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The VA Is Not Just a Hospital, It Is a Community
The residency applicant walking with me through the lobby of the Albuquerque VA hospital on the way to an interview in my office asked me, “Are all VAs like this?” She was referring to the mariachi band that was entertaining veterans, families, and staff and the volunteer who was serving popcorn—for many years a regular feature at our VA. I responded, “No, they are all a little different, but yes, every VA is more than a hospital.” If she had asked a follow-up question, I would have added, “It is a community.”
Merriam-Webster’s Collegiate Dictionary has multiple definitions of community, and it is remarkable that most of them in one way or another describe the VA from the perspective of many veterans and even career employees:
- 1: a unified body of individuals: as
a: state, commonwealth
b: the people with common interests living in a particular area; broadly: the area itself (eg, the problems of a large community)
c: an interacting population of various kinds of individuals (as species) in a common location
d: a group of people with a common characteristic or interest in living together within a larger society (eg, a community of retired persons)
e: a group linked by a common policy
f: a body of persons or nations having a common history or common social, economic, and political interests (eg, the international community)
g: a body of persons of common and especially professional interests scattered through a larger society (eg, the academic community) - 2: society at large
- 3a: joint ownership or participation (community of goods)
b: common character: likeness (community of interests)
c: social activity: fellowship d: a social state or condition
d: a social state or condition
There is much talk in the media about the privatization of the VA. There are zealous critics who argue that privatization would improve access and quality of care. I won’t debate that here.
What I want to consider is what the VA represents and provides in addition to health care. Each VA hospital and clinic serves “a body of persons or nations having a common history or common social, economic, and political interests.” Sit in the waiting area of any VA emergency department or pharmacy and you will hear bonding conversations between veterans. Even when the conversation is critical of the VA, it is because it is their hospital. That “joint ownership or participation” means that every VA employee, including the nearly 30% who wore a uniform, is there for a single purpose: to help veterans. That is our sole mission and advocacy.
Back to my VA. We are “a group of people with a common characteristic or interest living together within a larger society.” Similar to most other large medical centers, this VA is like the army base where I was born and raised—a small village. The single most popular service at my VA is the barber shop where veterans can get a haircut and shave. We also have an extensive clothing closet where eligible veterans experiencing tough times can get decent clothes.
Our VA, like almost any military base, has a post exchange that sells a little bit of everything from snacks to small appliances. When I was an intern, I treated an elderly patient who was in a deep psychotic depression and was transferred with only the clothes he was wearing. After several electroconvulsive treatments, I could tell he was feeling better when he asked me to buy him underwear from the post exchange downstairs. What this patient needed, the community provided.
A VA medical center is “a group of people with a common characteristic or interest living together within a larger society.” Like any American small town, there is a chapel where twice a year chaplains hold a memorial service for families and staff of patients who recently passed away in our hospital. At other times, we gather as a family of various and no faiths to grieve over the loss of a beloved fellow employee who, all too often, died too soon under tragic circumstances.
Much of this interaction naturally takes place around food. In the morning, there is a line at the coffee shop in the lobby that matches any Starbucks in town. Our VA also has an award-winning canteen that knows the favorite dishes of veterans and employees. If you go for breakfast or lunch, you will almost always run in to someone you have not seen in a while and have a quick visit.
At our VA, you also can browse kiosks of handcrafted items and military memorabilia and support small veteran-owned businesses. In good weather you can buy fruits and vegetables at the veteran farmers market and hear the stories of backyard gardeners and small farmers.
There are special events for every season. In the summer, concerts are held in the gazebo and veteran and guest musicians play all types of music. We even have a VA all-star band made up of current and former employees. The band is a big hit with patients and staff alike.
Although many of these community resources are unique to my VA, the effort to provide a welcoming atmosphere for veterans and health care providers to come together as a community is not unusual. Most VA medical centers have developed cultural responses to the needs of the veterans who return often over the course of years to their VA community.
One definition that does not apply to the large, diverse veteran population or to their health care providers is “a unified body of individuals.” There are many veterans who never have and never will set foot inside a VA hospital for many complex reasons. But for those who do call it home and want to receive care under VA auspices, a private VA would result in a deep and abiding loss of community. This loss is especially true for the most disadvantaged and vulnerable for whom the VA provides a broad and compassionate safety net. Under that protective tent, unbefriended veterans may grow closer to employees who have cared for them for years than to their family. Patients with complex medical and psychiatric needs, such as spinal cord injuries, polytrauma, substance use disorders, and posttraumatic stress disorder find specialized services dedicated to them that would be difficult to rival anywhere in the private sector.What also is not appreciated amid the fierce and too often well-deserved criticisms of VA business processes is that all VA health care practitioners are “a group linked by a common policy.” Even if we do not always live up to them, the VA has higher regulatory and ethical standards than almost any civilian health care organization. Ensuring those standards are followed in a myriad of health care entities not under VA policy and federal regulation seems a shibboleth.
The residency applicant walking with me through the lobby of the Albuquerque VA hospital on the way to an interview in my office asked me, “Are all VAs like this?” She was referring to the mariachi band that was entertaining veterans, families, and staff and the volunteer who was serving popcorn—for many years a regular feature at our VA. I responded, “No, they are all a little different, but yes, every VA is more than a hospital.” If she had asked a follow-up question, I would have added, “It is a community.”
Merriam-Webster’s Collegiate Dictionary has multiple definitions of community, and it is remarkable that most of them in one way or another describe the VA from the perspective of many veterans and even career employees:
- 1: a unified body of individuals: as
a: state, commonwealth
b: the people with common interests living in a particular area; broadly: the area itself (eg, the problems of a large community)
c: an interacting population of various kinds of individuals (as species) in a common location
d: a group of people with a common characteristic or interest in living together within a larger society (eg, a community of retired persons)
e: a group linked by a common policy
f: a body of persons or nations having a common history or common social, economic, and political interests (eg, the international community)
g: a body of persons of common and especially professional interests scattered through a larger society (eg, the academic community) - 2: society at large
- 3a: joint ownership or participation (community of goods)
b: common character: likeness (community of interests)
c: social activity: fellowship d: a social state or condition
d: a social state or condition
There is much talk in the media about the privatization of the VA. There are zealous critics who argue that privatization would improve access and quality of care. I won’t debate that here.
What I want to consider is what the VA represents and provides in addition to health care. Each VA hospital and clinic serves “a body of persons or nations having a common history or common social, economic, and political interests.” Sit in the waiting area of any VA emergency department or pharmacy and you will hear bonding conversations between veterans. Even when the conversation is critical of the VA, it is because it is their hospital. That “joint ownership or participation” means that every VA employee, including the nearly 30% who wore a uniform, is there for a single purpose: to help veterans. That is our sole mission and advocacy.
Back to my VA. We are “a group of people with a common characteristic or interest living together within a larger society.” Similar to most other large medical centers, this VA is like the army base where I was born and raised—a small village. The single most popular service at my VA is the barber shop where veterans can get a haircut and shave. We also have an extensive clothing closet where eligible veterans experiencing tough times can get decent clothes.
Our VA, like almost any military base, has a post exchange that sells a little bit of everything from snacks to small appliances. When I was an intern, I treated an elderly patient who was in a deep psychotic depression and was transferred with only the clothes he was wearing. After several electroconvulsive treatments, I could tell he was feeling better when he asked me to buy him underwear from the post exchange downstairs. What this patient needed, the community provided.
A VA medical center is “a group of people with a common characteristic or interest living together within a larger society.” Like any American small town, there is a chapel where twice a year chaplains hold a memorial service for families and staff of patients who recently passed away in our hospital. At other times, we gather as a family of various and no faiths to grieve over the loss of a beloved fellow employee who, all too often, died too soon under tragic circumstances.
Much of this interaction naturally takes place around food. In the morning, there is a line at the coffee shop in the lobby that matches any Starbucks in town. Our VA also has an award-winning canteen that knows the favorite dishes of veterans and employees. If you go for breakfast or lunch, you will almost always run in to someone you have not seen in a while and have a quick visit.
At our VA, you also can browse kiosks of handcrafted items and military memorabilia and support small veteran-owned businesses. In good weather you can buy fruits and vegetables at the veteran farmers market and hear the stories of backyard gardeners and small farmers.
There are special events for every season. In the summer, concerts are held in the gazebo and veteran and guest musicians play all types of music. We even have a VA all-star band made up of current and former employees. The band is a big hit with patients and staff alike.
Although many of these community resources are unique to my VA, the effort to provide a welcoming atmosphere for veterans and health care providers to come together as a community is not unusual. Most VA medical centers have developed cultural responses to the needs of the veterans who return often over the course of years to their VA community.
One definition that does not apply to the large, diverse veteran population or to their health care providers is “a unified body of individuals.” There are many veterans who never have and never will set foot inside a VA hospital for many complex reasons. But for those who do call it home and want to receive care under VA auspices, a private VA would result in a deep and abiding loss of community. This loss is especially true for the most disadvantaged and vulnerable for whom the VA provides a broad and compassionate safety net. Under that protective tent, unbefriended veterans may grow closer to employees who have cared for them for years than to their family. Patients with complex medical and psychiatric needs, such as spinal cord injuries, polytrauma, substance use disorders, and posttraumatic stress disorder find specialized services dedicated to them that would be difficult to rival anywhere in the private sector.What also is not appreciated amid the fierce and too often well-deserved criticisms of VA business processes is that all VA health care practitioners are “a group linked by a common policy.” Even if we do not always live up to them, the VA has higher regulatory and ethical standards than almost any civilian health care organization. Ensuring those standards are followed in a myriad of health care entities not under VA policy and federal regulation seems a shibboleth.
The residency applicant walking with me through the lobby of the Albuquerque VA hospital on the way to an interview in my office asked me, “Are all VAs like this?” She was referring to the mariachi band that was entertaining veterans, families, and staff and the volunteer who was serving popcorn—for many years a regular feature at our VA. I responded, “No, they are all a little different, but yes, every VA is more than a hospital.” If she had asked a follow-up question, I would have added, “It is a community.”
Merriam-Webster’s Collegiate Dictionary has multiple definitions of community, and it is remarkable that most of them in one way or another describe the VA from the perspective of many veterans and even career employees:
- 1: a unified body of individuals: as
a: state, commonwealth
b: the people with common interests living in a particular area; broadly: the area itself (eg, the problems of a large community)
c: an interacting population of various kinds of individuals (as species) in a common location
d: a group of people with a common characteristic or interest in living together within a larger society (eg, a community of retired persons)
e: a group linked by a common policy
f: a body of persons or nations having a common history or common social, economic, and political interests (eg, the international community)
g: a body of persons of common and especially professional interests scattered through a larger society (eg, the academic community) - 2: society at large
- 3a: joint ownership or participation (community of goods)
b: common character: likeness (community of interests)
c: social activity: fellowship d: a social state or condition
d: a social state or condition
There is much talk in the media about the privatization of the VA. There are zealous critics who argue that privatization would improve access and quality of care. I won’t debate that here.
What I want to consider is what the VA represents and provides in addition to health care. Each VA hospital and clinic serves “a body of persons or nations having a common history or common social, economic, and political interests.” Sit in the waiting area of any VA emergency department or pharmacy and you will hear bonding conversations between veterans. Even when the conversation is critical of the VA, it is because it is their hospital. That “joint ownership or participation” means that every VA employee, including the nearly 30% who wore a uniform, is there for a single purpose: to help veterans. That is our sole mission and advocacy.
Back to my VA. We are “a group of people with a common characteristic or interest living together within a larger society.” Similar to most other large medical centers, this VA is like the army base where I was born and raised—a small village. The single most popular service at my VA is the barber shop where veterans can get a haircut and shave. We also have an extensive clothing closet where eligible veterans experiencing tough times can get decent clothes.
Our VA, like almost any military base, has a post exchange that sells a little bit of everything from snacks to small appliances. When I was an intern, I treated an elderly patient who was in a deep psychotic depression and was transferred with only the clothes he was wearing. After several electroconvulsive treatments, I could tell he was feeling better when he asked me to buy him underwear from the post exchange downstairs. What this patient needed, the community provided.
A VA medical center is “a group of people with a common characteristic or interest living together within a larger society.” Like any American small town, there is a chapel where twice a year chaplains hold a memorial service for families and staff of patients who recently passed away in our hospital. At other times, we gather as a family of various and no faiths to grieve over the loss of a beloved fellow employee who, all too often, died too soon under tragic circumstances.
Much of this interaction naturally takes place around food. In the morning, there is a line at the coffee shop in the lobby that matches any Starbucks in town. Our VA also has an award-winning canteen that knows the favorite dishes of veterans and employees. If you go for breakfast or lunch, you will almost always run in to someone you have not seen in a while and have a quick visit.
At our VA, you also can browse kiosks of handcrafted items and military memorabilia and support small veteran-owned businesses. In good weather you can buy fruits and vegetables at the veteran farmers market and hear the stories of backyard gardeners and small farmers.
There are special events for every season. In the summer, concerts are held in the gazebo and veteran and guest musicians play all types of music. We even have a VA all-star band made up of current and former employees. The band is a big hit with patients and staff alike.
Although many of these community resources are unique to my VA, the effort to provide a welcoming atmosphere for veterans and health care providers to come together as a community is not unusual. Most VA medical centers have developed cultural responses to the needs of the veterans who return often over the course of years to their VA community.
One definition that does not apply to the large, diverse veteran population or to their health care providers is “a unified body of individuals.” There are many veterans who never have and never will set foot inside a VA hospital for many complex reasons. But for those who do call it home and want to receive care under VA auspices, a private VA would result in a deep and abiding loss of community. This loss is especially true for the most disadvantaged and vulnerable for whom the VA provides a broad and compassionate safety net. Under that protective tent, unbefriended veterans may grow closer to employees who have cared for them for years than to their family. Patients with complex medical and psychiatric needs, such as spinal cord injuries, polytrauma, substance use disorders, and posttraumatic stress disorder find specialized services dedicated to them that would be difficult to rival anywhere in the private sector.What also is not appreciated amid the fierce and too often well-deserved criticisms of VA business processes is that all VA health care practitioners are “a group linked by a common policy.” Even if we do not always live up to them, the VA has higher regulatory and ethical standards than almost any civilian health care organization. Ensuring those standards are followed in a myriad of health care entities not under VA policy and federal regulation seems a shibboleth.
Medical psychiatry: The skill of integrating medical and psychiatric care
Although the meaning of these terms varied from department to department, biologically oriented programs—influenced by Eli Robins and Samuel Guze and DSM-III—were focused on descriptive psychiatry: reliable, observable, and symptom-based elements of psychiatric illness. Related and important elements were a focus on psychopharmacologic treatments, genetics, epidemiology, and putative mechanisms for both diseases and treatments. Psychodynamic programs had a primary focus on psychodynamic theory, with extensive training in long-term, depth-oriented psychotherapy. Many of these are programs employed charismatic and brilliant teachers whose supervisory and interviewing skills were legendary. And, of course, all the programs claimed they did everything and did it well.
However, none of these programs were exactly what I was looking for. Although I had a long-standing interest in psychodynamics and was fascinated by the implications of—what was then a far more nascent—neurobiology, I was looking for a program that had all of these elements, but also had a focus on, what I thought of as, “medical psychiatry.” Although this may have meant different things to others, and was known as “psychosomatic medicine” or “consultation-liaison psychiatry,” to me, it was about the psychiatric manifestations of medical and neurologic disorders.
My years training in internal medicine were full of patients with neuropsychiatric illness due to a host of general medical and neurologic disorders. When I was an intern, the most common admitting diagnosis was what we called “Delta MS”—change in mental status. As I advanced in my residency and focused on a subspecialty of internal medicine, it became clear that whichever illnesses I studied, conditions such as anxiety disorders in Grave’s disease or the psychotic symptoms in lupus held my interest. Finally, the only specialty left was psychiatry.
The only program I found that seemed to understand medical psychiatry at the time was at Massachusetts General Hospital (MGH). MGH not only had eminent psychiatrists in every area of the field, it seemed, but also a special focus on training psychiatrists in medical settings and as medical experts. My first Chief of Psychiatry was Thomas P. Hackett, MD—a brilliant clinician, raconteur, and polymath—who had written a cri de coeur on the importance of medical skills and training in psychiatry.1 At last, I had found a place where I could remain a physician and think and learn about every aspect of psychiatry, especially medical psychiatry.
What is medical psychiatry, and why is it relevant now?
There has been substantial and increasing interest in the integration of medical and psychiatric care. Whether it is collaborative care or co-location models, the recognition of the high rate of combined medical and psychiatric illnesses and associated increased mortality and total health care costs of these patients requires psychiatrists to be deeply familiar with the interactions among medical and psychiatric conditions.
Building on long-developed expertise in consultation-liaison psychiatry and other forms of medical psychiatric training, such as double-board medicine–psychiatry programs, medical psychiatry includes several specific areas of knowledge and skill sets, including understanding the impact that psychiatric illnesses and the medications used to treat them can have on medical illnesses and the ways in which the presence of medical disorders can change the presentation of psychiatric illnesses. Similarly, the psychiatric impact of the general medical pharmacopeia and the ways in which psychiatric illness can affect the presentation of medical illness are important for all psychiatrists to know. Most importantly, medical psychiatry should focus on the medical and neurologic causes of psychiatric illnesses. Many general medical conditions produce symptoms, which, in whole or in part, mimic psychiatric illnesses and, in some cases, could lead to psychiatric disorders, which makes identification of the underlying cause difficult.
Whether due to infectious, autoimmune, metabolic, or endocrinologic disorders, being aware of these conditions and, where clinical circumstances warrant, be able to diagnose them, with other specialists as needed, and ensure they are appropriately treated should be an essential skill for psychiatrists.
An illustrative case
I remember a case from early in my training of a woman with a late-onset mood disorder with abulia, wide-based gait, and urinary incontinence, in addition to withdrawal and loss of pleasure. Despite the skepticism of the neurology team, at autopsy she was found to have arteriosclerosis of the deep, penetrating arterioles causing white matter hyperintensities—Binswanger’s disease. There was no question that despite the neurologic cause of her symptoms treating her depression with antidepressants was needed and helpful. It also was important that her family was aware of her underlying medical condition and its implications for her care.2
Medicine is our calling
Many of these illnesses, even when identified, require expert psychiatric management of psychiatric symptoms. This should not be surprising to psychiatrists or other clinicians. No one expects a cardiologist to beg off the care of a patient with heart failure caused by alcohol abuse or a virus rather than vascular heart disease, and psychiatrists likewise need to manage psychosis due to steroid use or N-methyl-
Medical psychiatry has a broader and more inclusive perspective than what we generally mean by “biological psychiatry,” if by the latter, we mean a focus on the neurobiology and psychopharmacology of “primary” psychiatric conditions that are not secondary to other medical or neurologic disorders. As important and fundamental as deep understanding of neurobiology, genetics, and psychopharmacology are, medical psychiatry embeds our work more broadly in all of human biology and requires the full breadth of our medical training.
At a time when political battles over prescriptive privileges by non-medically trained mental health clinicians engage legislatures and professional organizations, medical psychiatry is a powerful reminder that prescribing or not prescribing medications is the final step in, what should be, an extensive, clinical evaluation including a thorough medical work up and consideration of the medical–psychiatric interactions and the differential diagnosis of these illnesses. It is, after all, what physicians do and is essential to our calling as psychiatric physicians. If psychiatrists are not at home in medicine, as Tom Hackett reminded us in 19771—at a time when psychiatry had temporarily eliminated the requirement for medical internships—then, indeed, psychiatry would be “homeless.”
2. Summergrad P. Depression in Binswanger’s encephalopathy responsive to tranylcypromine: case report. J Clin Psychiatry. 1985;46(2):69-70.
Although the meaning of these terms varied from department to department, biologically oriented programs—influenced by Eli Robins and Samuel Guze and DSM-III—were focused on descriptive psychiatry: reliable, observable, and symptom-based elements of psychiatric illness. Related and important elements were a focus on psychopharmacologic treatments, genetics, epidemiology, and putative mechanisms for both diseases and treatments. Psychodynamic programs had a primary focus on psychodynamic theory, with extensive training in long-term, depth-oriented psychotherapy. Many of these are programs employed charismatic and brilliant teachers whose supervisory and interviewing skills were legendary. And, of course, all the programs claimed they did everything and did it well.
However, none of these programs were exactly what I was looking for. Although I had a long-standing interest in psychodynamics and was fascinated by the implications of—what was then a far more nascent—neurobiology, I was looking for a program that had all of these elements, but also had a focus on, what I thought of as, “medical psychiatry.” Although this may have meant different things to others, and was known as “psychosomatic medicine” or “consultation-liaison psychiatry,” to me, it was about the psychiatric manifestations of medical and neurologic disorders.
My years training in internal medicine were full of patients with neuropsychiatric illness due to a host of general medical and neurologic disorders. When I was an intern, the most common admitting diagnosis was what we called “Delta MS”—change in mental status. As I advanced in my residency and focused on a subspecialty of internal medicine, it became clear that whichever illnesses I studied, conditions such as anxiety disorders in Grave’s disease or the psychotic symptoms in lupus held my interest. Finally, the only specialty left was psychiatry.
The only program I found that seemed to understand medical psychiatry at the time was at Massachusetts General Hospital (MGH). MGH not only had eminent psychiatrists in every area of the field, it seemed, but also a special focus on training psychiatrists in medical settings and as medical experts. My first Chief of Psychiatry was Thomas P. Hackett, MD—a brilliant clinician, raconteur, and polymath—who had written a cri de coeur on the importance of medical skills and training in psychiatry.1 At last, I had found a place where I could remain a physician and think and learn about every aspect of psychiatry, especially medical psychiatry.
What is medical psychiatry, and why is it relevant now?
There has been substantial and increasing interest in the integration of medical and psychiatric care. Whether it is collaborative care or co-location models, the recognition of the high rate of combined medical and psychiatric illnesses and associated increased mortality and total health care costs of these patients requires psychiatrists to be deeply familiar with the interactions among medical and psychiatric conditions.
Building on long-developed expertise in consultation-liaison psychiatry and other forms of medical psychiatric training, such as double-board medicine–psychiatry programs, medical psychiatry includes several specific areas of knowledge and skill sets, including understanding the impact that psychiatric illnesses and the medications used to treat them can have on medical illnesses and the ways in which the presence of medical disorders can change the presentation of psychiatric illnesses. Similarly, the psychiatric impact of the general medical pharmacopeia and the ways in which psychiatric illness can affect the presentation of medical illness are important for all psychiatrists to know. Most importantly, medical psychiatry should focus on the medical and neurologic causes of psychiatric illnesses. Many general medical conditions produce symptoms, which, in whole or in part, mimic psychiatric illnesses and, in some cases, could lead to psychiatric disorders, which makes identification of the underlying cause difficult.
Whether due to infectious, autoimmune, metabolic, or endocrinologic disorders, being aware of these conditions and, where clinical circumstances warrant, be able to diagnose them, with other specialists as needed, and ensure they are appropriately treated should be an essential skill for psychiatrists.
An illustrative case
I remember a case from early in my training of a woman with a late-onset mood disorder with abulia, wide-based gait, and urinary incontinence, in addition to withdrawal and loss of pleasure. Despite the skepticism of the neurology team, at autopsy she was found to have arteriosclerosis of the deep, penetrating arterioles causing white matter hyperintensities—Binswanger’s disease. There was no question that despite the neurologic cause of her symptoms treating her depression with antidepressants was needed and helpful. It also was important that her family was aware of her underlying medical condition and its implications for her care.2
Medicine is our calling
Many of these illnesses, even when identified, require expert psychiatric management of psychiatric symptoms. This should not be surprising to psychiatrists or other clinicians. No one expects a cardiologist to beg off the care of a patient with heart failure caused by alcohol abuse or a virus rather than vascular heart disease, and psychiatrists likewise need to manage psychosis due to steroid use or N-methyl-
Medical psychiatry has a broader and more inclusive perspective than what we generally mean by “biological psychiatry,” if by the latter, we mean a focus on the neurobiology and psychopharmacology of “primary” psychiatric conditions that are not secondary to other medical or neurologic disorders. As important and fundamental as deep understanding of neurobiology, genetics, and psychopharmacology are, medical psychiatry embeds our work more broadly in all of human biology and requires the full breadth of our medical training.
At a time when political battles over prescriptive privileges by non-medically trained mental health clinicians engage legislatures and professional organizations, medical psychiatry is a powerful reminder that prescribing or not prescribing medications is the final step in, what should be, an extensive, clinical evaluation including a thorough medical work up and consideration of the medical–psychiatric interactions and the differential diagnosis of these illnesses. It is, after all, what physicians do and is essential to our calling as psychiatric physicians. If psychiatrists are not at home in medicine, as Tom Hackett reminded us in 19771—at a time when psychiatry had temporarily eliminated the requirement for medical internships—then, indeed, psychiatry would be “homeless.”
Although the meaning of these terms varied from department to department, biologically oriented programs—influenced by Eli Robins and Samuel Guze and DSM-III—were focused on descriptive psychiatry: reliable, observable, and symptom-based elements of psychiatric illness. Related and important elements were a focus on psychopharmacologic treatments, genetics, epidemiology, and putative mechanisms for both diseases and treatments. Psychodynamic programs had a primary focus on psychodynamic theory, with extensive training in long-term, depth-oriented psychotherapy. Many of these are programs employed charismatic and brilliant teachers whose supervisory and interviewing skills were legendary. And, of course, all the programs claimed they did everything and did it well.
However, none of these programs were exactly what I was looking for. Although I had a long-standing interest in psychodynamics and was fascinated by the implications of—what was then a far more nascent—neurobiology, I was looking for a program that had all of these elements, but also had a focus on, what I thought of as, “medical psychiatry.” Although this may have meant different things to others, and was known as “psychosomatic medicine” or “consultation-liaison psychiatry,” to me, it was about the psychiatric manifestations of medical and neurologic disorders.
My years training in internal medicine were full of patients with neuropsychiatric illness due to a host of general medical and neurologic disorders. When I was an intern, the most common admitting diagnosis was what we called “Delta MS”—change in mental status. As I advanced in my residency and focused on a subspecialty of internal medicine, it became clear that whichever illnesses I studied, conditions such as anxiety disorders in Grave’s disease or the psychotic symptoms in lupus held my interest. Finally, the only specialty left was psychiatry.
The only program I found that seemed to understand medical psychiatry at the time was at Massachusetts General Hospital (MGH). MGH not only had eminent psychiatrists in every area of the field, it seemed, but also a special focus on training psychiatrists in medical settings and as medical experts. My first Chief of Psychiatry was Thomas P. Hackett, MD—a brilliant clinician, raconteur, and polymath—who had written a cri de coeur on the importance of medical skills and training in psychiatry.1 At last, I had found a place where I could remain a physician and think and learn about every aspect of psychiatry, especially medical psychiatry.
What is medical psychiatry, and why is it relevant now?
There has been substantial and increasing interest in the integration of medical and psychiatric care. Whether it is collaborative care or co-location models, the recognition of the high rate of combined medical and psychiatric illnesses and associated increased mortality and total health care costs of these patients requires psychiatrists to be deeply familiar with the interactions among medical and psychiatric conditions.
Building on long-developed expertise in consultation-liaison psychiatry and other forms of medical psychiatric training, such as double-board medicine–psychiatry programs, medical psychiatry includes several specific areas of knowledge and skill sets, including understanding the impact that psychiatric illnesses and the medications used to treat them can have on medical illnesses and the ways in which the presence of medical disorders can change the presentation of psychiatric illnesses. Similarly, the psychiatric impact of the general medical pharmacopeia and the ways in which psychiatric illness can affect the presentation of medical illness are important for all psychiatrists to know. Most importantly, medical psychiatry should focus on the medical and neurologic causes of psychiatric illnesses. Many general medical conditions produce symptoms, which, in whole or in part, mimic psychiatric illnesses and, in some cases, could lead to psychiatric disorders, which makes identification of the underlying cause difficult.
Whether due to infectious, autoimmune, metabolic, or endocrinologic disorders, being aware of these conditions and, where clinical circumstances warrant, be able to diagnose them, with other specialists as needed, and ensure they are appropriately treated should be an essential skill for psychiatrists.
An illustrative case
I remember a case from early in my training of a woman with a late-onset mood disorder with abulia, wide-based gait, and urinary incontinence, in addition to withdrawal and loss of pleasure. Despite the skepticism of the neurology team, at autopsy she was found to have arteriosclerosis of the deep, penetrating arterioles causing white matter hyperintensities—Binswanger’s disease. There was no question that despite the neurologic cause of her symptoms treating her depression with antidepressants was needed and helpful. It also was important that her family was aware of her underlying medical condition and its implications for her care.2
Medicine is our calling
Many of these illnesses, even when identified, require expert psychiatric management of psychiatric symptoms. This should not be surprising to psychiatrists or other clinicians. No one expects a cardiologist to beg off the care of a patient with heart failure caused by alcohol abuse or a virus rather than vascular heart disease, and psychiatrists likewise need to manage psychosis due to steroid use or N-methyl-
Medical psychiatry has a broader and more inclusive perspective than what we generally mean by “biological psychiatry,” if by the latter, we mean a focus on the neurobiology and psychopharmacology of “primary” psychiatric conditions that are not secondary to other medical or neurologic disorders. As important and fundamental as deep understanding of neurobiology, genetics, and psychopharmacology are, medical psychiatry embeds our work more broadly in all of human biology and requires the full breadth of our medical training.
At a time when political battles over prescriptive privileges by non-medically trained mental health clinicians engage legislatures and professional organizations, medical psychiatry is a powerful reminder that prescribing or not prescribing medications is the final step in, what should be, an extensive, clinical evaluation including a thorough medical work up and consideration of the medical–psychiatric interactions and the differential diagnosis of these illnesses. It is, after all, what physicians do and is essential to our calling as psychiatric physicians. If psychiatrists are not at home in medicine, as Tom Hackett reminded us in 19771—at a time when psychiatry had temporarily eliminated the requirement for medical internships—then, indeed, psychiatry would be “homeless.”
2. Summergrad P. Depression in Binswanger’s encephalopathy responsive to tranylcypromine: case report. J Clin Psychiatry. 1985;46(2):69-70.
2. Summergrad P. Depression in Binswanger’s encephalopathy responsive to tranylcypromine: case report. J Clin Psychiatry. 1985;46(2):69-70.
Self-compassion benefits psychiatrists, too
Congratulations to Ricks Warren, PhD, ABPP, Elke Smeets, PhD, and Kristen Neff, MD, the authors of “Self-criticism and self-compassion: Risk and resilience,” (Evidence-Based Reviews,
H. Steven Moffic, MD
Retired Tenured Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, Wisconsin
Dr. Warren responds
We couldn’t agree more with Dr. Moffic’s perspective that psychiatrists and other mental health clinicians likely would benefit from self-compassion during our clinical work in a complex, demanding, and rapidly changing mental health environment. Fortunately, attention to the importance of self-compassion for caregivers has been advocated, and recent studies of self-compassion in health care professionals have reported promising results. Because the neuroticism and self-criticism personality traits are most associated with depression and burnout in physicians, interventions that promote self-compassion are likely to lead to improved mental health in psychiatrists and other health care professionals. Recent research has found that self-compassion in health care providers is associated with less burnout and compassion fatigue, increased resilience, adaptive emotion regulation, and reduced sleep disturbance.1
The time is now right for clinical trials of self-compassion interventions in psychiatrists and other caregivers. Neff and Germer’s mindful self-compassion intervention,2 discussed in our article, could be easily adapted for psychiatrists and other mental health professionals. As Mills and Chapman,3 stated, “While being self-critical and perfectionistic may be common among doctors, being kind to oneself is not a luxury: it is a necessity. Self-care is, in a sense, a sine qua non for giving care for patients.”
Ricks Warren, PhD, ABPP
Clinical Associate Professor
Department of Psychiatry
University of Michigan Medical School
Ann Arbor, Michigan
1. Baker K, Warren R, Abelson J, et al. Physician mental health: depression and anxiety. In: Brower K, Riba M, eds. Physician mental health and well-being: research and practice. New York, NY: Springer. In press.
2. Neff KD, Germer CK. A pilot study and randomized controlled trial of the mindful self-compassion program. J Clin Psychol. 2013;69(1):28-44.
3. Mills J, Chapman M. Compassion and self-compassion in medicine: self-care for the caregiver. AMJ. 2016:9(5):87-91.
Congratulations to Ricks Warren, PhD, ABPP, Elke Smeets, PhD, and Kristen Neff, MD, the authors of “Self-criticism and self-compassion: Risk and resilience,” (Evidence-Based Reviews,
H. Steven Moffic, MD
Retired Tenured Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, Wisconsin
Dr. Warren responds
We couldn’t agree more with Dr. Moffic’s perspective that psychiatrists and other mental health clinicians likely would benefit from self-compassion during our clinical work in a complex, demanding, and rapidly changing mental health environment. Fortunately, attention to the importance of self-compassion for caregivers has been advocated, and recent studies of self-compassion in health care professionals have reported promising results. Because the neuroticism and self-criticism personality traits are most associated with depression and burnout in physicians, interventions that promote self-compassion are likely to lead to improved mental health in psychiatrists and other health care professionals. Recent research has found that self-compassion in health care providers is associated with less burnout and compassion fatigue, increased resilience, adaptive emotion regulation, and reduced sleep disturbance.1
The time is now right for clinical trials of self-compassion interventions in psychiatrists and other caregivers. Neff and Germer’s mindful self-compassion intervention,2 discussed in our article, could be easily adapted for psychiatrists and other mental health professionals. As Mills and Chapman,3 stated, “While being self-critical and perfectionistic may be common among doctors, being kind to oneself is not a luxury: it is a necessity. Self-care is, in a sense, a sine qua non for giving care for patients.”
Ricks Warren, PhD, ABPP
Clinical Associate Professor
Department of Psychiatry
University of Michigan Medical School
Ann Arbor, Michigan
Congratulations to Ricks Warren, PhD, ABPP, Elke Smeets, PhD, and Kristen Neff, MD, the authors of “Self-criticism and self-compassion: Risk and resilience,” (Evidence-Based Reviews,
H. Steven Moffic, MD
Retired Tenured Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, Wisconsin
Dr. Warren responds
We couldn’t agree more with Dr. Moffic’s perspective that psychiatrists and other mental health clinicians likely would benefit from self-compassion during our clinical work in a complex, demanding, and rapidly changing mental health environment. Fortunately, attention to the importance of self-compassion for caregivers has been advocated, and recent studies of self-compassion in health care professionals have reported promising results. Because the neuroticism and self-criticism personality traits are most associated with depression and burnout in physicians, interventions that promote self-compassion are likely to lead to improved mental health in psychiatrists and other health care professionals. Recent research has found that self-compassion in health care providers is associated with less burnout and compassion fatigue, increased resilience, adaptive emotion regulation, and reduced sleep disturbance.1
The time is now right for clinical trials of self-compassion interventions in psychiatrists and other caregivers. Neff and Germer’s mindful self-compassion intervention,2 discussed in our article, could be easily adapted for psychiatrists and other mental health professionals. As Mills and Chapman,3 stated, “While being self-critical and perfectionistic may be common among doctors, being kind to oneself is not a luxury: it is a necessity. Self-care is, in a sense, a sine qua non for giving care for patients.”
Ricks Warren, PhD, ABPP
Clinical Associate Professor
Department of Psychiatry
University of Michigan Medical School
Ann Arbor, Michigan
1. Baker K, Warren R, Abelson J, et al. Physician mental health: depression and anxiety. In: Brower K, Riba M, eds. Physician mental health and well-being: research and practice. New York, NY: Springer. In press.
2. Neff KD, Germer CK. A pilot study and randomized controlled trial of the mindful self-compassion program. J Clin Psychol. 2013;69(1):28-44.
3. Mills J, Chapman M. Compassion and self-compassion in medicine: self-care for the caregiver. AMJ. 2016:9(5):87-91.
1. Baker K, Warren R, Abelson J, et al. Physician mental health: depression and anxiety. In: Brower K, Riba M, eds. Physician mental health and well-being: research and practice. New York, NY: Springer. In press.
2. Neff KD, Germer CK. A pilot study and randomized controlled trial of the mindful self-compassion program. J Clin Psychol. 2013;69(1):28-44.
3. Mills J, Chapman M. Compassion and self-compassion in medicine: self-care for the caregiver. AMJ. 2016:9(5):87-91.
It’s time to screen for bullying
When I became a family physician (FP), it never crossed my mind that I would one day be asking school-aged children about bullying. Not so much because bullying didn’t exist, but because I wasn’t aware of the pervasiveness and seriousness of the problem and because there were no professional recommendations to do so.
That said, my family had some first-hand experience with the issue: One of my children was bullied in grade school. When my wife found out, she promptly visited the 2 boys’ homes and told them and their parents that the behavior would stop or else! (She may have used more colorful language.) And it did stop. But times have changed, and so has the nature of bullying, which can now extend beyond the hallway to an entire school body in seconds with a few taps on a cell phone. And the adverse consequences can be significant, as described by McClowry and colleagues.
The prevalence of bullying is discouragingly high, estimated to be about 20% in national surveys.1 Because bullying occurs so frequently, public health, community-based, and school-based approaches, rather than one-on-one office-based interventions, are likely to have the greatest overall impact on decreasing bullying. Randomized trials bear this out, showing that prevention programs in schools can effectively reduce the behavior.2,3
What is our responsibility as FPs? Screening is a reasonable first step, even in the absence of randomized trials demonstrating benefit. Because there have been no physician office-based trials of screening or interventions for bullying, we must rely on “expert opinion” at this time, with no assurance that what we do will actually help children. Absence of proof of benefit, however, does not mean absence of benefit, and doing nothing will definitely not help anyone. The authors recommend a single screening question: "Are you being bullied?"—especially for children who are at higher risk, such as those with disabilities/special health needs, LGBTQ+ status, and who are under- or overweight.
Clearly we need research to know which interventions truly help these children/adolescents and their parents. In the meantime, however, identifying the problem and offering emotional support are unlikely to harm—and may help. Opening the lines of communication, connecting children and their parents with available community resources, and supporting anti-bullying programs in your schools are additional ways we can make a difference today.
1. Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance System – United States, 2015. MMWR Morb Mortal Wkly. 2016;65:1-174.
2. Waasdorp TE, Bradshaw CP, Leaf PJ. The impact of schoolwide positive behavioral interventions and supports on bullying and peer rejection: a randomized controlled effectiveness trial. Arch Pediatr Adolesc Med. 2012;166:149-156.
3. Espelage DL, Low S, Polanin JR, et al. The impact of a middle school program to reduce aggression, victimization, and sexual violence. J Adolesc Health. 2013;53:180-186.
Editor-in-Chief
Editor-in-Chief
Editor-in-Chief
When I became a family physician (FP), it never crossed my mind that I would one day be asking school-aged children about bullying. Not so much because bullying didn’t exist, but because I wasn’t aware of the pervasiveness and seriousness of the problem and because there were no professional recommendations to do so.
That said, my family had some first-hand experience with the issue: One of my children was bullied in grade school. When my wife found out, she promptly visited the 2 boys’ homes and told them and their parents that the behavior would stop or else! (She may have used more colorful language.) And it did stop. But times have changed, and so has the nature of bullying, which can now extend beyond the hallway to an entire school body in seconds with a few taps on a cell phone. And the adverse consequences can be significant, as described by McClowry and colleagues.
The prevalence of bullying is discouragingly high, estimated to be about 20% in national surveys.1 Because bullying occurs so frequently, public health, community-based, and school-based approaches, rather than one-on-one office-based interventions, are likely to have the greatest overall impact on decreasing bullying. Randomized trials bear this out, showing that prevention programs in schools can effectively reduce the behavior.2,3
What is our responsibility as FPs? Screening is a reasonable first step, even in the absence of randomized trials demonstrating benefit. Because there have been no physician office-based trials of screening or interventions for bullying, we must rely on “expert opinion” at this time, with no assurance that what we do will actually help children. Absence of proof of benefit, however, does not mean absence of benefit, and doing nothing will definitely not help anyone. The authors recommend a single screening question: "Are you being bullied?"—especially for children who are at higher risk, such as those with disabilities/special health needs, LGBTQ+ status, and who are under- or overweight.
Clearly we need research to know which interventions truly help these children/adolescents and their parents. In the meantime, however, identifying the problem and offering emotional support are unlikely to harm—and may help. Opening the lines of communication, connecting children and their parents with available community resources, and supporting anti-bullying programs in your schools are additional ways we can make a difference today.
When I became a family physician (FP), it never crossed my mind that I would one day be asking school-aged children about bullying. Not so much because bullying didn’t exist, but because I wasn’t aware of the pervasiveness and seriousness of the problem and because there were no professional recommendations to do so.
That said, my family had some first-hand experience with the issue: One of my children was bullied in grade school. When my wife found out, she promptly visited the 2 boys’ homes and told them and their parents that the behavior would stop or else! (She may have used more colorful language.) And it did stop. But times have changed, and so has the nature of bullying, which can now extend beyond the hallway to an entire school body in seconds with a few taps on a cell phone. And the adverse consequences can be significant, as described by McClowry and colleagues.
The prevalence of bullying is discouragingly high, estimated to be about 20% in national surveys.1 Because bullying occurs so frequently, public health, community-based, and school-based approaches, rather than one-on-one office-based interventions, are likely to have the greatest overall impact on decreasing bullying. Randomized trials bear this out, showing that prevention programs in schools can effectively reduce the behavior.2,3
What is our responsibility as FPs? Screening is a reasonable first step, even in the absence of randomized trials demonstrating benefit. Because there have been no physician office-based trials of screening or interventions for bullying, we must rely on “expert opinion” at this time, with no assurance that what we do will actually help children. Absence of proof of benefit, however, does not mean absence of benefit, and doing nothing will definitely not help anyone. The authors recommend a single screening question: "Are you being bullied?"—especially for children who are at higher risk, such as those with disabilities/special health needs, LGBTQ+ status, and who are under- or overweight.
Clearly we need research to know which interventions truly help these children/adolescents and their parents. In the meantime, however, identifying the problem and offering emotional support are unlikely to harm—and may help. Opening the lines of communication, connecting children and their parents with available community resources, and supporting anti-bullying programs in your schools are additional ways we can make a difference today.
1. Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance System – United States, 2015. MMWR Morb Mortal Wkly. 2016;65:1-174.
2. Waasdorp TE, Bradshaw CP, Leaf PJ. The impact of schoolwide positive behavioral interventions and supports on bullying and peer rejection: a randomized controlled effectiveness trial. Arch Pediatr Adolesc Med. 2012;166:149-156.
3. Espelage DL, Low S, Polanin JR, et al. The impact of a middle school program to reduce aggression, victimization, and sexual violence. J Adolesc Health. 2013;53:180-186.
1. Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance System – United States, 2015. MMWR Morb Mortal Wkly. 2016;65:1-174.
2. Waasdorp TE, Bradshaw CP, Leaf PJ. The impact of schoolwide positive behavioral interventions and supports on bullying and peer rejection: a randomized controlled effectiveness trial. Arch Pediatr Adolesc Med. 2012;166:149-156.
3. Espelage DL, Low S, Polanin JR, et al. The impact of a middle school program to reduce aggression, victimization, and sexual violence. J Adolesc Health. 2013;53:180-186.
Metformin for acne
Acne is the most common skin condition, affecting up to 50 million individuals annually. Self-esteem is affected, and scarring can result if left untreated or inadequately treated. Although still somewhat controversial in some circles, available data have linked acne to dairy products, refined sugar ingestion, and high glycemic loads.
Acne has been linked to insulin levels and insulin-like growth factor (IGF-1). Glycemic loads are associated with both insulin and IGF-1. Metformin reduces glucose release from the liver while increasing glucose uptake in muscles and adipocytes.
So, can interventions that reduce glycemic load, such as diet and metformin, decrease the incidence of acne in patients among whom other standard interventions have been tried?
Gabriella Fabbrocini, MD, of the University of Naples, Italy, and her colleagues tested this hypothesis by conducting a randomized, clinical trial evaluating the impact of a low glycemic diet and metformin on acne (Clin Exp Dermatol. 2016 Jan;41[1]:38-42). Twenty males aged 17-24 years with acne for at least 1 year were randomized to either metformin 500 mg twice daily with a 1,500- to 2,000-kcal diet rich in fruits, vegetables, fish, and low carbohydrates with standard therapy; or standard therapy alone. Standard therapy consisted of a bland skin detergent and a sebostatic cream. Acne severity was rated by four observers.
Patients in the metformin group demonstrated a statistically significant improvement in acne severity, compared with patients in the standard care only group. No side effects were reported with metformin.
In this study, only patients with an “altered metabolic profile” were enrolled and randomized. An “altered metabolic profile” was defined as impaired fasting glucose, high total cholesterol or LDL, reduced HDL, and elevated waist circumference and body mass index. Results should be generalizable only to patients with these characteristics. The sample size in this study was small, but the included picture of acne resolution on one subject was indeed impressive.
For patients among whom traditional acne treatment approaches have not been effective, and knowing the tolerability and affordability of metformin, this may be a reasonable intervention.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.
Acne is the most common skin condition, affecting up to 50 million individuals annually. Self-esteem is affected, and scarring can result if left untreated or inadequately treated. Although still somewhat controversial in some circles, available data have linked acne to dairy products, refined sugar ingestion, and high glycemic loads.
Acne has been linked to insulin levels and insulin-like growth factor (IGF-1). Glycemic loads are associated with both insulin and IGF-1. Metformin reduces glucose release from the liver while increasing glucose uptake in muscles and adipocytes.
So, can interventions that reduce glycemic load, such as diet and metformin, decrease the incidence of acne in patients among whom other standard interventions have been tried?
Gabriella Fabbrocini, MD, of the University of Naples, Italy, and her colleagues tested this hypothesis by conducting a randomized, clinical trial evaluating the impact of a low glycemic diet and metformin on acne (Clin Exp Dermatol. 2016 Jan;41[1]:38-42). Twenty males aged 17-24 years with acne for at least 1 year were randomized to either metformin 500 mg twice daily with a 1,500- to 2,000-kcal diet rich in fruits, vegetables, fish, and low carbohydrates with standard therapy; or standard therapy alone. Standard therapy consisted of a bland skin detergent and a sebostatic cream. Acne severity was rated by four observers.
Patients in the metformin group demonstrated a statistically significant improvement in acne severity, compared with patients in the standard care only group. No side effects were reported with metformin.
In this study, only patients with an “altered metabolic profile” were enrolled and randomized. An “altered metabolic profile” was defined as impaired fasting glucose, high total cholesterol or LDL, reduced HDL, and elevated waist circumference and body mass index. Results should be generalizable only to patients with these characteristics. The sample size in this study was small, but the included picture of acne resolution on one subject was indeed impressive.
For patients among whom traditional acne treatment approaches have not been effective, and knowing the tolerability and affordability of metformin, this may be a reasonable intervention.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.
Acne is the most common skin condition, affecting up to 50 million individuals annually. Self-esteem is affected, and scarring can result if left untreated or inadequately treated. Although still somewhat controversial in some circles, available data have linked acne to dairy products, refined sugar ingestion, and high glycemic loads.
Acne has been linked to insulin levels and insulin-like growth factor (IGF-1). Glycemic loads are associated with both insulin and IGF-1. Metformin reduces glucose release from the liver while increasing glucose uptake in muscles and adipocytes.
So, can interventions that reduce glycemic load, such as diet and metformin, decrease the incidence of acne in patients among whom other standard interventions have been tried?
Gabriella Fabbrocini, MD, of the University of Naples, Italy, and her colleagues tested this hypothesis by conducting a randomized, clinical trial evaluating the impact of a low glycemic diet and metformin on acne (Clin Exp Dermatol. 2016 Jan;41[1]:38-42). Twenty males aged 17-24 years with acne for at least 1 year were randomized to either metformin 500 mg twice daily with a 1,500- to 2,000-kcal diet rich in fruits, vegetables, fish, and low carbohydrates with standard therapy; or standard therapy alone. Standard therapy consisted of a bland skin detergent and a sebostatic cream. Acne severity was rated by four observers.
Patients in the metformin group demonstrated a statistically significant improvement in acne severity, compared with patients in the standard care only group. No side effects were reported with metformin.
In this study, only patients with an “altered metabolic profile” were enrolled and randomized. An “altered metabolic profile” was defined as impaired fasting glucose, high total cholesterol or LDL, reduced HDL, and elevated waist circumference and body mass index. Results should be generalizable only to patients with these characteristics. The sample size in this study was small, but the included picture of acne resolution on one subject was indeed impressive.
For patients among whom traditional acne treatment approaches have not been effective, and knowing the tolerability and affordability of metformin, this may be a reasonable intervention.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.
Promoting mental well-being in LGBTQ youth
For many the beginning of a new year is a time to set goals and resolutions for the upcoming year. Often these resolutions are related to health, for example, quit smoking, work out more, lose weight. It is sometimes easy to overlook mental health and well-being as an integral part of overall wellness. This month’s column will focus on how as pediatric providers we can help promote the mental well-being of our patients in practice.
Mental health problems are a significant cause of morbidity and mortality in youth. In 2014, suicide was the second leading cause of death for all youth 10-14 years and 15-24 years.1 While most lesbian, gay, bisexual, transgender, and questioning (LGBTQ) persons live healthy, happy lives, LGBTQ youth are at disproportionate risk for mental illness, probably related to lack of support and to stigma related to their sexual minority and gender minority identities. Studies suggest that LGBTQ youth have suicidality rates two to five times higher than their heterosexual cisgender peers.2,3,4
• Principle 1. A comprehensive diagnostic evaluation should include an age-appropriate assessment of psychosexual development for all youths.
While pediatric providers are unlikely to perform a comprehensive mental health diagnostic evaluation, psychosocial development should regularly be assessed at well visits. It may not be readily apparent which youth are struggling with development of their sexual and gender identity. Nonassuming questions regarding development in theses domains should ideally be integrated into the psychosocial assessment. For example, begin a sexual history by asking, “Are you romantically attracted to males, females, both, or neither?”
• Principle 2. The need for confidentiality in the clinical alliance is a special consideration in the assessment of sexual and gender minority youth.
Confidentiality is important when talking to any youth about their sexual and gender identity. LGBTQ youth in particular may have concerns of family or provider rejection, and they may look for cues that they can safely discuss their sexuality or gender identity without fear of being judged or shamed. Clinicians should be aware of confidentiality practices for minors when discussing these issues. Potential risks of premature disclosure to family and support systems, such as rejection or alienation, also should be considered.
• Principle 3. Family dynamics pertinent to sexual orientation, gender nonconformity, and gender identity should be explored in the context of the cultural values of the youth, family, and community.
Families can have a variety of responses to their child’s sexual minority or gender minority identity, ranging from acceptance to rejection, with some youth being forced to leave home. Many families need to alter their ideas and expectations for a child after their child comes out, and this can lead to feelings of loss and grief accompanied by feelings of anxiety, anger, shame, and guilt.5 Over time, however, the majority of families become affirming and supportive and are not distressed.7 Recognizing that family support reduces negative health outcomes for youth, providers should aim to support and preserve positive family relationships when possible. This may involve education and support for families as well as youth. It is important to be aware that sexual and gender minority youth who are also members of ethnic minorities may face additional challenges.
• Principle 4. Clinicians should inquire about circumstances commonly encountered by youth with sexual and gender minority status that confer increased psychiatric risk.
Providers should recognize that LGBTQ youth are at disproportionate risk of bullying, suicide, substance use, high-risk sexual behaviors, running away, and becoming homeless. Providers should assess for these risks and address them as appropriate.
• Principle 5. Clinicians should aim to foster healthy psychosexual development in sexual and gender minority youth, and protect these individuals’ full capacity for integrated identity formation and functioning.
Providers should support healthy youth development and self-discovery, recognizing that there is a spectrum of sexual and gender identities, with the goal of helping youth achieve their full developmental potential.
• Principle 6. Clinicians should be aware that there is no evidence that sexual orientation can be altered through therapy, and attempts to do so may be harmful.
Therapies targeted at altering sexual orientation or gender identity, often referred to as reparative therapies, can encourage family rejection and decrease self-esteem and connectedness, all of which have been identified as risk factors for suicidality. Providers should educate parents about the potential harm of these types of therapies and ensure that mental health providers to whom patients are being referred are not practicing these potentially harmful therapies.
• Principle 7. Clinicians should be aware of current evidence on the natural course of gender discordance and associated psychopathology in children and adolescents in choosing the treatment goals and modality.
Variation in gender role behavior (for example, dress preference, toy preference, types of play) is typical in early childhood and should be distinguished from gender dysphoria, in which a child expresses distress related to a gender identity that is different from or does not fully align with the child’s sex assigned at birth. Assessing gender development in childhood and the best approach to treatment is best done by professionals with experience and training in gender development, and providers should be familiar with resources in their area. For some, gender identity concerns may not be recognized until adolescence when the onset of puberty and secondary sex characteristics result in increased dysphoria. Best practice guidelines exist for treatment of youth with gender discordance, and there is limited but growing evidence to support best practices. Providers should ensure that the providers and specialists to whom families are referred practice according to current best practices.
• Principle 8. Clinicians should be prepared to consult and act as a liaison with schools, community agencies, and other health care providers, advocating for the unique needs of sexual and gender minority youth and their families.
Pediatric providers can work with mental health professionals to be advocates for their gender and sexual minority patients and raise awareness of issues affecting these special populations such as bullying and suicidality.
• Principle 9. Mental health professionals should be aware of community and professional resources relevant to sexual and gender minority youth.
As medical providers, we have a limited amount of time to see and assess patients, and often are able to best serve our patients and families by connecting them to specialists in the medical community and resources available in the school and community. It is important to know what resources exist in the community to be able to appropriately refer and connect patients.
Resources for providers
• American Academy of Child and Adolescent Psychiatry Practice Parameter on lesbian, gay, bisexual, and transgender youth .
• National LGBT Health Education Center: Training materials and modules with continuing education credits.
Resources for families
• Gay, Lesbian, and Straight Education Network.• Parents, Friends, Families of Lesbians and Gays (PFLAG).
References
1. “10 Leading Causes of Death by Age Group, United States – 2014,” National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
2. Lesbian, Gay, Bisexual, and Transgender Health: LGBT Youth, Centers for Disease Control and Prevention, Nov. 12, 2014.
3. Am J Public Health. 2001 Aug;91(8):1276-81.
4. Am J Prev Med. 2012 Mar;42(3):221-8.
5. J. Am Acad Child Adolesc Psychiatry. 2012;51(9):957–74.
6. Pediatr Clin North Am. 2016 Dec;63(6):971-83.
7. “Mom, Dad. I’m Gay: How Families Negotiate Coming Out” (Washington, DC: American Psychological Association, 2001).
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.
For many the beginning of a new year is a time to set goals and resolutions for the upcoming year. Often these resolutions are related to health, for example, quit smoking, work out more, lose weight. It is sometimes easy to overlook mental health and well-being as an integral part of overall wellness. This month’s column will focus on how as pediatric providers we can help promote the mental well-being of our patients in practice.
Mental health problems are a significant cause of morbidity and mortality in youth. In 2014, suicide was the second leading cause of death for all youth 10-14 years and 15-24 years.1 While most lesbian, gay, bisexual, transgender, and questioning (LGBTQ) persons live healthy, happy lives, LGBTQ youth are at disproportionate risk for mental illness, probably related to lack of support and to stigma related to their sexual minority and gender minority identities. Studies suggest that LGBTQ youth have suicidality rates two to five times higher than their heterosexual cisgender peers.2,3,4
• Principle 1. A comprehensive diagnostic evaluation should include an age-appropriate assessment of psychosexual development for all youths.
While pediatric providers are unlikely to perform a comprehensive mental health diagnostic evaluation, psychosocial development should regularly be assessed at well visits. It may not be readily apparent which youth are struggling with development of their sexual and gender identity. Nonassuming questions regarding development in theses domains should ideally be integrated into the psychosocial assessment. For example, begin a sexual history by asking, “Are you romantically attracted to males, females, both, or neither?”
• Principle 2. The need for confidentiality in the clinical alliance is a special consideration in the assessment of sexual and gender minority youth.
Confidentiality is important when talking to any youth about their sexual and gender identity. LGBTQ youth in particular may have concerns of family or provider rejection, and they may look for cues that they can safely discuss their sexuality or gender identity without fear of being judged or shamed. Clinicians should be aware of confidentiality practices for minors when discussing these issues. Potential risks of premature disclosure to family and support systems, such as rejection or alienation, also should be considered.
• Principle 3. Family dynamics pertinent to sexual orientation, gender nonconformity, and gender identity should be explored in the context of the cultural values of the youth, family, and community.
Families can have a variety of responses to their child’s sexual minority or gender minority identity, ranging from acceptance to rejection, with some youth being forced to leave home. Many families need to alter their ideas and expectations for a child after their child comes out, and this can lead to feelings of loss and grief accompanied by feelings of anxiety, anger, shame, and guilt.5 Over time, however, the majority of families become affirming and supportive and are not distressed.7 Recognizing that family support reduces negative health outcomes for youth, providers should aim to support and preserve positive family relationships when possible. This may involve education and support for families as well as youth. It is important to be aware that sexual and gender minority youth who are also members of ethnic minorities may face additional challenges.
• Principle 4. Clinicians should inquire about circumstances commonly encountered by youth with sexual and gender minority status that confer increased psychiatric risk.
Providers should recognize that LGBTQ youth are at disproportionate risk of bullying, suicide, substance use, high-risk sexual behaviors, running away, and becoming homeless. Providers should assess for these risks and address them as appropriate.
• Principle 5. Clinicians should aim to foster healthy psychosexual development in sexual and gender minority youth, and protect these individuals’ full capacity for integrated identity formation and functioning.
Providers should support healthy youth development and self-discovery, recognizing that there is a spectrum of sexual and gender identities, with the goal of helping youth achieve their full developmental potential.
• Principle 6. Clinicians should be aware that there is no evidence that sexual orientation can be altered through therapy, and attempts to do so may be harmful.
Therapies targeted at altering sexual orientation or gender identity, often referred to as reparative therapies, can encourage family rejection and decrease self-esteem and connectedness, all of which have been identified as risk factors for suicidality. Providers should educate parents about the potential harm of these types of therapies and ensure that mental health providers to whom patients are being referred are not practicing these potentially harmful therapies.
• Principle 7. Clinicians should be aware of current evidence on the natural course of gender discordance and associated psychopathology in children and adolescents in choosing the treatment goals and modality.
Variation in gender role behavior (for example, dress preference, toy preference, types of play) is typical in early childhood and should be distinguished from gender dysphoria, in which a child expresses distress related to a gender identity that is different from or does not fully align with the child’s sex assigned at birth. Assessing gender development in childhood and the best approach to treatment is best done by professionals with experience and training in gender development, and providers should be familiar with resources in their area. For some, gender identity concerns may not be recognized until adolescence when the onset of puberty and secondary sex characteristics result in increased dysphoria. Best practice guidelines exist for treatment of youth with gender discordance, and there is limited but growing evidence to support best practices. Providers should ensure that the providers and specialists to whom families are referred practice according to current best practices.
• Principle 8. Clinicians should be prepared to consult and act as a liaison with schools, community agencies, and other health care providers, advocating for the unique needs of sexual and gender minority youth and their families.
Pediatric providers can work with mental health professionals to be advocates for their gender and sexual minority patients and raise awareness of issues affecting these special populations such as bullying and suicidality.
• Principle 9. Mental health professionals should be aware of community and professional resources relevant to sexual and gender minority youth.
As medical providers, we have a limited amount of time to see and assess patients, and often are able to best serve our patients and families by connecting them to specialists in the medical community and resources available in the school and community. It is important to know what resources exist in the community to be able to appropriately refer and connect patients.
Resources for providers
• American Academy of Child and Adolescent Psychiatry Practice Parameter on lesbian, gay, bisexual, and transgender youth .
• National LGBT Health Education Center: Training materials and modules with continuing education credits.
Resources for families
• Gay, Lesbian, and Straight Education Network.• Parents, Friends, Families of Lesbians and Gays (PFLAG).
References
1. “10 Leading Causes of Death by Age Group, United States – 2014,” National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
2. Lesbian, Gay, Bisexual, and Transgender Health: LGBT Youth, Centers for Disease Control and Prevention, Nov. 12, 2014.
3. Am J Public Health. 2001 Aug;91(8):1276-81.
4. Am J Prev Med. 2012 Mar;42(3):221-8.
5. J. Am Acad Child Adolesc Psychiatry. 2012;51(9):957–74.
6. Pediatr Clin North Am. 2016 Dec;63(6):971-83.
7. “Mom, Dad. I’m Gay: How Families Negotiate Coming Out” (Washington, DC: American Psychological Association, 2001).
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.
For many the beginning of a new year is a time to set goals and resolutions for the upcoming year. Often these resolutions are related to health, for example, quit smoking, work out more, lose weight. It is sometimes easy to overlook mental health and well-being as an integral part of overall wellness. This month’s column will focus on how as pediatric providers we can help promote the mental well-being of our patients in practice.
Mental health problems are a significant cause of morbidity and mortality in youth. In 2014, suicide was the second leading cause of death for all youth 10-14 years and 15-24 years.1 While most lesbian, gay, bisexual, transgender, and questioning (LGBTQ) persons live healthy, happy lives, LGBTQ youth are at disproportionate risk for mental illness, probably related to lack of support and to stigma related to their sexual minority and gender minority identities. Studies suggest that LGBTQ youth have suicidality rates two to five times higher than their heterosexual cisgender peers.2,3,4
• Principle 1. A comprehensive diagnostic evaluation should include an age-appropriate assessment of psychosexual development for all youths.
While pediatric providers are unlikely to perform a comprehensive mental health diagnostic evaluation, psychosocial development should regularly be assessed at well visits. It may not be readily apparent which youth are struggling with development of their sexual and gender identity. Nonassuming questions regarding development in theses domains should ideally be integrated into the psychosocial assessment. For example, begin a sexual history by asking, “Are you romantically attracted to males, females, both, or neither?”
• Principle 2. The need for confidentiality in the clinical alliance is a special consideration in the assessment of sexual and gender minority youth.
Confidentiality is important when talking to any youth about their sexual and gender identity. LGBTQ youth in particular may have concerns of family or provider rejection, and they may look for cues that they can safely discuss their sexuality or gender identity without fear of being judged or shamed. Clinicians should be aware of confidentiality practices for minors when discussing these issues. Potential risks of premature disclosure to family and support systems, such as rejection or alienation, also should be considered.
• Principle 3. Family dynamics pertinent to sexual orientation, gender nonconformity, and gender identity should be explored in the context of the cultural values of the youth, family, and community.
Families can have a variety of responses to their child’s sexual minority or gender minority identity, ranging from acceptance to rejection, with some youth being forced to leave home. Many families need to alter their ideas and expectations for a child after their child comes out, and this can lead to feelings of loss and grief accompanied by feelings of anxiety, anger, shame, and guilt.5 Over time, however, the majority of families become affirming and supportive and are not distressed.7 Recognizing that family support reduces negative health outcomes for youth, providers should aim to support and preserve positive family relationships when possible. This may involve education and support for families as well as youth. It is important to be aware that sexual and gender minority youth who are also members of ethnic minorities may face additional challenges.
• Principle 4. Clinicians should inquire about circumstances commonly encountered by youth with sexual and gender minority status that confer increased psychiatric risk.
Providers should recognize that LGBTQ youth are at disproportionate risk of bullying, suicide, substance use, high-risk sexual behaviors, running away, and becoming homeless. Providers should assess for these risks and address them as appropriate.
• Principle 5. Clinicians should aim to foster healthy psychosexual development in sexual and gender minority youth, and protect these individuals’ full capacity for integrated identity formation and functioning.
Providers should support healthy youth development and self-discovery, recognizing that there is a spectrum of sexual and gender identities, with the goal of helping youth achieve their full developmental potential.
• Principle 6. Clinicians should be aware that there is no evidence that sexual orientation can be altered through therapy, and attempts to do so may be harmful.
Therapies targeted at altering sexual orientation or gender identity, often referred to as reparative therapies, can encourage family rejection and decrease self-esteem and connectedness, all of which have been identified as risk factors for suicidality. Providers should educate parents about the potential harm of these types of therapies and ensure that mental health providers to whom patients are being referred are not practicing these potentially harmful therapies.
• Principle 7. Clinicians should be aware of current evidence on the natural course of gender discordance and associated psychopathology in children and adolescents in choosing the treatment goals and modality.
Variation in gender role behavior (for example, dress preference, toy preference, types of play) is typical in early childhood and should be distinguished from gender dysphoria, in which a child expresses distress related to a gender identity that is different from or does not fully align with the child’s sex assigned at birth. Assessing gender development in childhood and the best approach to treatment is best done by professionals with experience and training in gender development, and providers should be familiar with resources in their area. For some, gender identity concerns may not be recognized until adolescence when the onset of puberty and secondary sex characteristics result in increased dysphoria. Best practice guidelines exist for treatment of youth with gender discordance, and there is limited but growing evidence to support best practices. Providers should ensure that the providers and specialists to whom families are referred practice according to current best practices.
• Principle 8. Clinicians should be prepared to consult and act as a liaison with schools, community agencies, and other health care providers, advocating for the unique needs of sexual and gender minority youth and their families.
Pediatric providers can work with mental health professionals to be advocates for their gender and sexual minority patients and raise awareness of issues affecting these special populations such as bullying and suicidality.
• Principle 9. Mental health professionals should be aware of community and professional resources relevant to sexual and gender minority youth.
As medical providers, we have a limited amount of time to see and assess patients, and often are able to best serve our patients and families by connecting them to specialists in the medical community and resources available in the school and community. It is important to know what resources exist in the community to be able to appropriately refer and connect patients.
Resources for providers
• American Academy of Child and Adolescent Psychiatry Practice Parameter on lesbian, gay, bisexual, and transgender youth .
• National LGBT Health Education Center: Training materials and modules with continuing education credits.
Resources for families
• Gay, Lesbian, and Straight Education Network.• Parents, Friends, Families of Lesbians and Gays (PFLAG).
References
1. “10 Leading Causes of Death by Age Group, United States – 2014,” National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
2. Lesbian, Gay, Bisexual, and Transgender Health: LGBT Youth, Centers for Disease Control and Prevention, Nov. 12, 2014.
3. Am J Public Health. 2001 Aug;91(8):1276-81.
4. Am J Prev Med. 2012 Mar;42(3):221-8.
5. J. Am Acad Child Adolesc Psychiatry. 2012;51(9):957–74.
6. Pediatr Clin North Am. 2016 Dec;63(6):971-83.
7. “Mom, Dad. I’m Gay: How Families Negotiate Coming Out” (Washington, DC: American Psychological Association, 2001).
Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.
Letters to the Editor: Your patients are talking: Isn’t it time you take responsibility for your online reputation?
“YOUR PATIENTS ARE TALKING: ISN’T IT TIME YOU TAKE RESPONSIBILITY FOR YOUR ONLINE REPUTATION?”
RON ROMANO AND NEIL H. BAUM, MD (NOVEMBER 2016)
Eschews meaningless Internet obfuscation
As a practicing physician I don’t have time for social media and its accompanying advertising rationale; it’s a wasteland that replaces television. My patients and I go one-on-one, eye-to-eye, and eschew meaningless Internet obfuscation. Don’t we have better things to do with our physician/patient relationship than check online reviews?
Warren Kendall, MD
Grants Pass, Oregon
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
“YOUR PATIENTS ARE TALKING: ISN’T IT TIME YOU TAKE RESPONSIBILITY FOR YOUR ONLINE REPUTATION?”
RON ROMANO AND NEIL H. BAUM, MD (NOVEMBER 2016)
Eschews meaningless Internet obfuscation
As a practicing physician I don’t have time for social media and its accompanying advertising rationale; it’s a wasteland that replaces television. My patients and I go one-on-one, eye-to-eye, and eschew meaningless Internet obfuscation. Don’t we have better things to do with our physician/patient relationship than check online reviews?
Warren Kendall, MD
Grants Pass, Oregon
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
“YOUR PATIENTS ARE TALKING: ISN’T IT TIME YOU TAKE RESPONSIBILITY FOR YOUR ONLINE REPUTATION?”
RON ROMANO AND NEIL H. BAUM, MD (NOVEMBER 2016)
Eschews meaningless Internet obfuscation
As a practicing physician I don’t have time for social media and its accompanying advertising rationale; it’s a wasteland that replaces television. My patients and I go one-on-one, eye-to-eye, and eschew meaningless Internet obfuscation. Don’t we have better things to do with our physician/patient relationship than check online reviews?
Warren Kendall, MD
Grants Pass, Oregon
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Letters to the Editor: Should we change instruments and gloves after closing the uterus?
“PREVENTING INFECTION AFTER CESAREAN DELIVERY: 5 MORE EVIDENCE-BASED MEASURES TO CONSIDER”
KATHRYN E. PATRICK, MD; SARA L. DEATSMAN, MD; AND PATRICK DUFF, MD (DECEMEBER 2016)
Should we change instruments and gloves after closing the uterus?
In reference to the recent article series on preventing infection after cesarean delivery by Drs. Patrick, Deatsman, and Duff, what are the thoughts on using clean instruments and changing gloves after closing the uterus?
Gerrit J. Schipper, MD
Frederick, Maryland
❯❯ Drs. Patrick, Deatsman, and Duff respond:
We appreciate Dr. Schipper’s thoughtful question concerning our recent articles. At present, we are not aware of any rigorous studies that have evaluated the possible protective effect of changing to a different set of surgical instruments after closure of the uterus.
The second part of the question concerning the effect of changing gloves at a certain point in the operation is more intriguing. In an earlier report from our institution, we showed that the dominant hand of the operator becomes heavily contaminated with bacteria during the process of extracting the fetal head from the lower uterine segment.1 The contamination is particularly heavy when the patient has had an extended duration of labor in the presence of ruptured membranes. In a subsequent investigation, we showed that avoidance of manual extraction of the placenta, a process in which the now-contaminated glove of the operator is placed between the placenta and the uterine wall, significantly reduced the frequency of postcesarean endometritis even in patients who already were receiving systemic antibiotic prophylaxis.2 Whether changing gloves after delivery of the baby will further decrease the frequency of postcesarean endometritis, beyond that which can be achieved with systemic antibiotic prophylaxis combined with delivery of the placenta by traction on the cord, has not been studied in a systematic manner.
Given the low frequency of infection that can be achieved with these 2 methods, it would require a very large sample size to show that glove change offered an additional protective effect. Nevertheless, on a practical basis, we think it is very reasonable to change the glove on the dominant hand following a difficult extraction of the presenting part in a patient who has had an extended duration of labor and ruptured membranes. The glove change is particularly important if manual extraction of the placenta is contemplated.
Of note, we would like to acknowledge that the US Food and Drug Administration finalized a ban on the use of powdered surgical gloves effective January 18, 2017.3 The aerosolized glove powder on latex gloves contains proteins that can provoke severe respiratory allergic reactions in patients who are sensitive to latex. Even powdered synthetic gloves can cause airway inflammation, wound inflammation, and postoperative adhesions.
“DOES ONE PARTICULAR CESAREAN TECHNIQUE CONFER BETTER MATERNAL AND NEONATAL OUTCOMES?”
JOHN M. THORP JR, MD (EXAMINING THE EVIDENCE; NOVEMBER 2016)
Choosing a cesarean technique based on “evidence”
I appreciate the commentary by Dr. Thorp concerning cesarean delivery techniques. I have always thought that there was no difference in the outcomes of the various techniques. However, we will continue to waver to the peer pressure of this evidence-based stuff—until we find out later, like now—until things change again. “The more things change, the more they remain the same.”
Dr. Smart Ebinne
Port Harcourt, Nigeria
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
- Yancey MK, Clark P, Duff P. The frequency of glove contamination during cesarean delivery. Obstet Gynecol. 1994;83(4):538–542.
- Lasley DS, Eblen A, Yancey MK, Duff P. The effect of placental removal method on the incidence of postcesarean infections. Am J Obstet Gynecol. 1997;176(6):1250–1254.
- US Food and Drug Administration. Banned devices; powdered surgeon’s gloves, powdered patient examination gloves, and absorbable powder for lubricating a surgeon’s glove. Final rule. Fed Regist. 2016;81(243):91722–91731.
“PREVENTING INFECTION AFTER CESAREAN DELIVERY: 5 MORE EVIDENCE-BASED MEASURES TO CONSIDER”
KATHRYN E. PATRICK, MD; SARA L. DEATSMAN, MD; AND PATRICK DUFF, MD (DECEMEBER 2016)
Should we change instruments and gloves after closing the uterus?
In reference to the recent article series on preventing infection after cesarean delivery by Drs. Patrick, Deatsman, and Duff, what are the thoughts on using clean instruments and changing gloves after closing the uterus?
Gerrit J. Schipper, MD
Frederick, Maryland
❯❯ Drs. Patrick, Deatsman, and Duff respond:
We appreciate Dr. Schipper’s thoughtful question concerning our recent articles. At present, we are not aware of any rigorous studies that have evaluated the possible protective effect of changing to a different set of surgical instruments after closure of the uterus.
The second part of the question concerning the effect of changing gloves at a certain point in the operation is more intriguing. In an earlier report from our institution, we showed that the dominant hand of the operator becomes heavily contaminated with bacteria during the process of extracting the fetal head from the lower uterine segment.1 The contamination is particularly heavy when the patient has had an extended duration of labor in the presence of ruptured membranes. In a subsequent investigation, we showed that avoidance of manual extraction of the placenta, a process in which the now-contaminated glove of the operator is placed between the placenta and the uterine wall, significantly reduced the frequency of postcesarean endometritis even in patients who already were receiving systemic antibiotic prophylaxis.2 Whether changing gloves after delivery of the baby will further decrease the frequency of postcesarean endometritis, beyond that which can be achieved with systemic antibiotic prophylaxis combined with delivery of the placenta by traction on the cord, has not been studied in a systematic manner.
Given the low frequency of infection that can be achieved with these 2 methods, it would require a very large sample size to show that glove change offered an additional protective effect. Nevertheless, on a practical basis, we think it is very reasonable to change the glove on the dominant hand following a difficult extraction of the presenting part in a patient who has had an extended duration of labor and ruptured membranes. The glove change is particularly important if manual extraction of the placenta is contemplated.
Of note, we would like to acknowledge that the US Food and Drug Administration finalized a ban on the use of powdered surgical gloves effective January 18, 2017.3 The aerosolized glove powder on latex gloves contains proteins that can provoke severe respiratory allergic reactions in patients who are sensitive to latex. Even powdered synthetic gloves can cause airway inflammation, wound inflammation, and postoperative adhesions.
“DOES ONE PARTICULAR CESAREAN TECHNIQUE CONFER BETTER MATERNAL AND NEONATAL OUTCOMES?”
JOHN M. THORP JR, MD (EXAMINING THE EVIDENCE; NOVEMBER 2016)
Choosing a cesarean technique based on “evidence”
I appreciate the commentary by Dr. Thorp concerning cesarean delivery techniques. I have always thought that there was no difference in the outcomes of the various techniques. However, we will continue to waver to the peer pressure of this evidence-based stuff—until we find out later, like now—until things change again. “The more things change, the more they remain the same.”
Dr. Smart Ebinne
Port Harcourt, Nigeria
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
“PREVENTING INFECTION AFTER CESAREAN DELIVERY: 5 MORE EVIDENCE-BASED MEASURES TO CONSIDER”
KATHRYN E. PATRICK, MD; SARA L. DEATSMAN, MD; AND PATRICK DUFF, MD (DECEMEBER 2016)
Should we change instruments and gloves after closing the uterus?
In reference to the recent article series on preventing infection after cesarean delivery by Drs. Patrick, Deatsman, and Duff, what are the thoughts on using clean instruments and changing gloves after closing the uterus?
Gerrit J. Schipper, MD
Frederick, Maryland
❯❯ Drs. Patrick, Deatsman, and Duff respond:
We appreciate Dr. Schipper’s thoughtful question concerning our recent articles. At present, we are not aware of any rigorous studies that have evaluated the possible protective effect of changing to a different set of surgical instruments after closure of the uterus.
The second part of the question concerning the effect of changing gloves at a certain point in the operation is more intriguing. In an earlier report from our institution, we showed that the dominant hand of the operator becomes heavily contaminated with bacteria during the process of extracting the fetal head from the lower uterine segment.1 The contamination is particularly heavy when the patient has had an extended duration of labor in the presence of ruptured membranes. In a subsequent investigation, we showed that avoidance of manual extraction of the placenta, a process in which the now-contaminated glove of the operator is placed between the placenta and the uterine wall, significantly reduced the frequency of postcesarean endometritis even in patients who already were receiving systemic antibiotic prophylaxis.2 Whether changing gloves after delivery of the baby will further decrease the frequency of postcesarean endometritis, beyond that which can be achieved with systemic antibiotic prophylaxis combined with delivery of the placenta by traction on the cord, has not been studied in a systematic manner.
Given the low frequency of infection that can be achieved with these 2 methods, it would require a very large sample size to show that glove change offered an additional protective effect. Nevertheless, on a practical basis, we think it is very reasonable to change the glove on the dominant hand following a difficult extraction of the presenting part in a patient who has had an extended duration of labor and ruptured membranes. The glove change is particularly important if manual extraction of the placenta is contemplated.
Of note, we would like to acknowledge that the US Food and Drug Administration finalized a ban on the use of powdered surgical gloves effective January 18, 2017.3 The aerosolized glove powder on latex gloves contains proteins that can provoke severe respiratory allergic reactions in patients who are sensitive to latex. Even powdered synthetic gloves can cause airway inflammation, wound inflammation, and postoperative adhesions.
“DOES ONE PARTICULAR CESAREAN TECHNIQUE CONFER BETTER MATERNAL AND NEONATAL OUTCOMES?”
JOHN M. THORP JR, MD (EXAMINING THE EVIDENCE; NOVEMBER 2016)
Choosing a cesarean technique based on “evidence”
I appreciate the commentary by Dr. Thorp concerning cesarean delivery techniques. I have always thought that there was no difference in the outcomes of the various techniques. However, we will continue to waver to the peer pressure of this evidence-based stuff—until we find out later, like now—until things change again. “The more things change, the more they remain the same.”
Dr. Smart Ebinne
Port Harcourt, Nigeria
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
- Yancey MK, Clark P, Duff P. The frequency of glove contamination during cesarean delivery. Obstet Gynecol. 1994;83(4):538–542.
- Lasley DS, Eblen A, Yancey MK, Duff P. The effect of placental removal method on the incidence of postcesarean infections. Am J Obstet Gynecol. 1997;176(6):1250–1254.
- US Food and Drug Administration. Banned devices; powdered surgeon’s gloves, powdered patient examination gloves, and absorbable powder for lubricating a surgeon’s glove. Final rule. Fed Regist. 2016;81(243):91722–91731.
- Yancey MK, Clark P, Duff P. The frequency of glove contamination during cesarean delivery. Obstet Gynecol. 1994;83(4):538–542.
- Lasley DS, Eblen A, Yancey MK, Duff P. The effect of placental removal method on the incidence of postcesarean infections. Am J Obstet Gynecol. 1997;176(6):1250–1254.
- US Food and Drug Administration. Banned devices; powdered surgeon’s gloves, powdered patient examination gloves, and absorbable powder for lubricating a surgeon’s glove. Final rule. Fed Regist. 2016;81(243):91722–91731.
It isn’t over until it’s over
Pediatricians take heart.
Yes, I know it is discouraging when families occasionally ignore our advice and refuse vaccines for their children. It is even worse when political leaders who ought to know better question the safety and value of vaccines.
But let’s not lose perspective. Let me share a quick reminder of why vaccines are (almost) universally considered one of the greatest public health achievements of the 20th century.
Not long ago, I reviewed a clinical case with students as part of a medical microbiology course. A 6-year-old girl presented with fever, headache, and flaccid paralysis of the right arm with areflexia. With little prompting, the students generated a short differential diagnosis. Enterovirus. West Nile virus. “I guess we should include polio,” one student offered. “But who gets that anymore?”
A mere 120 years changes everything. At the dawn of the 20th century, we didn’t even know with certainty what caused polio, although infection was suspected.
On Sept. 9, 1954, the Courier-Journal, a newspaper in my hometown of Louisville, Ky., carried a story about the annual number of polio cases in Jefferson County, noting that they had reached 198 and General Hospital had opened a polio ward usually reserved for epidemics. Concerns about the infection were rippling throughout the state, and the paper reported that at least one high school marching band had elected to withdraw from annual Kentucky State Fair competition because of concerns about infection.
My mom was 10 years old in the summer of 1954, and she recalls that it was a “scary” time. Swimming pools closed. Parents refused to allow their children to go to movie theaters or the local amusement park because of fear that they might come into contact with the virus. My mom said, “Then one of my friends was diagnosed with polio. We had played together the week before she got sick. We worried that we were going to get sick, too. And once you got sick, you didn’t necessarily get better.”
I probably don’t need to remind you that both Dr. Sabin and Dr. Salk did develop successful poliovirus vaccines. Dr. Enders, along with junior colleagues Fred C. Robbins, MD, and Thomas H. Weller, MD, developed the techniques to grow poliovirus and other viruses in culture, making the work of Dr. Sabin and Dr. Salk possible. For this, Dr. Enders, Dr. Robbins, and Dr. Weller received the Nobel Prize in 1954.
Regarding the prediction of long-term protection, I’d say we’re there. According to the Centers for Disease Control and Prevention, wild poliovirus cases have declined more than 99.9% since 1988. According to the Global Polio Eradication Initiative, that means that there are approximately 10 million people walking today who would have otherwise been paralyzed by the disease.
In 2015, there were only 74 cases identified in the world, and these were localized to two countries. Even better, a global commission announced that wild poliovirus type 2 had been eradicated from the world. Eradicated. The last known transmission occurred in India in 1999.
Type 3 poliovirus may not be far behind. The last known case of wildtype poliovirus 3 was detected in 2012.
The complete story of poliovirus eradication efforts could read like a suspense novel: There have been twists and turns, some missed deadlines, and now a bit of irony. Success, in large part, has hinged on the use of trivalent, live attenuated oral poliovirus vaccine (tOPV) throughout much of the world. Now eradication of all polio disease is going to require withdrawal of OPV in countries that still use it.
Rarely, the live attenuated vaccine viruses contained in OPV can cause polio, and since 2012, vaccine-derived cases have exceeded wild poliovirus cases. Vaccine-derived cases include vaccine-associated paralytic polio (VAPP) – paralysis occurs in a vaccine recipient or a close contact – as well as cases of circulating vaccine-derived polioviruses (cVDPVs). Remember that vaccine viruses are shed in the stool, and in communities with low immunization rates, they circulate and acquire mutations that confer the transmissibility and neurovirulence properties of wild viruses. Ultimately, cVDPVs lead to outbreaks.
In 2013, the Global Polio Eradication Initiative published a new “endgame plan” for polio that outlined a stepwise approach for removing OPV from immunization programs. First, it called on all countries to introduce at least one dose of inactivated poliovirus vaccine by the third quarter of 2015, immunizing infants at 14 weeks or at first contact thereafter. Second, it called for all countries to replace tOPV with a bivalent vaccine containing only types 1 and 3 by 2016. Given the eradication of wild poliovirus type 2, keeping type 2 in the oral vaccine just creates risk. An estimated 40% of VAPP cases and 98% of cVDPVs detected since 2012 were caused by poliovirus type 2. The type 2 component of tOPV also interferes with the immune response to the other types. Once poliovirus eradication has been achieved and certified, hopefully no later than 2019, all OPV will be withdrawn.
What’s the role of pediatricians in the United States in polio eradication? For now, our job is to continue to protect all children in the United States against all three types of poliovirus. Current Advisory Committee on Immunization Practices (ACIP) recommendations specify 4 doses of trivalent inactivated poliovirus vaccine (IPV) at ages 2 months, 4 months, 6-18 months, and 4-6 years. Children vaccinated outside the United States with bivalent vaccine, including immigrants and refugees, will need to be revaccinated. Those without appropriate documentation of vaccine (written, dated records that specify trivalent vaccine) also should be revaccinated.
Serologic testing for immunity is no longer recommended. In the past, children without documentation of vaccines could be tested for neutralizing antibodies to poliovirus types 1, 2, and 3. Moving forward, serologic testing for antibodies to poliovirus type 2 won’t be available because it requires live virus, and in accordance with World Health Organization recommendations, laboratories have been destroying supplies of poliovirus type 2.
We also need to make sure that our patients who are traveling internationally receive all recommended vaccines, including a dose of IPV when appropriate. Specific recommendations can be found on the CDC’s pages for travelers.
A 2015 statement from the American Academy of Pediatrics called on pediatricians to consider polio as a potential diagnosis of any child presenting with fever and acute flaccid paralysis (Pediatrics. 2015 Jan;135[1]:196-202). When polio is suspected, public health authorities should be notified and two stool samples collected 24 hours apart, and within 14 days of the onset of paralysis, sent for testing. According to lead author Walter A. Orenstein, MD, “because most polio infections are silent, a case of paralytic polio in the United States may have been acquired from an asymptomatic individual, so a history of travel to a polio-infected area may be absent in the case of paralysis.”
I’ll second what my mom said. Scary.
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Kosair Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at [email protected].
Pediatricians take heart.
Yes, I know it is discouraging when families occasionally ignore our advice and refuse vaccines for their children. It is even worse when political leaders who ought to know better question the safety and value of vaccines.
But let’s not lose perspective. Let me share a quick reminder of why vaccines are (almost) universally considered one of the greatest public health achievements of the 20th century.
Not long ago, I reviewed a clinical case with students as part of a medical microbiology course. A 6-year-old girl presented with fever, headache, and flaccid paralysis of the right arm with areflexia. With little prompting, the students generated a short differential diagnosis. Enterovirus. West Nile virus. “I guess we should include polio,” one student offered. “But who gets that anymore?”
A mere 120 years changes everything. At the dawn of the 20th century, we didn’t even know with certainty what caused polio, although infection was suspected.
On Sept. 9, 1954, the Courier-Journal, a newspaper in my hometown of Louisville, Ky., carried a story about the annual number of polio cases in Jefferson County, noting that they had reached 198 and General Hospital had opened a polio ward usually reserved for epidemics. Concerns about the infection were rippling throughout the state, and the paper reported that at least one high school marching band had elected to withdraw from annual Kentucky State Fair competition because of concerns about infection.
My mom was 10 years old in the summer of 1954, and she recalls that it was a “scary” time. Swimming pools closed. Parents refused to allow their children to go to movie theaters or the local amusement park because of fear that they might come into contact with the virus. My mom said, “Then one of my friends was diagnosed with polio. We had played together the week before she got sick. We worried that we were going to get sick, too. And once you got sick, you didn’t necessarily get better.”
I probably don’t need to remind you that both Dr. Sabin and Dr. Salk did develop successful poliovirus vaccines. Dr. Enders, along with junior colleagues Fred C. Robbins, MD, and Thomas H. Weller, MD, developed the techniques to grow poliovirus and other viruses in culture, making the work of Dr. Sabin and Dr. Salk possible. For this, Dr. Enders, Dr. Robbins, and Dr. Weller received the Nobel Prize in 1954.
Regarding the prediction of long-term protection, I’d say we’re there. According to the Centers for Disease Control and Prevention, wild poliovirus cases have declined more than 99.9% since 1988. According to the Global Polio Eradication Initiative, that means that there are approximately 10 million people walking today who would have otherwise been paralyzed by the disease.
In 2015, there were only 74 cases identified in the world, and these were localized to two countries. Even better, a global commission announced that wild poliovirus type 2 had been eradicated from the world. Eradicated. The last known transmission occurred in India in 1999.
Type 3 poliovirus may not be far behind. The last known case of wildtype poliovirus 3 was detected in 2012.
The complete story of poliovirus eradication efforts could read like a suspense novel: There have been twists and turns, some missed deadlines, and now a bit of irony. Success, in large part, has hinged on the use of trivalent, live attenuated oral poliovirus vaccine (tOPV) throughout much of the world. Now eradication of all polio disease is going to require withdrawal of OPV in countries that still use it.
Rarely, the live attenuated vaccine viruses contained in OPV can cause polio, and since 2012, vaccine-derived cases have exceeded wild poliovirus cases. Vaccine-derived cases include vaccine-associated paralytic polio (VAPP) – paralysis occurs in a vaccine recipient or a close contact – as well as cases of circulating vaccine-derived polioviruses (cVDPVs). Remember that vaccine viruses are shed in the stool, and in communities with low immunization rates, they circulate and acquire mutations that confer the transmissibility and neurovirulence properties of wild viruses. Ultimately, cVDPVs lead to outbreaks.
In 2013, the Global Polio Eradication Initiative published a new “endgame plan” for polio that outlined a stepwise approach for removing OPV from immunization programs. First, it called on all countries to introduce at least one dose of inactivated poliovirus vaccine by the third quarter of 2015, immunizing infants at 14 weeks or at first contact thereafter. Second, it called for all countries to replace tOPV with a bivalent vaccine containing only types 1 and 3 by 2016. Given the eradication of wild poliovirus type 2, keeping type 2 in the oral vaccine just creates risk. An estimated 40% of VAPP cases and 98% of cVDPVs detected since 2012 were caused by poliovirus type 2. The type 2 component of tOPV also interferes with the immune response to the other types. Once poliovirus eradication has been achieved and certified, hopefully no later than 2019, all OPV will be withdrawn.
What’s the role of pediatricians in the United States in polio eradication? For now, our job is to continue to protect all children in the United States against all three types of poliovirus. Current Advisory Committee on Immunization Practices (ACIP) recommendations specify 4 doses of trivalent inactivated poliovirus vaccine (IPV) at ages 2 months, 4 months, 6-18 months, and 4-6 years. Children vaccinated outside the United States with bivalent vaccine, including immigrants and refugees, will need to be revaccinated. Those without appropriate documentation of vaccine (written, dated records that specify trivalent vaccine) also should be revaccinated.
Serologic testing for immunity is no longer recommended. In the past, children without documentation of vaccines could be tested for neutralizing antibodies to poliovirus types 1, 2, and 3. Moving forward, serologic testing for antibodies to poliovirus type 2 won’t be available because it requires live virus, and in accordance with World Health Organization recommendations, laboratories have been destroying supplies of poliovirus type 2.
We also need to make sure that our patients who are traveling internationally receive all recommended vaccines, including a dose of IPV when appropriate. Specific recommendations can be found on the CDC’s pages for travelers.
A 2015 statement from the American Academy of Pediatrics called on pediatricians to consider polio as a potential diagnosis of any child presenting with fever and acute flaccid paralysis (Pediatrics. 2015 Jan;135[1]:196-202). When polio is suspected, public health authorities should be notified and two stool samples collected 24 hours apart, and within 14 days of the onset of paralysis, sent for testing. According to lead author Walter A. Orenstein, MD, “because most polio infections are silent, a case of paralytic polio in the United States may have been acquired from an asymptomatic individual, so a history of travel to a polio-infected area may be absent in the case of paralysis.”
I’ll second what my mom said. Scary.
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Kosair Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at [email protected].
Pediatricians take heart.
Yes, I know it is discouraging when families occasionally ignore our advice and refuse vaccines for their children. It is even worse when political leaders who ought to know better question the safety and value of vaccines.
But let’s not lose perspective. Let me share a quick reminder of why vaccines are (almost) universally considered one of the greatest public health achievements of the 20th century.
Not long ago, I reviewed a clinical case with students as part of a medical microbiology course. A 6-year-old girl presented with fever, headache, and flaccid paralysis of the right arm with areflexia. With little prompting, the students generated a short differential diagnosis. Enterovirus. West Nile virus. “I guess we should include polio,” one student offered. “But who gets that anymore?”
A mere 120 years changes everything. At the dawn of the 20th century, we didn’t even know with certainty what caused polio, although infection was suspected.
On Sept. 9, 1954, the Courier-Journal, a newspaper in my hometown of Louisville, Ky., carried a story about the annual number of polio cases in Jefferson County, noting that they had reached 198 and General Hospital had opened a polio ward usually reserved for epidemics. Concerns about the infection were rippling throughout the state, and the paper reported that at least one high school marching band had elected to withdraw from annual Kentucky State Fair competition because of concerns about infection.
My mom was 10 years old in the summer of 1954, and she recalls that it was a “scary” time. Swimming pools closed. Parents refused to allow their children to go to movie theaters or the local amusement park because of fear that they might come into contact with the virus. My mom said, “Then one of my friends was diagnosed with polio. We had played together the week before she got sick. We worried that we were going to get sick, too. And once you got sick, you didn’t necessarily get better.”
I probably don’t need to remind you that both Dr. Sabin and Dr. Salk did develop successful poliovirus vaccines. Dr. Enders, along with junior colleagues Fred C. Robbins, MD, and Thomas H. Weller, MD, developed the techniques to grow poliovirus and other viruses in culture, making the work of Dr. Sabin and Dr. Salk possible. For this, Dr. Enders, Dr. Robbins, and Dr. Weller received the Nobel Prize in 1954.
Regarding the prediction of long-term protection, I’d say we’re there. According to the Centers for Disease Control and Prevention, wild poliovirus cases have declined more than 99.9% since 1988. According to the Global Polio Eradication Initiative, that means that there are approximately 10 million people walking today who would have otherwise been paralyzed by the disease.
In 2015, there were only 74 cases identified in the world, and these were localized to two countries. Even better, a global commission announced that wild poliovirus type 2 had been eradicated from the world. Eradicated. The last known transmission occurred in India in 1999.
Type 3 poliovirus may not be far behind. The last known case of wildtype poliovirus 3 was detected in 2012.
The complete story of poliovirus eradication efforts could read like a suspense novel: There have been twists and turns, some missed deadlines, and now a bit of irony. Success, in large part, has hinged on the use of trivalent, live attenuated oral poliovirus vaccine (tOPV) throughout much of the world. Now eradication of all polio disease is going to require withdrawal of OPV in countries that still use it.
Rarely, the live attenuated vaccine viruses contained in OPV can cause polio, and since 2012, vaccine-derived cases have exceeded wild poliovirus cases. Vaccine-derived cases include vaccine-associated paralytic polio (VAPP) – paralysis occurs in a vaccine recipient or a close contact – as well as cases of circulating vaccine-derived polioviruses (cVDPVs). Remember that vaccine viruses are shed in the stool, and in communities with low immunization rates, they circulate and acquire mutations that confer the transmissibility and neurovirulence properties of wild viruses. Ultimately, cVDPVs lead to outbreaks.
In 2013, the Global Polio Eradication Initiative published a new “endgame plan” for polio that outlined a stepwise approach for removing OPV from immunization programs. First, it called on all countries to introduce at least one dose of inactivated poliovirus vaccine by the third quarter of 2015, immunizing infants at 14 weeks or at first contact thereafter. Second, it called for all countries to replace tOPV with a bivalent vaccine containing only types 1 and 3 by 2016. Given the eradication of wild poliovirus type 2, keeping type 2 in the oral vaccine just creates risk. An estimated 40% of VAPP cases and 98% of cVDPVs detected since 2012 were caused by poliovirus type 2. The type 2 component of tOPV also interferes with the immune response to the other types. Once poliovirus eradication has been achieved and certified, hopefully no later than 2019, all OPV will be withdrawn.
What’s the role of pediatricians in the United States in polio eradication? For now, our job is to continue to protect all children in the United States against all three types of poliovirus. Current Advisory Committee on Immunization Practices (ACIP) recommendations specify 4 doses of trivalent inactivated poliovirus vaccine (IPV) at ages 2 months, 4 months, 6-18 months, and 4-6 years. Children vaccinated outside the United States with bivalent vaccine, including immigrants and refugees, will need to be revaccinated. Those without appropriate documentation of vaccine (written, dated records that specify trivalent vaccine) also should be revaccinated.
Serologic testing for immunity is no longer recommended. In the past, children without documentation of vaccines could be tested for neutralizing antibodies to poliovirus types 1, 2, and 3. Moving forward, serologic testing for antibodies to poliovirus type 2 won’t be available because it requires live virus, and in accordance with World Health Organization recommendations, laboratories have been destroying supplies of poliovirus type 2.
We also need to make sure that our patients who are traveling internationally receive all recommended vaccines, including a dose of IPV when appropriate. Specific recommendations can be found on the CDC’s pages for travelers.
A 2015 statement from the American Academy of Pediatrics called on pediatricians to consider polio as a potential diagnosis of any child presenting with fever and acute flaccid paralysis (Pediatrics. 2015 Jan;135[1]:196-202). When polio is suspected, public health authorities should be notified and two stool samples collected 24 hours apart, and within 14 days of the onset of paralysis, sent for testing. According to lead author Walter A. Orenstein, MD, “because most polio infections are silent, a case of paralytic polio in the United States may have been acquired from an asymptomatic individual, so a history of travel to a polio-infected area may be absent in the case of paralysis.”
I’ll second what my mom said. Scary.
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Kosair Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at [email protected].
Charging for medical records: For whom and at what cost?
Do you charge for medical records?
You probably do, and so do I, at times.
Generally, I’m willing to give a patient one copy of their records or transfer them to another doctor for continuation of care, at no charge. People move away. They change insurance or doctors. They have urgent hospital admissions. To me, charging to forward records in these cases is like withholding care.
That’s not to say I don’t lose money on them. It takes a few minutes (or more) of staff time to print them up and fax them. If they need to be mailed, postage costs money. And then there’s paper, printer ink, and so on. I’m sure it adds up to something over the course of the year, although I have no idea how much.
How much you can charge is a more complex issue, with each state setting its own rules. A recent article published in JAMA Internal Medicine noted that a patient in Georgia could pay up to $111.68 for a 100-page record. Hitting someone up for that amount, who’s already having health problems and may be relocating or trying to find a new doctor, seems like making an already difficult situation worse.
But we’re in the digital age now. So how much does it cost to send records? Most files (.doc, .pdf, .jpg, and so on) are interchangeable between Mac and Windows.
Things get iffy here. I mean, it’s easy to send a .pdf file by email, but that’s not particularly secure. And I hate having to sign up and create passwords for the many allegedly safer file-sharing services out there.
Burning records on a CD or DVD certainly saves postage, though takes about the same amount of computer time as printing them up. Not only that, but this seems to be a format that’s on its way out. The last three computers I’ve bought didn’t even have optical drives. CD/DVD’s are starting to resemble VHS tapes in the late 1990s.
Flash drives are the present and immediate future of transferred records. Small, lightweight, and capable of holding a lot. But they still need to be mailed, and are more expensive than paper. They also have security risks that concern me. When a patient hands me one and asks me to plug it in, I never do. There could be a virus or spyware that can compromise the security and privacy of my office, and cost a fortune to reverse the damage.
And so, at the end of that chain of thought, paper still appears to be king. It’s not going to carry ransomware into my office. It can be mailed or faxed, and is easily adaptable to any system (like mine) with a scanner. The paper world may hypothetically no longer exist, but for many things in medicine it still does, and is critical.
Some ultimate solutions, such as a universal database of health care data on all patients or a complete interchangeability between systems, sound great. No one would need to transfer records between doctors and all would have access to their own charts. But at this point in time, while technologically achievable, the privacy concerns and high-stakes security risks make such a thing impossible.
It’s easy to hope that the age of electronic medical records will lead to, as the article states, “easy, inexpensive” reproduction of medical records. But things never seem to be that simple, for some of the reasons I’ve mentioned above.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Do you charge for medical records?
You probably do, and so do I, at times.
Generally, I’m willing to give a patient one copy of their records or transfer them to another doctor for continuation of care, at no charge. People move away. They change insurance or doctors. They have urgent hospital admissions. To me, charging to forward records in these cases is like withholding care.
That’s not to say I don’t lose money on them. It takes a few minutes (or more) of staff time to print them up and fax them. If they need to be mailed, postage costs money. And then there’s paper, printer ink, and so on. I’m sure it adds up to something over the course of the year, although I have no idea how much.
How much you can charge is a more complex issue, with each state setting its own rules. A recent article published in JAMA Internal Medicine noted that a patient in Georgia could pay up to $111.68 for a 100-page record. Hitting someone up for that amount, who’s already having health problems and may be relocating or trying to find a new doctor, seems like making an already difficult situation worse.
But we’re in the digital age now. So how much does it cost to send records? Most files (.doc, .pdf, .jpg, and so on) are interchangeable between Mac and Windows.
Things get iffy here. I mean, it’s easy to send a .pdf file by email, but that’s not particularly secure. And I hate having to sign up and create passwords for the many allegedly safer file-sharing services out there.
Burning records on a CD or DVD certainly saves postage, though takes about the same amount of computer time as printing them up. Not only that, but this seems to be a format that’s on its way out. The last three computers I’ve bought didn’t even have optical drives. CD/DVD’s are starting to resemble VHS tapes in the late 1990s.
Flash drives are the present and immediate future of transferred records. Small, lightweight, and capable of holding a lot. But they still need to be mailed, and are more expensive than paper. They also have security risks that concern me. When a patient hands me one and asks me to plug it in, I never do. There could be a virus or spyware that can compromise the security and privacy of my office, and cost a fortune to reverse the damage.
And so, at the end of that chain of thought, paper still appears to be king. It’s not going to carry ransomware into my office. It can be mailed or faxed, and is easily adaptable to any system (like mine) with a scanner. The paper world may hypothetically no longer exist, but for many things in medicine it still does, and is critical.
Some ultimate solutions, such as a universal database of health care data on all patients or a complete interchangeability between systems, sound great. No one would need to transfer records between doctors and all would have access to their own charts. But at this point in time, while technologically achievable, the privacy concerns and high-stakes security risks make such a thing impossible.
It’s easy to hope that the age of electronic medical records will lead to, as the article states, “easy, inexpensive” reproduction of medical records. But things never seem to be that simple, for some of the reasons I’ve mentioned above.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Do you charge for medical records?
You probably do, and so do I, at times.
Generally, I’m willing to give a patient one copy of their records or transfer them to another doctor for continuation of care, at no charge. People move away. They change insurance or doctors. They have urgent hospital admissions. To me, charging to forward records in these cases is like withholding care.
That’s not to say I don’t lose money on them. It takes a few minutes (or more) of staff time to print them up and fax them. If they need to be mailed, postage costs money. And then there’s paper, printer ink, and so on. I’m sure it adds up to something over the course of the year, although I have no idea how much.
How much you can charge is a more complex issue, with each state setting its own rules. A recent article published in JAMA Internal Medicine noted that a patient in Georgia could pay up to $111.68 for a 100-page record. Hitting someone up for that amount, who’s already having health problems and may be relocating or trying to find a new doctor, seems like making an already difficult situation worse.
But we’re in the digital age now. So how much does it cost to send records? Most files (.doc, .pdf, .jpg, and so on) are interchangeable between Mac and Windows.
Things get iffy here. I mean, it’s easy to send a .pdf file by email, but that’s not particularly secure. And I hate having to sign up and create passwords for the many allegedly safer file-sharing services out there.
Burning records on a CD or DVD certainly saves postage, though takes about the same amount of computer time as printing them up. Not only that, but this seems to be a format that’s on its way out. The last three computers I’ve bought didn’t even have optical drives. CD/DVD’s are starting to resemble VHS tapes in the late 1990s.
Flash drives are the present and immediate future of transferred records. Small, lightweight, and capable of holding a lot. But they still need to be mailed, and are more expensive than paper. They also have security risks that concern me. When a patient hands me one and asks me to plug it in, I never do. There could be a virus or spyware that can compromise the security and privacy of my office, and cost a fortune to reverse the damage.
And so, at the end of that chain of thought, paper still appears to be king. It’s not going to carry ransomware into my office. It can be mailed or faxed, and is easily adaptable to any system (like mine) with a scanner. The paper world may hypothetically no longer exist, but for many things in medicine it still does, and is critical.
Some ultimate solutions, such as a universal database of health care data on all patients or a complete interchangeability between systems, sound great. No one would need to transfer records between doctors and all would have access to their own charts. But at this point in time, while technologically achievable, the privacy concerns and high-stakes security risks make such a thing impossible.
It’s easy to hope that the age of electronic medical records will lead to, as the article states, “easy, inexpensive” reproduction of medical records. But things never seem to be that simple, for some of the reasons I’ve mentioned above.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.