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‘And a child shall lead them’
With a moistened index finger pointing skyward, I always have tried to remain alert to where the winds of change are blowing. But every now and then I miss a trend in child care, and that is the case with something known as “baby-led weaning.” Influenced by the questionable notion that there is a “natural” way of doing almost everything, the concept hinges on the belief that an infant will “tell” his mother when it is time to stop nursing and begin solids, aka complementary feeding.
At face value, the concept of allowing the baby to lead is a good one simply because of universality of biologic variation. Just as with the question of how much sleep a baby needs, I don’t think anyone (let alone clinicians) can give with assurance an answer that can easily be applied to all infants. There are just too many variables.
For most dyads, breastfeeding is more than just passing calories from one individual to another. Nursing can offer a sense of security and calming both for infants and their mothers. In many cases, the breast unfortunately has become a critical ingredient in the infant’s ritual for falling to sleep. For some mothers, success at breastfeeding becomes an important validation of her feelings of confidence and self-worth that in the past may have been battered by a male-dominated environment. If breastfeeding has been an unpleasant experience, a mother may be more likely to interpret her infant’s behavior as a message that it is time to wean. The bottom line is that a mother’s perception of her baby’s messages about weaning often reflects her own feelings about nursing.
Of course, we clinicians can influence a mother’s perception of her baby’s messages by introducing our own biases about what we believe is the safest, most nutritionally sound way to introduce complementary feeding. And let’s be honest and acknowledge that those are biases mostly unsupported by good scientific study. In many cases, they are more of a reflection of the cultures in which we have grown up.
When asked by parents how they will know when their infant is ready for complementary feeding, I suggest that it’s time when the infant is not only curious about what the adults around him are eating, but obviously is upset that he isn’t being offered a taste. I add that exactly what that food should be is a matter of debate and common sense.
I also encourage parents to allow the child to do as much self-feeding as possible and not worry about the mess. An old shower curtain floor and plenty of sponges and paper towels are a must.
In most cases, I think we can trust babies to take the lead in weaning. But I also believe that as clinicians we must remain alert to the few situations when extended nursing is not in the best interest for the baby who is not growing well or for the mother for whom the nursing is taking an unreasonable toll on her physical and mental health.
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].
With a moistened index finger pointing skyward, I always have tried to remain alert to where the winds of change are blowing. But every now and then I miss a trend in child care, and that is the case with something known as “baby-led weaning.” Influenced by the questionable notion that there is a “natural” way of doing almost everything, the concept hinges on the belief that an infant will “tell” his mother when it is time to stop nursing and begin solids, aka complementary feeding.
At face value, the concept of allowing the baby to lead is a good one simply because of universality of biologic variation. Just as with the question of how much sleep a baby needs, I don’t think anyone (let alone clinicians) can give with assurance an answer that can easily be applied to all infants. There are just too many variables.
For most dyads, breastfeeding is more than just passing calories from one individual to another. Nursing can offer a sense of security and calming both for infants and their mothers. In many cases, the breast unfortunately has become a critical ingredient in the infant’s ritual for falling to sleep. For some mothers, success at breastfeeding becomes an important validation of her feelings of confidence and self-worth that in the past may have been battered by a male-dominated environment. If breastfeeding has been an unpleasant experience, a mother may be more likely to interpret her infant’s behavior as a message that it is time to wean. The bottom line is that a mother’s perception of her baby’s messages about weaning often reflects her own feelings about nursing.
Of course, we clinicians can influence a mother’s perception of her baby’s messages by introducing our own biases about what we believe is the safest, most nutritionally sound way to introduce complementary feeding. And let’s be honest and acknowledge that those are biases mostly unsupported by good scientific study. In many cases, they are more of a reflection of the cultures in which we have grown up.
When asked by parents how they will know when their infant is ready for complementary feeding, I suggest that it’s time when the infant is not only curious about what the adults around him are eating, but obviously is upset that he isn’t being offered a taste. I add that exactly what that food should be is a matter of debate and common sense.
I also encourage parents to allow the child to do as much self-feeding as possible and not worry about the mess. An old shower curtain floor and plenty of sponges and paper towels are a must.
In most cases, I think we can trust babies to take the lead in weaning. But I also believe that as clinicians we must remain alert to the few situations when extended nursing is not in the best interest for the baby who is not growing well or for the mother for whom the nursing is taking an unreasonable toll on her physical and mental health.
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].
With a moistened index finger pointing skyward, I always have tried to remain alert to where the winds of change are blowing. But every now and then I miss a trend in child care, and that is the case with something known as “baby-led weaning.” Influenced by the questionable notion that there is a “natural” way of doing almost everything, the concept hinges on the belief that an infant will “tell” his mother when it is time to stop nursing and begin solids, aka complementary feeding.
At face value, the concept of allowing the baby to lead is a good one simply because of universality of biologic variation. Just as with the question of how much sleep a baby needs, I don’t think anyone (let alone clinicians) can give with assurance an answer that can easily be applied to all infants. There are just too many variables.
For most dyads, breastfeeding is more than just passing calories from one individual to another. Nursing can offer a sense of security and calming both for infants and their mothers. In many cases, the breast unfortunately has become a critical ingredient in the infant’s ritual for falling to sleep. For some mothers, success at breastfeeding becomes an important validation of her feelings of confidence and self-worth that in the past may have been battered by a male-dominated environment. If breastfeeding has been an unpleasant experience, a mother may be more likely to interpret her infant’s behavior as a message that it is time to wean. The bottom line is that a mother’s perception of her baby’s messages about weaning often reflects her own feelings about nursing.
Of course, we clinicians can influence a mother’s perception of her baby’s messages by introducing our own biases about what we believe is the safest, most nutritionally sound way to introduce complementary feeding. And let’s be honest and acknowledge that those are biases mostly unsupported by good scientific study. In many cases, they are more of a reflection of the cultures in which we have grown up.
When asked by parents how they will know when their infant is ready for complementary feeding, I suggest that it’s time when the infant is not only curious about what the adults around him are eating, but obviously is upset that he isn’t being offered a taste. I add that exactly what that food should be is a matter of debate and common sense.
I also encourage parents to allow the child to do as much self-feeding as possible and not worry about the mess. An old shower curtain floor and plenty of sponges and paper towels are a must.
In most cases, I think we can trust babies to take the lead in weaning. But I also believe that as clinicians we must remain alert to the few situations when extended nursing is not in the best interest for the baby who is not growing well or for the mother for whom the nursing is taking an unreasonable toll on her physical and mental health.
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].
ACA repeal will prove good for psychiatric practice
As a psychiatrist who ran a solo private practice for more than 40 years, I welcome the demise of the Affordable Care Act (ACA). Why? Because so many of the ACA’s requirements have worked against the best interests of my patients.
The reality is that patients want much greater power in a U.S. health care marketplace. Patient power will, or at least ought to be, an important objective for health care reform at all levels of government. The 2016 elections make it clear that citizens want to be personally invested when it comes to shopping for their health care insurance and engaging health care professionals of their choice. That means we as professionals must advocate for price transparency for our professional services, and give our patients much greater power to say where money goes to pay for their health care.
One ACA requirement that really turns off patients and clinical psychiatrists is government and third-party mandates that a patient’s clinical notes must be put on an electronic health record (EHR). (This requirement did not originate with the ACA but reinforces the HITECH mandate.)* Patient data privacy and confidentiality are essential to gaining and maintaining patient trust when doing psychotherapy and outpatient psychiatry, and more than 40% of U.S. clinical psychiatrists today are in solo or small group independent practices. They make patient data privacy and confidentiality a hallmark.
Unfortunately, the ACA does not support independent solo and small group psychiatric practices. Frustrations tied to the ACA’s current overreliance on payer-”provider” contracting in the private and public sectors are the reason for the growing interest in the Wedge of Health Freedom. The Wedge is a voluntary program conceived by the Citizens’ Council for Health Freedom to advance a “new vision of health care for patients and doctors” by eliminating third parties who “manage” medical care dollars and “medical necessity.” I know from the last 10 years that a direct pay (cash) practice experience is a necessary option and alternative to managed care for patients and doctors. Patient demand is spurring The Wedge concept, as Twila Brase, a registered nurse who serves as president of the Citizens’ Council for Health Freedom, has said.
“The right to pay cash, the right to accept cash, and the right to discount prices must be protected within the wedge of freedom,” Ms. Braise said in a 2014 presentation before the Association of American Physicians and Surgeons. “I’m asking you to engage your patients.”
To ensure continuity of care, patients need to have both access to competent professionals of their choice and discretion/control of how those professionals are paid. That is missing in the ACA.
The emphasis on patient (consumer) choice is one of many positive aspects of the ACA repeal legislation proposed in 2015 by Tom Price (R-Ga.), an orthopedic surgeon who has been nominated by President-Elect Donald J. Trump to be the next secretary of the U.S. Department of Health & Human Services. Health savings accounts (HSAs) are key, as are the use of indemnity (catastrophic) insurance offerings based on the costs of care. To incentivize insurance companies to develop and market insurance products appropriate to the demands and needs of all people, including young and healthy enrollees, federal and state laws involving third-party insurance, Medicaid, and Medicare must change. And they will.
Expanding high-risk pools can be accomplished only with help from the states. (Minnesota is now debating resurrecting a version of the 1976 high-risk pool called the Minnesota Comprehensive Health Association). New and innovative programs for Medicaid recipients allowing them to shop for care using debit cards is an interesting proposal. Financial “skin in the game” for patients (even when such discretionary money is provided by taxpayers) will empower patients to shop for services and coverage with real options for them if presented with diversion if they show up at emergency departments with needs for nonurgent health care services or primary care. Other appealing proposals involve primary care programs linking care access through concierge or direct-pay arrangements with patients.
Everyone with Internet access knows that he or she can purchase almost anything online. Other than legal considerations (often state-imposed sales taxes), there are no boundaries or constraints to most Internet purchases. If someone wants a product or service and has the money to buy it from a vendor anyplace in the world, all it takes is a few keystrokes, and, voila, the items are on the way! Soon, in fact, amazon.com may drop your “stuff” off via a drone on your front steps. So how is health care or the purchase of a doctor-patient relationship different from other “stuff” we buy online? And how, fundamentally, is the insurance that pays for health care different from other forms of insurance? Can we envision after a patient’s vetting and risk assessment that an Amazon drone might drop off an insurance contract or policy?
An important question and proposal for ACA replacement legislation is the opportunity for consumers to buy health care insurance across state lines. Competition based on coverage and price will drive down the cost of health care insurance for buyers. But there are serious obstacles to making interstate health care insurance a reality, such as state regulation of insurance, state licensure of health care professionals, and lack of a stomach by medical professionals for more “provider” networks.
Clearly, price transparency for health care services and insurance should be a first order priority for health care reform. There are no guarantees when it comes to markets, but it’s very unlikely that health insurance premiums will fall simply because people can buy health plans across state lines. Allowing companies to manage health plans in several states could bring down management expenses so long as there is real competition among insurance companies. That prospect, however, is countered by rampant consolidation of insurance companies, and associated oligopoly and antitrust issues.
In my view, health care insurance should be a contract between the enrollee (recipient) and the insurer rather than a deal that is usually hidden from consumers between “providers” of care and third-party payers.
We do need to get rid of individual and corporate ACA penalties for not having insurance while at the same time, make markets appealing to consumers of all incomes and needs. And people should be able to buy prepaid coverage from health maintenance organizations (HMOs) if people want prepaid care with its restrictions. We should expand HSAs, and encourage price disclosure/transparency for services and insurance coverage via the Internet.
I lobbied for mental health parity legislation for years, and the American Psychiatric Association supported the passage of the ACA in 2010 to ensure access to mental health benefits for Americans. But let’s stop kidding ourselves about the ACA’s real world consequences to the psychiatric care of our patients. Despite hard work over the years to expand parity for mental health services, psychiatric and substance use care at this moment is commonly restricted to managed care behavioral carve-out networks or time-limited programs. Those restrictions grew under the ACA.
In short, we need to create a true health care marketplace and access to insurance protections that enable psychiatrists and other mental health professionals to work for the best interests of our patients rather than the bottom line of health care organizations. Let’s urge our politicians to replace the ACA with measures that encourage and promote voluntary, motivated patients and their families to find quality professional relationships with competent professionals of their choice who are able to provide care continuity and confidential, data-safe practice environments.
Dr. Beecher is president of the Minnesota Physician-Patient Alliance (www.physician-patient.org), a health care think tank based in Saint Louis Park, Minn. He is a distinguished life fellow of the American Psychiatric Association and Fellow of the American Society of Addiction Medicine, and until 2015 served as adjunct professor of psychiatry at the University of Minnesota, Minneapolis.
*CORRECTION, 1/13/2017: The federal program that incentivizes physicians to use EHRs was part of the HITECH Act, which was part of the Recovery Act of 2009 and predates the ACA.
As a psychiatrist who ran a solo private practice for more than 40 years, I welcome the demise of the Affordable Care Act (ACA). Why? Because so many of the ACA’s requirements have worked against the best interests of my patients.
The reality is that patients want much greater power in a U.S. health care marketplace. Patient power will, or at least ought to be, an important objective for health care reform at all levels of government. The 2016 elections make it clear that citizens want to be personally invested when it comes to shopping for their health care insurance and engaging health care professionals of their choice. That means we as professionals must advocate for price transparency for our professional services, and give our patients much greater power to say where money goes to pay for their health care.
One ACA requirement that really turns off patients and clinical psychiatrists is government and third-party mandates that a patient’s clinical notes must be put on an electronic health record (EHR). (This requirement did not originate with the ACA but reinforces the HITECH mandate.)* Patient data privacy and confidentiality are essential to gaining and maintaining patient trust when doing psychotherapy and outpatient psychiatry, and more than 40% of U.S. clinical psychiatrists today are in solo or small group independent practices. They make patient data privacy and confidentiality a hallmark.
Unfortunately, the ACA does not support independent solo and small group psychiatric practices. Frustrations tied to the ACA’s current overreliance on payer-”provider” contracting in the private and public sectors are the reason for the growing interest in the Wedge of Health Freedom. The Wedge is a voluntary program conceived by the Citizens’ Council for Health Freedom to advance a “new vision of health care for patients and doctors” by eliminating third parties who “manage” medical care dollars and “medical necessity.” I know from the last 10 years that a direct pay (cash) practice experience is a necessary option and alternative to managed care for patients and doctors. Patient demand is spurring The Wedge concept, as Twila Brase, a registered nurse who serves as president of the Citizens’ Council for Health Freedom, has said.
“The right to pay cash, the right to accept cash, and the right to discount prices must be protected within the wedge of freedom,” Ms. Braise said in a 2014 presentation before the Association of American Physicians and Surgeons. “I’m asking you to engage your patients.”
To ensure continuity of care, patients need to have both access to competent professionals of their choice and discretion/control of how those professionals are paid. That is missing in the ACA.
The emphasis on patient (consumer) choice is one of many positive aspects of the ACA repeal legislation proposed in 2015 by Tom Price (R-Ga.), an orthopedic surgeon who has been nominated by President-Elect Donald J. Trump to be the next secretary of the U.S. Department of Health & Human Services. Health savings accounts (HSAs) are key, as are the use of indemnity (catastrophic) insurance offerings based on the costs of care. To incentivize insurance companies to develop and market insurance products appropriate to the demands and needs of all people, including young and healthy enrollees, federal and state laws involving third-party insurance, Medicaid, and Medicare must change. And they will.
Expanding high-risk pools can be accomplished only with help from the states. (Minnesota is now debating resurrecting a version of the 1976 high-risk pool called the Minnesota Comprehensive Health Association). New and innovative programs for Medicaid recipients allowing them to shop for care using debit cards is an interesting proposal. Financial “skin in the game” for patients (even when such discretionary money is provided by taxpayers) will empower patients to shop for services and coverage with real options for them if presented with diversion if they show up at emergency departments with needs for nonurgent health care services or primary care. Other appealing proposals involve primary care programs linking care access through concierge or direct-pay arrangements with patients.
Everyone with Internet access knows that he or she can purchase almost anything online. Other than legal considerations (often state-imposed sales taxes), there are no boundaries or constraints to most Internet purchases. If someone wants a product or service and has the money to buy it from a vendor anyplace in the world, all it takes is a few keystrokes, and, voila, the items are on the way! Soon, in fact, amazon.com may drop your “stuff” off via a drone on your front steps. So how is health care or the purchase of a doctor-patient relationship different from other “stuff” we buy online? And how, fundamentally, is the insurance that pays for health care different from other forms of insurance? Can we envision after a patient’s vetting and risk assessment that an Amazon drone might drop off an insurance contract or policy?
An important question and proposal for ACA replacement legislation is the opportunity for consumers to buy health care insurance across state lines. Competition based on coverage and price will drive down the cost of health care insurance for buyers. But there are serious obstacles to making interstate health care insurance a reality, such as state regulation of insurance, state licensure of health care professionals, and lack of a stomach by medical professionals for more “provider” networks.
Clearly, price transparency for health care services and insurance should be a first order priority for health care reform. There are no guarantees when it comes to markets, but it’s very unlikely that health insurance premiums will fall simply because people can buy health plans across state lines. Allowing companies to manage health plans in several states could bring down management expenses so long as there is real competition among insurance companies. That prospect, however, is countered by rampant consolidation of insurance companies, and associated oligopoly and antitrust issues.
In my view, health care insurance should be a contract between the enrollee (recipient) and the insurer rather than a deal that is usually hidden from consumers between “providers” of care and third-party payers.
We do need to get rid of individual and corporate ACA penalties for not having insurance while at the same time, make markets appealing to consumers of all incomes and needs. And people should be able to buy prepaid coverage from health maintenance organizations (HMOs) if people want prepaid care with its restrictions. We should expand HSAs, and encourage price disclosure/transparency for services and insurance coverage via the Internet.
I lobbied for mental health parity legislation for years, and the American Psychiatric Association supported the passage of the ACA in 2010 to ensure access to mental health benefits for Americans. But let’s stop kidding ourselves about the ACA’s real world consequences to the psychiatric care of our patients. Despite hard work over the years to expand parity for mental health services, psychiatric and substance use care at this moment is commonly restricted to managed care behavioral carve-out networks or time-limited programs. Those restrictions grew under the ACA.
In short, we need to create a true health care marketplace and access to insurance protections that enable psychiatrists and other mental health professionals to work for the best interests of our patients rather than the bottom line of health care organizations. Let’s urge our politicians to replace the ACA with measures that encourage and promote voluntary, motivated patients and their families to find quality professional relationships with competent professionals of their choice who are able to provide care continuity and confidential, data-safe practice environments.
Dr. Beecher is president of the Minnesota Physician-Patient Alliance (www.physician-patient.org), a health care think tank based in Saint Louis Park, Minn. He is a distinguished life fellow of the American Psychiatric Association and Fellow of the American Society of Addiction Medicine, and until 2015 served as adjunct professor of psychiatry at the University of Minnesota, Minneapolis.
*CORRECTION, 1/13/2017: The federal program that incentivizes physicians to use EHRs was part of the HITECH Act, which was part of the Recovery Act of 2009 and predates the ACA.
As a psychiatrist who ran a solo private practice for more than 40 years, I welcome the demise of the Affordable Care Act (ACA). Why? Because so many of the ACA’s requirements have worked against the best interests of my patients.
The reality is that patients want much greater power in a U.S. health care marketplace. Patient power will, or at least ought to be, an important objective for health care reform at all levels of government. The 2016 elections make it clear that citizens want to be personally invested when it comes to shopping for their health care insurance and engaging health care professionals of their choice. That means we as professionals must advocate for price transparency for our professional services, and give our patients much greater power to say where money goes to pay for their health care.
One ACA requirement that really turns off patients and clinical psychiatrists is government and third-party mandates that a patient’s clinical notes must be put on an electronic health record (EHR). (This requirement did not originate with the ACA but reinforces the HITECH mandate.)* Patient data privacy and confidentiality are essential to gaining and maintaining patient trust when doing psychotherapy and outpatient psychiatry, and more than 40% of U.S. clinical psychiatrists today are in solo or small group independent practices. They make patient data privacy and confidentiality a hallmark.
Unfortunately, the ACA does not support independent solo and small group psychiatric practices. Frustrations tied to the ACA’s current overreliance on payer-”provider” contracting in the private and public sectors are the reason for the growing interest in the Wedge of Health Freedom. The Wedge is a voluntary program conceived by the Citizens’ Council for Health Freedom to advance a “new vision of health care for patients and doctors” by eliminating third parties who “manage” medical care dollars and “medical necessity.” I know from the last 10 years that a direct pay (cash) practice experience is a necessary option and alternative to managed care for patients and doctors. Patient demand is spurring The Wedge concept, as Twila Brase, a registered nurse who serves as president of the Citizens’ Council for Health Freedom, has said.
“The right to pay cash, the right to accept cash, and the right to discount prices must be protected within the wedge of freedom,” Ms. Braise said in a 2014 presentation before the Association of American Physicians and Surgeons. “I’m asking you to engage your patients.”
To ensure continuity of care, patients need to have both access to competent professionals of their choice and discretion/control of how those professionals are paid. That is missing in the ACA.
The emphasis on patient (consumer) choice is one of many positive aspects of the ACA repeal legislation proposed in 2015 by Tom Price (R-Ga.), an orthopedic surgeon who has been nominated by President-Elect Donald J. Trump to be the next secretary of the U.S. Department of Health & Human Services. Health savings accounts (HSAs) are key, as are the use of indemnity (catastrophic) insurance offerings based on the costs of care. To incentivize insurance companies to develop and market insurance products appropriate to the demands and needs of all people, including young and healthy enrollees, federal and state laws involving third-party insurance, Medicaid, and Medicare must change. And they will.
Expanding high-risk pools can be accomplished only with help from the states. (Minnesota is now debating resurrecting a version of the 1976 high-risk pool called the Minnesota Comprehensive Health Association). New and innovative programs for Medicaid recipients allowing them to shop for care using debit cards is an interesting proposal. Financial “skin in the game” for patients (even when such discretionary money is provided by taxpayers) will empower patients to shop for services and coverage with real options for them if presented with diversion if they show up at emergency departments with needs for nonurgent health care services or primary care. Other appealing proposals involve primary care programs linking care access through concierge or direct-pay arrangements with patients.
Everyone with Internet access knows that he or she can purchase almost anything online. Other than legal considerations (often state-imposed sales taxes), there are no boundaries or constraints to most Internet purchases. If someone wants a product or service and has the money to buy it from a vendor anyplace in the world, all it takes is a few keystrokes, and, voila, the items are on the way! Soon, in fact, amazon.com may drop your “stuff” off via a drone on your front steps. So how is health care or the purchase of a doctor-patient relationship different from other “stuff” we buy online? And how, fundamentally, is the insurance that pays for health care different from other forms of insurance? Can we envision after a patient’s vetting and risk assessment that an Amazon drone might drop off an insurance contract or policy?
An important question and proposal for ACA replacement legislation is the opportunity for consumers to buy health care insurance across state lines. Competition based on coverage and price will drive down the cost of health care insurance for buyers. But there are serious obstacles to making interstate health care insurance a reality, such as state regulation of insurance, state licensure of health care professionals, and lack of a stomach by medical professionals for more “provider” networks.
Clearly, price transparency for health care services and insurance should be a first order priority for health care reform. There are no guarantees when it comes to markets, but it’s very unlikely that health insurance premiums will fall simply because people can buy health plans across state lines. Allowing companies to manage health plans in several states could bring down management expenses so long as there is real competition among insurance companies. That prospect, however, is countered by rampant consolidation of insurance companies, and associated oligopoly and antitrust issues.
In my view, health care insurance should be a contract between the enrollee (recipient) and the insurer rather than a deal that is usually hidden from consumers between “providers” of care and third-party payers.
We do need to get rid of individual and corporate ACA penalties for not having insurance while at the same time, make markets appealing to consumers of all incomes and needs. And people should be able to buy prepaid coverage from health maintenance organizations (HMOs) if people want prepaid care with its restrictions. We should expand HSAs, and encourage price disclosure/transparency for services and insurance coverage via the Internet.
I lobbied for mental health parity legislation for years, and the American Psychiatric Association supported the passage of the ACA in 2010 to ensure access to mental health benefits for Americans. But let’s stop kidding ourselves about the ACA’s real world consequences to the psychiatric care of our patients. Despite hard work over the years to expand parity for mental health services, psychiatric and substance use care at this moment is commonly restricted to managed care behavioral carve-out networks or time-limited programs. Those restrictions grew under the ACA.
In short, we need to create a true health care marketplace and access to insurance protections that enable psychiatrists and other mental health professionals to work for the best interests of our patients rather than the bottom line of health care organizations. Let’s urge our politicians to replace the ACA with measures that encourage and promote voluntary, motivated patients and their families to find quality professional relationships with competent professionals of their choice who are able to provide care continuity and confidential, data-safe practice environments.
Dr. Beecher is president of the Minnesota Physician-Patient Alliance (www.physician-patient.org), a health care think tank based in Saint Louis Park, Minn. He is a distinguished life fellow of the American Psychiatric Association and Fellow of the American Society of Addiction Medicine, and until 2015 served as adjunct professor of psychiatry at the University of Minnesota, Minneapolis.
*CORRECTION, 1/13/2017: The federal program that incentivizes physicians to use EHRs was part of the HITECH Act, which was part of the Recovery Act of 2009 and predates the ACA.
Analyses of Fort Lauderdale shooting need a reset
Once again, there has been another senseless tragedy: a mass murder that leaves us all feeling vulnerable.
Last Friday, a gunman flew from Anchorage, Alaska, to Florida; retrieved a gun from his checked baggage; and opened fire on total strangers in the baggage claim area of the Fort Lauderdale airport, killing five people and wounding eight others. Why? The media always find a few facts that leave the public to piece together a theory that may or may not hold true.
I heard about the shooting while I was on vacation: The suspected gunman reportedly had visited ISIS websites and was killed at the scene. Later, I saw that he was not a terrorist and was not killed but had been taken into custody without a struggle.
The next reports noted that the 26-year-old man is a former soldier who had served in Iraq, and had come back traumatized and with psychological issues, according to his brother – or, according to what the media say his brother said, since the facts are sometimes selectively reported.
It was then announced that the gunman had gone to the FBI and reported that he was having concerns that U.S. intelligence agencies were infiltrating his brain and commanding him to look at ISIS websites. The FBI sent him for a psychiatric evaluation. His gun was taken by police; he spent a few days in the hospital, and had been released. Soon after, his firearm was returned, and he used it to commit a mass shooting. 
So the story started as a terror attack and moved to the media’s default explanation for mass murder – mental illness. These few facts may be pieced together to tell a story of a man who was changed by war, struggled with posttraumatic symptoms that left him angry, and at some point, had a psychotic break that led him to fly across the continent and kill strangers at an airport in response to a command delusion. That’s one possible story that could be written with the very few facts we have.
My best guess is that as facts unfold, the story will change. Even if this story is right, one has to wonder why so many other young soldiers who return from military service so damaged, who also may coincidentally develop psychotic illnesses (or psychosis related to drug use) don’t routinely commit mass murder.
These stories are rare, but they capture the attention of the media in a way that common gun deaths in our inner cities do not. And they play out in a stereotyped way, regardless of how little we know: Mental health advocates use these examples to lobby for more involuntary care – “treatment before tragedy” in a population that does not recognize their own mental illnesses. Such incidents lead to calls to medicate every person with a psychotic illness, because that person may be the next killer, even though half of mass murderers don’t have mental disorders, and even though violence, in general, is more often caused by anger, substance abuse, and a history of exposure to violence. The plea for involuntary care goes out to a nation where voluntary care is often inaccessible to those who want it, where beds are scarce, where insurers – and not doctors – decide who can be hospitalized and for how long. One can only hope that if this young man was obviously dangerous, the hospital that evaluated him would not have discharged him, and that the police would not have returned his firearm. Predicting violence may seem plausible in retrospect, but it’s not always that obvious.
As more of the stereotyped response, antipsychiatry groups often assume mass murderers have been treated with psychotropic medications and use these events as one more example of how psychiatry is causing violence, suicide, and disability for unsuspecting souls who would have fared better without our interventions.
Among psychiatrists ourselves, these stories set off questions and fears. Why did a hospital release this patient? Was he given medications and follow up? What kind of follow up is even available in Alaska? Was he released because he’d taken medication that helped him, because a substance-induced psychosis cleared, or because he refused treatment and was not felt to be dangerous? Or was he released because he had no insurance, or because his insurance company refused to pay for continued treatment? Was a terrible outcome the result of negligence, or was the act of violence something that could not have been predicted? And finally, is the psychiatrist liable? The stock value for crystal balls rises, and we all wonder how we can know – and document – that our patients are safe, as it’s not unusual for distressed people to express violent fantasies. All of us have treated patients who have delusions – how many of those patients have gone on to become mass murderers? Have you ever treated a college student with depression, anxiety, and disturbing thoughts? Did he shoot 70 people in a movie theater and wire his apartment with explosives?
Finally, I’d like to share some concerns I have. First, before we talk about involuntary care to prevent such tragedies as those that happened in Fort Lauderdale last week, we need to be sure that everyone in our nation has access to high-quality, comprehensive psychiatric services, especially our veterans. In the plea for more forced psychiatric care, I believe we’ve become careless and disengaged. Patient rights’ groups have instituted barriers to involuntary treatment, while mental health advocates have touted the impossibility of convincing patients with anosognosia – an inability to see that they suffer from an illness – into accepting psychiatric treatment. Insurers chime in by managing benefits such that patients can be admitted only if they are dangerous, even if they are very sick and want to be in the hospital.
We need to use some commonsense: Patients with psychiatric disorders need to be offered voluntary care in much the same way that patients with other illnesses are approached. If someone in an ED refuses treatment for cancer or an MI, we don’t just say so be it, goodbye. Doctors cajole; they call family; they explain the risks and try quite hard to get the patient to accept help.
In psychiatry, we have stories where patients are asked if they are dangerous, and when they say no, they are sent out, without any further effort to engage them. Psychosis is often a tormenting state, and while patients may not be aware they have an illness, they can often be convinced to come into a hospital for respite, or to take medication to soothe the anxiety that accompanies paranoia or allow for restful sleep. Not everyone is beyond engagement, and the issue needs to be one of what is the best interests of any given patient – with involuntary care only as a true last resort– and not one of preventing mass murders.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Care,” which was released last fall (Baltimore: Johns Hopkins University Press).
Once again, there has been another senseless tragedy: a mass murder that leaves us all feeling vulnerable.
Last Friday, a gunman flew from Anchorage, Alaska, to Florida; retrieved a gun from his checked baggage; and opened fire on total strangers in the baggage claim area of the Fort Lauderdale airport, killing five people and wounding eight others. Why? The media always find a few facts that leave the public to piece together a theory that may or may not hold true.
I heard about the shooting while I was on vacation: The suspected gunman reportedly had visited ISIS websites and was killed at the scene. Later, I saw that he was not a terrorist and was not killed but had been taken into custody without a struggle.
The next reports noted that the 26-year-old man is a former soldier who had served in Iraq, and had come back traumatized and with psychological issues, according to his brother – or, according to what the media say his brother said, since the facts are sometimes selectively reported.
It was then announced that the gunman had gone to the FBI and reported that he was having concerns that U.S. intelligence agencies were infiltrating his brain and commanding him to look at ISIS websites. The FBI sent him for a psychiatric evaluation. His gun was taken by police; he spent a few days in the hospital, and had been released. Soon after, his firearm was returned, and he used it to commit a mass shooting.
So the story started as a terror attack and moved to the media’s default explanation for mass murder – mental illness. These few facts may be pieced together to tell a story of a man who was changed by war, struggled with posttraumatic symptoms that left him angry, and at some point, had a psychotic break that led him to fly across the continent and kill strangers at an airport in response to a command delusion. That’s one possible story that could be written with the very few facts we have.
My best guess is that as facts unfold, the story will change. Even if this story is right, one has to wonder why so many other young soldiers who return from military service so damaged, who also may coincidentally develop psychotic illnesses (or psychosis related to drug use) don’t routinely commit mass murder.
These stories are rare, but they capture the attention of the media in a way that common gun deaths in our inner cities do not. And they play out in a stereotyped way, regardless of how little we know: Mental health advocates use these examples to lobby for more involuntary care – “treatment before tragedy” in a population that does not recognize their own mental illnesses. Such incidents lead to calls to medicate every person with a psychotic illness, because that person may be the next killer, even though half of mass murderers don’t have mental disorders, and even though violence, in general, is more often caused by anger, substance abuse, and a history of exposure to violence. The plea for involuntary care goes out to a nation where voluntary care is often inaccessible to those who want it, where beds are scarce, where insurers – and not doctors – decide who can be hospitalized and for how long. One can only hope that if this young man was obviously dangerous, the hospital that evaluated him would not have discharged him, and that the police would not have returned his firearm. Predicting violence may seem plausible in retrospect, but it’s not always that obvious.
As more of the stereotyped response, antipsychiatry groups often assume mass murderers have been treated with psychotropic medications and use these events as one more example of how psychiatry is causing violence, suicide, and disability for unsuspecting souls who would have fared better without our interventions.
Among psychiatrists ourselves, these stories set off questions and fears. Why did a hospital release this patient? Was he given medications and follow up? What kind of follow up is even available in Alaska? Was he released because he’d taken medication that helped him, because a substance-induced psychosis cleared, or because he refused treatment and was not felt to be dangerous? Or was he released because he had no insurance, or because his insurance company refused to pay for continued treatment? Was a terrible outcome the result of negligence, or was the act of violence something that could not have been predicted? And finally, is the psychiatrist liable? The stock value for crystal balls rises, and we all wonder how we can know – and document – that our patients are safe, as it’s not unusual for distressed people to express violent fantasies. All of us have treated patients who have delusions – how many of those patients have gone on to become mass murderers? Have you ever treated a college student with depression, anxiety, and disturbing thoughts? Did he shoot 70 people in a movie theater and wire his apartment with explosives?
Finally, I’d like to share some concerns I have. First, before we talk about involuntary care to prevent such tragedies as those that happened in Fort Lauderdale last week, we need to be sure that everyone in our nation has access to high-quality, comprehensive psychiatric services, especially our veterans. In the plea for more forced psychiatric care, I believe we’ve become careless and disengaged. Patient rights’ groups have instituted barriers to involuntary treatment, while mental health advocates have touted the impossibility of convincing patients with anosognosia – an inability to see that they suffer from an illness – into accepting psychiatric treatment. Insurers chime in by managing benefits such that patients can be admitted only if they are dangerous, even if they are very sick and want to be in the hospital.
We need to use some commonsense: Patients with psychiatric disorders need to be offered voluntary care in much the same way that patients with other illnesses are approached. If someone in an ED refuses treatment for cancer or an MI, we don’t just say so be it, goodbye. Doctors cajole; they call family; they explain the risks and try quite hard to get the patient to accept help.
In psychiatry, we have stories where patients are asked if they are dangerous, and when they say no, they are sent out, without any further effort to engage them. Psychosis is often a tormenting state, and while patients may not be aware they have an illness, they can often be convinced to come into a hospital for respite, or to take medication to soothe the anxiety that accompanies paranoia or allow for restful sleep. Not everyone is beyond engagement, and the issue needs to be one of what is the best interests of any given patient – with involuntary care only as a true last resort– and not one of preventing mass murders.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Care,” which was released last fall (Baltimore: Johns Hopkins University Press).
Once again, there has been another senseless tragedy: a mass murder that leaves us all feeling vulnerable.
Last Friday, a gunman flew from Anchorage, Alaska, to Florida; retrieved a gun from his checked baggage; and opened fire on total strangers in the baggage claim area of the Fort Lauderdale airport, killing five people and wounding eight others. Why? The media always find a few facts that leave the public to piece together a theory that may or may not hold true.
I heard about the shooting while I was on vacation: The suspected gunman reportedly had visited ISIS websites and was killed at the scene. Later, I saw that he was not a terrorist and was not killed but had been taken into custody without a struggle.
The next reports noted that the 26-year-old man is a former soldier who had served in Iraq, and had come back traumatized and with psychological issues, according to his brother – or, according to what the media say his brother said, since the facts are sometimes selectively reported.
It was then announced that the gunman had gone to the FBI and reported that he was having concerns that U.S. intelligence agencies were infiltrating his brain and commanding him to look at ISIS websites. The FBI sent him for a psychiatric evaluation. His gun was taken by police; he spent a few days in the hospital, and had been released. Soon after, his firearm was returned, and he used it to commit a mass shooting.
So the story started as a terror attack and moved to the media’s default explanation for mass murder – mental illness. These few facts may be pieced together to tell a story of a man who was changed by war, struggled with posttraumatic symptoms that left him angry, and at some point, had a psychotic break that led him to fly across the continent and kill strangers at an airport in response to a command delusion. That’s one possible story that could be written with the very few facts we have.
My best guess is that as facts unfold, the story will change. Even if this story is right, one has to wonder why so many other young soldiers who return from military service so damaged, who also may coincidentally develop psychotic illnesses (or psychosis related to drug use) don’t routinely commit mass murder.
These stories are rare, but they capture the attention of the media in a way that common gun deaths in our inner cities do not. And they play out in a stereotyped way, regardless of how little we know: Mental health advocates use these examples to lobby for more involuntary care – “treatment before tragedy” in a population that does not recognize their own mental illnesses. Such incidents lead to calls to medicate every person with a psychotic illness, because that person may be the next killer, even though half of mass murderers don’t have mental disorders, and even though violence, in general, is more often caused by anger, substance abuse, and a history of exposure to violence. The plea for involuntary care goes out to a nation where voluntary care is often inaccessible to those who want it, where beds are scarce, where insurers – and not doctors – decide who can be hospitalized and for how long. One can only hope that if this young man was obviously dangerous, the hospital that evaluated him would not have discharged him, and that the police would not have returned his firearm. Predicting violence may seem plausible in retrospect, but it’s not always that obvious.
As more of the stereotyped response, antipsychiatry groups often assume mass murderers have been treated with psychotropic medications and use these events as one more example of how psychiatry is causing violence, suicide, and disability for unsuspecting souls who would have fared better without our interventions.
Among psychiatrists ourselves, these stories set off questions and fears. Why did a hospital release this patient? Was he given medications and follow up? What kind of follow up is even available in Alaska? Was he released because he’d taken medication that helped him, because a substance-induced psychosis cleared, or because he refused treatment and was not felt to be dangerous? Or was he released because he had no insurance, or because his insurance company refused to pay for continued treatment? Was a terrible outcome the result of negligence, or was the act of violence something that could not have been predicted? And finally, is the psychiatrist liable? The stock value for crystal balls rises, and we all wonder how we can know – and document – that our patients are safe, as it’s not unusual for distressed people to express violent fantasies. All of us have treated patients who have delusions – how many of those patients have gone on to become mass murderers? Have you ever treated a college student with depression, anxiety, and disturbing thoughts? Did he shoot 70 people in a movie theater and wire his apartment with explosives?
Finally, I’d like to share some concerns I have. First, before we talk about involuntary care to prevent such tragedies as those that happened in Fort Lauderdale last week, we need to be sure that everyone in our nation has access to high-quality, comprehensive psychiatric services, especially our veterans. In the plea for more forced psychiatric care, I believe we’ve become careless and disengaged. Patient rights’ groups have instituted barriers to involuntary treatment, while mental health advocates have touted the impossibility of convincing patients with anosognosia – an inability to see that they suffer from an illness – into accepting psychiatric treatment. Insurers chime in by managing benefits such that patients can be admitted only if they are dangerous, even if they are very sick and want to be in the hospital.
We need to use some commonsense: Patients with psychiatric disorders need to be offered voluntary care in much the same way that patients with other illnesses are approached. If someone in an ED refuses treatment for cancer or an MI, we don’t just say so be it, goodbye. Doctors cajole; they call family; they explain the risks and try quite hard to get the patient to accept help.
In psychiatry, we have stories where patients are asked if they are dangerous, and when they say no, they are sent out, without any further effort to engage them. Psychosis is often a tormenting state, and while patients may not be aware they have an illness, they can often be convinced to come into a hospital for respite, or to take medication to soothe the anxiety that accompanies paranoia or allow for restful sleep. Not everyone is beyond engagement, and the issue needs to be one of what is the best interests of any given patient – with involuntary care only as a true last resort– and not one of preventing mass murders.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Care,” which was released last fall (Baltimore: Johns Hopkins University Press).
Perfect attendance
A few years ago I audited a college course on leadership taught by Angus King (I-ME), former governor and now independent Senator from Maine. He emphasized that an important characteristic of effective leaders is that they show up for work. They are there, present, on the scene. Attempting to lead in absentia is seldom successful. Knowledge gathered firsthand can be critical when it’s decision-making time. And the connectedness fostered by the leader’s physical presence can bolster morale in a crisis.
Being a parent is more complex than simply being a leader, but showing up is just as important to being a good parent as it is to being an effective leader. Most parents already believe that “being there” is important, and feel guilty when they have obligations that prevent them from maintaining a perfect attendance record.
Common sense also may suggest to parents that their presence is less important as their children get older. Certainly, the behavior of most teenagers would suggest that adolescents couldn’t care less whether their parents were at home or vacationing in the Bahamas. However, this is one of those situations where appearances may be deceiving. The author of an opinion piece in the New York Times presents some compelling evidence that in fact, adolescents place a higher value on their parents’ presence than the common stereotype of teenage behavior would suggest (”What Do Teenagers Want? Potted Plants Parents,” By Lisa Damour, Dec. 14, 2016).
Citing her own experience as a psychologist in private practice in Ohio and several recent studies from the psychology literature, the author observes that “sheer proximity confers a benefit [to the adolescent’s psychological health] over and above feeling of closeness or connectedness between parent and child.” At present there is no explanation for this benefit of just being there for your teenage child. But it may be that a parental presence, even if it is silent, provides a stable base and comfort zone that the adolescent can return to as he or she tests the ability to function independently in the world outside of the family.
I suspect that most of you have observed this counter-intuitive phenomenon in which teenagers who give every outward appearance of wanting nothing to do with their parents actually would like to have at least one parent be at home. They just don’t want to be hovered over. Ninety-nine percent of the time the parent will receive no positive feedback for just being there like a “potted plant” to use Ms. Damour’s analogy.
The problem is how to get this message to parents early enough in their parenting trajectory that they can adjust work schedules and priorities to be home with their adolescents. It was not unusual for new parents to ask for my thoughts as they were considering various day care and work schedule options for their infants. If I thought they were really going to take my advice seriously I would add, “You know you should also be thinking ahead when she is a teen. She won’t ask, but she probably would like it if you were home in the afternoon when she gets home from school.”
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].
A few years ago I audited a college course on leadership taught by Angus King (I-ME), former governor and now independent Senator from Maine. He emphasized that an important characteristic of effective leaders is that they show up for work. They are there, present, on the scene. Attempting to lead in absentia is seldom successful. Knowledge gathered firsthand can be critical when it’s decision-making time. And the connectedness fostered by the leader’s physical presence can bolster morale in a crisis.
Being a parent is more complex than simply being a leader, but showing up is just as important to being a good parent as it is to being an effective leader. Most parents already believe that “being there” is important, and feel guilty when they have obligations that prevent them from maintaining a perfect attendance record.
Common sense also may suggest to parents that their presence is less important as their children get older. Certainly, the behavior of most teenagers would suggest that adolescents couldn’t care less whether their parents were at home or vacationing in the Bahamas. However, this is one of those situations where appearances may be deceiving. The author of an opinion piece in the New York Times presents some compelling evidence that in fact, adolescents place a higher value on their parents’ presence than the common stereotype of teenage behavior would suggest (”What Do Teenagers Want? Potted Plants Parents,” By Lisa Damour, Dec. 14, 2016).
Citing her own experience as a psychologist in private practice in Ohio and several recent studies from the psychology literature, the author observes that “sheer proximity confers a benefit [to the adolescent’s psychological health] over and above feeling of closeness or connectedness between parent and child.” At present there is no explanation for this benefit of just being there for your teenage child. But it may be that a parental presence, even if it is silent, provides a stable base and comfort zone that the adolescent can return to as he or she tests the ability to function independently in the world outside of the family.
I suspect that most of you have observed this counter-intuitive phenomenon in which teenagers who give every outward appearance of wanting nothing to do with their parents actually would like to have at least one parent be at home. They just don’t want to be hovered over. Ninety-nine percent of the time the parent will receive no positive feedback for just being there like a “potted plant” to use Ms. Damour’s analogy.
The problem is how to get this message to parents early enough in their parenting trajectory that they can adjust work schedules and priorities to be home with their adolescents. It was not unusual for new parents to ask for my thoughts as they were considering various day care and work schedule options for their infants. If I thought they were really going to take my advice seriously I would add, “You know you should also be thinking ahead when she is a teen. She won’t ask, but she probably would like it if you were home in the afternoon when she gets home from school.”
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].
A few years ago I audited a college course on leadership taught by Angus King (I-ME), former governor and now independent Senator from Maine. He emphasized that an important characteristic of effective leaders is that they show up for work. They are there, present, on the scene. Attempting to lead in absentia is seldom successful. Knowledge gathered firsthand can be critical when it’s decision-making time. And the connectedness fostered by the leader’s physical presence can bolster morale in a crisis.
Being a parent is more complex than simply being a leader, but showing up is just as important to being a good parent as it is to being an effective leader. Most parents already believe that “being there” is important, and feel guilty when they have obligations that prevent them from maintaining a perfect attendance record.
Common sense also may suggest to parents that their presence is less important as their children get older. Certainly, the behavior of most teenagers would suggest that adolescents couldn’t care less whether their parents were at home or vacationing in the Bahamas. However, this is one of those situations where appearances may be deceiving. The author of an opinion piece in the New York Times presents some compelling evidence that in fact, adolescents place a higher value on their parents’ presence than the common stereotype of teenage behavior would suggest (”What Do Teenagers Want? Potted Plants Parents,” By Lisa Damour, Dec. 14, 2016).
Citing her own experience as a psychologist in private practice in Ohio and several recent studies from the psychology literature, the author observes that “sheer proximity confers a benefit [to the adolescent’s psychological health] over and above feeling of closeness or connectedness between parent and child.” At present there is no explanation for this benefit of just being there for your teenage child. But it may be that a parental presence, even if it is silent, provides a stable base and comfort zone that the adolescent can return to as he or she tests the ability to function independently in the world outside of the family.
I suspect that most of you have observed this counter-intuitive phenomenon in which teenagers who give every outward appearance of wanting nothing to do with their parents actually would like to have at least one parent be at home. They just don’t want to be hovered over. Ninety-nine percent of the time the parent will receive no positive feedback for just being there like a “potted plant” to use Ms. Damour’s analogy.
The problem is how to get this message to parents early enough in their parenting trajectory that they can adjust work schedules and priorities to be home with their adolescents. It was not unusual for new parents to ask for my thoughts as they were considering various day care and work schedule options for their infants. If I thought they were really going to take my advice seriously I would add, “You know you should also be thinking ahead when she is a teen. She won’t ask, but she probably would like it if you were home in the afternoon when she gets home from school.”
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].
Physician Communications: Avoiding the Blame Game
A recent opinion piece in MedPage Today by an internist about poor communications between emergency physicians (EPs) and primary care physicians (PCPs) was subtitled “We’ve gotten better going from office to ER, but not the other way,” and complained about the lack of a “live, warm handoff” from EPs to PCPs of patients being discharged from EDs. Similar complaints were examined in two recent Emergency Medicine (EM) editorials (Anger Management, 2015;47[4]:149 and Broadside Journalism, 2015;47[6]:244). In the first, we noted that PCPs sometimes are angered when they are not consulted about one of their patients in the ED or about a treatment or disposition plan with which they disagree, while EPs are frustrated by the number of phone calls required to reach some PCPs or a knowledgeable covering physician.
Only 2 months later, we expressed concerns about a New York Times opinion editorial describing a young patient whose vertebral artery dissection had been “diagnosed correctly and acted on in the ED,” but then angrily criticizing an initial recommendation that the patient curtail her physical activities based on what a famous neurologist considered an erroneously interpreted vascular imaging study. (Presumably, the recommendation was by another neurologist and the interpretation by a radiologist, but all of the neurologist’s caustic criticism was directed at the EP and ED.) Although the neurologist subsequently apologized in a letter to his emergency medicine colleagues for “being quoted out of context,” few if any
We concluded the second EM editorial with the suggestion that “all physicians must be very, very careful in framing statements to the media, and should assume that their remarks will not be placed ‘in context’ or nuanced as they may have been intended....Most important, is to not disparage entire specialties or use belittling terms such as ‘ER docs’....[that] heighten...patients’ fears” of being treated in EDs.
Why another editorial about physician-to-physician miscommunications and name-calling? Because patient care is significantly affected.
The Centers for Medicare and Medicaid Services originally classified four medical specialties as “primary care” for reimbursement purposes: family medicine, internal medicine, pediatrics, and obstetrics-gynecology, and the 2010 Affordable Care Act added geriatrics. Although emergency medicine had been considered initially, it has never been categorized as a primary care specialty. That being the case, isn’t it incumbent upon us to learn as much as we can from PCPs about their ill patients en route to the ED for treatment or admission, and afterward ensure that an ED visit is part of a continuum of patient care and not an isolated episode?
In 1996, when I accepted an offer to become New York Presbyterian-Weill Cornell’s first Emergency Physician-in-Chief, I created a new position of full-time “ED follow-up nurse practitioner” to track and report test results to discharged patients and their designated PCPs. When we added a fourth unit to the ED a few years later, I designated an experienced, senior attending EP among the four on duty as the “administrative attending” (AA) who, among other tasks, took all phone calls from PCPs about patients they were sending to the ED and entered the information in the “en route” section of our electronic tracking board. In this way, important patient information, including PCP contact information, was no longer misplaced during shift changes. The AA carried a direct-dial cell phone-like device and eventually all attending EPs and the charge nurse were equipped with such phones. In a short time, most of the communications problems and complaints about incoming patients were eliminated.
But despite numerous attempts, for the reasons mentioned above, systematically ensuring effective communications with PCPs for discharged patients has proven to be a more difficult task. At present, handing off discharged patients to PCPs still depends largely on a combination of judgment, understanding, compassion, and respect.
A recent opinion piece in MedPage Today by an internist about poor communications between emergency physicians (EPs) and primary care physicians (PCPs) was subtitled “We’ve gotten better going from office to ER, but not the other way,” and complained about the lack of a “live, warm handoff” from EPs to PCPs of patients being discharged from EDs. Similar complaints were examined in two recent Emergency Medicine (EM) editorials (Anger Management, 2015;47[4]:149 and Broadside Journalism, 2015;47[6]:244). In the first, we noted that PCPs sometimes are angered when they are not consulted about one of their patients in the ED or about a treatment or disposition plan with which they disagree, while EPs are frustrated by the number of phone calls required to reach some PCPs or a knowledgeable covering physician.
Only 2 months later, we expressed concerns about a New York Times opinion editorial describing a young patient whose vertebral artery dissection had been “diagnosed correctly and acted on in the ED,” but then angrily criticizing an initial recommendation that the patient curtail her physical activities based on what a famous neurologist considered an erroneously interpreted vascular imaging study. (Presumably, the recommendation was by another neurologist and the interpretation by a radiologist, but all of the neurologist’s caustic criticism was directed at the EP and ED.) Although the neurologist subsequently apologized in a letter to his emergency medicine colleagues for “being quoted out of context,” few if any
We concluded the second EM editorial with the suggestion that “all physicians must be very, very careful in framing statements to the media, and should assume that their remarks will not be placed ‘in context’ or nuanced as they may have been intended....Most important, is to not disparage entire specialties or use belittling terms such as ‘ER docs’....[that] heighten...patients’ fears” of being treated in EDs.
Why another editorial about physician-to-physician miscommunications and name-calling? Because patient care is significantly affected.
The Centers for Medicare and Medicaid Services originally classified four medical specialties as “primary care” for reimbursement purposes: family medicine, internal medicine, pediatrics, and obstetrics-gynecology, and the 2010 Affordable Care Act added geriatrics. Although emergency medicine had been considered initially, it has never been categorized as a primary care specialty. That being the case, isn’t it incumbent upon us to learn as much as we can from PCPs about their ill patients en route to the ED for treatment or admission, and afterward ensure that an ED visit is part of a continuum of patient care and not an isolated episode?
In 1996, when I accepted an offer to become New York Presbyterian-Weill Cornell’s first Emergency Physician-in-Chief, I created a new position of full-time “ED follow-up nurse practitioner” to track and report test results to discharged patients and their designated PCPs. When we added a fourth unit to the ED a few years later, I designated an experienced, senior attending EP among the four on duty as the “administrative attending” (AA) who, among other tasks, took all phone calls from PCPs about patients they were sending to the ED and entered the information in the “en route” section of our electronic tracking board. In this way, important patient information, including PCP contact information, was no longer misplaced during shift changes. The AA carried a direct-dial cell phone-like device and eventually all attending EPs and the charge nurse were equipped with such phones. In a short time, most of the communications problems and complaints about incoming patients were eliminated.
But despite numerous attempts, for the reasons mentioned above, systematically ensuring effective communications with PCPs for discharged patients has proven to be a more difficult task. At present, handing off discharged patients to PCPs still depends largely on a combination of judgment, understanding, compassion, and respect.
A recent opinion piece in MedPage Today by an internist about poor communications between emergency physicians (EPs) and primary care physicians (PCPs) was subtitled “We’ve gotten better going from office to ER, but not the other way,” and complained about the lack of a “live, warm handoff” from EPs to PCPs of patients being discharged from EDs. Similar complaints were examined in two recent Emergency Medicine (EM) editorials (Anger Management, 2015;47[4]:149 and Broadside Journalism, 2015;47[6]:244). In the first, we noted that PCPs sometimes are angered when they are not consulted about one of their patients in the ED or about a treatment or disposition plan with which they disagree, while EPs are frustrated by the number of phone calls required to reach some PCPs or a knowledgeable covering physician.
Only 2 months later, we expressed concerns about a New York Times opinion editorial describing a young patient whose vertebral artery dissection had been “diagnosed correctly and acted on in the ED,” but then angrily criticizing an initial recommendation that the patient curtail her physical activities based on what a famous neurologist considered an erroneously interpreted vascular imaging study. (Presumably, the recommendation was by another neurologist and the interpretation by a radiologist, but all of the neurologist’s caustic criticism was directed at the EP and ED.) Although the neurologist subsequently apologized in a letter to his emergency medicine colleagues for “being quoted out of context,” few if any
We concluded the second EM editorial with the suggestion that “all physicians must be very, very careful in framing statements to the media, and should assume that their remarks will not be placed ‘in context’ or nuanced as they may have been intended....Most important, is to not disparage entire specialties or use belittling terms such as ‘ER docs’....[that] heighten...patients’ fears” of being treated in EDs.
Why another editorial about physician-to-physician miscommunications and name-calling? Because patient care is significantly affected.
The Centers for Medicare and Medicaid Services originally classified four medical specialties as “primary care” for reimbursement purposes: family medicine, internal medicine, pediatrics, and obstetrics-gynecology, and the 2010 Affordable Care Act added geriatrics. Although emergency medicine had been considered initially, it has never been categorized as a primary care specialty. That being the case, isn’t it incumbent upon us to learn as much as we can from PCPs about their ill patients en route to the ED for treatment or admission, and afterward ensure that an ED visit is part of a continuum of patient care and not an isolated episode?
In 1996, when I accepted an offer to become New York Presbyterian-Weill Cornell’s first Emergency Physician-in-Chief, I created a new position of full-time “ED follow-up nurse practitioner” to track and report test results to discharged patients and their designated PCPs. When we added a fourth unit to the ED a few years later, I designated an experienced, senior attending EP among the four on duty as the “administrative attending” (AA) who, among other tasks, took all phone calls from PCPs about patients they were sending to the ED and entered the information in the “en route” section of our electronic tracking board. In this way, important patient information, including PCP contact information, was no longer misplaced during shift changes. The AA carried a direct-dial cell phone-like device and eventually all attending EPs and the charge nurse were equipped with such phones. In a short time, most of the communications problems and complaints about incoming patients were eliminated.
But despite numerous attempts, for the reasons mentioned above, systematically ensuring effective communications with PCPs for discharged patients has proven to be a more difficult task. At present, handing off discharged patients to PCPs still depends largely on a combination of judgment, understanding, compassion, and respect.
When to discontinue contact precautions for patients with MRSA
Methicillin-resistant Staphylococcus aureus (MRSA) is a common hospital-acquired infection with significant morbidity and mortality. The CDC currently recommends contact precautions as a mainstay to prevent transmission of MRSA in health care settings. Most hospitals routinely screen patients for MRSA and use contact precautions for those who screen positive. The duration of these precautions vary across hospitals and no standard recommendation exists.
A recent study of members of the Society for Healthcare Epidemiology of America (SHEA) research network indicated that the majority of physicians (94%) and nurses (76%) dislike contact precautions (CP) and most (63%) were in favor of implementing CP in a different way than current practice.1 Patients also report less satisfaction and increased isolation.1
My colleagues and I recently published a study2 in the American Journal of Infection Control to explore the necessary duration of contact precautions for hospitalized patients with MRSA. Our goal was to maintain contact precautions as long as necessary to prevent undesired MRSA infections and colonization but minimize unnecessary days in contact isolation. We also sought to figure out whether patients with positive MRSA surveillance cultures should always remain in isolation and, if not, at what point they could be considered for rescreening and removal of precautions if culture negative.
Our hospital has been performing active surveillance cultures weekly to screen for MRSA among our hospitalized patients for many years; however from 2010 to 2014, we began screening patients who were previously known to be positive for MRSA colonization or infection for at least 1 year. We then assessed medical and demographic factors associated with persistent carriage of MRSA.
In our study, more than 400 patients with known MRSA were rescreened with an active surveillance culture at a subsequent hospital admission. Ultimately 20% of the patients remained MRSA positive on the active surveillance culture. Most patients who were culture positive for MRSA were found on the first active surveillance culture (16.4%) but the remaining positive cultures were found on a second active surveillance culture or a clinical culture.
The amount of time that passed since the patient was culture positive was significantly associated with a lower risk of a positive culture at screening. This continued to drop over time with only 12.5% of patients remaining active surveillance culture positive for MRSA at 5 years after the original positive culture.
Two factors were found to significantly impact the MRSA culture on the multivariate analysis: (1) Female sex reduced the risk of positivity, and (2) Presence of a foreign body increased the risk of positivity.
Most patients who remained positive for an MRSA culture were found with the first active surveillance culture, less than 4% were detected subsequently with a repeat surveillance or clinical culture and this percentage also decreased over time. This indicates that in the absence of a positive active surveillance culture it may be reasonable to discontinue contact precautions, which could result in a substantial cost savings for the hospital and improved patient and provider satisfaction without increasing the risk of MRSA transmission.
We concluded that in the absence of a foreign body and with at least a year from the last known positive culture, patients with known MRSA should be rescreened and, if negative on an active surveillance culture, should be removed from contact precautions.
Lauren Richey, MD, MPH, is assistant professor in the infectious diseases division at the Medical University of South Carolina.
References
1. Morgan DJ, Diekema DJ, Sepkowitz K, Perencevich EN. Adverse outcomes associated with contact precautions: A review of the literature. Am J Infect Control. 2009 Mar;37(2):85-93. doi: 10.1016/j.ajic.2008.04.257.
2. Richey LE, Oh Y, Tchamba DM, Engle M, Formby L, Salgado CD. When should contact precautions be discontinued for patients with Methicillin-resistant Staphylococcus aureus? Am J Infect Control. 2016 Aug 30. doi: 10.1016/j.ajic.2016.05.030.
Methicillin-resistant Staphylococcus aureus (MRSA) is a common hospital-acquired infection with significant morbidity and mortality. The CDC currently recommends contact precautions as a mainstay to prevent transmission of MRSA in health care settings. Most hospitals routinely screen patients for MRSA and use contact precautions for those who screen positive. The duration of these precautions vary across hospitals and no standard recommendation exists.
A recent study of members of the Society for Healthcare Epidemiology of America (SHEA) research network indicated that the majority of physicians (94%) and nurses (76%) dislike contact precautions (CP) and most (63%) were in favor of implementing CP in a different way than current practice.1 Patients also report less satisfaction and increased isolation.1
My colleagues and I recently published a study2 in the American Journal of Infection Control to explore the necessary duration of contact precautions for hospitalized patients with MRSA. Our goal was to maintain contact precautions as long as necessary to prevent undesired MRSA infections and colonization but minimize unnecessary days in contact isolation. We also sought to figure out whether patients with positive MRSA surveillance cultures should always remain in isolation and, if not, at what point they could be considered for rescreening and removal of precautions if culture negative.
Our hospital has been performing active surveillance cultures weekly to screen for MRSA among our hospitalized patients for many years; however from 2010 to 2014, we began screening patients who were previously known to be positive for MRSA colonization or infection for at least 1 year. We then assessed medical and demographic factors associated with persistent carriage of MRSA.
In our study, more than 400 patients with known MRSA were rescreened with an active surveillance culture at a subsequent hospital admission. Ultimately 20% of the patients remained MRSA positive on the active surveillance culture. Most patients who were culture positive for MRSA were found on the first active surveillance culture (16.4%) but the remaining positive cultures were found on a second active surveillance culture or a clinical culture.
The amount of time that passed since the patient was culture positive was significantly associated with a lower risk of a positive culture at screening. This continued to drop over time with only 12.5% of patients remaining active surveillance culture positive for MRSA at 5 years after the original positive culture.
Two factors were found to significantly impact the MRSA culture on the multivariate analysis: (1) Female sex reduced the risk of positivity, and (2) Presence of a foreign body increased the risk of positivity.
Most patients who remained positive for an MRSA culture were found with the first active surveillance culture, less than 4% were detected subsequently with a repeat surveillance or clinical culture and this percentage also decreased over time. This indicates that in the absence of a positive active surveillance culture it may be reasonable to discontinue contact precautions, which could result in a substantial cost savings for the hospital and improved patient and provider satisfaction without increasing the risk of MRSA transmission.
We concluded that in the absence of a foreign body and with at least a year from the last known positive culture, patients with known MRSA should be rescreened and, if negative on an active surveillance culture, should be removed from contact precautions.
Lauren Richey, MD, MPH, is assistant professor in the infectious diseases division at the Medical University of South Carolina.
References
1. Morgan DJ, Diekema DJ, Sepkowitz K, Perencevich EN. Adverse outcomes associated with contact precautions: A review of the literature. Am J Infect Control. 2009 Mar;37(2):85-93. doi: 10.1016/j.ajic.2008.04.257.
2. Richey LE, Oh Y, Tchamba DM, Engle M, Formby L, Salgado CD. When should contact precautions be discontinued for patients with Methicillin-resistant Staphylococcus aureus? Am J Infect Control. 2016 Aug 30. doi: 10.1016/j.ajic.2016.05.030.
Methicillin-resistant Staphylococcus aureus (MRSA) is a common hospital-acquired infection with significant morbidity and mortality. The CDC currently recommends contact precautions as a mainstay to prevent transmission of MRSA in health care settings. Most hospitals routinely screen patients for MRSA and use contact precautions for those who screen positive. The duration of these precautions vary across hospitals and no standard recommendation exists.
A recent study of members of the Society for Healthcare Epidemiology of America (SHEA) research network indicated that the majority of physicians (94%) and nurses (76%) dislike contact precautions (CP) and most (63%) were in favor of implementing CP in a different way than current practice.1 Patients also report less satisfaction and increased isolation.1
My colleagues and I recently published a study2 in the American Journal of Infection Control to explore the necessary duration of contact precautions for hospitalized patients with MRSA. Our goal was to maintain contact precautions as long as necessary to prevent undesired MRSA infections and colonization but minimize unnecessary days in contact isolation. We also sought to figure out whether patients with positive MRSA surveillance cultures should always remain in isolation and, if not, at what point they could be considered for rescreening and removal of precautions if culture negative.
Our hospital has been performing active surveillance cultures weekly to screen for MRSA among our hospitalized patients for many years; however from 2010 to 2014, we began screening patients who were previously known to be positive for MRSA colonization or infection for at least 1 year. We then assessed medical and demographic factors associated with persistent carriage of MRSA.
In our study, more than 400 patients with known MRSA were rescreened with an active surveillance culture at a subsequent hospital admission. Ultimately 20% of the patients remained MRSA positive on the active surveillance culture. Most patients who were culture positive for MRSA were found on the first active surveillance culture (16.4%) but the remaining positive cultures were found on a second active surveillance culture or a clinical culture.
The amount of time that passed since the patient was culture positive was significantly associated with a lower risk of a positive culture at screening. This continued to drop over time with only 12.5% of patients remaining active surveillance culture positive for MRSA at 5 years after the original positive culture.
Two factors were found to significantly impact the MRSA culture on the multivariate analysis: (1) Female sex reduced the risk of positivity, and (2) Presence of a foreign body increased the risk of positivity.
Most patients who remained positive for an MRSA culture were found with the first active surveillance culture, less than 4% were detected subsequently with a repeat surveillance or clinical culture and this percentage also decreased over time. This indicates that in the absence of a positive active surveillance culture it may be reasonable to discontinue contact precautions, which could result in a substantial cost savings for the hospital and improved patient and provider satisfaction without increasing the risk of MRSA transmission.
We concluded that in the absence of a foreign body and with at least a year from the last known positive culture, patients with known MRSA should be rescreened and, if negative on an active surveillance culture, should be removed from contact precautions.
Lauren Richey, MD, MPH, is assistant professor in the infectious diseases division at the Medical University of South Carolina.
References
1. Morgan DJ, Diekema DJ, Sepkowitz K, Perencevich EN. Adverse outcomes associated with contact precautions: A review of the literature. Am J Infect Control. 2009 Mar;37(2):85-93. doi: 10.1016/j.ajic.2008.04.257.
2. Richey LE, Oh Y, Tchamba DM, Engle M, Formby L, Salgado CD. When should contact precautions be discontinued for patients with Methicillin-resistant Staphylococcus aureus? Am J Infect Control. 2016 Aug 30. doi: 10.1016/j.ajic.2016.05.030.
Alexa
How many calories are there in a cheeseburger? (Yes, I too am looking forward to a svelter 2017). The answer, according to my new assistant, is 300 calories. She knows the dose of acetaminophen for a 10-year-old, 65-pound child is 325 mg every 4-6 hours. She also plays George Michael, reorders my Dentyne Ice gum, and turns off the lights. She is Alexa of Amazon’s Echo, the intelligent personal assistant.
Echo and Google Home are popular voice-assisted home appliances. Amazon has built a natural language processing system, so to use it, you simply say, “Alexa,” pause, then ask your question (What’s the weather in New York?) or deliver your command (Play Spotify). It’s hands free, so you can interface while typing, reading, or cooking dinner.
Some medical centers, such as the Boston Children’s Hospital, are leading the way to make voice-assisted technology useful in health care. Their KidsMD app, for example, gives Alexa the “skill” to offer simple health advice regarding their children’s fever and medication dosing. I found this Alexa skill interesting but rudimentary. Most of the advice was reasonable; however, the scope is small and the responses glitchy. For example, when I asked Alexa what to do for a feverish 2-month-old, it advised me to contact my doctor then immediately followed this with recommended antipyretic medication dosing. Although we physicians understand the child must see a doctor, some parents might be confused and choose only to administer the medication. As with any new digital health technology, the team at Boston Children’s are continually iterating and improving based upon feedback.
I found Alexa currently has a few other skills for health care. For example, a skill called Marvee functions as a “care companion” to help aging family members and their caregivers. Another skill, Health Care Genius, helps patients decipher healthcare terminology by asking questions such as, “What is a deductible?”
The potential of voice-assisted technology in clinical and home health care settings is limitless, and I expect this segment to grow dramatically. Here are a few examples:
1. Physicians can ask for real-time help such as: What are treatment options for juvenile dermatomyositis? Order doxycycline 100 mg by mouth, twice daily, quantity sufficient 10 days.
2. Physicians might also use it to dictate notes intelligently, and even extract patient instructions directly from the notes to be emailed to the patient.
3. Surgeons could command an MRI to be viewed without having to scrub out.
4. Bedridden or chronically ill patients could use it to refill medications, make doctor appointments, or contact a caregiver in an emergency.
5. Patients could receive customized instructions, such as the answer to “How often do I change my surgical bandage?”
For all its potential, voice-assisted personal assistants have a long way to go. It would be a mistake to think these won’t be integrated into the entire health care chain from care to wellness, but it will be awhile before we get there.
Interestingly, when I asked my Apple Siri how many calories are in a cheeseburger, she reported 500, which is much more than Alexa’s 300. Which is why, for now, devices like Alexa are ideal for ordering a pizza hands free from your recliner. Just don’t ask how many calories are in it.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]. He has no disclosures related to this column.
How many calories are there in a cheeseburger? (Yes, I too am looking forward to a svelter 2017). The answer, according to my new assistant, is 300 calories. She knows the dose of acetaminophen for a 10-year-old, 65-pound child is 325 mg every 4-6 hours. She also plays George Michael, reorders my Dentyne Ice gum, and turns off the lights. She is Alexa of Amazon’s Echo, the intelligent personal assistant.
Echo and Google Home are popular voice-assisted home appliances. Amazon has built a natural language processing system, so to use it, you simply say, “Alexa,” pause, then ask your question (What’s the weather in New York?) or deliver your command (Play Spotify). It’s hands free, so you can interface while typing, reading, or cooking dinner.
Some medical centers, such as the Boston Children’s Hospital, are leading the way to make voice-assisted technology useful in health care. Their KidsMD app, for example, gives Alexa the “skill” to offer simple health advice regarding their children’s fever and medication dosing. I found this Alexa skill interesting but rudimentary. Most of the advice was reasonable; however, the scope is small and the responses glitchy. For example, when I asked Alexa what to do for a feverish 2-month-old, it advised me to contact my doctor then immediately followed this with recommended antipyretic medication dosing. Although we physicians understand the child must see a doctor, some parents might be confused and choose only to administer the medication. As with any new digital health technology, the team at Boston Children’s are continually iterating and improving based upon feedback.
I found Alexa currently has a few other skills for health care. For example, a skill called Marvee functions as a “care companion” to help aging family members and their caregivers. Another skill, Health Care Genius, helps patients decipher healthcare terminology by asking questions such as, “What is a deductible?”
The potential of voice-assisted technology in clinical and home health care settings is limitless, and I expect this segment to grow dramatically. Here are a few examples:
1. Physicians can ask for real-time help such as: What are treatment options for juvenile dermatomyositis? Order doxycycline 100 mg by mouth, twice daily, quantity sufficient 10 days.
2. Physicians might also use it to dictate notes intelligently, and even extract patient instructions directly from the notes to be emailed to the patient.
3. Surgeons could command an MRI to be viewed without having to scrub out.
4. Bedridden or chronically ill patients could use it to refill medications, make doctor appointments, or contact a caregiver in an emergency.
5. Patients could receive customized instructions, such as the answer to “How often do I change my surgical bandage?”
For all its potential, voice-assisted personal assistants have a long way to go. It would be a mistake to think these won’t be integrated into the entire health care chain from care to wellness, but it will be awhile before we get there.
Interestingly, when I asked my Apple Siri how many calories are in a cheeseburger, she reported 500, which is much more than Alexa’s 300. Which is why, for now, devices like Alexa are ideal for ordering a pizza hands free from your recliner. Just don’t ask how many calories are in it.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]. He has no disclosures related to this column.
How many calories are there in a cheeseburger? (Yes, I too am looking forward to a svelter 2017). The answer, according to my new assistant, is 300 calories. She knows the dose of acetaminophen for a 10-year-old, 65-pound child is 325 mg every 4-6 hours. She also plays George Michael, reorders my Dentyne Ice gum, and turns off the lights. She is Alexa of Amazon’s Echo, the intelligent personal assistant.
Echo and Google Home are popular voice-assisted home appliances. Amazon has built a natural language processing system, so to use it, you simply say, “Alexa,” pause, then ask your question (What’s the weather in New York?) or deliver your command (Play Spotify). It’s hands free, so you can interface while typing, reading, or cooking dinner.
Some medical centers, such as the Boston Children’s Hospital, are leading the way to make voice-assisted technology useful in health care. Their KidsMD app, for example, gives Alexa the “skill” to offer simple health advice regarding their children’s fever and medication dosing. I found this Alexa skill interesting but rudimentary. Most of the advice was reasonable; however, the scope is small and the responses glitchy. For example, when I asked Alexa what to do for a feverish 2-month-old, it advised me to contact my doctor then immediately followed this with recommended antipyretic medication dosing. Although we physicians understand the child must see a doctor, some parents might be confused and choose only to administer the medication. As with any new digital health technology, the team at Boston Children’s are continually iterating and improving based upon feedback.
I found Alexa currently has a few other skills for health care. For example, a skill called Marvee functions as a “care companion” to help aging family members and their caregivers. Another skill, Health Care Genius, helps patients decipher healthcare terminology by asking questions such as, “What is a deductible?”
The potential of voice-assisted technology in clinical and home health care settings is limitless, and I expect this segment to grow dramatically. Here are a few examples:
1. Physicians can ask for real-time help such as: What are treatment options for juvenile dermatomyositis? Order doxycycline 100 mg by mouth, twice daily, quantity sufficient 10 days.
2. Physicians might also use it to dictate notes intelligently, and even extract patient instructions directly from the notes to be emailed to the patient.
3. Surgeons could command an MRI to be viewed without having to scrub out.
4. Bedridden or chronically ill patients could use it to refill medications, make doctor appointments, or contact a caregiver in an emergency.
5. Patients could receive customized instructions, such as the answer to “How often do I change my surgical bandage?”
For all its potential, voice-assisted personal assistants have a long way to go. It would be a mistake to think these won’t be integrated into the entire health care chain from care to wellness, but it will be awhile before we get there.
Interestingly, when I asked my Apple Siri how many calories are in a cheeseburger, she reported 500, which is much more than Alexa’s 300. Which is why, for now, devices like Alexa are ideal for ordering a pizza hands free from your recliner. Just don’t ask how many calories are in it.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]. He has no disclosures related to this column.
What’s New for Federal Practitioner in 2017?
It has been a long time since a new year has brought as much uncertainty as 2017 promises to bring, making some federal employees excited and others apprehensive. Rumors abound of how the federal health care sector may change: Hiring freezes, manpower cuts, and privatization are all concerns of Federal Practitioner readers. As in the past, we will keep you up-to-date with in-depth interviews of leaders in federal health care, intelligent coverage of news stories impacting your practice, and clinical and research articles about new programs and initiatives.
Also this year, we are pleased to announce several new regular columns that we hope will inform and entertain you. The first is a column on mental health and traumatic brain injury in the DoD and the VA. We are privileged to have U.S. Army COL (Ret) Elspeth Cameron Ritchie, MD, MPH, edit this column. She is widely known and respected and brings her vast experience to the column as an active-duty psychiatrist coupled with her current position as a VA physician. Dr. Ritchie will author articles as well as edit those of her VA and DoD colleagues. Mental health touches almost every aspect of federal practice, and we all will learn our contributions and challenges in this rapidly moving specialty.
Whereas the mental health column looks toward the scientific future, the second column looks back to the humanistic past. We are thrilled that 2 physician-historians of military medicine, Robert Hierholzer, MD, a VA psychiatrist, and John Pierce, MD, a retired U.S. Army pediatrician share the writing and editing for this column, which will debut this spring.
Have you ever wondered who or how VA and military hospitals were named? These 2 historical writers have a wealth of interesting anecdotes and stories about VA and military medical centers. We hope you will enjoy reading the stories of military and veteran health care: the war heroes, devoted clinicians, and groundbreaking researchers who have left their mark on DoD and VA health care.
We also will be launching a new pilot study feature for clinicians and researchers who have a novel or valuable idea but have only a small number of participants or preliminary results. This will be a great way for new investigators, trainees, and young health care practitioners to present their work to the medical community.
These new editorial offerings are just a start—we also want to invite you, your colleagues, and learners to start your own new tradition of writing for Federal Practitioner. For those who have submitted articles in the past, please keep up the habit.We are eager to receive original research, review articles, and clinical cases from DoD, PHS, and VA mid-career and senior clinicians and researchers as well as articles describing innovative programs and modes of health care treatment and delivery. With a print circulation of more than 35,000 readers and very active online presence, consider Federal Practitioner for your next article!
This year my New Year’s resolution as editor-in-chief is to encourage readers to contact either Editor Reid Paul or me if you have an idea for an article you would like to write, a column you would like to see, or if you have an interest in serving as a peer reviewer or joining our Editorial Advisory Association. We want to hear from you about what you want and need from Federal Practitioner.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.
It has been a long time since a new year has brought as much uncertainty as 2017 promises to bring, making some federal employees excited and others apprehensive. Rumors abound of how the federal health care sector may change: Hiring freezes, manpower cuts, and privatization are all concerns of Federal Practitioner readers. As in the past, we will keep you up-to-date with in-depth interviews of leaders in federal health care, intelligent coverage of news stories impacting your practice, and clinical and research articles about new programs and initiatives.
Also this year, we are pleased to announce several new regular columns that we hope will inform and entertain you. The first is a column on mental health and traumatic brain injury in the DoD and the VA. We are privileged to have U.S. Army COL (Ret) Elspeth Cameron Ritchie, MD, MPH, edit this column. She is widely known and respected and brings her vast experience to the column as an active-duty psychiatrist coupled with her current position as a VA physician. Dr. Ritchie will author articles as well as edit those of her VA and DoD colleagues. Mental health touches almost every aspect of federal practice, and we all will learn our contributions and challenges in this rapidly moving specialty.
Whereas the mental health column looks toward the scientific future, the second column looks back to the humanistic past. We are thrilled that 2 physician-historians of military medicine, Robert Hierholzer, MD, a VA psychiatrist, and John Pierce, MD, a retired U.S. Army pediatrician share the writing and editing for this column, which will debut this spring.
Have you ever wondered who or how VA and military hospitals were named? These 2 historical writers have a wealth of interesting anecdotes and stories about VA and military medical centers. We hope you will enjoy reading the stories of military and veteran health care: the war heroes, devoted clinicians, and groundbreaking researchers who have left their mark on DoD and VA health care.
We also will be launching a new pilot study feature for clinicians and researchers who have a novel or valuable idea but have only a small number of participants or preliminary results. This will be a great way for new investigators, trainees, and young health care practitioners to present their work to the medical community.
These new editorial offerings are just a start—we also want to invite you, your colleagues, and learners to start your own new tradition of writing for Federal Practitioner. For those who have submitted articles in the past, please keep up the habit.We are eager to receive original research, review articles, and clinical cases from DoD, PHS, and VA mid-career and senior clinicians and researchers as well as articles describing innovative programs and modes of health care treatment and delivery. With a print circulation of more than 35,000 readers and very active online presence, consider Federal Practitioner for your next article!
This year my New Year’s resolution as editor-in-chief is to encourage readers to contact either Editor Reid Paul or me if you have an idea for an article you would like to write, a column you would like to see, or if you have an interest in serving as a peer reviewer or joining our Editorial Advisory Association. We want to hear from you about what you want and need from Federal Practitioner.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.
It has been a long time since a new year has brought as much uncertainty as 2017 promises to bring, making some federal employees excited and others apprehensive. Rumors abound of how the federal health care sector may change: Hiring freezes, manpower cuts, and privatization are all concerns of Federal Practitioner readers. As in the past, we will keep you up-to-date with in-depth interviews of leaders in federal health care, intelligent coverage of news stories impacting your practice, and clinical and research articles about new programs and initiatives.
Also this year, we are pleased to announce several new regular columns that we hope will inform and entertain you. The first is a column on mental health and traumatic brain injury in the DoD and the VA. We are privileged to have U.S. Army COL (Ret) Elspeth Cameron Ritchie, MD, MPH, edit this column. She is widely known and respected and brings her vast experience to the column as an active-duty psychiatrist coupled with her current position as a VA physician. Dr. Ritchie will author articles as well as edit those of her VA and DoD colleagues. Mental health touches almost every aspect of federal practice, and we all will learn our contributions and challenges in this rapidly moving specialty.
Whereas the mental health column looks toward the scientific future, the second column looks back to the humanistic past. We are thrilled that 2 physician-historians of military medicine, Robert Hierholzer, MD, a VA psychiatrist, and John Pierce, MD, a retired U.S. Army pediatrician share the writing and editing for this column, which will debut this spring.
Have you ever wondered who or how VA and military hospitals were named? These 2 historical writers have a wealth of interesting anecdotes and stories about VA and military medical centers. We hope you will enjoy reading the stories of military and veteran health care: the war heroes, devoted clinicians, and groundbreaking researchers who have left their mark on DoD and VA health care.
We also will be launching a new pilot study feature for clinicians and researchers who have a novel or valuable idea but have only a small number of participants or preliminary results. This will be a great way for new investigators, trainees, and young health care practitioners to present their work to the medical community.
These new editorial offerings are just a start—we also want to invite you, your colleagues, and learners to start your own new tradition of writing for Federal Practitioner. For those who have submitted articles in the past, please keep up the habit.We are eager to receive original research, review articles, and clinical cases from DoD, PHS, and VA mid-career and senior clinicians and researchers as well as articles describing innovative programs and modes of health care treatment and delivery. With a print circulation of more than 35,000 readers and very active online presence, consider Federal Practitioner for your next article!
This year my New Year’s resolution as editor-in-chief is to encourage readers to contact either Editor Reid Paul or me if you have an idea for an article you would like to write, a column you would like to see, or if you have an interest in serving as a peer reviewer or joining our Editorial Advisory Association. We want to hear from you about what you want and need from Federal Practitioner.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.
Personality disorders on the acute care unit
We all know these patients:
The young man who, when his name shows up on the ED board, everyone lets out a little groan, knowing his hospital stay will be long and tumultuous.
The middle-aged woman who seems to do want your care and attention and yet rebuffs your attempts to help her, meanwhile, making constant demands on nursing staff.
The older man who trusts no one and will not cooperate with any of his needed care, frustrating staff and physicians alike.
Caring for the patient is integral to the art of doctoring, and yet, there are some people for whom this is incredibly hard to do. They frustrate even the most seasoned professional and work their way under our skin. While their disruptive acts may feel volitional to those of us attempting to provide care, these individuals may suffer from a personality disorder.
In the hospital, a patient must to relate to, and cooperate with, a revolving team of care providers all while under some degree of physical and emotional distress. While this can be destabilizing for even the most resilient patient, for those with personality disorders, it is nearly inevitable that conflict will arise. In a recent article in the Journal of Hospital Medicine, my colleagues and I discussed the management of such patients, with a focus on evidence-based interventions (doi: 10.1002/jhm.2643).2
While the behaviors associated with personality disorders can feel deliberate and even manipulative, research shows that these disorders arise from a complex set of genetic and environmental factors. Alterations found in the serotonin system and regions of the brain involved in emotional reactivity and social processing suggest an underlying neurophysiology contributing to difficulties with interpersonal relationships seen in these disorders.3-9
Many do not realize that having a personality disorder has real implications for an individual’s healthcare outcomes; those with a personality disorder have a life expectancy nearly two decades shorter than the general population.10 While there are a number of factors that likely contribute to the effect on mortality, it has been suggested that dysfunctional personality structures may interfere with the individual’s ability to access and utilize care, resulting in higher morbidity and mortality.11
Although it can be difficult to make a formal diagnosis of a personality disorder on the acute care unit, we provide guideline for recognizing individuals based on the way in which they interact with others. Specifically, we propose a team should consider a personality disorder when the following features are present:
The patient elicits a strong emotional reaction from providers; these may vary markedly between providers
The patient’s emotional responses may appear disproportionate to the inciting event
The patient is on a number of different psychiatric medications with little relief of symptoms
The patient takes up an disproportionate amount of providers’ time
The patient externalizes blame, seeing others as the source of discomfort or distress and therefore sees others as the solution.2
When the team suspects a patient’s behavior may be driven by an underlying dysfunctional personality structure, there are a number of steps that can be taken to help facilitate care and shape behaviors. Key among these is recognizing our own complicated responses to these individuals. These patients evoke strong responses and no team member – from nurses and aides to residents and senior attendings – is immune.12-15
Reactions can range from a need to care for and protect the patient to feelings of futility or contempt.15 Other important behavioral interventions include providing consistency, reinforcing desired behaviors, offering empathy, and providing boundaries while also recognizing the importance of picking your battles.2 Of note, while medications may offer some help, there is limited evidence for use of pharmacological interventions. Although they may be somewhat helpful in addressing particular features of these disorders, such as impulsivity, affective dysregulation or cognitive-perceptual symptoms16, many of these patients end up on a cocktail of psychotropic medications with minimal evidence for their use or efficacy. Thus behavioral management remains the cornerstone of treatment.
While care of the patient with personality disorders can present unique challenges, it offers the opportunity for therapeutic intervention. By appreciating the underlying genetic and environmental factors, we are in a better position to offer empathy and support. For these patients, managing their personality disorder can be just as important as managing any of their other medical comorbidities. By taking an approach that acknowledges the emotional responses of the team while also reinforcing and facilitating positive behaviors of the patient, the hospital stay can prove therapeutic, helping these individuals to develop new skills while also getting their physical needs addressed.
Megan Riddle, MD, PhD, is based in the department of psychiatry and behavioral sciences at the University of Washington, Seattle.
NOTES
1. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA: American Psychiatric Association; 2013.
2. Riddle M, Meeks T, Alvarez C, Dubovsky A. When personality is the problem: Managing patients with difficult personalities on the acute care unit. J Hosp Med. 2016 Dec;11(12):873-878.
3. Bukh JD, Bock C, Kessing LV. Association between genetic polymorphisms in the serotonergic system and comorbid personality disorders among patients with first-episode depression. J Pers Disord. 2014 Jun;28(3):365-378.
4. Perez-Rodriguez MM, Weinstein S, New AS, et al. Tryptophan-hydroxylase 2 haplotype association with borderline personality disorder and aggression in a sample of patients with personality disorders and healthy controls. J Psychiatr Res. 2010 Nov; 44(15):1075-1081.
5. Checknita D, Maussion G, Labonte B, et al. Monoamine oxidase: A gene promoter methylation and transcriptional downregulation in an offender population with antisocial personality disorder. Br J Psychiatry. 2015 Mar;206(3):216-222.
6. Boen E, Westlye LT, Elvsashagen T, et al. Regional cortical thinning may be a biological marker for borderline personality disorder. Acta Psychiatr Scand. 2014 Sep;130(3):193-204.
7. Thoma P, Friedmann C, Suchan B. Empathy and social problem solving in alcohol dependence, mood disorders and selected personality disorders. Neurosci Biobehav Rev. 2013 Mar;37(3):448-470.
8. Liu H, Liao J, Jiang W, Wang W. Changes in low-frequency fluctuations in patients with antisocial personality disorder revealed by resting-state functional MRI. PLoS One. 2014 Mar 5;9(3):e89790.
9. Yang Y, Raine A. Prefrontal structural and functional brain imaging findings in antisocial, violent, and psychopathic individuals: A meta-analysis. Psychiatry Res. 2009 Nov 30;174(2):81-88.
10. Fok ML, Hayes RD, Chang CK, Stewart R, Callard FJ, Moran P. Life expectancy at birth and all-cause mortality among people with personality disorder. J Psychosom Res. 2012 Aug;73(2):104-107.
11. Tyrer P, Reed GM, Crawford MJ. Classification, assessment, prevalence, and effect of personality disorder. Lancet. 2015 Feb 21;385:717-726.
12. Groves JE. Taking care of the hateful patient. N Engl J Med. 1978 Apr 20; 298:883-887.
13. Groves JE. Management of the borderline patient on a medical or surgical ward: The psychiatric consultant’s role. Int J Psychiatry Med. 1975;6(3):337-348.
14. Bodner E, Cohen-Fridel S, Mashiah M, et al. The attitudes of psychiatric hospital staff toward hospitalization and treatment of patients with borderline personality disorder. BMC psychiatry. 2015 Jan 22;15:2.
15. Colli A, Tanzilli A, Dimaggio G, Lingiardi V. Patient personality and therapist response: An empirical investigation. Am J Psychiatry. 2014 Jan;171(1):102-108.
16. Ingenhoven T, Lafay P, Rinne T, Passchier J, Duivenvoorden H. Effectiveness of pharmacotherapy for severe personality disorders: Meta-analyses of randomized controlled trials. J Clin Psychiatry. 2010 Jan;71(1):14-25.
We all know these patients:
The young man who, when his name shows up on the ED board, everyone lets out a little groan, knowing his hospital stay will be long and tumultuous.
The middle-aged woman who seems to do want your care and attention and yet rebuffs your attempts to help her, meanwhile, making constant demands on nursing staff.
The older man who trusts no one and will not cooperate with any of his needed care, frustrating staff and physicians alike.
Caring for the patient is integral to the art of doctoring, and yet, there are some people for whom this is incredibly hard to do. They frustrate even the most seasoned professional and work their way under our skin. While their disruptive acts may feel volitional to those of us attempting to provide care, these individuals may suffer from a personality disorder.
In the hospital, a patient must to relate to, and cooperate with, a revolving team of care providers all while under some degree of physical and emotional distress. While this can be destabilizing for even the most resilient patient, for those with personality disorders, it is nearly inevitable that conflict will arise. In a recent article in the Journal of Hospital Medicine, my colleagues and I discussed the management of such patients, with a focus on evidence-based interventions (doi: 10.1002/jhm.2643).2
While the behaviors associated with personality disorders can feel deliberate and even manipulative, research shows that these disorders arise from a complex set of genetic and environmental factors. Alterations found in the serotonin system and regions of the brain involved in emotional reactivity and social processing suggest an underlying neurophysiology contributing to difficulties with interpersonal relationships seen in these disorders.3-9
Many do not realize that having a personality disorder has real implications for an individual’s healthcare outcomes; those with a personality disorder have a life expectancy nearly two decades shorter than the general population.10 While there are a number of factors that likely contribute to the effect on mortality, it has been suggested that dysfunctional personality structures may interfere with the individual’s ability to access and utilize care, resulting in higher morbidity and mortality.11
Although it can be difficult to make a formal diagnosis of a personality disorder on the acute care unit, we provide guideline for recognizing individuals based on the way in which they interact with others. Specifically, we propose a team should consider a personality disorder when the following features are present:
The patient elicits a strong emotional reaction from providers; these may vary markedly between providers
The patient’s emotional responses may appear disproportionate to the inciting event
The patient is on a number of different psychiatric medications with little relief of symptoms
The patient takes up an disproportionate amount of providers’ time
The patient externalizes blame, seeing others as the source of discomfort or distress and therefore sees others as the solution.2
When the team suspects a patient’s behavior may be driven by an underlying dysfunctional personality structure, there are a number of steps that can be taken to help facilitate care and shape behaviors. Key among these is recognizing our own complicated responses to these individuals. These patients evoke strong responses and no team member – from nurses and aides to residents and senior attendings – is immune.12-15
Reactions can range from a need to care for and protect the patient to feelings of futility or contempt.15 Other important behavioral interventions include providing consistency, reinforcing desired behaviors, offering empathy, and providing boundaries while also recognizing the importance of picking your battles.2 Of note, while medications may offer some help, there is limited evidence for use of pharmacological interventions. Although they may be somewhat helpful in addressing particular features of these disorders, such as impulsivity, affective dysregulation or cognitive-perceptual symptoms16, many of these patients end up on a cocktail of psychotropic medications with minimal evidence for their use or efficacy. Thus behavioral management remains the cornerstone of treatment.
While care of the patient with personality disorders can present unique challenges, it offers the opportunity for therapeutic intervention. By appreciating the underlying genetic and environmental factors, we are in a better position to offer empathy and support. For these patients, managing their personality disorder can be just as important as managing any of their other medical comorbidities. By taking an approach that acknowledges the emotional responses of the team while also reinforcing and facilitating positive behaviors of the patient, the hospital stay can prove therapeutic, helping these individuals to develop new skills while also getting their physical needs addressed.
Megan Riddle, MD, PhD, is based in the department of psychiatry and behavioral sciences at the University of Washington, Seattle.
NOTES
1. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA: American Psychiatric Association; 2013.
2. Riddle M, Meeks T, Alvarez C, Dubovsky A. When personality is the problem: Managing patients with difficult personalities on the acute care unit. J Hosp Med. 2016 Dec;11(12):873-878.
3. Bukh JD, Bock C, Kessing LV. Association between genetic polymorphisms in the serotonergic system and comorbid personality disorders among patients with first-episode depression. J Pers Disord. 2014 Jun;28(3):365-378.
4. Perez-Rodriguez MM, Weinstein S, New AS, et al. Tryptophan-hydroxylase 2 haplotype association with borderline personality disorder and aggression in a sample of patients with personality disorders and healthy controls. J Psychiatr Res. 2010 Nov; 44(15):1075-1081.
5. Checknita D, Maussion G, Labonte B, et al. Monoamine oxidase: A gene promoter methylation and transcriptional downregulation in an offender population with antisocial personality disorder. Br J Psychiatry. 2015 Mar;206(3):216-222.
6. Boen E, Westlye LT, Elvsashagen T, et al. Regional cortical thinning may be a biological marker for borderline personality disorder. Acta Psychiatr Scand. 2014 Sep;130(3):193-204.
7. Thoma P, Friedmann C, Suchan B. Empathy and social problem solving in alcohol dependence, mood disorders and selected personality disorders. Neurosci Biobehav Rev. 2013 Mar;37(3):448-470.
8. Liu H, Liao J, Jiang W, Wang W. Changes in low-frequency fluctuations in patients with antisocial personality disorder revealed by resting-state functional MRI. PLoS One. 2014 Mar 5;9(3):e89790.
9. Yang Y, Raine A. Prefrontal structural and functional brain imaging findings in antisocial, violent, and psychopathic individuals: A meta-analysis. Psychiatry Res. 2009 Nov 30;174(2):81-88.
10. Fok ML, Hayes RD, Chang CK, Stewart R, Callard FJ, Moran P. Life expectancy at birth and all-cause mortality among people with personality disorder. J Psychosom Res. 2012 Aug;73(2):104-107.
11. Tyrer P, Reed GM, Crawford MJ. Classification, assessment, prevalence, and effect of personality disorder. Lancet. 2015 Feb 21;385:717-726.
12. Groves JE. Taking care of the hateful patient. N Engl J Med. 1978 Apr 20; 298:883-887.
13. Groves JE. Management of the borderline patient on a medical or surgical ward: The psychiatric consultant’s role. Int J Psychiatry Med. 1975;6(3):337-348.
14. Bodner E, Cohen-Fridel S, Mashiah M, et al. The attitudes of psychiatric hospital staff toward hospitalization and treatment of patients with borderline personality disorder. BMC psychiatry. 2015 Jan 22;15:2.
15. Colli A, Tanzilli A, Dimaggio G, Lingiardi V. Patient personality and therapist response: An empirical investigation. Am J Psychiatry. 2014 Jan;171(1):102-108.
16. Ingenhoven T, Lafay P, Rinne T, Passchier J, Duivenvoorden H. Effectiveness of pharmacotherapy for severe personality disorders: Meta-analyses of randomized controlled trials. J Clin Psychiatry. 2010 Jan;71(1):14-25.
We all know these patients:
The young man who, when his name shows up on the ED board, everyone lets out a little groan, knowing his hospital stay will be long and tumultuous.
The middle-aged woman who seems to do want your care and attention and yet rebuffs your attempts to help her, meanwhile, making constant demands on nursing staff.
The older man who trusts no one and will not cooperate with any of his needed care, frustrating staff and physicians alike.
Caring for the patient is integral to the art of doctoring, and yet, there are some people for whom this is incredibly hard to do. They frustrate even the most seasoned professional and work their way under our skin. While their disruptive acts may feel volitional to those of us attempting to provide care, these individuals may suffer from a personality disorder.
In the hospital, a patient must to relate to, and cooperate with, a revolving team of care providers all while under some degree of physical and emotional distress. While this can be destabilizing for even the most resilient patient, for those with personality disorders, it is nearly inevitable that conflict will arise. In a recent article in the Journal of Hospital Medicine, my colleagues and I discussed the management of such patients, with a focus on evidence-based interventions (doi: 10.1002/jhm.2643).2
While the behaviors associated with personality disorders can feel deliberate and even manipulative, research shows that these disorders arise from a complex set of genetic and environmental factors. Alterations found in the serotonin system and regions of the brain involved in emotional reactivity and social processing suggest an underlying neurophysiology contributing to difficulties with interpersonal relationships seen in these disorders.3-9
Many do not realize that having a personality disorder has real implications for an individual’s healthcare outcomes; those with a personality disorder have a life expectancy nearly two decades shorter than the general population.10 While there are a number of factors that likely contribute to the effect on mortality, it has been suggested that dysfunctional personality structures may interfere with the individual’s ability to access and utilize care, resulting in higher morbidity and mortality.11
Although it can be difficult to make a formal diagnosis of a personality disorder on the acute care unit, we provide guideline for recognizing individuals based on the way in which they interact with others. Specifically, we propose a team should consider a personality disorder when the following features are present:
The patient elicits a strong emotional reaction from providers; these may vary markedly between providers
The patient’s emotional responses may appear disproportionate to the inciting event
The patient is on a number of different psychiatric medications with little relief of symptoms
The patient takes up an disproportionate amount of providers’ time
The patient externalizes blame, seeing others as the source of discomfort or distress and therefore sees others as the solution.2
When the team suspects a patient’s behavior may be driven by an underlying dysfunctional personality structure, there are a number of steps that can be taken to help facilitate care and shape behaviors. Key among these is recognizing our own complicated responses to these individuals. These patients evoke strong responses and no team member – from nurses and aides to residents and senior attendings – is immune.12-15
Reactions can range from a need to care for and protect the patient to feelings of futility or contempt.15 Other important behavioral interventions include providing consistency, reinforcing desired behaviors, offering empathy, and providing boundaries while also recognizing the importance of picking your battles.2 Of note, while medications may offer some help, there is limited evidence for use of pharmacological interventions. Although they may be somewhat helpful in addressing particular features of these disorders, such as impulsivity, affective dysregulation or cognitive-perceptual symptoms16, many of these patients end up on a cocktail of psychotropic medications with minimal evidence for their use or efficacy. Thus behavioral management remains the cornerstone of treatment.
While care of the patient with personality disorders can present unique challenges, it offers the opportunity for therapeutic intervention. By appreciating the underlying genetic and environmental factors, we are in a better position to offer empathy and support. For these patients, managing their personality disorder can be just as important as managing any of their other medical comorbidities. By taking an approach that acknowledges the emotional responses of the team while also reinforcing and facilitating positive behaviors of the patient, the hospital stay can prove therapeutic, helping these individuals to develop new skills while also getting their physical needs addressed.
Megan Riddle, MD, PhD, is based in the department of psychiatry and behavioral sciences at the University of Washington, Seattle.
NOTES
1. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA: American Psychiatric Association; 2013.
2. Riddle M, Meeks T, Alvarez C, Dubovsky A. When personality is the problem: Managing patients with difficult personalities on the acute care unit. J Hosp Med. 2016 Dec;11(12):873-878.
3. Bukh JD, Bock C, Kessing LV. Association between genetic polymorphisms in the serotonergic system and comorbid personality disorders among patients with first-episode depression. J Pers Disord. 2014 Jun;28(3):365-378.
4. Perez-Rodriguez MM, Weinstein S, New AS, et al. Tryptophan-hydroxylase 2 haplotype association with borderline personality disorder and aggression in a sample of patients with personality disorders and healthy controls. J Psychiatr Res. 2010 Nov; 44(15):1075-1081.
5. Checknita D, Maussion G, Labonte B, et al. Monoamine oxidase: A gene promoter methylation and transcriptional downregulation in an offender population with antisocial personality disorder. Br J Psychiatry. 2015 Mar;206(3):216-222.
6. Boen E, Westlye LT, Elvsashagen T, et al. Regional cortical thinning may be a biological marker for borderline personality disorder. Acta Psychiatr Scand. 2014 Sep;130(3):193-204.
7. Thoma P, Friedmann C, Suchan B. Empathy and social problem solving in alcohol dependence, mood disorders and selected personality disorders. Neurosci Biobehav Rev. 2013 Mar;37(3):448-470.
8. Liu H, Liao J, Jiang W, Wang W. Changes in low-frequency fluctuations in patients with antisocial personality disorder revealed by resting-state functional MRI. PLoS One. 2014 Mar 5;9(3):e89790.
9. Yang Y, Raine A. Prefrontal structural and functional brain imaging findings in antisocial, violent, and psychopathic individuals: A meta-analysis. Psychiatry Res. 2009 Nov 30;174(2):81-88.
10. Fok ML, Hayes RD, Chang CK, Stewart R, Callard FJ, Moran P. Life expectancy at birth and all-cause mortality among people with personality disorder. J Psychosom Res. 2012 Aug;73(2):104-107.
11. Tyrer P, Reed GM, Crawford MJ. Classification, assessment, prevalence, and effect of personality disorder. Lancet. 2015 Feb 21;385:717-726.
12. Groves JE. Taking care of the hateful patient. N Engl J Med. 1978 Apr 20; 298:883-887.
13. Groves JE. Management of the borderline patient on a medical or surgical ward: The psychiatric consultant’s role. Int J Psychiatry Med. 1975;6(3):337-348.
14. Bodner E, Cohen-Fridel S, Mashiah M, et al. The attitudes of psychiatric hospital staff toward hospitalization and treatment of patients with borderline personality disorder. BMC psychiatry. 2015 Jan 22;15:2.
15. Colli A, Tanzilli A, Dimaggio G, Lingiardi V. Patient personality and therapist response: An empirical investigation. Am J Psychiatry. 2014 Jan;171(1):102-108.
16. Ingenhoven T, Lafay P, Rinne T, Passchier J, Duivenvoorden H. Effectiveness of pharmacotherapy for severe personality disorders: Meta-analyses of randomized controlled trials. J Clin Psychiatry. 2010 Jan;71(1):14-25.
ACL injuries: Why are teen females at greater risk?
Over the last 2 decades, the number of teen females involved in competitive sports has skyrocketed. Research studies continue to show that girls involved in sports have better self-esteem and reduce the risk of obesity.But this involvement in competitive sports has not come without a cost. Recent studies have shown that females are four to six times more likely to tear their anterior cruciate ligament (ACL) than are their male counterparts playing the same sport.1,2 But why is this? And can it be prevented?
Researchers have spent countless hours studying videos to better determine why females are at greater risk. Their findings showed that there were many contributing factors for the difference between the sexes. The general mechanics that put the ACL at risk are landing on an extended knee, the center of mass being off the base, and internal rotation and adduction of the knee. These combined movements put the ACL at its most vulnerable position.
Hormones are another contributing factor. Estrogen and relaxin give strength and flexibility to the ligaments. But during surges of these hormones – such as during menses or a growth spurt – there is laxity within the ligament, putting it at further risk of injury.1 Testosterone increases muscle mass and strength. For males, this is protective because they rely less on their ligaments during jumping and deceleration. Puberty also contributes to the increased risk by accelerating the body mass index quickly over a short period, and therefore, greater strength is needed.1,3
Core strength, which helps with balance, is another contributing factor. Females tend to have lower core strength, which puts them at greater risk for rotational forces, especially when landing on one foot.1,4 As core strength improves, athletes can change direction more efficiently and hold their bodies upright on a single limb, which prevents the torsion that contributes to injury.
Prevention for ACL injuries occurs through very specific training in repetitive jumping and balance exercises are known as plyometric exercises. Neuromuscular training (NMT) includes plyometric training along with strengthening exercises such as lunges, squats, and plank exercises.4 One can reduce the risk of injury by 72% with 6-8 weeks of training by a professional experienced in NMT.5
Educating parents on the increased risk of injury to the ACL in females and importance of proper training can reduce injury and the risk of degenerative joint disease in later years.6 The Institute for Sports Medicine has a website that offers a knee injury prevention program you can refer families to for more information to prevent knee injuries. Sportsmetrics can help locate an NMT professional near them. Knowledge is power!
Reference
1. Pediatrics. 2014 May;133(5):e1437-50
2. Bull Hosp Jt Dis. 2000;59(4):217-26
3. Clin Biomech (Bristol, Avon). 2006 Dec;21(10):1060-6
4. Am J Phys Med Rehabil. 2005 Feb;84(2):122-30
5. Am J Sports Med. 2008 Aug;36(8):1476-83
6. Curr Womens Health Rep. 2001 Dec;1(3):218-24
Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at [email protected].
Over the last 2 decades, the number of teen females involved in competitive sports has skyrocketed. Research studies continue to show that girls involved in sports have better self-esteem and reduce the risk of obesity.But this involvement in competitive sports has not come without a cost. Recent studies have shown that females are four to six times more likely to tear their anterior cruciate ligament (ACL) than are their male counterparts playing the same sport.1,2 But why is this? And can it be prevented?
Researchers have spent countless hours studying videos to better determine why females are at greater risk. Their findings showed that there were many contributing factors for the difference between the sexes. The general mechanics that put the ACL at risk are landing on an extended knee, the center of mass being off the base, and internal rotation and adduction of the knee. These combined movements put the ACL at its most vulnerable position.
Hormones are another contributing factor. Estrogen and relaxin give strength and flexibility to the ligaments. But during surges of these hormones – such as during menses or a growth spurt – there is laxity within the ligament, putting it at further risk of injury.1 Testosterone increases muscle mass and strength. For males, this is protective because they rely less on their ligaments during jumping and deceleration. Puberty also contributes to the increased risk by accelerating the body mass index quickly over a short period, and therefore, greater strength is needed.1,3
Core strength, which helps with balance, is another contributing factor. Females tend to have lower core strength, which puts them at greater risk for rotational forces, especially when landing on one foot.1,4 As core strength improves, athletes can change direction more efficiently and hold their bodies upright on a single limb, which prevents the torsion that contributes to injury.
Prevention for ACL injuries occurs through very specific training in repetitive jumping and balance exercises are known as plyometric exercises. Neuromuscular training (NMT) includes plyometric training along with strengthening exercises such as lunges, squats, and plank exercises.4 One can reduce the risk of injury by 72% with 6-8 weeks of training by a professional experienced in NMT.5
Educating parents on the increased risk of injury to the ACL in females and importance of proper training can reduce injury and the risk of degenerative joint disease in later years.6 The Institute for Sports Medicine has a website that offers a knee injury prevention program you can refer families to for more information to prevent knee injuries. Sportsmetrics can help locate an NMT professional near them. Knowledge is power!
Reference
1. Pediatrics. 2014 May;133(5):e1437-50
2. Bull Hosp Jt Dis. 2000;59(4):217-26
3. Clin Biomech (Bristol, Avon). 2006 Dec;21(10):1060-6
4. Am J Phys Med Rehabil. 2005 Feb;84(2):122-30
5. Am J Sports Med. 2008 Aug;36(8):1476-83
6. Curr Womens Health Rep. 2001 Dec;1(3):218-24
Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at [email protected].
Over the last 2 decades, the number of teen females involved in competitive sports has skyrocketed. Research studies continue to show that girls involved in sports have better self-esteem and reduce the risk of obesity.But this involvement in competitive sports has not come without a cost. Recent studies have shown that females are four to six times more likely to tear their anterior cruciate ligament (ACL) than are their male counterparts playing the same sport.1,2 But why is this? And can it be prevented?
Researchers have spent countless hours studying videos to better determine why females are at greater risk. Their findings showed that there were many contributing factors for the difference between the sexes. The general mechanics that put the ACL at risk are landing on an extended knee, the center of mass being off the base, and internal rotation and adduction of the knee. These combined movements put the ACL at its most vulnerable position.
Hormones are another contributing factor. Estrogen and relaxin give strength and flexibility to the ligaments. But during surges of these hormones – such as during menses or a growth spurt – there is laxity within the ligament, putting it at further risk of injury.1 Testosterone increases muscle mass and strength. For males, this is protective because they rely less on their ligaments during jumping and deceleration. Puberty also contributes to the increased risk by accelerating the body mass index quickly over a short period, and therefore, greater strength is needed.1,3
Core strength, which helps with balance, is another contributing factor. Females tend to have lower core strength, which puts them at greater risk for rotational forces, especially when landing on one foot.1,4 As core strength improves, athletes can change direction more efficiently and hold their bodies upright on a single limb, which prevents the torsion that contributes to injury.
Prevention for ACL injuries occurs through very specific training in repetitive jumping and balance exercises are known as plyometric exercises. Neuromuscular training (NMT) includes plyometric training along with strengthening exercises such as lunges, squats, and plank exercises.4 One can reduce the risk of injury by 72% with 6-8 weeks of training by a professional experienced in NMT.5
Educating parents on the increased risk of injury to the ACL in females and importance of proper training can reduce injury and the risk of degenerative joint disease in later years.6 The Institute for Sports Medicine has a website that offers a knee injury prevention program you can refer families to for more information to prevent knee injuries. Sportsmetrics can help locate an NMT professional near them. Knowledge is power!
Reference
1. Pediatrics. 2014 May;133(5):e1437-50
2. Bull Hosp Jt Dis. 2000;59(4):217-26
3. Clin Biomech (Bristol, Avon). 2006 Dec;21(10):1060-6
4. Am J Phys Med Rehabil. 2005 Feb;84(2):122-30
5. Am J Sports Med. 2008 Aug;36(8):1476-83
6. Curr Womens Health Rep. 2001 Dec;1(3):218-24
Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at [email protected].