning of the next paragraph.
Regardless of where the transition occurs, the goal remains to help the reader follow your logic. A subsequent paragraph can extend or refute the argument that has been presented, or it can introduce an entirely new point. No matter what, you want the reader to be prepared for a change in focus and to stay with you through your transition to a new perspective or subtopic.
On the other hand, if the argument is exhausted—it stops. When your discussion is complete, the transition to the next paragraph is very different (eg, “In summary…”). This is an appropriate time to move to a new paragraph and new section.
Speaking of a new section, let’s switch our focus to form.
5. Take action. There are two types of “voice” in communication: active, in which the subject is taking some form of action (eg, You are reading this article), and passive, in which the action is performed upon the subject (eg, This article is being read by you). Active voice is preferred for several reasons—namely, clarity and space. An active sentence identifies who is doing what. The same conclusion may be reached through a passive sentence, with some effort on the reader’s part—but active sentences tend to be more concise. They also convey a sense of immediacy, hopefully drawing the reader into your article.
6. Punctuate like a pro. Punctuation is important! It provides structure, improving clarity and comprehension. Can you fathom the confusion that would occur if an author misused (or failed to use) appropriate punctuation?
Thankfully, rules regarding punctuation have not changed much over the past century. One notable exception is use of the serial (or “Oxford”) comma, which incites passionate debate among both amateur and professional linguists.7 (For the record, this publication uses the Oxford comma. Just ask the editors: Karen, Ann, and Amy.)
A full review of punctuation is beyond the scope of this article; however, be it known that the most problematic marks—the ones to double-check in your own writing—are the apostrophe (plural or singular possessive use), the semi-colon, the comma (or lack of), and quotation marks.8 To improve your punctuation, obtain a basic grammar handbook or search online.
7. Don’t volley with verbs. Verb tense should remain consistent throughout the paragraph.9 Paragraphs with multiple verb tenses bounce the reader’s mind back and forth. It’s like watching a ping pong match, but less enjoyable.
To check for consistency, print the manuscript and mix the order of the pages. Circle the verbs. Look at the circled words and assess the tense of each. Then, repair the damage.
It is easier to identify these types of problems with a manuscript when you’re reading the pages out of order. Editors will tell you that it is difficult to focus on particulars when you are distracted by the content of the paper. Out-of-order pages are harder to read for “sense,” so you can focus on tense, voice, and punctuation.
In conclusion, I hope I’ve helped you see that writing is a process—some say a craft—but it is one that anyone can tackle with the right mindset and preparation. Most authors have a key message; they may just need help expressing it. Starting with small elements, such as the paragraph, helps the author deliver the message clearly.
Writing for publication fulfills a professional obligation to contribute to the body of knowledge. In the past decade, we’ve seen increases in the number of journals and in the number of NPs and PAs—providing more publishing opportunities and more potential authors. Yet many of my colleagues have little interest in publishing; perhaps they fear the writing process or believe they lack the skills to compose a manuscript.
How, then, do we cajole them into sharing their expertise in written form? Much has been written about why you should write.1,2 What is needed is guidance on the process to help overcome the common barriers to success in publishing. If it’s been a long time since you were in school at all—or at least since you took English Composition 101—allow me to offer a solid starting point for the journey of writing.
A manuscript, in essence, is a collection of paragraphs that follow a traditional flow. But to be sufficiently developed, paragraphs must (1) contain a main idea, (2) be structurally coherent, and (3) maintain a sense of unity around the idea.3 Once authors master the composition of a strong paragraph, the development of the manuscript comes naturally. Here are seven tips—four on content development and three on form—for compiling a manuscript worthy of publication and personal pride.
1. Start strong. Everyone understands the importance of grabbing a reader’s attention right out of the gate, right? A strong topic sentence does more than introduce the subject; it sets the tone for those that follow. A short sentence at the beginning of a paragraph establishes an understanding that a discussion will follow—and offers a preview of what the discussion will entail. But writers need not be limited; a topic sentence can take the form of a question or be placed later in the paragraph. Less experienced authors may prefer to open the paragraph with the topic sentence, however, as this allows for a quick assessment of whether the subsequent sentences follow logically. In other words, start simple—there is room to grow as you gain confidence with writing.
2. Use the MEAL plan. A paragraph should extend from the topic sentence. Collectively, the paragraph’s sentences should follow the steps outlined in the “MEAL plan,” a valuable resource conceptualized by the Duke University Thompson Writing Program.4 The “M” stands for the main topic; “E,” for the evidence that supports or refutes the topic sentence; “A,” for analysis and its importance; and “L,” for the link back to the larger claim (ie, the overall topic of the paper).
Using the MEAL approach is relatively straightforward. Picture yourself as the sender of a message; the reader is your recipient. You need to convey the information to your reader so that he or she understands it.
Limiting the number of words in a sentence and the number of sentences in a paragraph may help. Exceedingly long sentences are cumbersome and threaten to muddle the author’s message. They also pose the risk for improper noun/verb agreement, irregular punctuation, and hindered readability. (But then, what are editors for?)
A paragraph presents a well-formulated argument; one that contains only two sentences is unlikely to support the author’s assertion. Novice writers, however, often go to the other extreme, which dilutes the point. As a rule of thumb, if you can speak the entire paragraph with a single breath, the length is adequate. Reading your work aloud also helps identify hidden hazards.
3. Make connections. The result would be confusing and nonsensical. Similarly, you wouldn’t conclude your paragraph before you’ve started it. Imagine if you tried to clean out a wound after applying a dressing. The key to a good paragraph is cohesion.
If you’re scratching your head at the previous paragraph, you take my next point: All sentences within a paragraph should have a natural flow. In a well-developed paragraph, each sentence directly relates to the one before and the one after; they work together to convey your point. If the topic sentence contains an assertion, the following sentences provide supporting evidence. In medical writing, this evidence comes from citations to published literature.
If you are using the MEAL plan, you have an outline for how to support your topic sentence in a logical manner. You can then link sentences by capitalizing on words or phrases to form bridges that carry the reader through the paragraph.5 These links are created through repetition of key words or through parallel grammatical forms.
4. Pump the brakes. No one likes an abrupt stop. When you’re winding down on a paragraph, you need to signal to the reader that you’re going to shift gears. The last sentence of a paragraph should serve as a natural transition to the next paragraph.6 Equally important is the transition line at the beginning of the next paragraph.
Regardless of where the transition occurs, the goal remains to help the reader follow your logic. A subsequent paragraph can extend or refute the argument that has been presented, or it can introduce an entirely new point. No matter what, you want the reader to be prepared for a change in focus and to stay with you through your transition to a new perspective or subtopic.
On the other hand, if the argument is exhausted—it stops. When your discussion is complete, the transition to the next paragraph is very different (eg, “In summary…”). This is an appropriate time to move to a new paragraph and new section.
Speaking of a new section, let’s switch our focus to form.
5. Take action. There are two types of “voice” in communication: active, in which the subject is taking some form of action (eg, You are reading this article), and passive, in which the action is performed upon the subject (eg, This article is being read by you). Active voice is preferred for several reasons—namely, clarity and space. An active sentence identifies who is doing what. The same conclusion may be reached through a passive sentence, with some effort on the reader’s part—but active sentences tend to be more concise. They also convey a sense of immediacy, hopefully drawing the reader into your article.
6. Punctuate like a pro. Punctuation is important! It provides structure, improving clarity and comprehension. Can you fathom the confusion that would occur if an author misused (or failed to use) appropriate punctuation?
Thankfully, rules regarding punctuation have not changed much over the past century. One notable exception is use of the serial (or “Oxford”) comma, which incites passionate debate among both amateur and professional linguists.7 (For the record, this publication uses the Oxford comma. Just ask the editors: Karen, Ann, and Amy.)
A full review of punctuation is beyond the scope of this article; however, be it known that the most problematic marks—the ones to double-check in your own writing—are the apostrophe (plural or singular possessive use), the semi-colon, the comma (or lack of), and quotation marks.8 To improve your punctuation, obtain a basic grammar handbook or search online.
7. Don’t volley with verbs. Verb tense should remain consistent throughout the paragraph.9 Paragraphs with multiple verb tenses bounce the reader’s mind back and forth. It’s like watching a ping pong match, but less enjoyable.
To check for consistency, print the manuscript and mix the order of the pages. Circle the verbs. Look at the circled words and assess the tense of each. Then, repair the damage.
It is easier to identify these types of problems with a manuscript when you’re reading the pages out of order. Editors will tell you that it is difficult to focus on particulars when you are distracted by the content of the paper. Out-of-order pages are harder to read for “sense,” so you can focus on tense, voice, and punctuation.
In conclusion, I hope I’ve helped you see that writing is a process—some say a craft—but it is one that anyone can tackle with the right mindset and preparation. Most authors have a key message; they may just need help expressing it. Starting with small elements, such as the paragraph, helps the author deliver the message clearly.
1. Danielsen RD. I’d like to write a medical article, but …. Clinician Reviews. 2013;23(12):11-12.
2. Onieal ME. Be the change you wish to see. Clinician Reviews. 2015;25(7):8-9.
3. Monmouth University Tutoring and Writing Services. Paragraphs. www.monmouth.edu/uploadedFiles/Resources_for_Writers/The_Writing_Process/Paragraphs2013.pdf. Accessed June 1, 2017.
4. Duke University Thompson Writing Program. Paragraphing: The MEAL Plan. https://twp.duke.edu/sites/twp.duke.edu/files/file-attachments/meal-plan.original.pdf. Accessed June 1, 2017.
5. Purdue Online Writing Lab. On paragraphs. https://owl.english.purdue.edu/owl/resource/606/01/. Accessed June 1, 2017.
6. The Writing Center at UNC–Chapel Hill. Transitions. http://writingcenter.unc.edu/handouts/transitions/. Accessed June 1, 2017.
7. Edwards A. What is the Oxford comma and why do people care so much about it? www.grammarly.com/blog/what-is-the-oxford-comma-and-why-do-people-care-so-much-about-it/. Accessed June 1, 2017.
8. Endpaper: the Paperblanks blog. Writing Wednesday: 3 most commonly misused punctuation marks. February 1, 2017. http://blog.paperblanks.com/2017/02/writing-wednesday-3-most-commonly-misused-punctuation-marks/. Accessed June 1, 2017.
9. Towson University Online Writing Support. Verb tense consistency. https://webapps.towson.edu/ows/tenseconsistency.htm. Accessed June 1, 2017.
1. Danielsen RD. I’d like to write a medical article, but …. Clinician Reviews. 2013;23(12):11-12.
2. Onieal ME. Be the change you wish to see. Clinician Reviews. 2015;25(7):8-9.
3. Monmouth University Tutoring and Writing Services. Paragraphs. www.monmouth.edu/uploadedFiles/Resources_for_Writers/The_Writing_Process/Paragraphs2013.pdf. Accessed June 1, 2017.
4. Duke University Thompson Writing Program. Paragraphing: The MEAL Plan. https://twp.duke.edu/sites/twp.duke.edu/files/file-attachments/meal-plan.original.pdf. Accessed June 1, 2017.
5. Purdue Online Writing Lab. On paragraphs. https://owl.english.purdue.edu/owl/resource/606/01/. Accessed June 1, 2017.
6. The Writing Center at UNC–Chapel Hill. Transitions. http://writingcenter.unc.edu/handouts/transitions/. Accessed June 1, 2017.
7. Edwards A. What is the Oxford comma and why do people care so much about it? www.grammarly.com/blog/what-is-the-oxford-comma-and-why-do-people-care-so-much-about-it/. Accessed June 1, 2017.
8. Endpaper: the Paperblanks blog. Writing Wednesday: 3 most commonly misused punctuation marks. February 1, 2017. http://blog.paperblanks.com/2017/02/writing-wednesday-3-most-commonly-misused-punctuation-marks/. Accessed June 1, 2017.
9. Towson University Online Writing Support. Verb tense consistency. https://webapps.towson.edu/ows/tenseconsistency.htm. Accessed June 1, 2017.
Not so fast
If you are a busy primary care physician, wouldn’t you like to get some quick confirmation that your patient with a fever and runny nose has a viral upper respiratory infection? If there were a test or a simple physical finding that could give you the answer while the patient was still in the office, you could dispense a quick dose of reassurance and send him or her on their way. It would probably help you inch a bit closer to relieving the congestion in your waiting room.
I am sure most of you realize that relying on the patient’s temperature or the color of his or her nasal mucus is not going to give you that reliable and swift answer you would like. There have been rapid diagnostic tests for influenza on the market for several years, but I have not been aware of a similar test for rhinovirus. But I recently came across a study that offers some hope that such a test might become a reality in the future (EBioMedicine. 2017 Mar;17:172-81). In the study, researchers at Duke University and elsewhere identified a group of proteins in mucus that can confirm – with 86% accuracy – that the patient is infected with a cold or flu virus. They anticipate that this discovery could be adapted into a rapid test that could be performed in the doctor’s office.
However, I am sure that most of you would do a careful exam and spend a few minutes on a slightly more detailed discussion of what worrisome symptoms the parents should be watching for. But let’s be honest. Isn’t it likely that knowing that the patient has a rhinovirus infection might derail your diagnostic process short of a full consideration? Isn’t it tempting to say to yourself, “He only has a viral URI, and I even know the name of the virus. My job is done.”
Although the odds are that the virus is causing all your patient’s symptoms, there is always the chance that he or she is harboring a bacterial coinfection. Or, that what appears to be “only” a virus is actually an early step in the deadly spiral of the first episode of diabetic ketoacidosis.
This quandary is another example of the paradox in which more information can make your job as a diagnostician more difficult. Does your patient’s positive rapid strep test mean that strep is the primary cause of your patient’s fever and sore throat? Couldn’t he or she just be a carrier? Should a positive test that confirms your clinical impression put an end to your evaluation of the patient?
You could answer that you don’t have the time to go looking for zebra stripes hidden on the underbelly of every equine that gallops into your exam room. Of course you don’t. But, you are obligated to keep your mind open to the possibility that a lab test promising to make your job easy may not be telling you the whole story.
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].
If you are a busy primary care physician, wouldn’t you like to get some quick confirmation that your patient with a fever and runny nose has a viral upper respiratory infection? If there were a test or a simple physical finding that could give you the answer while the patient was still in the office, you could dispense a quick dose of reassurance and send him or her on their way. It would probably help you inch a bit closer to relieving the congestion in your waiting room.
I am sure most of you realize that relying on the patient’s temperature or the color of his or her nasal mucus is not going to give you that reliable and swift answer you would like. There have been rapid diagnostic tests for influenza on the market for several years, but I have not been aware of a similar test for rhinovirus. But I recently came across a study that offers some hope that such a test might become a reality in the future (EBioMedicine. 2017 Mar;17:172-81). In the study, researchers at Duke University and elsewhere identified a group of proteins in mucus that can confirm – with 86% accuracy – that the patient is infected with a cold or flu virus. They anticipate that this discovery could be adapted into a rapid test that could be performed in the doctor’s office.
However, I am sure that most of you would do a careful exam and spend a few minutes on a slightly more detailed discussion of what worrisome symptoms the parents should be watching for. But let’s be honest. Isn’t it likely that knowing that the patient has a rhinovirus infection might derail your diagnostic process short of a full consideration? Isn’t it tempting to say to yourself, “He only has a viral URI, and I even know the name of the virus. My job is done.”
Although the odds are that the virus is causing all your patient’s symptoms, there is always the chance that he or she is harboring a bacterial coinfection. Or, that what appears to be “only” a virus is actually an early step in the deadly spiral of the first episode of diabetic ketoacidosis.
This quandary is another example of the paradox in which more information can make your job as a diagnostician more difficult. Does your patient’s positive rapid strep test mean that strep is the primary cause of your patient’s fever and sore throat? Couldn’t he or she just be a carrier? Should a positive test that confirms your clinical impression put an end to your evaluation of the patient?
You could answer that you don’t have the time to go looking for zebra stripes hidden on the underbelly of every equine that gallops into your exam room. Of course you don’t. But, you are obligated to keep your mind open to the possibility that a lab test promising to make your job easy may not be telling you the whole story.
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].
If you are a busy primary care physician, wouldn’t you like to get some quick confirmation that your patient with a fever and runny nose has a viral upper respiratory infection? If there were a test or a simple physical finding that could give you the answer while the patient was still in the office, you could dispense a quick dose of reassurance and send him or her on their way. It would probably help you inch a bit closer to relieving the congestion in your waiting room.
I am sure most of you realize that relying on the patient’s temperature or the color of his or her nasal mucus is not going to give you that reliable and swift answer you would like. There have been rapid diagnostic tests for influenza on the market for several years, but I have not been aware of a similar test for rhinovirus. But I recently came across a study that offers some hope that such a test might become a reality in the future (EBioMedicine. 2017 Mar;17:172-81). In the study, researchers at Duke University and elsewhere identified a group of proteins in mucus that can confirm – with 86% accuracy – that the patient is infected with a cold or flu virus. They anticipate that this discovery could be adapted into a rapid test that could be performed in the doctor’s office.
However, I am sure that most of you would do a careful exam and spend a few minutes on a slightly more detailed discussion of what worrisome symptoms the parents should be watching for. But let’s be honest. Isn’t it likely that knowing that the patient has a rhinovirus infection might derail your diagnostic process short of a full consideration? Isn’t it tempting to say to yourself, “He only has a viral URI, and I even know the name of the virus. My job is done.”
Although the odds are that the virus is causing all your patient’s symptoms, there is always the chance that he or she is harboring a bacterial coinfection. Or, that what appears to be “only” a virus is actually an early step in the deadly spiral of the first episode of diabetic ketoacidosis.
This quandary is another example of the paradox in which more information can make your job as a diagnostician more difficult. Does your patient’s positive rapid strep test mean that strep is the primary cause of your patient’s fever and sore throat? Couldn’t he or she just be a carrier? Should a positive test that confirms your clinical impression put an end to your evaluation of the patient?
You could answer that you don’t have the time to go looking for zebra stripes hidden on the underbelly of every equine that gallops into your exam room. Of course you don’t. But, you are obligated to keep your mind open to the possibility that a lab test promising to make your job easy may not be telling you the whole story.
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].
Letter from the Editor: Brace yourself, but have a nice summer
By the time this column appears in print we will know whether the US Senate passed a version of the GOP health care bill. If so, millions of our patients will be at risk of losing insurance coverage in the name of tax and deficit reduction. I refer you to an article I wrote for the June issue of Clinical Gastroenterology and Hepatology about the potential transition from Obamacare to Trumpcare.
Our “Flashback” article this month concerns another long-running Congressional issue: repeal of the Sustainable Growth Rate and implementation of value-based reimbursement. We thank Dr. Larry Kosinski for his commentary and for successfully creating the first GI-specific alternative payment model to be endorsed by CMS.
John I. Allen, MD, MBA, AGAF, FACP
Editor in Chief
By the time this column appears in print we will know whether the US Senate passed a version of the GOP health care bill. If so, millions of our patients will be at risk of losing insurance coverage in the name of tax and deficit reduction. I refer you to an article I wrote for the June issue of Clinical Gastroenterology and Hepatology about the potential transition from Obamacare to Trumpcare.
Our “Flashback” article this month concerns another long-running Congressional issue: repeal of the Sustainable Growth Rate and implementation of value-based reimbursement. We thank Dr. Larry Kosinski for his commentary and for successfully creating the first GI-specific alternative payment model to be endorsed by CMS.
John I. Allen, MD, MBA, AGAF, FACP
Editor in Chief
By the time this column appears in print we will know whether the US Senate passed a version of the GOP health care bill. If so, millions of our patients will be at risk of losing insurance coverage in the name of tax and deficit reduction. I refer you to an article I wrote for the June issue of Clinical Gastroenterology and Hepatology about the potential transition from Obamacare to Trumpcare.
Our “Flashback” article this month concerns another long-running Congressional issue: repeal of the Sustainable Growth Rate and implementation of value-based reimbursement. We thank Dr. Larry Kosinski for his commentary and for successfully creating the first GI-specific alternative payment model to be endorsed by CMS.
John I. Allen, MD, MBA, AGAF, FACP
Editor in Chief
What stops physicians from getting mental health care?
Physician burnout is rampant, and every seat was taken at a workshop on physician burnout and depression at this year’s APA annual meeting in San Diego.
In his book, “Why Physicians Die By Suicide” (Amazon, 2017), Michael F. Myers, MD, describes “burnout.”
Myers notes that there is no stigma to having burnout, as there is to having major depression – a condition that may have remarkably similar symptoms.
What stops physicians from getting help? It’s a complex question – especially in a group that has the means to access medical services – but one factor is that most state licensing boards specifically ask about mental illnesses and substance abuse in intrusive and stigmatizing ways. States vary both with their questions and with their responses to a box checked “yes.”
Katherine Gold, MD, MSW, MS, a family physician at the University of Michigan, Ann Arbor, has studied the topic extensively. Her review of licensing questions from all 50 states revealed that most states ask for information about mental health, and there is tremendous variation as to what is asked (Fam Med. 2017 Jun;49[6]:464-7).
“Some states are very specific and very intrusive,” Gold noted. “They may ask if a physician has a specific diagnosis, a history of treatment or hospitalization. The questions may ask about current impairment, or they may ask about mental health conditions back to age 18 years. There may be very specific questions about diagnosis that are not asked about medical conditions, such as whether the applicant has kleptomania, pyromania, or seasonal affective disorder.”
Gold conducted an online survey of physician-mothers. Nearly half believed they had met criteria for an episode of mental illness at some point during their lives. Of those who did have a diagnosis, only 6% of physicians reported this on licensing forms, though she was quick to say that not all states ask for this information, and some may just ask about current impairment. “The people who are self-disclosing are probably not the physicians we need to be worrying about,” she said.
There is no research that supports the idea that asking physicians about mental illness improves patient safety. Not every state licensing board asks about psychiatric history, but many do ask these questions in a way that violates the Americans with Disabilities Act (Acad Med. 2009;84[6]:776-81). This is not a new issue: In 1993, The State Medical Society of New Jersey filed an injunction against the New Jersey medical board (Medical Society vs. Jacobs et al.) and questions asked on the licensing forms were changed.
Dr. Gold noted that if a physician checks yes to a question about a mental health history, the board response also varies. The doctor can be asked to provide a letter from his physician stating he is fit to work, or can be required to release all of his psychiatric record, or even to appear before the board to justify his fitness to practice.
Chae Kwak, LCSW-C, is the director of the Maryland Physician Health Program for Maryland MedChi. In the fall 2016 Board of Physicians newsletter, Kwak wrote, “An applicant has to affirmatively answer this question only if a current condition affects their ability to practice medicine. Diagnosis and/or treatment of mental health issues such as depression or anxiety is not the same as ‘impairment’ in the practice of medicine.”
Kwak was pleased that the board published his letter. “We want physicians to get the help they need. But this is not just about licensing boards, it’s an issue with hospital credentialing and applications for malpractice insurance as well.”
“We need to advocate on the level of the Federation of State Medical Boards on this subject, and there is a sense of increasing awareness that this is a problem, said Richard Summers, MD, who cochaired the American Psychiatric Association workshop on physician burnout and depression. “The increased salience and awareness of physician burnout, and its relationship to stigma might help this organization and the various state boards become more sympathetic and open to questioning the stigmatizing element of their questions. So, we’ve got to work on this situation both nationally and at the level of the state boards. Hopefully, some successes will stimulate others and will begin to help to change the culture of secrecy and shame.”
Nathaniel Morris, MD, is doing his psychiatry residency at Stanford (Calif.) University. He wrote about this issue in a Washington Post article, “Why doctors are leery about seeking mental health care for themselves” (Jan. 7, 2017). Morris wrote, “When I was a medical student, I suffered an episode of depression and refused to seek treatment for weeks. My fears about licensing applications were a major reason I kept quiet. I didn’t want a mark on my record. I didn’t want to check “yes” on those forms.”
Questions about mental health on licensing board applications were recently addressed by the American Medical Association’s House of Delegates meeting as part of Resolution 301. The AMA concluded with a suggestion that state medical boards inquire about mental health and physical health in a similar way and went on to suggest that boards not request psychotherapy records if the psychotherapy were a requirement of training. This is a profoundly disappointing and inadequate response from the AMA, and my hope is that the APA will move ahead with both words and actions that condemn stigmatizing inquiries.
Questions that differentiate other medical disabilities from psychiatric disabilities need to be stricken from licensing and credentialing forms. Our treatments work, and the cost of not getting care can be catastrophic for both physicians and for their patients. Why ask intrusive and detailed questions about mental illness or substance abuse, and not about diabetes control, seizures, hypotension, atrial fibrillation, or any illness that may cause impairment? It would seem enough to simply ask if the applicant suffers from any condition that impairs ability to function as a physician. Furthermore, it is unreasonable to ask for a full release of psychiatric records following an affirmative statement if detailed records of other illnesses are not required to confirm competency to practice and may prevent psychiatrists from being honest with their therapists. Self-report has limited value on applications, and questions about past sanctions, employment history, and criminal records are more likely to identify physicians who are impaired for any reason.
Dr. Miller, who practices in Baltimore, is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016).
Physician burnout is rampant, and every seat was taken at a workshop on physician burnout and depression at this year’s APA annual meeting in San Diego.
In his book, “Why Physicians Die By Suicide” (Amazon, 2017), Michael F. Myers, MD, describes “burnout.”
Myers notes that there is no stigma to having burnout, as there is to having major depression – a condition that may have remarkably similar symptoms.
What stops physicians from getting help? It’s a complex question – especially in a group that has the means to access medical services – but one factor is that most state licensing boards specifically ask about mental illnesses and substance abuse in intrusive and stigmatizing ways. States vary both with their questions and with their responses to a box checked “yes.”
Katherine Gold, MD, MSW, MS, a family physician at the University of Michigan, Ann Arbor, has studied the topic extensively. Her review of licensing questions from all 50 states revealed that most states ask for information about mental health, and there is tremendous variation as to what is asked (Fam Med. 2017 Jun;49[6]:464-7).
“Some states are very specific and very intrusive,” Gold noted. “They may ask if a physician has a specific diagnosis, a history of treatment or hospitalization. The questions may ask about current impairment, or they may ask about mental health conditions back to age 18 years. There may be very specific questions about diagnosis that are not asked about medical conditions, such as whether the applicant has kleptomania, pyromania, or seasonal affective disorder.”
Gold conducted an online survey of physician-mothers. Nearly half believed they had met criteria for an episode of mental illness at some point during their lives. Of those who did have a diagnosis, only 6% of physicians reported this on licensing forms, though she was quick to say that not all states ask for this information, and some may just ask about current impairment. “The people who are self-disclosing are probably not the physicians we need to be worrying about,” she said.
There is no research that supports the idea that asking physicians about mental illness improves patient safety. Not every state licensing board asks about psychiatric history, but many do ask these questions in a way that violates the Americans with Disabilities Act (Acad Med. 2009;84[6]:776-81). This is not a new issue: In 1993, The State Medical Society of New Jersey filed an injunction against the New Jersey medical board (Medical Society vs. Jacobs et al.) and questions asked on the licensing forms were changed.
Dr. Gold noted that if a physician checks yes to a question about a mental health history, the board response also varies. The doctor can be asked to provide a letter from his physician stating he is fit to work, or can be required to release all of his psychiatric record, or even to appear before the board to justify his fitness to practice.
Chae Kwak, LCSW-C, is the director of the Maryland Physician Health Program for Maryland MedChi. In the fall 2016 Board of Physicians newsletter, Kwak wrote, “An applicant has to affirmatively answer this question only if a current condition affects their ability to practice medicine. Diagnosis and/or treatment of mental health issues such as depression or anxiety is not the same as ‘impairment’ in the practice of medicine.”
Kwak was pleased that the board published his letter. “We want physicians to get the help they need. But this is not just about licensing boards, it’s an issue with hospital credentialing and applications for malpractice insurance as well.”
“We need to advocate on the level of the Federation of State Medical Boards on this subject, and there is a sense of increasing awareness that this is a problem, said Richard Summers, MD, who cochaired the American Psychiatric Association workshop on physician burnout and depression. “The increased salience and awareness of physician burnout, and its relationship to stigma might help this organization and the various state boards become more sympathetic and open to questioning the stigmatizing element of their questions. So, we’ve got to work on this situation both nationally and at the level of the state boards. Hopefully, some successes will stimulate others and will begin to help to change the culture of secrecy and shame.”
Nathaniel Morris, MD, is doing his psychiatry residency at Stanford (Calif.) University. He wrote about this issue in a Washington Post article, “Why doctors are leery about seeking mental health care for themselves” (Jan. 7, 2017). Morris wrote, “When I was a medical student, I suffered an episode of depression and refused to seek treatment for weeks. My fears about licensing applications were a major reason I kept quiet. I didn’t want a mark on my record. I didn’t want to check “yes” on those forms.”
Questions about mental health on licensing board applications were recently addressed by the American Medical Association’s House of Delegates meeting as part of Resolution 301. The AMA concluded with a suggestion that state medical boards inquire about mental health and physical health in a similar way and went on to suggest that boards not request psychotherapy records if the psychotherapy were a requirement of training. This is a profoundly disappointing and inadequate response from the AMA, and my hope is that the APA will move ahead with both words and actions that condemn stigmatizing inquiries.
Questions that differentiate other medical disabilities from psychiatric disabilities need to be stricken from licensing and credentialing forms. Our treatments work, and the cost of not getting care can be catastrophic for both physicians and for their patients. Why ask intrusive and detailed questions about mental illness or substance abuse, and not about diabetes control, seizures, hypotension, atrial fibrillation, or any illness that may cause impairment? It would seem enough to simply ask if the applicant suffers from any condition that impairs ability to function as a physician. Furthermore, it is unreasonable to ask for a full release of psychiatric records following an affirmative statement if detailed records of other illnesses are not required to confirm competency to practice and may prevent psychiatrists from being honest with their therapists. Self-report has limited value on applications, and questions about past sanctions, employment history, and criminal records are more likely to identify physicians who are impaired for any reason.
Dr. Miller, who practices in Baltimore, is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016).
Physician burnout is rampant, and every seat was taken at a workshop on physician burnout and depression at this year’s APA annual meeting in San Diego.
In his book, “Why Physicians Die By Suicide” (Amazon, 2017), Michael F. Myers, MD, describes “burnout.”
Myers notes that there is no stigma to having burnout, as there is to having major depression – a condition that may have remarkably similar symptoms.
What stops physicians from getting help? It’s a complex question – especially in a group that has the means to access medical services – but one factor is that most state licensing boards specifically ask about mental illnesses and substance abuse in intrusive and stigmatizing ways. States vary both with their questions and with their responses to a box checked “yes.”
Katherine Gold, MD, MSW, MS, a family physician at the University of Michigan, Ann Arbor, has studied the topic extensively. Her review of licensing questions from all 50 states revealed that most states ask for information about mental health, and there is tremendous variation as to what is asked (Fam Med. 2017 Jun;49[6]:464-7).
“Some states are very specific and very intrusive,” Gold noted. “They may ask if a physician has a specific diagnosis, a history of treatment or hospitalization. The questions may ask about current impairment, or they may ask about mental health conditions back to age 18 years. There may be very specific questions about diagnosis that are not asked about medical conditions, such as whether the applicant has kleptomania, pyromania, or seasonal affective disorder.”
Gold conducted an online survey of physician-mothers. Nearly half believed they had met criteria for an episode of mental illness at some point during their lives. Of those who did have a diagnosis, only 6% of physicians reported this on licensing forms, though she was quick to say that not all states ask for this information, and some may just ask about current impairment. “The people who are self-disclosing are probably not the physicians we need to be worrying about,” she said.
There is no research that supports the idea that asking physicians about mental illness improves patient safety. Not every state licensing board asks about psychiatric history, but many do ask these questions in a way that violates the Americans with Disabilities Act (Acad Med. 2009;84[6]:776-81). This is not a new issue: In 1993, The State Medical Society of New Jersey filed an injunction against the New Jersey medical board (Medical Society vs. Jacobs et al.) and questions asked on the licensing forms were changed.
Dr. Gold noted that if a physician checks yes to a question about a mental health history, the board response also varies. The doctor can be asked to provide a letter from his physician stating he is fit to work, or can be required to release all of his psychiatric record, or even to appear before the board to justify his fitness to practice.
Chae Kwak, LCSW-C, is the director of the Maryland Physician Health Program for Maryland MedChi. In the fall 2016 Board of Physicians newsletter, Kwak wrote, “An applicant has to affirmatively answer this question only if a current condition affects their ability to practice medicine. Diagnosis and/or treatment of mental health issues such as depression or anxiety is not the same as ‘impairment’ in the practice of medicine.”
Kwak was pleased that the board published his letter. “We want physicians to get the help they need. But this is not just about licensing boards, it’s an issue with hospital credentialing and applications for malpractice insurance as well.”
“We need to advocate on the level of the Federation of State Medical Boards on this subject, and there is a sense of increasing awareness that this is a problem, said Richard Summers, MD, who cochaired the American Psychiatric Association workshop on physician burnout and depression. “The increased salience and awareness of physician burnout, and its relationship to stigma might help this organization and the various state boards become more sympathetic and open to questioning the stigmatizing element of their questions. So, we’ve got to work on this situation both nationally and at the level of the state boards. Hopefully, some successes will stimulate others and will begin to help to change the culture of secrecy and shame.”
Nathaniel Morris, MD, is doing his psychiatry residency at Stanford (Calif.) University. He wrote about this issue in a Washington Post article, “Why doctors are leery about seeking mental health care for themselves” (Jan. 7, 2017). Morris wrote, “When I was a medical student, I suffered an episode of depression and refused to seek treatment for weeks. My fears about licensing applications were a major reason I kept quiet. I didn’t want a mark on my record. I didn’t want to check “yes” on those forms.”
Questions about mental health on licensing board applications were recently addressed by the American Medical Association’s House of Delegates meeting as part of Resolution 301. The AMA concluded with a suggestion that state medical boards inquire about mental health and physical health in a similar way and went on to suggest that boards not request psychotherapy records if the psychotherapy were a requirement of training. This is a profoundly disappointing and inadequate response from the AMA, and my hope is that the APA will move ahead with both words and actions that condemn stigmatizing inquiries.
Questions that differentiate other medical disabilities from psychiatric disabilities need to be stricken from licensing and credentialing forms. Our treatments work, and the cost of not getting care can be catastrophic for both physicians and for their patients. Why ask intrusive and detailed questions about mental illness or substance abuse, and not about diabetes control, seizures, hypotension, atrial fibrillation, or any illness that may cause impairment? It would seem enough to simply ask if the applicant suffers from any condition that impairs ability to function as a physician. Furthermore, it is unreasonable to ask for a full release of psychiatric records following an affirmative statement if detailed records of other illnesses are not required to confirm competency to practice and may prevent psychiatrists from being honest with their therapists. Self-report has limited value on applications, and questions about past sanctions, employment history, and criminal records are more likely to identify physicians who are impaired for any reason.
Dr. Miller, who practices in Baltimore, is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016).
How would you handle predictions of Alzheimer’s disease?
We love to try and predict the future. Some of it is scientific, like checking the weather forecast to see what we’re in for. (Here in Phoenix, it’s always hot, hotter, or melting.)
On the other hand, some of it is just for entertainment, like checking a horoscope or seeing what a fortune cookie says.
The breakthroughs in biomarkers for Alzheimer’s disease are accelerating. Although still experimental, we’re getting pretty close to predicting the disease many years before it develops. At the same time, we aren’t nearly as close to a treatment that will have a meaningful impact on the course of the disease.
In 1993, the genetic marker for Huntington’s disease was identified, quickly leading to a blood test with high accuracy to know if you were – or were not – going to develop the fatal disorder down the road.
Some wanted to know and used the information to decide if they wanted to have families. Others, understandably fearful, decided not to and let their lives play out as they will. Sadly, either way we have nothing close to a cure for the disease.
Now, we come to Alzheimer’s disease, many times more common than Huntington’s. Close to predicting its coming and not really close to a cure.
What would you do?
[polldaddy:9778279]
In “Back to the Future,” Doc Brown said “no man should know too much about their own destiny” (though later changed his mind). But, for Doc Brown, a bulletproof vest was all he needed. In Alzheimer’s disease, it’s not that simple.
I’m sure some would see it as a way to have their affairs in order long in advance, to spare themselves and their loved ones the frantic scramble that often comes after a diagnosis. Others would be afraid to know what the future holds, with every misplaced set of keys or iPhone becoming a reason to panic.
Obviously, if we had a true cure for the disorder, the decision would be easy. Then, it becomes a preventive measure in the same category as mammograms and colonoscopies. Early detection saves lives.
What would you do? And how will you guide the patients who ask your opinion?
For better or worse, these questions are coming. All of us need to think about how we’ll handle them.
Dr. Block has a solo neurology private practice in Scottsdale, Ariz.
We love to try and predict the future. Some of it is scientific, like checking the weather forecast to see what we’re in for. (Here in Phoenix, it’s always hot, hotter, or melting.)
On the other hand, some of it is just for entertainment, like checking a horoscope or seeing what a fortune cookie says.
The breakthroughs in biomarkers for Alzheimer’s disease are accelerating. Although still experimental, we’re getting pretty close to predicting the disease many years before it develops. At the same time, we aren’t nearly as close to a treatment that will have a meaningful impact on the course of the disease.
In 1993, the genetic marker for Huntington’s disease was identified, quickly leading to a blood test with high accuracy to know if you were – or were not – going to develop the fatal disorder down the road.
Some wanted to know and used the information to decide if they wanted to have families. Others, understandably fearful, decided not to and let their lives play out as they will. Sadly, either way we have nothing close to a cure for the disease.
Now, we come to Alzheimer’s disease, many times more common than Huntington’s. Close to predicting its coming and not really close to a cure.
What would you do?
[polldaddy:9778279]
In “Back to the Future,” Doc Brown said “no man should know too much about their own destiny” (though later changed his mind). But, for Doc Brown, a bulletproof vest was all he needed. In Alzheimer’s disease, it’s not that simple.
I’m sure some would see it as a way to have their affairs in order long in advance, to spare themselves and their loved ones the frantic scramble that often comes after a diagnosis. Others would be afraid to know what the future holds, with every misplaced set of keys or iPhone becoming a reason to panic.
Obviously, if we had a true cure for the disorder, the decision would be easy. Then, it becomes a preventive measure in the same category as mammograms and colonoscopies. Early detection saves lives.
What would you do? And how will you guide the patients who ask your opinion?
For better or worse, these questions are coming. All of us need to think about how we’ll handle them.
Dr. Block has a solo neurology private practice in Scottsdale, Ariz.
We love to try and predict the future. Some of it is scientific, like checking the weather forecast to see what we’re in for. (Here in Phoenix, it’s always hot, hotter, or melting.)
On the other hand, some of it is just for entertainment, like checking a horoscope or seeing what a fortune cookie says.
The breakthroughs in biomarkers for Alzheimer’s disease are accelerating. Although still experimental, we’re getting pretty close to predicting the disease many years before it develops. At the same time, we aren’t nearly as close to a treatment that will have a meaningful impact on the course of the disease.
In 1993, the genetic marker for Huntington’s disease was identified, quickly leading to a blood test with high accuracy to know if you were – or were not – going to develop the fatal disorder down the road.
Some wanted to know and used the information to decide if they wanted to have families. Others, understandably fearful, decided not to and let their lives play out as they will. Sadly, either way we have nothing close to a cure for the disease.
Now, we come to Alzheimer’s disease, many times more common than Huntington’s. Close to predicting its coming and not really close to a cure.
What would you do?
[polldaddy:9778279]
In “Back to the Future,” Doc Brown said “no man should know too much about their own destiny” (though later changed his mind). But, for Doc Brown, a bulletproof vest was all he needed. In Alzheimer’s disease, it’s not that simple.
I’m sure some would see it as a way to have their affairs in order long in advance, to spare themselves and their loved ones the frantic scramble that often comes after a diagnosis. Others would be afraid to know what the future holds, with every misplaced set of keys or iPhone becoming a reason to panic.
Obviously, if we had a true cure for the disorder, the decision would be easy. Then, it becomes a preventive measure in the same category as mammograms and colonoscopies. Early detection saves lives.
What would you do? And how will you guide the patients who ask your opinion?
For better or worse, these questions are coming. All of us need to think about how we’ll handle them.
Dr. Block has a solo neurology private practice in Scottsdale, Ariz.
Nocturia and sleep apnea
Author’s note: I have been writing “Myth of the Month” columns for the last several years. I will try to continue to write about myths when possible, but I would like to introduce a new column, “Pearl of the Month.” I want to share with you pearls that I have found really helpful in medical practice. Some of these will be new news, while some may be old news that may not be well known.
A 65-year-old man comes to a clinic concerned about frequent nocturia. He is getting up four times a night to urinate, and he has been urinating about every 5 hours during the day. He has been seen twice for this problem and was diagnosed with benign prostatic hyperplasia and started on tamsulosin.
He found a slight improvement when he started on 0.4 mg qhs, reducing his nocturia episodes from four to three. His dose was increased to 0.8 mg qhs, with no improvement in nocturia.
Exam today: BP, 140/94; pulse, 70. Rectal exam: Prostate is twice normal size without nodules. Labs: Na, 140; K, 4.0; glucose, 80; Ca, 9.6.
He is frustrated because he feels tired and sleepy from having to get up so often to urinate every night.
What is the best treatment/advice at this point?
A. Check hemoglobin A1C.
B. Start finasteride.
C. Switch tamsulosin to terazosin.
D. Evaluate for sleep apnea.
Umpei Yamamoto, MD, of Kyushu University Hospital, Japan, and colleagues studied the prevalence of sleep-disordered breathing among patients who presented to a urology clinic with nocturia and in those who visited a sleep apnea clinic with symptoms of excessive daytime sleepiness.1 Sleep-disordered breathing was found in 91% of the patients from the sleep apnea clinic and 70% of the patients from the urology clinic. The frequency of nocturia was reduced with continuous positive airway pressure (CPAP) in both groups in the patients who had not responded to conventional therapy or nocturia.
The symptom of nocturia as a symptom of sleep apnea might be even more common in women.2 Ozen K. Basoglu, MD, and Mehmet Sezai Tasbakan, MD, of Ege University, Izmir, Turkey, described clinical similarities and differences based on gender in a large group of patients with sleep apnea. Both men and women with sleep apnea had similar rates of excessive daytime sleepiness, snoring, and impaired concentration. Women had more frequent nocturia.
Nocturia especially should be considered a possible clue for the presence of sleep apnea in younger patients who have fewer other reasons to have nocturia. Takahiro Maeda, MD, of Keio University, Tokyo, and colleagues found that men younger than 50 years had more nocturnal urinations the worse their apnea-hypopnea index was.3 Overall in the study, 85% of the patients had a reduction in nighttime urination after CPAP therapy.
Treatment of sleep apnea has been shown in several studies to improve the nocturia that occurs in patients with sleep apnea. Hyoung Keun Park, MD, of Konkuk University, Seoul, and colleagues studied whether surgical intervention with uvulopalatopharyngoplasty (UPPP) reduced nocturia in patients with sleep apnea.4 In the study, there was a 73% success rate in treatment for sleep apnea with the UPPP surgery, and, among those who had successful surgeries, nocturia episodes decreased from 1.9 preoperatively to 0.7 postoperatively (P less than .001).
Minoru Miyazato, MD, PhD, of University of the Ryukyus, Okinawa, Japan, and colleagues looked at the effect of CPAP treatment on nighttime urine production in patients with obstructive sleep apnea.5 In this small study of 40 patients, mean nighttime voiding episodes decreased from 2.1 to 1.2 (P less than .01).
Pearl: Sleep apnea should be considered in the differential diagnosis of patients with nocturia, and treatment of sleep apnea may decrease nocturia.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
References
1. Intern Med. 2016;55(8):901-5.
2. Sleep Breath. 2017 Feb 14. doi: 10.1007/s11325-017-1482-9.
3. Can Urol Assoc J. 2016 Jul-Aug;10(7-8):E241-5.
4. Int Neurourol J. 2016 Dec;20(4):329-34.
5. Neurourol Urodyn. 2017 Feb;36(2):376-9.
Author’s note: I have been writing “Myth of the Month” columns for the last several years. I will try to continue to write about myths when possible, but I would like to introduce a new column, “Pearl of the Month.” I want to share with you pearls that I have found really helpful in medical practice. Some of these will be new news, while some may be old news that may not be well known.
A 65-year-old man comes to a clinic concerned about frequent nocturia. He is getting up four times a night to urinate, and he has been urinating about every 5 hours during the day. He has been seen twice for this problem and was diagnosed with benign prostatic hyperplasia and started on tamsulosin.
He found a slight improvement when he started on 0.4 mg qhs, reducing his nocturia episodes from four to three. His dose was increased to 0.8 mg qhs, with no improvement in nocturia.
Exam today: BP, 140/94; pulse, 70. Rectal exam: Prostate is twice normal size without nodules. Labs: Na, 140; K, 4.0; glucose, 80; Ca, 9.6.
He is frustrated because he feels tired and sleepy from having to get up so often to urinate every night.
What is the best treatment/advice at this point?
A. Check hemoglobin A1C.
B. Start finasteride.
C. Switch tamsulosin to terazosin.
D. Evaluate for sleep apnea.
Umpei Yamamoto, MD, of Kyushu University Hospital, Japan, and colleagues studied the prevalence of sleep-disordered breathing among patients who presented to a urology clinic with nocturia and in those who visited a sleep apnea clinic with symptoms of excessive daytime sleepiness.1 Sleep-disordered breathing was found in 91% of the patients from the sleep apnea clinic and 70% of the patients from the urology clinic. The frequency of nocturia was reduced with continuous positive airway pressure (CPAP) in both groups in the patients who had not responded to conventional therapy or nocturia.
The symptom of nocturia as a symptom of sleep apnea might be even more common in women.2 Ozen K. Basoglu, MD, and Mehmet Sezai Tasbakan, MD, of Ege University, Izmir, Turkey, described clinical similarities and differences based on gender in a large group of patients with sleep apnea. Both men and women with sleep apnea had similar rates of excessive daytime sleepiness, snoring, and impaired concentration. Women had more frequent nocturia.
Nocturia especially should be considered a possible clue for the presence of sleep apnea in younger patients who have fewer other reasons to have nocturia. Takahiro Maeda, MD, of Keio University, Tokyo, and colleagues found that men younger than 50 years had more nocturnal urinations the worse their apnea-hypopnea index was.3 Overall in the study, 85% of the patients had a reduction in nighttime urination after CPAP therapy.
Treatment of sleep apnea has been shown in several studies to improve the nocturia that occurs in patients with sleep apnea. Hyoung Keun Park, MD, of Konkuk University, Seoul, and colleagues studied whether surgical intervention with uvulopalatopharyngoplasty (UPPP) reduced nocturia in patients with sleep apnea.4 In the study, there was a 73% success rate in treatment for sleep apnea with the UPPP surgery, and, among those who had successful surgeries, nocturia episodes decreased from 1.9 preoperatively to 0.7 postoperatively (P less than .001).
Minoru Miyazato, MD, PhD, of University of the Ryukyus, Okinawa, Japan, and colleagues looked at the effect of CPAP treatment on nighttime urine production in patients with obstructive sleep apnea.5 In this small study of 40 patients, mean nighttime voiding episodes decreased from 2.1 to 1.2 (P less than .01).
Pearl: Sleep apnea should be considered in the differential diagnosis of patients with nocturia, and treatment of sleep apnea may decrease nocturia.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
References
1. Intern Med. 2016;55(8):901-5.
2. Sleep Breath. 2017 Feb 14. doi: 10.1007/s11325-017-1482-9.
3. Can Urol Assoc J. 2016 Jul-Aug;10(7-8):E241-5.
4. Int Neurourol J. 2016 Dec;20(4):329-34.
5. Neurourol Urodyn. 2017 Feb;36(2):376-9.
Author’s note: I have been writing “Myth of the Month” columns for the last several years. I will try to continue to write about myths when possible, but I would like to introduce a new column, “Pearl of the Month.” I want to share with you pearls that I have found really helpful in medical practice. Some of these will be new news, while some may be old news that may not be well known.
A 65-year-old man comes to a clinic concerned about frequent nocturia. He is getting up four times a night to urinate, and he has been urinating about every 5 hours during the day. He has been seen twice for this problem and was diagnosed with benign prostatic hyperplasia and started on tamsulosin.
He found a slight improvement when he started on 0.4 mg qhs, reducing his nocturia episodes from four to three. His dose was increased to 0.8 mg qhs, with no improvement in nocturia.
Exam today: BP, 140/94; pulse, 70. Rectal exam: Prostate is twice normal size without nodules. Labs: Na, 140; K, 4.0; glucose, 80; Ca, 9.6.
He is frustrated because he feels tired and sleepy from having to get up so often to urinate every night.
What is the best treatment/advice at this point?
A. Check hemoglobin A1C.
B. Start finasteride.
C. Switch tamsulosin to terazosin.
D. Evaluate for sleep apnea.
Umpei Yamamoto, MD, of Kyushu University Hospital, Japan, and colleagues studied the prevalence of sleep-disordered breathing among patients who presented to a urology clinic with nocturia and in those who visited a sleep apnea clinic with symptoms of excessive daytime sleepiness.1 Sleep-disordered breathing was found in 91% of the patients from the sleep apnea clinic and 70% of the patients from the urology clinic. The frequency of nocturia was reduced with continuous positive airway pressure (CPAP) in both groups in the patients who had not responded to conventional therapy or nocturia.
The symptom of nocturia as a symptom of sleep apnea might be even more common in women.2 Ozen K. Basoglu, MD, and Mehmet Sezai Tasbakan, MD, of Ege University, Izmir, Turkey, described clinical similarities and differences based on gender in a large group of patients with sleep apnea. Both men and women with sleep apnea had similar rates of excessive daytime sleepiness, snoring, and impaired concentration. Women had more frequent nocturia.
Nocturia especially should be considered a possible clue for the presence of sleep apnea in younger patients who have fewer other reasons to have nocturia. Takahiro Maeda, MD, of Keio University, Tokyo, and colleagues found that men younger than 50 years had more nocturnal urinations the worse their apnea-hypopnea index was.3 Overall in the study, 85% of the patients had a reduction in nighttime urination after CPAP therapy.
Treatment of sleep apnea has been shown in several studies to improve the nocturia that occurs in patients with sleep apnea. Hyoung Keun Park, MD, of Konkuk University, Seoul, and colleagues studied whether surgical intervention with uvulopalatopharyngoplasty (UPPP) reduced nocturia in patients with sleep apnea.4 In the study, there was a 73% success rate in treatment for sleep apnea with the UPPP surgery, and, among those who had successful surgeries, nocturia episodes decreased from 1.9 preoperatively to 0.7 postoperatively (P less than .001).
Minoru Miyazato, MD, PhD, of University of the Ryukyus, Okinawa, Japan, and colleagues looked at the effect of CPAP treatment on nighttime urine production in patients with obstructive sleep apnea.5 In this small study of 40 patients, mean nighttime voiding episodes decreased from 2.1 to 1.2 (P less than .01).
Pearl: Sleep apnea should be considered in the differential diagnosis of patients with nocturia, and treatment of sleep apnea may decrease nocturia.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
References
1. Intern Med. 2016;55(8):901-5.
2. Sleep Breath. 2017 Feb 14. doi: 10.1007/s11325-017-1482-9.
3. Can Urol Assoc J. 2016 Jul-Aug;10(7-8):E241-5.
4. Int Neurourol J. 2016 Dec;20(4):329-34.
5. Neurourol Urodyn. 2017 Feb;36(2):376-9.
Solving stool refusal
When parents bring in their delightful, verbal 3-year-old for refusing to poop on the potty, it may seem laughable. But with impending preschool and costs of diapers, stool refusal can be a major aggravation for families! Fortunately,
Commonly a healthy, typically developing boy stands and urinates in the toilet just fine, but sneaks off behind the sofa to poop. Parent gyrations have gone from cajoling, to punishing, to offering trips to Disney! Flaring tempers can set the stage for stool refusal to be a power play.
There are a number of reasons stool refusal may give clues to child and family tendencies and relevant intervention. We always should be alert to rare medical problems such as Hirschsprung disease or traumas (from slammed toilet lids to sexual abuse). But while learning to use the toilet for urination and defecation generally occur around the same time, there are pitfalls making pooping in the potty different. An impending stool provides stronger sensations and more advance warning than urine and tends to come at regular times, making it logical to start toilet learning with sitting on the potty after meals.
But once seated on the potty, stools can require some waiting – not a typical toddler forte! While running to sit has novelty at first and may be reinforced by celebration, this quickly becomes routine and boring. Very active or very intense children especially hate having their play interrupted by a trip to the bathroom. Oppositional children just won’t perform if they think the parent cares! And unlike for urination, everyone can inhibit defecation long enough for the urge to pass. Repeated stool retention from ignoring the urge makes stools dessicated and harder, with resulting pain when finally passed. One painful stool makes many a young child decide “Never again!” and simply refuse the toilet. A rectal fissure can both start 
During unclogging and establishing a new stool pattern, the toddler should be matter-of-factly put back in diapers (not pull ups) saying “Oh well, you are just not ready for pants yet.” Dramatically placing the treasured Superhero underwear on the top shelf increases motivation (or promised if none have been acquired). Returning to diapers without shaming the child is key, and all caregivers need to buy in. They need to be good “actors,” conveying that they don’t really care about toileting to reduce the power struggle. If controlling poop is a battle, only the child can win!
When the soft stools are occurring several times per day, I suggest “M&M treatment”: 1 for sitting, 2 for peeing, and 3 for pooping = 6 potential M&Ms per episode. The “1 for sitting” (the easiest part), is not painful and restores the habit of complying. Remember, M&Ms are no match for a game on an iPad! By charting the times of stools, the parent can remove electronics ½ hour before the expected poop and restrict the child to one room of the house with a potty nearby. Parents can interact, but should avoid making this a rewarding playtime. When the child uses the potty rather than their pants, the room restriction is removed until the next window for pooping. If they poop outside the toilet, they remain restricted (and no electronics) until the next window (even the next day).
Some parents are especially sensitive to the smell and mess of stools and pass that attitude along to their child by saying “Ugh, you stink!” or “I can’t stand this mess!” or even handing the child to another caregiver in a gesture of rejection. These messages are not missed by the child, who may then not want to deal with the mess, either. I coach parents to stay at least neutral about stools, reminding them that, “Your child is going to have to poop her whole life!”
Demanding a diaper and then getting the special intimacy of bottom cleaning can be reinforcing. If there is a younger sibling, diaper changes may be a desired opportunity for the toddler to regress and retain some “baby privileges.” Other clues to this dynamic include thumb sucking, baby talk, clinginess, or being rough on the sibling. One part of addressing this issue is to prescribe “babying” the toddler by holding in arms, rocking, talking baby talk, offering a pacifier, and feeding him during daily parent-child one-on-one Special Time. This sounds crazy to parents aiming for grown up toileting, but I promise them the child will not go backwards! It addresses the child’s deep fear that the nurturing of infancy is no longer available.
You may have noticed that boys are much more likely to refuse stools than girls. Some of this difference may be that high activity, but learning to urinate standing up also is fun, a Big Boy feat, and a source of pride to fathers. If regular sitting to poop has not been well established before the fun of standing to pee is offered, the little guys are not so interested in sitting again to poop. Plus the wiping and hand washing after poops are further aggravations delaying return to the Legos. But more! By around age 3 years, both genders make the horrifying discovery that boys have a penis and girls don’t. At this age of confusion about potential transformations, the obvious conclusion is that the girl’s penis was lost! And that turd disappearing down the toilet looks a lot like a dismembered body part! Reassurance and education is in order. I address this with my “Penis Talk”: “Boys are made with a penis and girls are made with a vagina. (For boys:) When you get big like your Dad, your penis will be big, too. No one can ever take your penis away. (For girls, a less common concern.) You have always had a vagina. You did not lose a penis.” I recommend that you practice this in front of a mirror before first use!
Another cognitive milestone concerns what sorts of things can disappear dow
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at [email protected].
When parents bring in their delightful, verbal 3-year-old for refusing to poop on the potty, it may seem laughable. But with impending preschool and costs of diapers, stool refusal can be a major aggravation for families! Fortunately,
Commonly a healthy, typically developing boy stands and urinates in the toilet just fine, but sneaks off behind the sofa to poop. Parent gyrations have gone from cajoling, to punishing, to offering trips to Disney! Flaring tempers can set the stage for stool refusal to be a power play.
There are a number of reasons stool refusal may give clues to child and family tendencies and relevant intervention. We always should be alert to rare medical problems such as Hirschsprung disease or traumas (from slammed toilet lids to sexual abuse). But while learning to use the toilet for urination and defecation generally occur around the same time, there are pitfalls making pooping in the potty different. An impending stool provides stronger sensations and more advance warning than urine and tends to come at regular times, making it logical to start toilet learning with sitting on the potty after meals.
But once seated on the potty, stools can require some waiting – not a typical toddler forte! While running to sit has novelty at first and may be reinforced by celebration, this quickly becomes routine and boring. Very active or very intense children especially hate having their play interrupted by a trip to the bathroom. Oppositional children just won’t perform if they think the parent cares! And unlike for urination, everyone can inhibit defecation long enough for the urge to pass. Repeated stool retention from ignoring the urge makes stools dessicated and harder, with resulting pain when finally passed. One painful stool makes many a young child decide “Never again!” and simply refuse the toilet. A rectal fissure can both start
During unclogging and establishing a new stool pattern, the toddler should be matter-of-factly put back in diapers (not pull ups) saying “Oh well, you are just not ready for pants yet.” Dramatically placing the treasured Superhero underwear on the top shelf increases motivation (or promised if none have been acquired). Returning to diapers without shaming the child is key, and all caregivers need to buy in. They need to be good “actors,” conveying that they don’t really care about toileting to reduce the power struggle. If controlling poop is a battle, only the child can win!
When the soft stools are occurring several times per day, I suggest “M&M treatment”: 1 for sitting, 2 for peeing, and 3 for pooping = 6 potential M&Ms per episode. The “1 for sitting” (the easiest part), is not painful and restores the habit of complying. Remember, M&Ms are no match for a game on an iPad! By charting the times of stools, the parent can remove electronics ½ hour before the expected poop and restrict the child to one room of the house with a potty nearby. Parents can interact, but should avoid making this a rewarding playtime. When the child uses the potty rather than their pants, the room restriction is removed until the next window for pooping. If they poop outside the toilet, they remain restricted (and no electronics) until the next window (even the next day).
Some parents are especially sensitive to the smell and mess of stools and pass that attitude along to their child by saying “Ugh, you stink!” or “I can’t stand this mess!” or even handing the child to another caregiver in a gesture of rejection. These messages are not missed by the child, who may then not want to deal with the mess, either. I coach parents to stay at least neutral about stools, reminding them that, “Your child is going to have to poop her whole life!”
Demanding a diaper and then getting the special intimacy of bottom cleaning can be reinforcing. If there is a younger sibling, diaper changes may be a desired opportunity for the toddler to regress and retain some “baby privileges.” Other clues to this dynamic include thumb sucking, baby talk, clinginess, or being rough on the sibling. One part of addressing this issue is to prescribe “babying” the toddler by holding in arms, rocking, talking baby talk, offering a pacifier, and feeding him during daily parent-child one-on-one Special Time. This sounds crazy to parents aiming for grown up toileting, but I promise them the child will not go backwards! It addresses the child’s deep fear that the nurturing of infancy is no longer available.
You may have noticed that boys are much more likely to refuse stools than girls. Some of this difference may be that high activity, but learning to urinate standing up also is fun, a Big Boy feat, and a source of pride to fathers. If regular sitting to poop has not been well established before the fun of standing to pee is offered, the little guys are not so interested in sitting again to poop. Plus the wiping and hand washing after poops are further aggravations delaying return to the Legos. But more! By around age 3 years, both genders make the horrifying discovery that boys have a penis and girls don’t. At this age of confusion about potential transformations, the obvious conclusion is that the girl’s penis was lost! And that turd disappearing down the toilet looks a lot like a dismembered body part! Reassurance and education is in order. I address this with my “Penis Talk”: “Boys are made with a penis and girls are made with a vagina. (For boys:) When you get big like your Dad, your penis will be big, too. No one can ever take your penis away. (For girls, a less common concern.) You have always had a vagina. You did not lose a penis.” I recommend that you practice this in front of a mirror before first use!
Another cognitive milestone concerns what sorts of things can disappear dow
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at [email protected].
When parents bring in their delightful, verbal 3-year-old for refusing to poop on the potty, it may seem laughable. But with impending preschool and costs of diapers, stool refusal can be a major aggravation for families! Fortunately,
Commonly a healthy, typically developing boy stands and urinates in the toilet just fine, but sneaks off behind the sofa to poop. Parent gyrations have gone from cajoling, to punishing, to offering trips to Disney! Flaring tempers can set the stage for stool refusal to be a power play.
There are a number of reasons stool refusal may give clues to child and family tendencies and relevant intervention. We always should be alert to rare medical problems such as Hirschsprung disease or traumas (from slammed toilet lids to sexual abuse). But while learning to use the toilet for urination and defecation generally occur around the same time, there are pitfalls making pooping in the potty different. An impending stool provides stronger sensations and more advance warning than urine and tends to come at regular times, making it logical to start toilet learning with sitting on the potty after meals.
But once seated on the potty, stools can require some waiting – not a typical toddler forte! While running to sit has novelty at first and may be reinforced by celebration, this quickly becomes routine and boring. Very active or very intense children especially hate having their play interrupted by a trip to the bathroom. Oppositional children just won’t perform if they think the parent cares! And unlike for urination, everyone can inhibit defecation long enough for the urge to pass. Repeated stool retention from ignoring the urge makes stools dessicated and harder, with resulting pain when finally passed. One painful stool makes many a young child decide “Never again!” and simply refuse the toilet. A rectal fissure can both start
During unclogging and establishing a new stool pattern, the toddler should be matter-of-factly put back in diapers (not pull ups) saying “Oh well, you are just not ready for pants yet.” Dramatically placing the treasured Superhero underwear on the top shelf increases motivation (or promised if none have been acquired). Returning to diapers without shaming the child is key, and all caregivers need to buy in. They need to be good “actors,” conveying that they don’t really care about toileting to reduce the power struggle. If controlling poop is a battle, only the child can win!
When the soft stools are occurring several times per day, I suggest “M&M treatment”: 1 for sitting, 2 for peeing, and 3 for pooping = 6 potential M&Ms per episode. The “1 for sitting” (the easiest part), is not painful and restores the habit of complying. Remember, M&Ms are no match for a game on an iPad! By charting the times of stools, the parent can remove electronics ½ hour before the expected poop and restrict the child to one room of the house with a potty nearby. Parents can interact, but should avoid making this a rewarding playtime. When the child uses the potty rather than their pants, the room restriction is removed until the next window for pooping. If they poop outside the toilet, they remain restricted (and no electronics) until the next window (even the next day).
Some parents are especially sensitive to the smell and mess of stools and pass that attitude along to their child by saying “Ugh, you stink!” or “I can’t stand this mess!” or even handing the child to another caregiver in a gesture of rejection. These messages are not missed by the child, who may then not want to deal with the mess, either. I coach parents to stay at least neutral about stools, reminding them that, “Your child is going to have to poop her whole life!”
Demanding a diaper and then getting the special intimacy of bottom cleaning can be reinforcing. If there is a younger sibling, diaper changes may be a desired opportunity for the toddler to regress and retain some “baby privileges.” Other clues to this dynamic include thumb sucking, baby talk, clinginess, or being rough on the sibling. One part of addressing this issue is to prescribe “babying” the toddler by holding in arms, rocking, talking baby talk, offering a pacifier, and feeding him during daily parent-child one-on-one Special Time. This sounds crazy to parents aiming for grown up toileting, but I promise them the child will not go backwards! It addresses the child’s deep fear that the nurturing of infancy is no longer available.
You may have noticed that boys are much more likely to refuse stools than girls. Some of this difference may be that high activity, but learning to urinate standing up also is fun, a Big Boy feat, and a source of pride to fathers. If regular sitting to poop has not been well established before the fun of standing to pee is offered, the little guys are not so interested in sitting again to poop. Plus the wiping and hand washing after poops are further aggravations delaying return to the Legos. But more! By around age 3 years, both genders make the horrifying discovery that boys have a penis and girls don’t. At this age of confusion about potential transformations, the obvious conclusion is that the girl’s penis was lost! And that turd disappearing down the toilet looks a lot like a dismembered body part! Reassurance and education is in order. I address this with my “Penis Talk”: “Boys are made with a penis and girls are made with a vagina. (For boys:) When you get big like your Dad, your penis will be big, too. No one can ever take your penis away. (For girls, a less common concern.) You have always had a vagina. You did not lose a penis.” I recommend that you practice this in front of a mirror before first use!
Another cognitive milestone concerns what sorts of things can disappear dow
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at [email protected].
Obtaining coverage for transgender and gender-expansive youth
Transgender and gender-expansive youth face many barriers to health care. (Gender-expansive youth are defined as “youth who do not identify with traditional gender roles but are otherwise not confined to one gender narrative or experience.”) Although some of these youth may be fortunate to have a supportive family and access to health care providers proficient in transgender health care, they still face difficulties in having their insurance cover transgender-related services. This is not an impossible task, but it is a constant struggle for many clinicians.
In this column, I will provide some tips and strategies to help clinicians get insurance companies to cover these critical services. However, keep in mind that there is no one-size-fits-all approach to obtaining insurance coverage. In addition, growing uncertainty over the repeal of the Affordable Care Act (ACA) – which was critical in lifting many of the barriers to insurance coverage for transgender individuals – will make this task challenging.
Health insurance is extraordinarily complex. There are multiple private and public plans that vary in the services they cover. This variation is state dependent. And even within states, there is additional variability. Most health insurance plans are purchased by employers, and employers have a choice of what can be covered in their health plans. So even though an insurance company may state that it covers transgender-related services, the patient’s employer may pay for a plan that doesn’t cover such services. The only way to be sure whether a patient’s insurance will cover transgender-related services or not is to contact the insurance provider directly, but with extremely busy schedules and heavy patient loads, this is easier said than done. It would be helpful to have a social worker perform this task, but even having a social worker can be a luxury for some clinics.
The ACA made it easier for transgender individuals to obtain insurance coverage. Three years ago, the U.S. Department of Health and Human Services stated that Medicare’s longstanding exclusion of “transsexual surgical procedures” was no longer valid.1 Although it did not universally ban transgender exclusion policies, it did allow individual states to do so. Thirteen states have explicit policies that ban exclusions of transgender-related services in both private insurance and in Medicaid, and an additional five states have some policies that discourage such practices.2 This allowed some insurance providers and state Medicaid plans to offer coverage of transgender-related services.
Another challenge in obtaining insurance coverage for transgender and gender-expansive youth is claims denial for sex-specific procedures. For example, if a transwoman is designated as “male” in the electronic medical record and requires a breast ultrasound, the insurance company may automatically reject this claim because this procedure is covered for bodies designated as “female.” If the patient’s insurance plan covers transgender-related services, the clinic can notify the insurance company that the patient is transgender; if the patient’s plan does not, then the clinic will need to appeal to the insurance provider. Alternatively, for clinics associated with federally-funded institutions (e.g., most hospitals), the clinician can use Condition Code 45 in the billing to override the sex mismatch, although not all hospitals have implemented this code.3
1. Patient’s identifying information. Usually the patient’s name and date of birth is sufficient. Clinicians should use the patient’s preferred name in the letter, but provide the insurance or legal name of the patient so that the insurance provider can locate the patient’s records.
2. Result of a psychosocial evaluation and diagnosis (if any). Many insurance providers are looking specifically for the gender dysphoria diagnosis.
3. The duration of the referring health professional’s relationship with the patient, which includes the type of evaluation and therapy or counseling (e.g., cognitive behavior therapy or gender coaching).
4. An explanation that the criteria (usually from the World Professional Association for Transgender Health standard of care4 or the Endocrine Society Guidelines titled Endocrine Treatment of Transsexual Persons5) for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy.
5. A statement that informed consent has been obtained from the patient (or parental permission if the patient is younger than 18 years).
6. A statement that the referring health professional is available for coordination of care.
If the clinician fails to convince the insurance provider of the necessity of covering transgender-related services, the patient still can pay out of pocket. Some hormones can be affordable to certain patients. In the state of Pennsylvania, for example, a 10-mL vial of testosterone can cost anywhere from $60 to $80, and may generally last anywhere from 10 weeks to a year, depending on dosage. Nevertheless, these costs still may be prohibitive for many transgender youth. Many are chronically unemployed or underemployed, or struggle with homelessness.6 Some transgender youth have to the face the excruciatingly difficult choice between having something to eat for the day or living another day with gender dysphoria.
Clinicians should work very hard to make sure that their transgender and gender-expansive patients obtain the care they need. The above strategies may help navigate the complex insurance system. However, insurance policies vary by state, and anti-trans discrimination creates additional barriers to health care. Therefore, clinicians who take care of transgender youth also should advocate for policies that protect these patients from discrimination, and they should advocate for policies that expand medical coverage for this vulnerable population.
Resources
• The Human Rights Campaign keeps a list of insurance plans that cover transgender-related services, but this list is far from comprehensive.
• Healthcare.gov provides some guidance on how to obtain coverage and navigate the insurance system for transgender individuals.
• UCSF Center of Excellence for Transgender Health provides some excellent resources and guidance on obtaining insurance coverage for transgender individuals.
References
1. LGBT Health 2014;1(4):256-8.
2. Map: State Health Insurance Rules: National Center for Transgender Equality, 2016 [Available from: www.transequality.org/issues/resources/map-state-health-insurance-rules].
3. Health insurance coverage issues for transgender people in the United States: University of California, San Fransisco Center of Excellence for Transgender Health, 2017 [Available from: http://transhealth.ucsf.edu/trans?page=guidelines-insurance].
4. International Journal of Transgenderism 2012;13(4):165-232.
5. J Clin Endocrinol Metab 2009;94(9):3132-54.
6. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.
Transgender and gender-expansive youth face many barriers to health care. (Gender-expansive youth are defined as “youth who do not identify with traditional gender roles but are otherwise not confined to one gender narrative or experience.”) Although some of these youth may be fortunate to have a supportive family and access to health care providers proficient in transgender health care, they still face difficulties in having their insurance cover transgender-related services. This is not an impossible task, but it is a constant struggle for many clinicians.
In this column, I will provide some tips and strategies to help clinicians get insurance companies to cover these critical services. However, keep in mind that there is no one-size-fits-all approach to obtaining insurance coverage. In addition, growing uncertainty over the repeal of the Affordable Care Act (ACA) – which was critical in lifting many of the barriers to insurance coverage for transgender individuals – will make this task challenging.
Health insurance is extraordinarily complex. There are multiple private and public plans that vary in the services they cover. This variation is state dependent. And even within states, there is additional variability. Most health insurance plans are purchased by employers, and employers have a choice of what can be covered in their health plans. So even though an insurance company may state that it covers transgender-related services, the patient’s employer may pay for a plan that doesn’t cover such services. The only way to be sure whether a patient’s insurance will cover transgender-related services or not is to contact the insurance provider directly, but with extremely busy schedules and heavy patient loads, this is easier said than done. It would be helpful to have a social worker perform this task, but even having a social worker can be a luxury for some clinics.
The ACA made it easier for transgender individuals to obtain insurance coverage. Three years ago, the U.S. Department of Health and Human Services stated that Medicare’s longstanding exclusion of “transsexual surgical procedures” was no longer valid.1 Although it did not universally ban transgender exclusion policies, it did allow individual states to do so. Thirteen states have explicit policies that ban exclusions of transgender-related services in both private insurance and in Medicaid, and an additional five states have some policies that discourage such practices.2 This allowed some insurance providers and state Medicaid plans to offer coverage of transgender-related services.
Another challenge in obtaining insurance coverage for transgender and gender-expansive youth is claims denial for sex-specific procedures. For example, if a transwoman is designated as “male” in the electronic medical record and requires a breast ultrasound, the insurance company may automatically reject this claim because this procedure is covered for bodies designated as “female.” If the patient’s insurance plan covers transgender-related services, the clinic can notify the insurance company that the patient is transgender; if the patient’s plan does not, then the clinic will need to appeal to the insurance provider. Alternatively, for clinics associated with federally-funded institutions (e.g., most hospitals), the clinician can use Condition Code 45 in the billing to override the sex mismatch, although not all hospitals have implemented this code.3
1. Patient’s identifying information. Usually the patient’s name and date of birth is sufficient. Clinicians should use the patient’s preferred name in the letter, but provide the insurance or legal name of the patient so that the insurance provider can locate the patient’s records.
2. Result of a psychosocial evaluation and diagnosis (if any). Many insurance providers are looking specifically for the gender dysphoria diagnosis.
3. The duration of the referring health professional’s relationship with the patient, which includes the type of evaluation and therapy or counseling (e.g., cognitive behavior therapy or gender coaching).
4. An explanation that the criteria (usually from the World Professional Association for Transgender Health standard of care4 or the Endocrine Society Guidelines titled Endocrine Treatment of Transsexual Persons5) for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy.
5. A statement that informed consent has been obtained from the patient (or parental permission if the patient is younger than 18 years).
6. A statement that the referring health professional is available for coordination of care.
If the clinician fails to convince the insurance provider of the necessity of covering transgender-related services, the patient still can pay out of pocket. Some hormones can be affordable to certain patients. In the state of Pennsylvania, for example, a 10-mL vial of testosterone can cost anywhere from $60 to $80, and may generally last anywhere from 10 weeks to a year, depending on dosage. Nevertheless, these costs still may be prohibitive for many transgender youth. Many are chronically unemployed or underemployed, or struggle with homelessness.6 Some transgender youth have to the face the excruciatingly difficult choice between having something to eat for the day or living another day with gender dysphoria.
Clinicians should work very hard to make sure that their transgender and gender-expansive patients obtain the care they need. The above strategies may help navigate the complex insurance system. However, insurance policies vary by state, and anti-trans discrimination creates additional barriers to health care. Therefore, clinicians who take care of transgender youth also should advocate for policies that protect these patients from discrimination, and they should advocate for policies that expand medical coverage for this vulnerable population.
Resources
• The Human Rights Campaign keeps a list of insurance plans that cover transgender-related services, but this list is far from comprehensive.
• Healthcare.gov provides some guidance on how to obtain coverage and navigate the insurance system for transgender individuals.
• UCSF Center of Excellence for Transgender Health provides some excellent resources and guidance on obtaining insurance coverage for transgender individuals.
References
1. LGBT Health 2014;1(4):256-8.
2. Map: State Health Insurance Rules: National Center for Transgender Equality, 2016 [Available from: www.transequality.org/issues/resources/map-state-health-insurance-rules].
3. Health insurance coverage issues for transgender people in the United States: University of California, San Fransisco Center of Excellence for Transgender Health, 2017 [Available from: http://transhealth.ucsf.edu/trans?page=guidelines-insurance].
4. International Journal of Transgenderism 2012;13(4):165-232.
5. J Clin Endocrinol Metab 2009;94(9):3132-54.
6. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.
Transgender and gender-expansive youth face many barriers to health care. (Gender-expansive youth are defined as “youth who do not identify with traditional gender roles but are otherwise not confined to one gender narrative or experience.”) Although some of these youth may be fortunate to have a supportive family and access to health care providers proficient in transgender health care, they still face difficulties in having their insurance cover transgender-related services. This is not an impossible task, but it is a constant struggle for many clinicians.
In this column, I will provide some tips and strategies to help clinicians get insurance companies to cover these critical services. However, keep in mind that there is no one-size-fits-all approach to obtaining insurance coverage. In addition, growing uncertainty over the repeal of the Affordable Care Act (ACA) – which was critical in lifting many of the barriers to insurance coverage for transgender individuals – will make this task challenging.
Health insurance is extraordinarily complex. There are multiple private and public plans that vary in the services they cover. This variation is state dependent. And even within states, there is additional variability. Most health insurance plans are purchased by employers, and employers have a choice of what can be covered in their health plans. So even though an insurance company may state that it covers transgender-related services, the patient’s employer may pay for a plan that doesn’t cover such services. The only way to be sure whether a patient’s insurance will cover transgender-related services or not is to contact the insurance provider directly, but with extremely busy schedules and heavy patient loads, this is easier said than done. It would be helpful to have a social worker perform this task, but even having a social worker can be a luxury for some clinics.
The ACA made it easier for transgender individuals to obtain insurance coverage. Three years ago, the U.S. Department of Health and Human Services stated that Medicare’s longstanding exclusion of “transsexual surgical procedures” was no longer valid.1 Although it did not universally ban transgender exclusion policies, it did allow individual states to do so. Thirteen states have explicit policies that ban exclusions of transgender-related services in both private insurance and in Medicaid, and an additional five states have some policies that discourage such practices.2 This allowed some insurance providers and state Medicaid plans to offer coverage of transgender-related services.
Another challenge in obtaining insurance coverage for transgender and gender-expansive youth is claims denial for sex-specific procedures. For example, if a transwoman is designated as “male” in the electronic medical record and requires a breast ultrasound, the insurance company may automatically reject this claim because this procedure is covered for bodies designated as “female.” If the patient’s insurance plan covers transgender-related services, the clinic can notify the insurance company that the patient is transgender; if the patient’s plan does not, then the clinic will need to appeal to the insurance provider. Alternatively, for clinics associated with federally-funded institutions (e.g., most hospitals), the clinician can use Condition Code 45 in the billing to override the sex mismatch, although not all hospitals have implemented this code.3
1. Patient’s identifying information. Usually the patient’s name and date of birth is sufficient. Clinicians should use the patient’s preferred name in the letter, but provide the insurance or legal name of the patient so that the insurance provider can locate the patient’s records.
2. Result of a psychosocial evaluation and diagnosis (if any). Many insurance providers are looking specifically for the gender dysphoria diagnosis.
3. The duration of the referring health professional’s relationship with the patient, which includes the type of evaluation and therapy or counseling (e.g., cognitive behavior therapy or gender coaching).
4. An explanation that the criteria (usually from the World Professional Association for Transgender Health standard of care4 or the Endocrine Society Guidelines titled Endocrine Treatment of Transsexual Persons5) for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy.
5. A statement that informed consent has been obtained from the patient (or parental permission if the patient is younger than 18 years).
6. A statement that the referring health professional is available for coordination of care.
If the clinician fails to convince the insurance provider of the necessity of covering transgender-related services, the patient still can pay out of pocket. Some hormones can be affordable to certain patients. In the state of Pennsylvania, for example, a 10-mL vial of testosterone can cost anywhere from $60 to $80, and may generally last anywhere from 10 weeks to a year, depending on dosage. Nevertheless, these costs still may be prohibitive for many transgender youth. Many are chronically unemployed or underemployed, or struggle with homelessness.6 Some transgender youth have to the face the excruciatingly difficult choice between having something to eat for the day or living another day with gender dysphoria.
Clinicians should work very hard to make sure that their transgender and gender-expansive patients obtain the care they need. The above strategies may help navigate the complex insurance system. However, insurance policies vary by state, and anti-trans discrimination creates additional barriers to health care. Therefore, clinicians who take care of transgender youth also should advocate for policies that protect these patients from discrimination, and they should advocate for policies that expand medical coverage for this vulnerable population.
Resources
• The Human Rights Campaign keeps a list of insurance plans that cover transgender-related services, but this list is far from comprehensive.
• Healthcare.gov provides some guidance on how to obtain coverage and navigate the insurance system for transgender individuals.
• UCSF Center of Excellence for Transgender Health provides some excellent resources and guidance on obtaining insurance coverage for transgender individuals.
References
1. LGBT Health 2014;1(4):256-8.
2. Map: State Health Insurance Rules: National Center for Transgender Equality, 2016 [Available from: www.transequality.org/issues/resources/map-state-health-insurance-rules].
3. Health insurance coverage issues for transgender people in the United States: University of California, San Fransisco Center of Excellence for Transgender Health, 2017 [Available from: http://transhealth.ucsf.edu/trans?page=guidelines-insurance].
4. International Journal of Transgenderism 2012;13(4):165-232.
5. J Clin Endocrinol Metab 2009;94(9):3132-54.
6. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.