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Letter from the Editor: Spring brings flowers and liver stories
Happy spring (finally, for many of us)! This month’s issue of GI & Hepatology News is “weighted” towards liver. The decrease in hepatitis C–related liver disease means that steatohepatitis will emerge as the most frequent cause of cirrhosis and transplantation. Finding medical therapies to slow obesity-related liver damage has proven challenging. Bariatric surgery may be the best option for patients, as pointed out by one of our lead stories. Another page one story lays out a roadmap to eliminate viral hepatitis in the United States, a situation unheard of until direct-acting antiviral agents were developed.
The AGA’s contribution to this month’s issue is excellent. First, there is the continuing controversy regarding maintenance of certification. AGA has worked hard to eliminate the 10-year high-impact closed book examination (now an anachronism). We will have the option of a 2-year exam (open book) and you will need to become familiar with testing proposals so we all can add voices of reason to the ABIM process.
Additionally, the AGA highlights the POWER guideline (weight management) and its obesity resources, DDSEP® 8 and a new clinical guideline concerning transient elastography.
We close this month’s issue with a discussion from Ray Cross and Sunanda Kane about telemedicine and its impact on gastroenterology. There are multiple examples of how telemedicine is changing our practices and the piece provides hope for increased efficiencies and leveraged resources.
I hope you enjoy this issue. I have avoided my usual hints about our chaotic politics and its impact on our practices. We all need some relief and should take time to note the spring flowers.
John I. Allen, MD, MBA, AGAF
Editor in Chief
Happy spring (finally, for many of us)! This month’s issue of GI & Hepatology News is “weighted” towards liver. The decrease in hepatitis C–related liver disease means that steatohepatitis will emerge as the most frequent cause of cirrhosis and transplantation. Finding medical therapies to slow obesity-related liver damage has proven challenging. Bariatric surgery may be the best option for patients, as pointed out by one of our lead stories. Another page one story lays out a roadmap to eliminate viral hepatitis in the United States, a situation unheard of until direct-acting antiviral agents were developed.
The AGA’s contribution to this month’s issue is excellent. First, there is the continuing controversy regarding maintenance of certification. AGA has worked hard to eliminate the 10-year high-impact closed book examination (now an anachronism). We will have the option of a 2-year exam (open book) and you will need to become familiar with testing proposals so we all can add voices of reason to the ABIM process.
Additionally, the AGA highlights the POWER guideline (weight management) and its obesity resources, DDSEP® 8 and a new clinical guideline concerning transient elastography.
We close this month’s issue with a discussion from Ray Cross and Sunanda Kane about telemedicine and its impact on gastroenterology. There are multiple examples of how telemedicine is changing our practices and the piece provides hope for increased efficiencies and leveraged resources.
I hope you enjoy this issue. I have avoided my usual hints about our chaotic politics and its impact on our practices. We all need some relief and should take time to note the spring flowers.
John I. Allen, MD, MBA, AGAF
Editor in Chief
Happy spring (finally, for many of us)! This month’s issue of GI & Hepatology News is “weighted” towards liver. The decrease in hepatitis C–related liver disease means that steatohepatitis will emerge as the most frequent cause of cirrhosis and transplantation. Finding medical therapies to slow obesity-related liver damage has proven challenging. Bariatric surgery may be the best option for patients, as pointed out by one of our lead stories. Another page one story lays out a roadmap to eliminate viral hepatitis in the United States, a situation unheard of until direct-acting antiviral agents were developed.
The AGA’s contribution to this month’s issue is excellent. First, there is the continuing controversy regarding maintenance of certification. AGA has worked hard to eliminate the 10-year high-impact closed book examination (now an anachronism). We will have the option of a 2-year exam (open book) and you will need to become familiar with testing proposals so we all can add voices of reason to the ABIM process.
Additionally, the AGA highlights the POWER guideline (weight management) and its obesity resources, DDSEP® 8 and a new clinical guideline concerning transient elastography.
We close this month’s issue with a discussion from Ray Cross and Sunanda Kane about telemedicine and its impact on gastroenterology. There are multiple examples of how telemedicine is changing our practices and the piece provides hope for increased efficiencies and leveraged resources.
I hope you enjoy this issue. I have avoided my usual hints about our chaotic politics and its impact on our practices. We all need some relief and should take time to note the spring flowers.
John I. Allen, MD, MBA, AGAF
Editor in Chief
Dealing with stealing
A 7-year-old boy, Jacob, with a history of ADHD and frequent impulsive behavior, takes a calculator from another child’s desk. About 3 months before, he had come home after taking another child’s action figure. His parents have been working on parent training for ADHD, but don’t know how to respond to this behavior and are very upset at their son.
Discussion
Stealing is an issue of serious concern to parents. To understand how common this is in younger children, researchers need to rely on the reports of parents and teachers, which may be underestimates of the problem because stealing is usually a hidden or covert behavior. Research on older youth can include anonymous self-reports.
Stealing and dishonesty are such disappointing behaviors to adults that it is tempting to resort to harsh punishments, long lectures, or harshly disparaging words. But these kinds of punishments backfire. The goal is an overall positive relationship and a calm consistent response to undesired behaviors. Parents often need support in how to be positive with a child who is frustrating them. Taking 15 minutes a day to do some activity a child likes – playing catch, playing a board game, cooking together, or doing crafts – all while noticing the positive things a child is doing rather than teaching, criticizing, or grilling a child on what happened in school sets a happier tone to the relationship, which is a background for any discipline. Jacob’s parents had already been working on this through their parent training class, but it helped to encourage them to keep doing this.
Because of the covert nature of stealing, it is sometimes hard to know where an item has come from, and children are likely to lie about this, saying that a friend gave it to them or they found it. To avoid this, when working with a child who has been stealing, the expectation should be made clear in advance that it is the child’s responsibility to avoid suspicion by having nothing in his possession that is not known to the adult. It is important to avoid back and forth arguments. The adult’s decision is final. With frequent stealing, it is helpful to make an inventory of the child’s possessions as a baseline.
When it comes to consequences, the important thing is to be sure that they are consistent and predictable. Returning an item to the owner and apologizing are logical. Another excellent type of consequence for behaviors that happen rarely is an extra work chore of about half an hour.
So a parent might say something like, “Jacob, we know that a stealing monster has been getting you, and we want to fight against him. I have made up a list of everything you have right now, and it is going to be your responsibility to make sure you don’t bring home anything else. So that means even if you find something or someone gives you something, you shouldn’t take it. If I find anything that isn’t on the list, you are going to have to return it to the person it belongs to and apologize, and then do an extra work chore for half an hour. A habit can be hard to change, but I know we can do it together. Let’s go play catch.” Then when the child is found with something in his possession, the adult should remain calm, avoid a lecture, and just say something like, “Jacob, this is something that doesn’t belong to you. You need to return it to the person it belongs to, and you have an extra half hour of raking leaves. No TV until the leaves are done.” The parent also should be alert to opportunities to attend to or praise behaviors like the child saving money to spend on things he wants, or asking to borrow things from other family members rather than just taking them.
Stealing can be a tough problem and often goes along with other rule-breaking behavior. If a parent is struggling to stay calm and find the positive, referral to group or individual parent training through programs like the Incredible Years or Triple P can give a parent the chance to learn and practice skills step by step.
As children enter their teen years, stealing becomes much more common, and can be reinforced by peers as well as by the action itself. The same principles of finding positive activities, continuing positive interactions with parents, and predictable and consistent – rather than harsh – consequences continue to apply, but may require additional supports. Larger programs such as Multisystemic Therapy, which works with families, peers, and communities, have been demonstrated to be effective for young people with juvenile delinquency.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
Resource
Stealing, in “Children’s needs III: Development, prevention, and intervention,” (Washington: National Association of School Psychologists, 2006, pp. 171-83).
A 7-year-old boy, Jacob, with a history of ADHD and frequent impulsive behavior, takes a calculator from another child’s desk. About 3 months before, he had come home after taking another child’s action figure. His parents have been working on parent training for ADHD, but don’t know how to respond to this behavior and are very upset at their son.
Discussion
Stealing is an issue of serious concern to parents. To understand how common this is in younger children, researchers need to rely on the reports of parents and teachers, which may be underestimates of the problem because stealing is usually a hidden or covert behavior. Research on older youth can include anonymous self-reports.
Stealing and dishonesty are such disappointing behaviors to adults that it is tempting to resort to harsh punishments, long lectures, or harshly disparaging words. But these kinds of punishments backfire. The goal is an overall positive relationship and a calm consistent response to undesired behaviors. Parents often need support in how to be positive with a child who is frustrating them. Taking 15 minutes a day to do some activity a child likes – playing catch, playing a board game, cooking together, or doing crafts – all while noticing the positive things a child is doing rather than teaching, criticizing, or grilling a child on what happened in school sets a happier tone to the relationship, which is a background for any discipline. Jacob’s parents had already been working on this through their parent training class, but it helped to encourage them to keep doing this.
Because of the covert nature of stealing, it is sometimes hard to know where an item has come from, and children are likely to lie about this, saying that a friend gave it to them or they found it. To avoid this, when working with a child who has been stealing, the expectation should be made clear in advance that it is the child’s responsibility to avoid suspicion by having nothing in his possession that is not known to the adult. It is important to avoid back and forth arguments. The adult’s decision is final. With frequent stealing, it is helpful to make an inventory of the child’s possessions as a baseline.
When it comes to consequences, the important thing is to be sure that they are consistent and predictable. Returning an item to the owner and apologizing are logical. Another excellent type of consequence for behaviors that happen rarely is an extra work chore of about half an hour.
So a parent might say something like, “Jacob, we know that a stealing monster has been getting you, and we want to fight against him. I have made up a list of everything you have right now, and it is going to be your responsibility to make sure you don’t bring home anything else. So that means even if you find something or someone gives you something, you shouldn’t take it. If I find anything that isn’t on the list, you are going to have to return it to the person it belongs to and apologize, and then do an extra work chore for half an hour. A habit can be hard to change, but I know we can do it together. Let’s go play catch.” Then when the child is found with something in his possession, the adult should remain calm, avoid a lecture, and just say something like, “Jacob, this is something that doesn’t belong to you. You need to return it to the person it belongs to, and you have an extra half hour of raking leaves. No TV until the leaves are done.” The parent also should be alert to opportunities to attend to or praise behaviors like the child saving money to spend on things he wants, or asking to borrow things from other family members rather than just taking them.
Stealing can be a tough problem and often goes along with other rule-breaking behavior. If a parent is struggling to stay calm and find the positive, referral to group or individual parent training through programs like the Incredible Years or Triple P can give a parent the chance to learn and practice skills step by step.
As children enter their teen years, stealing becomes much more common, and can be reinforced by peers as well as by the action itself. The same principles of finding positive activities, continuing positive interactions with parents, and predictable and consistent – rather than harsh – consequences continue to apply, but may require additional supports. Larger programs such as Multisystemic Therapy, which works with families, peers, and communities, have been demonstrated to be effective for young people with juvenile delinquency.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
Resource
Stealing, in “Children’s needs III: Development, prevention, and intervention,” (Washington: National Association of School Psychologists, 2006, pp. 171-83).
A 7-year-old boy, Jacob, with a history of ADHD and frequent impulsive behavior, takes a calculator from another child’s desk. About 3 months before, he had come home after taking another child’s action figure. His parents have been working on parent training for ADHD, but don’t know how to respond to this behavior and are very upset at their son.
Discussion
Stealing is an issue of serious concern to parents. To understand how common this is in younger children, researchers need to rely on the reports of parents and teachers, which may be underestimates of the problem because stealing is usually a hidden or covert behavior. Research on older youth can include anonymous self-reports.
Stealing and dishonesty are such disappointing behaviors to adults that it is tempting to resort to harsh punishments, long lectures, or harshly disparaging words. But these kinds of punishments backfire. The goal is an overall positive relationship and a calm consistent response to undesired behaviors. Parents often need support in how to be positive with a child who is frustrating them. Taking 15 minutes a day to do some activity a child likes – playing catch, playing a board game, cooking together, or doing crafts – all while noticing the positive things a child is doing rather than teaching, criticizing, or grilling a child on what happened in school sets a happier tone to the relationship, which is a background for any discipline. Jacob’s parents had already been working on this through their parent training class, but it helped to encourage them to keep doing this.
Because of the covert nature of stealing, it is sometimes hard to know where an item has come from, and children are likely to lie about this, saying that a friend gave it to them or they found it. To avoid this, when working with a child who has been stealing, the expectation should be made clear in advance that it is the child’s responsibility to avoid suspicion by having nothing in his possession that is not known to the adult. It is important to avoid back and forth arguments. The adult’s decision is final. With frequent stealing, it is helpful to make an inventory of the child’s possessions as a baseline.
When it comes to consequences, the important thing is to be sure that they are consistent and predictable. Returning an item to the owner and apologizing are logical. Another excellent type of consequence for behaviors that happen rarely is an extra work chore of about half an hour.
So a parent might say something like, “Jacob, we know that a stealing monster has been getting you, and we want to fight against him. I have made up a list of everything you have right now, and it is going to be your responsibility to make sure you don’t bring home anything else. So that means even if you find something or someone gives you something, you shouldn’t take it. If I find anything that isn’t on the list, you are going to have to return it to the person it belongs to and apologize, and then do an extra work chore for half an hour. A habit can be hard to change, but I know we can do it together. Let’s go play catch.” Then when the child is found with something in his possession, the adult should remain calm, avoid a lecture, and just say something like, “Jacob, this is something that doesn’t belong to you. You need to return it to the person it belongs to, and you have an extra half hour of raking leaves. No TV until the leaves are done.” The parent also should be alert to opportunities to attend to or praise behaviors like the child saving money to spend on things he wants, or asking to borrow things from other family members rather than just taking them.
Stealing can be a tough problem and often goes along with other rule-breaking behavior. If a parent is struggling to stay calm and find the positive, referral to group or individual parent training through programs like the Incredible Years or Triple P can give a parent the chance to learn and practice skills step by step.
As children enter their teen years, stealing becomes much more common, and can be reinforced by peers as well as by the action itself. The same principles of finding positive activities, continuing positive interactions with parents, and predictable and consistent – rather than harsh – consequences continue to apply, but may require additional supports. Larger programs such as Multisystemic Therapy, which works with families, peers, and communities, have been demonstrated to be effective for young people with juvenile delinquency.
Dr. Hall is assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She said she had no relevant financial disclosures.
Resource
Stealing, in “Children’s needs III: Development, prevention, and intervention,” (Washington: National Association of School Psychologists, 2006, pp. 171-83).
Beyond Residency: No more black and white
The obstetrics and gynecology written board exam made everything seem cut and dry. A patient with fibroids causing heavy bleeding? Management options include hormone treatment, minor surgical procedures, or major surgical procedures like myomectomy or hysterectomy. A pregnant patient in labor with a fetal heart rate deceleration? The next step is to shut off the oxytocin infusion, turn the patient on her left side, administer intravenous fluids, and give her oxygen via a nasal cannula. A patient who has ruptured her membranes at 28 weeks? That’s an easy one: magnesium for neuroprotection, latency antibiotics, prenatal steroids, neonatalogy consult. Straightforward.
At the end of June, I was grateful for my residency experience – even though some of it seemed hectic and haphazard – because it ensured that I understood the reasoning behind these multiple-choice questions. But then I started my maternal-fetal medicine fellowship this past July. I was learning the names of new residents, attendings, and nurses, and having to orient myself to an entirely different hospital system. Even labor and delivery board sign-out was completely different. I reassured myself by thinking: Obstetrics is obstetrics. The rules and guidelines of obstetrics are universal, practiced at every level, and always make sense, right?
One day I had a patient come in with chronic, refractory immune thrombocytopenia. Her plan for delivery was induction at 37 weeks after our hematology colleagues used medications we had never heard of to finally get her platelets into the 100s. But upon admission, her platelets were down to the 70s. I wondered, should we induce anyway because her platelets are likely to drop even further if we wait? Or do we give her the slew of medications that didn’t completely work initially as a last-ditch effort to boost her platelets again before delivery? I looked at practice bulletins, hematology guidelines, and numerous other publications and still I could not find a protocol for this specific kind of patient. After discussion with anesthesiologists, hematologists, maternal-fetal medicine specialists, labor and delivery nurses, and the patient herself, we came up with a plan. We gave her additional doses of thrombopoietic agents and steroids and continued to monitor her platelet count. Within a week, she had an uncomplicated vaginal delivery with an epidural.*
Taking a lead role in the decision-making process and organizing a management plan made me feel like I was the quarterback of a football team, with a healthy mother and baby substituting for a game-winning touchdown. The decisions we make in maternal-fetal medicine are not supposed to be easy. However, I’ve heard over and over that when our colleagues ask for our input, the guidance they want to hear is “deliver” or “don’t deliver.” Over the last several months, I’ve learned that there is so much more to it than that. I now examine the entire patient and fetus in two ways: as one physiologically inseparable unit, and as two patients, weighing the neonatal risks of delivery against the maternal risks of the pregnancy itself. Determining an appropriate time for delivery is just part of it.
There are also the questions about antepartum fetal testing. Should we do additional monitoring for patients with isolated polyhydramnios? What about patients who are at advanced maternal age? What about patients whose fetuses have “decreased growth velocity” but not growth restriction? Should these patients get umbilical artery Dopplers, too? ACOG and the SMFM often do not give us specific monitoring guidelines, which forces us to make a plan based on each individual clinical scenario.
In other words, we must practice in that ever-changing, ever-frustrating, and confusing gray area. I hope in fellowship I learn to not only navigate through this area effectively, but to one day confidently hold out my hand to others to help guide them through it, too.
Dr. Grossman recently completed her residency in obstetrics and gynecology at Albert Einstein College of Medicine–Montefiore Hospital in the Bronx, N.Y., and is currently a first-year maternal-fetal medicine fellow at Weill Cornell Medical College in New York. She reported having no financial disclosures.
*This article was update April 21, 2107.
The obstetrics and gynecology written board exam made everything seem cut and dry. A patient with fibroids causing heavy bleeding? Management options include hormone treatment, minor surgical procedures, or major surgical procedures like myomectomy or hysterectomy. A pregnant patient in labor with a fetal heart rate deceleration? The next step is to shut off the oxytocin infusion, turn the patient on her left side, administer intravenous fluids, and give her oxygen via a nasal cannula. A patient who has ruptured her membranes at 28 weeks? That’s an easy one: magnesium for neuroprotection, latency antibiotics, prenatal steroids, neonatalogy consult. Straightforward.
At the end of June, I was grateful for my residency experience – even though some of it seemed hectic and haphazard – because it ensured that I understood the reasoning behind these multiple-choice questions. But then I started my maternal-fetal medicine fellowship this past July. I was learning the names of new residents, attendings, and nurses, and having to orient myself to an entirely different hospital system. Even labor and delivery board sign-out was completely different. I reassured myself by thinking: Obstetrics is obstetrics. The rules and guidelines of obstetrics are universal, practiced at every level, and always make sense, right?
One day I had a patient come in with chronic, refractory immune thrombocytopenia. Her plan for delivery was induction at 37 weeks after our hematology colleagues used medications we had never heard of to finally get her platelets into the 100s. But upon admission, her platelets were down to the 70s. I wondered, should we induce anyway because her platelets are likely to drop even further if we wait? Or do we give her the slew of medications that didn’t completely work initially as a last-ditch effort to boost her platelets again before delivery? I looked at practice bulletins, hematology guidelines, and numerous other publications and still I could not find a protocol for this specific kind of patient. After discussion with anesthesiologists, hematologists, maternal-fetal medicine specialists, labor and delivery nurses, and the patient herself, we came up with a plan. We gave her additional doses of thrombopoietic agents and steroids and continued to monitor her platelet count. Within a week, she had an uncomplicated vaginal delivery with an epidural.*
Taking a lead role in the decision-making process and organizing a management plan made me feel like I was the quarterback of a football team, with a healthy mother and baby substituting for a game-winning touchdown. The decisions we make in maternal-fetal medicine are not supposed to be easy. However, I’ve heard over and over that when our colleagues ask for our input, the guidance they want to hear is “deliver” or “don’t deliver.” Over the last several months, I’ve learned that there is so much more to it than that. I now examine the entire patient and fetus in two ways: as one physiologically inseparable unit, and as two patients, weighing the neonatal risks of delivery against the maternal risks of the pregnancy itself. Determining an appropriate time for delivery is just part of it.
There are also the questions about antepartum fetal testing. Should we do additional monitoring for patients with isolated polyhydramnios? What about patients who are at advanced maternal age? What about patients whose fetuses have “decreased growth velocity” but not growth restriction? Should these patients get umbilical artery Dopplers, too? ACOG and the SMFM often do not give us specific monitoring guidelines, which forces us to make a plan based on each individual clinical scenario.
In other words, we must practice in that ever-changing, ever-frustrating, and confusing gray area. I hope in fellowship I learn to not only navigate through this area effectively, but to one day confidently hold out my hand to others to help guide them through it, too.
Dr. Grossman recently completed her residency in obstetrics and gynecology at Albert Einstein College of Medicine–Montefiore Hospital in the Bronx, N.Y., and is currently a first-year maternal-fetal medicine fellow at Weill Cornell Medical College in New York. She reported having no financial disclosures.
*This article was update April 21, 2107.
The obstetrics and gynecology written board exam made everything seem cut and dry. A patient with fibroids causing heavy bleeding? Management options include hormone treatment, minor surgical procedures, or major surgical procedures like myomectomy or hysterectomy. A pregnant patient in labor with a fetal heart rate deceleration? The next step is to shut off the oxytocin infusion, turn the patient on her left side, administer intravenous fluids, and give her oxygen via a nasal cannula. A patient who has ruptured her membranes at 28 weeks? That’s an easy one: magnesium for neuroprotection, latency antibiotics, prenatal steroids, neonatalogy consult. Straightforward.
At the end of June, I was grateful for my residency experience – even though some of it seemed hectic and haphazard – because it ensured that I understood the reasoning behind these multiple-choice questions. But then I started my maternal-fetal medicine fellowship this past July. I was learning the names of new residents, attendings, and nurses, and having to orient myself to an entirely different hospital system. Even labor and delivery board sign-out was completely different. I reassured myself by thinking: Obstetrics is obstetrics. The rules and guidelines of obstetrics are universal, practiced at every level, and always make sense, right?
One day I had a patient come in with chronic, refractory immune thrombocytopenia. Her plan for delivery was induction at 37 weeks after our hematology colleagues used medications we had never heard of to finally get her platelets into the 100s. But upon admission, her platelets were down to the 70s. I wondered, should we induce anyway because her platelets are likely to drop even further if we wait? Or do we give her the slew of medications that didn’t completely work initially as a last-ditch effort to boost her platelets again before delivery? I looked at practice bulletins, hematology guidelines, and numerous other publications and still I could not find a protocol for this specific kind of patient. After discussion with anesthesiologists, hematologists, maternal-fetal medicine specialists, labor and delivery nurses, and the patient herself, we came up with a plan. We gave her additional doses of thrombopoietic agents and steroids and continued to monitor her platelet count. Within a week, she had an uncomplicated vaginal delivery with an epidural.*
Taking a lead role in the decision-making process and organizing a management plan made me feel like I was the quarterback of a football team, with a healthy mother and baby substituting for a game-winning touchdown. The decisions we make in maternal-fetal medicine are not supposed to be easy. However, I’ve heard over and over that when our colleagues ask for our input, the guidance they want to hear is “deliver” or “don’t deliver.” Over the last several months, I’ve learned that there is so much more to it than that. I now examine the entire patient and fetus in two ways: as one physiologically inseparable unit, and as two patients, weighing the neonatal risks of delivery against the maternal risks of the pregnancy itself. Determining an appropriate time for delivery is just part of it.
There are also the questions about antepartum fetal testing. Should we do additional monitoring for patients with isolated polyhydramnios? What about patients who are at advanced maternal age? What about patients whose fetuses have “decreased growth velocity” but not growth restriction? Should these patients get umbilical artery Dopplers, too? ACOG and the SMFM often do not give us specific monitoring guidelines, which forces us to make a plan based on each individual clinical scenario.
In other words, we must practice in that ever-changing, ever-frustrating, and confusing gray area. I hope in fellowship I learn to not only navigate through this area effectively, but to one day confidently hold out my hand to others to help guide them through it, too.
Dr. Grossman recently completed her residency in obstetrics and gynecology at Albert Einstein College of Medicine–Montefiore Hospital in the Bronx, N.Y., and is currently a first-year maternal-fetal medicine fellow at Weill Cornell Medical College in New York. She reported having no financial disclosures.
*This article was update April 21, 2107.
DTC genetic health risk tests: Beware
The Food and Drug Administration recently authorized 23andMe to provide consumers with results of germline DNA sequence variants associated with risk for 10 health conditions, among them hereditary hemochromatosis, alpha-1 antitrypsin deficiency, celiac disease, Alzheimer’s disease, and Parkinson’s disease. After they submit a saliva sample and pay a test fee, customers ordering the online test will receive a report delineating their ancestry markers and informing them whether they carry any of the genetic variants associated with selected health risks included on the targeted DNA sequencing panel.
As more consumers partake in “recreational genomic testing,” clinicians should understand the limitations of DTC genetic tests and should be prepared to discuss with patients why these should not supersede clinical diagnostic evaluations.
Dr. Stoffel is a gastroenterologist, assistant professor of internal medicine, and director of the cancer genetics clinic at the University of Michigan, Ann Arbor. She has no disclosures.
The Food and Drug Administration recently authorized 23andMe to provide consumers with results of germline DNA sequence variants associated with risk for 10 health conditions, among them hereditary hemochromatosis, alpha-1 antitrypsin deficiency, celiac disease, Alzheimer’s disease, and Parkinson’s disease. After they submit a saliva sample and pay a test fee, customers ordering the online test will receive a report delineating their ancestry markers and informing them whether they carry any of the genetic variants associated with selected health risks included on the targeted DNA sequencing panel.
As more consumers partake in “recreational genomic testing,” clinicians should understand the limitations of DTC genetic tests and should be prepared to discuss with patients why these should not supersede clinical diagnostic evaluations.
Dr. Stoffel is a gastroenterologist, assistant professor of internal medicine, and director of the cancer genetics clinic at the University of Michigan, Ann Arbor. She has no disclosures.
The Food and Drug Administration recently authorized 23andMe to provide consumers with results of germline DNA sequence variants associated with risk for 10 health conditions, among them hereditary hemochromatosis, alpha-1 antitrypsin deficiency, celiac disease, Alzheimer’s disease, and Parkinson’s disease. After they submit a saliva sample and pay a test fee, customers ordering the online test will receive a report delineating their ancestry markers and informing them whether they carry any of the genetic variants associated with selected health risks included on the targeted DNA sequencing panel.
As more consumers partake in “recreational genomic testing,” clinicians should understand the limitations of DTC genetic tests and should be prepared to discuss with patients why these should not supersede clinical diagnostic evaluations.
Dr. Stoffel is a gastroenterologist, assistant professor of internal medicine, and director of the cancer genetics clinic at the University of Michigan, Ann Arbor. She has no disclosures.
Imagining Sisyphus Happy–Redux
The cover of the May 2013 edition of Emerging Infectious Diseases offered an appropriate analogy to reflect on the advances in infectious disease medicine over the last 30 years and to put in perspective those accomplishments against current and future challenges. The artwork portrayed Titian’s masterpiece of Sisyphus toiling with the never-ending burden of pushing the stone up the hill as punishment for cheating death. Polyxeni Potter provided an accompanying editorial comparing Sisyphus’ endless journey to public health efforts to understand and battle against emerging and reemerging infectious diseases. Ms. Potter draws on the final chapter of The Myth of Sisyphus by Albert Camus that in public health one must imagine Sisyphus happy as the struggle itself is enough to fill one’s heart.1 Potter concludes, “…and in public health, where monumental effort sometimes brings incremental improvement, success is still measured by tying up Death.”2
The last 30 years have seen a number of significant advances in the understanding, prevention, and treatment of infectious diseases. Unfortunately, the world of infectious diseases is far from static, and new threats emerge or old threats evolve faster than available countermeasures. Describing the many significant advances in infectious disease medicine (as well as the numerous new threats) would occupy volumes. Moreover, several journals exist for the specific purpose of describing advances in infectious diseases. However, it is worthwhile to describe a few key advances as well as to discuss the lessons learned over the last 30 years and to put in perspective some of the challenges and opportunities available for federal practitioners.
First, a short disclaimer. I am not an infectious disease researcher or clinician. I have an enviable position of supporting the infectious disease clinical research enterprise through helping researchers navigate through the regulatory matrix with the least burden possible. As such, I have the opportunity to work with clinical researchers who are surrogates for Sisyphus with every hypothesis geared toward answering questions that advance our understanding of respective infectious diseases resulting in the need to continue their struggles to answer the subsequent questions generated by their findings. I have the good fortune of currently working with many highly skilled and truly dedicated clinicians and researchers in the National Institute of Allergy and Infectious Diseases (NIAID) and had the opportunity of gaining experience with a similar group in the DoD while serving in the U.S. Army Medical Research and Materiel Command. It is from the work of these many experts that I have gained some appreciation for the advances and challenges of infectious disease medicine.
Advances in public health programs took the U.S. death rate from 797 per 100,000 in 1900 to a low of 39 per 100,000 in 1982. Improvements in sanitation, water, standard of living, vaccination, and the development of antibiotics had much to do with the tremendous reduction seen during that 8 decade run. Since the early 1980s, the emergence of the human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS), the development of resistance to antibiotics, and the emergence of new threats have conspired to limit the opportunity for additional reductions. Moreover, while the situation in the U.S. is somewhat stable, the situation abroad is far different. Geo-political realities and the multimodal nature of international transportation compel all of us to recognize that infectious disease threats across the globe impact all of us in this increasingly interconnected world.
On the plus side, the full-court press applied to the emergence of HIV/AIDS resulted in the reversal of a universally fatal outcome to that of a chronic, albeit a serious, illness that is manageable with medication. The development of highly active antiretroviral therapy (HAART) that is relatively convenient to take has made living with AIDS a reality for millions. Additionally, the President’s Emergency Plan for AIDS Relief has made headway in addressing the availability of medication on a global basis. Moreover, several prevention strategies focused on educating the public as well as making condoms and circumcision available have stemmed the tide in HIV acquisition.
Also, the spike in hepatitis C infections resulted in a substantial response from the research community. The growth of available effective treatments has expanded substantially, resulting in the capacity to clear the virus in many patients. Vaccines to prevent hepatitis B, hepatitis A, Haemophilus influenzae type b, human papillomavirus, Lyme disease, rotavirus, and a nasal influenza vaccine have all been introduced in the last 30 years. Basic science advances in the genomic and proteomic underpinnings of bacterial and viral processes as well as host susceptibility have opened the door for applied sciences to move the field further ahead in the next generation.
Regardless, the uphill struggle continues. As pointed out by NIAID Director Anthony Fauci, “If history is our guide, we can assume that the battle between the intellect and will of the human species and the extraordinary adaptability of microbes will be never-ending.”3 Challenges such as methicillin resistant Staphlococcus aureus, multidrug and cross-drug resistant tuberculosis, emerging infections such as the novel Middle East respiratory syndrome coronavirus, bird-tohuman influenza transmission in China, sporadic outbreaks of chikungunya, Marburg, and Ebola viruses as well as the always present threat of malaria and dengue fever throughout most of Africa, parts of Asia, and South America continue to overwhelm health care systems and perplex practitioners and researchers. Added to this burden are those diseases resulting from inadequate sanitary conditions leading to cholera and bacterial diarrhea. Moreover, while AIDS treatment allows patients to live nearly normal lives, the long-term effects of prolonged therapy with HAART, such as the increased incidence of atherosclerosis, continue to push the research community to discover a cure as well as an effective vaccine. And for diseases for which childhood immunizations are effective, poorly informed information campaigns have inappropriately scared away parents from making appropriate vaccination decisions for their children.
Practitioners and researchers in the federal sector are in the forefront of the struggle. The unique capabilities of the various agencies when used through a coordinated and collaborative effort, especially when working with nongovernmental organizations such as the Gates Foundation and willing industry partners, can be a formidable force. Whether it be the infectious disease physician consulting on cases in the health care setting, the researcher at the bench or in the field, or the public health information specialist developing messages to advocate for appropriate adherence to vaccination schedules, we all have a place in pushing the stone forward—and perhaps imagining ourselves as happy doing it.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.
1. Camus A. The Myth of Sisyphus: And Other Essays. New York, NY: Alfred A. Knopf; 1955:212.
2. Potter P. Imagining sisyphus happy. Emerg Infect Dis. 2013;19(5):846-847.
3. Fauci AS, Touchette NA, Folkers GK. Emerging infectious diseases: a 10-year perspective from the National Institute of Allergy and Infectious Diseases. Emerg Infect Dis. 2005;11(4):519-525.
The cover of the May 2013 edition of Emerging Infectious Diseases offered an appropriate analogy to reflect on the advances in infectious disease medicine over the last 30 years and to put in perspective those accomplishments against current and future challenges. The artwork portrayed Titian’s masterpiece of Sisyphus toiling with the never-ending burden of pushing the stone up the hill as punishment for cheating death. Polyxeni Potter provided an accompanying editorial comparing Sisyphus’ endless journey to public health efforts to understand and battle against emerging and reemerging infectious diseases. Ms. Potter draws on the final chapter of The Myth of Sisyphus by Albert Camus that in public health one must imagine Sisyphus happy as the struggle itself is enough to fill one’s heart.1 Potter concludes, “…and in public health, where monumental effort sometimes brings incremental improvement, success is still measured by tying up Death.”2
The last 30 years have seen a number of significant advances in the understanding, prevention, and treatment of infectious diseases. Unfortunately, the world of infectious diseases is far from static, and new threats emerge or old threats evolve faster than available countermeasures. Describing the many significant advances in infectious disease medicine (as well as the numerous new threats) would occupy volumes. Moreover, several journals exist for the specific purpose of describing advances in infectious diseases. However, it is worthwhile to describe a few key advances as well as to discuss the lessons learned over the last 30 years and to put in perspective some of the challenges and opportunities available for federal practitioners.
First, a short disclaimer. I am not an infectious disease researcher or clinician. I have an enviable position of supporting the infectious disease clinical research enterprise through helping researchers navigate through the regulatory matrix with the least burden possible. As such, I have the opportunity to work with clinical researchers who are surrogates for Sisyphus with every hypothesis geared toward answering questions that advance our understanding of respective infectious diseases resulting in the need to continue their struggles to answer the subsequent questions generated by their findings. I have the good fortune of currently working with many highly skilled and truly dedicated clinicians and researchers in the National Institute of Allergy and Infectious Diseases (NIAID) and had the opportunity of gaining experience with a similar group in the DoD while serving in the U.S. Army Medical Research and Materiel Command. It is from the work of these many experts that I have gained some appreciation for the advances and challenges of infectious disease medicine.
Advances in public health programs took the U.S. death rate from 797 per 100,000 in 1900 to a low of 39 per 100,000 in 1982. Improvements in sanitation, water, standard of living, vaccination, and the development of antibiotics had much to do with the tremendous reduction seen during that 8 decade run. Since the early 1980s, the emergence of the human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS), the development of resistance to antibiotics, and the emergence of new threats have conspired to limit the opportunity for additional reductions. Moreover, while the situation in the U.S. is somewhat stable, the situation abroad is far different. Geo-political realities and the multimodal nature of international transportation compel all of us to recognize that infectious disease threats across the globe impact all of us in this increasingly interconnected world.
On the plus side, the full-court press applied to the emergence of HIV/AIDS resulted in the reversal of a universally fatal outcome to that of a chronic, albeit a serious, illness that is manageable with medication. The development of highly active antiretroviral therapy (HAART) that is relatively convenient to take has made living with AIDS a reality for millions. Additionally, the President’s Emergency Plan for AIDS Relief has made headway in addressing the availability of medication on a global basis. Moreover, several prevention strategies focused on educating the public as well as making condoms and circumcision available have stemmed the tide in HIV acquisition.
Also, the spike in hepatitis C infections resulted in a substantial response from the research community. The growth of available effective treatments has expanded substantially, resulting in the capacity to clear the virus in many patients. Vaccines to prevent hepatitis B, hepatitis A, Haemophilus influenzae type b, human papillomavirus, Lyme disease, rotavirus, and a nasal influenza vaccine have all been introduced in the last 30 years. Basic science advances in the genomic and proteomic underpinnings of bacterial and viral processes as well as host susceptibility have opened the door for applied sciences to move the field further ahead in the next generation.
Regardless, the uphill struggle continues. As pointed out by NIAID Director Anthony Fauci, “If history is our guide, we can assume that the battle between the intellect and will of the human species and the extraordinary adaptability of microbes will be never-ending.”3 Challenges such as methicillin resistant Staphlococcus aureus, multidrug and cross-drug resistant tuberculosis, emerging infections such as the novel Middle East respiratory syndrome coronavirus, bird-tohuman influenza transmission in China, sporadic outbreaks of chikungunya, Marburg, and Ebola viruses as well as the always present threat of malaria and dengue fever throughout most of Africa, parts of Asia, and South America continue to overwhelm health care systems and perplex practitioners and researchers. Added to this burden are those diseases resulting from inadequate sanitary conditions leading to cholera and bacterial diarrhea. Moreover, while AIDS treatment allows patients to live nearly normal lives, the long-term effects of prolonged therapy with HAART, such as the increased incidence of atherosclerosis, continue to push the research community to discover a cure as well as an effective vaccine. And for diseases for which childhood immunizations are effective, poorly informed information campaigns have inappropriately scared away parents from making appropriate vaccination decisions for their children.
Practitioners and researchers in the federal sector are in the forefront of the struggle. The unique capabilities of the various agencies when used through a coordinated and collaborative effort, especially when working with nongovernmental organizations such as the Gates Foundation and willing industry partners, can be a formidable force. Whether it be the infectious disease physician consulting on cases in the health care setting, the researcher at the bench or in the field, or the public health information specialist developing messages to advocate for appropriate adherence to vaccination schedules, we all have a place in pushing the stone forward—and perhaps imagining ourselves as happy doing it.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.
The cover of the May 2013 edition of Emerging Infectious Diseases offered an appropriate analogy to reflect on the advances in infectious disease medicine over the last 30 years and to put in perspective those accomplishments against current and future challenges. The artwork portrayed Titian’s masterpiece of Sisyphus toiling with the never-ending burden of pushing the stone up the hill as punishment for cheating death. Polyxeni Potter provided an accompanying editorial comparing Sisyphus’ endless journey to public health efforts to understand and battle against emerging and reemerging infectious diseases. Ms. Potter draws on the final chapter of The Myth of Sisyphus by Albert Camus that in public health one must imagine Sisyphus happy as the struggle itself is enough to fill one’s heart.1 Potter concludes, “…and in public health, where monumental effort sometimes brings incremental improvement, success is still measured by tying up Death.”2
The last 30 years have seen a number of significant advances in the understanding, prevention, and treatment of infectious diseases. Unfortunately, the world of infectious diseases is far from static, and new threats emerge or old threats evolve faster than available countermeasures. Describing the many significant advances in infectious disease medicine (as well as the numerous new threats) would occupy volumes. Moreover, several journals exist for the specific purpose of describing advances in infectious diseases. However, it is worthwhile to describe a few key advances as well as to discuss the lessons learned over the last 30 years and to put in perspective some of the challenges and opportunities available for federal practitioners.
First, a short disclaimer. I am not an infectious disease researcher or clinician. I have an enviable position of supporting the infectious disease clinical research enterprise through helping researchers navigate through the regulatory matrix with the least burden possible. As such, I have the opportunity to work with clinical researchers who are surrogates for Sisyphus with every hypothesis geared toward answering questions that advance our understanding of respective infectious diseases resulting in the need to continue their struggles to answer the subsequent questions generated by their findings. I have the good fortune of currently working with many highly skilled and truly dedicated clinicians and researchers in the National Institute of Allergy and Infectious Diseases (NIAID) and had the opportunity of gaining experience with a similar group in the DoD while serving in the U.S. Army Medical Research and Materiel Command. It is from the work of these many experts that I have gained some appreciation for the advances and challenges of infectious disease medicine.
Advances in public health programs took the U.S. death rate from 797 per 100,000 in 1900 to a low of 39 per 100,000 in 1982. Improvements in sanitation, water, standard of living, vaccination, and the development of antibiotics had much to do with the tremendous reduction seen during that 8 decade run. Since the early 1980s, the emergence of the human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS), the development of resistance to antibiotics, and the emergence of new threats have conspired to limit the opportunity for additional reductions. Moreover, while the situation in the U.S. is somewhat stable, the situation abroad is far different. Geo-political realities and the multimodal nature of international transportation compel all of us to recognize that infectious disease threats across the globe impact all of us in this increasingly interconnected world.
On the plus side, the full-court press applied to the emergence of HIV/AIDS resulted in the reversal of a universally fatal outcome to that of a chronic, albeit a serious, illness that is manageable with medication. The development of highly active antiretroviral therapy (HAART) that is relatively convenient to take has made living with AIDS a reality for millions. Additionally, the President’s Emergency Plan for AIDS Relief has made headway in addressing the availability of medication on a global basis. Moreover, several prevention strategies focused on educating the public as well as making condoms and circumcision available have stemmed the tide in HIV acquisition.
Also, the spike in hepatitis C infections resulted in a substantial response from the research community. The growth of available effective treatments has expanded substantially, resulting in the capacity to clear the virus in many patients. Vaccines to prevent hepatitis B, hepatitis A, Haemophilus influenzae type b, human papillomavirus, Lyme disease, rotavirus, and a nasal influenza vaccine have all been introduced in the last 30 years. Basic science advances in the genomic and proteomic underpinnings of bacterial and viral processes as well as host susceptibility have opened the door for applied sciences to move the field further ahead in the next generation.
Regardless, the uphill struggle continues. As pointed out by NIAID Director Anthony Fauci, “If history is our guide, we can assume that the battle between the intellect and will of the human species and the extraordinary adaptability of microbes will be never-ending.”3 Challenges such as methicillin resistant Staphlococcus aureus, multidrug and cross-drug resistant tuberculosis, emerging infections such as the novel Middle East respiratory syndrome coronavirus, bird-tohuman influenza transmission in China, sporadic outbreaks of chikungunya, Marburg, and Ebola viruses as well as the always present threat of malaria and dengue fever throughout most of Africa, parts of Asia, and South America continue to overwhelm health care systems and perplex practitioners and researchers. Added to this burden are those diseases resulting from inadequate sanitary conditions leading to cholera and bacterial diarrhea. Moreover, while AIDS treatment allows patients to live nearly normal lives, the long-term effects of prolonged therapy with HAART, such as the increased incidence of atherosclerosis, continue to push the research community to discover a cure as well as an effective vaccine. And for diseases for which childhood immunizations are effective, poorly informed information campaigns have inappropriately scared away parents from making appropriate vaccination decisions for their children.
Practitioners and researchers in the federal sector are in the forefront of the struggle. The unique capabilities of the various agencies when used through a coordinated and collaborative effort, especially when working with nongovernmental organizations such as the Gates Foundation and willing industry partners, can be a formidable force. Whether it be the infectious disease physician consulting on cases in the health care setting, the researcher at the bench or in the field, or the public health information specialist developing messages to advocate for appropriate adherence to vaccination schedules, we all have a place in pushing the stone forward—and perhaps imagining ourselves as happy doing it.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.
1. Camus A. The Myth of Sisyphus: And Other Essays. New York, NY: Alfred A. Knopf; 1955:212.
2. Potter P. Imagining sisyphus happy. Emerg Infect Dis. 2013;19(5):846-847.
3. Fauci AS, Touchette NA, Folkers GK. Emerging infectious diseases: a 10-year perspective from the National Institute of Allergy and Infectious Diseases. Emerg Infect Dis. 2005;11(4):519-525.
1. Camus A. The Myth of Sisyphus: And Other Essays. New York, NY: Alfred A. Knopf; 1955:212.
2. Potter P. Imagining sisyphus happy. Emerg Infect Dis. 2013;19(5):846-847.
3. Fauci AS, Touchette NA, Folkers GK. Emerging infectious diseases: a 10-year perspective from the National Institute of Allergy and Infectious Diseases. Emerg Infect Dis. 2005;11(4):519-525.
Clearer heads are a fuzzy subject
Those of you who were in high school or middle school in 1987, when the DSM II-R first included “Attention Deficit Disorder With and Without Hyperactivity” for the first time, missed out on the “discovery,” and subsequent commercialization, of a condition that had been percolating under physicians’ noses for hundreds of years.
You may have wondered what primary care physicians did with their time before they were inundated with requests for evaluations and medications to treat ADHD. You may not realize that we didn’t always have ADHD specialists to help us or several dozen stimulant concoctions from which to choose. In the beginning, ADHD specialists had to invent themselves while the pharmaceutical companies scrambled to meet the demand for drugs that were longer lasting and more palatable.
The increasing popularity of professional contact sports is probably what we have to thank for sharpening this focus on head injury. I suspect that, for the general population, there are no more concussions occurring today than there were 50 years ago. However, in the subgroup of professional and elite college athletes, the players’ increasing speed, size, and flagrant ignorance of the rules have resulted in more significant head injuries. When a highly paid megastar athlete must sit out key games, the management of his head injury generates a lot of attention and discussion.
I am sure that there also has been an increase in concussions among young women who now have more opportunities to participate in contact sports. However, I suspect that most of the apparent increase in the diagnosis among high school and younger athletes of both sexes is primarily the result of heightened awareness. I don’t know of data to support or refute this opinion.
I may be wrong about lack of a real increase in concussion injuries, but there can be no arguing about the explosion in the number of clinics and providers who advertise themselves as concussion specialists. Neurologists, psychologists, chiropractors, orthopedists, and sports medicine practitioners and trainers all have climbed on the bandwagon to satisfy the demand generated by this country’s new concussion awareness.
The problem is that, just as in the early days after the “discovery” of ADHD, the science behind much of the advice and management strategies for concussion just isn’t there. For example, resting the brain after a head injury sounds like a good idea. After all, it works for a torn hamstring. However, “sounds like” and “is” are two very different things.
In an excellent article in this publication (“Spotlight shifts to active treatment for concussions,” by Christine Kilgore), I found some comforting news that concussion management may be taking some baby steps into the realm of evidence-based decision management. The original results came from a pediatric population, but it now appears that prolonged rest, which is routinely recommended, can be counterproductive in many concussed patients. The physicians quoted in this article suggest that their experience is pointing to the need for active management in patients with a variety of postconcussion symptoms. Brian Hainline, MD, a clinical professor of neurology at New York University and Indiana University, Indianapolis, observes, “It’s rare that prolonged rest is the answer. Look at stroke – you don’t have patients resting indefinitely. You have to get their nervous systems re-engaged.”
Of course, the science is still lagging behind and the observations by the physicians quoted in this article are based on small series, but their agreement deserves our attention. I urge you to take a look at this article to get an idea of where the management of concussion appears to be going. Not surprisingly, no two concussion patients are the same, and their management should be tailored to their needs. Reliance on overly simplistic guidelines not only doesn’t work but can do harm. It’s that old Hippocratic Oath thing again.
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].
Those of you who were in high school or middle school in 1987, when the DSM II-R first included “Attention Deficit Disorder With and Without Hyperactivity” for the first time, missed out on the “discovery,” and subsequent commercialization, of a condition that had been percolating under physicians’ noses for hundreds of years.
You may have wondered what primary care physicians did with their time before they were inundated with requests for evaluations and medications to treat ADHD. You may not realize that we didn’t always have ADHD specialists to help us or several dozen stimulant concoctions from which to choose. In the beginning, ADHD specialists had to invent themselves while the pharmaceutical companies scrambled to meet the demand for drugs that were longer lasting and more palatable.
The increasing popularity of professional contact sports is probably what we have to thank for sharpening this focus on head injury. I suspect that, for the general population, there are no more concussions occurring today than there were 50 years ago. However, in the subgroup of professional and elite college athletes, the players’ increasing speed, size, and flagrant ignorance of the rules have resulted in more significant head injuries. When a highly paid megastar athlete must sit out key games, the management of his head injury generates a lot of attention and discussion.
I am sure that there also has been an increase in concussions among young women who now have more opportunities to participate in contact sports. However, I suspect that most of the apparent increase in the diagnosis among high school and younger athletes of both sexes is primarily the result of heightened awareness. I don’t know of data to support or refute this opinion.
I may be wrong about lack of a real increase in concussion injuries, but there can be no arguing about the explosion in the number of clinics and providers who advertise themselves as concussion specialists. Neurologists, psychologists, chiropractors, orthopedists, and sports medicine practitioners and trainers all have climbed on the bandwagon to satisfy the demand generated by this country’s new concussion awareness.
The problem is that, just as in the early days after the “discovery” of ADHD, the science behind much of the advice and management strategies for concussion just isn’t there. For example, resting the brain after a head injury sounds like a good idea. After all, it works for a torn hamstring. However, “sounds like” and “is” are two very different things.
In an excellent article in this publication (“Spotlight shifts to active treatment for concussions,” by Christine Kilgore), I found some comforting news that concussion management may be taking some baby steps into the realm of evidence-based decision management. The original results came from a pediatric population, but it now appears that prolonged rest, which is routinely recommended, can be counterproductive in many concussed patients. The physicians quoted in this article suggest that their experience is pointing to the need for active management in patients with a variety of postconcussion symptoms. Brian Hainline, MD, a clinical professor of neurology at New York University and Indiana University, Indianapolis, observes, “It’s rare that prolonged rest is the answer. Look at stroke – you don’t have patients resting indefinitely. You have to get their nervous systems re-engaged.”
Of course, the science is still lagging behind and the observations by the physicians quoted in this article are based on small series, but their agreement deserves our attention. I urge you to take a look at this article to get an idea of where the management of concussion appears to be going. Not surprisingly, no two concussion patients are the same, and their management should be tailored to their needs. Reliance on overly simplistic guidelines not only doesn’t work but can do harm. It’s that old Hippocratic Oath thing again.
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].
Those of you who were in high school or middle school in 1987, when the DSM II-R first included “Attention Deficit Disorder With and Without Hyperactivity” for the first time, missed out on the “discovery,” and subsequent commercialization, of a condition that had been percolating under physicians’ noses for hundreds of years.
You may have wondered what primary care physicians did with their time before they were inundated with requests for evaluations and medications to treat ADHD. You may not realize that we didn’t always have ADHD specialists to help us or several dozen stimulant concoctions from which to choose. In the beginning, ADHD specialists had to invent themselves while the pharmaceutical companies scrambled to meet the demand for drugs that were longer lasting and more palatable.
The increasing popularity of professional contact sports is probably what we have to thank for sharpening this focus on head injury. I suspect that, for the general population, there are no more concussions occurring today than there were 50 years ago. However, in the subgroup of professional and elite college athletes, the players’ increasing speed, size, and flagrant ignorance of the rules have resulted in more significant head injuries. When a highly paid megastar athlete must sit out key games, the management of his head injury generates a lot of attention and discussion.
I am sure that there also has been an increase in concussions among young women who now have more opportunities to participate in contact sports. However, I suspect that most of the apparent increase in the diagnosis among high school and younger athletes of both sexes is primarily the result of heightened awareness. I don’t know of data to support or refute this opinion.
I may be wrong about lack of a real increase in concussion injuries, but there can be no arguing about the explosion in the number of clinics and providers who advertise themselves as concussion specialists. Neurologists, psychologists, chiropractors, orthopedists, and sports medicine practitioners and trainers all have climbed on the bandwagon to satisfy the demand generated by this country’s new concussion awareness.
The problem is that, just as in the early days after the “discovery” of ADHD, the science behind much of the advice and management strategies for concussion just isn’t there. For example, resting the brain after a head injury sounds like a good idea. After all, it works for a torn hamstring. However, “sounds like” and “is” are two very different things.
In an excellent article in this publication (“Spotlight shifts to active treatment for concussions,” by Christine Kilgore), I found some comforting news that concussion management may be taking some baby steps into the realm of evidence-based decision management. The original results came from a pediatric population, but it now appears that prolonged rest, which is routinely recommended, can be counterproductive in many concussed patients. The physicians quoted in this article suggest that their experience is pointing to the need for active management in patients with a variety of postconcussion symptoms. Brian Hainline, MD, a clinical professor of neurology at New York University and Indiana University, Indianapolis, observes, “It’s rare that prolonged rest is the answer. Look at stroke – you don’t have patients resting indefinitely. You have to get their nervous systems re-engaged.”
Of course, the science is still lagging behind and the observations by the physicians quoted in this article are based on small series, but their agreement deserves our attention. I urge you to take a look at this article to get an idea of where the management of concussion appears to be going. Not surprisingly, no two concussion patients are the same, and their management should be tailored to their needs. Reliance on overly simplistic guidelines not only doesn’t work but can do harm. It’s that old Hippocratic Oath thing again.
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].
Fat City
“Honey, does this town make me look fat?”
“Yes, Dear, I’m afraid it does.”
No, that really wasn’t a typo in the first line. I intended to type “town” and not “gown.” A recent article by Dionysus Powell in healthcareinamerica.us has prompted me to think a bit more about the relationship between obesity and the communities we inhabit (“Fit Cities vs. Fat Cities – What available data can tell us about the difference in lifestyle and obesity between cities,” by Dionysus Powell, March 28, 2017). The author is a biotech researcher who has collected readily available Centers for Disease Control and Prevention data on body mass index (BMI) and self-reported sedentary behavior in almost 200 U.S. cities. He then sliced and diced these numbers with each cities’ walkability score, which is a crude measure of how easily citizens and visitors on foot can reach a variety of destinations such as shops, schools, churches, libraries, and municipal offices. You can easily find your own town’s score by going to walkscore.com.
Not surprisingly, the author discovered that “differences in obesity rates between cities can largely be explained by differences in physical activity.” Of course, there is a point at which a community has sufficient walkable infrastructure so that its obesity rate is a result of the citizens choosing not to walk rather than the community’s failure to provide pedestrians with enough connectivity to do their daily errands on foot. That threshold point appears to be a walkability score of 50, yet Mr. Powell observes that most American cities fail to reach even that minimum.
Although rich people tend to have better health outcomes than poor people, and there is a “general trend for richer cities to be more physically active than poorer cities,” Mr. Powell could not find a relationship between a city’s median income and its walkability.
If, like most of us, you have been frustrated in your efforts to lower the BMI of your patients, it may be time to emerge from the confines of your office and take a look at your town’s walkability score. If it is less than 50, you and your fellow concerned citizens and officials have some work to do. It may mean advocating for improved pedestrian infrastructure and/or dismantling the physical and zoning barriers to pedestrian connectivity. For example, maybe your community should be adding more pedestrian-activated crossing signals or tapping into federal and state safe routes to school programs or adopting zoning ordinances that require sidewalks in all new developments.
Here in Brunswick, we have a very enviable walkability score of 87, meaning “most errands can be accomplished on foot.” We have a bicycle and pedestrian advisory committee that reports to the town council and works with the town engineer to advocate for infrastructure improvements that encourage pedestrian connectivity. However, funding these improvements in walkability is always a challenge. But as the analysis in this recent study suggestions, our biggest challenge continues to be encouraging our citizens to take advantage of our existing pedestrian infrastructure.
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].
“Honey, does this town make me look fat?”
“Yes, Dear, I’m afraid it does.”
No, that really wasn’t a typo in the first line. I intended to type “town” and not “gown.” A recent article by Dionysus Powell in healthcareinamerica.us has prompted me to think a bit more about the relationship between obesity and the communities we inhabit (“Fit Cities vs. Fat Cities – What available data can tell us about the difference in lifestyle and obesity between cities,” by Dionysus Powell, March 28, 2017). The author is a biotech researcher who has collected readily available Centers for Disease Control and Prevention data on body mass index (BMI) and self-reported sedentary behavior in almost 200 U.S. cities. He then sliced and diced these numbers with each cities’ walkability score, which is a crude measure of how easily citizens and visitors on foot can reach a variety of destinations such as shops, schools, churches, libraries, and municipal offices. You can easily find your own town’s score by going to walkscore.com.
Not surprisingly, the author discovered that “differences in obesity rates between cities can largely be explained by differences in physical activity.” Of course, there is a point at which a community has sufficient walkable infrastructure so that its obesity rate is a result of the citizens choosing not to walk rather than the community’s failure to provide pedestrians with enough connectivity to do their daily errands on foot. That threshold point appears to be a walkability score of 50, yet Mr. Powell observes that most American cities fail to reach even that minimum.
Although rich people tend to have better health outcomes than poor people, and there is a “general trend for richer cities to be more physically active than poorer cities,” Mr. Powell could not find a relationship between a city’s median income and its walkability.
If, like most of us, you have been frustrated in your efforts to lower the BMI of your patients, it may be time to emerge from the confines of your office and take a look at your town’s walkability score. If it is less than 50, you and your fellow concerned citizens and officials have some work to do. It may mean advocating for improved pedestrian infrastructure and/or dismantling the physical and zoning barriers to pedestrian connectivity. For example, maybe your community should be adding more pedestrian-activated crossing signals or tapping into federal and state safe routes to school programs or adopting zoning ordinances that require sidewalks in all new developments.
Here in Brunswick, we have a very enviable walkability score of 87, meaning “most errands can be accomplished on foot.” We have a bicycle and pedestrian advisory committee that reports to the town council and works with the town engineer to advocate for infrastructure improvements that encourage pedestrian connectivity. However, funding these improvements in walkability is always a challenge. But as the analysis in this recent study suggestions, our biggest challenge continues to be encouraging our citizens to take advantage of our existing pedestrian infrastructure.
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].
“Honey, does this town make me look fat?”
“Yes, Dear, I’m afraid it does.”
No, that really wasn’t a typo in the first line. I intended to type “town” and not “gown.” A recent article by Dionysus Powell in healthcareinamerica.us has prompted me to think a bit more about the relationship between obesity and the communities we inhabit (“Fit Cities vs. Fat Cities – What available data can tell us about the difference in lifestyle and obesity between cities,” by Dionysus Powell, March 28, 2017). The author is a biotech researcher who has collected readily available Centers for Disease Control and Prevention data on body mass index (BMI) and self-reported sedentary behavior in almost 200 U.S. cities. He then sliced and diced these numbers with each cities’ walkability score, which is a crude measure of how easily citizens and visitors on foot can reach a variety of destinations such as shops, schools, churches, libraries, and municipal offices. You can easily find your own town’s score by going to walkscore.com.
Not surprisingly, the author discovered that “differences in obesity rates between cities can largely be explained by differences in physical activity.” Of course, there is a point at which a community has sufficient walkable infrastructure so that its obesity rate is a result of the citizens choosing not to walk rather than the community’s failure to provide pedestrians with enough connectivity to do their daily errands on foot. That threshold point appears to be a walkability score of 50, yet Mr. Powell observes that most American cities fail to reach even that minimum.
Although rich people tend to have better health outcomes than poor people, and there is a “general trend for richer cities to be more physically active than poorer cities,” Mr. Powell could not find a relationship between a city’s median income and its walkability.
If, like most of us, you have been frustrated in your efforts to lower the BMI of your patients, it may be time to emerge from the confines of your office and take a look at your town’s walkability score. If it is less than 50, you and your fellow concerned citizens and officials have some work to do. It may mean advocating for improved pedestrian infrastructure and/or dismantling the physical and zoning barriers to pedestrian connectivity. For example, maybe your community should be adding more pedestrian-activated crossing signals or tapping into federal and state safe routes to school programs or adopting zoning ordinances that require sidewalks in all new developments.
Here in Brunswick, we have a very enviable walkability score of 87, meaning “most errands can be accomplished on foot.” We have a bicycle and pedestrian advisory committee that reports to the town council and works with the town engineer to advocate for infrastructure improvements that encourage pedestrian connectivity. However, funding these improvements in walkability is always a challenge. But as the analysis in this recent study suggestions, our biggest challenge continues to be encouraging our citizens to take advantage of our existing pedestrian infrastructure.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
The psychiatric care system of the future
Yogi Berra once said, “It’s tough to make predictions, especially about the future.” It is particularly difficult to talk about the future of psychiatric care and the profession of psychiatry given the current state of affairs and the dysfunction of the mental health services system in America today.
The current system is broken. Needs are not being met. Care is underfunded and uncoordinated. Patients fall through the cracks and are criminalized or homeless. And although there are some early signs of reform, such as the push for integration of psychiatry in medical care systems, it is unclear with the potential repeal of the Affordable Care Act and the undoing of parity whether the situation for our patients and the profession might get even worse.
In the year 2067, most physicians will be employees of one out of four major health care nonprofit corporations that are vertically or horizontally integrated systems of care. All Americans will be enrolled through a government-financed universal single payer plan of care, as employer-based health insurance will have disappeared for the last 25 years. Americans will choose which of the four health systems they wish to join during an annual open season and be able to select their primary and specialty care physicians. Many of the services provided will be in the home or workplace through broad and interactive computing and telemedicine capacity and high-tech centers. Hospitals will provide sophisticated gene therapy, organ transplantation, and biomedical engineering. Approximately 30% of the gross national product will be spent on health care.
Americans will live to an average age of 125 years, but it would not be unusual to find some individuals living to age 150. These Americans will have had many of their organs replaced by either genetically programmed animal organs or harvested organs from special banks. However, the brain is the only irreplaceable organ, and psychiatrists will be prominently involved in the interface of brain and behavior as they have been for the past 200 years.
In the year 2067, an expanded specialty of psychiatric physicians will be certified in one of four major categories of practice. Those certifications will be in neuroscience, medical psychiatry, psychotherapy, and social psychiatry.
The neuroscience psychiatrists will combine an MD with a PhD, and will be the most highly technical and specialized and the most highly compensated psychiatrists. They will be the clinician scientists. The neuroscience psychiatrist will be an expert on the human genome, sophisticated brain imaging and mapping, and the differential use of a variety of neurochemicals, as well as the application of technology such as magnetic fields for the treatment of mental illness and direct intervention into the brain with psychosurgery.
The medical psychiatrists will most resemble the early 21st century psychiatrists with subspecialties in geriatrics, adult, child and adolescent, and substance use. The medical psychiatrists will be integrated with other medical colleagues in many ambulatory as well as residential settings. Geriatrics will be the specialty for the treatment of the very old working with the neuroscience psychiatrist in the treatment of dementias and similarly, the child psychiatrist will work with the neuroscience psychiatrists in early preventive interventions at the intrauterine level with genetic abnormalities being corrected before birth. The medical psychiatrist will be a very popular area for all physicians, with more than 20% of all medical graduates specializing in medical psychiatry.
The psychotherapy psychiatrists will combine the MD degree with psychology education, religion, and the humanities. This psychotherapist will work one to one and in group settings on the age-old problems of individuation, separation, grief, loss, insight, and self-actualization.
The social psychiatrists will combine the MD degree with a degree in sociology or criminology and/or a law degree. They will focus on the social control issues of the day. Forensic prisons will be an area of government-sponsored treatment and will dominate the criminal justice system with interventions in an effort to reduce criminal behavior.
Managed care will not exist 50 years from now. It will be perceived as a regrettable experiment of the late 20th century ending in the first part of the 21st century. With the enactment of a universal single payer system of care, the high-cost intrusive middle management of carve-out behavioral health care companies will become moot.
Human progress comes in many forms. By the year 2067, psychiatry will have made significant advances that will make the prior 200 years of psychiatric care seem crude, quaint, and absurd.
Dr. Sharfstein, a past president of the American Psychiatric Association, is president emeritus of the Sheppard Pratt Health System, Baltimore. This essay is based on a presentation he made in February 2017 at the annual meeting of the American College of Psychiatrists in Scottsdale, Ariz.
Yogi Berra once said, “It’s tough to make predictions, especially about the future.” It is particularly difficult to talk about the future of psychiatric care and the profession of psychiatry given the current state of affairs and the dysfunction of the mental health services system in America today.
The current system is broken. Needs are not being met. Care is underfunded and uncoordinated. Patients fall through the cracks and are criminalized or homeless. And although there are some early signs of reform, such as the push for integration of psychiatry in medical care systems, it is unclear with the potential repeal of the Affordable Care Act and the undoing of parity whether the situation for our patients and the profession might get even worse.
In the year 2067, most physicians will be employees of one out of four major health care nonprofit corporations that are vertically or horizontally integrated systems of care. All Americans will be enrolled through a government-financed universal single payer plan of care, as employer-based health insurance will have disappeared for the last 25 years. Americans will choose which of the four health systems they wish to join during an annual open season and be able to select their primary and specialty care physicians. Many of the services provided will be in the home or workplace through broad and interactive computing and telemedicine capacity and high-tech centers. Hospitals will provide sophisticated gene therapy, organ transplantation, and biomedical engineering. Approximately 30% of the gross national product will be spent on health care.
Americans will live to an average age of 125 years, but it would not be unusual to find some individuals living to age 150. These Americans will have had many of their organs replaced by either genetically programmed animal organs or harvested organs from special banks. However, the brain is the only irreplaceable organ, and psychiatrists will be prominently involved in the interface of brain and behavior as they have been for the past 200 years.
In the year 2067, an expanded specialty of psychiatric physicians will be certified in one of four major categories of practice. Those certifications will be in neuroscience, medical psychiatry, psychotherapy, and social psychiatry.
The neuroscience psychiatrists will combine an MD with a PhD, and will be the most highly technical and specialized and the most highly compensated psychiatrists. They will be the clinician scientists. The neuroscience psychiatrist will be an expert on the human genome, sophisticated brain imaging and mapping, and the differential use of a variety of neurochemicals, as well as the application of technology such as magnetic fields for the treatment of mental illness and direct intervention into the brain with psychosurgery.
The medical psychiatrists will most resemble the early 21st century psychiatrists with subspecialties in geriatrics, adult, child and adolescent, and substance use. The medical psychiatrists will be integrated with other medical colleagues in many ambulatory as well as residential settings. Geriatrics will be the specialty for the treatment of the very old working with the neuroscience psychiatrist in the treatment of dementias and similarly, the child psychiatrist will work with the neuroscience psychiatrists in early preventive interventions at the intrauterine level with genetic abnormalities being corrected before birth. The medical psychiatrist will be a very popular area for all physicians, with more than 20% of all medical graduates specializing in medical psychiatry.
The psychotherapy psychiatrists will combine the MD degree with psychology education, religion, and the humanities. This psychotherapist will work one to one and in group settings on the age-old problems of individuation, separation, grief, loss, insight, and self-actualization.
The social psychiatrists will combine the MD degree with a degree in sociology or criminology and/or a law degree. They will focus on the social control issues of the day. Forensic prisons will be an area of government-sponsored treatment and will dominate the criminal justice system with interventions in an effort to reduce criminal behavior.
Managed care will not exist 50 years from now. It will be perceived as a regrettable experiment of the late 20th century ending in the first part of the 21st century. With the enactment of a universal single payer system of care, the high-cost intrusive middle management of carve-out behavioral health care companies will become moot.
Human progress comes in many forms. By the year 2067, psychiatry will have made significant advances that will make the prior 200 years of psychiatric care seem crude, quaint, and absurd.
Dr. Sharfstein, a past president of the American Psychiatric Association, is president emeritus of the Sheppard Pratt Health System, Baltimore. This essay is based on a presentation he made in February 2017 at the annual meeting of the American College of Psychiatrists in Scottsdale, Ariz.
Yogi Berra once said, “It’s tough to make predictions, especially about the future.” It is particularly difficult to talk about the future of psychiatric care and the profession of psychiatry given the current state of affairs and the dysfunction of the mental health services system in America today.
The current system is broken. Needs are not being met. Care is underfunded and uncoordinated. Patients fall through the cracks and are criminalized or homeless. And although there are some early signs of reform, such as the push for integration of psychiatry in medical care systems, it is unclear with the potential repeal of the Affordable Care Act and the undoing of parity whether the situation for our patients and the profession might get even worse.
In the year 2067, most physicians will be employees of one out of four major health care nonprofit corporations that are vertically or horizontally integrated systems of care. All Americans will be enrolled through a government-financed universal single payer plan of care, as employer-based health insurance will have disappeared for the last 25 years. Americans will choose which of the four health systems they wish to join during an annual open season and be able to select their primary and specialty care physicians. Many of the services provided will be in the home or workplace through broad and interactive computing and telemedicine capacity and high-tech centers. Hospitals will provide sophisticated gene therapy, organ transplantation, and biomedical engineering. Approximately 30% of the gross national product will be spent on health care.
Americans will live to an average age of 125 years, but it would not be unusual to find some individuals living to age 150. These Americans will have had many of their organs replaced by either genetically programmed animal organs or harvested organs from special banks. However, the brain is the only irreplaceable organ, and psychiatrists will be prominently involved in the interface of brain and behavior as they have been for the past 200 years.
In the year 2067, an expanded specialty of psychiatric physicians will be certified in one of four major categories of practice. Those certifications will be in neuroscience, medical psychiatry, psychotherapy, and social psychiatry.
The neuroscience psychiatrists will combine an MD with a PhD, and will be the most highly technical and specialized and the most highly compensated psychiatrists. They will be the clinician scientists. The neuroscience psychiatrist will be an expert on the human genome, sophisticated brain imaging and mapping, and the differential use of a variety of neurochemicals, as well as the application of technology such as magnetic fields for the treatment of mental illness and direct intervention into the brain with psychosurgery.
The medical psychiatrists will most resemble the early 21st century psychiatrists with subspecialties in geriatrics, adult, child and adolescent, and substance use. The medical psychiatrists will be integrated with other medical colleagues in many ambulatory as well as residential settings. Geriatrics will be the specialty for the treatment of the very old working with the neuroscience psychiatrist in the treatment of dementias and similarly, the child psychiatrist will work with the neuroscience psychiatrists in early preventive interventions at the intrauterine level with genetic abnormalities being corrected before birth. The medical psychiatrist will be a very popular area for all physicians, with more than 20% of all medical graduates specializing in medical psychiatry.
The psychotherapy psychiatrists will combine the MD degree with psychology education, religion, and the humanities. This psychotherapist will work one to one and in group settings on the age-old problems of individuation, separation, grief, loss, insight, and self-actualization.
The social psychiatrists will combine the MD degree with a degree in sociology or criminology and/or a law degree. They will focus on the social control issues of the day. Forensic prisons will be an area of government-sponsored treatment and will dominate the criminal justice system with interventions in an effort to reduce criminal behavior.
Managed care will not exist 50 years from now. It will be perceived as a regrettable experiment of the late 20th century ending in the first part of the 21st century. With the enactment of a universal single payer system of care, the high-cost intrusive middle management of carve-out behavioral health care companies will become moot.
Human progress comes in many forms. By the year 2067, psychiatry will have made significant advances that will make the prior 200 years of psychiatric care seem crude, quaint, and absurd.
Dr. Sharfstein, a past president of the American Psychiatric Association, is president emeritus of the Sheppard Pratt Health System, Baltimore. This essay is based on a presentation he made in February 2017 at the annual meeting of the American College of Psychiatrists in Scottsdale, Ariz.
Unforgiveness
Her visit seemed uneventful enough. Back for the semester break of her senior year, Jenna came in for acne follow-up.
She seemed to be doing pretty well: just a couple of active papules on each cheek, as well as some residual fading red marks from old lesions. Still, Jenna was not happy with her situation.
“Some of the marks you have just haven’t had time to fade away yet,” I said. “But since you’re still getting new ones, perhaps we should change antibiotics. After 4 months, it’s not likely that the one you’re taking will clear you up as fully as you want. Perhaps a different one will, although complete clearing can be a hard goal to reach.”
I discussed alternative choices with Jenna, settling on one as being most likely to help and unlikely to cause problems while she was away at school. I encouraged her to continue the same topical treatment she was on – she had had “reactions” to several previous topical tries – to contact me with any problems, and to return in May.
As I wrote up her prescriptions, I asked her about her academic major.
“Electrical engineering,” she said. “My goal is to work for a couple of years, then get advanced degrees in both engineering and law. I want to fuse both disciplines in a business context.”
I congratulated her on her clarity of vision. Few college seniors have more than a vague notion of where they’re headed. I wished her well and left the room.
Because the encounter seemed pleasant and innocuous, I was taken aback when my secretary came in a couple of hours later.
“Jenna’s father has called twice,” she said. “He says he’s furious that you didn’t spend enough time with his daughter or answer all of her questions.”
Sighing inwardly, I sat down during a break and called her.
“This is Dr. Rockoff,” I said. “I understand that you were unhappy with your visit.”
“That’s right,” she said, evenly. “Very unhappy. You only spent five minutes with me. I forgot to ask you all my questions.”
“I’m sorry,” I said. “What questions did you forget to ask me?”
“I have marks on my back where the acne used to be, and they haven’t gone away.”
“I see,” I said. “I thought we had covered that in connection with the marks still on your face, but I’m sorry if I didn’t make that clear. The marks need to fade on their own, and they will, though it will probably take a few more months.”
“You didn’t give me enough time at my previous visit,” she said. “I give people the benefit of the doubt, so I gave you a second chance, and again you kept me waiting, and then you didn’t spend enough time with me.”
“I’m very sorry that I didn’t meet your expectations,” I said. “If you come back to see me, I will try to do a better job. If you decide you want to get care elsewhere, of course I’ll be happy to forward your records to another physician.”
“I gave you a second chance,” Jenna said, “and again you failed to spend adequate time or deliver satisfactory service.”
“Again, my apologies,” I said. I wished her luck and ended the call.
After all these years, I think I’m pretty good at picking up physical and verbal cues of anger and dissatisfaction, but clearly I missed them all in Jenna’s case. Like everyone else, I’ve had my share of unhappy patients, but I’m hard put to remember being laid out in lavender with such gusto before.
When I finally hang up my spurs, there are a lot of things about practicing medicine that I will miss. Being dressed-down by unforgiving kids less than a third my age will not be one of them.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
Her visit seemed uneventful enough. Back for the semester break of her senior year, Jenna came in for acne follow-up.
She seemed to be doing pretty well: just a couple of active papules on each cheek, as well as some residual fading red marks from old lesions. Still, Jenna was not happy with her situation.
“Some of the marks you have just haven’t had time to fade away yet,” I said. “But since you’re still getting new ones, perhaps we should change antibiotics. After 4 months, it’s not likely that the one you’re taking will clear you up as fully as you want. Perhaps a different one will, although complete clearing can be a hard goal to reach.”
I discussed alternative choices with Jenna, settling on one as being most likely to help and unlikely to cause problems while she was away at school. I encouraged her to continue the same topical treatment she was on – she had had “reactions” to several previous topical tries – to contact me with any problems, and to return in May.
As I wrote up her prescriptions, I asked her about her academic major.
“Electrical engineering,” she said. “My goal is to work for a couple of years, then get advanced degrees in both engineering and law. I want to fuse both disciplines in a business context.”
I congratulated her on her clarity of vision. Few college seniors have more than a vague notion of where they’re headed. I wished her well and left the room.
Because the encounter seemed pleasant and innocuous, I was taken aback when my secretary came in a couple of hours later.
“Jenna’s father has called twice,” she said. “He says he’s furious that you didn’t spend enough time with his daughter or answer all of her questions.”
Sighing inwardly, I sat down during a break and called her.
“This is Dr. Rockoff,” I said. “I understand that you were unhappy with your visit.”
“That’s right,” she said, evenly. “Very unhappy. You only spent five minutes with me. I forgot to ask you all my questions.”
“I’m sorry,” I said. “What questions did you forget to ask me?”
“I have marks on my back where the acne used to be, and they haven’t gone away.”
“I see,” I said. “I thought we had covered that in connection with the marks still on your face, but I’m sorry if I didn’t make that clear. The marks need to fade on their own, and they will, though it will probably take a few more months.”
“You didn’t give me enough time at my previous visit,” she said. “I give people the benefit of the doubt, so I gave you a second chance, and again you kept me waiting, and then you didn’t spend enough time with me.”
“I’m very sorry that I didn’t meet your expectations,” I said. “If you come back to see me, I will try to do a better job. If you decide you want to get care elsewhere, of course I’ll be happy to forward your records to another physician.”
“I gave you a second chance,” Jenna said, “and again you failed to spend adequate time or deliver satisfactory service.”
“Again, my apologies,” I said. I wished her luck and ended the call.
After all these years, I think I’m pretty good at picking up physical and verbal cues of anger and dissatisfaction, but clearly I missed them all in Jenna’s case. Like everyone else, I’ve had my share of unhappy patients, but I’m hard put to remember being laid out in lavender with such gusto before.
When I finally hang up my spurs, there are a lot of things about practicing medicine that I will miss. Being dressed-down by unforgiving kids less than a third my age will not be one of them.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
Her visit seemed uneventful enough. Back for the semester break of her senior year, Jenna came in for acne follow-up.
She seemed to be doing pretty well: just a couple of active papules on each cheek, as well as some residual fading red marks from old lesions. Still, Jenna was not happy with her situation.
“Some of the marks you have just haven’t had time to fade away yet,” I said. “But since you’re still getting new ones, perhaps we should change antibiotics. After 4 months, it’s not likely that the one you’re taking will clear you up as fully as you want. Perhaps a different one will, although complete clearing can be a hard goal to reach.”
I discussed alternative choices with Jenna, settling on one as being most likely to help and unlikely to cause problems while she was away at school. I encouraged her to continue the same topical treatment she was on – she had had “reactions” to several previous topical tries – to contact me with any problems, and to return in May.
As I wrote up her prescriptions, I asked her about her academic major.
“Electrical engineering,” she said. “My goal is to work for a couple of years, then get advanced degrees in both engineering and law. I want to fuse both disciplines in a business context.”
I congratulated her on her clarity of vision. Few college seniors have more than a vague notion of where they’re headed. I wished her well and left the room.
Because the encounter seemed pleasant and innocuous, I was taken aback when my secretary came in a couple of hours later.
“Jenna’s father has called twice,” she said. “He says he’s furious that you didn’t spend enough time with his daughter or answer all of her questions.”
Sighing inwardly, I sat down during a break and called her.
“This is Dr. Rockoff,” I said. “I understand that you were unhappy with your visit.”
“That’s right,” she said, evenly. “Very unhappy. You only spent five minutes with me. I forgot to ask you all my questions.”
“I’m sorry,” I said. “What questions did you forget to ask me?”
“I have marks on my back where the acne used to be, and they haven’t gone away.”
“I see,” I said. “I thought we had covered that in connection with the marks still on your face, but I’m sorry if I didn’t make that clear. The marks need to fade on their own, and they will, though it will probably take a few more months.”
“You didn’t give me enough time at my previous visit,” she said. “I give people the benefit of the doubt, so I gave you a second chance, and again you kept me waiting, and then you didn’t spend enough time with me.”
“I’m very sorry that I didn’t meet your expectations,” I said. “If you come back to see me, I will try to do a better job. If you decide you want to get care elsewhere, of course I’ll be happy to forward your records to another physician.”
“I gave you a second chance,” Jenna said, “and again you failed to spend adequate time or deliver satisfactory service.”
“Again, my apologies,” I said. I wished her luck and ended the call.
After all these years, I think I’m pretty good at picking up physical and verbal cues of anger and dissatisfaction, but clearly I missed them all in Jenna’s case. Like everyone else, I’ve had my share of unhappy patients, but I’m hard put to remember being laid out in lavender with such gusto before.
When I finally hang up my spurs, there are a lot of things about practicing medicine that I will miss. Being dressed-down by unforgiving kids less than a third my age will not be one of them.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].