Commentary

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.

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.

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.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.
 

Has this ever happened to you? You are an adult neurologist who has been asked to take on the care of a pediatric neurology patient. The patient who comes to your clinic is a 20-year-old woman with a history of moderate developmental delay and intractable epilepsy. She is on numerous medications, including valproic acid,and has tried the ketogenic diet. You receive a report that she has focal epilepsy, she is having frequent seizures, and her last MRI was performed at age 2.

Prior notes talk about her summer vacations but not much about the future plans for her epilepsy. You see the patient in the clinic, and the family is not happy to be in the adult clinic. They are disappointed that you don’t spend more time with them or fill out myriad forms. You find out that they have not obtained legal guardianship for their daughter and have no plan for work placement after school. She also has various other medical comorbidities that were previously addressed by the pediatric neurologist.

Why does this happen? When patients are simply transferred instead of transitioned between providers when they get too old to be seen by pediatric specialists, the process often does not go smoothly. A true transition of care prepares the patient and the family to understand the underlying disease and everything that goes along with it to be able to successfully seek appropriate care as they move into the adult world.

There is not much evidence on the right way to do this. In 2013, the American Epilepsy Society approved a transition tool that is helpful in outlining the steps for a successful transition. In 2016, the Child Neurology Foundation put forth a consensus statement with eight principles to guide a successful transition. Transitions are an expectation of good care, and they recommend that all offices have a written policy.

Talking about transitioning should start as early as 10 to 12 years of age and should be discussed every year. Thinking about prognosis and a realistic plan for each child as they enter adult life is important. Patients and families should be able to understand how the disease affects them, what their medications are and how to independently obtain them, what comorbidities are associated with their disease, how to stay healthy, how to improve their quality of life, and how to advocate for themselves. As children become teenagers, they should have a concrete plan for ongoing education, work, women’s issues, and an understanding of decision-making capacity and whether legal guardianship or a power of attorney needs to be implemented.

When the pediatric epilepsy patient reaches young adulthood (18 years or older), the adult model of care should be implemented, even if they are still being seen in the pediatric setting. A transition packet should be created that includes a summary of the diagnosis, work-up, previous treatments, and considerations for future treatments and emergency care. Also included is a plan for who will continue to address any non–seizure-related diagnoses the pediatric neurologist may have been managing. The patient and family also have an opportunity to review and contribute to this plan. This packet enables the adult neurologist to easily understand all issues and assume care of the patient, easing this aspect of the transition.

An advance meeting of the patient and family with the adult provider should be arranged whenever possible. To address this, some centers are now creating a transition clinic staffed by both pediatric and adult neurologists and/or nurses. This ideally takes place in the adult setting and is an excellent way to ensure a smooth transition for the patient, family, and providers. Good transition is important to help prevent gaps in care, avoid reinventing the wheel, and improve satisfaction for everyone involved (patient, family, nurses, and neurologists).

The key points are that transition discussions start early, patients and families should be involved and empowered in the process, and the creation of a transition packet for the adult provider is very helpful. Care transitions are something we will be hearing a lot more about in the upcoming years. And hopefully, next time, the patient scenario seen above will go more smoothly!

Suggested Reading

Brown LW, Camfield P, Capers M, et al. The neurologist’s role in supporting transition to adult health care. Neurology. 2016;87(8):835-840.

Has this ever happened to you? You are an adult neurologist who has been asked to take on the care of a pediatric neurology patient. The patient who comes to your clinic is a 20-year-old woman with a history of moderate developmental delay and intractable epilepsy. She is on numerous medications, including valproic acid,and has tried the ketogenic diet. You receive a report that she has focal epilepsy, she is having frequent seizures, and her last MRI was performed at age 2.

Prior notes talk about her summer vacations but not much about the future plans for her epilepsy. You see the patient in the clinic, and the family is not happy to be in the adult clinic. They are disappointed that you don’t spend more time with them or fill out myriad forms. You find out that they have not obtained legal guardianship for their daughter and have no plan for work placement after school. She also has various other medical comorbidities that were previously addressed by the pediatric neurologist.

Why does this happen? When patients are simply transferred instead of transitioned between providers when they get too old to be seen by pediatric specialists, the process often does not go smoothly. A true transition of care prepares the patient and the family to understand the underlying disease and everything that goes along with it to be able to successfully seek appropriate care as they move into the adult world.

There is not much evidence on the right way to do this. In 2013, the American Epilepsy Society approved a transition tool that is helpful in outlining the steps for a successful transition. In 2016, the Child Neurology Foundation put forth a consensus statement with eight principles to guide a successful transition. Transitions are an expectation of good care, and they recommend that all offices have a written policy.

Talking about transitioning should start as early as 10 to 12 years of age and should be discussed every year. Thinking about prognosis and a realistic plan for each child as they enter adult life is important. Patients and families should be able to understand how the disease affects them, what their medications are and how to independently obtain them, what comorbidities are associated with their disease, how to stay healthy, how to improve their quality of life, and how to advocate for themselves. As children become teenagers, they should have a concrete plan for ongoing education, work, women’s issues, and an understanding of decision-making capacity and whether legal guardianship or a power of attorney needs to be implemented.

When the pediatric epilepsy patient reaches young adulthood (18 years or older), the adult model of care should be implemented, even if they are still being seen in the pediatric setting. A transition packet should be created that includes a summary of the diagnosis, work-up, previous treatments, and considerations for future treatments and emergency care. Also included is a plan for who will continue to address any non–seizure-related diagnoses the pediatric neurologist may have been managing. The patient and family also have an opportunity to review and contribute to this plan. This packet enables the adult neurologist to easily understand all issues and assume care of the patient, easing this aspect of the transition.

An advance meeting of the patient and family with the adult provider should be arranged whenever possible. To address this, some centers are now creating a transition clinic staffed by both pediatric and adult neurologists and/or nurses. This ideally takes place in the adult setting and is an excellent way to ensure a smooth transition for the patient, family, and providers. Good transition is important to help prevent gaps in care, avoid reinventing the wheel, and improve satisfaction for everyone involved (patient, family, nurses, and neurologists).

The key points are that transition discussions start early, patients and families should be involved and empowered in the process, and the creation of a transition packet for the adult provider is very helpful. Care transitions are something we will be hearing a lot more about in the upcoming years. And hopefully, next time, the patient scenario seen above will go more smoothly!

Suggested Reading

Brown LW, Camfield P, Capers M, et al. The neurologist’s role in supporting transition to adult health care. Neurology. 2016;87(8):835-840.

Has this ever happened to you? You are an adult neurologist who has been asked to take on the care of a pediatric neurology patient. The patient who comes to your clinic is a 20-year-old woman with a history of moderate developmental delay and intractable epilepsy. She is on numerous medications, including valproic acid,and has tried the ketogenic diet. You receive a report that she has focal epilepsy, she is having frequent seizures, and her last MRI was performed at age 2.

Prior notes talk about her summer vacations but not much about the future plans for her epilepsy. You see the patient in the clinic, and the family is not happy to be in the adult clinic. They are disappointed that you don’t spend more time with them or fill out myriad forms. You find out that they have not obtained legal guardianship for their daughter and have no plan for work placement after school. She also has various other medical comorbidities that were previously addressed by the pediatric neurologist.

Why does this happen? When patients are simply transferred instead of transitioned between providers when they get too old to be seen by pediatric specialists, the process often does not go smoothly. A true transition of care prepares the patient and the family to understand the underlying disease and everything that goes along with it to be able to successfully seek appropriate care as they move into the adult world.

There is not much evidence on the right way to do this. In 2013, the American Epilepsy Society approved a transition tool that is helpful in outlining the steps for a successful transition. In 2016, the Child Neurology Foundation put forth a consensus statement with eight principles to guide a successful transition. Transitions are an expectation of good care, and they recommend that all offices have a written policy.

Talking about transitioning should start as early as 10 to 12 years of age and should be discussed every year. Thinking about prognosis and a realistic plan for each child as they enter adult life is important. Patients and families should be able to understand how the disease affects them, what their medications are and how to independently obtain them, what comorbidities are associated with their disease, how to stay healthy, how to improve their quality of life, and how to advocate for themselves. As children become teenagers, they should have a concrete plan for ongoing education, work, women’s issues, and an understanding of decision-making capacity and whether legal guardianship or a power of attorney needs to be implemented.

When the pediatric epilepsy patient reaches young adulthood (18 years or older), the adult model of care should be implemented, even if they are still being seen in the pediatric setting. A transition packet should be created that includes a summary of the diagnosis, work-up, previous treatments, and considerations for future treatments and emergency care. Also included is a plan for who will continue to address any non–seizure-related diagnoses the pediatric neurologist may have been managing. The patient and family also have an opportunity to review and contribute to this plan. This packet enables the adult neurologist to easily understand all issues and assume care of the patient, easing this aspect of the transition.

An advance meeting of the patient and family with the adult provider should be arranged whenever possible. To address this, some centers are now creating a transition clinic staffed by both pediatric and adult neurologists and/or nurses. This ideally takes place in the adult setting and is an excellent way to ensure a smooth transition for the patient, family, and providers. Good transition is important to help prevent gaps in care, avoid reinventing the wheel, and improve satisfaction for everyone involved (patient, family, nurses, and neurologists).

The key points are that transition discussions start early, patients and families should be involved and empowered in the process, and the creation of a transition packet for the adult provider is very helpful. Care transitions are something we will be hearing a lot more about in the upcoming years. And hopefully, next time, the patient scenario seen above will go more smoothly!

Suggested Reading

Brown LW, Camfield P, Capers M, et al. The neurologist’s role in supporting transition to adult health care. Neurology. 2016;87(8):835-840.

As you may have read, accountable care organizations have met uneven success over the last several years. But, when they are broken down into categories, physician-sponsored ACOs have done better, particularly those with a strong primary care core.

This is true for several reasons.

In this transition period from a fee-for-service payment system that rewards volume and expensive inpatient care to a pay-for-value system, some ACOs set up by health systems or specialists envisioned the savings coming through lower utilization of their services. They had an inherent impediment to fully committing to keeping people well and avoiding acute care. In contrast, primary care providers are free to be all in with population health value-based programs.

New upfront payments are game changers

A successful ACO will be assigned one or more patient populations and be given a minimum of 50% of the savings for the overall costs for those populations, if the quality of their health is maintained or improved.

To excise avoidable waste, the ACO looks at gaps in care for those populations – frequent emergency department use for nonemergencies, avoidably high levels of diabetes and obesity, too-high readmission rates, unnecessarily high postacute care costs, etc. They then use evidence-based best team care practices – from patient self care and prevention, to multispecialty coordination and PCMH care management.

Why? Because these proved to give the highest impact on quality and reducing costs. To achieve significant shared savings, the costs are usually measured for a calendar year, then it takes about 6 months for the claims to be reported and paid. Thus, the shared savings check to the ACO will arrive about 18 months after all this is started.

The CMS has also figured out that primary care physician care coordination and management drive quality and savings. The agency knows that incentivizing this type of care, the very type calculated to create ACO success, will net significant savings to the Medicare program.

For example, the pilot project for preventing diabetes will be expanded, because Medicare hopes to save several thousand dollars a year per beneficiary in health care costs.

In a blog entry the day the expanded population health management codes were announced, the CMS acting administrator wrote that, “Over time, if the clinicians qualified to provide these services were to fully provide these services to all eligible beneficiaries, the increase would be as much as $4 billion or more in additional support for care coordination and patient-centered care.”

CMS revenue streams to support ACO success-driving activities include:

• Value-based screening and counseling codes to decrease downstream costs.

• Upward adjustment of evaluation and management reimbursement for assessment of care and care plan development for mobility-impaired patients.

• Annual wellness visits.

• Prolonged E&M services that accrue outside of a patient visit.

• Collaboration with mental health specialists.

• Comprehensive assessment and care planning for patients with cognitive impairment.

• Expansion of the diabetes prevention pilot program; diabetes prevention and diabetes education are two separate services.

• Transitional care management for high-risk patients post discharge.

• Structured obesity management.

The 2017 Medicare fee schedule smoothed some of the bumps in administering and being paid for chronic care management (CCM) services, and it added codes with increased reimbursement aligned with increased complexity of comorbidities/illness.

Perhaps the biggest new payment boost for primary care to engage in ACO high-value activities is actually the Merit-Based Incentive Payment System (MIPS) under MACRA, the Medicare Access and CHIP Reauthorization Act of 2015.

Under MACRA, all Medicare compensation for physicians will be determined by relative delivery of quality and efficient care. Experts are recommending that primary care physicians participate in non–risk-taking ACOs to optimize MIPS value scoring, while also reducing administrative burdens of compliance. Use an ACO’s analytics to support collaborative care and provide the reports required under MIPS.

Let’s be smart about it

According to Gordon Wilhoit, MD, a practicing physician and chief medical officer of an all–primary-care-physician ACO in South Carolina, “This is a no brainer. Start first with your MSSP ACO high-value game plan, then align the complementary care coordination codes, CCM, MIPS, and other revenue stream and reporting activities with it. Now, primary care physicians can finance their ACO and MIPS care coordination efforts with a stream of ongoing payments from these care management codes.

“One of my colleagues saw a 27% increase in revenues in 6 months just from providing and billing for this type of care,” Dr. Wilhoit explained. “And, not counting shared savings or MIPS incentive payments, our office’s reimbursement from these care management codes now exceeds our fee-for-service income, which has not decreased.”

Even with these payments, the CMS will reduce overall net expenditures. Your impact on health care will be more powerful as a manager of the team addressing patients’ overall health than reacting to patient sickness one at a time. The patients you impact the most may be ones you don’t actually see. Your empowerment to practice medicine the right way will continue to grow.

Now, finally, you may start getting compensation that takes away the last big hurdle to creating the infrastructure you need to succeed.
 

Mr. Bobbitt is a head of the health law group at the Smith Anderson law firm in Raleigh, N.C. He is president of, and Dr. Wilhoit is a consultant with, Value Health Partners, LLC, a health care strategic consulting company. He has years of experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at either [email protected] or 919-906-4054.

As you may have read, accountable care organizations have met uneven success over the last several years. But, when they are broken down into categories, physician-sponsored ACOs have done better, particularly those with a strong primary care core.

This is true for several reasons.

In this transition period from a fee-for-service payment system that rewards volume and expensive inpatient care to a pay-for-value system, some ACOs set up by health systems or specialists envisioned the savings coming through lower utilization of their services. They had an inherent impediment to fully committing to keeping people well and avoiding acute care. In contrast, primary care providers are free to be all in with population health value-based programs.

New upfront payments are game changers

A successful ACO will be assigned one or more patient populations and be given a minimum of 50% of the savings for the overall costs for those populations, if the quality of their health is maintained or improved.

To excise avoidable waste, the ACO looks at gaps in care for those populations – frequent emergency department use for nonemergencies, avoidably high levels of diabetes and obesity, too-high readmission rates, unnecessarily high postacute care costs, etc. They then use evidence-based best team care practices – from patient self care and prevention, to multispecialty coordination and PCMH care management.

Why? Because these proved to give the highest impact on quality and reducing costs. To achieve significant shared savings, the costs are usually measured for a calendar year, then it takes about 6 months for the claims to be reported and paid. Thus, the shared savings check to the ACO will arrive about 18 months after all this is started.

The CMS has also figured out that primary care physician care coordination and management drive quality and savings. The agency knows that incentivizing this type of care, the very type calculated to create ACO success, will net significant savings to the Medicare program.

For example, the pilot project for preventing diabetes will be expanded, because Medicare hopes to save several thousand dollars a year per beneficiary in health care costs.

In a blog entry the day the expanded population health management codes were announced, the CMS acting administrator wrote that, “Over time, if the clinicians qualified to provide these services were to fully provide these services to all eligible beneficiaries, the increase would be as much as $4 billion or more in additional support for care coordination and patient-centered care.”

CMS revenue streams to support ACO success-driving activities include:

• Value-based screening and counseling codes to decrease downstream costs.

• Upward adjustment of evaluation and management reimbursement for assessment of care and care plan development for mobility-impaired patients.

• Annual wellness visits.

• Prolonged E&M services that accrue outside of a patient visit.

• Collaboration with mental health specialists.

• Comprehensive assessment and care planning for patients with cognitive impairment.

• Expansion of the diabetes prevention pilot program; diabetes prevention and diabetes education are two separate services.

• Transitional care management for high-risk patients post discharge.

• Structured obesity management.

The 2017 Medicare fee schedule smoothed some of the bumps in administering and being paid for chronic care management (CCM) services, and it added codes with increased reimbursement aligned with increased complexity of comorbidities/illness.

Perhaps the biggest new payment boost for primary care to engage in ACO high-value activities is actually the Merit-Based Incentive Payment System (MIPS) under MACRA, the Medicare Access and CHIP Reauthorization Act of 2015.

Under MACRA, all Medicare compensation for physicians will be determined by relative delivery of quality and efficient care. Experts are recommending that primary care physicians participate in non–risk-taking ACOs to optimize MIPS value scoring, while also reducing administrative burdens of compliance. Use an ACO’s analytics to support collaborative care and provide the reports required under MIPS.

Let’s be smart about it

According to Gordon Wilhoit, MD, a practicing physician and chief medical officer of an all–primary-care-physician ACO in South Carolina, “This is a no brainer. Start first with your MSSP ACO high-value game plan, then align the complementary care coordination codes, CCM, MIPS, and other revenue stream and reporting activities with it. Now, primary care physicians can finance their ACO and MIPS care coordination efforts with a stream of ongoing payments from these care management codes.

“One of my colleagues saw a 27% increase in revenues in 6 months just from providing and billing for this type of care,” Dr. Wilhoit explained. “And, not counting shared savings or MIPS incentive payments, our office’s reimbursement from these care management codes now exceeds our fee-for-service income, which has not decreased.”

Even with these payments, the CMS will reduce overall net expenditures. Your impact on health care will be more powerful as a manager of the team addressing patients’ overall health than reacting to patient sickness one at a time. The patients you impact the most may be ones you don’t actually see. Your empowerment to practice medicine the right way will continue to grow.

Now, finally, you may start getting compensation that takes away the last big hurdle to creating the infrastructure you need to succeed.
 

Mr. Bobbitt is a head of the health law group at the Smith Anderson law firm in Raleigh, N.C. He is president of, and Dr. Wilhoit is a consultant with, Value Health Partners, LLC, a health care strategic consulting company. He has years of experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at either [email protected] or 919-906-4054.

As you may have read, accountable care organizations have met uneven success over the last several years. But, when they are broken down into categories, physician-sponsored ACOs have done better, particularly those with a strong primary care core.

This is true for several reasons.

In this transition period from a fee-for-service payment system that rewards volume and expensive inpatient care to a pay-for-value system, some ACOs set up by health systems or specialists envisioned the savings coming through lower utilization of their services. They had an inherent impediment to fully committing to keeping people well and avoiding acute care. In contrast, primary care providers are free to be all in with population health value-based programs.

New upfront payments are game changers

A successful ACO will be assigned one or more patient populations and be given a minimum of 50% of the savings for the overall costs for those populations, if the quality of their health is maintained or improved.

To excise avoidable waste, the ACO looks at gaps in care for those populations – frequent emergency department use for nonemergencies, avoidably high levels of diabetes and obesity, too-high readmission rates, unnecessarily high postacute care costs, etc. They then use evidence-based best team care practices – from patient self care and prevention, to multispecialty coordination and PCMH care management.

Why? Because these proved to give the highest impact on quality and reducing costs. To achieve significant shared savings, the costs are usually measured for a calendar year, then it takes about 6 months for the claims to be reported and paid. Thus, the shared savings check to the ACO will arrive about 18 months after all this is started.

The CMS has also figured out that primary care physician care coordination and management drive quality and savings. The agency knows that incentivizing this type of care, the very type calculated to create ACO success, will net significant savings to the Medicare program.

For example, the pilot project for preventing diabetes will be expanded, because Medicare hopes to save several thousand dollars a year per beneficiary in health care costs.

In a blog entry the day the expanded population health management codes were announced, the CMS acting administrator wrote that, “Over time, if the clinicians qualified to provide these services were to fully provide these services to all eligible beneficiaries, the increase would be as much as $4 billion or more in additional support for care coordination and patient-centered care.”

CMS revenue streams to support ACO success-driving activities include:

• Value-based screening and counseling codes to decrease downstream costs.

• Upward adjustment of evaluation and management reimbursement for assessment of care and care plan development for mobility-impaired patients.

• Annual wellness visits.

• Prolonged E&M services that accrue outside of a patient visit.

• Collaboration with mental health specialists.

• Comprehensive assessment and care planning for patients with cognitive impairment.

• Expansion of the diabetes prevention pilot program; diabetes prevention and diabetes education are two separate services.

• Transitional care management for high-risk patients post discharge.

• Structured obesity management.

The 2017 Medicare fee schedule smoothed some of the bumps in administering and being paid for chronic care management (CCM) services, and it added codes with increased reimbursement aligned with increased complexity of comorbidities/illness.

Perhaps the biggest new payment boost for primary care to engage in ACO high-value activities is actually the Merit-Based Incentive Payment System (MIPS) under MACRA, the Medicare Access and CHIP Reauthorization Act of 2015.

Under MACRA, all Medicare compensation for physicians will be determined by relative delivery of quality and efficient care. Experts are recommending that primary care physicians participate in non–risk-taking ACOs to optimize MIPS value scoring, while also reducing administrative burdens of compliance. Use an ACO’s analytics to support collaborative care and provide the reports required under MIPS.

Let’s be smart about it

According to Gordon Wilhoit, MD, a practicing physician and chief medical officer of an all–primary-care-physician ACO in South Carolina, “This is a no brainer. Start first with your MSSP ACO high-value game plan, then align the complementary care coordination codes, CCM, MIPS, and other revenue stream and reporting activities with it. Now, primary care physicians can finance their ACO and MIPS care coordination efforts with a stream of ongoing payments from these care management codes.

“One of my colleagues saw a 27% increase in revenues in 6 months just from providing and billing for this type of care,” Dr. Wilhoit explained. “And, not counting shared savings or MIPS incentive payments, our office’s reimbursement from these care management codes now exceeds our fee-for-service income, which has not decreased.”

Even with these payments, the CMS will reduce overall net expenditures. Your impact on health care will be more powerful as a manager of the team addressing patients’ overall health than reacting to patient sickness one at a time. The patients you impact the most may be ones you don’t actually see. Your empowerment to practice medicine the right way will continue to grow.

Now, finally, you may start getting compensation that takes away the last big hurdle to creating the infrastructure you need to succeed.
 

Mr. Bobbitt is a head of the health law group at the Smith Anderson law firm in Raleigh, N.C. He is president of, and Dr. Wilhoit is a consultant with, Value Health Partners, LLC, a health care strategic consulting company. He has years of experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at either [email protected] or 919-906-4054.

On most days when I walk into the exam room for a well-child visit, I find an anxious mom or a fretful father sitting next to a fearless child. I quickly shove aside my unrealistic expectation of finding both parents together holding the child. During the progression of my day, I see a diversity of parents playing their parts in caring for their children. It is sometimes a single mom, strong and robust, surrounded by a firm aura of principles and rules; she is concealing all signs of weakness, to make sure her child doesn’t cross any line that she has so cautiously made. Sometimes it is a single mom who is nervous and scared with a galaxy of fear in her eyes, desperately seeking for reassurance of her parenting. Fathers also come playing many roles, from someone struggling with tears as his child gets immunizations, to someone who has parenting in his bag, and skillfully plays eeny meeny miny moe with the little ones in the waiting room.

They all have one thing in common: the immense love for their children and the pressure of being a single or separated parent. It is indeed a reality that I see in most of the clinic rooms – that 60%-70% of children are not living with both mom and dad in the same house. Please note that these are raw data based entirely on my observation. While I watch each parent struggling as mentioned above, my mind often wanders to how each young child copes with such a situation.

• “Are you and your child undergoing any sort of stress?”

• “How do you think your child is coping with the separation?”

• “Do you identify any flaws in how things are going now?”

Of course, we need to ask questions about stress and family dynamics of all parents. We also should maintain a high level of sensitivity as we approach such questions. It is important to identify any changes in a child’s emotional and social development as we see them on every visit. And when we deem the need, to intervene and identify resources for the family. We also can help parents with ideas for communication with the child; anger management; helping parents and children understand changes; and encouraging open discussion when possible, instead of bottling up unsaid feelings and emotions. This is especially true for single-parent families, but two-parent families undergo stresses as well, for which pediatricians should keep an eye out.

While it is extremely important for us on every well-child visit to ensure that a child’s physical health is up to par, it is equally important not to ignore their emotional and social well-being as we walk in the room so we can help them flourish into the best version of themselves.

Dr. Fatima is a first-year pediatric resident at Albert Einstein Medical Center, Philadelphia. Email her at [email protected].

On most days when I walk into the exam room for a well-child visit, I find an anxious mom or a fretful father sitting next to a fearless child. I quickly shove aside my unrealistic expectation of finding both parents together holding the child. During the progression of my day, I see a diversity of parents playing their parts in caring for their children. It is sometimes a single mom, strong and robust, surrounded by a firm aura of principles and rules; she is concealing all signs of weakness, to make sure her child doesn’t cross any line that she has so cautiously made. Sometimes it is a single mom who is nervous and scared with a galaxy of fear in her eyes, desperately seeking for reassurance of her parenting. Fathers also come playing many roles, from someone struggling with tears as his child gets immunizations, to someone who has parenting in his bag, and skillfully plays eeny meeny miny moe with the little ones in the waiting room.

They all have one thing in common: the immense love for their children and the pressure of being a single or separated parent. It is indeed a reality that I see in most of the clinic rooms – that 60%-70% of children are not living with both mom and dad in the same house. Please note that these are raw data based entirely on my observation. While I watch each parent struggling as mentioned above, my mind often wanders to how each young child copes with such a situation.

• “Are you and your child undergoing any sort of stress?”

• “How do you think your child is coping with the separation?”

• “Do you identify any flaws in how things are going now?”

Of course, we need to ask questions about stress and family dynamics of all parents. We also should maintain a high level of sensitivity as we approach such questions. It is important to identify any changes in a child’s emotional and social development as we see them on every visit. And when we deem the need, to intervene and identify resources for the family. We also can help parents with ideas for communication with the child; anger management; helping parents and children understand changes; and encouraging open discussion when possible, instead of bottling up unsaid feelings and emotions. This is especially true for single-parent families, but two-parent families undergo stresses as well, for which pediatricians should keep an eye out.

While it is extremely important for us on every well-child visit to ensure that a child’s physical health is up to par, it is equally important not to ignore their emotional and social well-being as we walk in the room so we can help them flourish into the best version of themselves.

Dr. Fatima is a first-year pediatric resident at Albert Einstein Medical Center, Philadelphia. Email her at [email protected].

On most days when I walk into the exam room for a well-child visit, I find an anxious mom or a fretful father sitting next to a fearless child. I quickly shove aside my unrealistic expectation of finding both parents together holding the child. During the progression of my day, I see a diversity of parents playing their parts in caring for their children. It is sometimes a single mom, strong and robust, surrounded by a firm aura of principles and rules; she is concealing all signs of weakness, to make sure her child doesn’t cross any line that she has so cautiously made. Sometimes it is a single mom who is nervous and scared with a galaxy of fear in her eyes, desperately seeking for reassurance of her parenting. Fathers also come playing many roles, from someone struggling with tears as his child gets immunizations, to someone who has parenting in his bag, and skillfully plays eeny meeny miny moe with the little ones in the waiting room.

They all have one thing in common: the immense love for their children and the pressure of being a single or separated parent. It is indeed a reality that I see in most of the clinic rooms – that 60%-70% of children are not living with both mom and dad in the same house. Please note that these are raw data based entirely on my observation. While I watch each parent struggling as mentioned above, my mind often wanders to how each young child copes with such a situation.

• “Are you and your child undergoing any sort of stress?”

• “How do you think your child is coping with the separation?”

• “Do you identify any flaws in how things are going now?”

Of course, we need to ask questions about stress and family dynamics of all parents. We also should maintain a high level of sensitivity as we approach such questions. It is important to identify any changes in a child’s emotional and social development as we see them on every visit. And when we deem the need, to intervene and identify resources for the family. We also can help parents with ideas for communication with the child; anger management; helping parents and children understand changes; and encouraging open discussion when possible, instead of bottling up unsaid feelings and emotions. This is especially true for single-parent families, but two-parent families undergo stresses as well, for which pediatricians should keep an eye out.

While it is extremely important for us on every well-child visit to ensure that a child’s physical health is up to par, it is equally important not to ignore their emotional and social well-being as we walk in the room so we can help them flourish into the best version of themselves.

Dr. Fatima is a first-year pediatric resident at Albert Einstein Medical Center, Philadelphia. Email her at [email protected].

As pediatric and adolescent gynecologists, we are seeing an increasing number of adolescents with gender identity issues and have come to believe that all obstetrician-gynecologists need to have an understanding of varying gender identities, as well as their role in managing these patients’ care.

We had the honor to assist the American College of Obstetricians and Gynecologists’ (ACOG) Committee on Adolescent Health Care in the development of a new Committee Opinion to guide ob.gyns. in caring for transgender adolescents (Obstet Gynecol 2017;129:e11-6). As our culture grows more aware of the nuances and spectrum of gender identity, our health care practices must grow as well. Ob.gyns. are often uniquely positioned as being among the first people transgender adolescents present to – whether it’s signaling disassociation with their gender when answering routine medical questions or directly addressing gender with them as a trusted and private resource. Even when seeing a patient too young to consider hormone therapy, an ob.gyn. can offer vital early behavioral health support, educational and community resources, and specialist referrals.

Transgender adolescent patients have likely faced negative stereotypes and stigmas in social settings or through media that make them cautious and protective of their identity. They are also more likely to face social ostracism such as bullying and/or dissent and rejection from their parents, deepening the vulnerability of their situation. As a result, transgender adolescents can have increased instances of anxiety, depression, sexual harassment, homelessness, and risk-taking behavior. Medical practices can signal to transgender patients that they are safe and welcoming from the start by offering gender neutral forms, brochures, and information for LGBT patients in the waiting room, and having sensitive employees at every step – from the front desk onward.

As we’ve just outlined, transgender adolescent patients face unique challenges, including increased rates of social and mental health risks. In response, ob.gyns. must be prepared to have a comprehensive conversation about health and well-being beyond sexual and reproductive health. They must also be equipped to address the psychosocial issues associated with transgender adolescents. This includes knowledge of what to look for and offering patients resources, education, and referrals to guarantee their health and safety.

It is important that ob.gyns. are aware that transgender men have female reproductive organs and can present with common gynecological problems such as abnormal bleeding, ovarian cysts, and torsion, as well as pregnancy and pregnancy complications. Finally, ob.gyns. can serve a unique role in counseling about fertility and fertility preservation. Thus, not only do we provide essential health care, including ongoing primary care, but we can position ourselves as part of the support network for these adolescents and their families.

Most importantly, when addressing an adolescent transgender patient, we must understand there is no uniform transgender experience. Expressing gender, sexual identity, and behavior patterns will vary from patient to patient. There are a wide range of treatment options available for transgender patients, from hormone to surgical therapies. An ob.gyn.’s responsibility is to help each individual make an informed decision, and help that patient think ahead to the future.

While this all may seem like a lot, it’s important to remember the essential components of our role as health care providers do not change because an adolescent patient is transgender. Care should always include education about their bodies, safe sex, deliberate and thoughtful assessment of symptoms or concerns, and preventive care services such as STI screenings and contraception. We are simply adding more nuanced cultural and medical understanding to those practices.
 

Dr. Gomez-Lobo is director of pediatric and adolescent obstetrics and gynecology, Medstar Washington Hospital Center/Children’s National Health System, Washington, D.C. Dr. Sokkary is associate professor of ob.gyn. at Navicent Health Center/Mercer School of Medicine in Macon, Ga. They are members of the ACOG Committee on Adolescent Health Care. They reported having no relevant financial disclosures.

As pediatric and adolescent gynecologists, we are seeing an increasing number of adolescents with gender identity issues and have come to believe that all obstetrician-gynecologists need to have an understanding of varying gender identities, as well as their role in managing these patients’ care.

We had the honor to assist the American College of Obstetricians and Gynecologists’ (ACOG) Committee on Adolescent Health Care in the development of a new Committee Opinion to guide ob.gyns. in caring for transgender adolescents (Obstet Gynecol 2017;129:e11-6). As our culture grows more aware of the nuances and spectrum of gender identity, our health care practices must grow as well. Ob.gyns. are often uniquely positioned as being among the first people transgender adolescents present to – whether it’s signaling disassociation with their gender when answering routine medical questions or directly addressing gender with them as a trusted and private resource. Even when seeing a patient too young to consider hormone therapy, an ob.gyn. can offer vital early behavioral health support, educational and community resources, and specialist referrals.

Transgender adolescent patients have likely faced negative stereotypes and stigmas in social settings or through media that make them cautious and protective of their identity. They are also more likely to face social ostracism such as bullying and/or dissent and rejection from their parents, deepening the vulnerability of their situation. As a result, transgender adolescents can have increased instances of anxiety, depression, sexual harassment, homelessness, and risk-taking behavior. Medical practices can signal to transgender patients that they are safe and welcoming from the start by offering gender neutral forms, brochures, and information for LGBT patients in the waiting room, and having sensitive employees at every step – from the front desk onward.

As we’ve just outlined, transgender adolescent patients face unique challenges, including increased rates of social and mental health risks. In response, ob.gyns. must be prepared to have a comprehensive conversation about health and well-being beyond sexual and reproductive health. They must also be equipped to address the psychosocial issues associated with transgender adolescents. This includes knowledge of what to look for and offering patients resources, education, and referrals to guarantee their health and safety.

It is important that ob.gyns. are aware that transgender men have female reproductive organs and can present with common gynecological problems such as abnormal bleeding, ovarian cysts, and torsion, as well as pregnancy and pregnancy complications. Finally, ob.gyns. can serve a unique role in counseling about fertility and fertility preservation. Thus, not only do we provide essential health care, including ongoing primary care, but we can position ourselves as part of the support network for these adolescents and their families.

Most importantly, when addressing an adolescent transgender patient, we must understand there is no uniform transgender experience. Expressing gender, sexual identity, and behavior patterns will vary from patient to patient. There are a wide range of treatment options available for transgender patients, from hormone to surgical therapies. An ob.gyn.’s responsibility is to help each individual make an informed decision, and help that patient think ahead to the future.

While this all may seem like a lot, it’s important to remember the essential components of our role as health care providers do not change because an adolescent patient is transgender. Care should always include education about their bodies, safe sex, deliberate and thoughtful assessment of symptoms or concerns, and preventive care services such as STI screenings and contraception. We are simply adding more nuanced cultural and medical understanding to those practices.
 

Dr. Gomez-Lobo is director of pediatric and adolescent obstetrics and gynecology, Medstar Washington Hospital Center/Children’s National Health System, Washington, D.C. Dr. Sokkary is associate professor of ob.gyn. at Navicent Health Center/Mercer School of Medicine in Macon, Ga. They are members of the ACOG Committee on Adolescent Health Care. They reported having no relevant financial disclosures.

As pediatric and adolescent gynecologists, we are seeing an increasing number of adolescents with gender identity issues and have come to believe that all obstetrician-gynecologists need to have an understanding of varying gender identities, as well as their role in managing these patients’ care.

We had the honor to assist the American College of Obstetricians and Gynecologists’ (ACOG) Committee on Adolescent Health Care in the development of a new Committee Opinion to guide ob.gyns. in caring for transgender adolescents (Obstet Gynecol 2017;129:e11-6). As our culture grows more aware of the nuances and spectrum of gender identity, our health care practices must grow as well. Ob.gyns. are often uniquely positioned as being among the first people transgender adolescents present to – whether it’s signaling disassociation with their gender when answering routine medical questions or directly addressing gender with them as a trusted and private resource. Even when seeing a patient too young to consider hormone therapy, an ob.gyn. can offer vital early behavioral health support, educational and community resources, and specialist referrals.

Transgender adolescent patients have likely faced negative stereotypes and stigmas in social settings or through media that make them cautious and protective of their identity. They are also more likely to face social ostracism such as bullying and/or dissent and rejection from their parents, deepening the vulnerability of their situation. As a result, transgender adolescents can have increased instances of anxiety, depression, sexual harassment, homelessness, and risk-taking behavior. Medical practices can signal to transgender patients that they are safe and welcoming from the start by offering gender neutral forms, brochures, and information for LGBT patients in the waiting room, and having sensitive employees at every step – from the front desk onward.

As we’ve just outlined, transgender adolescent patients face unique challenges, including increased rates of social and mental health risks. In response, ob.gyns. must be prepared to have a comprehensive conversation about health and well-being beyond sexual and reproductive health. They must also be equipped to address the psychosocial issues associated with transgender adolescents. This includes knowledge of what to look for and offering patients resources, education, and referrals to guarantee their health and safety.

It is important that ob.gyns. are aware that transgender men have female reproductive organs and can present with common gynecological problems such as abnormal bleeding, ovarian cysts, and torsion, as well as pregnancy and pregnancy complications. Finally, ob.gyns. can serve a unique role in counseling about fertility and fertility preservation. Thus, not only do we provide essential health care, including ongoing primary care, but we can position ourselves as part of the support network for these adolescents and their families.

Most importantly, when addressing an adolescent transgender patient, we must understand there is no uniform transgender experience. Expressing gender, sexual identity, and behavior patterns will vary from patient to patient. There are a wide range of treatment options available for transgender patients, from hormone to surgical therapies. An ob.gyn.’s responsibility is to help each individual make an informed decision, and help that patient think ahead to the future.

While this all may seem like a lot, it’s important to remember the essential components of our role as health care providers do not change because an adolescent patient is transgender. Care should always include education about their bodies, safe sex, deliberate and thoughtful assessment of symptoms or concerns, and preventive care services such as STI screenings and contraception. We are simply adding more nuanced cultural and medical understanding to those practices.
 

Dr. Gomez-Lobo is director of pediatric and adolescent obstetrics and gynecology, Medstar Washington Hospital Center/Children’s National Health System, Washington, D.C. Dr. Sokkary is associate professor of ob.gyn. at Navicent Health Center/Mercer School of Medicine in Macon, Ga. They are members of the ACOG Committee on Adolescent Health Care. They reported having no relevant financial disclosures.

In a recent survey of about 90 psychiatrists attending a national general psychiatry meeting, the overwhelming majority believed that climate change is human caused and the impacts were already or would soon be harming their patients. They expressed an interest in knowing more, reporting that they sometimes had little knowledge about the issues. They also believed that psychiatrists have a role to play in making the case to be better prepared for what our communities are facing. Professional organizations were a desirable choice as a source of information and training.

Because of these responses we, the Climate Psychiatry Alliance, believe that a scientific and well thought out program addressing the mental health impacts of climate disruption with practical advice on how to help our patients and our communities in the face of climate disasters while emphasizing preparedness and prevention, is called for.

Rob Wilson

Dr. Van Susteren wrote this commentary on behalf of the Climate Psychiatry Alliance, a professional group dedicated to promoting awareness and action on climate from a mental health perspective. She is a practicing general and forensic psychiatrist in Washington. Dr. Van Susteren serves on the advisory board of the Center for Health and the Global Environment at Harvard T.H. Chan School of Public Health, Boston. She is a former member of the board of directors of the National Wildlife Federation and coauthor of group’s report, “The Psychological Effects of Global Warming on the United States – Why the U.S. Mental Health System is Not Prepared.” In 2006, Dr. Van Susteren sought the Democratic nomination for a U.S. Senate seat in Maryland. Recently, she founded Lucky Planet Foods, a company that provides plant-based, low carbon foods.

In a recent survey of about 90 psychiatrists attending a national general psychiatry meeting, the overwhelming majority believed that climate change is human caused and the impacts were already or would soon be harming their patients. They expressed an interest in knowing more, reporting that they sometimes had little knowledge about the issues. They also believed that psychiatrists have a role to play in making the case to be better prepared for what our communities are facing. Professional organizations were a desirable choice as a source of information and training.

Because of these responses we, the Climate Psychiatry Alliance, believe that a scientific and well thought out program addressing the mental health impacts of climate disruption with practical advice on how to help our patients and our communities in the face of climate disasters while emphasizing preparedness and prevention, is called for.

Rob Wilson

Dr. Van Susteren wrote this commentary on behalf of the Climate Psychiatry Alliance, a professional group dedicated to promoting awareness and action on climate from a mental health perspective. She is a practicing general and forensic psychiatrist in Washington. Dr. Van Susteren serves on the advisory board of the Center for Health and the Global Environment at Harvard T.H. Chan School of Public Health, Boston. She is a former member of the board of directors of the National Wildlife Federation and coauthor of group’s report, “The Psychological Effects of Global Warming on the United States – Why the U.S. Mental Health System is Not Prepared.” In 2006, Dr. Van Susteren sought the Democratic nomination for a U.S. Senate seat in Maryland. Recently, she founded Lucky Planet Foods, a company that provides plant-based, low carbon foods.

In a recent survey of about 90 psychiatrists attending a national general psychiatry meeting, the overwhelming majority believed that climate change is human caused and the impacts were already or would soon be harming their patients. They expressed an interest in knowing more, reporting that they sometimes had little knowledge about the issues. They also believed that psychiatrists have a role to play in making the case to be better prepared for what our communities are facing. Professional organizations were a desirable choice as a source of information and training.

Because of these responses we, the Climate Psychiatry Alliance, believe that a scientific and well thought out program addressing the mental health impacts of climate disruption with practical advice on how to help our patients and our communities in the face of climate disasters while emphasizing preparedness and prevention, is called for.

Rob Wilson

Dr. Van Susteren wrote this commentary on behalf of the Climate Psychiatry Alliance, a professional group dedicated to promoting awareness and action on climate from a mental health perspective. She is a practicing general and forensic psychiatrist in Washington. Dr. Van Susteren serves on the advisory board of the Center for Health and the Global Environment at Harvard T.H. Chan School of Public Health, Boston. She is a former member of the board of directors of the National Wildlife Federation and coauthor of group’s report, “The Psychological Effects of Global Warming on the United States – Why the U.S. Mental Health System is Not Prepared.” In 2006, Dr. Van Susteren sought the Democratic nomination for a U.S. Senate seat in Maryland. Recently, she founded Lucky Planet Foods, a company that provides plant-based, low carbon foods.

WASHINGTON – A new president is taking office along with new staffers to lead the country’s top health care agencies.

In this video, Joyce Hall, chair of the American Bar Association Health Law Section, discusses what changes she foresees in health law issues under the new administration and what to expect from the leadership transition. Ms. Hall also speaks on potential alterations to the Medicare Access and CHIP Reauthorization Act of 2015 and whether the potential appointment of Rep. Tom Price (R-Ga.) as U.S. Department of Health and Human Services Secretary will be positive or negative for health care providers.

[email protected]

On Twitter @legal_med

WASHINGTON – A new president is taking office along with new staffers to lead the country’s top health care agencies.

In this video, Joyce Hall, chair of the American Bar Association Health Law Section, discusses what changes she foresees in health law issues under the new administration and what to expect from the leadership transition. Ms. Hall also speaks on potential alterations to the Medicare Access and CHIP Reauthorization Act of 2015 and whether the potential appointment of Rep. Tom Price (R-Ga.) as U.S. Department of Health and Human Services Secretary will be positive or negative for health care providers.

[email protected]

On Twitter @legal_med

WASHINGTON – A new president is taking office along with new staffers to lead the country’s top health care agencies.

In this video, Joyce Hall, chair of the American Bar Association Health Law Section, discusses what changes she foresees in health law issues under the new administration and what to expect from the leadership transition. Ms. Hall also speaks on potential alterations to the Medicare Access and CHIP Reauthorization Act of 2015 and whether the potential appointment of Rep. Tom Price (R-Ga.) as U.S. Department of Health and Human Services Secretary will be positive or negative for health care providers.

[email protected]

On Twitter @legal_med

There are many topics within the child psychiatry community that are controversial. How many kids really deserve a diagnosis of bipolar disorder? Which type of therapy works best? Is cannabis a gateway drug? The existence of attention-deficit/hyperactivity disorder as a legitimate psychiatric entity, however, is not one of them.

Despite this fact, there remains considerable controversy in the public about how “real” ADHD actually is. Social media, blogs, and even entire books have been written that disparage the diagnosis and even suggest that ADHD was fabricated by the pharmaceutical industry to sell medications. Although these publications and posts generally ignore the scientific literature or at least twist it beyond recognition, there are several aspects of ADHD that legitimately cause more confusion and less confidence about the diagnosis, relative to other common pediatric problems. This column attempts to describe and contextualize these elements so that pediatricians can be more fully informed when they are called to respond to some of the allegations against ADHD that often are brought up by families.

Case summary

Hunter is a 6-year-old boy who presents with his mother and father for “behavioral concerns.” He always has been an energetic child, but the school has been having increasing difficulties with his behavior. Hunter struggles to stay in his seat and take part in quiet activities. His teacher needs to give multiple reminders per day about not interrupting others or speaking out in class. Without redirection, Hunter typically loses focus in class and does not complete his work. Because of these difficulties, the question of ADHD arose during a recent parent-teacher conference. While Hunter’s mother acknowledges these behaviors and notes similar ones at home, the father is resisting any further evaluation, claiming that Hunter “is just being a boy.” The father notes that he acted similarly as a child and “turned out okay.” When the mother tried to research ADHD online, she encountered several sites that claimed that the diagnosis of ADHD was “made up” by drug companies wanting “to turn kids into zombies.” At the appointment, the parents state that they want their son to succeed and be happy, but are concerned about some of the things they have read on the Internet.

Discussion

This example represents a common dilemma for parents who encounter so many mixed messages when doing background research on ADHD. Although the legitimacy of ADHD has been supported in literally hundreds of research studies that have examined areas such as genetics, neuropsychological testing, and brain imaging^1,2, some of the lingering doubts about ADHD validity are rooted in characteristics of the diagnosis that do differ from some nonpsychiatric diagnoses. At the same time, however, further inspection reveals that these qualities exist for many other entities that have received far less public criticism. Three of these main qualities include the following:

1. ADHD is a dimensional rather than binary entity. Despite the fact that the current nomenclature continues to frame ADHD as an all-or-nothing diagnosis, there is now overwhelming scientific evidence that it is much more accurately conceptualized as a dimension³. As such, there is no clear-cut boundary between what should be judged as “typical” levels of attention and activity and ADHD. As written in a previous column⁴, in some ways the label of ADHD is a lot like the label of someone being tall, with some individuals clearly falling into the category of “tall” or “not tall,” while many others could be considered in-between. However, many of the most common nonpsychiatric conditions such as hypertension and hypercholesterolemia also exist this way without high levels of public controversy.

2. ADHD lacks a specific known neurobiologic marker that can be measured by a lab or neuroimaging test. As mentioned, there is a vast literature supporting the idea that the brains of people with ADHD are different from those without ADHD, but these differences tend to describe quantitative differences in regional brain volume, cortical thickness, activity levels, or connectivity rather than a discrete “thing” that a radiologist can point to on a scan. Given the dimensional nature of ADHD and the broad brain processes required for complex functions such as attention and motor activity, the lack of a specific and universal “lesion” underlying ADHD is to be expected, yet it still remains easy ammunition for those who criticize the diagnosis. Again, very similar cases can be made for other entities such as autism or low intelligence, which few argue are not real but also have no reliable biomarker to support them.

3. Medications often are used to treat ADHD. The diagnosis of ADHD would probably be far less controversial if one of its primary treatments did not involve psychiatric medications. While it is probably fair to say that the many nonpharmacologic approaches to ADHD are quite underutilized, it seems a stretch to use potential overreliance on medication as a legitimate reason to question the validity of a diagnosis. Opiate abuse also is a problem in this country, but that doesn’t mean a person’s pain doesn’t exist. As a practical tip, it can be reassuring for families to hear explicitly from their physician that “zombification” is not considered an acceptable medical outcome and that the prescribing clinician will promptly deal with any side effects that might occur with treatment⁵.

Understanding these aspects about ADHD and how they are misinterpreted in the media can help families make more informed and comfortable decisions about their child’s care in collaboration with their pediatrician. It also is important for pediatricians to be proactive in distributing reliable and science-backed material to the public in this new age of information overload.

Case follow-up

The pediatrician hears the family’s concerns and discusses the evidence supporting the scientific legitimacy of ADHD, as well as some of the qualities of the diagnosis that have led to its controversy. The parents are reassured but would like to proceed carefully and cautiously with further work-up and treatment. The pediatrician sends the family home with some quantitative rating scales to be completed by Hunter’s parents and teacher. She also makes a plan to begin monitoring several health promotion areas that could be impacting Hunter’s behavior including sleep quality, physical activity, screen time, and nutrition.

References

1. Psychiatr Clin North Am. 2010 Mar;33(1):159-80.

2. Dev Neuropsychol. 2013;38(4):211-25.3. Can Fam Physician. 2016 Dec;62(12):979-82.

4. ADHD boundaries with normal behavior. Pediatric News; published online Aug. 27, 2014.

5. Zombification is not an acceptable medical outcome. Psychology Today, ABCs of Child Psychiatry blog; published online Oct. 18, 2013.
 

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont Larner College of Medicine, Burlington. Follow him on Twitter @PediPsych.

There are many topics within the child psychiatry community that are controversial. How many kids really deserve a diagnosis of bipolar disorder? Which type of therapy works best? Is cannabis a gateway drug? The existence of attention-deficit/hyperactivity disorder as a legitimate psychiatric entity, however, is not one of them.

Despite this fact, there remains considerable controversy in the public about how “real” ADHD actually is. Social media, blogs, and even entire books have been written that disparage the diagnosis and even suggest that ADHD was fabricated by the pharmaceutical industry to sell medications. Although these publications and posts generally ignore the scientific literature or at least twist it beyond recognition, there are several aspects of ADHD that legitimately cause more confusion and less confidence about the diagnosis, relative to other common pediatric problems. This column attempts to describe and contextualize these elements so that pediatricians can be more fully informed when they are called to respond to some of the allegations against ADHD that often are brought up by families.

Case summary

Hunter is a 6-year-old boy who presents with his mother and father for “behavioral concerns.” He always has been an energetic child, but the school has been having increasing difficulties with his behavior. Hunter struggles to stay in his seat and take part in quiet activities. His teacher needs to give multiple reminders per day about not interrupting others or speaking out in class. Without redirection, Hunter typically loses focus in class and does not complete his work. Because of these difficulties, the question of ADHD arose during a recent parent-teacher conference. While Hunter’s mother acknowledges these behaviors and notes similar ones at home, the father is resisting any further evaluation, claiming that Hunter “is just being a boy.” The father notes that he acted similarly as a child and “turned out okay.” When the mother tried to research ADHD online, she encountered several sites that claimed that the diagnosis of ADHD was “made up” by drug companies wanting “to turn kids into zombies.” At the appointment, the parents state that they want their son to succeed and be happy, but are concerned about some of the things they have read on the Internet.

Discussion

This example represents a common dilemma for parents who encounter so many mixed messages when doing background research on ADHD. Although the legitimacy of ADHD has been supported in literally hundreds of research studies that have examined areas such as genetics, neuropsychological testing, and brain imaging^1,2, some of the lingering doubts about ADHD validity are rooted in characteristics of the diagnosis that do differ from some nonpsychiatric diagnoses. At the same time, however, further inspection reveals that these qualities exist for many other entities that have received far less public criticism. Three of these main qualities include the following:

1. ADHD is a dimensional rather than binary entity. Despite the fact that the current nomenclature continues to frame ADHD as an all-or-nothing diagnosis, there is now overwhelming scientific evidence that it is much more accurately conceptualized as a dimension³. As such, there is no clear-cut boundary between what should be judged as “typical” levels of attention and activity and ADHD. As written in a previous column⁴, in some ways the label of ADHD is a lot like the label of someone being tall, with some individuals clearly falling into the category of “tall” or “not tall,” while many others could be considered in-between. However, many of the most common nonpsychiatric conditions such as hypertension and hypercholesterolemia also exist this way without high levels of public controversy.

2. ADHD lacks a specific known neurobiologic marker that can be measured by a lab or neuroimaging test. As mentioned, there is a vast literature supporting the idea that the brains of people with ADHD are different from those without ADHD, but these differences tend to describe quantitative differences in regional brain volume, cortical thickness, activity levels, or connectivity rather than a discrete “thing” that a radiologist can point to on a scan. Given the dimensional nature of ADHD and the broad brain processes required for complex functions such as attention and motor activity, the lack of a specific and universal “lesion” underlying ADHD is to be expected, yet it still remains easy ammunition for those who criticize the diagnosis. Again, very similar cases can be made for other entities such as autism or low intelligence, which few argue are not real but also have no reliable biomarker to support them.

3. Medications often are used to treat ADHD. The diagnosis of ADHD would probably be far less controversial if one of its primary treatments did not involve psychiatric medications. While it is probably fair to say that the many nonpharmacologic approaches to ADHD are quite underutilized, it seems a stretch to use potential overreliance on medication as a legitimate reason to question the validity of a diagnosis. Opiate abuse also is a problem in this country, but that doesn’t mean a person’s pain doesn’t exist. As a practical tip, it can be reassuring for families to hear explicitly from their physician that “zombification” is not considered an acceptable medical outcome and that the prescribing clinician will promptly deal with any side effects that might occur with treatment⁵.

Understanding these aspects about ADHD and how they are misinterpreted in the media can help families make more informed and comfortable decisions about their child’s care in collaboration with their pediatrician. It also is important for pediatricians to be proactive in distributing reliable and science-backed material to the public in this new age of information overload.

Case follow-up

The pediatrician hears the family’s concerns and discusses the evidence supporting the scientific legitimacy of ADHD, as well as some of the qualities of the diagnosis that have led to its controversy. The parents are reassured but would like to proceed carefully and cautiously with further work-up and treatment. The pediatrician sends the family home with some quantitative rating scales to be completed by Hunter’s parents and teacher. She also makes a plan to begin monitoring several health promotion areas that could be impacting Hunter’s behavior including sleep quality, physical activity, screen time, and nutrition.

References

1. Psychiatr Clin North Am. 2010 Mar;33(1):159-80.

2. Dev Neuropsychol. 2013;38(4):211-25.3. Can Fam Physician. 2016 Dec;62(12):979-82.

4. ADHD boundaries with normal behavior. Pediatric News; published online Aug. 27, 2014.

5. Zombification is not an acceptable medical outcome. Psychology Today, ABCs of Child Psychiatry blog; published online Oct. 18, 2013.
 

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont Larner College of Medicine, Burlington. Follow him on Twitter @PediPsych.

There are many topics within the child psychiatry community that are controversial. How many kids really deserve a diagnosis of bipolar disorder? Which type of therapy works best? Is cannabis a gateway drug? The existence of attention-deficit/hyperactivity disorder as a legitimate psychiatric entity, however, is not one of them.

Despite this fact, there remains considerable controversy in the public about how “real” ADHD actually is. Social media, blogs, and even entire books have been written that disparage the diagnosis and even suggest that ADHD was fabricated by the pharmaceutical industry to sell medications. Although these publications and posts generally ignore the scientific literature or at least twist it beyond recognition, there are several aspects of ADHD that legitimately cause more confusion and less confidence about the diagnosis, relative to other common pediatric problems. This column attempts to describe and contextualize these elements so that pediatricians can be more fully informed when they are called to respond to some of the allegations against ADHD that often are brought up by families.

Case summary

Hunter is a 6-year-old boy who presents with his mother and father for “behavioral concerns.” He always has been an energetic child, but the school has been having increasing difficulties with his behavior. Hunter struggles to stay in his seat and take part in quiet activities. His teacher needs to give multiple reminders per day about not interrupting others or speaking out in class. Without redirection, Hunter typically loses focus in class and does not complete his work. Because of these difficulties, the question of ADHD arose during a recent parent-teacher conference. While Hunter’s mother acknowledges these behaviors and notes similar ones at home, the father is resisting any further evaluation, claiming that Hunter “is just being a boy.” The father notes that he acted similarly as a child and “turned out okay.” When the mother tried to research ADHD online, she encountered several sites that claimed that the diagnosis of ADHD was “made up” by drug companies wanting “to turn kids into zombies.” At the appointment, the parents state that they want their son to succeed and be happy, but are concerned about some of the things they have read on the Internet.

Discussion

This example represents a common dilemma for parents who encounter so many mixed messages when doing background research on ADHD. Although the legitimacy of ADHD has been supported in literally hundreds of research studies that have examined areas such as genetics, neuropsychological testing, and brain imaging^1,2, some of the lingering doubts about ADHD validity are rooted in characteristics of the diagnosis that do differ from some nonpsychiatric diagnoses. At the same time, however, further inspection reveals that these qualities exist for many other entities that have received far less public criticism. Three of these main qualities include the following:

1. ADHD is a dimensional rather than binary entity. Despite the fact that the current nomenclature continues to frame ADHD as an all-or-nothing diagnosis, there is now overwhelming scientific evidence that it is much more accurately conceptualized as a dimension³. As such, there is no clear-cut boundary between what should be judged as “typical” levels of attention and activity and ADHD. As written in a previous column⁴, in some ways the label of ADHD is a lot like the label of someone being tall, with some individuals clearly falling into the category of “tall” or “not tall,” while many others could be considered in-between. However, many of the most common nonpsychiatric conditions such as hypertension and hypercholesterolemia also exist this way without high levels of public controversy.

2. ADHD lacks a specific known neurobiologic marker that can be measured by a lab or neuroimaging test. As mentioned, there is a vast literature supporting the idea that the brains of people with ADHD are different from those without ADHD, but these differences tend to describe quantitative differences in regional brain volume, cortical thickness, activity levels, or connectivity rather than a discrete “thing” that a radiologist can point to on a scan. Given the dimensional nature of ADHD and the broad brain processes required for complex functions such as attention and motor activity, the lack of a specific and universal “lesion” underlying ADHD is to be expected, yet it still remains easy ammunition for those who criticize the diagnosis. Again, very similar cases can be made for other entities such as autism or low intelligence, which few argue are not real but also have no reliable biomarker to support them.

3. Medications often are used to treat ADHD. The diagnosis of ADHD would probably be far less controversial if one of its primary treatments did not involve psychiatric medications. While it is probably fair to say that the many nonpharmacologic approaches to ADHD are quite underutilized, it seems a stretch to use potential overreliance on medication as a legitimate reason to question the validity of a diagnosis. Opiate abuse also is a problem in this country, but that doesn’t mean a person’s pain doesn’t exist. As a practical tip, it can be reassuring for families to hear explicitly from their physician that “zombification” is not considered an acceptable medical outcome and that the prescribing clinician will promptly deal with any side effects that might occur with treatment⁵.

Understanding these aspects about ADHD and how they are misinterpreted in the media can help families make more informed and comfortable decisions about their child’s care in collaboration with their pediatrician. It also is important for pediatricians to be proactive in distributing reliable and science-backed material to the public in this new age of information overload.

Case follow-up

The pediatrician hears the family’s concerns and discusses the evidence supporting the scientific legitimacy of ADHD, as well as some of the qualities of the diagnosis that have led to its controversy. The parents are reassured but would like to proceed carefully and cautiously with further work-up and treatment. The pediatrician sends the family home with some quantitative rating scales to be completed by Hunter’s parents and teacher. She also makes a plan to begin monitoring several health promotion areas that could be impacting Hunter’s behavior including sleep quality, physical activity, screen time, and nutrition.

References

1. Psychiatr Clin North Am. 2010 Mar;33(1):159-80.

2. Dev Neuropsychol. 2013;38(4):211-25.3. Can Fam Physician. 2016 Dec;62(12):979-82.

4. ADHD boundaries with normal behavior. Pediatric News; published online Aug. 27, 2014.

5. Zombification is not an acceptable medical outcome. Psychology Today, ABCs of Child Psychiatry blog; published online Oct. 18, 2013.
 

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont Larner College of Medicine, Burlington. Follow him on Twitter @PediPsych.

The fact that the United States spends more of its gross domestic product on health care (18%) than any other nation is old and depressing news (JAMA. 2012 Apr 11;307[14]:1513-6). There may be some debate about whether the quality of the product we are getting is worth this outsized investment. But it is safe to assume that there must be some wastage in the system. Exactly how much of our health care dollar is going down the drain is unknown. And the thorny question of who is responsible for the leaks has escaped close scrutiny, probably because the answer is guaranteed to result in an uncomfortable and ugly circle of finger pointing. Is it the insurance companies, hospitals, the superspecialists, the drug companies, impatient patients, or those dastardly lawyers? Pediatricians are such small players on the health care stage that our contribution to the wastage must be minimal. Our patients are little people who are generally healthy. Most of us drive midsized cars and live in modest homes. We try to be careful users of the expensive diagnostic and therapeutic tools at our disposal. We don’t deserve a place on the list of likely suspects, do we?

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

The fact that the United States spends more of its gross domestic product on health care (18%) than any other nation is old and depressing news (JAMA. 2012 Apr 11;307[14]:1513-6). There may be some debate about whether the quality of the product we are getting is worth this outsized investment. But it is safe to assume that there must be some wastage in the system. Exactly how much of our health care dollar is going down the drain is unknown. And the thorny question of who is responsible for the leaks has escaped close scrutiny, probably because the answer is guaranteed to result in an uncomfortable and ugly circle of finger pointing. Is it the insurance companies, hospitals, the superspecialists, the drug companies, impatient patients, or those dastardly lawyers? Pediatricians are such small players on the health care stage that our contribution to the wastage must be minimal. Our patients are little people who are generally healthy. Most of us drive midsized cars and live in modest homes. We try to be careful users of the expensive diagnostic and therapeutic tools at our disposal. We don’t deserve a place on the list of likely suspects, do we?

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

The fact that the United States spends more of its gross domestic product on health care (18%) than any other nation is old and depressing news (JAMA. 2012 Apr 11;307[14]:1513-6). There may be some debate about whether the quality of the product we are getting is worth this outsized investment. But it is safe to assume that there must be some wastage in the system. Exactly how much of our health care dollar is going down the drain is unknown. And the thorny question of who is responsible for the leaks has escaped close scrutiny, probably because the answer is guaranteed to result in an uncomfortable and ugly circle of finger pointing. Is it the insurance companies, hospitals, the superspecialists, the drug companies, impatient patients, or those dastardly lawyers? Pediatricians are such small players on the health care stage that our contribution to the wastage must be minimal. Our patients are little people who are generally healthy. Most of us drive midsized cars and live in modest homes. We try to be careful users of the expensive diagnostic and therapeutic tools at our disposal. We don’t deserve a place on the list of likely suspects, do we?

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