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How to prepare to care for transgender adolescents
As pediatric and adolescent gynecologists, we are seeing an increasing number of adolescents with gender identity issues and have come to believe that all obstetrician-gynecologists need to have an understanding of varying gender identities, as well as their role in managing these patients’ care.
We had the honor to assist the American College of Obstetricians and Gynecologists’ (ACOG) Committee on Adolescent Health Care in the development of a new Committee Opinion to guide ob.gyns. in caring for transgender adolescents (Obstet Gynecol 2017;129:e11-6). As our culture grows more aware of the nuances and spectrum of gender identity, our health care practices must grow as well. Ob.gyns. are often uniquely positioned as being among the first people transgender adolescents present to – whether it’s signaling disassociation with their gender when answering routine medical questions or directly addressing gender with them as a trusted and private resource. Even when seeing a patient too young to consider hormone therapy, an ob.gyn. can offer vital early behavioral health support, educational and community resources, and specialist referrals.
Transgender adolescent patients have likely faced negative stereotypes and stigmas in social settings or through media that make them cautious and protective of their identity. They are also more likely to face social ostracism such as bullying and/or dissent and rejection from their parents, deepening the vulnerability of their situation. As a result, transgender adolescents can have increased instances of anxiety, depression, sexual harassment, homelessness, and risk-taking behavior. Medical practices can signal to transgender patients that they are safe and welcoming from the start by offering gender neutral forms, brochures, and information for LGBT patients in the waiting room, and having sensitive employees at every step – from the front desk onward.
As we’ve just outlined, transgender adolescent patients face unique challenges, including increased rates of social and mental health risks. In response, ob.gyns. must be prepared to have a comprehensive conversation about health and well-being beyond sexual and reproductive health. They must also be equipped to address the psychosocial issues associated with transgender adolescents. This includes knowledge of what to look for and offering patients resources, education, and referrals to guarantee their health and safety.
It is important that ob.gyns. are aware that transgender men have female reproductive organs and can present with common gynecological problems such as abnormal bleeding, ovarian cysts, and torsion, as well as pregnancy and pregnancy complications. Finally, ob.gyns. can serve a unique role in counseling about fertility and fertility preservation. Thus, not only do we provide essential health care, including ongoing primary care, but we can position ourselves as part of the support network for these adolescents and their families.
Most importantly, when addressing an adolescent transgender patient, we must understand there is no uniform transgender experience. Expressing gender, sexual identity, and behavior patterns will vary from patient to patient. There are a wide range of treatment options available for transgender patients, from hormone to surgical therapies. An ob.gyn.’s responsibility is to help each individual make an informed decision, and help that patient think ahead to the future.
While this all may seem like a lot, it’s important to remember the essential components of our role as health care providers do not change because an adolescent patient is transgender. Care should always include education about their bodies, safe sex, deliberate and thoughtful assessment of symptoms or concerns, and preventive care services such as STI screenings and contraception. We are simply adding more nuanced cultural and medical understanding to those practices.
Dr. Gomez-Lobo is director of pediatric and adolescent obstetrics and gynecology, Medstar Washington Hospital Center/Children’s National Health System, Washington, D.C. Dr. Sokkary is associate professor of ob.gyn. at Navicent Health Center/Mercer School of Medicine in Macon, Ga. They are members of the ACOG Committee on Adolescent Health Care. They reported having no relevant financial disclosures.
As pediatric and adolescent gynecologists, we are seeing an increasing number of adolescents with gender identity issues and have come to believe that all obstetrician-gynecologists need to have an understanding of varying gender identities, as well as their role in managing these patients’ care.
We had the honor to assist the American College of Obstetricians and Gynecologists’ (ACOG) Committee on Adolescent Health Care in the development of a new Committee Opinion to guide ob.gyns. in caring for transgender adolescents (Obstet Gynecol 2017;129:e11-6). As our culture grows more aware of the nuances and spectrum of gender identity, our health care practices must grow as well. Ob.gyns. are often uniquely positioned as being among the first people transgender adolescents present to – whether it’s signaling disassociation with their gender when answering routine medical questions or directly addressing gender with them as a trusted and private resource. Even when seeing a patient too young to consider hormone therapy, an ob.gyn. can offer vital early behavioral health support, educational and community resources, and specialist referrals.
Transgender adolescent patients have likely faced negative stereotypes and stigmas in social settings or through media that make them cautious and protective of their identity. They are also more likely to face social ostracism such as bullying and/or dissent and rejection from their parents, deepening the vulnerability of their situation. As a result, transgender adolescents can have increased instances of anxiety, depression, sexual harassment, homelessness, and risk-taking behavior. Medical practices can signal to transgender patients that they are safe and welcoming from the start by offering gender neutral forms, brochures, and information for LGBT patients in the waiting room, and having sensitive employees at every step – from the front desk onward.
As we’ve just outlined, transgender adolescent patients face unique challenges, including increased rates of social and mental health risks. In response, ob.gyns. must be prepared to have a comprehensive conversation about health and well-being beyond sexual and reproductive health. They must also be equipped to address the psychosocial issues associated with transgender adolescents. This includes knowledge of what to look for and offering patients resources, education, and referrals to guarantee their health and safety.
It is important that ob.gyns. are aware that transgender men have female reproductive organs and can present with common gynecological problems such as abnormal bleeding, ovarian cysts, and torsion, as well as pregnancy and pregnancy complications. Finally, ob.gyns. can serve a unique role in counseling about fertility and fertility preservation. Thus, not only do we provide essential health care, including ongoing primary care, but we can position ourselves as part of the support network for these adolescents and their families.
Most importantly, when addressing an adolescent transgender patient, we must understand there is no uniform transgender experience. Expressing gender, sexual identity, and behavior patterns will vary from patient to patient. There are a wide range of treatment options available for transgender patients, from hormone to surgical therapies. An ob.gyn.’s responsibility is to help each individual make an informed decision, and help that patient think ahead to the future.
While this all may seem like a lot, it’s important to remember the essential components of our role as health care providers do not change because an adolescent patient is transgender. Care should always include education about their bodies, safe sex, deliberate and thoughtful assessment of symptoms or concerns, and preventive care services such as STI screenings and contraception. We are simply adding more nuanced cultural and medical understanding to those practices.
Dr. Gomez-Lobo is director of pediatric and adolescent obstetrics and gynecology, Medstar Washington Hospital Center/Children’s National Health System, Washington, D.C. Dr. Sokkary is associate professor of ob.gyn. at Navicent Health Center/Mercer School of Medicine in Macon, Ga. They are members of the ACOG Committee on Adolescent Health Care. They reported having no relevant financial disclosures.
As pediatric and adolescent gynecologists, we are seeing an increasing number of adolescents with gender identity issues and have come to believe that all obstetrician-gynecologists need to have an understanding of varying gender identities, as well as their role in managing these patients’ care.
We had the honor to assist the American College of Obstetricians and Gynecologists’ (ACOG) Committee on Adolescent Health Care in the development of a new Committee Opinion to guide ob.gyns. in caring for transgender adolescents (Obstet Gynecol 2017;129:e11-6). As our culture grows more aware of the nuances and spectrum of gender identity, our health care practices must grow as well. Ob.gyns. are often uniquely positioned as being among the first people transgender adolescents present to – whether it’s signaling disassociation with their gender when answering routine medical questions or directly addressing gender with them as a trusted and private resource. Even when seeing a patient too young to consider hormone therapy, an ob.gyn. can offer vital early behavioral health support, educational and community resources, and specialist referrals.
Transgender adolescent patients have likely faced negative stereotypes and stigmas in social settings or through media that make them cautious and protective of their identity. They are also more likely to face social ostracism such as bullying and/or dissent and rejection from their parents, deepening the vulnerability of their situation. As a result, transgender adolescents can have increased instances of anxiety, depression, sexual harassment, homelessness, and risk-taking behavior. Medical practices can signal to transgender patients that they are safe and welcoming from the start by offering gender neutral forms, brochures, and information for LGBT patients in the waiting room, and having sensitive employees at every step – from the front desk onward.
As we’ve just outlined, transgender adolescent patients face unique challenges, including increased rates of social and mental health risks. In response, ob.gyns. must be prepared to have a comprehensive conversation about health and well-being beyond sexual and reproductive health. They must also be equipped to address the psychosocial issues associated with transgender adolescents. This includes knowledge of what to look for and offering patients resources, education, and referrals to guarantee their health and safety.
It is important that ob.gyns. are aware that transgender men have female reproductive organs and can present with common gynecological problems such as abnormal bleeding, ovarian cysts, and torsion, as well as pregnancy and pregnancy complications. Finally, ob.gyns. can serve a unique role in counseling about fertility and fertility preservation. Thus, not only do we provide essential health care, including ongoing primary care, but we can position ourselves as part of the support network for these adolescents and their families.
Most importantly, when addressing an adolescent transgender patient, we must understand there is no uniform transgender experience. Expressing gender, sexual identity, and behavior patterns will vary from patient to patient. There are a wide range of treatment options available for transgender patients, from hormone to surgical therapies. An ob.gyn.’s responsibility is to help each individual make an informed decision, and help that patient think ahead to the future.
While this all may seem like a lot, it’s important to remember the essential components of our role as health care providers do not change because an adolescent patient is transgender. Care should always include education about their bodies, safe sex, deliberate and thoughtful assessment of symptoms or concerns, and preventive care services such as STI screenings and contraception. We are simply adding more nuanced cultural and medical understanding to those practices.
Dr. Gomez-Lobo is director of pediatric and adolescent obstetrics and gynecology, Medstar Washington Hospital Center/Children’s National Health System, Washington, D.C. Dr. Sokkary is associate professor of ob.gyn. at Navicent Health Center/Mercer School of Medicine in Macon, Ga. They are members of the ACOG Committee on Adolescent Health Care. They reported having no relevant financial disclosures.
Climate change: A call to action for psychiatry
In a recent survey of about 90 psychiatrists attending a national general psychiatry meeting, the overwhelming majority believed that climate change is human caused and the impacts were already or would soon be harming their patients. They expressed an interest in knowing more, reporting that they sometimes had little knowledge about the issues. They also believed that psychiatrists have a role to play in making the case to be better prepared for what our communities are facing. Professional organizations were a desirable choice as a source of information and training.
Because of these responses we, the Climate Psychiatry Alliance, believe that a scientific and well thought out program addressing the mental health impacts of climate disruption with practical advice on how to help our patients and our communities in the face of climate disasters while emphasizing preparedness and prevention, is called for.
As physicians, we are keenly aware of and concerned about the physical harm of extreme weather events causing acute harm, including tornadoes, fires, floods, hurricanes, and so on. We also know about the longer-term chronic conditions, including sea level rise, drought, and permanent and high temperatures.
We also know that the spread of infectious diseases, both old and some new, on us, our children, and even the unborn, is a rising challenge to our communities. The National Academy of Sciences, for example, recently linked the Zika outbreak to a rise in temperature (Proc Nat Acad Sci. 2017;114[1]:119-24). The expanding reach of malaria and the growing incidence of such illnesses as dengue, chikungunya, and Lyme also are linked to higher temperatures.
Though the physical harm from climate disruption is increasingly being discussed, more attention needs to be given to the psychological harm: When the place we call home is burned down, blown away, flooded … when we lose our possessions; maybe our pets, our livelihood; see injuries, illness, and death; the mix of fear, anger, sorrow, and trauma can bring on a full range of psychiatric disorders. Mental health professionals are already seeing posttraumatic stress disorder, depression, and anxiety disorders, as well as an increase in drug and alcohol abuse, violence against women, and child abuse (Ann Glob Health. 2014 Jul-Aug;80[4]:332-44), (Soc Sci Med. 2015;[141]:133-41), (Soc Sci Res. 2013;42[5]:1222-35), (Soc Sci Med. 2017 Jan 6;[175]:161-8).
The link between climate and aggression is clear: For each standard deviation of increased temperature and rainfall, a 4% rise in aggression between individuals and a 14% rise among groups can be expected (Science. 2013 Sep 13;34[6151]:1235367). This is true across all ethnicities and regions. General unrest around the world should come as no surprise to us – nor should its rise in the years ahead, given that temperatures will continue to rise.
The psychological needs and impacts on our communities of exploding numbers of refugees from mounting climate disruption in many areas of the world are of grave concern as the impacts of the upheaval grow ever more profound. The United Nations reports that what we are seeing now and are already unable to address, is just the tip of the iceberg.
Psychiatrists have a special role to play in all of this, because we not only are experts in physical health, we are experts on psychological harm.
We also know that any physical condition or illness carries an attendant emotional toll. Trained in science, we respect the scientific method and the peer-reviewed work that goes into validating what the scientists are telling us.
We know that harm that is entirely accidental is much easier to get over than harm experienced as avoidable. That appropriate action to protect our climate was not taken in time will become more apparent – with fear and anger among patients, families, and communities directed at policy makers and a compounding erosion of trust in our institutions. We must look at how fear, anger, and mistrust drive politics not only in our country but elsewhere since we are now a global village, interconnected.
And we must confront our values: Climate disruption is an issue of social justice, because those who will be hurt the most are from disadvantaged communities, and it is an intergenerational justice issue, because our children will inherit our mistakes. How will we answer these questions?
As experts focused on changing behaviors before it is too late, at confronting denial and resistance in ways that build people up and help influence them to change, and with the standing we have in the community, as psychiatrists we have a unique role to play. We also take seriously that our canon of ethics states our responsibility to serve our communities in ways that enhance their health.
We call upon our professional communities to help us respond to the growing public health crises. Among the many needs: education – putting together trainings for our colleagues and other thought leaders and policy makers that identify the public health burdens and drive action on them; preparedness – advising communities and individuals about how to deal with climate challenges; and prevention – advocating for solutions that reduce our vulnerability with sustainable habits and promote resilience. There is much more for us to uncover and act upon together in the months ahead.
We call upon one another for action, because only collective success will restore our health and keep us safe.
Dr. Van Susteren wrote this commentary on behalf of the Climate Psychiatry Alliance, a professional group dedicated to promoting awareness and action on climate from a mental health perspective. She is a practicing general and forensic psychiatrist in Washington. Dr. Van Susteren serves on the advisory board of the Center for Health and the Global Environment at Harvard T.H. Chan School of Public Health, Boston. She is a former member of the board of directors of the National Wildlife Federation and coauthor of group’s report, “The Psychological Effects of Global Warming on the United States – Why the U.S. Mental Health System is Not Prepared.” In 2006, Dr. Van Susteren sought the Democratic nomination for a U.S. Senate seat in Maryland. Recently, she founded Lucky Planet Foods, a company that provides plant-based, low carbon foods.
In a recent survey of about 90 psychiatrists attending a national general psychiatry meeting, the overwhelming majority believed that climate change is human caused and the impacts were already or would soon be harming their patients. They expressed an interest in knowing more, reporting that they sometimes had little knowledge about the issues. They also believed that psychiatrists have a role to play in making the case to be better prepared for what our communities are facing. Professional organizations were a desirable choice as a source of information and training.
Because of these responses we, the Climate Psychiatry Alliance, believe that a scientific and well thought out program addressing the mental health impacts of climate disruption with practical advice on how to help our patients and our communities in the face of climate disasters while emphasizing preparedness and prevention, is called for.
As physicians, we are keenly aware of and concerned about the physical harm of extreme weather events causing acute harm, including tornadoes, fires, floods, hurricanes, and so on. We also know about the longer-term chronic conditions, including sea level rise, drought, and permanent and high temperatures.
We also know that the spread of infectious diseases, both old and some new, on us, our children, and even the unborn, is a rising challenge to our communities. The National Academy of Sciences, for example, recently linked the Zika outbreak to a rise in temperature (Proc Nat Acad Sci. 2017;114[1]:119-24). The expanding reach of malaria and the growing incidence of such illnesses as dengue, chikungunya, and Lyme also are linked to higher temperatures.
Though the physical harm from climate disruption is increasingly being discussed, more attention needs to be given to the psychological harm: When the place we call home is burned down, blown away, flooded … when we lose our possessions; maybe our pets, our livelihood; see injuries, illness, and death; the mix of fear, anger, sorrow, and trauma can bring on a full range of psychiatric disorders. Mental health professionals are already seeing posttraumatic stress disorder, depression, and anxiety disorders, as well as an increase in drug and alcohol abuse, violence against women, and child abuse (Ann Glob Health. 2014 Jul-Aug;80[4]:332-44), (Soc Sci Med. 2015;[141]:133-41), (Soc Sci Res. 2013;42[5]:1222-35), (Soc Sci Med. 2017 Jan 6;[175]:161-8).
The link between climate and aggression is clear: For each standard deviation of increased temperature and rainfall, a 4% rise in aggression between individuals and a 14% rise among groups can be expected (Science. 2013 Sep 13;34[6151]:1235367). This is true across all ethnicities and regions. General unrest around the world should come as no surprise to us – nor should its rise in the years ahead, given that temperatures will continue to rise.
The psychological needs and impacts on our communities of exploding numbers of refugees from mounting climate disruption in many areas of the world are of grave concern as the impacts of the upheaval grow ever more profound. The United Nations reports that what we are seeing now and are already unable to address, is just the tip of the iceberg.
Psychiatrists have a special role to play in all of this, because we not only are experts in physical health, we are experts on psychological harm.
We also know that any physical condition or illness carries an attendant emotional toll. Trained in science, we respect the scientific method and the peer-reviewed work that goes into validating what the scientists are telling us.
We know that harm that is entirely accidental is much easier to get over than harm experienced as avoidable. That appropriate action to protect our climate was not taken in time will become more apparent – with fear and anger among patients, families, and communities directed at policy makers and a compounding erosion of trust in our institutions. We must look at how fear, anger, and mistrust drive politics not only in our country but elsewhere since we are now a global village, interconnected.
And we must confront our values: Climate disruption is an issue of social justice, because those who will be hurt the most are from disadvantaged communities, and it is an intergenerational justice issue, because our children will inherit our mistakes. How will we answer these questions?
As experts focused on changing behaviors before it is too late, at confronting denial and resistance in ways that build people up and help influence them to change, and with the standing we have in the community, as psychiatrists we have a unique role to play. We also take seriously that our canon of ethics states our responsibility to serve our communities in ways that enhance their health.
We call upon our professional communities to help us respond to the growing public health crises. Among the many needs: education – putting together trainings for our colleagues and other thought leaders and policy makers that identify the public health burdens and drive action on them; preparedness – advising communities and individuals about how to deal with climate challenges; and prevention – advocating for solutions that reduce our vulnerability with sustainable habits and promote resilience. There is much more for us to uncover and act upon together in the months ahead.
We call upon one another for action, because only collective success will restore our health and keep us safe.
Dr. Van Susteren wrote this commentary on behalf of the Climate Psychiatry Alliance, a professional group dedicated to promoting awareness and action on climate from a mental health perspective. She is a practicing general and forensic psychiatrist in Washington. Dr. Van Susteren serves on the advisory board of the Center for Health and the Global Environment at Harvard T.H. Chan School of Public Health, Boston. She is a former member of the board of directors of the National Wildlife Federation and coauthor of group’s report, “The Psychological Effects of Global Warming on the United States – Why the U.S. Mental Health System is Not Prepared.” In 2006, Dr. Van Susteren sought the Democratic nomination for a U.S. Senate seat in Maryland. Recently, she founded Lucky Planet Foods, a company that provides plant-based, low carbon foods.
In a recent survey of about 90 psychiatrists attending a national general psychiatry meeting, the overwhelming majority believed that climate change is human caused and the impacts were already or would soon be harming their patients. They expressed an interest in knowing more, reporting that they sometimes had little knowledge about the issues. They also believed that psychiatrists have a role to play in making the case to be better prepared for what our communities are facing. Professional organizations were a desirable choice as a source of information and training.
Because of these responses we, the Climate Psychiatry Alliance, believe that a scientific and well thought out program addressing the mental health impacts of climate disruption with practical advice on how to help our patients and our communities in the face of climate disasters while emphasizing preparedness and prevention, is called for.
As physicians, we are keenly aware of and concerned about the physical harm of extreme weather events causing acute harm, including tornadoes, fires, floods, hurricanes, and so on. We also know about the longer-term chronic conditions, including sea level rise, drought, and permanent and high temperatures.
We also know that the spread of infectious diseases, both old and some new, on us, our children, and even the unborn, is a rising challenge to our communities. The National Academy of Sciences, for example, recently linked the Zika outbreak to a rise in temperature (Proc Nat Acad Sci. 2017;114[1]:119-24). The expanding reach of malaria and the growing incidence of such illnesses as dengue, chikungunya, and Lyme also are linked to higher temperatures.
Though the physical harm from climate disruption is increasingly being discussed, more attention needs to be given to the psychological harm: When the place we call home is burned down, blown away, flooded … when we lose our possessions; maybe our pets, our livelihood; see injuries, illness, and death; the mix of fear, anger, sorrow, and trauma can bring on a full range of psychiatric disorders. Mental health professionals are already seeing posttraumatic stress disorder, depression, and anxiety disorders, as well as an increase in drug and alcohol abuse, violence against women, and child abuse (Ann Glob Health. 2014 Jul-Aug;80[4]:332-44), (Soc Sci Med. 2015;[141]:133-41), (Soc Sci Res. 2013;42[5]:1222-35), (Soc Sci Med. 2017 Jan 6;[175]:161-8).
The link between climate and aggression is clear: For each standard deviation of increased temperature and rainfall, a 4% rise in aggression between individuals and a 14% rise among groups can be expected (Science. 2013 Sep 13;34[6151]:1235367). This is true across all ethnicities and regions. General unrest around the world should come as no surprise to us – nor should its rise in the years ahead, given that temperatures will continue to rise.
The psychological needs and impacts on our communities of exploding numbers of refugees from mounting climate disruption in many areas of the world are of grave concern as the impacts of the upheaval grow ever more profound. The United Nations reports that what we are seeing now and are already unable to address, is just the tip of the iceberg.
Psychiatrists have a special role to play in all of this, because we not only are experts in physical health, we are experts on psychological harm.
We also know that any physical condition or illness carries an attendant emotional toll. Trained in science, we respect the scientific method and the peer-reviewed work that goes into validating what the scientists are telling us.
We know that harm that is entirely accidental is much easier to get over than harm experienced as avoidable. That appropriate action to protect our climate was not taken in time will become more apparent – with fear and anger among patients, families, and communities directed at policy makers and a compounding erosion of trust in our institutions. We must look at how fear, anger, and mistrust drive politics not only in our country but elsewhere since we are now a global village, interconnected.
And we must confront our values: Climate disruption is an issue of social justice, because those who will be hurt the most are from disadvantaged communities, and it is an intergenerational justice issue, because our children will inherit our mistakes. How will we answer these questions?
As experts focused on changing behaviors before it is too late, at confronting denial and resistance in ways that build people up and help influence them to change, and with the standing we have in the community, as psychiatrists we have a unique role to play. We also take seriously that our canon of ethics states our responsibility to serve our communities in ways that enhance their health.
We call upon our professional communities to help us respond to the growing public health crises. Among the many needs: education – putting together trainings for our colleagues and other thought leaders and policy makers that identify the public health burdens and drive action on them; preparedness – advising communities and individuals about how to deal with climate challenges; and prevention – advocating for solutions that reduce our vulnerability with sustainable habits and promote resilience. There is much more for us to uncover and act upon together in the months ahead.
We call upon one another for action, because only collective success will restore our health and keep us safe.
Dr. Van Susteren wrote this commentary on behalf of the Climate Psychiatry Alliance, a professional group dedicated to promoting awareness and action on climate from a mental health perspective. She is a practicing general and forensic psychiatrist in Washington. Dr. Van Susteren serves on the advisory board of the Center for Health and the Global Environment at Harvard T.H. Chan School of Public Health, Boston. She is a former member of the board of directors of the National Wildlife Federation and coauthor of group’s report, “The Psychological Effects of Global Warming on the United States – Why the U.S. Mental Health System is Not Prepared.” In 2006, Dr. Van Susteren sought the Democratic nomination for a U.S. Senate seat in Maryland. Recently, she founded Lucky Planet Foods, a company that provides plant-based, low carbon foods.
VIDEO: Health law changes under new administration
WASHINGTON – A new president is taking office along with new staffers to lead the country’s top health care agencies.
In this video, Joyce Hall, chair of the American Bar Association Health Law Section, discusses what changes she foresees in health law issues under the new administration and what to expect from the leadership transition. Ms. Hall also speaks on potential alterations to the Medicare Access and CHIP Reauthorization Act of 2015 and whether the potential appointment of Rep. Tom Price (R-Ga.) as U.S. Department of Health and Human Services Secretary will be positive or negative for health care providers.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
WASHINGTON – A new president is taking office along with new staffers to lead the country’s top health care agencies.
In this video, Joyce Hall, chair of the American Bar Association Health Law Section, discusses what changes she foresees in health law issues under the new administration and what to expect from the leadership transition. Ms. Hall also speaks on potential alterations to the Medicare Access and CHIP Reauthorization Act of 2015 and whether the potential appointment of Rep. Tom Price (R-Ga.) as U.S. Department of Health and Human Services Secretary will be positive or negative for health care providers.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
WASHINGTON – A new president is taking office along with new staffers to lead the country’s top health care agencies.
In this video, Joyce Hall, chair of the American Bar Association Health Law Section, discusses what changes she foresees in health law issues under the new administration and what to expect from the leadership transition. Ms. Hall also speaks on potential alterations to the Medicare Access and CHIP Reauthorization Act of 2015 and whether the potential appointment of Rep. Tom Price (R-Ga.) as U.S. Department of Health and Human Services Secretary will be positive or negative for health care providers.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
AT THE WASHINGTON HEALTH LAW SUMMIT
Discussing the ADHD ‘controversy’ with patients and parents
There are many topics within the child psychiatry community that are controversial. How many kids really deserve a diagnosis of bipolar disorder? Which type of therapy works best? Is cannabis a gateway drug? The existence of attention-deficit/hyperactivity disorder as a legitimate psychiatric entity, however, is not one of them.
Despite this fact, there remains considerable controversy in the public about how “real” ADHD actually is. Social media, blogs, and even entire books have been written that disparage the diagnosis and even suggest that ADHD was fabricated by the pharmaceutical industry to sell medications. Although these publications and posts generally ignore the scientific literature or at least twist it beyond recognition, there are several aspects of ADHD that legitimately cause more confusion and less confidence about the diagnosis, relative to other common pediatric problems. This column attempts to describe and contextualize these elements so that pediatricians can be more fully informed when they are called to respond to some of the allegations against ADHD that often are brought up by families.
Case summary
Hunter is a 6-year-old boy who presents with his mother and father for “behavioral concerns.” He always has been an energetic child, but the school has been having increasing difficulties with his behavior. Hunter struggles to stay in his seat and take part in quiet activities. His teacher needs to give multiple reminders per day about not interrupting others or speaking out in class. Without redirection, Hunter typically loses focus in class and does not complete his work. Because of these difficulties, the question of ADHD arose during a recent parent-teacher conference. While Hunter’s mother acknowledges these behaviors and notes similar ones at home, the father is resisting any further evaluation, claiming that Hunter “is just being a boy.” The father notes that he acted similarly as a child and “turned out okay.” When the mother tried to research ADHD online, she encountered several sites that claimed that the diagnosis of ADHD was “made up” by drug companies wanting “to turn kids into zombies.” At the appointment, the parents state that they want their son to succeed and be happy, but are concerned about some of the things they have read on the Internet.
Discussion
This example represents a common dilemma for parents who encounter so many mixed messages when doing background research on ADHD. Although the legitimacy of ADHD has been supported in literally hundreds of research studies that have examined areas such as genetics, neuropsychological testing, and brain imaging1,2, some of the lingering doubts about ADHD validity are rooted in characteristics of the diagnosis that do differ from some nonpsychiatric diagnoses. At the same time, however, further inspection reveals that these qualities exist for many other entities that have received far less public criticism. Three of these main qualities include the following:
1. ADHD is a dimensional rather than binary entity. Despite the fact that the current nomenclature continues to frame ADHD as an all-or-nothing diagnosis, there is now overwhelming scientific evidence that it is much more accurately conceptualized as a dimension3. As such, there is no clear-cut boundary between what should be judged as “typical” levels of attention and activity and ADHD. As written in a previous column4, in some ways the label of ADHD is a lot like the label of someone being tall, with some individuals clearly falling into the category of “tall” or “not tall,” while many others could be considered in-between. However, many of the most common nonpsychiatric conditions such as hypertension and hypercholesterolemia also exist this way without high levels of public controversy.
2. ADHD lacks a specific known neurobiologic marker that can be measured by a lab or neuroimaging test. As mentioned, there is a vast literature supporting the idea that the brains of people with ADHD are different from those without ADHD, but these differences tend to describe quantitative differences in regional brain volume, cortical thickness, activity levels, or connectivity rather than a discrete “thing” that a radiologist can point to on a scan. Given the dimensional nature of ADHD and the broad brain processes required for complex functions such as attention and motor activity, the lack of a specific and universal “lesion” underlying ADHD is to be expected, yet it still remains easy ammunition for those who criticize the diagnosis. Again, very similar cases can be made for other entities such as autism or low intelligence, which few argue are not real but also have no reliable biomarker to support them.
3. Medications often are used to treat ADHD. The diagnosis of ADHD would probably be far less controversial if one of its primary treatments did not involve psychiatric medications. While it is probably fair to say that the many nonpharmacologic approaches to ADHD are quite underutilized, it seems a stretch to use potential overreliance on medication as a legitimate reason to question the validity of a diagnosis. Opiate abuse also is a problem in this country, but that doesn’t mean a person’s pain doesn’t exist. As a practical tip, it can be reassuring for families to hear explicitly from their physician that “zombification” is not considered an acceptable medical outcome and that the prescribing clinician will promptly deal with any side effects that might occur with treatment5.
Understanding these aspects about ADHD and how they are misinterpreted in the media can help families make more informed and comfortable decisions about their child’s care in collaboration with their pediatrician. It also is important for pediatricians to be proactive in distributing reliable and science-backed material to the public in this new age of information overload.
Case follow-up
The pediatrician hears the family’s concerns and discusses the evidence supporting the scientific legitimacy of ADHD, as well as some of the qualities of the diagnosis that have led to its controversy. The parents are reassured but would like to proceed carefully and cautiously with further work-up and treatment. The pediatrician sends the family home with some quantitative rating scales to be completed by Hunter’s parents and teacher. She also makes a plan to begin monitoring several health promotion areas that could be impacting Hunter’s behavior including sleep quality, physical activity, screen time, and nutrition.
References
1. Psychiatr Clin North Am. 2010 Mar;33(1):159-80.
2. Dev Neuropsychol. 2013;38(4):211-25.3. Can Fam Physician. 2016 Dec;62(12):979-82.
4. ADHD boundaries with normal behavior. Pediatric News; published online Aug. 27, 2014.
5. Zombification is not an acceptable medical outcome. Psychology Today, ABCs of Child Psychiatry blog; published online Oct. 18, 2013.
Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont Larner College of Medicine, Burlington. Follow him on Twitter @PediPsych.
There are many topics within the child psychiatry community that are controversial. How many kids really deserve a diagnosis of bipolar disorder? Which type of therapy works best? Is cannabis a gateway drug? The existence of attention-deficit/hyperactivity disorder as a legitimate psychiatric entity, however, is not one of them.
Despite this fact, there remains considerable controversy in the public about how “real” ADHD actually is. Social media, blogs, and even entire books have been written that disparage the diagnosis and even suggest that ADHD was fabricated by the pharmaceutical industry to sell medications. Although these publications and posts generally ignore the scientific literature or at least twist it beyond recognition, there are several aspects of ADHD that legitimately cause more confusion and less confidence about the diagnosis, relative to other common pediatric problems. This column attempts to describe and contextualize these elements so that pediatricians can be more fully informed when they are called to respond to some of the allegations against ADHD that often are brought up by families.
Case summary
Hunter is a 6-year-old boy who presents with his mother and father for “behavioral concerns.” He always has been an energetic child, but the school has been having increasing difficulties with his behavior. Hunter struggles to stay in his seat and take part in quiet activities. His teacher needs to give multiple reminders per day about not interrupting others or speaking out in class. Without redirection, Hunter typically loses focus in class and does not complete his work. Because of these difficulties, the question of ADHD arose during a recent parent-teacher conference. While Hunter’s mother acknowledges these behaviors and notes similar ones at home, the father is resisting any further evaluation, claiming that Hunter “is just being a boy.” The father notes that he acted similarly as a child and “turned out okay.” When the mother tried to research ADHD online, she encountered several sites that claimed that the diagnosis of ADHD was “made up” by drug companies wanting “to turn kids into zombies.” At the appointment, the parents state that they want their son to succeed and be happy, but are concerned about some of the things they have read on the Internet.
Discussion
This example represents a common dilemma for parents who encounter so many mixed messages when doing background research on ADHD. Although the legitimacy of ADHD has been supported in literally hundreds of research studies that have examined areas such as genetics, neuropsychological testing, and brain imaging1,2, some of the lingering doubts about ADHD validity are rooted in characteristics of the diagnosis that do differ from some nonpsychiatric diagnoses. At the same time, however, further inspection reveals that these qualities exist for many other entities that have received far less public criticism. Three of these main qualities include the following:
1. ADHD is a dimensional rather than binary entity. Despite the fact that the current nomenclature continues to frame ADHD as an all-or-nothing diagnosis, there is now overwhelming scientific evidence that it is much more accurately conceptualized as a dimension3. As such, there is no clear-cut boundary between what should be judged as “typical” levels of attention and activity and ADHD. As written in a previous column4, in some ways the label of ADHD is a lot like the label of someone being tall, with some individuals clearly falling into the category of “tall” or “not tall,” while many others could be considered in-between. However, many of the most common nonpsychiatric conditions such as hypertension and hypercholesterolemia also exist this way without high levels of public controversy.
2. ADHD lacks a specific known neurobiologic marker that can be measured by a lab or neuroimaging test. As mentioned, there is a vast literature supporting the idea that the brains of people with ADHD are different from those without ADHD, but these differences tend to describe quantitative differences in regional brain volume, cortical thickness, activity levels, or connectivity rather than a discrete “thing” that a radiologist can point to on a scan. Given the dimensional nature of ADHD and the broad brain processes required for complex functions such as attention and motor activity, the lack of a specific and universal “lesion” underlying ADHD is to be expected, yet it still remains easy ammunition for those who criticize the diagnosis. Again, very similar cases can be made for other entities such as autism or low intelligence, which few argue are not real but also have no reliable biomarker to support them.
3. Medications often are used to treat ADHD. The diagnosis of ADHD would probably be far less controversial if one of its primary treatments did not involve psychiatric medications. While it is probably fair to say that the many nonpharmacologic approaches to ADHD are quite underutilized, it seems a stretch to use potential overreliance on medication as a legitimate reason to question the validity of a diagnosis. Opiate abuse also is a problem in this country, but that doesn’t mean a person’s pain doesn’t exist. As a practical tip, it can be reassuring for families to hear explicitly from their physician that “zombification” is not considered an acceptable medical outcome and that the prescribing clinician will promptly deal with any side effects that might occur with treatment5.
Understanding these aspects about ADHD and how they are misinterpreted in the media can help families make more informed and comfortable decisions about their child’s care in collaboration with their pediatrician. It also is important for pediatricians to be proactive in distributing reliable and science-backed material to the public in this new age of information overload.
Case follow-up
The pediatrician hears the family’s concerns and discusses the evidence supporting the scientific legitimacy of ADHD, as well as some of the qualities of the diagnosis that have led to its controversy. The parents are reassured but would like to proceed carefully and cautiously with further work-up and treatment. The pediatrician sends the family home with some quantitative rating scales to be completed by Hunter’s parents and teacher. She also makes a plan to begin monitoring several health promotion areas that could be impacting Hunter’s behavior including sleep quality, physical activity, screen time, and nutrition.
References
1. Psychiatr Clin North Am. 2010 Mar;33(1):159-80.
2. Dev Neuropsychol. 2013;38(4):211-25.3. Can Fam Physician. 2016 Dec;62(12):979-82.
4. ADHD boundaries with normal behavior. Pediatric News; published online Aug. 27, 2014.
5. Zombification is not an acceptable medical outcome. Psychology Today, ABCs of Child Psychiatry blog; published online Oct. 18, 2013.
Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont Larner College of Medicine, Burlington. Follow him on Twitter @PediPsych.
There are many topics within the child psychiatry community that are controversial. How many kids really deserve a diagnosis of bipolar disorder? Which type of therapy works best? Is cannabis a gateway drug? The existence of attention-deficit/hyperactivity disorder as a legitimate psychiatric entity, however, is not one of them.
Despite this fact, there remains considerable controversy in the public about how “real” ADHD actually is. Social media, blogs, and even entire books have been written that disparage the diagnosis and even suggest that ADHD was fabricated by the pharmaceutical industry to sell medications. Although these publications and posts generally ignore the scientific literature or at least twist it beyond recognition, there are several aspects of ADHD that legitimately cause more confusion and less confidence about the diagnosis, relative to other common pediatric problems. This column attempts to describe and contextualize these elements so that pediatricians can be more fully informed when they are called to respond to some of the allegations against ADHD that often are brought up by families.
Case summary
Hunter is a 6-year-old boy who presents with his mother and father for “behavioral concerns.” He always has been an energetic child, but the school has been having increasing difficulties with his behavior. Hunter struggles to stay in his seat and take part in quiet activities. His teacher needs to give multiple reminders per day about not interrupting others or speaking out in class. Without redirection, Hunter typically loses focus in class and does not complete his work. Because of these difficulties, the question of ADHD arose during a recent parent-teacher conference. While Hunter’s mother acknowledges these behaviors and notes similar ones at home, the father is resisting any further evaluation, claiming that Hunter “is just being a boy.” The father notes that he acted similarly as a child and “turned out okay.” When the mother tried to research ADHD online, she encountered several sites that claimed that the diagnosis of ADHD was “made up” by drug companies wanting “to turn kids into zombies.” At the appointment, the parents state that they want their son to succeed and be happy, but are concerned about some of the things they have read on the Internet.
Discussion
This example represents a common dilemma for parents who encounter so many mixed messages when doing background research on ADHD. Although the legitimacy of ADHD has been supported in literally hundreds of research studies that have examined areas such as genetics, neuropsychological testing, and brain imaging1,2, some of the lingering doubts about ADHD validity are rooted in characteristics of the diagnosis that do differ from some nonpsychiatric diagnoses. At the same time, however, further inspection reveals that these qualities exist for many other entities that have received far less public criticism. Three of these main qualities include the following:
1. ADHD is a dimensional rather than binary entity. Despite the fact that the current nomenclature continues to frame ADHD as an all-or-nothing diagnosis, there is now overwhelming scientific evidence that it is much more accurately conceptualized as a dimension3. As such, there is no clear-cut boundary between what should be judged as “typical” levels of attention and activity and ADHD. As written in a previous column4, in some ways the label of ADHD is a lot like the label of someone being tall, with some individuals clearly falling into the category of “tall” or “not tall,” while many others could be considered in-between. However, many of the most common nonpsychiatric conditions such as hypertension and hypercholesterolemia also exist this way without high levels of public controversy.
2. ADHD lacks a specific known neurobiologic marker that can be measured by a lab or neuroimaging test. As mentioned, there is a vast literature supporting the idea that the brains of people with ADHD are different from those without ADHD, but these differences tend to describe quantitative differences in regional brain volume, cortical thickness, activity levels, or connectivity rather than a discrete “thing” that a radiologist can point to on a scan. Given the dimensional nature of ADHD and the broad brain processes required for complex functions such as attention and motor activity, the lack of a specific and universal “lesion” underlying ADHD is to be expected, yet it still remains easy ammunition for those who criticize the diagnosis. Again, very similar cases can be made for other entities such as autism or low intelligence, which few argue are not real but also have no reliable biomarker to support them.
3. Medications often are used to treat ADHD. The diagnosis of ADHD would probably be far less controversial if one of its primary treatments did not involve psychiatric medications. While it is probably fair to say that the many nonpharmacologic approaches to ADHD are quite underutilized, it seems a stretch to use potential overreliance on medication as a legitimate reason to question the validity of a diagnosis. Opiate abuse also is a problem in this country, but that doesn’t mean a person’s pain doesn’t exist. As a practical tip, it can be reassuring for families to hear explicitly from their physician that “zombification” is not considered an acceptable medical outcome and that the prescribing clinician will promptly deal with any side effects that might occur with treatment5.
Understanding these aspects about ADHD and how they are misinterpreted in the media can help families make more informed and comfortable decisions about their child’s care in collaboration with their pediatrician. It also is important for pediatricians to be proactive in distributing reliable and science-backed material to the public in this new age of information overload.
Case follow-up
The pediatrician hears the family’s concerns and discusses the evidence supporting the scientific legitimacy of ADHD, as well as some of the qualities of the diagnosis that have led to its controversy. The parents are reassured but would like to proceed carefully and cautiously with further work-up and treatment. The pediatrician sends the family home with some quantitative rating scales to be completed by Hunter’s parents and teacher. She also makes a plan to begin monitoring several health promotion areas that could be impacting Hunter’s behavior including sleep quality, physical activity, screen time, and nutrition.
References
1. Psychiatr Clin North Am. 2010 Mar;33(1):159-80.
2. Dev Neuropsychol. 2013;38(4):211-25.3. Can Fam Physician. 2016 Dec;62(12):979-82.
4. ADHD boundaries with normal behavior. Pediatric News; published online Aug. 27, 2014.
5. Zombification is not an acceptable medical outcome. Psychology Today, ABCs of Child Psychiatry blog; published online Oct. 18, 2013.
Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont Larner College of Medicine, Burlington. Follow him on Twitter @PediPsych.
Low value
The fact that the United States spends more of its gross domestic product on health care (18%) than any other nation is old and depressing news (JAMA. 2012 Apr 11;307[14]:1513-6). There may be some debate about whether the quality of the product we are getting is worth this outsized investment. But it is safe to assume that there must be some wastage in the system. Exactly how much of our health care dollar is going down the drain is unknown. And the thorny question of who is responsible for the leaks has escaped close scrutiny, probably because the answer is guaranteed to result in an uncomfortable and ugly circle of finger pointing. Is it the insurance companies, hospitals, the superspecialists, the drug companies, impatient patients, or those dastardly lawyers? Pediatricians are such small players on the health care stage that our contribution to the wastage must be minimal. Our patients are little people who are generally healthy. Most of us drive midsized cars and live in modest homes. We try to be careful users of the expensive diagnostic and therapeutic tools at our disposal. We don’t deserve a place on the list of likely suspects, do we?
Using a claims-based measure of 20 services that according to evidenced-based guidelines do not improve health, the authors discovered that among the nearly four and half million commercially insured children they studied, 9.6% received at least one of these 20 “low-value” services in 1 year. The ticket for these worthless services was $27 million,of which more than $9 million was out of pocket expenses for families. If extrapolated to all of the commercially insured children in the United States, the total cost of low-value services would be $227 million for 1 year. Regardless of how wasteful cardiologists or plastic surgeons may be, this contribution to the national cost of health care for low-value services by pediatricians cannot be considered chump change.
I urge you to check out the online version of Dr. Chua’s article and then click on Table 1 so you can look at the 20 services that the authors have chosen to label low value. Although I am always leery of accepting a guideline simply because it is has been labeled “evidence-based,” I think you will find that it hard to argue with their choices, such as blood tests in children with a simple febrile seizure, oral antibiotics after tonsillectomy, or neuroimaging in children with headache. How does your practice’s behavior stack up against their list?
The list could be much longer. For example, the authors chose to exclude head imaging ordered for minor head trauma because their claims-based method didn’t provide enough clinical information. I suspect that with an expanded list of clearly low-value services, the annual cost for low-value pediatric services would be a half a billion dollars.
As concerning as the findings in this study may be, it doesn’t answer the question of what we should do to correct the problem. We can dance around the issue by saying that patients and parents are pressuring us to do something even if it’s a low-value service. We can complain that for decades we have been practicing under the dark cloud of a malpractice suit, and that if we don’t turn over every stone in our evaluation of a patient we’re going to trip on one of them and end up in court.
But the bottom line is that we are the ones who are making the choice to order a study or prescribe a medication that is not only of low value, but more than likely worthless and possibly damaging to the patient. With the help of the American Academy of Pediatrics, we need to swallow hard and begin cleaning house, throwing out those low-value services we have gotten in the habit of ordering and prescribing. Education helps, but sometimes we have to do some finger pointing even if the finger points to us.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
The fact that the United States spends more of its gross domestic product on health care (18%) than any other nation is old and depressing news (JAMA. 2012 Apr 11;307[14]:1513-6). There may be some debate about whether the quality of the product we are getting is worth this outsized investment. But it is safe to assume that there must be some wastage in the system. Exactly how much of our health care dollar is going down the drain is unknown. And the thorny question of who is responsible for the leaks has escaped close scrutiny, probably because the answer is guaranteed to result in an uncomfortable and ugly circle of finger pointing. Is it the insurance companies, hospitals, the superspecialists, the drug companies, impatient patients, or those dastardly lawyers? Pediatricians are such small players on the health care stage that our contribution to the wastage must be minimal. Our patients are little people who are generally healthy. Most of us drive midsized cars and live in modest homes. We try to be careful users of the expensive diagnostic and therapeutic tools at our disposal. We don’t deserve a place on the list of likely suspects, do we?
Using a claims-based measure of 20 services that according to evidenced-based guidelines do not improve health, the authors discovered that among the nearly four and half million commercially insured children they studied, 9.6% received at least one of these 20 “low-value” services in 1 year. The ticket for these worthless services was $27 million,of which more than $9 million was out of pocket expenses for families. If extrapolated to all of the commercially insured children in the United States, the total cost of low-value services would be $227 million for 1 year. Regardless of how wasteful cardiologists or plastic surgeons may be, this contribution to the national cost of health care for low-value services by pediatricians cannot be considered chump change.
I urge you to check out the online version of Dr. Chua’s article and then click on Table 1 so you can look at the 20 services that the authors have chosen to label low value. Although I am always leery of accepting a guideline simply because it is has been labeled “evidence-based,” I think you will find that it hard to argue with their choices, such as blood tests in children with a simple febrile seizure, oral antibiotics after tonsillectomy, or neuroimaging in children with headache. How does your practice’s behavior stack up against their list?
The list could be much longer. For example, the authors chose to exclude head imaging ordered for minor head trauma because their claims-based method didn’t provide enough clinical information. I suspect that with an expanded list of clearly low-value services, the annual cost for low-value pediatric services would be a half a billion dollars.
As concerning as the findings in this study may be, it doesn’t answer the question of what we should do to correct the problem. We can dance around the issue by saying that patients and parents are pressuring us to do something even if it’s a low-value service. We can complain that for decades we have been practicing under the dark cloud of a malpractice suit, and that if we don’t turn over every stone in our evaluation of a patient we’re going to trip on one of them and end up in court.
But the bottom line is that we are the ones who are making the choice to order a study or prescribe a medication that is not only of low value, but more than likely worthless and possibly damaging to the patient. With the help of the American Academy of Pediatrics, we need to swallow hard and begin cleaning house, throwing out those low-value services we have gotten in the habit of ordering and prescribing. Education helps, but sometimes we have to do some finger pointing even if the finger points to us.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
The fact that the United States spends more of its gross domestic product on health care (18%) than any other nation is old and depressing news (JAMA. 2012 Apr 11;307[14]:1513-6). There may be some debate about whether the quality of the product we are getting is worth this outsized investment. But it is safe to assume that there must be some wastage in the system. Exactly how much of our health care dollar is going down the drain is unknown. And the thorny question of who is responsible for the leaks has escaped close scrutiny, probably because the answer is guaranteed to result in an uncomfortable and ugly circle of finger pointing. Is it the insurance companies, hospitals, the superspecialists, the drug companies, impatient patients, or those dastardly lawyers? Pediatricians are such small players on the health care stage that our contribution to the wastage must be minimal. Our patients are little people who are generally healthy. Most of us drive midsized cars and live in modest homes. We try to be careful users of the expensive diagnostic and therapeutic tools at our disposal. We don’t deserve a place on the list of likely suspects, do we?
Using a claims-based measure of 20 services that according to evidenced-based guidelines do not improve health, the authors discovered that among the nearly four and half million commercially insured children they studied, 9.6% received at least one of these 20 “low-value” services in 1 year. The ticket for these worthless services was $27 million,of which more than $9 million was out of pocket expenses for families. If extrapolated to all of the commercially insured children in the United States, the total cost of low-value services would be $227 million for 1 year. Regardless of how wasteful cardiologists or plastic surgeons may be, this contribution to the national cost of health care for low-value services by pediatricians cannot be considered chump change.
I urge you to check out the online version of Dr. Chua’s article and then click on Table 1 so you can look at the 20 services that the authors have chosen to label low value. Although I am always leery of accepting a guideline simply because it is has been labeled “evidence-based,” I think you will find that it hard to argue with their choices, such as blood tests in children with a simple febrile seizure, oral antibiotics after tonsillectomy, or neuroimaging in children with headache. How does your practice’s behavior stack up against their list?
The list could be much longer. For example, the authors chose to exclude head imaging ordered for minor head trauma because their claims-based method didn’t provide enough clinical information. I suspect that with an expanded list of clearly low-value services, the annual cost for low-value pediatric services would be a half a billion dollars.
As concerning as the findings in this study may be, it doesn’t answer the question of what we should do to correct the problem. We can dance around the issue by saying that patients and parents are pressuring us to do something even if it’s a low-value service. We can complain that for decades we have been practicing under the dark cloud of a malpractice suit, and that if we don’t turn over every stone in our evaluation of a patient we’re going to trip on one of them and end up in court.
But the bottom line is that we are the ones who are making the choice to order a study or prescribe a medication that is not only of low value, but more than likely worthless and possibly damaging to the patient. With the help of the American Academy of Pediatrics, we need to swallow hard and begin cleaning house, throwing out those low-value services we have gotten in the habit of ordering and prescribing. Education helps, but sometimes we have to do some finger pointing even if the finger points to us.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
‘And a child shall lead them’
With a moistened index finger pointing skyward, I always have tried to remain alert to where the winds of change are blowing. But every now and then I miss a trend in child care, and that is the case with something known as “baby-led weaning.” Influenced by the questionable notion that there is a “natural” way of doing almost everything, the concept hinges on the belief that an infant will “tell” his mother when it is time to stop nursing and begin solids, aka complementary feeding.
At face value, the concept of allowing the baby to lead is a good one simply because of universality of biologic variation. Just as with the question of how much sleep a baby needs, I don’t think anyone (let alone clinicians) can give with assurance an answer that can easily be applied to all infants. There are just too many variables.
For most dyads, breastfeeding is more than just passing calories from one individual to another. Nursing can offer a sense of security and calming both for infants and their mothers. In many cases, the breast unfortunately has become a critical ingredient in the infant’s ritual for falling to sleep. For some mothers, success at breastfeeding becomes an important validation of her feelings of confidence and self-worth that in the past may have been battered by a male-dominated environment. If breastfeeding has been an unpleasant experience, a mother may be more likely to interpret her infant’s behavior as a message that it is time to wean. The bottom line is that a mother’s perception of her baby’s messages about weaning often reflects her own feelings about nursing.
Of course, we clinicians can influence a mother’s perception of her baby’s messages by introducing our own biases about what we believe is the safest, most nutritionally sound way to introduce complementary feeding. And let’s be honest and acknowledge that those are biases mostly unsupported by good scientific study. In many cases, they are more of a reflection of the cultures in which we have grown up.
When asked by parents how they will know when their infant is ready for complementary feeding, I suggest that it’s time when the infant is not only curious about what the adults around him are eating, but obviously is upset that he isn’t being offered a taste. I add that exactly what that food should be is a matter of debate and common sense.
I also encourage parents to allow the child to do as much self-feeding as possible and not worry about the mess. An old shower curtain floor and plenty of sponges and paper towels are a must.
In most cases, I think we can trust babies to take the lead in weaning. But I also believe that as clinicians we must remain alert to the few situations when extended nursing is not in the best interest for the baby who is not growing well or for the mother for whom the nursing is taking an unreasonable toll on her physical and mental health.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
With a moistened index finger pointing skyward, I always have tried to remain alert to where the winds of change are blowing. But every now and then I miss a trend in child care, and that is the case with something known as “baby-led weaning.” Influenced by the questionable notion that there is a “natural” way of doing almost everything, the concept hinges on the belief that an infant will “tell” his mother when it is time to stop nursing and begin solids, aka complementary feeding.
At face value, the concept of allowing the baby to lead is a good one simply because of universality of biologic variation. Just as with the question of how much sleep a baby needs, I don’t think anyone (let alone clinicians) can give with assurance an answer that can easily be applied to all infants. There are just too many variables.
For most dyads, breastfeeding is more than just passing calories from one individual to another. Nursing can offer a sense of security and calming both for infants and their mothers. In many cases, the breast unfortunately has become a critical ingredient in the infant’s ritual for falling to sleep. For some mothers, success at breastfeeding becomes an important validation of her feelings of confidence and self-worth that in the past may have been battered by a male-dominated environment. If breastfeeding has been an unpleasant experience, a mother may be more likely to interpret her infant’s behavior as a message that it is time to wean. The bottom line is that a mother’s perception of her baby’s messages about weaning often reflects her own feelings about nursing.
Of course, we clinicians can influence a mother’s perception of her baby’s messages by introducing our own biases about what we believe is the safest, most nutritionally sound way to introduce complementary feeding. And let’s be honest and acknowledge that those are biases mostly unsupported by good scientific study. In many cases, they are more of a reflection of the cultures in which we have grown up.
When asked by parents how they will know when their infant is ready for complementary feeding, I suggest that it’s time when the infant is not only curious about what the adults around him are eating, but obviously is upset that he isn’t being offered a taste. I add that exactly what that food should be is a matter of debate and common sense.
I also encourage parents to allow the child to do as much self-feeding as possible and not worry about the mess. An old shower curtain floor and plenty of sponges and paper towels are a must.
In most cases, I think we can trust babies to take the lead in weaning. But I also believe that as clinicians we must remain alert to the few situations when extended nursing is not in the best interest for the baby who is not growing well or for the mother for whom the nursing is taking an unreasonable toll on her physical and mental health.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
With a moistened index finger pointing skyward, I always have tried to remain alert to where the winds of change are blowing. But every now and then I miss a trend in child care, and that is the case with something known as “baby-led weaning.” Influenced by the questionable notion that there is a “natural” way of doing almost everything, the concept hinges on the belief that an infant will “tell” his mother when it is time to stop nursing and begin solids, aka complementary feeding.
At face value, the concept of allowing the baby to lead is a good one simply because of universality of biologic variation. Just as with the question of how much sleep a baby needs, I don’t think anyone (let alone clinicians) can give with assurance an answer that can easily be applied to all infants. There are just too many variables.
For most dyads, breastfeeding is more than just passing calories from one individual to another. Nursing can offer a sense of security and calming both for infants and their mothers. In many cases, the breast unfortunately has become a critical ingredient in the infant’s ritual for falling to sleep. For some mothers, success at breastfeeding becomes an important validation of her feelings of confidence and self-worth that in the past may have been battered by a male-dominated environment. If breastfeeding has been an unpleasant experience, a mother may be more likely to interpret her infant’s behavior as a message that it is time to wean. The bottom line is that a mother’s perception of her baby’s messages about weaning often reflects her own feelings about nursing.
Of course, we clinicians can influence a mother’s perception of her baby’s messages by introducing our own biases about what we believe is the safest, most nutritionally sound way to introduce complementary feeding. And let’s be honest and acknowledge that those are biases mostly unsupported by good scientific study. In many cases, they are more of a reflection of the cultures in which we have grown up.
When asked by parents how they will know when their infant is ready for complementary feeding, I suggest that it’s time when the infant is not only curious about what the adults around him are eating, but obviously is upset that he isn’t being offered a taste. I add that exactly what that food should be is a matter of debate and common sense.
I also encourage parents to allow the child to do as much self-feeding as possible and not worry about the mess. An old shower curtain floor and plenty of sponges and paper towels are a must.
In most cases, I think we can trust babies to take the lead in weaning. But I also believe that as clinicians we must remain alert to the few situations when extended nursing is not in the best interest for the baby who is not growing well or for the mother for whom the nursing is taking an unreasonable toll on her physical and mental health.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
ACA repeal will prove good for psychiatric practice
As a psychiatrist who ran a solo private practice for more than 40 years, I welcome the demise of the Affordable Care Act (ACA). Why? Because so many of the ACA’s requirements have worked against the best interests of my patients.
The reality is that patients want much greater power in a U.S. health care marketplace. Patient power will, or at least ought to be, an important objective for health care reform at all levels of government. The 2016 elections make it clear that citizens want to be personally invested when it comes to shopping for their health care insurance and engaging health care professionals of their choice. That means we as professionals must advocate for price transparency for our professional services, and give our patients much greater power to say where money goes to pay for their health care.
One ACA requirement that really turns off patients and clinical psychiatrists is government and third-party mandates that a patient’s clinical notes must be put on an electronic health record (EHR). (This requirement did not originate with the ACA but reinforces the HITECH mandate.)* Patient data privacy and confidentiality are essential to gaining and maintaining patient trust when doing psychotherapy and outpatient psychiatry, and more than 40% of U.S. clinical psychiatrists today are in solo or small group independent practices. They make patient data privacy and confidentiality a hallmark.
Unfortunately, the ACA does not support independent solo and small group psychiatric practices. Frustrations tied to the ACA’s current overreliance on payer-”provider” contracting in the private and public sectors are the reason for the growing interest in the Wedge of Health Freedom. The Wedge is a voluntary program conceived by the Citizens’ Council for Health Freedom to advance a “new vision of health care for patients and doctors” by eliminating third parties who “manage” medical care dollars and “medical necessity.” I know from the last 10 years that a direct pay (cash) practice experience is a necessary option and alternative to managed care for patients and doctors. Patient demand is spurring The Wedge concept, as Twila Brase, a registered nurse who serves as president of the Citizens’ Council for Health Freedom, has said.
“The right to pay cash, the right to accept cash, and the right to discount prices must be protected within the wedge of freedom,” Ms. Braise said in a 2014 presentation before the Association of American Physicians and Surgeons. “I’m asking you to engage your patients.”
To ensure continuity of care, patients need to have both access to competent professionals of their choice and discretion/control of how those professionals are paid. That is missing in the ACA.
The emphasis on patient (consumer) choice is one of many positive aspects of the ACA repeal legislation proposed in 2015 by Tom Price (R-Ga.), an orthopedic surgeon who has been nominated by President-Elect Donald J. Trump to be the next secretary of the U.S. Department of Health & Human Services. Health savings accounts (HSAs) are key, as are the use of indemnity (catastrophic) insurance offerings based on the costs of care. To incentivize insurance companies to develop and market insurance products appropriate to the demands and needs of all people, including young and healthy enrollees, federal and state laws involving third-party insurance, Medicaid, and Medicare must change. And they will.
Expanding high-risk pools can be accomplished only with help from the states. (Minnesota is now debating resurrecting a version of the 1976 high-risk pool called the Minnesota Comprehensive Health Association). New and innovative programs for Medicaid recipients allowing them to shop for care using debit cards is an interesting proposal. Financial “skin in the game” for patients (even when such discretionary money is provided by taxpayers) will empower patients to shop for services and coverage with real options for them if presented with diversion if they show up at emergency departments with needs for nonurgent health care services or primary care. Other appealing proposals involve primary care programs linking care access through concierge or direct-pay arrangements with patients.
Everyone with Internet access knows that he or she can purchase almost anything online. Other than legal considerations (often state-imposed sales taxes), there are no boundaries or constraints to most Internet purchases. If someone wants a product or service and has the money to buy it from a vendor anyplace in the world, all it takes is a few keystrokes, and, voila, the items are on the way! Soon, in fact, amazon.com may drop your “stuff” off via a drone on your front steps. So how is health care or the purchase of a doctor-patient relationship different from other “stuff” we buy online? And how, fundamentally, is the insurance that pays for health care different from other forms of insurance? Can we envision after a patient’s vetting and risk assessment that an Amazon drone might drop off an insurance contract or policy?
An important question and proposal for ACA replacement legislation is the opportunity for consumers to buy health care insurance across state lines. Competition based on coverage and price will drive down the cost of health care insurance for buyers. But there are serious obstacles to making interstate health care insurance a reality, such as state regulation of insurance, state licensure of health care professionals, and lack of a stomach by medical professionals for more “provider” networks.
Clearly, price transparency for health care services and insurance should be a first order priority for health care reform. There are no guarantees when it comes to markets, but it’s very unlikely that health insurance premiums will fall simply because people can buy health plans across state lines. Allowing companies to manage health plans in several states could bring down management expenses so long as there is real competition among insurance companies. That prospect, however, is countered by rampant consolidation of insurance companies, and associated oligopoly and antitrust issues.
In my view, health care insurance should be a contract between the enrollee (recipient) and the insurer rather than a deal that is usually hidden from consumers between “providers” of care and third-party payers.
We do need to get rid of individual and corporate ACA penalties for not having insurance while at the same time, make markets appealing to consumers of all incomes and needs. And people should be able to buy prepaid coverage from health maintenance organizations (HMOs) if people want prepaid care with its restrictions. We should expand HSAs, and encourage price disclosure/transparency for services and insurance coverage via the Internet.
I lobbied for mental health parity legislation for years, and the American Psychiatric Association supported the passage of the ACA in 2010 to ensure access to mental health benefits for Americans. But let’s stop kidding ourselves about the ACA’s real world consequences to the psychiatric care of our patients. Despite hard work over the years to expand parity for mental health services, psychiatric and substance use care at this moment is commonly restricted to managed care behavioral carve-out networks or time-limited programs. Those restrictions grew under the ACA.
In short, we need to create a true health care marketplace and access to insurance protections that enable psychiatrists and other mental health professionals to work for the best interests of our patients rather than the bottom line of health care organizations. Let’s urge our politicians to replace the ACA with measures that encourage and promote voluntary, motivated patients and their families to find quality professional relationships with competent professionals of their choice who are able to provide care continuity and confidential, data-safe practice environments.
Dr. Beecher is president of the Minnesota Physician-Patient Alliance (www.physician-patient.org), a health care think tank based in Saint Louis Park, Minn. He is a distinguished life fellow of the American Psychiatric Association and Fellow of the American Society of Addiction Medicine, and until 2015 served as adjunct professor of psychiatry at the University of Minnesota, Minneapolis.
*CORRECTION, 1/13/2017: The federal program that incentivizes physicians to use EHRs was part of the HITECH Act, which was part of the Recovery Act of 2009 and predates the ACA.
As a psychiatrist who ran a solo private practice for more than 40 years, I welcome the demise of the Affordable Care Act (ACA). Why? Because so many of the ACA’s requirements have worked against the best interests of my patients.
The reality is that patients want much greater power in a U.S. health care marketplace. Patient power will, or at least ought to be, an important objective for health care reform at all levels of government. The 2016 elections make it clear that citizens want to be personally invested when it comes to shopping for their health care insurance and engaging health care professionals of their choice. That means we as professionals must advocate for price transparency for our professional services, and give our patients much greater power to say where money goes to pay for their health care.
One ACA requirement that really turns off patients and clinical psychiatrists is government and third-party mandates that a patient’s clinical notes must be put on an electronic health record (EHR). (This requirement did not originate with the ACA but reinforces the HITECH mandate.)* Patient data privacy and confidentiality are essential to gaining and maintaining patient trust when doing psychotherapy and outpatient psychiatry, and more than 40% of U.S. clinical psychiatrists today are in solo or small group independent practices. They make patient data privacy and confidentiality a hallmark.
Unfortunately, the ACA does not support independent solo and small group psychiatric practices. Frustrations tied to the ACA’s current overreliance on payer-”provider” contracting in the private and public sectors are the reason for the growing interest in the Wedge of Health Freedom. The Wedge is a voluntary program conceived by the Citizens’ Council for Health Freedom to advance a “new vision of health care for patients and doctors” by eliminating third parties who “manage” medical care dollars and “medical necessity.” I know from the last 10 years that a direct pay (cash) practice experience is a necessary option and alternative to managed care for patients and doctors. Patient demand is spurring The Wedge concept, as Twila Brase, a registered nurse who serves as president of the Citizens’ Council for Health Freedom, has said.
“The right to pay cash, the right to accept cash, and the right to discount prices must be protected within the wedge of freedom,” Ms. Braise said in a 2014 presentation before the Association of American Physicians and Surgeons. “I’m asking you to engage your patients.”
To ensure continuity of care, patients need to have both access to competent professionals of their choice and discretion/control of how those professionals are paid. That is missing in the ACA.
The emphasis on patient (consumer) choice is one of many positive aspects of the ACA repeal legislation proposed in 2015 by Tom Price (R-Ga.), an orthopedic surgeon who has been nominated by President-Elect Donald J. Trump to be the next secretary of the U.S. Department of Health & Human Services. Health savings accounts (HSAs) are key, as are the use of indemnity (catastrophic) insurance offerings based on the costs of care. To incentivize insurance companies to develop and market insurance products appropriate to the demands and needs of all people, including young and healthy enrollees, federal and state laws involving third-party insurance, Medicaid, and Medicare must change. And they will.
Expanding high-risk pools can be accomplished only with help from the states. (Minnesota is now debating resurrecting a version of the 1976 high-risk pool called the Minnesota Comprehensive Health Association). New and innovative programs for Medicaid recipients allowing them to shop for care using debit cards is an interesting proposal. Financial “skin in the game” for patients (even when such discretionary money is provided by taxpayers) will empower patients to shop for services and coverage with real options for them if presented with diversion if they show up at emergency departments with needs for nonurgent health care services or primary care. Other appealing proposals involve primary care programs linking care access through concierge or direct-pay arrangements with patients.
Everyone with Internet access knows that he or she can purchase almost anything online. Other than legal considerations (often state-imposed sales taxes), there are no boundaries or constraints to most Internet purchases. If someone wants a product or service and has the money to buy it from a vendor anyplace in the world, all it takes is a few keystrokes, and, voila, the items are on the way! Soon, in fact, amazon.com may drop your “stuff” off via a drone on your front steps. So how is health care or the purchase of a doctor-patient relationship different from other “stuff” we buy online? And how, fundamentally, is the insurance that pays for health care different from other forms of insurance? Can we envision after a patient’s vetting and risk assessment that an Amazon drone might drop off an insurance contract or policy?
An important question and proposal for ACA replacement legislation is the opportunity for consumers to buy health care insurance across state lines. Competition based on coverage and price will drive down the cost of health care insurance for buyers. But there are serious obstacles to making interstate health care insurance a reality, such as state regulation of insurance, state licensure of health care professionals, and lack of a stomach by medical professionals for more “provider” networks.
Clearly, price transparency for health care services and insurance should be a first order priority for health care reform. There are no guarantees when it comes to markets, but it’s very unlikely that health insurance premiums will fall simply because people can buy health plans across state lines. Allowing companies to manage health plans in several states could bring down management expenses so long as there is real competition among insurance companies. That prospect, however, is countered by rampant consolidation of insurance companies, and associated oligopoly and antitrust issues.
In my view, health care insurance should be a contract between the enrollee (recipient) and the insurer rather than a deal that is usually hidden from consumers between “providers” of care and third-party payers.
We do need to get rid of individual and corporate ACA penalties for not having insurance while at the same time, make markets appealing to consumers of all incomes and needs. And people should be able to buy prepaid coverage from health maintenance organizations (HMOs) if people want prepaid care with its restrictions. We should expand HSAs, and encourage price disclosure/transparency for services and insurance coverage via the Internet.
I lobbied for mental health parity legislation for years, and the American Psychiatric Association supported the passage of the ACA in 2010 to ensure access to mental health benefits for Americans. But let’s stop kidding ourselves about the ACA’s real world consequences to the psychiatric care of our patients. Despite hard work over the years to expand parity for mental health services, psychiatric and substance use care at this moment is commonly restricted to managed care behavioral carve-out networks or time-limited programs. Those restrictions grew under the ACA.
In short, we need to create a true health care marketplace and access to insurance protections that enable psychiatrists and other mental health professionals to work for the best interests of our patients rather than the bottom line of health care organizations. Let’s urge our politicians to replace the ACA with measures that encourage and promote voluntary, motivated patients and their families to find quality professional relationships with competent professionals of their choice who are able to provide care continuity and confidential, data-safe practice environments.
Dr. Beecher is president of the Minnesota Physician-Patient Alliance (www.physician-patient.org), a health care think tank based in Saint Louis Park, Minn. He is a distinguished life fellow of the American Psychiatric Association and Fellow of the American Society of Addiction Medicine, and until 2015 served as adjunct professor of psychiatry at the University of Minnesota, Minneapolis.
*CORRECTION, 1/13/2017: The federal program that incentivizes physicians to use EHRs was part of the HITECH Act, which was part of the Recovery Act of 2009 and predates the ACA.
As a psychiatrist who ran a solo private practice for more than 40 years, I welcome the demise of the Affordable Care Act (ACA). Why? Because so many of the ACA’s requirements have worked against the best interests of my patients.
The reality is that patients want much greater power in a U.S. health care marketplace. Patient power will, or at least ought to be, an important objective for health care reform at all levels of government. The 2016 elections make it clear that citizens want to be personally invested when it comes to shopping for their health care insurance and engaging health care professionals of their choice. That means we as professionals must advocate for price transparency for our professional services, and give our patients much greater power to say where money goes to pay for their health care.
One ACA requirement that really turns off patients and clinical psychiatrists is government and third-party mandates that a patient’s clinical notes must be put on an electronic health record (EHR). (This requirement did not originate with the ACA but reinforces the HITECH mandate.)* Patient data privacy and confidentiality are essential to gaining and maintaining patient trust when doing psychotherapy and outpatient psychiatry, and more than 40% of U.S. clinical psychiatrists today are in solo or small group independent practices. They make patient data privacy and confidentiality a hallmark.
Unfortunately, the ACA does not support independent solo and small group psychiatric practices. Frustrations tied to the ACA’s current overreliance on payer-”provider” contracting in the private and public sectors are the reason for the growing interest in the Wedge of Health Freedom. The Wedge is a voluntary program conceived by the Citizens’ Council for Health Freedom to advance a “new vision of health care for patients and doctors” by eliminating third parties who “manage” medical care dollars and “medical necessity.” I know from the last 10 years that a direct pay (cash) practice experience is a necessary option and alternative to managed care for patients and doctors. Patient demand is spurring The Wedge concept, as Twila Brase, a registered nurse who serves as president of the Citizens’ Council for Health Freedom, has said.
“The right to pay cash, the right to accept cash, and the right to discount prices must be protected within the wedge of freedom,” Ms. Braise said in a 2014 presentation before the Association of American Physicians and Surgeons. “I’m asking you to engage your patients.”
To ensure continuity of care, patients need to have both access to competent professionals of their choice and discretion/control of how those professionals are paid. That is missing in the ACA.
The emphasis on patient (consumer) choice is one of many positive aspects of the ACA repeal legislation proposed in 2015 by Tom Price (R-Ga.), an orthopedic surgeon who has been nominated by President-Elect Donald J. Trump to be the next secretary of the U.S. Department of Health & Human Services. Health savings accounts (HSAs) are key, as are the use of indemnity (catastrophic) insurance offerings based on the costs of care. To incentivize insurance companies to develop and market insurance products appropriate to the demands and needs of all people, including young and healthy enrollees, federal and state laws involving third-party insurance, Medicaid, and Medicare must change. And they will.
Expanding high-risk pools can be accomplished only with help from the states. (Minnesota is now debating resurrecting a version of the 1976 high-risk pool called the Minnesota Comprehensive Health Association). New and innovative programs for Medicaid recipients allowing them to shop for care using debit cards is an interesting proposal. Financial “skin in the game” for patients (even when such discretionary money is provided by taxpayers) will empower patients to shop for services and coverage with real options for them if presented with diversion if they show up at emergency departments with needs for nonurgent health care services or primary care. Other appealing proposals involve primary care programs linking care access through concierge or direct-pay arrangements with patients.
Everyone with Internet access knows that he or she can purchase almost anything online. Other than legal considerations (often state-imposed sales taxes), there are no boundaries or constraints to most Internet purchases. If someone wants a product or service and has the money to buy it from a vendor anyplace in the world, all it takes is a few keystrokes, and, voila, the items are on the way! Soon, in fact, amazon.com may drop your “stuff” off via a drone on your front steps. So how is health care or the purchase of a doctor-patient relationship different from other “stuff” we buy online? And how, fundamentally, is the insurance that pays for health care different from other forms of insurance? Can we envision after a patient’s vetting and risk assessment that an Amazon drone might drop off an insurance contract or policy?
An important question and proposal for ACA replacement legislation is the opportunity for consumers to buy health care insurance across state lines. Competition based on coverage and price will drive down the cost of health care insurance for buyers. But there are serious obstacles to making interstate health care insurance a reality, such as state regulation of insurance, state licensure of health care professionals, and lack of a stomach by medical professionals for more “provider” networks.
Clearly, price transparency for health care services and insurance should be a first order priority for health care reform. There are no guarantees when it comes to markets, but it’s very unlikely that health insurance premiums will fall simply because people can buy health plans across state lines. Allowing companies to manage health plans in several states could bring down management expenses so long as there is real competition among insurance companies. That prospect, however, is countered by rampant consolidation of insurance companies, and associated oligopoly and antitrust issues.
In my view, health care insurance should be a contract between the enrollee (recipient) and the insurer rather than a deal that is usually hidden from consumers between “providers” of care and third-party payers.
We do need to get rid of individual and corporate ACA penalties for not having insurance while at the same time, make markets appealing to consumers of all incomes and needs. And people should be able to buy prepaid coverage from health maintenance organizations (HMOs) if people want prepaid care with its restrictions. We should expand HSAs, and encourage price disclosure/transparency for services and insurance coverage via the Internet.
I lobbied for mental health parity legislation for years, and the American Psychiatric Association supported the passage of the ACA in 2010 to ensure access to mental health benefits for Americans. But let’s stop kidding ourselves about the ACA’s real world consequences to the psychiatric care of our patients. Despite hard work over the years to expand parity for mental health services, psychiatric and substance use care at this moment is commonly restricted to managed care behavioral carve-out networks or time-limited programs. Those restrictions grew under the ACA.
In short, we need to create a true health care marketplace and access to insurance protections that enable psychiatrists and other mental health professionals to work for the best interests of our patients rather than the bottom line of health care organizations. Let’s urge our politicians to replace the ACA with measures that encourage and promote voluntary, motivated patients and their families to find quality professional relationships with competent professionals of their choice who are able to provide care continuity and confidential, data-safe practice environments.
Dr. Beecher is president of the Minnesota Physician-Patient Alliance (www.physician-patient.org), a health care think tank based in Saint Louis Park, Minn. He is a distinguished life fellow of the American Psychiatric Association and Fellow of the American Society of Addiction Medicine, and until 2015 served as adjunct professor of psychiatry at the University of Minnesota, Minneapolis.
*CORRECTION, 1/13/2017: The federal program that incentivizes physicians to use EHRs was part of the HITECH Act, which was part of the Recovery Act of 2009 and predates the ACA.
Analyses of Fort Lauderdale shooting need a reset
Once again, there has been another senseless tragedy: a mass murder that leaves us all feeling vulnerable.
Last Friday, a gunman flew from Anchorage, Alaska, to Florida; retrieved a gun from his checked baggage; and opened fire on total strangers in the baggage claim area of the Fort Lauderdale airport, killing five people and wounding eight others. Why? The media always find a few facts that leave the public to piece together a theory that may or may not hold true.
I heard about the shooting while I was on vacation: The suspected gunman reportedly had visited ISIS websites and was killed at the scene. Later, I saw that he was not a terrorist and was not killed but had been taken into custody without a struggle.
The next reports noted that the 26-year-old man is a former soldier who had served in Iraq, and had come back traumatized and with psychological issues, according to his brother – or, according to what the media say his brother said, since the facts are sometimes selectively reported.
It was then announced that the gunman had gone to the FBI and reported that he was having concerns that U.S. intelligence agencies were infiltrating his brain and commanding him to look at ISIS websites. The FBI sent him for a psychiatric evaluation. His gun was taken by police; he spent a few days in the hospital, and had been released. Soon after, his firearm was returned, and he used it to commit a mass shooting.
So the story started as a terror attack and moved to the media’s default explanation for mass murder – mental illness. These few facts may be pieced together to tell a story of a man who was changed by war, struggled with posttraumatic symptoms that left him angry, and at some point, had a psychotic break that led him to fly across the continent and kill strangers at an airport in response to a command delusion. That’s one possible story that could be written with the very few facts we have.
My best guess is that as facts unfold, the story will change. Even if this story is right, one has to wonder why so many other young soldiers who return from military service so damaged, who also may coincidentally develop psychotic illnesses (or psychosis related to drug use) don’t routinely commit mass murder.
These stories are rare, but they capture the attention of the media in a way that common gun deaths in our inner cities do not. And they play out in a stereotyped way, regardless of how little we know: Mental health advocates use these examples to lobby for more involuntary care – “treatment before tragedy” in a population that does not recognize their own mental illnesses. Such incidents lead to calls to medicate every person with a psychotic illness, because that person may be the next killer, even though half of mass murderers don’t have mental disorders, and even though violence, in general, is more often caused by anger, substance abuse, and a history of exposure to violence. The plea for involuntary care goes out to a nation where voluntary care is often inaccessible to those who want it, where beds are scarce, where insurers – and not doctors – decide who can be hospitalized and for how long. One can only hope that if this young man was obviously dangerous, the hospital that evaluated him would not have discharged him, and that the police would not have returned his firearm. Predicting violence may seem plausible in retrospect, but it’s not always that obvious.
As more of the stereotyped response, antipsychiatry groups often assume mass murderers have been treated with psychotropic medications and use these events as one more example of how psychiatry is causing violence, suicide, and disability for unsuspecting souls who would have fared better without our interventions.
Among psychiatrists ourselves, these stories set off questions and fears. Why did a hospital release this patient? Was he given medications and follow up? What kind of follow up is even available in Alaska? Was he released because he’d taken medication that helped him, because a substance-induced psychosis cleared, or because he refused treatment and was not felt to be dangerous? Or was he released because he had no insurance, or because his insurance company refused to pay for continued treatment? Was a terrible outcome the result of negligence, or was the act of violence something that could not have been predicted? And finally, is the psychiatrist liable? The stock value for crystal balls rises, and we all wonder how we can know – and document – that our patients are safe, as it’s not unusual for distressed people to express violent fantasies. All of us have treated patients who have delusions – how many of those patients have gone on to become mass murderers? Have you ever treated a college student with depression, anxiety, and disturbing thoughts? Did he shoot 70 people in a movie theater and wire his apartment with explosives?
Finally, I’d like to share some concerns I have. First, before we talk about involuntary care to prevent such tragedies as those that happened in Fort Lauderdale last week, we need to be sure that everyone in our nation has access to high-quality, comprehensive psychiatric services, especially our veterans. In the plea for more forced psychiatric care, I believe we’ve become careless and disengaged. Patient rights’ groups have instituted barriers to involuntary treatment, while mental health advocates have touted the impossibility of convincing patients with anosognosia – an inability to see that they suffer from an illness – into accepting psychiatric treatment. Insurers chime in by managing benefits such that patients can be admitted only if they are dangerous, even if they are very sick and want to be in the hospital.
We need to use some commonsense: Patients with psychiatric disorders need to be offered voluntary care in much the same way that patients with other illnesses are approached. If someone in an ED refuses treatment for cancer or an MI, we don’t just say so be it, goodbye. Doctors cajole; they call family; they explain the risks and try quite hard to get the patient to accept help.
In psychiatry, we have stories where patients are asked if they are dangerous, and when they say no, they are sent out, without any further effort to engage them. Psychosis is often a tormenting state, and while patients may not be aware they have an illness, they can often be convinced to come into a hospital for respite, or to take medication to soothe the anxiety that accompanies paranoia or allow for restful sleep. Not everyone is beyond engagement, and the issue needs to be one of what is the best interests of any given patient – with involuntary care only as a true last resort– and not one of preventing mass murders.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Care,” which was released last fall (Baltimore: Johns Hopkins University Press).
Once again, there has been another senseless tragedy: a mass murder that leaves us all feeling vulnerable.
Last Friday, a gunman flew from Anchorage, Alaska, to Florida; retrieved a gun from his checked baggage; and opened fire on total strangers in the baggage claim area of the Fort Lauderdale airport, killing five people and wounding eight others. Why? The media always find a few facts that leave the public to piece together a theory that may or may not hold true.
I heard about the shooting while I was on vacation: The suspected gunman reportedly had visited ISIS websites and was killed at the scene. Later, I saw that he was not a terrorist and was not killed but had been taken into custody without a struggle.
The next reports noted that the 26-year-old man is a former soldier who had served in Iraq, and had come back traumatized and with psychological issues, according to his brother – or, according to what the media say his brother said, since the facts are sometimes selectively reported.
It was then announced that the gunman had gone to the FBI and reported that he was having concerns that U.S. intelligence agencies were infiltrating his brain and commanding him to look at ISIS websites. The FBI sent him for a psychiatric evaluation. His gun was taken by police; he spent a few days in the hospital, and had been released. Soon after, his firearm was returned, and he used it to commit a mass shooting.
So the story started as a terror attack and moved to the media’s default explanation for mass murder – mental illness. These few facts may be pieced together to tell a story of a man who was changed by war, struggled with posttraumatic symptoms that left him angry, and at some point, had a psychotic break that led him to fly across the continent and kill strangers at an airport in response to a command delusion. That’s one possible story that could be written with the very few facts we have.
My best guess is that as facts unfold, the story will change. Even if this story is right, one has to wonder why so many other young soldiers who return from military service so damaged, who also may coincidentally develop psychotic illnesses (or psychosis related to drug use) don’t routinely commit mass murder.
These stories are rare, but they capture the attention of the media in a way that common gun deaths in our inner cities do not. And they play out in a stereotyped way, regardless of how little we know: Mental health advocates use these examples to lobby for more involuntary care – “treatment before tragedy” in a population that does not recognize their own mental illnesses. Such incidents lead to calls to medicate every person with a psychotic illness, because that person may be the next killer, even though half of mass murderers don’t have mental disorders, and even though violence, in general, is more often caused by anger, substance abuse, and a history of exposure to violence. The plea for involuntary care goes out to a nation where voluntary care is often inaccessible to those who want it, where beds are scarce, where insurers – and not doctors – decide who can be hospitalized and for how long. One can only hope that if this young man was obviously dangerous, the hospital that evaluated him would not have discharged him, and that the police would not have returned his firearm. Predicting violence may seem plausible in retrospect, but it’s not always that obvious.
As more of the stereotyped response, antipsychiatry groups often assume mass murderers have been treated with psychotropic medications and use these events as one more example of how psychiatry is causing violence, suicide, and disability for unsuspecting souls who would have fared better without our interventions.
Among psychiatrists ourselves, these stories set off questions and fears. Why did a hospital release this patient? Was he given medications and follow up? What kind of follow up is even available in Alaska? Was he released because he’d taken medication that helped him, because a substance-induced psychosis cleared, or because he refused treatment and was not felt to be dangerous? Or was he released because he had no insurance, or because his insurance company refused to pay for continued treatment? Was a terrible outcome the result of negligence, or was the act of violence something that could not have been predicted? And finally, is the psychiatrist liable? The stock value for crystal balls rises, and we all wonder how we can know – and document – that our patients are safe, as it’s not unusual for distressed people to express violent fantasies. All of us have treated patients who have delusions – how many of those patients have gone on to become mass murderers? Have you ever treated a college student with depression, anxiety, and disturbing thoughts? Did he shoot 70 people in a movie theater and wire his apartment with explosives?
Finally, I’d like to share some concerns I have. First, before we talk about involuntary care to prevent such tragedies as those that happened in Fort Lauderdale last week, we need to be sure that everyone in our nation has access to high-quality, comprehensive psychiatric services, especially our veterans. In the plea for more forced psychiatric care, I believe we’ve become careless and disengaged. Patient rights’ groups have instituted barriers to involuntary treatment, while mental health advocates have touted the impossibility of convincing patients with anosognosia – an inability to see that they suffer from an illness – into accepting psychiatric treatment. Insurers chime in by managing benefits such that patients can be admitted only if they are dangerous, even if they are very sick and want to be in the hospital.
We need to use some commonsense: Patients with psychiatric disorders need to be offered voluntary care in much the same way that patients with other illnesses are approached. If someone in an ED refuses treatment for cancer or an MI, we don’t just say so be it, goodbye. Doctors cajole; they call family; they explain the risks and try quite hard to get the patient to accept help.
In psychiatry, we have stories where patients are asked if they are dangerous, and when they say no, they are sent out, without any further effort to engage them. Psychosis is often a tormenting state, and while patients may not be aware they have an illness, they can often be convinced to come into a hospital for respite, or to take medication to soothe the anxiety that accompanies paranoia or allow for restful sleep. Not everyone is beyond engagement, and the issue needs to be one of what is the best interests of any given patient – with involuntary care only as a true last resort– and not one of preventing mass murders.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Care,” which was released last fall (Baltimore: Johns Hopkins University Press).
Once again, there has been another senseless tragedy: a mass murder that leaves us all feeling vulnerable.
Last Friday, a gunman flew from Anchorage, Alaska, to Florida; retrieved a gun from his checked baggage; and opened fire on total strangers in the baggage claim area of the Fort Lauderdale airport, killing five people and wounding eight others. Why? The media always find a few facts that leave the public to piece together a theory that may or may not hold true.
I heard about the shooting while I was on vacation: The suspected gunman reportedly had visited ISIS websites and was killed at the scene. Later, I saw that he was not a terrorist and was not killed but had been taken into custody without a struggle.
The next reports noted that the 26-year-old man is a former soldier who had served in Iraq, and had come back traumatized and with psychological issues, according to his brother – or, according to what the media say his brother said, since the facts are sometimes selectively reported.
It was then announced that the gunman had gone to the FBI and reported that he was having concerns that U.S. intelligence agencies were infiltrating his brain and commanding him to look at ISIS websites. The FBI sent him for a psychiatric evaluation. His gun was taken by police; he spent a few days in the hospital, and had been released. Soon after, his firearm was returned, and he used it to commit a mass shooting.
So the story started as a terror attack and moved to the media’s default explanation for mass murder – mental illness. These few facts may be pieced together to tell a story of a man who was changed by war, struggled with posttraumatic symptoms that left him angry, and at some point, had a psychotic break that led him to fly across the continent and kill strangers at an airport in response to a command delusion. That’s one possible story that could be written with the very few facts we have.
My best guess is that as facts unfold, the story will change. Even if this story is right, one has to wonder why so many other young soldiers who return from military service so damaged, who also may coincidentally develop psychotic illnesses (or psychosis related to drug use) don’t routinely commit mass murder.
These stories are rare, but they capture the attention of the media in a way that common gun deaths in our inner cities do not. And they play out in a stereotyped way, regardless of how little we know: Mental health advocates use these examples to lobby for more involuntary care – “treatment before tragedy” in a population that does not recognize their own mental illnesses. Such incidents lead to calls to medicate every person with a psychotic illness, because that person may be the next killer, even though half of mass murderers don’t have mental disorders, and even though violence, in general, is more often caused by anger, substance abuse, and a history of exposure to violence. The plea for involuntary care goes out to a nation where voluntary care is often inaccessible to those who want it, where beds are scarce, where insurers – and not doctors – decide who can be hospitalized and for how long. One can only hope that if this young man was obviously dangerous, the hospital that evaluated him would not have discharged him, and that the police would not have returned his firearm. Predicting violence may seem plausible in retrospect, but it’s not always that obvious.
As more of the stereotyped response, antipsychiatry groups often assume mass murderers have been treated with psychotropic medications and use these events as one more example of how psychiatry is causing violence, suicide, and disability for unsuspecting souls who would have fared better without our interventions.
Among psychiatrists ourselves, these stories set off questions and fears. Why did a hospital release this patient? Was he given medications and follow up? What kind of follow up is even available in Alaska? Was he released because he’d taken medication that helped him, because a substance-induced psychosis cleared, or because he refused treatment and was not felt to be dangerous? Or was he released because he had no insurance, or because his insurance company refused to pay for continued treatment? Was a terrible outcome the result of negligence, or was the act of violence something that could not have been predicted? And finally, is the psychiatrist liable? The stock value for crystal balls rises, and we all wonder how we can know – and document – that our patients are safe, as it’s not unusual for distressed people to express violent fantasies. All of us have treated patients who have delusions – how many of those patients have gone on to become mass murderers? Have you ever treated a college student with depression, anxiety, and disturbing thoughts? Did he shoot 70 people in a movie theater and wire his apartment with explosives?
Finally, I’d like to share some concerns I have. First, before we talk about involuntary care to prevent such tragedies as those that happened in Fort Lauderdale last week, we need to be sure that everyone in our nation has access to high-quality, comprehensive psychiatric services, especially our veterans. In the plea for more forced psychiatric care, I believe we’ve become careless and disengaged. Patient rights’ groups have instituted barriers to involuntary treatment, while mental health advocates have touted the impossibility of convincing patients with anosognosia – an inability to see that they suffer from an illness – into accepting psychiatric treatment. Insurers chime in by managing benefits such that patients can be admitted only if they are dangerous, even if they are very sick and want to be in the hospital.
We need to use some commonsense: Patients with psychiatric disorders need to be offered voluntary care in much the same way that patients with other illnesses are approached. If someone in an ED refuses treatment for cancer or an MI, we don’t just say so be it, goodbye. Doctors cajole; they call family; they explain the risks and try quite hard to get the patient to accept help.
In psychiatry, we have stories where patients are asked if they are dangerous, and when they say no, they are sent out, without any further effort to engage them. Psychosis is often a tormenting state, and while patients may not be aware they have an illness, they can often be convinced to come into a hospital for respite, or to take medication to soothe the anxiety that accompanies paranoia or allow for restful sleep. Not everyone is beyond engagement, and the issue needs to be one of what is the best interests of any given patient – with involuntary care only as a true last resort– and not one of preventing mass murders.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Care,” which was released last fall (Baltimore: Johns Hopkins University Press).
Perfect attendance
A few years ago I audited a college course on leadership taught by Angus King (I-ME), former governor and now independent Senator from Maine. He emphasized that an important characteristic of effective leaders is that they show up for work. They are there, present, on the scene. Attempting to lead in absentia is seldom successful. Knowledge gathered firsthand can be critical when it’s decision-making time. And the connectedness fostered by the leader’s physical presence can bolster morale in a crisis.
Being a parent is more complex than simply being a leader, but showing up is just as important to being a good parent as it is to being an effective leader. Most parents already believe that “being there” is important, and feel guilty when they have obligations that prevent them from maintaining a perfect attendance record.
Common sense also may suggest to parents that their presence is less important as their children get older. Certainly, the behavior of most teenagers would suggest that adolescents couldn’t care less whether their parents were at home or vacationing in the Bahamas. However, this is one of those situations where appearances may be deceiving. The author of an opinion piece in the New York Times presents some compelling evidence that in fact, adolescents place a higher value on their parents’ presence than the common stereotype of teenage behavior would suggest (”What Do Teenagers Want? Potted Plants Parents,” By Lisa Damour, Dec. 14, 2016).
Citing her own experience as a psychologist in private practice in Ohio and several recent studies from the psychology literature, the author observes that “sheer proximity confers a benefit [to the adolescent’s psychological health] over and above feeling of closeness or connectedness between parent and child.” At present there is no explanation for this benefit of just being there for your teenage child. But it may be that a parental presence, even if it is silent, provides a stable base and comfort zone that the adolescent can return to as he or she tests the ability to function independently in the world outside of the family.
I suspect that most of you have observed this counter-intuitive phenomenon in which teenagers who give every outward appearance of wanting nothing to do with their parents actually would like to have at least one parent be at home. They just don’t want to be hovered over. Ninety-nine percent of the time the parent will receive no positive feedback for just being there like a “potted plant” to use Ms. Damour’s analogy.
The problem is how to get this message to parents early enough in their parenting trajectory that they can adjust work schedules and priorities to be home with their adolescents. It was not unusual for new parents to ask for my thoughts as they were considering various day care and work schedule options for their infants. If I thought they were really going to take my advice seriously I would add, “You know you should also be thinking ahead when she is a teen. She won’t ask, but she probably would like it if you were home in the afternoon when she gets home from school.”
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
A few years ago I audited a college course on leadership taught by Angus King (I-ME), former governor and now independent Senator from Maine. He emphasized that an important characteristic of effective leaders is that they show up for work. They are there, present, on the scene. Attempting to lead in absentia is seldom successful. Knowledge gathered firsthand can be critical when it’s decision-making time. And the connectedness fostered by the leader’s physical presence can bolster morale in a crisis.
Being a parent is more complex than simply being a leader, but showing up is just as important to being a good parent as it is to being an effective leader. Most parents already believe that “being there” is important, and feel guilty when they have obligations that prevent them from maintaining a perfect attendance record.
Common sense also may suggest to parents that their presence is less important as their children get older. Certainly, the behavior of most teenagers would suggest that adolescents couldn’t care less whether their parents were at home or vacationing in the Bahamas. However, this is one of those situations where appearances may be deceiving. The author of an opinion piece in the New York Times presents some compelling evidence that in fact, adolescents place a higher value on their parents’ presence than the common stereotype of teenage behavior would suggest (”What Do Teenagers Want? Potted Plants Parents,” By Lisa Damour, Dec. 14, 2016).
Citing her own experience as a psychologist in private practice in Ohio and several recent studies from the psychology literature, the author observes that “sheer proximity confers a benefit [to the adolescent’s psychological health] over and above feeling of closeness or connectedness between parent and child.” At present there is no explanation for this benefit of just being there for your teenage child. But it may be that a parental presence, even if it is silent, provides a stable base and comfort zone that the adolescent can return to as he or she tests the ability to function independently in the world outside of the family.
I suspect that most of you have observed this counter-intuitive phenomenon in which teenagers who give every outward appearance of wanting nothing to do with their parents actually would like to have at least one parent be at home. They just don’t want to be hovered over. Ninety-nine percent of the time the parent will receive no positive feedback for just being there like a “potted plant” to use Ms. Damour’s analogy.
The problem is how to get this message to parents early enough in their parenting trajectory that they can adjust work schedules and priorities to be home with their adolescents. It was not unusual for new parents to ask for my thoughts as they were considering various day care and work schedule options for their infants. If I thought they were really going to take my advice seriously I would add, “You know you should also be thinking ahead when she is a teen. She won’t ask, but she probably would like it if you were home in the afternoon when she gets home from school.”
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
A few years ago I audited a college course on leadership taught by Angus King (I-ME), former governor and now independent Senator from Maine. He emphasized that an important characteristic of effective leaders is that they show up for work. They are there, present, on the scene. Attempting to lead in absentia is seldom successful. Knowledge gathered firsthand can be critical when it’s decision-making time. And the connectedness fostered by the leader’s physical presence can bolster morale in a crisis.
Being a parent is more complex than simply being a leader, but showing up is just as important to being a good parent as it is to being an effective leader. Most parents already believe that “being there” is important, and feel guilty when they have obligations that prevent them from maintaining a perfect attendance record.
Common sense also may suggest to parents that their presence is less important as their children get older. Certainly, the behavior of most teenagers would suggest that adolescents couldn’t care less whether their parents were at home or vacationing in the Bahamas. However, this is one of those situations where appearances may be deceiving. The author of an opinion piece in the New York Times presents some compelling evidence that in fact, adolescents place a higher value on their parents’ presence than the common stereotype of teenage behavior would suggest (”What Do Teenagers Want? Potted Plants Parents,” By Lisa Damour, Dec. 14, 2016).
Citing her own experience as a psychologist in private practice in Ohio and several recent studies from the psychology literature, the author observes that “sheer proximity confers a benefit [to the adolescent’s psychological health] over and above feeling of closeness or connectedness between parent and child.” At present there is no explanation for this benefit of just being there for your teenage child. But it may be that a parental presence, even if it is silent, provides a stable base and comfort zone that the adolescent can return to as he or she tests the ability to function independently in the world outside of the family.
I suspect that most of you have observed this counter-intuitive phenomenon in which teenagers who give every outward appearance of wanting nothing to do with their parents actually would like to have at least one parent be at home. They just don’t want to be hovered over. Ninety-nine percent of the time the parent will receive no positive feedback for just being there like a “potted plant” to use Ms. Damour’s analogy.
The problem is how to get this message to parents early enough in their parenting trajectory that they can adjust work schedules and priorities to be home with their adolescents. It was not unusual for new parents to ask for my thoughts as they were considering various day care and work schedule options for their infants. If I thought they were really going to take my advice seriously I would add, “You know you should also be thinking ahead when she is a teen. She won’t ask, but she probably would like it if you were home in the afternoon when she gets home from school.”
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].