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Estate planning
The latest anniversary of my birth recently passed; I am now a provider and a beneficiary in the Medicare system. Fortunately, I have learned to celebrate these annual events, and the changes they bring, rather than dread them. I now appreciate that life gets better as we get older, on all levels – except, perhaps, the physical.
But I have also learned that birthdays are a good time to pause and consider the various financial arrangements that I’ve set up over the years, and to determine whether any of them need updating.
Estate plans, in particular, need regular review and revision. Nothing important has changed in your life since you drafted your will, you say? Well, chances are the laws have changed, or other factors may have rendered your plan obsolete without your even realizing it.
I am assuming, of course, that you have in fact drafted a will. If not – regardless of your age – do it as soon as possible. Stuff happens; if you die without a will (“intestate,” in lawyer lingo), your heirs will be at the mercy of attorneys, bureaucrats, state and federal laws, and greed. Quarrels will ensue; decisions will be made that are almost certainly at variance with what you would have wanted; and a substantial chunk of your estate that could have gone to loved ones, or to charity, will be lost to taxes and legal fees.
In other words, if you don’t write a will, others will write one for you – one your heirs probably won’t like. Don’t let that happen. That said, let’s consider some variables that mandate your constant vigilance:
Laws change. Trust laws, in particular, have changed a great deal in recent years, and trust strategies have changed with them. New instruments such as perpetual trusts, trust protectors, directed trusts, and total return trusts may or may not work to your advantage, but you won’t know without asking. State laws change too.
Once a year, my wife and I meet with our estate lawyer to learn about any new legislation that may have affected our plan. A few years ago, for example, I learned that my irrevocable trust was no longer irrevocable; new laws now permit certain provisions to be modified.
Laws that don’t directly regulate wills and trusts can impact your plan as well. For instance, the ever-popular Health Insurance Portability and Accountability Act (HIPAA) applies to your estate as well as your practice; under its provisions, your family cannot access your medical information or make treatment and life-support decisions without your specific permission. So if a Health Care Power of Attorney is not already part of your will, add it. And remember to modify it if your medical status, or your philosophy of life, changes.
Financial markets change. It’s not exactly a secret that asset values and interest rates are considerably different than they were even a few years ago. Real estate or securities bequests could now be significantly larger or smaller. Your accountant and estate lawyer should take a look at your assets periodically, and their apportionment in your will, to be sure all arrangements remain as you intend. And be sure to notify them whenever the composition of your assets changes, even if their value doesn’t. Say, for example, you sell a business or property, and reinvest the proceeds in something completely different; a different set of tax laws will apply, and your will must reflect that.
Fiduciaries change. Keep track of the executor of your estate and the trustee(s) of your trust(s), and be prepared to make changes if needed. If your brother-in-law is your executor, and your sister divorces him, you may want to name a new executor. A once-vigorous trustee who is now old or sick should be replaced. Trustees are often financial institutions; if a corporate trustee goes belly up, or the employee you were working with leaves or retires, you’ll need a replacement.
Personal circumstances change. Some changes – marriage, divorce, the death of an heir, or the birth of a new one – obviously require modifications to wills and trusts. But any significant alteration of your personal or financial circumstances probably merits a phone call to your financial planners. The need for changes, and your options, are not always obvious.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
The latest anniversary of my birth recently passed; I am now a provider and a beneficiary in the Medicare system. Fortunately, I have learned to celebrate these annual events, and the changes they bring, rather than dread them. I now appreciate that life gets better as we get older, on all levels – except, perhaps, the physical.
But I have also learned that birthdays are a good time to pause and consider the various financial arrangements that I’ve set up over the years, and to determine whether any of them need updating.
Estate plans, in particular, need regular review and revision. Nothing important has changed in your life since you drafted your will, you say? Well, chances are the laws have changed, or other factors may have rendered your plan obsolete without your even realizing it.
I am assuming, of course, that you have in fact drafted a will. If not – regardless of your age – do it as soon as possible. Stuff happens; if you die without a will (“intestate,” in lawyer lingo), your heirs will be at the mercy of attorneys, bureaucrats, state and federal laws, and greed. Quarrels will ensue; decisions will be made that are almost certainly at variance with what you would have wanted; and a substantial chunk of your estate that could have gone to loved ones, or to charity, will be lost to taxes and legal fees.
In other words, if you don’t write a will, others will write one for you – one your heirs probably won’t like. Don’t let that happen. That said, let’s consider some variables that mandate your constant vigilance:
Laws change. Trust laws, in particular, have changed a great deal in recent years, and trust strategies have changed with them. New instruments such as perpetual trusts, trust protectors, directed trusts, and total return trusts may or may not work to your advantage, but you won’t know without asking. State laws change too.
Once a year, my wife and I meet with our estate lawyer to learn about any new legislation that may have affected our plan. A few years ago, for example, I learned that my irrevocable trust was no longer irrevocable; new laws now permit certain provisions to be modified.
Laws that don’t directly regulate wills and trusts can impact your plan as well. For instance, the ever-popular Health Insurance Portability and Accountability Act (HIPAA) applies to your estate as well as your practice; under its provisions, your family cannot access your medical information or make treatment and life-support decisions without your specific permission. So if a Health Care Power of Attorney is not already part of your will, add it. And remember to modify it if your medical status, or your philosophy of life, changes.
Financial markets change. It’s not exactly a secret that asset values and interest rates are considerably different than they were even a few years ago. Real estate or securities bequests could now be significantly larger or smaller. Your accountant and estate lawyer should take a look at your assets periodically, and their apportionment in your will, to be sure all arrangements remain as you intend. And be sure to notify them whenever the composition of your assets changes, even if their value doesn’t. Say, for example, you sell a business or property, and reinvest the proceeds in something completely different; a different set of tax laws will apply, and your will must reflect that.
Fiduciaries change. Keep track of the executor of your estate and the trustee(s) of your trust(s), and be prepared to make changes if needed. If your brother-in-law is your executor, and your sister divorces him, you may want to name a new executor. A once-vigorous trustee who is now old or sick should be replaced. Trustees are often financial institutions; if a corporate trustee goes belly up, or the employee you were working with leaves or retires, you’ll need a replacement.
Personal circumstances change. Some changes – marriage, divorce, the death of an heir, or the birth of a new one – obviously require modifications to wills and trusts. But any significant alteration of your personal or financial circumstances probably merits a phone call to your financial planners. The need for changes, and your options, are not always obvious.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
The latest anniversary of my birth recently passed; I am now a provider and a beneficiary in the Medicare system. Fortunately, I have learned to celebrate these annual events, and the changes they bring, rather than dread them. I now appreciate that life gets better as we get older, on all levels – except, perhaps, the physical.
But I have also learned that birthdays are a good time to pause and consider the various financial arrangements that I’ve set up over the years, and to determine whether any of them need updating.
Estate plans, in particular, need regular review and revision. Nothing important has changed in your life since you drafted your will, you say? Well, chances are the laws have changed, or other factors may have rendered your plan obsolete without your even realizing it.
I am assuming, of course, that you have in fact drafted a will. If not – regardless of your age – do it as soon as possible. Stuff happens; if you die without a will (“intestate,” in lawyer lingo), your heirs will be at the mercy of attorneys, bureaucrats, state and federal laws, and greed. Quarrels will ensue; decisions will be made that are almost certainly at variance with what you would have wanted; and a substantial chunk of your estate that could have gone to loved ones, or to charity, will be lost to taxes and legal fees.
In other words, if you don’t write a will, others will write one for you – one your heirs probably won’t like. Don’t let that happen. That said, let’s consider some variables that mandate your constant vigilance:
Laws change. Trust laws, in particular, have changed a great deal in recent years, and trust strategies have changed with them. New instruments such as perpetual trusts, trust protectors, directed trusts, and total return trusts may or may not work to your advantage, but you won’t know without asking. State laws change too.
Once a year, my wife and I meet with our estate lawyer to learn about any new legislation that may have affected our plan. A few years ago, for example, I learned that my irrevocable trust was no longer irrevocable; new laws now permit certain provisions to be modified.
Laws that don’t directly regulate wills and trusts can impact your plan as well. For instance, the ever-popular Health Insurance Portability and Accountability Act (HIPAA) applies to your estate as well as your practice; under its provisions, your family cannot access your medical information or make treatment and life-support decisions without your specific permission. So if a Health Care Power of Attorney is not already part of your will, add it. And remember to modify it if your medical status, or your philosophy of life, changes.
Financial markets change. It’s not exactly a secret that asset values and interest rates are considerably different than they were even a few years ago. Real estate or securities bequests could now be significantly larger or smaller. Your accountant and estate lawyer should take a look at your assets periodically, and their apportionment in your will, to be sure all arrangements remain as you intend. And be sure to notify them whenever the composition of your assets changes, even if their value doesn’t. Say, for example, you sell a business or property, and reinvest the proceeds in something completely different; a different set of tax laws will apply, and your will must reflect that.
Fiduciaries change. Keep track of the executor of your estate and the trustee(s) of your trust(s), and be prepared to make changes if needed. If your brother-in-law is your executor, and your sister divorces him, you may want to name a new executor. A once-vigorous trustee who is now old or sick should be replaced. Trustees are often financial institutions; if a corporate trustee goes belly up, or the employee you were working with leaves or retires, you’ll need a replacement.
Personal circumstances change. Some changes – marriage, divorce, the death of an heir, or the birth of a new one – obviously require modifications to wills and trusts. But any significant alteration of your personal or financial circumstances probably merits a phone call to your financial planners. The need for changes, and your options, are not always obvious.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
The PERT Movement – Vascular surgeons must answer the call
Pulmonary embolism (PE) is the third most common cause of cardiovascular death in the United States and remains the most common preventable cause of in-hospital death. One might think that, in 2017, such a life-threatening cardiovascular emergency would be managed by guideline-driven care based upon robust evidence gathered through clinical trials and large observational studies. Yet, unlike stroke and myocardial infarction (STEMI), a true consensus for best management of acute PE has not been reached.
Management of PE has received increasing attention recently at major cardiovascular meetings such as VEITH, TCT, and national and regional societies. This excitement has been driven by recent trial data demonstrating that right ventricular failure with an acute PE is associated with poor outcomes and rapid clot debulking can reduce mortality not only in patients with high risk (massive) PE but even in intermediate risk (submassive) PE.
Systemic thrombolysis has been the standard of care for higher risk PEs but multiple contraindications and high complication rates shifted care toward catheter interventions assumed to have a safer profile. The huge gap of past decades between therapeutic anticoagulation alone versus systemic thrombolysis or surgical pulmonary embolectomy has been filled with an array of catheter-based techniques. Contemporary management of intermediate and high-risk PE employs thrombolytic infusion catheters at the clot site with or without ultrasound technology, mechanical fragmentation, and aspiration/suction thrombectomy devices. These techniques may lack robust evidence supporting them, still their use has been exponentially growing over the past 2 years. Yet, there is no clear consensus guiding management. Who needs to be treated? What’s the best technique for any given patient? What are the therapeutic endpoints? A myriad of questions remain to be answered.
Uncertainty about best management for an individual patient with acute PE stimulated formation of a multidisciplinary, collaborative approach beginning in 2012 at Massachusetts General Hospital in Boston.
This approach, led by Kenneth Rosenfield, MD, involved the formal development of a call team of various specialists who would be rapidly activated to develop a care plan for any patient with acute PE. The term “Pulmonary Embolism Response Team” (PERT) was coined by MGH pulmonologist Richard Channick, MD, and since then, the PERT approach has been adopted by more than 100 centers across the United States and internationally.
Rapid communication between frontline physicians who diagnose PE and those who can offer definitive management is the hallmark of the PERT approach. PERTs at both Piedmont Atlanta Hospital (care plan shown below) and the University of Pittsburgh Medical Center (UPMC) function similarly. Patients are triaged by a critical care pulmonologist. For those with massive PE (hemodynamically unstable), the emergency call center establishes a cellular link between the bedside emergency physician, triaging critical care pulmonologist, the PE interventionalist, cardiothoracic surgeon, and ECMO team. CTAs may be viewed electronically, management plans initiated, and teams rapidly mobilized. For patients with submassive PE, the triaging critical care pulmonologist initiates management discussion with the “PE interventionalist” on call. Patient presentation, physiologic data, biomarkers, and preexisting comorbidities are discussed. CTAs are viewed. Multiple treatment plans are considered from traditional medical management to catheter-based techniques for more peripheral emboli to surgical pulmonary embolectomy for centrally located thrombus. Treatment plans are influenced by factors such as patient age and comorbidity and are collaboratively tailored to each individual patient.
Management decisions for acute PE are driven by risk stratification. Most patients who present with PE are considered “low risk” for PE-related death and are managed with therapeutic anticoagulation. Five percent of patients present with massive PE characterized by shock and are at “high-risk” for PE-related death. These patients require intervention. Up to 40% of patients present with submassive PE. These patients are hemodynamically stable (not hypotensive) but have evidence on CTA or echocardiogram for right ventricular dysfunction and are at “intermediate risk” for PE-related death. This group is further stratified as intermediate low-risk vs. intermediate high-risk by biomarkers that indicate myocardial damage, primarily troponin and BNP. In this intermediate-risk or submassive group, intervention is more commonly offered to those patients stratified as intermediate “high-risk.”
Significant variability in the management of both massive and submassive PE patients beyond therapeutic anticoagulation, e.g., upon whom to offer intervention and how, is the point where a PERT may have greatest impact. Rapid, collaborative decision making between physicians/surgeons from multiple specialties offers hope for minimizing morbidity and achievement of best outcome.
Who is the “Pulmonary Interventionalist” and where does the contemporarily-trained vascular surgeon with catheter and critical-care skills fit into this new paradigm? The answer to this question depends on each individual institution.
At the University of Pittsburgh Medical Center and Piedmont Heart and Vascular Institute at Piedmont Atlanta Hospital, catheter-based intervention programs for PE were initiated by vascular surgeons. As their interest developed over time, interventional cardiologists joined th “PE Interventional” call as full participants in the PERT programs.
PE interventions at other institutions such as Emory Midtown Medical Center in Atlanta have been driven by interventional cardiology in partnership with cardiothoracic surgery. Still, at others, such as Miami Heart and Vascular Institute, vascular and interventional radiology has led the charge. PE intervention, not owned by any single specialty, has been taken on by those groups interested in answering the call. In the case of the two programs that we represent, it was our established involvement in major venous interventions that followed a natural progression to PE intervention.
Management of PE may be challenging. Multidisciplinary collaboration is key. Recognition of the importance of collaboration in moving the field forward (and saving lives) led Dr. Rosenfield and others to host the first PERT Consortium Meeting in Boston 2015. This clarion call was answered by 80 individuals representing 40 institutions.
In 2016, the PERT Consortium was incorporated, and in June 2016, more than 140 people from nearly 80 institutions attended the second annual meeting. We attended the meeting last June, and with concern we noted only a few vascular surgeons representing other institutions. A participant survey, later published in a letter in CHEST (December 2016), suggested little involvement of vascular surgeons in PERT programs. Was this an artifact based on a survey of “those registered in the PERT mailing list” or does this represent the true interest of vascular surgeons in managing PE in this country? Whether the meeting survey accurately reflects the current involvement of vascular surgeons in the care of PE or not, one thing is certain: Vascular surgical visibility, as a specialty, in PE is poor.
Failure to be involved in the PERT movement deprives patients of the experience of vascular surgeons and potentially threatens the venous intervention practice of nonparticipating surgeons. Forty percent or more of cases of iliofemoral venous thrombosis have associated PE. Vena cava thrombosis may present with PE. Inferior vena cava tumors such as leiomyomatosis may be mistaken for PE. It is foreseeable that PERT activation will represent the gateway to care for many of these patients, who may in turn receive their care from others new to the management of venous and VTE disease.
Participation in a collaborative decision among colleagues about the best way to treat an individual patient is a gratifying experience. When the treatment fits, relieving the struggle of a patient with an acute PE through catheter-directed thrombus dissolution and debulking represents an opportunity to save productive lives using techniques that lie within the skill set of the contemporarily trained vascular surgeon. A save in the case of a challenging PE can be every bit as rewarding as successful management of a ruptured aneurysm.
Even in metropolitan regions, patients with acute PE are underserved because specialized care is frequently unavailable or PE programs nonexistent. In communities and hospitals where vascular surgeons represent the lead interventionalists, involvement in this field might even be considered a solemn responsibility.
Vascular surgeons such as Peter Lin, MD, previously at the University of Texas in Houston, and the group led by Rabih Chaer, MD, at UPMC, have advanced the science of PE intervention over the past 7 years. It is time for more vascular surgeons to enter the field and embrace pulmonary interventions. To achieve this, we need to embrace collaboration with pulmonary and critical care as well as emergency medicine since these are the main referral specialties. We need to promote initiatives participating in our local PERTs or bringing specialists together to start one where nonexistent. There is no reason for exclusivity, and collaboration with other interventionalists is essential for smooth interspecialty relations, multidisciplinary approaches, and optimal outcomes.
Academic and large community vascular centers need to include the vascular surgeons’ role in their descriptions of their PERTs. Toward this direction the vascular division of UPMC is consistently presenting and publishing results and outcomes of PE catheter interventions; very recently a randomized trial (SUNSET sPE) comparing lysis outcomes with and without ultrasound acceleration has been launched by the UPMC PERT, led and coordinated by vascular surgeons, and has already stimulated national interest. Vascular surgeons at Piedmont Heart and Vascular Institute are participating in national clinical trials (OPTALYSE) and actively collaborating with other PERT programs to advance the management of acute PE in Georgia and the southeast. Both UPMC and Piedmont Heart and Vascular Institute are founding institutional members of the PERT Consortium.
The third annual meeting of the PERT Consortium will occur in Boston in June 2017. Vascular surgeons who attend will assuredly be welcome. Answer the call.
Charles B. Ross, MD, is chief, Vascular and Endovascular Services, Piedmont Heart Institute, Atlanta. Efthymios Avgerinos, MD, is associate professor of surgery, Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center. They had no relevant disclosures.
Pulmonary embolism (PE) is the third most common cause of cardiovascular death in the United States and remains the most common preventable cause of in-hospital death. One might think that, in 2017, such a life-threatening cardiovascular emergency would be managed by guideline-driven care based upon robust evidence gathered through clinical trials and large observational studies. Yet, unlike stroke and myocardial infarction (STEMI), a true consensus for best management of acute PE has not been reached.
Management of PE has received increasing attention recently at major cardiovascular meetings such as VEITH, TCT, and national and regional societies. This excitement has been driven by recent trial data demonstrating that right ventricular failure with an acute PE is associated with poor outcomes and rapid clot debulking can reduce mortality not only in patients with high risk (massive) PE but even in intermediate risk (submassive) PE.
Systemic thrombolysis has been the standard of care for higher risk PEs but multiple contraindications and high complication rates shifted care toward catheter interventions assumed to have a safer profile. The huge gap of past decades between therapeutic anticoagulation alone versus systemic thrombolysis or surgical pulmonary embolectomy has been filled with an array of catheter-based techniques. Contemporary management of intermediate and high-risk PE employs thrombolytic infusion catheters at the clot site with or without ultrasound technology, mechanical fragmentation, and aspiration/suction thrombectomy devices. These techniques may lack robust evidence supporting them, still their use has been exponentially growing over the past 2 years. Yet, there is no clear consensus guiding management. Who needs to be treated? What’s the best technique for any given patient? What are the therapeutic endpoints? A myriad of questions remain to be answered.
Uncertainty about best management for an individual patient with acute PE stimulated formation of a multidisciplinary, collaborative approach beginning in 2012 at Massachusetts General Hospital in Boston.
This approach, led by Kenneth Rosenfield, MD, involved the formal development of a call team of various specialists who would be rapidly activated to develop a care plan for any patient with acute PE. The term “Pulmonary Embolism Response Team” (PERT) was coined by MGH pulmonologist Richard Channick, MD, and since then, the PERT approach has been adopted by more than 100 centers across the United States and internationally.
Rapid communication between frontline physicians who diagnose PE and those who can offer definitive management is the hallmark of the PERT approach. PERTs at both Piedmont Atlanta Hospital (care plan shown below) and the University of Pittsburgh Medical Center (UPMC) function similarly. Patients are triaged by a critical care pulmonologist. For those with massive PE (hemodynamically unstable), the emergency call center establishes a cellular link between the bedside emergency physician, triaging critical care pulmonologist, the PE interventionalist, cardiothoracic surgeon, and ECMO team. CTAs may be viewed electronically, management plans initiated, and teams rapidly mobilized. For patients with submassive PE, the triaging critical care pulmonologist initiates management discussion with the “PE interventionalist” on call. Patient presentation, physiologic data, biomarkers, and preexisting comorbidities are discussed. CTAs are viewed. Multiple treatment plans are considered from traditional medical management to catheter-based techniques for more peripheral emboli to surgical pulmonary embolectomy for centrally located thrombus. Treatment plans are influenced by factors such as patient age and comorbidity and are collaboratively tailored to each individual patient.
Management decisions for acute PE are driven by risk stratification. Most patients who present with PE are considered “low risk” for PE-related death and are managed with therapeutic anticoagulation. Five percent of patients present with massive PE characterized by shock and are at “high-risk” for PE-related death. These patients require intervention. Up to 40% of patients present with submassive PE. These patients are hemodynamically stable (not hypotensive) but have evidence on CTA or echocardiogram for right ventricular dysfunction and are at “intermediate risk” for PE-related death. This group is further stratified as intermediate low-risk vs. intermediate high-risk by biomarkers that indicate myocardial damage, primarily troponin and BNP. In this intermediate-risk or submassive group, intervention is more commonly offered to those patients stratified as intermediate “high-risk.”
Significant variability in the management of both massive and submassive PE patients beyond therapeutic anticoagulation, e.g., upon whom to offer intervention and how, is the point where a PERT may have greatest impact. Rapid, collaborative decision making between physicians/surgeons from multiple specialties offers hope for minimizing morbidity and achievement of best outcome.
Who is the “Pulmonary Interventionalist” and where does the contemporarily-trained vascular surgeon with catheter and critical-care skills fit into this new paradigm? The answer to this question depends on each individual institution.
At the University of Pittsburgh Medical Center and Piedmont Heart and Vascular Institute at Piedmont Atlanta Hospital, catheter-based intervention programs for PE were initiated by vascular surgeons. As their interest developed over time, interventional cardiologists joined th “PE Interventional” call as full participants in the PERT programs.
PE interventions at other institutions such as Emory Midtown Medical Center in Atlanta have been driven by interventional cardiology in partnership with cardiothoracic surgery. Still, at others, such as Miami Heart and Vascular Institute, vascular and interventional radiology has led the charge. PE intervention, not owned by any single specialty, has been taken on by those groups interested in answering the call. In the case of the two programs that we represent, it was our established involvement in major venous interventions that followed a natural progression to PE intervention.
Management of PE may be challenging. Multidisciplinary collaboration is key. Recognition of the importance of collaboration in moving the field forward (and saving lives) led Dr. Rosenfield and others to host the first PERT Consortium Meeting in Boston 2015. This clarion call was answered by 80 individuals representing 40 institutions.
In 2016, the PERT Consortium was incorporated, and in June 2016, more than 140 people from nearly 80 institutions attended the second annual meeting. We attended the meeting last June, and with concern we noted only a few vascular surgeons representing other institutions. A participant survey, later published in a letter in CHEST (December 2016), suggested little involvement of vascular surgeons in PERT programs. Was this an artifact based on a survey of “those registered in the PERT mailing list” or does this represent the true interest of vascular surgeons in managing PE in this country? Whether the meeting survey accurately reflects the current involvement of vascular surgeons in the care of PE or not, one thing is certain: Vascular surgical visibility, as a specialty, in PE is poor.
Failure to be involved in the PERT movement deprives patients of the experience of vascular surgeons and potentially threatens the venous intervention practice of nonparticipating surgeons. Forty percent or more of cases of iliofemoral venous thrombosis have associated PE. Vena cava thrombosis may present with PE. Inferior vena cava tumors such as leiomyomatosis may be mistaken for PE. It is foreseeable that PERT activation will represent the gateway to care for many of these patients, who may in turn receive their care from others new to the management of venous and VTE disease.
Participation in a collaborative decision among colleagues about the best way to treat an individual patient is a gratifying experience. When the treatment fits, relieving the struggle of a patient with an acute PE through catheter-directed thrombus dissolution and debulking represents an opportunity to save productive lives using techniques that lie within the skill set of the contemporarily trained vascular surgeon. A save in the case of a challenging PE can be every bit as rewarding as successful management of a ruptured aneurysm.
Even in metropolitan regions, patients with acute PE are underserved because specialized care is frequently unavailable or PE programs nonexistent. In communities and hospitals where vascular surgeons represent the lead interventionalists, involvement in this field might even be considered a solemn responsibility.
Vascular surgeons such as Peter Lin, MD, previously at the University of Texas in Houston, and the group led by Rabih Chaer, MD, at UPMC, have advanced the science of PE intervention over the past 7 years. It is time for more vascular surgeons to enter the field and embrace pulmonary interventions. To achieve this, we need to embrace collaboration with pulmonary and critical care as well as emergency medicine since these are the main referral specialties. We need to promote initiatives participating in our local PERTs or bringing specialists together to start one where nonexistent. There is no reason for exclusivity, and collaboration with other interventionalists is essential for smooth interspecialty relations, multidisciplinary approaches, and optimal outcomes.
Academic and large community vascular centers need to include the vascular surgeons’ role in their descriptions of their PERTs. Toward this direction the vascular division of UPMC is consistently presenting and publishing results and outcomes of PE catheter interventions; very recently a randomized trial (SUNSET sPE) comparing lysis outcomes with and without ultrasound acceleration has been launched by the UPMC PERT, led and coordinated by vascular surgeons, and has already stimulated national interest. Vascular surgeons at Piedmont Heart and Vascular Institute are participating in national clinical trials (OPTALYSE) and actively collaborating with other PERT programs to advance the management of acute PE in Georgia and the southeast. Both UPMC and Piedmont Heart and Vascular Institute are founding institutional members of the PERT Consortium.
The third annual meeting of the PERT Consortium will occur in Boston in June 2017. Vascular surgeons who attend will assuredly be welcome. Answer the call.
Charles B. Ross, MD, is chief, Vascular and Endovascular Services, Piedmont Heart Institute, Atlanta. Efthymios Avgerinos, MD, is associate professor of surgery, Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center. They had no relevant disclosures.
Pulmonary embolism (PE) is the third most common cause of cardiovascular death in the United States and remains the most common preventable cause of in-hospital death. One might think that, in 2017, such a life-threatening cardiovascular emergency would be managed by guideline-driven care based upon robust evidence gathered through clinical trials and large observational studies. Yet, unlike stroke and myocardial infarction (STEMI), a true consensus for best management of acute PE has not been reached.
Management of PE has received increasing attention recently at major cardiovascular meetings such as VEITH, TCT, and national and regional societies. This excitement has been driven by recent trial data demonstrating that right ventricular failure with an acute PE is associated with poor outcomes and rapid clot debulking can reduce mortality not only in patients with high risk (massive) PE but even in intermediate risk (submassive) PE.
Systemic thrombolysis has been the standard of care for higher risk PEs but multiple contraindications and high complication rates shifted care toward catheter interventions assumed to have a safer profile. The huge gap of past decades between therapeutic anticoagulation alone versus systemic thrombolysis or surgical pulmonary embolectomy has been filled with an array of catheter-based techniques. Contemporary management of intermediate and high-risk PE employs thrombolytic infusion catheters at the clot site with or without ultrasound technology, mechanical fragmentation, and aspiration/suction thrombectomy devices. These techniques may lack robust evidence supporting them, still their use has been exponentially growing over the past 2 years. Yet, there is no clear consensus guiding management. Who needs to be treated? What’s the best technique for any given patient? What are the therapeutic endpoints? A myriad of questions remain to be answered.
Uncertainty about best management for an individual patient with acute PE stimulated formation of a multidisciplinary, collaborative approach beginning in 2012 at Massachusetts General Hospital in Boston.
This approach, led by Kenneth Rosenfield, MD, involved the formal development of a call team of various specialists who would be rapidly activated to develop a care plan for any patient with acute PE. The term “Pulmonary Embolism Response Team” (PERT) was coined by MGH pulmonologist Richard Channick, MD, and since then, the PERT approach has been adopted by more than 100 centers across the United States and internationally.
Rapid communication between frontline physicians who diagnose PE and those who can offer definitive management is the hallmark of the PERT approach. PERTs at both Piedmont Atlanta Hospital (care plan shown below) and the University of Pittsburgh Medical Center (UPMC) function similarly. Patients are triaged by a critical care pulmonologist. For those with massive PE (hemodynamically unstable), the emergency call center establishes a cellular link between the bedside emergency physician, triaging critical care pulmonologist, the PE interventionalist, cardiothoracic surgeon, and ECMO team. CTAs may be viewed electronically, management plans initiated, and teams rapidly mobilized. For patients with submassive PE, the triaging critical care pulmonologist initiates management discussion with the “PE interventionalist” on call. Patient presentation, physiologic data, biomarkers, and preexisting comorbidities are discussed. CTAs are viewed. Multiple treatment plans are considered from traditional medical management to catheter-based techniques for more peripheral emboli to surgical pulmonary embolectomy for centrally located thrombus. Treatment plans are influenced by factors such as patient age and comorbidity and are collaboratively tailored to each individual patient.
Management decisions for acute PE are driven by risk stratification. Most patients who present with PE are considered “low risk” for PE-related death and are managed with therapeutic anticoagulation. Five percent of patients present with massive PE characterized by shock and are at “high-risk” for PE-related death. These patients require intervention. Up to 40% of patients present with submassive PE. These patients are hemodynamically stable (not hypotensive) but have evidence on CTA or echocardiogram for right ventricular dysfunction and are at “intermediate risk” for PE-related death. This group is further stratified as intermediate low-risk vs. intermediate high-risk by biomarkers that indicate myocardial damage, primarily troponin and BNP. In this intermediate-risk or submassive group, intervention is more commonly offered to those patients stratified as intermediate “high-risk.”
Significant variability in the management of both massive and submassive PE patients beyond therapeutic anticoagulation, e.g., upon whom to offer intervention and how, is the point where a PERT may have greatest impact. Rapid, collaborative decision making between physicians/surgeons from multiple specialties offers hope for minimizing morbidity and achievement of best outcome.
Who is the “Pulmonary Interventionalist” and where does the contemporarily-trained vascular surgeon with catheter and critical-care skills fit into this new paradigm? The answer to this question depends on each individual institution.
At the University of Pittsburgh Medical Center and Piedmont Heart and Vascular Institute at Piedmont Atlanta Hospital, catheter-based intervention programs for PE were initiated by vascular surgeons. As their interest developed over time, interventional cardiologists joined th “PE Interventional” call as full participants in the PERT programs.
PE interventions at other institutions such as Emory Midtown Medical Center in Atlanta have been driven by interventional cardiology in partnership with cardiothoracic surgery. Still, at others, such as Miami Heart and Vascular Institute, vascular and interventional radiology has led the charge. PE intervention, not owned by any single specialty, has been taken on by those groups interested in answering the call. In the case of the two programs that we represent, it was our established involvement in major venous interventions that followed a natural progression to PE intervention.
Management of PE may be challenging. Multidisciplinary collaboration is key. Recognition of the importance of collaboration in moving the field forward (and saving lives) led Dr. Rosenfield and others to host the first PERT Consortium Meeting in Boston 2015. This clarion call was answered by 80 individuals representing 40 institutions.
In 2016, the PERT Consortium was incorporated, and in June 2016, more than 140 people from nearly 80 institutions attended the second annual meeting. We attended the meeting last June, and with concern we noted only a few vascular surgeons representing other institutions. A participant survey, later published in a letter in CHEST (December 2016), suggested little involvement of vascular surgeons in PERT programs. Was this an artifact based on a survey of “those registered in the PERT mailing list” or does this represent the true interest of vascular surgeons in managing PE in this country? Whether the meeting survey accurately reflects the current involvement of vascular surgeons in the care of PE or not, one thing is certain: Vascular surgical visibility, as a specialty, in PE is poor.
Failure to be involved in the PERT movement deprives patients of the experience of vascular surgeons and potentially threatens the venous intervention practice of nonparticipating surgeons. Forty percent or more of cases of iliofemoral venous thrombosis have associated PE. Vena cava thrombosis may present with PE. Inferior vena cava tumors such as leiomyomatosis may be mistaken for PE. It is foreseeable that PERT activation will represent the gateway to care for many of these patients, who may in turn receive their care from others new to the management of venous and VTE disease.
Participation in a collaborative decision among colleagues about the best way to treat an individual patient is a gratifying experience. When the treatment fits, relieving the struggle of a patient with an acute PE through catheter-directed thrombus dissolution and debulking represents an opportunity to save productive lives using techniques that lie within the skill set of the contemporarily trained vascular surgeon. A save in the case of a challenging PE can be every bit as rewarding as successful management of a ruptured aneurysm.
Even in metropolitan regions, patients with acute PE are underserved because specialized care is frequently unavailable or PE programs nonexistent. In communities and hospitals where vascular surgeons represent the lead interventionalists, involvement in this field might even be considered a solemn responsibility.
Vascular surgeons such as Peter Lin, MD, previously at the University of Texas in Houston, and the group led by Rabih Chaer, MD, at UPMC, have advanced the science of PE intervention over the past 7 years. It is time for more vascular surgeons to enter the field and embrace pulmonary interventions. To achieve this, we need to embrace collaboration with pulmonary and critical care as well as emergency medicine since these are the main referral specialties. We need to promote initiatives participating in our local PERTs or bringing specialists together to start one where nonexistent. There is no reason for exclusivity, and collaboration with other interventionalists is essential for smooth interspecialty relations, multidisciplinary approaches, and optimal outcomes.
Academic and large community vascular centers need to include the vascular surgeons’ role in their descriptions of their PERTs. Toward this direction the vascular division of UPMC is consistently presenting and publishing results and outcomes of PE catheter interventions; very recently a randomized trial (SUNSET sPE) comparing lysis outcomes with and without ultrasound acceleration has been launched by the UPMC PERT, led and coordinated by vascular surgeons, and has already stimulated national interest. Vascular surgeons at Piedmont Heart and Vascular Institute are participating in national clinical trials (OPTALYSE) and actively collaborating with other PERT programs to advance the management of acute PE in Georgia and the southeast. Both UPMC and Piedmont Heart and Vascular Institute are founding institutional members of the PERT Consortium.
The third annual meeting of the PERT Consortium will occur in Boston in June 2017. Vascular surgeons who attend will assuredly be welcome. Answer the call.
Charles B. Ross, MD, is chief, Vascular and Endovascular Services, Piedmont Heart Institute, Atlanta. Efthymios Avgerinos, MD, is associate professor of surgery, Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center. They had no relevant disclosures.
The Pill: A pediatric perspective
Arguably, the introduction of the birth control pill has transformed female health more than any other drug in modern medicine. Although many of us practicing now do not know life without it, its history is not that long.
“The Pill” – as it is often referred to – was introduced in May of 1950.1 At that time, prevention of pregnancy was not listed as an indication, and promoting birth control was politically, socially, and legally unacceptable. In fact, the Comstock Law prohibited public discussion and research about contraception.1 Therefore, when the birth control pill was introduced, it was for cycle control and for married women only. It was not indicated for use as contraception in the United States until 1960.
Since that time, the birth control pill has evolved dramatically, not only in its formulation but in its indications as well. As pediatricians, we do not always find it easy to discuss with parents hormonal regulation and starting a patient on the birth control pill, particularly when it will not be used for contraception. There are many fears about using hormonal control, but there are many useful indications that improve the health and well-being of the pediatric patient.
Menorrhagia and dysmenorrhea are likely the most common reasons that hormonal therapy is started in adolescence. Beginning with the lowest estrogen dose to reduce side effects is prudent, adjusting accordingly if side effects should occur. Breakthrough bleeding is a common side effect that usually improves over time. Patients should continue treatment for at least 3 months before deciding if treatment is effective or not. If breakthrough bleeding continues, increasing the estrogen component or changing to a triphasic pill might reduce bleeding.
For a child with mental or significant physical disabilities, suppression of ovulation to prevent a menstrual cycle is very useful. Extended regimens can help to completely suppress ovulation, thereby avoiding withdrawal bleeding. There is anxiety about extended regimens, but there is no greater risk with using hormonal therapy continuously vs. intermittently.2 In fact, using it continuously reduces many of the unwanted side effects associated with the use of oral contraceptive pills (OCPs), for example, heavy bleeding, headaches, and nausea. Complete suppression is difficult, but the odds are better with continuous treatment. Using monophasic OCPs for 42-63 days on and 4-7 days off can be tried. The benefit of using monophasic pills is if a dose is missed, it is easy to make it up by just taking an extra pill. Companies have come out with extended-regimen packs, for example, Seasonale, Seasonique, Quartette, and Lybrel. There now is a chewable pill known as Femcon Fe, which would be useful in those patients who are not able to swallow pills.
Another indication for OCPs in the adolescent patient is acne. Although the exact mechanism is not completely understood, estrogen does decrease sebum by reducing the size of the gland4, and, therefore, all OCPs can reduce acne. Norgestimate combinations have the highest androgen to progesterone binding ratio, so they are more effective than OCPs that do not. A newer progestin, drospirenone, is a 17 alpha-spironolactone derivative that produces antiandrogenic activity.5 When used in a combination OCP, acne control appears to be even greater. Hormonal therapy should be considered whenever there has been limited improvement with topical treatment or if acne breakouts are associated with the onset of menses.
Another consideration is to add spironolactone 100 mg by mouth daily to the regimen. Studies have shown it can be safely used in women to reduce acne.6 Patients should be monitored frequently for hyperkalemia, and it should not be used in patients who are already pregnant.4 Lab work should be done to rule out other causes of hyperandrogenism; lab tests would include serum testosterone, androstenedione, dehydroepiandrosterone, sex hormone–binding globulin, and prolactin.4
Premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD) – which is the onset of depression, irritability, or anxiety in the second half of the menstrual cycle and remits with the onset of the menstrual cycle – also can be treated with hormonal therapy. This can be particularly helpful in teens with depression, as well as in those who are on treatment without significant resolution. PMS/PMDD appears to be best regulated with OCPs containing drospirenone,7 and using either a shortened course of the placebo phase or a continuous regimen appears to be the most beneficial.
Regardless of the indication for hormonal therapy, the initiation and management are essentially the same. Initiation can be on the first day of the menstrual cycle, on the Sunday after, or at the time of the visit. Initiation midcycle may result in breakthrough bleeding, but that will likely resolve over the next 3 months. No lab tests are required to start hormonal therapy, except for an HCG to rule out pregnancy. Weight and blood pressure should be documented so they can be monitored on follow-up visits. A detailed verbal explanation along with a handout should be provided on proper administration and side effects. Contraindications for the use of OCPs can be found on the Centers for Disease Control and Prevention’s website under medical criteria for the use of contraceptives.
Educating families and patients on their options for hormonal therapy can be life changing. Detailed questions about the menstrual cycle should be asked at every visit, and understanding the wide variety of indications for hormonal therapy can maximize treatment for a better outcome.
References
1. Can Fam Physician. 2012 Dec;58(12):e757–60.
2. J Midwifery Womens Health. 2012 Nov-Dec;57(6):585-92.
3. Obstet Gynecol. 2009;114:1428-31.
4. Semin Cutan Med Surg. 2008 Sep;27(3):188-96.
5. Pediatr Rev. 2008;29(11);386-97.
6. J Eur Acad Dermatol Venereol. 2005 Mar;19(2):163-6.
7. Obstet Gynecol. 2005 Sep;106(3):492-501.
Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures.
Arguably, the introduction of the birth control pill has transformed female health more than any other drug in modern medicine. Although many of us practicing now do not know life without it, its history is not that long.
“The Pill” – as it is often referred to – was introduced in May of 1950.1 At that time, prevention of pregnancy was not listed as an indication, and promoting birth control was politically, socially, and legally unacceptable. In fact, the Comstock Law prohibited public discussion and research about contraception.1 Therefore, when the birth control pill was introduced, it was for cycle control and for married women only. It was not indicated for use as contraception in the United States until 1960.
Since that time, the birth control pill has evolved dramatically, not only in its formulation but in its indications as well. As pediatricians, we do not always find it easy to discuss with parents hormonal regulation and starting a patient on the birth control pill, particularly when it will not be used for contraception. There are many fears about using hormonal control, but there are many useful indications that improve the health and well-being of the pediatric patient.
Menorrhagia and dysmenorrhea are likely the most common reasons that hormonal therapy is started in adolescence. Beginning with the lowest estrogen dose to reduce side effects is prudent, adjusting accordingly if side effects should occur. Breakthrough bleeding is a common side effect that usually improves over time. Patients should continue treatment for at least 3 months before deciding if treatment is effective or not. If breakthrough bleeding continues, increasing the estrogen component or changing to a triphasic pill might reduce bleeding.
For a child with mental or significant physical disabilities, suppression of ovulation to prevent a menstrual cycle is very useful. Extended regimens can help to completely suppress ovulation, thereby avoiding withdrawal bleeding. There is anxiety about extended regimens, but there is no greater risk with using hormonal therapy continuously vs. intermittently.2 In fact, using it continuously reduces many of the unwanted side effects associated with the use of oral contraceptive pills (OCPs), for example, heavy bleeding, headaches, and nausea. Complete suppression is difficult, but the odds are better with continuous treatment. Using monophasic OCPs for 42-63 days on and 4-7 days off can be tried. The benefit of using monophasic pills is if a dose is missed, it is easy to make it up by just taking an extra pill. Companies have come out with extended-regimen packs, for example, Seasonale, Seasonique, Quartette, and Lybrel. There now is a chewable pill known as Femcon Fe, which would be useful in those patients who are not able to swallow pills.
Another indication for OCPs in the adolescent patient is acne. Although the exact mechanism is not completely understood, estrogen does decrease sebum by reducing the size of the gland4, and, therefore, all OCPs can reduce acne. Norgestimate combinations have the highest androgen to progesterone binding ratio, so they are more effective than OCPs that do not. A newer progestin, drospirenone, is a 17 alpha-spironolactone derivative that produces antiandrogenic activity.5 When used in a combination OCP, acne control appears to be even greater. Hormonal therapy should be considered whenever there has been limited improvement with topical treatment or if acne breakouts are associated with the onset of menses.
Another consideration is to add spironolactone 100 mg by mouth daily to the regimen. Studies have shown it can be safely used in women to reduce acne.6 Patients should be monitored frequently for hyperkalemia, and it should not be used in patients who are already pregnant.4 Lab work should be done to rule out other causes of hyperandrogenism; lab tests would include serum testosterone, androstenedione, dehydroepiandrosterone, sex hormone–binding globulin, and prolactin.4
Premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD) – which is the onset of depression, irritability, or anxiety in the second half of the menstrual cycle and remits with the onset of the menstrual cycle – also can be treated with hormonal therapy. This can be particularly helpful in teens with depression, as well as in those who are on treatment without significant resolution. PMS/PMDD appears to be best regulated with OCPs containing drospirenone,7 and using either a shortened course of the placebo phase or a continuous regimen appears to be the most beneficial.
Regardless of the indication for hormonal therapy, the initiation and management are essentially the same. Initiation can be on the first day of the menstrual cycle, on the Sunday after, or at the time of the visit. Initiation midcycle may result in breakthrough bleeding, but that will likely resolve over the next 3 months. No lab tests are required to start hormonal therapy, except for an HCG to rule out pregnancy. Weight and blood pressure should be documented so they can be monitored on follow-up visits. A detailed verbal explanation along with a handout should be provided on proper administration and side effects. Contraindications for the use of OCPs can be found on the Centers for Disease Control and Prevention’s website under medical criteria for the use of contraceptives.
Educating families and patients on their options for hormonal therapy can be life changing. Detailed questions about the menstrual cycle should be asked at every visit, and understanding the wide variety of indications for hormonal therapy can maximize treatment for a better outcome.
References
1. Can Fam Physician. 2012 Dec;58(12):e757–60.
2. J Midwifery Womens Health. 2012 Nov-Dec;57(6):585-92.
3. Obstet Gynecol. 2009;114:1428-31.
4. Semin Cutan Med Surg. 2008 Sep;27(3):188-96.
5. Pediatr Rev. 2008;29(11);386-97.
6. J Eur Acad Dermatol Venereol. 2005 Mar;19(2):163-6.
7. Obstet Gynecol. 2005 Sep;106(3):492-501.
Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures.
Arguably, the introduction of the birth control pill has transformed female health more than any other drug in modern medicine. Although many of us practicing now do not know life without it, its history is not that long.
“The Pill” – as it is often referred to – was introduced in May of 1950.1 At that time, prevention of pregnancy was not listed as an indication, and promoting birth control was politically, socially, and legally unacceptable. In fact, the Comstock Law prohibited public discussion and research about contraception.1 Therefore, when the birth control pill was introduced, it was for cycle control and for married women only. It was not indicated for use as contraception in the United States until 1960.
Since that time, the birth control pill has evolved dramatically, not only in its formulation but in its indications as well. As pediatricians, we do not always find it easy to discuss with parents hormonal regulation and starting a patient on the birth control pill, particularly when it will not be used for contraception. There are many fears about using hormonal control, but there are many useful indications that improve the health and well-being of the pediatric patient.
Menorrhagia and dysmenorrhea are likely the most common reasons that hormonal therapy is started in adolescence. Beginning with the lowest estrogen dose to reduce side effects is prudent, adjusting accordingly if side effects should occur. Breakthrough bleeding is a common side effect that usually improves over time. Patients should continue treatment for at least 3 months before deciding if treatment is effective or not. If breakthrough bleeding continues, increasing the estrogen component or changing to a triphasic pill might reduce bleeding.
For a child with mental or significant physical disabilities, suppression of ovulation to prevent a menstrual cycle is very useful. Extended regimens can help to completely suppress ovulation, thereby avoiding withdrawal bleeding. There is anxiety about extended regimens, but there is no greater risk with using hormonal therapy continuously vs. intermittently.2 In fact, using it continuously reduces many of the unwanted side effects associated with the use of oral contraceptive pills (OCPs), for example, heavy bleeding, headaches, and nausea. Complete suppression is difficult, but the odds are better with continuous treatment. Using monophasic OCPs for 42-63 days on and 4-7 days off can be tried. The benefit of using monophasic pills is if a dose is missed, it is easy to make it up by just taking an extra pill. Companies have come out with extended-regimen packs, for example, Seasonale, Seasonique, Quartette, and Lybrel. There now is a chewable pill known as Femcon Fe, which would be useful in those patients who are not able to swallow pills.
Another indication for OCPs in the adolescent patient is acne. Although the exact mechanism is not completely understood, estrogen does decrease sebum by reducing the size of the gland4, and, therefore, all OCPs can reduce acne. Norgestimate combinations have the highest androgen to progesterone binding ratio, so they are more effective than OCPs that do not. A newer progestin, drospirenone, is a 17 alpha-spironolactone derivative that produces antiandrogenic activity.5 When used in a combination OCP, acne control appears to be even greater. Hormonal therapy should be considered whenever there has been limited improvement with topical treatment or if acne breakouts are associated with the onset of menses.
Another consideration is to add spironolactone 100 mg by mouth daily to the regimen. Studies have shown it can be safely used in women to reduce acne.6 Patients should be monitored frequently for hyperkalemia, and it should not be used in patients who are already pregnant.4 Lab work should be done to rule out other causes of hyperandrogenism; lab tests would include serum testosterone, androstenedione, dehydroepiandrosterone, sex hormone–binding globulin, and prolactin.4
Premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD) – which is the onset of depression, irritability, or anxiety in the second half of the menstrual cycle and remits with the onset of the menstrual cycle – also can be treated with hormonal therapy. This can be particularly helpful in teens with depression, as well as in those who are on treatment without significant resolution. PMS/PMDD appears to be best regulated with OCPs containing drospirenone,7 and using either a shortened course of the placebo phase or a continuous regimen appears to be the most beneficial.
Regardless of the indication for hormonal therapy, the initiation and management are essentially the same. Initiation can be on the first day of the menstrual cycle, on the Sunday after, or at the time of the visit. Initiation midcycle may result in breakthrough bleeding, but that will likely resolve over the next 3 months. No lab tests are required to start hormonal therapy, except for an HCG to rule out pregnancy. Weight and blood pressure should be documented so they can be monitored on follow-up visits. A detailed verbal explanation along with a handout should be provided on proper administration and side effects. Contraindications for the use of OCPs can be found on the Centers for Disease Control and Prevention’s website under medical criteria for the use of contraceptives.
Educating families and patients on their options for hormonal therapy can be life changing. Detailed questions about the menstrual cycle should be asked at every visit, and understanding the wide variety of indications for hormonal therapy can maximize treatment for a better outcome.
References
1. Can Fam Physician. 2012 Dec;58(12):e757–60.
2. J Midwifery Womens Health. 2012 Nov-Dec;57(6):585-92.
3. Obstet Gynecol. 2009;114:1428-31.
4. Semin Cutan Med Surg. 2008 Sep;27(3):188-96.
5. Pediatr Rev. 2008;29(11);386-97.
6. J Eur Acad Dermatol Venereol. 2005 Mar;19(2):163-6.
7. Obstet Gynecol. 2005 Sep;106(3):492-501.
Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures.
The VA Is Not Just a Hospital, It Is a Community
The residency applicant walking with me through the lobby of the Albuquerque VA hospital on the way to an interview in my office asked me, “Are all VAs like this?” She was referring to the mariachi band that was entertaining veterans, families, and staff and the volunteer who was serving popcorn—for many years a regular feature at our VA. I responded, “No, they are all a little different, but yes, every VA is more than a hospital.” If she had asked a follow-up question, I would have added, “It is a community.”
Merriam-Webster’s Collegiate Dictionary has multiple definitions of community, and it is remarkable that most of them in one way or another describe the VA from the perspective of many veterans and even career employees:
- 1: a unified body of individuals: as
a: state, commonwealth
b: the people with common interests living in a particular area; broadly: the area itself (eg, the problems of a large community)
c: an interacting population of various kinds of individuals (as species) in a common location
d: a group of people with a common characteristic or interest in living together within a larger society (eg, a community of retired persons)
e: a group linked by a common policy
f: a body of persons or nations having a common history or common social, economic, and political interests (eg, the international community)
g: a body of persons of common and especially professional interests scattered through a larger society (eg, the academic community) - 2: society at large
- 3a: joint ownership or participation (community of goods)
b: common character: likeness (community of interests)
c: social activity: fellowship d: a social state or condition
d: a social state or condition
There is much talk in the media about the privatization of the VA. There are zealous critics who argue that privatization would improve access and quality of care. I won’t debate that here.
What I want to consider is what the VA represents and provides in addition to health care. Each VA hospital and clinic serves “a body of persons or nations having a common history or common social, economic, and political interests.” Sit in the waiting area of any VA emergency department or pharmacy and you will hear bonding conversations between veterans. Even when the conversation is critical of the VA, it is because it is their hospital. That “joint ownership or participation” means that every VA employee, including the nearly 30% who wore a uniform, is there for a single purpose: to help veterans. That is our sole mission and advocacy.
Back to my VA. We are “a group of people with a common characteristic or interest living together within a larger society.” Similar to most other large medical centers, this VA is like the army base where I was born and raised—a small village. The single most popular service at my VA is the barber shop where veterans can get a haircut and shave. We also have an extensive clothing closet where eligible veterans experiencing tough times can get decent clothes.
Our VA, like almost any military base, has a post exchange that sells a little bit of everything from snacks to small appliances. When I was an intern, I treated an elderly patient who was in a deep psychotic depression and was transferred with only the clothes he was wearing. After several electroconvulsive treatments, I could tell he was feeling better when he asked me to buy him underwear from the post exchange downstairs. What this patient needed, the community provided.
A VA medical center is “a group of people with a common characteristic or interest living together within a larger society.” Like any American small town, there is a chapel where twice a year chaplains hold a memorial service for families and staff of patients who recently passed away in our hospital. At other times, we gather as a family of various and no faiths to grieve over the loss of a beloved fellow employee who, all too often, died too soon under tragic circumstances.
Much of this interaction naturally takes place around food. In the morning, there is a line at the coffee shop in the lobby that matches any Starbucks in town. Our VA also has an award-winning canteen that knows the favorite dishes of veterans and employees. If you go for breakfast or lunch, you will almost always run in to someone you have not seen in a while and have a quick visit.
At our VA, you also can browse kiosks of handcrafted items and military memorabilia and support small veteran-owned businesses. In good weather you can buy fruits and vegetables at the veteran farmers market and hear the stories of backyard gardeners and small farmers.
There are special events for every season. In the summer, concerts are held in the gazebo and veteran and guest musicians play all types of music. We even have a VA all-star band made up of current and former employees. The band is a big hit with patients and staff alike.
Although many of these community resources are unique to my VA, the effort to provide a welcoming atmosphere for veterans and health care providers to come together as a community is not unusual. Most VA medical centers have developed cultural responses to the needs of the veterans who return often over the course of years to their VA community.
One definition that does not apply to the large, diverse veteran population or to their health care providers is “a unified body of individuals.” There are many veterans who never have and never will set foot inside a VA hospital for many complex reasons. But for those who do call it home and want to receive care under VA auspices, a private VA would result in a deep and abiding loss of community. This loss is especially true for the most disadvantaged and vulnerable for whom the VA provides a broad and compassionate safety net. Under that protective tent, unbefriended veterans may grow closer to employees who have cared for them for years than to their family. Patients with complex medical and psychiatric needs, such as spinal cord injuries, polytrauma, substance use disorders, and posttraumatic stress disorder find specialized services dedicated to them that would be difficult to rival anywhere in the private sector.What also is not appreciated amid the fierce and too often well-deserved criticisms of VA business processes is that all VA health care practitioners are “a group linked by a common policy.” Even if we do not always live up to them, the VA has higher regulatory and ethical standards than almost any civilian health care organization. Ensuring those standards are followed in a myriad of health care entities not under VA policy and federal regulation seems a shibboleth.
The residency applicant walking with me through the lobby of the Albuquerque VA hospital on the way to an interview in my office asked me, “Are all VAs like this?” She was referring to the mariachi band that was entertaining veterans, families, and staff and the volunteer who was serving popcorn—for many years a regular feature at our VA. I responded, “No, they are all a little different, but yes, every VA is more than a hospital.” If she had asked a follow-up question, I would have added, “It is a community.”
Merriam-Webster’s Collegiate Dictionary has multiple definitions of community, and it is remarkable that most of them in one way or another describe the VA from the perspective of many veterans and even career employees:
- 1: a unified body of individuals: as
a: state, commonwealth
b: the people with common interests living in a particular area; broadly: the area itself (eg, the problems of a large community)
c: an interacting population of various kinds of individuals (as species) in a common location
d: a group of people with a common characteristic or interest in living together within a larger society (eg, a community of retired persons)
e: a group linked by a common policy
f: a body of persons or nations having a common history or common social, economic, and political interests (eg, the international community)
g: a body of persons of common and especially professional interests scattered through a larger society (eg, the academic community) - 2: society at large
- 3a: joint ownership or participation (community of goods)
b: common character: likeness (community of interests)
c: social activity: fellowship d: a social state or condition
d: a social state or condition
There is much talk in the media about the privatization of the VA. There are zealous critics who argue that privatization would improve access and quality of care. I won’t debate that here.
What I want to consider is what the VA represents and provides in addition to health care. Each VA hospital and clinic serves “a body of persons or nations having a common history or common social, economic, and political interests.” Sit in the waiting area of any VA emergency department or pharmacy and you will hear bonding conversations between veterans. Even when the conversation is critical of the VA, it is because it is their hospital. That “joint ownership or participation” means that every VA employee, including the nearly 30% who wore a uniform, is there for a single purpose: to help veterans. That is our sole mission and advocacy.
Back to my VA. We are “a group of people with a common characteristic or interest living together within a larger society.” Similar to most other large medical centers, this VA is like the army base where I was born and raised—a small village. The single most popular service at my VA is the barber shop where veterans can get a haircut and shave. We also have an extensive clothing closet where eligible veterans experiencing tough times can get decent clothes.
Our VA, like almost any military base, has a post exchange that sells a little bit of everything from snacks to small appliances. When I was an intern, I treated an elderly patient who was in a deep psychotic depression and was transferred with only the clothes he was wearing. After several electroconvulsive treatments, I could tell he was feeling better when he asked me to buy him underwear from the post exchange downstairs. What this patient needed, the community provided.
A VA medical center is “a group of people with a common characteristic or interest living together within a larger society.” Like any American small town, there is a chapel where twice a year chaplains hold a memorial service for families and staff of patients who recently passed away in our hospital. At other times, we gather as a family of various and no faiths to grieve over the loss of a beloved fellow employee who, all too often, died too soon under tragic circumstances.
Much of this interaction naturally takes place around food. In the morning, there is a line at the coffee shop in the lobby that matches any Starbucks in town. Our VA also has an award-winning canteen that knows the favorite dishes of veterans and employees. If you go for breakfast or lunch, you will almost always run in to someone you have not seen in a while and have a quick visit.
At our VA, you also can browse kiosks of handcrafted items and military memorabilia and support small veteran-owned businesses. In good weather you can buy fruits and vegetables at the veteran farmers market and hear the stories of backyard gardeners and small farmers.
There are special events for every season. In the summer, concerts are held in the gazebo and veteran and guest musicians play all types of music. We even have a VA all-star band made up of current and former employees. The band is a big hit with patients and staff alike.
Although many of these community resources are unique to my VA, the effort to provide a welcoming atmosphere for veterans and health care providers to come together as a community is not unusual. Most VA medical centers have developed cultural responses to the needs of the veterans who return often over the course of years to their VA community.
One definition that does not apply to the large, diverse veteran population or to their health care providers is “a unified body of individuals.” There are many veterans who never have and never will set foot inside a VA hospital for many complex reasons. But for those who do call it home and want to receive care under VA auspices, a private VA would result in a deep and abiding loss of community. This loss is especially true for the most disadvantaged and vulnerable for whom the VA provides a broad and compassionate safety net. Under that protective tent, unbefriended veterans may grow closer to employees who have cared for them for years than to their family. Patients with complex medical and psychiatric needs, such as spinal cord injuries, polytrauma, substance use disorders, and posttraumatic stress disorder find specialized services dedicated to them that would be difficult to rival anywhere in the private sector.What also is not appreciated amid the fierce and too often well-deserved criticisms of VA business processes is that all VA health care practitioners are “a group linked by a common policy.” Even if we do not always live up to them, the VA has higher regulatory and ethical standards than almost any civilian health care organization. Ensuring those standards are followed in a myriad of health care entities not under VA policy and federal regulation seems a shibboleth.
The residency applicant walking with me through the lobby of the Albuquerque VA hospital on the way to an interview in my office asked me, “Are all VAs like this?” She was referring to the mariachi band that was entertaining veterans, families, and staff and the volunteer who was serving popcorn—for many years a regular feature at our VA. I responded, “No, they are all a little different, but yes, every VA is more than a hospital.” If she had asked a follow-up question, I would have added, “It is a community.”
Merriam-Webster’s Collegiate Dictionary has multiple definitions of community, and it is remarkable that most of them in one way or another describe the VA from the perspective of many veterans and even career employees:
- 1: a unified body of individuals: as
a: state, commonwealth
b: the people with common interests living in a particular area; broadly: the area itself (eg, the problems of a large community)
c: an interacting population of various kinds of individuals (as species) in a common location
d: a group of people with a common characteristic or interest in living together within a larger society (eg, a community of retired persons)
e: a group linked by a common policy
f: a body of persons or nations having a common history or common social, economic, and political interests (eg, the international community)
g: a body of persons of common and especially professional interests scattered through a larger society (eg, the academic community) - 2: society at large
- 3a: joint ownership or participation (community of goods)
b: common character: likeness (community of interests)
c: social activity: fellowship d: a social state or condition
d: a social state or condition
There is much talk in the media about the privatization of the VA. There are zealous critics who argue that privatization would improve access and quality of care. I won’t debate that here.
What I want to consider is what the VA represents and provides in addition to health care. Each VA hospital and clinic serves “a body of persons or nations having a common history or common social, economic, and political interests.” Sit in the waiting area of any VA emergency department or pharmacy and you will hear bonding conversations between veterans. Even when the conversation is critical of the VA, it is because it is their hospital. That “joint ownership or participation” means that every VA employee, including the nearly 30% who wore a uniform, is there for a single purpose: to help veterans. That is our sole mission and advocacy.
Back to my VA. We are “a group of people with a common characteristic or interest living together within a larger society.” Similar to most other large medical centers, this VA is like the army base where I was born and raised—a small village. The single most popular service at my VA is the barber shop where veterans can get a haircut and shave. We also have an extensive clothing closet where eligible veterans experiencing tough times can get decent clothes.
Our VA, like almost any military base, has a post exchange that sells a little bit of everything from snacks to small appliances. When I was an intern, I treated an elderly patient who was in a deep psychotic depression and was transferred with only the clothes he was wearing. After several electroconvulsive treatments, I could tell he was feeling better when he asked me to buy him underwear from the post exchange downstairs. What this patient needed, the community provided.
A VA medical center is “a group of people with a common characteristic or interest living together within a larger society.” Like any American small town, there is a chapel where twice a year chaplains hold a memorial service for families and staff of patients who recently passed away in our hospital. At other times, we gather as a family of various and no faiths to grieve over the loss of a beloved fellow employee who, all too often, died too soon under tragic circumstances.
Much of this interaction naturally takes place around food. In the morning, there is a line at the coffee shop in the lobby that matches any Starbucks in town. Our VA also has an award-winning canteen that knows the favorite dishes of veterans and employees. If you go for breakfast or lunch, you will almost always run in to someone you have not seen in a while and have a quick visit.
At our VA, you also can browse kiosks of handcrafted items and military memorabilia and support small veteran-owned businesses. In good weather you can buy fruits and vegetables at the veteran farmers market and hear the stories of backyard gardeners and small farmers.
There are special events for every season. In the summer, concerts are held in the gazebo and veteran and guest musicians play all types of music. We even have a VA all-star band made up of current and former employees. The band is a big hit with patients and staff alike.
Although many of these community resources are unique to my VA, the effort to provide a welcoming atmosphere for veterans and health care providers to come together as a community is not unusual. Most VA medical centers have developed cultural responses to the needs of the veterans who return often over the course of years to their VA community.
One definition that does not apply to the large, diverse veteran population or to their health care providers is “a unified body of individuals.” There are many veterans who never have and never will set foot inside a VA hospital for many complex reasons. But for those who do call it home and want to receive care under VA auspices, a private VA would result in a deep and abiding loss of community. This loss is especially true for the most disadvantaged and vulnerable for whom the VA provides a broad and compassionate safety net. Under that protective tent, unbefriended veterans may grow closer to employees who have cared for them for years than to their family. Patients with complex medical and psychiatric needs, such as spinal cord injuries, polytrauma, substance use disorders, and posttraumatic stress disorder find specialized services dedicated to them that would be difficult to rival anywhere in the private sector.What also is not appreciated amid the fierce and too often well-deserved criticisms of VA business processes is that all VA health care practitioners are “a group linked by a common policy.” Even if we do not always live up to them, the VA has higher regulatory and ethical standards than almost any civilian health care organization. Ensuring those standards are followed in a myriad of health care entities not under VA policy and federal regulation seems a shibboleth.
Medical psychiatry: The skill of integrating medical and psychiatric care
Although the meaning of these terms varied from department to department, biologically oriented programs—influenced by Eli Robins and Samuel Guze and DSM-III—were focused on descriptive psychiatry: reliable, observable, and symptom-based elements of psychiatric illness. Related and important elements were a focus on psychopharmacologic treatments, genetics, epidemiology, and putative mechanisms for both diseases and treatments. Psychodynamic programs had a primary focus on psychodynamic theory, with extensive training in long-term, depth-oriented psychotherapy. Many of these are programs employed charismatic and brilliant teachers whose supervisory and interviewing skills were legendary. And, of course, all the programs claimed they did everything and did it well.
However, none of these programs were exactly what I was looking for. Although I had a long-standing interest in psychodynamics and was fascinated by the implications of—what was then a far more nascent—neurobiology, I was looking for a program that had all of these elements, but also had a focus on, what I thought of as, “medical psychiatry.” Although this may have meant different things to others, and was known as “psychosomatic medicine” or “consultation-liaison psychiatry,” to me, it was about the psychiatric manifestations of medical and neurologic disorders.
My years training in internal medicine were full of patients with neuropsychiatric illness due to a host of general medical and neurologic disorders. When I was an intern, the most common admitting diagnosis was what we called “Delta MS”—change in mental status. As I advanced in my residency and focused on a subspecialty of internal medicine, it became clear that whichever illnesses I studied, conditions such as anxiety disorders in Grave’s disease or the psychotic symptoms in lupus held my interest. Finally, the only specialty left was psychiatry.
The only program I found that seemed to understand medical psychiatry at the time was at Massachusetts General Hospital (MGH). MGH not only had eminent psychiatrists in every area of the field, it seemed, but also a special focus on training psychiatrists in medical settings and as medical experts. My first Chief of Psychiatry was Thomas P. Hackett, MD—a brilliant clinician, raconteur, and polymath—who had written a cri de coeur on the importance of medical skills and training in psychiatry.1 At last, I had found a place where I could remain a physician and think and learn about every aspect of psychiatry, especially medical psychiatry.
What is medical psychiatry, and why is it relevant now?
There has been substantial and increasing interest in the integration of medical and psychiatric care. Whether it is collaborative care or co-location models, the recognition of the high rate of combined medical and psychiatric illnesses and associated increased mortality and total health care costs of these patients requires psychiatrists to be deeply familiar with the interactions among medical and psychiatric conditions.
Building on long-developed expertise in consultation-liaison psychiatry and other forms of medical psychiatric training, such as double-board medicine–psychiatry programs, medical psychiatry includes several specific areas of knowledge and skill sets, including understanding the impact that psychiatric illnesses and the medications used to treat them can have on medical illnesses and the ways in which the presence of medical disorders can change the presentation of psychiatric illnesses. Similarly, the psychiatric impact of the general medical pharmacopeia and the ways in which psychiatric illness can affect the presentation of medical illness are important for all psychiatrists to know. Most importantly, medical psychiatry should focus on the medical and neurologic causes of psychiatric illnesses. Many general medical conditions produce symptoms, which, in whole or in part, mimic psychiatric illnesses and, in some cases, could lead to psychiatric disorders, which makes identification of the underlying cause difficult.
Whether due to infectious, autoimmune, metabolic, or endocrinologic disorders, being aware of these conditions and, where clinical circumstances warrant, be able to diagnose them, with other specialists as needed, and ensure they are appropriately treated should be an essential skill for psychiatrists.
An illustrative case
I remember a case from early in my training of a woman with a late-onset mood disorder with abulia, wide-based gait, and urinary incontinence, in addition to withdrawal and loss of pleasure. Despite the skepticism of the neurology team, at autopsy she was found to have arteriosclerosis of the deep, penetrating arterioles causing white matter hyperintensities—Binswanger’s disease. There was no question that despite the neurologic cause of her symptoms treating her depression with antidepressants was needed and helpful. It also was important that her family was aware of her underlying medical condition and its implications for her care.2
Medicine is our calling
Many of these illnesses, even when identified, require expert psychiatric management of psychiatric symptoms. This should not be surprising to psychiatrists or other clinicians. No one expects a cardiologist to beg off the care of a patient with heart failure caused by alcohol abuse or a virus rather than vascular heart disease, and psychiatrists likewise need to manage psychosis due to steroid use or N-methyl-
Medical psychiatry has a broader and more inclusive perspective than what we generally mean by “biological psychiatry,” if by the latter, we mean a focus on the neurobiology and psychopharmacology of “primary” psychiatric conditions that are not secondary to other medical or neurologic disorders. As important and fundamental as deep understanding of neurobiology, genetics, and psychopharmacology are, medical psychiatry embeds our work more broadly in all of human biology and requires the full breadth of our medical training.
At a time when political battles over prescriptive privileges by non-medically trained mental health clinicians engage legislatures and professional organizations, medical psychiatry is a powerful reminder that prescribing or not prescribing medications is the final step in, what should be, an extensive, clinical evaluation including a thorough medical work up and consideration of the medical–psychiatric interactions and the differential diagnosis of these illnesses. It is, after all, what physicians do and is essential to our calling as psychiatric physicians. If psychiatrists are not at home in medicine, as Tom Hackett reminded us in 19771—at a time when psychiatry had temporarily eliminated the requirement for medical internships—then, indeed, psychiatry would be “homeless.”
2. Summergrad P. Depression in Binswanger’s encephalopathy responsive to tranylcypromine: case report. J Clin Psychiatry. 1985;46(2):69-70.
Although the meaning of these terms varied from department to department, biologically oriented programs—influenced by Eli Robins and Samuel Guze and DSM-III—were focused on descriptive psychiatry: reliable, observable, and symptom-based elements of psychiatric illness. Related and important elements were a focus on psychopharmacologic treatments, genetics, epidemiology, and putative mechanisms for both diseases and treatments. Psychodynamic programs had a primary focus on psychodynamic theory, with extensive training in long-term, depth-oriented psychotherapy. Many of these are programs employed charismatic and brilliant teachers whose supervisory and interviewing skills were legendary. And, of course, all the programs claimed they did everything and did it well.
However, none of these programs were exactly what I was looking for. Although I had a long-standing interest in psychodynamics and was fascinated by the implications of—what was then a far more nascent—neurobiology, I was looking for a program that had all of these elements, but also had a focus on, what I thought of as, “medical psychiatry.” Although this may have meant different things to others, and was known as “psychosomatic medicine” or “consultation-liaison psychiatry,” to me, it was about the psychiatric manifestations of medical and neurologic disorders.
My years training in internal medicine were full of patients with neuropsychiatric illness due to a host of general medical and neurologic disorders. When I was an intern, the most common admitting diagnosis was what we called “Delta MS”—change in mental status. As I advanced in my residency and focused on a subspecialty of internal medicine, it became clear that whichever illnesses I studied, conditions such as anxiety disorders in Grave’s disease or the psychotic symptoms in lupus held my interest. Finally, the only specialty left was psychiatry.
The only program I found that seemed to understand medical psychiatry at the time was at Massachusetts General Hospital (MGH). MGH not only had eminent psychiatrists in every area of the field, it seemed, but also a special focus on training psychiatrists in medical settings and as medical experts. My first Chief of Psychiatry was Thomas P. Hackett, MD—a brilliant clinician, raconteur, and polymath—who had written a cri de coeur on the importance of medical skills and training in psychiatry.1 At last, I had found a place where I could remain a physician and think and learn about every aspect of psychiatry, especially medical psychiatry.
What is medical psychiatry, and why is it relevant now?
There has been substantial and increasing interest in the integration of medical and psychiatric care. Whether it is collaborative care or co-location models, the recognition of the high rate of combined medical and psychiatric illnesses and associated increased mortality and total health care costs of these patients requires psychiatrists to be deeply familiar with the interactions among medical and psychiatric conditions.
Building on long-developed expertise in consultation-liaison psychiatry and other forms of medical psychiatric training, such as double-board medicine–psychiatry programs, medical psychiatry includes several specific areas of knowledge and skill sets, including understanding the impact that psychiatric illnesses and the medications used to treat them can have on medical illnesses and the ways in which the presence of medical disorders can change the presentation of psychiatric illnesses. Similarly, the psychiatric impact of the general medical pharmacopeia and the ways in which psychiatric illness can affect the presentation of medical illness are important for all psychiatrists to know. Most importantly, medical psychiatry should focus on the medical and neurologic causes of psychiatric illnesses. Many general medical conditions produce symptoms, which, in whole or in part, mimic psychiatric illnesses and, in some cases, could lead to psychiatric disorders, which makes identification of the underlying cause difficult.
Whether due to infectious, autoimmune, metabolic, or endocrinologic disorders, being aware of these conditions and, where clinical circumstances warrant, be able to diagnose them, with other specialists as needed, and ensure they are appropriately treated should be an essential skill for psychiatrists.
An illustrative case
I remember a case from early in my training of a woman with a late-onset mood disorder with abulia, wide-based gait, and urinary incontinence, in addition to withdrawal and loss of pleasure. Despite the skepticism of the neurology team, at autopsy she was found to have arteriosclerosis of the deep, penetrating arterioles causing white matter hyperintensities—Binswanger’s disease. There was no question that despite the neurologic cause of her symptoms treating her depression with antidepressants was needed and helpful. It also was important that her family was aware of her underlying medical condition and its implications for her care.2
Medicine is our calling
Many of these illnesses, even when identified, require expert psychiatric management of psychiatric symptoms. This should not be surprising to psychiatrists or other clinicians. No one expects a cardiologist to beg off the care of a patient with heart failure caused by alcohol abuse or a virus rather than vascular heart disease, and psychiatrists likewise need to manage psychosis due to steroid use or N-methyl-
Medical psychiatry has a broader and more inclusive perspective than what we generally mean by “biological psychiatry,” if by the latter, we mean a focus on the neurobiology and psychopharmacology of “primary” psychiatric conditions that are not secondary to other medical or neurologic disorders. As important and fundamental as deep understanding of neurobiology, genetics, and psychopharmacology are, medical psychiatry embeds our work more broadly in all of human biology and requires the full breadth of our medical training.
At a time when political battles over prescriptive privileges by non-medically trained mental health clinicians engage legislatures and professional organizations, medical psychiatry is a powerful reminder that prescribing or not prescribing medications is the final step in, what should be, an extensive, clinical evaluation including a thorough medical work up and consideration of the medical–psychiatric interactions and the differential diagnosis of these illnesses. It is, after all, what physicians do and is essential to our calling as psychiatric physicians. If psychiatrists are not at home in medicine, as Tom Hackett reminded us in 19771—at a time when psychiatry had temporarily eliminated the requirement for medical internships—then, indeed, psychiatry would be “homeless.”
Although the meaning of these terms varied from department to department, biologically oriented programs—influenced by Eli Robins and Samuel Guze and DSM-III—were focused on descriptive psychiatry: reliable, observable, and symptom-based elements of psychiatric illness. Related and important elements were a focus on psychopharmacologic treatments, genetics, epidemiology, and putative mechanisms for both diseases and treatments. Psychodynamic programs had a primary focus on psychodynamic theory, with extensive training in long-term, depth-oriented psychotherapy. Many of these are programs employed charismatic and brilliant teachers whose supervisory and interviewing skills were legendary. And, of course, all the programs claimed they did everything and did it well.
However, none of these programs were exactly what I was looking for. Although I had a long-standing interest in psychodynamics and was fascinated by the implications of—what was then a far more nascent—neurobiology, I was looking for a program that had all of these elements, but also had a focus on, what I thought of as, “medical psychiatry.” Although this may have meant different things to others, and was known as “psychosomatic medicine” or “consultation-liaison psychiatry,” to me, it was about the psychiatric manifestations of medical and neurologic disorders.
My years training in internal medicine were full of patients with neuropsychiatric illness due to a host of general medical and neurologic disorders. When I was an intern, the most common admitting diagnosis was what we called “Delta MS”—change in mental status. As I advanced in my residency and focused on a subspecialty of internal medicine, it became clear that whichever illnesses I studied, conditions such as anxiety disorders in Grave’s disease or the psychotic symptoms in lupus held my interest. Finally, the only specialty left was psychiatry.
The only program I found that seemed to understand medical psychiatry at the time was at Massachusetts General Hospital (MGH). MGH not only had eminent psychiatrists in every area of the field, it seemed, but also a special focus on training psychiatrists in medical settings and as medical experts. My first Chief of Psychiatry was Thomas P. Hackett, MD—a brilliant clinician, raconteur, and polymath—who had written a cri de coeur on the importance of medical skills and training in psychiatry.1 At last, I had found a place where I could remain a physician and think and learn about every aspect of psychiatry, especially medical psychiatry.
What is medical psychiatry, and why is it relevant now?
There has been substantial and increasing interest in the integration of medical and psychiatric care. Whether it is collaborative care or co-location models, the recognition of the high rate of combined medical and psychiatric illnesses and associated increased mortality and total health care costs of these patients requires psychiatrists to be deeply familiar with the interactions among medical and psychiatric conditions.
Building on long-developed expertise in consultation-liaison psychiatry and other forms of medical psychiatric training, such as double-board medicine–psychiatry programs, medical psychiatry includes several specific areas of knowledge and skill sets, including understanding the impact that psychiatric illnesses and the medications used to treat them can have on medical illnesses and the ways in which the presence of medical disorders can change the presentation of psychiatric illnesses. Similarly, the psychiatric impact of the general medical pharmacopeia and the ways in which psychiatric illness can affect the presentation of medical illness are important for all psychiatrists to know. Most importantly, medical psychiatry should focus on the medical and neurologic causes of psychiatric illnesses. Many general medical conditions produce symptoms, which, in whole or in part, mimic psychiatric illnesses and, in some cases, could lead to psychiatric disorders, which makes identification of the underlying cause difficult.
Whether due to infectious, autoimmune, metabolic, or endocrinologic disorders, being aware of these conditions and, where clinical circumstances warrant, be able to diagnose them, with other specialists as needed, and ensure they are appropriately treated should be an essential skill for psychiatrists.
An illustrative case
I remember a case from early in my training of a woman with a late-onset mood disorder with abulia, wide-based gait, and urinary incontinence, in addition to withdrawal and loss of pleasure. Despite the skepticism of the neurology team, at autopsy she was found to have arteriosclerosis of the deep, penetrating arterioles causing white matter hyperintensities—Binswanger’s disease. There was no question that despite the neurologic cause of her symptoms treating her depression with antidepressants was needed and helpful. It also was important that her family was aware of her underlying medical condition and its implications for her care.2
Medicine is our calling
Many of these illnesses, even when identified, require expert psychiatric management of psychiatric symptoms. This should not be surprising to psychiatrists or other clinicians. No one expects a cardiologist to beg off the care of a patient with heart failure caused by alcohol abuse or a virus rather than vascular heart disease, and psychiatrists likewise need to manage psychosis due to steroid use or N-methyl-
Medical psychiatry has a broader and more inclusive perspective than what we generally mean by “biological psychiatry,” if by the latter, we mean a focus on the neurobiology and psychopharmacology of “primary” psychiatric conditions that are not secondary to other medical or neurologic disorders. As important and fundamental as deep understanding of neurobiology, genetics, and psychopharmacology are, medical psychiatry embeds our work more broadly in all of human biology and requires the full breadth of our medical training.
At a time when political battles over prescriptive privileges by non-medically trained mental health clinicians engage legislatures and professional organizations, medical psychiatry is a powerful reminder that prescribing or not prescribing medications is the final step in, what should be, an extensive, clinical evaluation including a thorough medical work up and consideration of the medical–psychiatric interactions and the differential diagnosis of these illnesses. It is, after all, what physicians do and is essential to our calling as psychiatric physicians. If psychiatrists are not at home in medicine, as Tom Hackett reminded us in 19771—at a time when psychiatry had temporarily eliminated the requirement for medical internships—then, indeed, psychiatry would be “homeless.”
2. Summergrad P. Depression in Binswanger’s encephalopathy responsive to tranylcypromine: case report. J Clin Psychiatry. 1985;46(2):69-70.
2. Summergrad P. Depression in Binswanger’s encephalopathy responsive to tranylcypromine: case report. J Clin Psychiatry. 1985;46(2):69-70.
Self-compassion benefits psychiatrists, too
Congratulations to Ricks Warren, PhD, ABPP, Elke Smeets, PhD, and Kristen Neff, MD, the authors of “Self-criticism and self-compassion: Risk and resilience,” (Evidence-Based Reviews,
H. Steven Moffic, MD
Retired Tenured Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, Wisconsin
Dr. Warren responds
We couldn’t agree more with Dr. Moffic’s perspective that psychiatrists and other mental health clinicians likely would benefit from self-compassion during our clinical work in a complex, demanding, and rapidly changing mental health environment. Fortunately, attention to the importance of self-compassion for caregivers has been advocated, and recent studies of self-compassion in health care professionals have reported promising results. Because the neuroticism and self-criticism personality traits are most associated with depression and burnout in physicians, interventions that promote self-compassion are likely to lead to improved mental health in psychiatrists and other health care professionals. Recent research has found that self-compassion in health care providers is associated with less burnout and compassion fatigue, increased resilience, adaptive emotion regulation, and reduced sleep disturbance.1
The time is now right for clinical trials of self-compassion interventions in psychiatrists and other caregivers. Neff and Germer’s mindful self-compassion intervention,2 discussed in our article, could be easily adapted for psychiatrists and other mental health professionals. As Mills and Chapman,3 stated, “While being self-critical and perfectionistic may be common among doctors, being kind to oneself is not a luxury: it is a necessity. Self-care is, in a sense, a sine qua non for giving care for patients.”
Ricks Warren, PhD, ABPP
Clinical Associate Professor
Department of Psychiatry
University of Michigan Medical School
Ann Arbor, Michigan
1. Baker K, Warren R, Abelson J, et al. Physician mental health: depression and anxiety. In: Brower K, Riba M, eds. Physician mental health and well-being: research and practice. New York, NY: Springer. In press.
2. Neff KD, Germer CK. A pilot study and randomized controlled trial of the mindful self-compassion program. J Clin Psychol. 2013;69(1):28-44.
3. Mills J, Chapman M. Compassion and self-compassion in medicine: self-care for the caregiver. AMJ. 2016:9(5):87-91.
Congratulations to Ricks Warren, PhD, ABPP, Elke Smeets, PhD, and Kristen Neff, MD, the authors of “Self-criticism and self-compassion: Risk and resilience,” (Evidence-Based Reviews,
H. Steven Moffic, MD
Retired Tenured Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, Wisconsin
Dr. Warren responds
We couldn’t agree more with Dr. Moffic’s perspective that psychiatrists and other mental health clinicians likely would benefit from self-compassion during our clinical work in a complex, demanding, and rapidly changing mental health environment. Fortunately, attention to the importance of self-compassion for caregivers has been advocated, and recent studies of self-compassion in health care professionals have reported promising results. Because the neuroticism and self-criticism personality traits are most associated with depression and burnout in physicians, interventions that promote self-compassion are likely to lead to improved mental health in psychiatrists and other health care professionals. Recent research has found that self-compassion in health care providers is associated with less burnout and compassion fatigue, increased resilience, adaptive emotion regulation, and reduced sleep disturbance.1
The time is now right for clinical trials of self-compassion interventions in psychiatrists and other caregivers. Neff and Germer’s mindful self-compassion intervention,2 discussed in our article, could be easily adapted for psychiatrists and other mental health professionals. As Mills and Chapman,3 stated, “While being self-critical and perfectionistic may be common among doctors, being kind to oneself is not a luxury: it is a necessity. Self-care is, in a sense, a sine qua non for giving care for patients.”
Ricks Warren, PhD, ABPP
Clinical Associate Professor
Department of Psychiatry
University of Michigan Medical School
Ann Arbor, Michigan
Congratulations to Ricks Warren, PhD, ABPP, Elke Smeets, PhD, and Kristen Neff, MD, the authors of “Self-criticism and self-compassion: Risk and resilience,” (Evidence-Based Reviews,
H. Steven Moffic, MD
Retired Tenured Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, Wisconsin
Dr. Warren responds
We couldn’t agree more with Dr. Moffic’s perspective that psychiatrists and other mental health clinicians likely would benefit from self-compassion during our clinical work in a complex, demanding, and rapidly changing mental health environment. Fortunately, attention to the importance of self-compassion for caregivers has been advocated, and recent studies of self-compassion in health care professionals have reported promising results. Because the neuroticism and self-criticism personality traits are most associated with depression and burnout in physicians, interventions that promote self-compassion are likely to lead to improved mental health in psychiatrists and other health care professionals. Recent research has found that self-compassion in health care providers is associated with less burnout and compassion fatigue, increased resilience, adaptive emotion regulation, and reduced sleep disturbance.1
The time is now right for clinical trials of self-compassion interventions in psychiatrists and other caregivers. Neff and Germer’s mindful self-compassion intervention,2 discussed in our article, could be easily adapted for psychiatrists and other mental health professionals. As Mills and Chapman,3 stated, “While being self-critical and perfectionistic may be common among doctors, being kind to oneself is not a luxury: it is a necessity. Self-care is, in a sense, a sine qua non for giving care for patients.”
Ricks Warren, PhD, ABPP
Clinical Associate Professor
Department of Psychiatry
University of Michigan Medical School
Ann Arbor, Michigan
1. Baker K, Warren R, Abelson J, et al. Physician mental health: depression and anxiety. In: Brower K, Riba M, eds. Physician mental health and well-being: research and practice. New York, NY: Springer. In press.
2. Neff KD, Germer CK. A pilot study and randomized controlled trial of the mindful self-compassion program. J Clin Psychol. 2013;69(1):28-44.
3. Mills J, Chapman M. Compassion and self-compassion in medicine: self-care for the caregiver. AMJ. 2016:9(5):87-91.
1. Baker K, Warren R, Abelson J, et al. Physician mental health: depression and anxiety. In: Brower K, Riba M, eds. Physician mental health and well-being: research and practice. New York, NY: Springer. In press.
2. Neff KD, Germer CK. A pilot study and randomized controlled trial of the mindful self-compassion program. J Clin Psychol. 2013;69(1):28-44.
3. Mills J, Chapman M. Compassion and self-compassion in medicine: self-care for the caregiver. AMJ. 2016:9(5):87-91.
It’s time to screen for bullying
When I became a family physician (FP), it never crossed my mind that I would one day be asking school-aged children about bullying. Not so much because bullying didn’t exist, but because I wasn’t aware of the pervasiveness and seriousness of the problem and because there were no professional recommendations to do so.
That said, my family had some first-hand experience with the issue: One of my children was bullied in grade school. When my wife found out, she promptly visited the 2 boys’ homes and told them and their parents that the behavior would stop or else! (She may have used more colorful language.) And it did stop. But times have changed, and so has the nature of bullying, which can now extend beyond the hallway to an entire school body in seconds with a few taps on a cell phone. And the adverse consequences can be significant, as described by McClowry and colleagues.
The prevalence of bullying is discouragingly high, estimated to be about 20% in national surveys.1 Because bullying occurs so frequently, public health, community-based, and school-based approaches, rather than one-on-one office-based interventions, are likely to have the greatest overall impact on decreasing bullying. Randomized trials bear this out, showing that prevention programs in schools can effectively reduce the behavior.2,3
What is our responsibility as FPs? Screening is a reasonable first step, even in the absence of randomized trials demonstrating benefit. Because there have been no physician office-based trials of screening or interventions for bullying, we must rely on “expert opinion” at this time, with no assurance that what we do will actually help children. Absence of proof of benefit, however, does not mean absence of benefit, and doing nothing will definitely not help anyone. The authors recommend a single screening question: "Are you being bullied?"—especially for children who are at higher risk, such as those with disabilities/special health needs, LGBTQ+ status, and who are under- or overweight.
Clearly we need research to know which interventions truly help these children/adolescents and their parents. In the meantime, however, identifying the problem and offering emotional support are unlikely to harm—and may help. Opening the lines of communication, connecting children and their parents with available community resources, and supporting anti-bullying programs in your schools are additional ways we can make a difference today.
1. Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance System – United States, 2015. MMWR Morb Mortal Wkly. 2016;65:1-174.
2. Waasdorp TE, Bradshaw CP, Leaf PJ. The impact of schoolwide positive behavioral interventions and supports on bullying and peer rejection: a randomized controlled effectiveness trial. Arch Pediatr Adolesc Med. 2012;166:149-156.
3. Espelage DL, Low S, Polanin JR, et al. The impact of a middle school program to reduce aggression, victimization, and sexual violence. J Adolesc Health. 2013;53:180-186.
Editor-in-Chief
Editor-in-Chief
Editor-in-Chief
When I became a family physician (FP), it never crossed my mind that I would one day be asking school-aged children about bullying. Not so much because bullying didn’t exist, but because I wasn’t aware of the pervasiveness and seriousness of the problem and because there were no professional recommendations to do so.
That said, my family had some first-hand experience with the issue: One of my children was bullied in grade school. When my wife found out, she promptly visited the 2 boys’ homes and told them and their parents that the behavior would stop or else! (She may have used more colorful language.) And it did stop. But times have changed, and so has the nature of bullying, which can now extend beyond the hallway to an entire school body in seconds with a few taps on a cell phone. And the adverse consequences can be significant, as described by McClowry and colleagues.
The prevalence of bullying is discouragingly high, estimated to be about 20% in national surveys.1 Because bullying occurs so frequently, public health, community-based, and school-based approaches, rather than one-on-one office-based interventions, are likely to have the greatest overall impact on decreasing bullying. Randomized trials bear this out, showing that prevention programs in schools can effectively reduce the behavior.2,3
What is our responsibility as FPs? Screening is a reasonable first step, even in the absence of randomized trials demonstrating benefit. Because there have been no physician office-based trials of screening or interventions for bullying, we must rely on “expert opinion” at this time, with no assurance that what we do will actually help children. Absence of proof of benefit, however, does not mean absence of benefit, and doing nothing will definitely not help anyone. The authors recommend a single screening question: "Are you being bullied?"—especially for children who are at higher risk, such as those with disabilities/special health needs, LGBTQ+ status, and who are under- or overweight.
Clearly we need research to know which interventions truly help these children/adolescents and their parents. In the meantime, however, identifying the problem and offering emotional support are unlikely to harm—and may help. Opening the lines of communication, connecting children and their parents with available community resources, and supporting anti-bullying programs in your schools are additional ways we can make a difference today.
When I became a family physician (FP), it never crossed my mind that I would one day be asking school-aged children about bullying. Not so much because bullying didn’t exist, but because I wasn’t aware of the pervasiveness and seriousness of the problem and because there were no professional recommendations to do so.
That said, my family had some first-hand experience with the issue: One of my children was bullied in grade school. When my wife found out, she promptly visited the 2 boys’ homes and told them and their parents that the behavior would stop or else! (She may have used more colorful language.) And it did stop. But times have changed, and so has the nature of bullying, which can now extend beyond the hallway to an entire school body in seconds with a few taps on a cell phone. And the adverse consequences can be significant, as described by McClowry and colleagues.
The prevalence of bullying is discouragingly high, estimated to be about 20% in national surveys.1 Because bullying occurs so frequently, public health, community-based, and school-based approaches, rather than one-on-one office-based interventions, are likely to have the greatest overall impact on decreasing bullying. Randomized trials bear this out, showing that prevention programs in schools can effectively reduce the behavior.2,3
What is our responsibility as FPs? Screening is a reasonable first step, even in the absence of randomized trials demonstrating benefit. Because there have been no physician office-based trials of screening or interventions for bullying, we must rely on “expert opinion” at this time, with no assurance that what we do will actually help children. Absence of proof of benefit, however, does not mean absence of benefit, and doing nothing will definitely not help anyone. The authors recommend a single screening question: "Are you being bullied?"—especially for children who are at higher risk, such as those with disabilities/special health needs, LGBTQ+ status, and who are under- or overweight.
Clearly we need research to know which interventions truly help these children/adolescents and their parents. In the meantime, however, identifying the problem and offering emotional support are unlikely to harm—and may help. Opening the lines of communication, connecting children and their parents with available community resources, and supporting anti-bullying programs in your schools are additional ways we can make a difference today.
1. Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance System – United States, 2015. MMWR Morb Mortal Wkly. 2016;65:1-174.
2. Waasdorp TE, Bradshaw CP, Leaf PJ. The impact of schoolwide positive behavioral interventions and supports on bullying and peer rejection: a randomized controlled effectiveness trial. Arch Pediatr Adolesc Med. 2012;166:149-156.
3. Espelage DL, Low S, Polanin JR, et al. The impact of a middle school program to reduce aggression, victimization, and sexual violence. J Adolesc Health. 2013;53:180-186.
1. Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance System – United States, 2015. MMWR Morb Mortal Wkly. 2016;65:1-174.
2. Waasdorp TE, Bradshaw CP, Leaf PJ. The impact of schoolwide positive behavioral interventions and supports on bullying and peer rejection: a randomized controlled effectiveness trial. Arch Pediatr Adolesc Med. 2012;166:149-156.
3. Espelage DL, Low S, Polanin JR, et al. The impact of a middle school program to reduce aggression, victimization, and sexual violence. J Adolesc Health. 2013;53:180-186.
Metformin for acne
Acne is the most common skin condition, affecting up to 50 million individuals annually. Self-esteem is affected, and scarring can result if left untreated or inadequately treated. Although still somewhat controversial in some circles, available data have linked acne to dairy products, refined sugar ingestion, and high glycemic loads.
Acne has been linked to insulin levels and insulin-like growth factor (IGF-1). Glycemic loads are associated with both insulin and IGF-1. Metformin reduces glucose release from the liver while increasing glucose uptake in muscles and adipocytes.
So, can interventions that reduce glycemic load, such as diet and metformin, decrease the incidence of acne in patients among whom other standard interventions have been tried?
Gabriella Fabbrocini, MD, of the University of Naples, Italy, and her colleagues tested this hypothesis by conducting a randomized, clinical trial evaluating the impact of a low glycemic diet and metformin on acne (Clin Exp Dermatol. 2016 Jan;41[1]:38-42). Twenty males aged 17-24 years with acne for at least 1 year were randomized to either metformin 500 mg twice daily with a 1,500- to 2,000-kcal diet rich in fruits, vegetables, fish, and low carbohydrates with standard therapy; or standard therapy alone. Standard therapy consisted of a bland skin detergent and a sebostatic cream. Acne severity was rated by four observers.
Patients in the metformin group demonstrated a statistically significant improvement in acne severity, compared with patients in the standard care only group. No side effects were reported with metformin.
In this study, only patients with an “altered metabolic profile” were enrolled and randomized. An “altered metabolic profile” was defined as impaired fasting glucose, high total cholesterol or LDL, reduced HDL, and elevated waist circumference and body mass index. Results should be generalizable only to patients with these characteristics. The sample size in this study was small, but the included picture of acne resolution on one subject was indeed impressive.
For patients among whom traditional acne treatment approaches have not been effective, and knowing the tolerability and affordability of metformin, this may be a reasonable intervention.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.
Acne is the most common skin condition, affecting up to 50 million individuals annually. Self-esteem is affected, and scarring can result if left untreated or inadequately treated. Although still somewhat controversial in some circles, available data have linked acne to dairy products, refined sugar ingestion, and high glycemic loads.
Acne has been linked to insulin levels and insulin-like growth factor (IGF-1). Glycemic loads are associated with both insulin and IGF-1. Metformin reduces glucose release from the liver while increasing glucose uptake in muscles and adipocytes.
So, can interventions that reduce glycemic load, such as diet and metformin, decrease the incidence of acne in patients among whom other standard interventions have been tried?
Gabriella Fabbrocini, MD, of the University of Naples, Italy, and her colleagues tested this hypothesis by conducting a randomized, clinical trial evaluating the impact of a low glycemic diet and metformin on acne (Clin Exp Dermatol. 2016 Jan;41[1]:38-42). Twenty males aged 17-24 years with acne for at least 1 year were randomized to either metformin 500 mg twice daily with a 1,500- to 2,000-kcal diet rich in fruits, vegetables, fish, and low carbohydrates with standard therapy; or standard therapy alone. Standard therapy consisted of a bland skin detergent and a sebostatic cream. Acne severity was rated by four observers.
Patients in the metformin group demonstrated a statistically significant improvement in acne severity, compared with patients in the standard care only group. No side effects were reported with metformin.
In this study, only patients with an “altered metabolic profile” were enrolled and randomized. An “altered metabolic profile” was defined as impaired fasting glucose, high total cholesterol or LDL, reduced HDL, and elevated waist circumference and body mass index. Results should be generalizable only to patients with these characteristics. The sample size in this study was small, but the included picture of acne resolution on one subject was indeed impressive.
For patients among whom traditional acne treatment approaches have not been effective, and knowing the tolerability and affordability of metformin, this may be a reasonable intervention.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.
Acne is the most common skin condition, affecting up to 50 million individuals annually. Self-esteem is affected, and scarring can result if left untreated or inadequately treated. Although still somewhat controversial in some circles, available data have linked acne to dairy products, refined sugar ingestion, and high glycemic loads.
Acne has been linked to insulin levels and insulin-like growth factor (IGF-1). Glycemic loads are associated with both insulin and IGF-1. Metformin reduces glucose release from the liver while increasing glucose uptake in muscles and adipocytes.
So, can interventions that reduce glycemic load, such as diet and metformin, decrease the incidence of acne in patients among whom other standard interventions have been tried?
Gabriella Fabbrocini, MD, of the University of Naples, Italy, and her colleagues tested this hypothesis by conducting a randomized, clinical trial evaluating the impact of a low glycemic diet and metformin on acne (Clin Exp Dermatol. 2016 Jan;41[1]:38-42). Twenty males aged 17-24 years with acne for at least 1 year were randomized to either metformin 500 mg twice daily with a 1,500- to 2,000-kcal diet rich in fruits, vegetables, fish, and low carbohydrates with standard therapy; or standard therapy alone. Standard therapy consisted of a bland skin detergent and a sebostatic cream. Acne severity was rated by four observers.
Patients in the metformin group demonstrated a statistically significant improvement in acne severity, compared with patients in the standard care only group. No side effects were reported with metformin.
In this study, only patients with an “altered metabolic profile” were enrolled and randomized. An “altered metabolic profile” was defined as impaired fasting glucose, high total cholesterol or LDL, reduced HDL, and elevated waist circumference and body mass index. Results should be generalizable only to patients with these characteristics. The sample size in this study was small, but the included picture of acne resolution on one subject was indeed impressive.
For patients among whom traditional acne treatment approaches have not been effective, and knowing the tolerability and affordability of metformin, this may be a reasonable intervention.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.