Commentary

In our December 2016 issue, we reported the results of our first annual survey on nonmonetary compensation (ie, the “perks”) and overall employment satisfaction (Clinician Reviews. 2016;26[12]:23-26). But the feedback I found most interesting came from the narrative responses—particularly those referencing patient satisfaction and the stress it creates for NPs and PAs.

Safety, quality, and affordability have been touted as today’s health care priorities. But it is unclear whether the majority of health care consumers agree with them. Patients may express understanding or accord initially, but when the discussion turns to what is appropriate as opposed to what is desired, conflict may arise.

Judging by the verbatim responses to our survey, NPs and PAs are concerned that quality measures don’t reflect the demands of our practice or focus on what matters to our patients.

One participant analogized, “Medicine is now like McDonalds or Burger King—patients want it their way, regardless of whether it’s in their best interest. I was fee-for-service for more than 10 years. As reimbursements have decreased significantly over time, I’m now employed by a hospital. I have become a waitress, considering my patients’ wishes—not for the benefit of their health, but to meet their more trivial ‘needs.’ These requirements can be as absurd as a specific brand of sweetener! If patients’ preferred sugar substitutes aren’t offered at my hospital, their ‘satisfaction’ may drop and I won’t get reimbursed as much. It’s a miserable experience.”

Perhaps the disparate views of what matters—Is it the softness of the pillows, or is it measurable improvement in the patient’s condition?—is the origin of the stress expressed by clinicians. This dissonance, in my opinion, exists among all involved—providers, patients, and payers. Today, patients see themselves as buyers of health services, and health care corporations have begun to function as a service industry. It may also explain why the concept of patient satisfaction has seemingly morphed into customer service, frustrating many of our colleagues.

Because it can affect clinical outcomes, patient retention, and medical malpractice claims, patient satisfaction is commonly used as a proxy for the success of doctors and hospitals.¹ We know there is a correlation between higher patient satisfaction rates and improved outcomes—and conversely, research has demonstrated that unmet expectations significantly decrease satisfaction.²

However, there has been no explicit definition of patient satisfaction, nor systematic consideration of its determinants and consequences.³ As a result, measurement of “satisfaction” and its use as an indicator of quality of care remains controversial among health care providers. It can be a difficult concept to embrace.

Even setting aside the question of “amenities” and focusing on actual clinical care, satisfaction has different meanings for different people. For some, it is a positive, immediate improvement in the patient’s condition (recall my comments on pain management in my previous editorial).⁴ While that might be an unrealistic expectation, it is a factor in whether the patient and/or family express satisfaction with the care provided.

These high (if not unreasonable) expectations are fueled by the availability of information via the Internet. Patient attitudes and perceptions prior to receiving care also play a role. Instead of correlating with high-quality, appropriate, affordable care, a patient’s satisfaction might instead be based on the fulfillment of his or her predetermined ideas as to what treatment is needed!

The impetus for this change in perspective was the development of the patient-centered care model, which has patient satisfaction at its core.⁵ The model is intended to make patients partners in their health care; instead of depending solely on provider tools or standards, patients and providers discuss the options and preferences and develop a plan of care together. We all know that the relationship between patients and their providers greatly affects both treatment outcomes and patient satisfaction. But implementing a patient-centered care model means understanding and accepting from the start that patients will be asked to rate or judge their health care. It is therefore essential that there is agreement as to the standards that constitute “quality care” and congruence between these beliefs and the satisfaction ratings. You need to know what your patient expects to determine your likelihood of delivering it.

The patient-provider relationship has been a focus of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospital Survey, which, since 2006, has measured patients’ perceptions of their hospital experiences.⁶ The CAHPS Clinician and Group Survey, initiated in 2011, is a standardized tool to measure patients’ perceptions of care in an office setting.⁷ Data from both surveys are used to improve performance and productivity in these settings. But while the information about quality of care has enabled consumers to make more informed decisions, the data are in many ways limited and subjective.

What cannot be measured by either survey alone is the health of patients, employees, and the community. This limitation is reflected in the feedback to our survey, which suggests a preponderance of NP and PA dissatisfaction with the current methods of evaluating the health care system. How much strain is incurred when evaluative measures fail to demonstrate that high-quality, safe, affordable care is being provided? That is difficult to ascertain, but it does give one pause. We know that providers who experience professional satisfaction have higher overall patient satisfaction scores.⁸ If we’re frustrated, are we able to provide the highest quality care? If not, our scores will suffer. If our scores drop … around we go again.

Currently, most data collection methods focus on physicians, making NPs and PAs “invisible” providers. That certainly won’t help our satisfaction! Only when the data gleaned from these measurement tools include all ambulatory settings, and all providers are recognized as valued contributors to patient health and satisfaction, will we have the information we need to improve satisfaction levels. That will benefit not only our patients, but also ourselves.

Please share your thoughts on patient satisfaction and “customer service” by emailing [email protected].

In our December 2016 issue, we reported the results of our first annual survey on nonmonetary compensation (ie, the “perks”) and overall employment satisfaction (Clinician Reviews. 2016;26[12]:23-26). But the feedback I found most interesting came from the narrative responses—particularly those referencing patient satisfaction and the stress it creates for NPs and PAs.

Safety, quality, and affordability have been touted as today’s health care priorities. But it is unclear whether the majority of health care consumers agree with them. Patients may express understanding or accord initially, but when the discussion turns to what is appropriate as opposed to what is desired, conflict may arise.

Judging by the verbatim responses to our survey, NPs and PAs are concerned that quality measures don’t reflect the demands of our practice or focus on what matters to our patients.

One participant analogized, “Medicine is now like McDonalds or Burger King—patients want it their way, regardless of whether it’s in their best interest. I was fee-for-service for more than 10 years. As reimbursements have decreased significantly over time, I’m now employed by a hospital. I have become a waitress, considering my patients’ wishes—not for the benefit of their health, but to meet their more trivial ‘needs.’ These requirements can be as absurd as a specific brand of sweetener! If patients’ preferred sugar substitutes aren’t offered at my hospital, their ‘satisfaction’ may drop and I won’t get reimbursed as much. It’s a miserable experience.”

Perhaps the disparate views of what matters—Is it the softness of the pillows, or is it measurable improvement in the patient’s condition?—is the origin of the stress expressed by clinicians. This dissonance, in my opinion, exists among all involved—providers, patients, and payers. Today, patients see themselves as buyers of health services, and health care corporations have begun to function as a service industry. It may also explain why the concept of patient satisfaction has seemingly morphed into customer service, frustrating many of our colleagues.

Because it can affect clinical outcomes, patient retention, and medical malpractice claims, patient satisfaction is commonly used as a proxy for the success of doctors and hospitals.¹ We know there is a correlation between higher patient satisfaction rates and improved outcomes—and conversely, research has demonstrated that unmet expectations significantly decrease satisfaction.²

However, there has been no explicit definition of patient satisfaction, nor systematic consideration of its determinants and consequences.³ As a result, measurement of “satisfaction” and its use as an indicator of quality of care remains controversial among health care providers. It can be a difficult concept to embrace.

Even setting aside the question of “amenities” and focusing on actual clinical care, satisfaction has different meanings for different people. For some, it is a positive, immediate improvement in the patient’s condition (recall my comments on pain management in my previous editorial).⁴ While that might be an unrealistic expectation, it is a factor in whether the patient and/or family express satisfaction with the care provided.

These high (if not unreasonable) expectations are fueled by the availability of information via the Internet. Patient attitudes and perceptions prior to receiving care also play a role. Instead of correlating with high-quality, appropriate, affordable care, a patient’s satisfaction might instead be based on the fulfillment of his or her predetermined ideas as to what treatment is needed!

The impetus for this change in perspective was the development of the patient-centered care model, which has patient satisfaction at its core.⁵ The model is intended to make patients partners in their health care; instead of depending solely on provider tools or standards, patients and providers discuss the options and preferences and develop a plan of care together. We all know that the relationship between patients and their providers greatly affects both treatment outcomes and patient satisfaction. But implementing a patient-centered care model means understanding and accepting from the start that patients will be asked to rate or judge their health care. It is therefore essential that there is agreement as to the standards that constitute “quality care” and congruence between these beliefs and the satisfaction ratings. You need to know what your patient expects to determine your likelihood of delivering it.

The patient-provider relationship has been a focus of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospital Survey, which, since 2006, has measured patients’ perceptions of their hospital experiences.⁶ The CAHPS Clinician and Group Survey, initiated in 2011, is a standardized tool to measure patients’ perceptions of care in an office setting.⁷ Data from both surveys are used to improve performance and productivity in these settings. But while the information about quality of care has enabled consumers to make more informed decisions, the data are in many ways limited and subjective.

What cannot be measured by either survey alone is the health of patients, employees, and the community. This limitation is reflected in the feedback to our survey, which suggests a preponderance of NP and PA dissatisfaction with the current methods of evaluating the health care system. How much strain is incurred when evaluative measures fail to demonstrate that high-quality, safe, affordable care is being provided? That is difficult to ascertain, but it does give one pause. We know that providers who experience professional satisfaction have higher overall patient satisfaction scores.⁸ If we’re frustrated, are we able to provide the highest quality care? If not, our scores will suffer. If our scores drop … around we go again.

Currently, most data collection methods focus on physicians, making NPs and PAs “invisible” providers. That certainly won’t help our satisfaction! Only when the data gleaned from these measurement tools include all ambulatory settings, and all providers are recognized as valued contributors to patient health and satisfaction, will we have the information we need to improve satisfaction levels. That will benefit not only our patients, but also ourselves.

Please share your thoughts on patient satisfaction and “customer service” by emailing [email protected].

In our December 2016 issue, we reported the results of our first annual survey on nonmonetary compensation (ie, the “perks”) and overall employment satisfaction (Clinician Reviews. 2016;26[12]:23-26). But the feedback I found most interesting came from the narrative responses—particularly those referencing patient satisfaction and the stress it creates for NPs and PAs.

Safety, quality, and affordability have been touted as today’s health care priorities. But it is unclear whether the majority of health care consumers agree with them. Patients may express understanding or accord initially, but when the discussion turns to what is appropriate as opposed to what is desired, conflict may arise.

Judging by the verbatim responses to our survey, NPs and PAs are concerned that quality measures don’t reflect the demands of our practice or focus on what matters to our patients.

One participant analogized, “Medicine is now like McDonalds or Burger King—patients want it their way, regardless of whether it’s in their best interest. I was fee-for-service for more than 10 years. As reimbursements have decreased significantly over time, I’m now employed by a hospital. I have become a waitress, considering my patients’ wishes—not for the benefit of their health, but to meet their more trivial ‘needs.’ These requirements can be as absurd as a specific brand of sweetener! If patients’ preferred sugar substitutes aren’t offered at my hospital, their ‘satisfaction’ may drop and I won’t get reimbursed as much. It’s a miserable experience.”

Perhaps the disparate views of what matters—Is it the softness of the pillows, or is it measurable improvement in the patient’s condition?—is the origin of the stress expressed by clinicians. This dissonance, in my opinion, exists among all involved—providers, patients, and payers. Today, patients see themselves as buyers of health services, and health care corporations have begun to function as a service industry. It may also explain why the concept of patient satisfaction has seemingly morphed into customer service, frustrating many of our colleagues.

Because it can affect clinical outcomes, patient retention, and medical malpractice claims, patient satisfaction is commonly used as a proxy for the success of doctors and hospitals.¹ We know there is a correlation between higher patient satisfaction rates and improved outcomes—and conversely, research has demonstrated that unmet expectations significantly decrease satisfaction.²

However, there has been no explicit definition of patient satisfaction, nor systematic consideration of its determinants and consequences.³ As a result, measurement of “satisfaction” and its use as an indicator of quality of care remains controversial among health care providers. It can be a difficult concept to embrace.

Even setting aside the question of “amenities” and focusing on actual clinical care, satisfaction has different meanings for different people. For some, it is a positive, immediate improvement in the patient’s condition (recall my comments on pain management in my previous editorial).⁴ While that might be an unrealistic expectation, it is a factor in whether the patient and/or family express satisfaction with the care provided.

These high (if not unreasonable) expectations are fueled by the availability of information via the Internet. Patient attitudes and perceptions prior to receiving care also play a role. Instead of correlating with high-quality, appropriate, affordable care, a patient’s satisfaction might instead be based on the fulfillment of his or her predetermined ideas as to what treatment is needed!

The impetus for this change in perspective was the development of the patient-centered care model, which has patient satisfaction at its core.⁵ The model is intended to make patients partners in their health care; instead of depending solely on provider tools or standards, patients and providers discuss the options and preferences and develop a plan of care together. We all know that the relationship between patients and their providers greatly affects both treatment outcomes and patient satisfaction. But implementing a patient-centered care model means understanding and accepting from the start that patients will be asked to rate or judge their health care. It is therefore essential that there is agreement as to the standards that constitute “quality care” and congruence between these beliefs and the satisfaction ratings. You need to know what your patient expects to determine your likelihood of delivering it.

The patient-provider relationship has been a focus of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospital Survey, which, since 2006, has measured patients’ perceptions of their hospital experiences.⁶ The CAHPS Clinician and Group Survey, initiated in 2011, is a standardized tool to measure patients’ perceptions of care in an office setting.⁷ Data from both surveys are used to improve performance and productivity in these settings. But while the information about quality of care has enabled consumers to make more informed decisions, the data are in many ways limited and subjective.

What cannot be measured by either survey alone is the health of patients, employees, and the community. This limitation is reflected in the feedback to our survey, which suggests a preponderance of NP and PA dissatisfaction with the current methods of evaluating the health care system. How much strain is incurred when evaluative measures fail to demonstrate that high-quality, safe, affordable care is being provided? That is difficult to ascertain, but it does give one pause. We know that providers who experience professional satisfaction have higher overall patient satisfaction scores.⁸ If we’re frustrated, are we able to provide the highest quality care? If not, our scores will suffer. If our scores drop … around we go again.

Currently, most data collection methods focus on physicians, making NPs and PAs “invisible” providers. That certainly won’t help our satisfaction! Only when the data gleaned from these measurement tools include all ambulatory settings, and all providers are recognized as valued contributors to patient health and satisfaction, will we have the information we need to improve satisfaction levels. That will benefit not only our patients, but also ourselves.

Please share your thoughts on patient satisfaction and “customer service” by emailing [email protected].

A man walks into a doctor’s office, snapping his fingers.

“Why are you snapping your fingers?” asks the doctor.

“To keep the elephants away,” says the man, still snapping his fingers.

“That’s ridiculous!” says the doctor. “There are no elephants within 3,000 miles of here!”

“You see,” says the man, still snapping. “It’s working!”

Acne

• Henrietta, for whom I’d prescribed clindamycin in the morning and tretinoin at night. Her verdict? “I stopped the clindamycin because it didn’t work. But I love the tretinoin—it works great!”

Since she was putting both creams on exactly the same area, what did Henrietta observe to lead her to this paradoxical conclusion?

• Janet has two pimples, yet she’s decided that minocycline doesn’t work. Her evidence? “I still get breakouts around my period.”

Eczema

• “Amcinonide worked amazingly but clobetasol didn’t work at all!”

• “I stopped the betamethasone. Calendula works better.”

• And of course: “Sure the cream helped, but the rash came back!”

Patients say things like this all day long. From a medical standpoint, active ingredients work better than inert vehicles. In theory, class 1 steroids are more effective than class 3 steroids.

Perhaps, but many of my patients don’t agree. Maybe their eczema has gone into remission, in which case anything will work. Even if so, there is no way I can prove that to them. So I usually don’t try.

Psoriasis

“Your psoriasis looks better.”

“No, it’s worse.”

“Why? It covers a lot less skin than it used to.”

“But now it’s coming in new places.”

One could go on. With my students, I often do. If they learn nothing else, I try to convey the essential difference between a person and a toaster. Which is this:

If you know how to fix a toaster, the toaster does not have to agree with you.

A person is another matter. Patients have minds to go with their parts. They pick up knowledge from places doctors have never been and make inferences doctors would never make. Then they act on this knowledge and those inferences by saying things like: “The morning cream didn’t work but the night cream did, so I stopped the morning cream.”

I therefore advise students to ask patients two questions first thing:

• What treatments are the patients actually using? Assuming that they are doing what the chart says you asked them to do can jam your foot so deep in your mouth that you’ll never get it out.

• How do the patients themselves think they’re doing? One man with a couple of pimples or scaly spots is thrilled. Another with the same pimples or spots is miserable. It’s helpful to find out which he is before making suggestions. (See foot in mouth, above.)

Emma, by the way, was unhappy that she couldn’t find a practitioner of craniosacral therapy (look it up) as proficient as the one she had in Austria.

I asked her how she judged proficiency but won’t bother you with her answer. I just referred her to a physician who practices both Eastern and Western medicine.

That worked for her.
 

Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected] .

A man walks into a doctor’s office, snapping his fingers.

“Why are you snapping your fingers?” asks the doctor.

“To keep the elephants away,” says the man, still snapping his fingers.

“That’s ridiculous!” says the doctor. “There are no elephants within 3,000 miles of here!”

“You see,” says the man, still snapping. “It’s working!”

Acne

• Henrietta, for whom I’d prescribed clindamycin in the morning and tretinoin at night. Her verdict? “I stopped the clindamycin because it didn’t work. But I love the tretinoin—it works great!”

Since she was putting both creams on exactly the same area, what did Henrietta observe to lead her to this paradoxical conclusion?

• Janet has two pimples, yet she’s decided that minocycline doesn’t work. Her evidence? “I still get breakouts around my period.”

Eczema

• “Amcinonide worked amazingly but clobetasol didn’t work at all!”

• “I stopped the betamethasone. Calendula works better.”

• And of course: “Sure the cream helped, but the rash came back!”

Patients say things like this all day long. From a medical standpoint, active ingredients work better than inert vehicles. In theory, class 1 steroids are more effective than class 3 steroids.

Perhaps, but many of my patients don’t agree. Maybe their eczema has gone into remission, in which case anything will work. Even if so, there is no way I can prove that to them. So I usually don’t try.

Psoriasis

“Your psoriasis looks better.”

“No, it’s worse.”

“Why? It covers a lot less skin than it used to.”

“But now it’s coming in new places.”

One could go on. With my students, I often do. If they learn nothing else, I try to convey the essential difference between a person and a toaster. Which is this:

If you know how to fix a toaster, the toaster does not have to agree with you.

A person is another matter. Patients have minds to go with their parts. They pick up knowledge from places doctors have never been and make inferences doctors would never make. Then they act on this knowledge and those inferences by saying things like: “The morning cream didn’t work but the night cream did, so I stopped the morning cream.”

I therefore advise students to ask patients two questions first thing:

• What treatments are the patients actually using? Assuming that they are doing what the chart says you asked them to do can jam your foot so deep in your mouth that you’ll never get it out.

• How do the patients themselves think they’re doing? One man with a couple of pimples or scaly spots is thrilled. Another with the same pimples or spots is miserable. It’s helpful to find out which he is before making suggestions. (See foot in mouth, above.)

Emma, by the way, was unhappy that she couldn’t find a practitioner of craniosacral therapy (look it up) as proficient as the one she had in Austria.

I asked her how she judged proficiency but won’t bother you with her answer. I just referred her to a physician who practices both Eastern and Western medicine.

That worked for her.
 

Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected] .

A man walks into a doctor’s office, snapping his fingers.

“Why are you snapping your fingers?” asks the doctor.

“To keep the elephants away,” says the man, still snapping his fingers.

“That’s ridiculous!” says the doctor. “There are no elephants within 3,000 miles of here!”

“You see,” says the man, still snapping. “It’s working!”

Acne

• Henrietta, for whom I’d prescribed clindamycin in the morning and tretinoin at night. Her verdict? “I stopped the clindamycin because it didn’t work. But I love the tretinoin—it works great!”

Since she was putting both creams on exactly the same area, what did Henrietta observe to lead her to this paradoxical conclusion?

• Janet has two pimples, yet she’s decided that minocycline doesn’t work. Her evidence? “I still get breakouts around my period.”

Eczema

• “Amcinonide worked amazingly but clobetasol didn’t work at all!”

• “I stopped the betamethasone. Calendula works better.”

• And of course: “Sure the cream helped, but the rash came back!”

Patients say things like this all day long. From a medical standpoint, active ingredients work better than inert vehicles. In theory, class 1 steroids are more effective than class 3 steroids.

Perhaps, but many of my patients don’t agree. Maybe their eczema has gone into remission, in which case anything will work. Even if so, there is no way I can prove that to them. So I usually don’t try.

Psoriasis

“Your psoriasis looks better.”

“No, it’s worse.”

“Why? It covers a lot less skin than it used to.”

“But now it’s coming in new places.”

One could go on. With my students, I often do. If they learn nothing else, I try to convey the essential difference between a person and a toaster. Which is this:

If you know how to fix a toaster, the toaster does not have to agree with you.

A person is another matter. Patients have minds to go with their parts. They pick up knowledge from places doctors have never been and make inferences doctors would never make. Then they act on this knowledge and those inferences by saying things like: “The morning cream didn’t work but the night cream did, so I stopped the morning cream.”

I therefore advise students to ask patients two questions first thing:

• What treatments are the patients actually using? Assuming that they are doing what the chart says you asked them to do can jam your foot so deep in your mouth that you’ll never get it out.

• How do the patients themselves think they’re doing? One man with a couple of pimples or scaly spots is thrilled. Another with the same pimples or spots is miserable. It’s helpful to find out which he is before making suggestions. (See foot in mouth, above.)

Emma, by the way, was unhappy that she couldn’t find a practitioner of craniosacral therapy (look it up) as proficient as the one she had in Austria.

I asked her how she judged proficiency but won’t bother you with her answer. I just referred her to a physician who practices both Eastern and Western medicine.

That worked for her.
 

Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected] .

In hematologic malignancies, there is a deep and direct connection between each individual patient, that patient’s symptoms, the visible cells that cause the disease, and the direct measurements and assessments of those cells. The totality of these factors helps to determine the diagnosis and treatment plan. As a butterfly needle often is sufficient for obtaining a diagnostic tumor biopsy, it is not surprising that these same diagnostic techniques are now standardly being used to monitor disease response.

The techniques differ in their limits of detection, however. With sequencing depths able to reliably detect variant allele frequencies of less than 10%, even when patients’ overt leukemia may no longer be detectable, clinicians may be left to ponder what to do with persistent “preleukemic” or “rising clones.”^1-3

References

1. Jan, M. et al. Clonal evolution of preleukemic hematopoietic stem cells precedes human acute myeloid leukemia. Science Translational Medicine 4, 149ra118, doi: 10.1126/scitranslmed.3004315 (2012).

2. Klco, J. M. et al. Association Between Mutation Clearance After Induction Therapy and Outcomes in Acute Myeloid Leukemia. JAMA 2015;314:811-22. doi: 10.1001/jama.2015.9643.

3. Wong, T. N. et al. Rapid expansion of preexisting nonleukemic hematopoietic clones frequently follows induction therapy for de novo AML. Blood 2016;127:893-7. doi: 10.1182/blood-2015-10-677021 (2016).

4. Lane, A. A. et al. Results from Ongoing Phase II Trial of SL-401 As Consolidation Therapy in Patients with Acute Myeloid Leukemia (AML) in Remission with High Relapse Risk Including Minimal Residual Disease (MRD), Abstract 215, ASH 2016.

5. Getta, B. M. et al. Multicolor Flow Cytometry and Multi-Gene Next Generation Sequencing Are Complimentary and Highly Predictive for Relapse in Acute Myeloid Leukemia Following Allogeneic Hematopoietic Stem Cell Transplant, Abstract 834, ASH 2016.

Dr. Viny is with the Memorial Sloan-Kettering Cancer Center, New York, where he is a clinical instructor, on the staff of the leukemia service, and a clinical researcher in The Ross Levine Lab. Contact Dr. Viny at [email protected].

In hematologic malignancies, there is a deep and direct connection between each individual patient, that patient’s symptoms, the visible cells that cause the disease, and the direct measurements and assessments of those cells. The totality of these factors helps to determine the diagnosis and treatment plan. As a butterfly needle often is sufficient for obtaining a diagnostic tumor biopsy, it is not surprising that these same diagnostic techniques are now standardly being used to monitor disease response.

The techniques differ in their limits of detection, however. With sequencing depths able to reliably detect variant allele frequencies of less than 10%, even when patients’ overt leukemia may no longer be detectable, clinicians may be left to ponder what to do with persistent “preleukemic” or “rising clones.”^1-3

References

1. Jan, M. et al. Clonal evolution of preleukemic hematopoietic stem cells precedes human acute myeloid leukemia. Science Translational Medicine 4, 149ra118, doi: 10.1126/scitranslmed.3004315 (2012).

2. Klco, J. M. et al. Association Between Mutation Clearance After Induction Therapy and Outcomes in Acute Myeloid Leukemia. JAMA 2015;314:811-22. doi: 10.1001/jama.2015.9643.

3. Wong, T. N. et al. Rapid expansion of preexisting nonleukemic hematopoietic clones frequently follows induction therapy for de novo AML. Blood 2016;127:893-7. doi: 10.1182/blood-2015-10-677021 (2016).

4. Lane, A. A. et al. Results from Ongoing Phase II Trial of SL-401 As Consolidation Therapy in Patients with Acute Myeloid Leukemia (AML) in Remission with High Relapse Risk Including Minimal Residual Disease (MRD), Abstract 215, ASH 2016.

5. Getta, B. M. et al. Multicolor Flow Cytometry and Multi-Gene Next Generation Sequencing Are Complimentary and Highly Predictive for Relapse in Acute Myeloid Leukemia Following Allogeneic Hematopoietic Stem Cell Transplant, Abstract 834, ASH 2016.

Dr. Viny is with the Memorial Sloan-Kettering Cancer Center, New York, where he is a clinical instructor, on the staff of the leukemia service, and a clinical researcher in The Ross Levine Lab. Contact Dr. Viny at [email protected].

In hematologic malignancies, there is a deep and direct connection between each individual patient, that patient’s symptoms, the visible cells that cause the disease, and the direct measurements and assessments of those cells. The totality of these factors helps to determine the diagnosis and treatment plan. As a butterfly needle often is sufficient for obtaining a diagnostic tumor biopsy, it is not surprising that these same diagnostic techniques are now standardly being used to monitor disease response.

The techniques differ in their limits of detection, however. With sequencing depths able to reliably detect variant allele frequencies of less than 10%, even when patients’ overt leukemia may no longer be detectable, clinicians may be left to ponder what to do with persistent “preleukemic” or “rising clones.”^1-3

References

1. Jan, M. et al. Clonal evolution of preleukemic hematopoietic stem cells precedes human acute myeloid leukemia. Science Translational Medicine 4, 149ra118, doi: 10.1126/scitranslmed.3004315 (2012).

2. Klco, J. M. et al. Association Between Mutation Clearance After Induction Therapy and Outcomes in Acute Myeloid Leukemia. JAMA 2015;314:811-22. doi: 10.1001/jama.2015.9643.

3. Wong, T. N. et al. Rapid expansion of preexisting nonleukemic hematopoietic clones frequently follows induction therapy for de novo AML. Blood 2016;127:893-7. doi: 10.1182/blood-2015-10-677021 (2016).

4. Lane, A. A. et al. Results from Ongoing Phase II Trial of SL-401 As Consolidation Therapy in Patients with Acute Myeloid Leukemia (AML) in Remission with High Relapse Risk Including Minimal Residual Disease (MRD), Abstract 215, ASH 2016.

5. Getta, B. M. et al. Multicolor Flow Cytometry and Multi-Gene Next Generation Sequencing Are Complimentary and Highly Predictive for Relapse in Acute Myeloid Leukemia Following Allogeneic Hematopoietic Stem Cell Transplant, Abstract 834, ASH 2016.

Dr. Viny is with the Memorial Sloan-Kettering Cancer Center, New York, where he is a clinical instructor, on the staff of the leukemia service, and a clinical researcher in The Ross Levine Lab. Contact Dr. Viny at [email protected].

Most parents hope that their children will be motivated and hard-working at school, but ambitious students usually face very high levels of stress. Ambitious young people typically push themselves very hard and may not spend enough time in play, relaxation, or exploring potential interests. Their time with peers might be more competitive than social or fun. They may become rigidly focused on a goal, paving the way for devastation if they fall short of their own expectations. They may internalize stress and not ask for help if it starts to take a toll on their mental health. But ambition is not incompatible with healthy development and well-being. Pediatricians usually know who the ambitious students in their practice are, and will hear about the stress they may be experiencing. You have the opportunity to offer them (or their parents) some strategies to manage their high stress levels, and build resilience.

Support ambition, but not perfectionism

It can be helpful to acknowledge to young people that they are ambitious, enabling them to acknowledge this fact about themselves. This kind of drive can be an admirable strength when it is part of an emerging identity, a wish to be successful as defined by the patient.

It is more likely to be problematic if it is a product of a parent’s need to have a child perform as they deem best. Second, it is critical to differentiate ambition from perfectionism. While ambition can keep someone focused and motivated in the face of difficulty, perfectionism is a bully that leaves a person feeling perpetually inadequate. Ambition without a specific interest or focus can lead to general perfectionism in a young person, and parents might unwittingly support this by applauding successes or becoming overinvested in this success reflecting onto them. When the pediatrician points out to a patient (and parents) that perfection is neither possible nor desirable, they may respond, “why wouldn’t I want to be perfect?” Remind them that perfectionism is actually the enemy of long-term accomplishment, discouraging risk-taking, reflection, and growth.

Celebrate failure!

The critical difference between an ambitious person who is persistent and determined (and thus equipped to succeed) and the brittle perfectionist is the ability to tolerate failure and setbacks. Point out to your patients that ambition means there will be a lot of setbacks, disappointments, and failures, as they attempt things that are challenging. Indeed, they should embrace each little failure, as that is how real learning and growth happen, especially if they are constantly stretching their goals.

As children or teenagers learn that failure is evidence that they are on track, working hard, and improving, they will develop tenacity and flexibility. Carol S. Dweck, PhD, a psychologist who has studied school performance in young people, has demonstrated that when young people are praised for their results they tend to give up when they fail, whereas if they are praised for their hard work and persistence, they redouble their effort when they fail. Parents, teachers, and pediatricians have the power to shift an ambitious child’s mindset (Dweck’s term) by helping the child change his or her thinking about what failure really means.

Cultivate self-awareness and perspective

It is one of the central tasks of growing up to learn what one’s interests, talents, and values are, and this self-knowledge is especially critical in ambitious young people. Without genuine interests or passions, ambition may feel like a hollow quest for approval. It is more likely to become general perfectionism. So children and teenagers need adults who are curious about their underlying interests, who patiently help them to cultivate these interests and dedicate their ambition to the pursuit of these passions. Younger children need adult time and support to explore a variety of interests, dabbling so they might figure out where their interests and talents converge. This can provide plenty of opportunity to celebrate effort over achievement. By adolescence, they should have a clearer sense of their personal interests and abilities, and will be deepening their efforts in fewer areas. Adolescence is also when they start to build a narrative of who they are and what values are truly their own. Parents can serve as models and facilitators for their teenagers’ emerging sets of values. Values such as honesty, compassion, or generosity (for example) organize one’s efforts, giving them deeper meaning and keeping difficulties in perspective. Values also will help ambitious young people set their own goals and create an individualized and meaningful definition of success, and keep bigger failures, losses, or disappointments in perspective.

Teach self-care

It seems obvious to state that learning how to care for one’s self is essential to well-being, but for ambitious young people (and adults), self-care is often the first thing to go (or the last thing they consider) in their busy days. Explain to your patients (and parents) that without adequate, consistent, restful sleep, all of their hard work will be inefficient or likely squandered. Explain that daily cardiovascular exercise is not frivolous, but rather essential to balance their cognitive efforts, and offers potent protection for their physical and mental health. There is even robust evidence that sleep and exercise are directly helpful to memory, learning, and creativity. When a parent models this kind of self-care, it is far more powerful than simply talking about it!

Relaxation is self-care!

While most teenagers do not need to be taught how to relax, those very ambitious ones are likely to need permission and even help in learning how to effectively and efficiently blow off steam. Help them to approach relaxation as they would approach a new subject, open-minded and trying different things to determine what works for them. Some may find exercise relaxing, while some may need a cognitive distraction (sometimes called “senseless fun,” an activity not dedicated to achievement) such as reading, family games, or television. Social time often is very effective relaxation for teenagers, and they should know that it is as important as sleep and studying for their performance. Some may find that a calming activity such as yoga or meditation recharges their batteries, whereas others may need noisy video games to feel renewed. Suggest that they should protect (just a little) time for relaxation even on their busiest days to help them develop good habits of self-care. Without consistent, reliable relaxation, ambitious young people are at risk for burnout or for impulsive and extreme behaviors such as binge-drinking.

Be on the lookout for red flags

In the same way that high performing athletes are at risk for stress fractures or other injuries of repetitive, intense physical activity, ambitious students are vulnerable to some of the problems that can follow sustained, intense cognitive effort. These risks go up if they are sleep deprived, stop exercising, or are socially isolated. Parents can be on the lookout for signs of depression or anxiety disorders, such as loss of energy, withdrawal from friends or beloved activities, persistent unhappiness or irritability (sustained over days to weeks), and of course morbid preoccupations.

Intense perfectionism is common among young people at risk for eating disorders, depression and self-injury, and anxiety disorders. Beyond recognizing signs, it is even more important for parents and pediatricians to equip ambitious young people to stay connected and ask for help if they experience a change in their emotional equilibrium. Suggest to your patients that they should never worry alone. They should ask for help if they are struggling to sleep, to sustain their motivation or effort, or notice feeling panicked, unusually tearful, or hopeless. Depression and anxiety are common and treatable problems in adolescents, but ambitious adolescents might be inclined to try to soldier through them. Caring adults should demystify and destigmatize mood and anxiety problems. You might point out that they would ask for help for a toothache or a painful knee joint, and that their mental health should be no different.

Many ambitious children have ambitious parents who might look back on their own adolescence and wonder if they were sufficiently balanced in their approach or whether they overreacted to failure. Sometimes honest sharing of successes, failures, and enduring dilemmas can build an empathic bridge from one generation to the next.
 

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

Most parents hope that their children will be motivated and hard-working at school, but ambitious students usually face very high levels of stress. Ambitious young people typically push themselves very hard and may not spend enough time in play, relaxation, or exploring potential interests. Their time with peers might be more competitive than social or fun. They may become rigidly focused on a goal, paving the way for devastation if they fall short of their own expectations. They may internalize stress and not ask for help if it starts to take a toll on their mental health. But ambition is not incompatible with healthy development and well-being. Pediatricians usually know who the ambitious students in their practice are, and will hear about the stress they may be experiencing. You have the opportunity to offer them (or their parents) some strategies to manage their high stress levels, and build resilience.

Support ambition, but not perfectionism

It can be helpful to acknowledge to young people that they are ambitious, enabling them to acknowledge this fact about themselves. This kind of drive can be an admirable strength when it is part of an emerging identity, a wish to be successful as defined by the patient.

It is more likely to be problematic if it is a product of a parent’s need to have a child perform as they deem best. Second, it is critical to differentiate ambition from perfectionism. While ambition can keep someone focused and motivated in the face of difficulty, perfectionism is a bully that leaves a person feeling perpetually inadequate. Ambition without a specific interest or focus can lead to general perfectionism in a young person, and parents might unwittingly support this by applauding successes or becoming overinvested in this success reflecting onto them. When the pediatrician points out to a patient (and parents) that perfection is neither possible nor desirable, they may respond, “why wouldn’t I want to be perfect?” Remind them that perfectionism is actually the enemy of long-term accomplishment, discouraging risk-taking, reflection, and growth.

Celebrate failure!

The critical difference between an ambitious person who is persistent and determined (and thus equipped to succeed) and the brittle perfectionist is the ability to tolerate failure and setbacks. Point out to your patients that ambition means there will be a lot of setbacks, disappointments, and failures, as they attempt things that are challenging. Indeed, they should embrace each little failure, as that is how real learning and growth happen, especially if they are constantly stretching their goals.

As children or teenagers learn that failure is evidence that they are on track, working hard, and improving, they will develop tenacity and flexibility. Carol S. Dweck, PhD, a psychologist who has studied school performance in young people, has demonstrated that when young people are praised for their results they tend to give up when they fail, whereas if they are praised for their hard work and persistence, they redouble their effort when they fail. Parents, teachers, and pediatricians have the power to shift an ambitious child’s mindset (Dweck’s term) by helping the child change his or her thinking about what failure really means.

Cultivate self-awareness and perspective

It is one of the central tasks of growing up to learn what one’s interests, talents, and values are, and this self-knowledge is especially critical in ambitious young people. Without genuine interests or passions, ambition may feel like a hollow quest for approval. It is more likely to become general perfectionism. So children and teenagers need adults who are curious about their underlying interests, who patiently help them to cultivate these interests and dedicate their ambition to the pursuit of these passions. Younger children need adult time and support to explore a variety of interests, dabbling so they might figure out where their interests and talents converge. This can provide plenty of opportunity to celebrate effort over achievement. By adolescence, they should have a clearer sense of their personal interests and abilities, and will be deepening their efforts in fewer areas. Adolescence is also when they start to build a narrative of who they are and what values are truly their own. Parents can serve as models and facilitators for their teenagers’ emerging sets of values. Values such as honesty, compassion, or generosity (for example) organize one’s efforts, giving them deeper meaning and keeping difficulties in perspective. Values also will help ambitious young people set their own goals and create an individualized and meaningful definition of success, and keep bigger failures, losses, or disappointments in perspective.

Teach self-care

It seems obvious to state that learning how to care for one’s self is essential to well-being, but for ambitious young people (and adults), self-care is often the first thing to go (or the last thing they consider) in their busy days. Explain to your patients (and parents) that without adequate, consistent, restful sleep, all of their hard work will be inefficient or likely squandered. Explain that daily cardiovascular exercise is not frivolous, but rather essential to balance their cognitive efforts, and offers potent protection for their physical and mental health. There is even robust evidence that sleep and exercise are directly helpful to memory, learning, and creativity. When a parent models this kind of self-care, it is far more powerful than simply talking about it!

Relaxation is self-care!

While most teenagers do not need to be taught how to relax, those very ambitious ones are likely to need permission and even help in learning how to effectively and efficiently blow off steam. Help them to approach relaxation as they would approach a new subject, open-minded and trying different things to determine what works for them. Some may find exercise relaxing, while some may need a cognitive distraction (sometimes called “senseless fun,” an activity not dedicated to achievement) such as reading, family games, or television. Social time often is very effective relaxation for teenagers, and they should know that it is as important as sleep and studying for their performance. Some may find that a calming activity such as yoga or meditation recharges their batteries, whereas others may need noisy video games to feel renewed. Suggest that they should protect (just a little) time for relaxation even on their busiest days to help them develop good habits of self-care. Without consistent, reliable relaxation, ambitious young people are at risk for burnout or for impulsive and extreme behaviors such as binge-drinking.

Be on the lookout for red flags

In the same way that high performing athletes are at risk for stress fractures or other injuries of repetitive, intense physical activity, ambitious students are vulnerable to some of the problems that can follow sustained, intense cognitive effort. These risks go up if they are sleep deprived, stop exercising, or are socially isolated. Parents can be on the lookout for signs of depression or anxiety disorders, such as loss of energy, withdrawal from friends or beloved activities, persistent unhappiness or irritability (sustained over days to weeks), and of course morbid preoccupations.

Intense perfectionism is common among young people at risk for eating disorders, depression and self-injury, and anxiety disorders. Beyond recognizing signs, it is even more important for parents and pediatricians to equip ambitious young people to stay connected and ask for help if they experience a change in their emotional equilibrium. Suggest to your patients that they should never worry alone. They should ask for help if they are struggling to sleep, to sustain their motivation or effort, or notice feeling panicked, unusually tearful, or hopeless. Depression and anxiety are common and treatable problems in adolescents, but ambitious adolescents might be inclined to try to soldier through them. Caring adults should demystify and destigmatize mood and anxiety problems. You might point out that they would ask for help for a toothache or a painful knee joint, and that their mental health should be no different.

Many ambitious children have ambitious parents who might look back on their own adolescence and wonder if they were sufficiently balanced in their approach or whether they overreacted to failure. Sometimes honest sharing of successes, failures, and enduring dilemmas can build an empathic bridge from one generation to the next.
 

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

Most parents hope that their children will be motivated and hard-working at school, but ambitious students usually face very high levels of stress. Ambitious young people typically push themselves very hard and may not spend enough time in play, relaxation, or exploring potential interests. Their time with peers might be more competitive than social or fun. They may become rigidly focused on a goal, paving the way for devastation if they fall short of their own expectations. They may internalize stress and not ask for help if it starts to take a toll on their mental health. But ambition is not incompatible with healthy development and well-being. Pediatricians usually know who the ambitious students in their practice are, and will hear about the stress they may be experiencing. You have the opportunity to offer them (or their parents) some strategies to manage their high stress levels, and build resilience.

Support ambition, but not perfectionism

It can be helpful to acknowledge to young people that they are ambitious, enabling them to acknowledge this fact about themselves. This kind of drive can be an admirable strength when it is part of an emerging identity, a wish to be successful as defined by the patient.

It is more likely to be problematic if it is a product of a parent’s need to have a child perform as they deem best. Second, it is critical to differentiate ambition from perfectionism. While ambition can keep someone focused and motivated in the face of difficulty, perfectionism is a bully that leaves a person feeling perpetually inadequate. Ambition without a specific interest or focus can lead to general perfectionism in a young person, and parents might unwittingly support this by applauding successes or becoming overinvested in this success reflecting onto them. When the pediatrician points out to a patient (and parents) that perfection is neither possible nor desirable, they may respond, “why wouldn’t I want to be perfect?” Remind them that perfectionism is actually the enemy of long-term accomplishment, discouraging risk-taking, reflection, and growth.

Celebrate failure!

The critical difference between an ambitious person who is persistent and determined (and thus equipped to succeed) and the brittle perfectionist is the ability to tolerate failure and setbacks. Point out to your patients that ambition means there will be a lot of setbacks, disappointments, and failures, as they attempt things that are challenging. Indeed, they should embrace each little failure, as that is how real learning and growth happen, especially if they are constantly stretching their goals.

As children or teenagers learn that failure is evidence that they are on track, working hard, and improving, they will develop tenacity and flexibility. Carol S. Dweck, PhD, a psychologist who has studied school performance in young people, has demonstrated that when young people are praised for their results they tend to give up when they fail, whereas if they are praised for their hard work and persistence, they redouble their effort when they fail. Parents, teachers, and pediatricians have the power to shift an ambitious child’s mindset (Dweck’s term) by helping the child change his or her thinking about what failure really means.

Cultivate self-awareness and perspective

It is one of the central tasks of growing up to learn what one’s interests, talents, and values are, and this self-knowledge is especially critical in ambitious young people. Without genuine interests or passions, ambition may feel like a hollow quest for approval. It is more likely to become general perfectionism. So children and teenagers need adults who are curious about their underlying interests, who patiently help them to cultivate these interests and dedicate their ambition to the pursuit of these passions. Younger children need adult time and support to explore a variety of interests, dabbling so they might figure out where their interests and talents converge. This can provide plenty of opportunity to celebrate effort over achievement. By adolescence, they should have a clearer sense of their personal interests and abilities, and will be deepening their efforts in fewer areas. Adolescence is also when they start to build a narrative of who they are and what values are truly their own. Parents can serve as models and facilitators for their teenagers’ emerging sets of values. Values such as honesty, compassion, or generosity (for example) organize one’s efforts, giving them deeper meaning and keeping difficulties in perspective. Values also will help ambitious young people set their own goals and create an individualized and meaningful definition of success, and keep bigger failures, losses, or disappointments in perspective.

Teach self-care

It seems obvious to state that learning how to care for one’s self is essential to well-being, but for ambitious young people (and adults), self-care is often the first thing to go (or the last thing they consider) in their busy days. Explain to your patients (and parents) that without adequate, consistent, restful sleep, all of their hard work will be inefficient or likely squandered. Explain that daily cardiovascular exercise is not frivolous, but rather essential to balance their cognitive efforts, and offers potent protection for their physical and mental health. There is even robust evidence that sleep and exercise are directly helpful to memory, learning, and creativity. When a parent models this kind of self-care, it is far more powerful than simply talking about it!

Relaxation is self-care!

While most teenagers do not need to be taught how to relax, those very ambitious ones are likely to need permission and even help in learning how to effectively and efficiently blow off steam. Help them to approach relaxation as they would approach a new subject, open-minded and trying different things to determine what works for them. Some may find exercise relaxing, while some may need a cognitive distraction (sometimes called “senseless fun,” an activity not dedicated to achievement) such as reading, family games, or television. Social time often is very effective relaxation for teenagers, and they should know that it is as important as sleep and studying for their performance. Some may find that a calming activity such as yoga or meditation recharges their batteries, whereas others may need noisy video games to feel renewed. Suggest that they should protect (just a little) time for relaxation even on their busiest days to help them develop good habits of self-care. Without consistent, reliable relaxation, ambitious young people are at risk for burnout or for impulsive and extreme behaviors such as binge-drinking.

Be on the lookout for red flags

In the same way that high performing athletes are at risk for stress fractures or other injuries of repetitive, intense physical activity, ambitious students are vulnerable to some of the problems that can follow sustained, intense cognitive effort. These risks go up if they are sleep deprived, stop exercising, or are socially isolated. Parents can be on the lookout for signs of depression or anxiety disorders, such as loss of energy, withdrawal from friends or beloved activities, persistent unhappiness or irritability (sustained over days to weeks), and of course morbid preoccupations.

Intense perfectionism is common among young people at risk for eating disorders, depression and self-injury, and anxiety disorders. Beyond recognizing signs, it is even more important for parents and pediatricians to equip ambitious young people to stay connected and ask for help if they experience a change in their emotional equilibrium. Suggest to your patients that they should never worry alone. They should ask for help if they are struggling to sleep, to sustain their motivation or effort, or notice feeling panicked, unusually tearful, or hopeless. Depression and anxiety are common and treatable problems in adolescents, but ambitious adolescents might be inclined to try to soldier through them. Caring adults should demystify and destigmatize mood and anxiety problems. You might point out that they would ask for help for a toothache or a painful knee joint, and that their mental health should be no different.

Many ambitious children have ambitious parents who might look back on their own adolescence and wonder if they were sufficiently balanced in their approach or whether they overreacted to failure. Sometimes honest sharing of successes, failures, and enduring dilemmas can build an empathic bridge from one generation to the next.
 

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

As I write this article, the snow is piling up outside. While Cleveland’s west side citizens are raking up the last of fallen leaves, its east siders will dig out of 2 feet of snow. The lake effect is affecting us. The snow plow trucks vainly clear a path only for it to disappear in minutes. There seems to be no end to the torrents of white flakes that are each unique and tiny, but in aggregate uniform and overwhelming.

A blizzard of patients awaits my return from the annual meeting of the American Society of Hematology in San Diego. Like snowflakes, they are each unique, but in aggregate can be overwhelming. Plowing through a clinic, we go from patient to patient knowing that we will eventually see them all, then return to our offices or home to finish the labor of charting.

Dr. Kalaycio is Editor in Chief of Hematology News. Dr. Kalaycio chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

As I write this article, the snow is piling up outside. While Cleveland’s west side citizens are raking up the last of fallen leaves, its east siders will dig out of 2 feet of snow. The lake effect is affecting us. The snow plow trucks vainly clear a path only for it to disappear in minutes. There seems to be no end to the torrents of white flakes that are each unique and tiny, but in aggregate uniform and overwhelming.

A blizzard of patients awaits my return from the annual meeting of the American Society of Hematology in San Diego. Like snowflakes, they are each unique, but in aggregate can be overwhelming. Plowing through a clinic, we go from patient to patient knowing that we will eventually see them all, then return to our offices or home to finish the labor of charting.

Dr. Kalaycio is Editor in Chief of Hematology News. Dr. Kalaycio chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

As I write this article, the snow is piling up outside. While Cleveland’s west side citizens are raking up the last of fallen leaves, its east siders will dig out of 2 feet of snow. The lake effect is affecting us. The snow plow trucks vainly clear a path only for it to disappear in minutes. There seems to be no end to the torrents of white flakes that are each unique and tiny, but in aggregate uniform and overwhelming.

A blizzard of patients awaits my return from the annual meeting of the American Society of Hematology in San Diego. Like snowflakes, they are each unique, but in aggregate can be overwhelming. Plowing through a clinic, we go from patient to patient knowing that we will eventually see them all, then return to our offices or home to finish the labor of charting.

Dr. Kalaycio is Editor in Chief of Hematology News. Dr. Kalaycio chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

Advocating on behalf of the power of prevention in psychiatry has been my life’s work. I ran a world-class community mental health center with a strong wellness component; have taught, researched, written, and spoken extensively about the importance of prevention; and have incorporated preventive ideas into my current clinical practice.

I would like to think that I have been one of the forces that helped start a new movement called “positive psychiatry,” the idea that mental health must encompass more than the reduction or elimination of psychiatric illness. In the new book edited by American Psychiatric Association Past-President Dilip V. Jeste, MD, and Barton W. Palmer, PhD, called “Positive Psychiatry” (Arlington, Va.: American Psychiatric Association Publishing, 2015), I contributed a chapter on the psychosocial factors tied to positive outcomes. In addition, I am part of a group of psychiatrists and researchers affiliated with the World Psychiatric Association who are starting an interest group focusing on positive psychiatry.

Dr. Bell is a staff psychiatrist at Jackson Park Hospital Family Medicine Clinic in Chicago; clinical psychiatrist emeritus, department of psychiatry, at the University of Illinois at Chicago; former president/CEO of Community Mental Health Council; and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.

Advocating on behalf of the power of prevention in psychiatry has been my life’s work. I ran a world-class community mental health center with a strong wellness component; have taught, researched, written, and spoken extensively about the importance of prevention; and have incorporated preventive ideas into my current clinical practice.

I would like to think that I have been one of the forces that helped start a new movement called “positive psychiatry,” the idea that mental health must encompass more than the reduction or elimination of psychiatric illness. In the new book edited by American Psychiatric Association Past-President Dilip V. Jeste, MD, and Barton W. Palmer, PhD, called “Positive Psychiatry” (Arlington, Va.: American Psychiatric Association Publishing, 2015), I contributed a chapter on the psychosocial factors tied to positive outcomes. In addition, I am part of a group of psychiatrists and researchers affiliated with the World Psychiatric Association who are starting an interest group focusing on positive psychiatry.

Dr. Bell is a staff psychiatrist at Jackson Park Hospital Family Medicine Clinic in Chicago; clinical psychiatrist emeritus, department of psychiatry, at the University of Illinois at Chicago; former president/CEO of Community Mental Health Council; and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.

Advocating on behalf of the power of prevention in psychiatry has been my life’s work. I ran a world-class community mental health center with a strong wellness component; have taught, researched, written, and spoken extensively about the importance of prevention; and have incorporated preventive ideas into my current clinical practice.

I would like to think that I have been one of the forces that helped start a new movement called “positive psychiatry,” the idea that mental health must encompass more than the reduction or elimination of psychiatric illness. In the new book edited by American Psychiatric Association Past-President Dilip V. Jeste, MD, and Barton W. Palmer, PhD, called “Positive Psychiatry” (Arlington, Va.: American Psychiatric Association Publishing, 2015), I contributed a chapter on the psychosocial factors tied to positive outcomes. In addition, I am part of a group of psychiatrists and researchers affiliated with the World Psychiatric Association who are starting an interest group focusing on positive psychiatry.

Dr. Bell is a staff psychiatrist at Jackson Park Hospital Family Medicine Clinic in Chicago; clinical psychiatrist emeritus, department of psychiatry, at the University of Illinois at Chicago; former president/CEO of Community Mental Health Council; and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.

This month’s column comes directly by request from a pediatric colleague. She asked about a common diagnostic dilemma for pediatricians that involves what at least on the surface appears like disruptive or oppositional behavior at the home, school, or both, but is complicated by the possibility that the primary engine of this behavior is anxiety. This is an important challenge to try and get right because the treatment plan will take different paths, depending on the final call that is made.

Case summary

Devin is a 6-year-old boy who comes in with his parents for concerns about his behavior. His parents note that he has always been “high strung” but not disruptive or aggressive. When he was younger, Devin was quite sensitive to sounds, textures, and tactile sensations, but this has improved on its own. Thunderstorms continue to bother him quite a bit, though, and he often will ask his parents repeated questions when it is cloudy about the possibility of a thunderstorm. With some extra teacher and parent support, Devin made the transition to kindergarten fairly well. Now, however, he is struggling in a larger 1st grade class. His teacher states that he often seems distracted, fidgety, and easily frustrated, causing him to “shut down” and refuse to do his work. This past week, during a more challenging assignment, he crawled under his desk and would not come out. The teacher is now recommending an evaluation for attention-deficit/hyperactivity disorder (ADHD).

Discussion

1. Are there other times in the child’s life when clearly he is very anxious? The presence of developmentally elevated levels of anxiety in areas outside the particular situations in question can provide a clue that anxiety is contributing to what otherwise might be seen as more oppositional behavior. In this case, the high levels of anxiety about thunderstorms show that anxiety is present in the child and could be playing a role in his disruptive behavior at school.

2. When he’s not focusing on the task at hand, what is he thinking about? Nonanxious children with or without ADHD can frequently daydream and go “off task,” but the content of those thoughts frequently involves anticipation for more preferred activities, reminisces of positive events from the past, or attention to other stimuli in the environment (for example, the bird in a tree outside). More anxious children, by contrast, may have more worried and ruminating thoughts about poor performance, possible bad events that might happen in the future, or “what if?” kinds of concerns.

3. Is there a family history of anxiety? While one should not over-rely on family history, the presence of one or more family members with clinically significant anxiety does raise the possibility of anxiety in the identified patient. Research indicates that the heritability of anxiety is about 50%,^1,2 but that a significant amount of the transmission of anxiety from parent to child comes from environmental mechanisms.³

4. Is there a consistent trigger to his outbursts? For anxious children, meltdowns are frequently provoked by situations in which a child feels uncomfortable, overstimulated, or overwhelmed, and the outburst is a reflection of those intense feelings that are difficult to manage. An outburst like that above, which occurs when a child is pushed to finish difficult work, might be a good example of one that is triggered by anxiety.

5. What does the rating scale show? A broad-based rating scale that assesses multiple domains of symptoms can be a big help for diagnostic dilemmas such as this one. Our clinic uses the Child Behavior Checklist⁴ which has subscales for both anxiety and attention problems. Evidence of a spike in either of those domains, or both, really can help guide our thinking.

Of course, it is very possible that the answer to the ADHD versus anxiety question is that both are present. This is a common conclusion when it comes to mental health assessment, and it is different from the traditional “this or that” thinking present in more classic differential diagnosis decision making. Research indicates that the ADHD and anxiety disorders frequently co-occur.⁵ When that happens, concurrent evidence-based psychotherapy for anxiety in conjunction with multimodal treatment for ADHD has been recommended as a first step.⁶

Case follow-up

Based on all the information, the pediatrician judges that Devin’s disruptive behavior is in large part being driven by his level of anxiety. She makes a referral to a child psychologist to begin evidence-based psychotherapy and recommends that the school consider some modifications and accommodations that may help his behavior at school. At a follow-up appointment, Devin’s difficulties have improved, and there is little evidence of ADHD now that the anxiety has been fully addressed.

References

1. Genes Brain Behav. 2005;4(8):466-81.

2. J Am Acad Child Adolesc Psychiatry. 2010;49(3):248-55.

3. Am J Psychiatry. 2015;172(7):630-7.

4. Manual for the ASEBA School-Age Forms & Profiles (Burlington, Vt.: University of Vermont, Research Center for Children, Youth, and Families, 2001).

5. J Anxiety Disord. 1997;11(4):377-94.

6. J Abnorm Child Psychol. 2000;28(6):527-41.
 

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

This month’s column comes directly by request from a pediatric colleague. She asked about a common diagnostic dilemma for pediatricians that involves what at least on the surface appears like disruptive or oppositional behavior at the home, school, or both, but is complicated by the possibility that the primary engine of this behavior is anxiety. This is an important challenge to try and get right because the treatment plan will take different paths, depending on the final call that is made.

Case summary

Devin is a 6-year-old boy who comes in with his parents for concerns about his behavior. His parents note that he has always been “high strung” but not disruptive or aggressive. When he was younger, Devin was quite sensitive to sounds, textures, and tactile sensations, but this has improved on its own. Thunderstorms continue to bother him quite a bit, though, and he often will ask his parents repeated questions when it is cloudy about the possibility of a thunderstorm. With some extra teacher and parent support, Devin made the transition to kindergarten fairly well. Now, however, he is struggling in a larger 1st grade class. His teacher states that he often seems distracted, fidgety, and easily frustrated, causing him to “shut down” and refuse to do his work. This past week, during a more challenging assignment, he crawled under his desk and would not come out. The teacher is now recommending an evaluation for attention-deficit/hyperactivity disorder (ADHD).

Discussion

1. Are there other times in the child’s life when clearly he is very anxious? The presence of developmentally elevated levels of anxiety in areas outside the particular situations in question can provide a clue that anxiety is contributing to what otherwise might be seen as more oppositional behavior. In this case, the high levels of anxiety about thunderstorms show that anxiety is present in the child and could be playing a role in his disruptive behavior at school.

2. When he’s not focusing on the task at hand, what is he thinking about? Nonanxious children with or without ADHD can frequently daydream and go “off task,” but the content of those thoughts frequently involves anticipation for more preferred activities, reminisces of positive events from the past, or attention to other stimuli in the environment (for example, the bird in a tree outside). More anxious children, by contrast, may have more worried and ruminating thoughts about poor performance, possible bad events that might happen in the future, or “what if?” kinds of concerns.

3. Is there a family history of anxiety? While one should not over-rely on family history, the presence of one or more family members with clinically significant anxiety does raise the possibility of anxiety in the identified patient. Research indicates that the heritability of anxiety is about 50%,^1,2 but that a significant amount of the transmission of anxiety from parent to child comes from environmental mechanisms.³

4. Is there a consistent trigger to his outbursts? For anxious children, meltdowns are frequently provoked by situations in which a child feels uncomfortable, overstimulated, or overwhelmed, and the outburst is a reflection of those intense feelings that are difficult to manage. An outburst like that above, which occurs when a child is pushed to finish difficult work, might be a good example of one that is triggered by anxiety.

5. What does the rating scale show? A broad-based rating scale that assesses multiple domains of symptoms can be a big help for diagnostic dilemmas such as this one. Our clinic uses the Child Behavior Checklist⁴ which has subscales for both anxiety and attention problems. Evidence of a spike in either of those domains, or both, really can help guide our thinking.

Of course, it is very possible that the answer to the ADHD versus anxiety question is that both are present. This is a common conclusion when it comes to mental health assessment, and it is different from the traditional “this or that” thinking present in more classic differential diagnosis decision making. Research indicates that the ADHD and anxiety disorders frequently co-occur.⁵ When that happens, concurrent evidence-based psychotherapy for anxiety in conjunction with multimodal treatment for ADHD has been recommended as a first step.⁶

Case follow-up

Based on all the information, the pediatrician judges that Devin’s disruptive behavior is in large part being driven by his level of anxiety. She makes a referral to a child psychologist to begin evidence-based psychotherapy and recommends that the school consider some modifications and accommodations that may help his behavior at school. At a follow-up appointment, Devin’s difficulties have improved, and there is little evidence of ADHD now that the anxiety has been fully addressed.

References

1. Genes Brain Behav. 2005;4(8):466-81.

2. J Am Acad Child Adolesc Psychiatry. 2010;49(3):248-55.

3. Am J Psychiatry. 2015;172(7):630-7.

4. Manual for the ASEBA School-Age Forms & Profiles (Burlington, Vt.: University of Vermont, Research Center for Children, Youth, and Families, 2001).

5. J Anxiety Disord. 1997;11(4):377-94.

6. J Abnorm Child Psychol. 2000;28(6):527-41.
 

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

This month’s column comes directly by request from a pediatric colleague. She asked about a common diagnostic dilemma for pediatricians that involves what at least on the surface appears like disruptive or oppositional behavior at the home, school, or both, but is complicated by the possibility that the primary engine of this behavior is anxiety. This is an important challenge to try and get right because the treatment plan will take different paths, depending on the final call that is made.

Case summary

Devin is a 6-year-old boy who comes in with his parents for concerns about his behavior. His parents note that he has always been “high strung” but not disruptive or aggressive. When he was younger, Devin was quite sensitive to sounds, textures, and tactile sensations, but this has improved on its own. Thunderstorms continue to bother him quite a bit, though, and he often will ask his parents repeated questions when it is cloudy about the possibility of a thunderstorm. With some extra teacher and parent support, Devin made the transition to kindergarten fairly well. Now, however, he is struggling in a larger 1st grade class. His teacher states that he often seems distracted, fidgety, and easily frustrated, causing him to “shut down” and refuse to do his work. This past week, during a more challenging assignment, he crawled under his desk and would not come out. The teacher is now recommending an evaluation for attention-deficit/hyperactivity disorder (ADHD).

Discussion

1. Are there other times in the child’s life when clearly he is very anxious? The presence of developmentally elevated levels of anxiety in areas outside the particular situations in question can provide a clue that anxiety is contributing to what otherwise might be seen as more oppositional behavior. In this case, the high levels of anxiety about thunderstorms show that anxiety is present in the child and could be playing a role in his disruptive behavior at school.

2. When he’s not focusing on the task at hand, what is he thinking about? Nonanxious children with or without ADHD can frequently daydream and go “off task,” but the content of those thoughts frequently involves anticipation for more preferred activities, reminisces of positive events from the past, or attention to other stimuli in the environment (for example, the bird in a tree outside). More anxious children, by contrast, may have more worried and ruminating thoughts about poor performance, possible bad events that might happen in the future, or “what if?” kinds of concerns.

3. Is there a family history of anxiety? While one should not over-rely on family history, the presence of one or more family members with clinically significant anxiety does raise the possibility of anxiety in the identified patient. Research indicates that the heritability of anxiety is about 50%,^1,2 but that a significant amount of the transmission of anxiety from parent to child comes from environmental mechanisms.³

4. Is there a consistent trigger to his outbursts? For anxious children, meltdowns are frequently provoked by situations in which a child feels uncomfortable, overstimulated, or overwhelmed, and the outburst is a reflection of those intense feelings that are difficult to manage. An outburst like that above, which occurs when a child is pushed to finish difficult work, might be a good example of one that is triggered by anxiety.

5. What does the rating scale show? A broad-based rating scale that assesses multiple domains of symptoms can be a big help for diagnostic dilemmas such as this one. Our clinic uses the Child Behavior Checklist⁴ which has subscales for both anxiety and attention problems. Evidence of a spike in either of those domains, or both, really can help guide our thinking.

Of course, it is very possible that the answer to the ADHD versus anxiety question is that both are present. This is a common conclusion when it comes to mental health assessment, and it is different from the traditional “this or that” thinking present in more classic differential diagnosis decision making. Research indicates that the ADHD and anxiety disorders frequently co-occur.⁵ When that happens, concurrent evidence-based psychotherapy for anxiety in conjunction with multimodal treatment for ADHD has been recommended as a first step.⁶

Case follow-up

Based on all the information, the pediatrician judges that Devin’s disruptive behavior is in large part being driven by his level of anxiety. She makes a referral to a child psychologist to begin evidence-based psychotherapy and recommends that the school consider some modifications and accommodations that may help his behavior at school. At a follow-up appointment, Devin’s difficulties have improved, and there is little evidence of ADHD now that the anxiety has been fully addressed.

References

1. Genes Brain Behav. 2005;4(8):466-81.

2. J Am Acad Child Adolesc Psychiatry. 2010;49(3):248-55.

3. Am J Psychiatry. 2015;172(7):630-7.

4. Manual for the ASEBA School-Age Forms & Profiles (Burlington, Vt.: University of Vermont, Research Center for Children, Youth, and Families, 2001).

5. J Anxiety Disord. 1997;11(4):377-94.

6. J Abnorm Child Psychol. 2000;28(6):527-41.
 

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

The recent report from the SYNTAX trials should give pause to our interventionalist colleagues embarking on multiple angioplasty and stenting procedures in patients with complex coronary anatomy.

SYNTAX randomized 1,800 patients with left main or triple-vessel coronary artery disease to either percutaneous coronary intervention (PCI) with the TAXUS drug-eluting stent or coronary artery bypass grafting (CABG) after being judged by a heart team as being in equipoise in regard to the appropriateness of either procedure (Eur Heart J. 2011;32;2125-34). The findings of several previous analyses have trended toward benefit for CABG, but none as clearly as SYNTAX. The original study was reported 6 years ago (Lancet 2013 Feb;381:629-38) and indicated that CABG was superior to PCI in patients with complex lesions. The most recent 5-year data of that study (J Am Coll Cardiol. 2016 Jan:67;42-55) indicates that cardiac mortality in the CABG patients is superior to that in the PCI group (5.3% vs. 9.6%, respectively), and the follow-up data provide more in-depth analysis in addition to the mechanism of death. Most importantly, the recent 5-year data clarify the reasons PCI fails to measure up to the results of CABG in patients with complex coronary artery disease.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

The recent report from the SYNTAX trials should give pause to our interventionalist colleagues embarking on multiple angioplasty and stenting procedures in patients with complex coronary anatomy.

SYNTAX randomized 1,800 patients with left main or triple-vessel coronary artery disease to either percutaneous coronary intervention (PCI) with the TAXUS drug-eluting stent or coronary artery bypass grafting (CABG) after being judged by a heart team as being in equipoise in regard to the appropriateness of either procedure (Eur Heart J. 2011;32;2125-34). The findings of several previous analyses have trended toward benefit for CABG, but none as clearly as SYNTAX. The original study was reported 6 years ago (Lancet 2013 Feb;381:629-38) and indicated that CABG was superior to PCI in patients with complex lesions. The most recent 5-year data of that study (J Am Coll Cardiol. 2016 Jan:67;42-55) indicates that cardiac mortality in the CABG patients is superior to that in the PCI group (5.3% vs. 9.6%, respectively), and the follow-up data provide more in-depth analysis in addition to the mechanism of death. Most importantly, the recent 5-year data clarify the reasons PCI fails to measure up to the results of CABG in patients with complex coronary artery disease.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

The recent report from the SYNTAX trials should give pause to our interventionalist colleagues embarking on multiple angioplasty and stenting procedures in patients with complex coronary anatomy.

SYNTAX randomized 1,800 patients with left main or triple-vessel coronary artery disease to either percutaneous coronary intervention (PCI) with the TAXUS drug-eluting stent or coronary artery bypass grafting (CABG) after being judged by a heart team as being in equipoise in regard to the appropriateness of either procedure (Eur Heart J. 2011;32;2125-34). The findings of several previous analyses have trended toward benefit for CABG, but none as clearly as SYNTAX. The original study was reported 6 years ago (Lancet 2013 Feb;381:629-38) and indicated that CABG was superior to PCI in patients with complex lesions. The most recent 5-year data of that study (J Am Coll Cardiol. 2016 Jan:67;42-55) indicates that cardiac mortality in the CABG patients is superior to that in the PCI group (5.3% vs. 9.6%, respectively), and the follow-up data provide more in-depth analysis in addition to the mechanism of death. Most importantly, the recent 5-year data clarify the reasons PCI fails to measure up to the results of CABG in patients with complex coronary artery disease.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

A while ago, I gave a talk on LGBT health to a group of primary care pediatricians. Although I was glad that they invited me to speak, I also sensed some discomfort in the audience. At the end of the lecture, many pediatricians told me that they were uncomfortable with bringing up the topic of sexuality and gender identity with their patients, and others wanted guidance on how to ask questions on sexuality and gender identity.

There are many barriers for primary pediatricians in addressing sexuality and gender identity concerns in their patients. First, pediatricians often will have up to 15 minutes for a visit, so they will have little time to address a complex issue. Second, primary care pediatricians may have known many of their patients since birth, and asking questions on sexuality and gender can feel awkward. Finally, many pediatricians may be working in more conservative areas in the country where asking questions on sexuality and gender identity may be controversial.

Tip No. 1: The environment counts

I cannot overstate how important it is to make your clinic a welcoming place for LGBT youth. Having various signs and stickers – like rainbow flags or the Human Rights Campaign sticker – will signal to LGBT youth that they are safe in your clinic. Creating a safe and welcoming environment is important because many people in the LGBT community have experienced rejection and discrimination from their primary care doctors.¹ Making your clinic a safe space will make it easier and efficient for patients to ask questions about sexuality and gender identity (see Dr. Gaya Chelvakumar’s column “Creating safe spaces for LGBTQ youth, families in health care settings” at pediatricnews.com).

Tip No. 2: Consider the context

Most likely, many presenting complaints – such as colds or sports injuries – of your adolescent patients will not involve sexual orientation or gender identity. There are exceptions. If you suspect an STD, then the risk for certain infections, such as HIV² or gonorrhea of the anus or of the pharynx³ are higher in gay young men. For the latter, your screening method would be different (that is, obtaining a pharyngeal swab or an anal swab instead of a urine sample). Also, because many LGBT youth have higher rates of mental health problems compared with heterosexual youth,⁴ you may want to ask questions about sexuality or gender identity to patients complaining of depressive or anxiety symptoms. This is especially important for transgender youth, because the implementation of pubertal blockers or cross-sex hormones can be therapeutic.⁵ To prevent or reduce many of these health problems, asking about sexuality and gender identity is a good idea during the well visit, when you may have more time.

Tip No. 3: Not all developmental stages are considered equal

Adolescence is a period of rapid and phasic growth. Formation of an identity is one of the major psychosocial tasks for adolescence,⁶ and sexuality and gender are important identities. In general, in early adolescence identity becomes an issue as the teenager gains autonomy from parents. I typically start asking questions about sexuality and gender when the patient is 11 or 12, because many children may not understand sexuality and gender identity at a younger age. At these ages, I ask these questions with the parents in the room, then I ask them confidentially on subsequent well visits. This approach serves two purposes: it will prepare the adolescent for these complex and thought-provoking questions in future encounters, and it gives the parents an idea of the type of questions you will ask the children when they are old enough for the confidential visit, helping parents feel more comfortable in stepping out of the room during this time.

Tip No. 4: Keep it confidential

Many adolescents are reluctant to see a doctor, even if they are sick. The primary reason adolescents do not seek care is the fear that the provider will tell their parents about their illness.⁷ Although this should be applicable to all of your adolescent patients, you should make an extra effort to explicitly state to LGBT patients that the clinic visit is confidential (with the exception of risk of suicide, homicide, or child abuse). This is important for LGBT youth who are not out to their parents and may be in danger if they do come out.⁸

Tip No. 5: Normalize, normalize, normalize

Because of the stigma and discrimination surrounding sexual orientation and gender identity, many LGBT youth will be reluctant to disclose their sexual orientation or gender identity to their health care providers. At the same time, heterosexual youth may think that you’re asking them questions about sexuality or gender identity because you suspect them to be a member of the LGBT community. To avoid this awkward situation, many pediatricians do not ask these questions at all. A good remedy for this is to preface your questions about sexual orientation or gender identity by saying that you ask these questions to all your patients – that way no one feels singled out.

Tip No. 6: Ask for permission

As previously mentioned, members of the LGBT community may experience discrimination from their health care providers after disclosing to them their sexual orientation or gender identity.¹ This rejection can be traumatizing for LGBT youth, making them reluctant to discuss any issues related to sexual orientation or gender identity with any medical provider. As part of the trauma-informed approach, asking for permission before delving into issues related to sexual orientation and gender identity will give LGBT patients a sense of control, especially in an environment where there is a significant power differential.

Tip No. 7: Treat this as a skill

Despite the pressures for primary care pediatricians to maintain an efficient and effective clinical practice, many strive to learn new skills to provide the best care for their patients. Asking questions about sexuality and gender identity should be one of those skills. As with any skill, it will feel unnatural at first, and it will require practice. Mastering this skill, however, will help you address the health needs of this vulnerable population.

Asking questions about sexuality and gender identity is difficult for the primary care pediatrician. Hopefully, these tips can help you develop this important skill. It will also help you reach out to a population that is wary of the health care system.

References

1. J Am Board Fam Med. 2016;29(1):156-60.

2. https://www.cdc.gov/hiv/group/msm/index.html.

3. https://www.cdc.gov/std/tg2015/default.htm.

4. J Adolesc Health. 2011;49(2):115-23.

5. Nat Rev Endocrinol. 2011;7(8):466-72.
6. Neinstein LS. Adolescent health care: a practical guide. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2008.

7. J Adolesc Health. 2007;40(3):218-26.

8. Am J Orthopsychiatry. 1998;68(3):361-71.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at [email protected].

A while ago, I gave a talk on LGBT health to a group of primary care pediatricians. Although I was glad that they invited me to speak, I also sensed some discomfort in the audience. At the end of the lecture, many pediatricians told me that they were uncomfortable with bringing up the topic of sexuality and gender identity with their patients, and others wanted guidance on how to ask questions on sexuality and gender identity.

There are many barriers for primary pediatricians in addressing sexuality and gender identity concerns in their patients. First, pediatricians often will have up to 15 minutes for a visit, so they will have little time to address a complex issue. Second, primary care pediatricians may have known many of their patients since birth, and asking questions on sexuality and gender can feel awkward. Finally, many pediatricians may be working in more conservative areas in the country where asking questions on sexuality and gender identity may be controversial.

Tip No. 1: The environment counts

I cannot overstate how important it is to make your clinic a welcoming place for LGBT youth. Having various signs and stickers – like rainbow flags or the Human Rights Campaign sticker – will signal to LGBT youth that they are safe in your clinic. Creating a safe and welcoming environment is important because many people in the LGBT community have experienced rejection and discrimination from their primary care doctors.¹ Making your clinic a safe space will make it easier and efficient for patients to ask questions about sexuality and gender identity (see Dr. Gaya Chelvakumar’s column “Creating safe spaces for LGBTQ youth, families in health care settings” at pediatricnews.com).

Tip No. 2: Consider the context

Most likely, many presenting complaints – such as colds or sports injuries – of your adolescent patients will not involve sexual orientation or gender identity. There are exceptions. If you suspect an STD, then the risk for certain infections, such as HIV² or gonorrhea of the anus or of the pharynx³ are higher in gay young men. For the latter, your screening method would be different (that is, obtaining a pharyngeal swab or an anal swab instead of a urine sample). Also, because many LGBT youth have higher rates of mental health problems compared with heterosexual youth,⁴ you may want to ask questions about sexuality or gender identity to patients complaining of depressive or anxiety symptoms. This is especially important for transgender youth, because the implementation of pubertal blockers or cross-sex hormones can be therapeutic.⁵ To prevent or reduce many of these health problems, asking about sexuality and gender identity is a good idea during the well visit, when you may have more time.

Tip No. 3: Not all developmental stages are considered equal

Adolescence is a period of rapid and phasic growth. Formation of an identity is one of the major psychosocial tasks for adolescence,⁶ and sexuality and gender are important identities. In general, in early adolescence identity becomes an issue as the teenager gains autonomy from parents. I typically start asking questions about sexuality and gender when the patient is 11 or 12, because many children may not understand sexuality and gender identity at a younger age. At these ages, I ask these questions with the parents in the room, then I ask them confidentially on subsequent well visits. This approach serves two purposes: it will prepare the adolescent for these complex and thought-provoking questions in future encounters, and it gives the parents an idea of the type of questions you will ask the children when they are old enough for the confidential visit, helping parents feel more comfortable in stepping out of the room during this time.

Tip No. 4: Keep it confidential

Many adolescents are reluctant to see a doctor, even if they are sick. The primary reason adolescents do not seek care is the fear that the provider will tell their parents about their illness.⁷ Although this should be applicable to all of your adolescent patients, you should make an extra effort to explicitly state to LGBT patients that the clinic visit is confidential (with the exception of risk of suicide, homicide, or child abuse). This is important for LGBT youth who are not out to their parents and may be in danger if they do come out.⁸

Tip No. 5: Normalize, normalize, normalize

Because of the stigma and discrimination surrounding sexual orientation and gender identity, many LGBT youth will be reluctant to disclose their sexual orientation or gender identity to their health care providers. At the same time, heterosexual youth may think that you’re asking them questions about sexuality or gender identity because you suspect them to be a member of the LGBT community. To avoid this awkward situation, many pediatricians do not ask these questions at all. A good remedy for this is to preface your questions about sexual orientation or gender identity by saying that you ask these questions to all your patients – that way no one feels singled out.

Tip No. 6: Ask for permission

As previously mentioned, members of the LGBT community may experience discrimination from their health care providers after disclosing to them their sexual orientation or gender identity.¹ This rejection can be traumatizing for LGBT youth, making them reluctant to discuss any issues related to sexual orientation or gender identity with any medical provider. As part of the trauma-informed approach, asking for permission before delving into issues related to sexual orientation and gender identity will give LGBT patients a sense of control, especially in an environment where there is a significant power differential.

Tip No. 7: Treat this as a skill

Despite the pressures for primary care pediatricians to maintain an efficient and effective clinical practice, many strive to learn new skills to provide the best care for their patients. Asking questions about sexuality and gender identity should be one of those skills. As with any skill, it will feel unnatural at first, and it will require practice. Mastering this skill, however, will help you address the health needs of this vulnerable population.

Asking questions about sexuality and gender identity is difficult for the primary care pediatrician. Hopefully, these tips can help you develop this important skill. It will also help you reach out to a population that is wary of the health care system.

References

1. J Am Board Fam Med. 2016;29(1):156-60.

2. https://www.cdc.gov/hiv/group/msm/index.html.

3. https://www.cdc.gov/std/tg2015/default.htm.

4. J Adolesc Health. 2011;49(2):115-23.

5. Nat Rev Endocrinol. 2011;7(8):466-72.
6. Neinstein LS. Adolescent health care: a practical guide. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2008.

7. J Adolesc Health. 2007;40(3):218-26.

8. Am J Orthopsychiatry. 1998;68(3):361-71.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at [email protected].

A while ago, I gave a talk on LGBT health to a group of primary care pediatricians. Although I was glad that they invited me to speak, I also sensed some discomfort in the audience. At the end of the lecture, many pediatricians told me that they were uncomfortable with bringing up the topic of sexuality and gender identity with their patients, and others wanted guidance on how to ask questions on sexuality and gender identity.

There are many barriers for primary pediatricians in addressing sexuality and gender identity concerns in their patients. First, pediatricians often will have up to 15 minutes for a visit, so they will have little time to address a complex issue. Second, primary care pediatricians may have known many of their patients since birth, and asking questions on sexuality and gender can feel awkward. Finally, many pediatricians may be working in more conservative areas in the country where asking questions on sexuality and gender identity may be controversial.

Tip No. 1: The environment counts

I cannot overstate how important it is to make your clinic a welcoming place for LGBT youth. Having various signs and stickers – like rainbow flags or the Human Rights Campaign sticker – will signal to LGBT youth that they are safe in your clinic. Creating a safe and welcoming environment is important because many people in the LGBT community have experienced rejection and discrimination from their primary care doctors.¹ Making your clinic a safe space will make it easier and efficient for patients to ask questions about sexuality and gender identity (see Dr. Gaya Chelvakumar’s column “Creating safe spaces for LGBTQ youth, families in health care settings” at pediatricnews.com).

Tip No. 2: Consider the context

Most likely, many presenting complaints – such as colds or sports injuries – of your adolescent patients will not involve sexual orientation or gender identity. There are exceptions. If you suspect an STD, then the risk for certain infections, such as HIV² or gonorrhea of the anus or of the pharynx³ are higher in gay young men. For the latter, your screening method would be different (that is, obtaining a pharyngeal swab or an anal swab instead of a urine sample). Also, because many LGBT youth have higher rates of mental health problems compared with heterosexual youth,⁴ you may want to ask questions about sexuality or gender identity to patients complaining of depressive or anxiety symptoms. This is especially important for transgender youth, because the implementation of pubertal blockers or cross-sex hormones can be therapeutic.⁵ To prevent or reduce many of these health problems, asking about sexuality and gender identity is a good idea during the well visit, when you may have more time.

Tip No. 3: Not all developmental stages are considered equal

Adolescence is a period of rapid and phasic growth. Formation of an identity is one of the major psychosocial tasks for adolescence,⁶ and sexuality and gender are important identities. In general, in early adolescence identity becomes an issue as the teenager gains autonomy from parents. I typically start asking questions about sexuality and gender when the patient is 11 or 12, because many children may not understand sexuality and gender identity at a younger age. At these ages, I ask these questions with the parents in the room, then I ask them confidentially on subsequent well visits. This approach serves two purposes: it will prepare the adolescent for these complex and thought-provoking questions in future encounters, and it gives the parents an idea of the type of questions you will ask the children when they are old enough for the confidential visit, helping parents feel more comfortable in stepping out of the room during this time.

Tip No. 4: Keep it confidential

Many adolescents are reluctant to see a doctor, even if they are sick. The primary reason adolescents do not seek care is the fear that the provider will tell their parents about their illness.⁷ Although this should be applicable to all of your adolescent patients, you should make an extra effort to explicitly state to LGBT patients that the clinic visit is confidential (with the exception of risk of suicide, homicide, or child abuse). This is important for LGBT youth who are not out to their parents and may be in danger if they do come out.⁸

Tip No. 5: Normalize, normalize, normalize

Because of the stigma and discrimination surrounding sexual orientation and gender identity, many LGBT youth will be reluctant to disclose their sexual orientation or gender identity to their health care providers. At the same time, heterosexual youth may think that you’re asking them questions about sexuality or gender identity because you suspect them to be a member of the LGBT community. To avoid this awkward situation, many pediatricians do not ask these questions at all. A good remedy for this is to preface your questions about sexual orientation or gender identity by saying that you ask these questions to all your patients – that way no one feels singled out.

Tip No. 6: Ask for permission

As previously mentioned, members of the LGBT community may experience discrimination from their health care providers after disclosing to them their sexual orientation or gender identity.¹ This rejection can be traumatizing for LGBT youth, making them reluctant to discuss any issues related to sexual orientation or gender identity with any medical provider. As part of the trauma-informed approach, asking for permission before delving into issues related to sexual orientation and gender identity will give LGBT patients a sense of control, especially in an environment where there is a significant power differential.

Tip No. 7: Treat this as a skill

Despite the pressures for primary care pediatricians to maintain an efficient and effective clinical practice, many strive to learn new skills to provide the best care for their patients. Asking questions about sexuality and gender identity should be one of those skills. As with any skill, it will feel unnatural at first, and it will require practice. Mastering this skill, however, will help you address the health needs of this vulnerable population.

Asking questions about sexuality and gender identity is difficult for the primary care pediatrician. Hopefully, these tips can help you develop this important skill. It will also help you reach out to a population that is wary of the health care system.

References

1. J Am Board Fam Med. 2016;29(1):156-60.

2. https://www.cdc.gov/hiv/group/msm/index.html.

3. https://www.cdc.gov/std/tg2015/default.htm.

4. J Adolesc Health. 2011;49(2):115-23.

5. Nat Rev Endocrinol. 2011;7(8):466-72.
6. Neinstein LS. Adolescent health care: a practical guide. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2008.

7. J Adolesc Health. 2007;40(3):218-26.

8. Am J Orthopsychiatry. 1998;68(3):361-71.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at [email protected].