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French psychiatrist condemned for society’s deficiency
On Dec. 14, 2016, a French psychiatrist was sentenced to an 18-month suspended prison sentence. Lekhraj Gujadhur, MD, was the supervisor of unit 101 at the Psychiatric Hospital Center of Saint-Egrève in France. In November 2008, he had approved the nonsupervised release of a schizophrenia patient, Jean-Pierre Guillaud, to outside of his unit but within the hospital facility. Mr. Guillaud, while outside supervision, escaped. He subsequently purchased a large knife and murdered a 26-year-old student, Luc Meunier, Le Monde reported.1
This is reminiscent of a similar case in 2012 in Marseille, where a psychiatrist received a suspended prison sentence after his patient committed murder. That prior case was later dismissed in appellate court. In my opinion, both trials point to a failure in psychiatry’s responsibility to educate the public in our limitations and roles. They also highlight the necessary discourse that society should have on the role of mental illness when it comes to crime.
Although I appreciate society’s concern about such crimes, I think that displacement of our anger onto Dr. Gujadhur is misguided, and instead, allows us to forget to look at our own poor judgment. Dr. Gujadhur, other psychiatrists, and mental hospitals do not have the responsibility to enact sentences for crimes; the legal system does. Law enforcement and prosecutors had numerous opportunities to charge and commit Mr. Guillaud over the years but chose not to do so, instead permitting him to stay within society under the care of the mental health system.
Asking Dr. Gujadhur to primarily focus on becoming an agent of the law, instead of treating his patient, is unfair. Schizophrenia, and in particular paranoia, are greatly worsened by social isolation. Confining Mr. Guillaud would be countertherapeutic and possibly lead to his suicide. Would Dr. Gujadhur have been responsible for the suicide? Mental health providers have to understand and support the psychological functioning of their patients. Creating a dual agency blurs and effaces the doctor-patient relationship, already so fragile in the treatment of paranoid patients.
The publicity of such cases, and of Mr. Guillaud’s mental illness, seems to go against current mental health research. Recent work has suggested that mental illness is not a significant risk factor for violence but rather a risk factor for being the victim of violence. Certainly, some patients with mental illness commit acts of violence, but studies suggest that this is mostly independent of their mental illness (Law Hum Behav. 2014 Oct;38[5];439-49).2 Our overemphasis on the mental status of criminals belittles their crimes and suggests that psychiatrists are responsible for the failings of our legal system.
As a supervising psychiatrist at one of the largest jail systems in America, I am familiar with the challenges in such cases. All of my patients are facing legal charges, and many suffer from severe mental illness like schizophrenia. As their treating psychiatrist, I am not asked to also sentence them for the charges they are facing. Simply working for the sheriff makes my ability to gain the trust of my patients much more difficult. Conspiring with the city or district attorney in an attempt to protect society would obliterate any chance at rapport building.
Working in corrections, I am deeply familiar with the current debate on the solitary confinement of our mentally ill offenders. Ironically, in that context, society has blamed the legal system for socially isolating our mentally ill offenders, especially ones with severe mental illness.3 In our jail, we meet regularly and discuss in an interdisciplinary fashion the role and consequences of social isolation. During our weekly sessions, a case involving stabbing someone 2 years prior would not have justified the punishment of social isolation and constant monitoring.
As a field, psychiatry must educate society on its ability to create a therapeutic environment and its ability to provide risk assessment of violence. We must also remind others of the impossibility of doing both simultaneously. Decisions on removing patients’ right to freedom can be informed by the mental health perspective but should be left to the courts. Society’s need to find a target after such tragedies is understandable, but blaming the treating psychiatrists will not help past or future victims.
References
1. Le psychiatre d’un schizophrène meurtrier condamné pour homicide involontaire, Le Monde, Dec. 14, 2016.
2. How often and how consistently do symptoms directly precede criminal behavior among offenders with mental illness? (Law Hum Behav. 2014 Oct;38[5]:439-49).
3. How to fix solitary confinement in American prisons, Los Angeles Times, Oct. 17, 2016.
Dr. Badre is a supervising psychiatric contractor at the San Diego Central Jail. He also holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches on medical education, psychopharmacology, ethics in psychiatry, and correctional care. He mentors several residents on projects, including reduction in the use of solitary confinement of patients with mental illness, reduction in the use of involuntary treatment of the mentally ill, and examination of the mentally ill offender.
On Dec. 14, 2016, a French psychiatrist was sentenced to an 18-month suspended prison sentence. Lekhraj Gujadhur, MD, was the supervisor of unit 101 at the Psychiatric Hospital Center of Saint-Egrève in France. In November 2008, he had approved the nonsupervised release of a schizophrenia patient, Jean-Pierre Guillaud, to outside of his unit but within the hospital facility. Mr. Guillaud, while outside supervision, escaped. He subsequently purchased a large knife and murdered a 26-year-old student, Luc Meunier, Le Monde reported.1
This is reminiscent of a similar case in 2012 in Marseille, where a psychiatrist received a suspended prison sentence after his patient committed murder. That prior case was later dismissed in appellate court. In my opinion, both trials point to a failure in psychiatry’s responsibility to educate the public in our limitations and roles. They also highlight the necessary discourse that society should have on the role of mental illness when it comes to crime.
Although I appreciate society’s concern about such crimes, I think that displacement of our anger onto Dr. Gujadhur is misguided, and instead, allows us to forget to look at our own poor judgment. Dr. Gujadhur, other psychiatrists, and mental hospitals do not have the responsibility to enact sentences for crimes; the legal system does. Law enforcement and prosecutors had numerous opportunities to charge and commit Mr. Guillaud over the years but chose not to do so, instead permitting him to stay within society under the care of the mental health system.
Asking Dr. Gujadhur to primarily focus on becoming an agent of the law, instead of treating his patient, is unfair. Schizophrenia, and in particular paranoia, are greatly worsened by social isolation. Confining Mr. Guillaud would be countertherapeutic and possibly lead to his suicide. Would Dr. Gujadhur have been responsible for the suicide? Mental health providers have to understand and support the psychological functioning of their patients. Creating a dual agency blurs and effaces the doctor-patient relationship, already so fragile in the treatment of paranoid patients.
The publicity of such cases, and of Mr. Guillaud’s mental illness, seems to go against current mental health research. Recent work has suggested that mental illness is not a significant risk factor for violence but rather a risk factor for being the victim of violence. Certainly, some patients with mental illness commit acts of violence, but studies suggest that this is mostly independent of their mental illness (Law Hum Behav. 2014 Oct;38[5];439-49).2 Our overemphasis on the mental status of criminals belittles their crimes and suggests that psychiatrists are responsible for the failings of our legal system.
As a supervising psychiatrist at one of the largest jail systems in America, I am familiar with the challenges in such cases. All of my patients are facing legal charges, and many suffer from severe mental illness like schizophrenia. As their treating psychiatrist, I am not asked to also sentence them for the charges they are facing. Simply working for the sheriff makes my ability to gain the trust of my patients much more difficult. Conspiring with the city or district attorney in an attempt to protect society would obliterate any chance at rapport building.
Working in corrections, I am deeply familiar with the current debate on the solitary confinement of our mentally ill offenders. Ironically, in that context, society has blamed the legal system for socially isolating our mentally ill offenders, especially ones with severe mental illness.3 In our jail, we meet regularly and discuss in an interdisciplinary fashion the role and consequences of social isolation. During our weekly sessions, a case involving stabbing someone 2 years prior would not have justified the punishment of social isolation and constant monitoring.
As a field, psychiatry must educate society on its ability to create a therapeutic environment and its ability to provide risk assessment of violence. We must also remind others of the impossibility of doing both simultaneously. Decisions on removing patients’ right to freedom can be informed by the mental health perspective but should be left to the courts. Society’s need to find a target after such tragedies is understandable, but blaming the treating psychiatrists will not help past or future victims.
References
1. Le psychiatre d’un schizophrène meurtrier condamné pour homicide involontaire, Le Monde, Dec. 14, 2016.
2. How often and how consistently do symptoms directly precede criminal behavior among offenders with mental illness? (Law Hum Behav. 2014 Oct;38[5]:439-49).
3. How to fix solitary confinement in American prisons, Los Angeles Times, Oct. 17, 2016.
Dr. Badre is a supervising psychiatric contractor at the San Diego Central Jail. He also holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches on medical education, psychopharmacology, ethics in psychiatry, and correctional care. He mentors several residents on projects, including reduction in the use of solitary confinement of patients with mental illness, reduction in the use of involuntary treatment of the mentally ill, and examination of the mentally ill offender.
On Dec. 14, 2016, a French psychiatrist was sentenced to an 18-month suspended prison sentence. Lekhraj Gujadhur, MD, was the supervisor of unit 101 at the Psychiatric Hospital Center of Saint-Egrève in France. In November 2008, he had approved the nonsupervised release of a schizophrenia patient, Jean-Pierre Guillaud, to outside of his unit but within the hospital facility. Mr. Guillaud, while outside supervision, escaped. He subsequently purchased a large knife and murdered a 26-year-old student, Luc Meunier, Le Monde reported.1
This is reminiscent of a similar case in 2012 in Marseille, where a psychiatrist received a suspended prison sentence after his patient committed murder. That prior case was later dismissed in appellate court. In my opinion, both trials point to a failure in psychiatry’s responsibility to educate the public in our limitations and roles. They also highlight the necessary discourse that society should have on the role of mental illness when it comes to crime.
Although I appreciate society’s concern about such crimes, I think that displacement of our anger onto Dr. Gujadhur is misguided, and instead, allows us to forget to look at our own poor judgment. Dr. Gujadhur, other psychiatrists, and mental hospitals do not have the responsibility to enact sentences for crimes; the legal system does. Law enforcement and prosecutors had numerous opportunities to charge and commit Mr. Guillaud over the years but chose not to do so, instead permitting him to stay within society under the care of the mental health system.
Asking Dr. Gujadhur to primarily focus on becoming an agent of the law, instead of treating his patient, is unfair. Schizophrenia, and in particular paranoia, are greatly worsened by social isolation. Confining Mr. Guillaud would be countertherapeutic and possibly lead to his suicide. Would Dr. Gujadhur have been responsible for the suicide? Mental health providers have to understand and support the psychological functioning of their patients. Creating a dual agency blurs and effaces the doctor-patient relationship, already so fragile in the treatment of paranoid patients.
The publicity of such cases, and of Mr. Guillaud’s mental illness, seems to go against current mental health research. Recent work has suggested that mental illness is not a significant risk factor for violence but rather a risk factor for being the victim of violence. Certainly, some patients with mental illness commit acts of violence, but studies suggest that this is mostly independent of their mental illness (Law Hum Behav. 2014 Oct;38[5];439-49).2 Our overemphasis on the mental status of criminals belittles their crimes and suggests that psychiatrists are responsible for the failings of our legal system.
As a supervising psychiatrist at one of the largest jail systems in America, I am familiar with the challenges in such cases. All of my patients are facing legal charges, and many suffer from severe mental illness like schizophrenia. As their treating psychiatrist, I am not asked to also sentence them for the charges they are facing. Simply working for the sheriff makes my ability to gain the trust of my patients much more difficult. Conspiring with the city or district attorney in an attempt to protect society would obliterate any chance at rapport building.
Working in corrections, I am deeply familiar with the current debate on the solitary confinement of our mentally ill offenders. Ironically, in that context, society has blamed the legal system for socially isolating our mentally ill offenders, especially ones with severe mental illness.3 In our jail, we meet regularly and discuss in an interdisciplinary fashion the role and consequences of social isolation. During our weekly sessions, a case involving stabbing someone 2 years prior would not have justified the punishment of social isolation and constant monitoring.
As a field, psychiatry must educate society on its ability to create a therapeutic environment and its ability to provide risk assessment of violence. We must also remind others of the impossibility of doing both simultaneously. Decisions on removing patients’ right to freedom can be informed by the mental health perspective but should be left to the courts. Society’s need to find a target after such tragedies is understandable, but blaming the treating psychiatrists will not help past or future victims.
References
1. Le psychiatre d’un schizophrène meurtrier condamné pour homicide involontaire, Le Monde, Dec. 14, 2016.
2. How often and how consistently do symptoms directly precede criminal behavior among offenders with mental illness? (Law Hum Behav. 2014 Oct;38[5]:439-49).
3. How to fix solitary confinement in American prisons, Los Angeles Times, Oct. 17, 2016.
Dr. Badre is a supervising psychiatric contractor at the San Diego Central Jail. He also holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches on medical education, psychopharmacology, ethics in psychiatry, and correctional care. He mentors several residents on projects, including reduction in the use of solitary confinement of patients with mental illness, reduction in the use of involuntary treatment of the mentally ill, and examination of the mentally ill offender.
Pain Management: How About Holistic?
I recently received the letter and instruction card for prescribing narcotic analgesics from US Surgeon General Vice Admiral Vivek H. Murthy, MD, MBA. While I agree in principle with the movement to improve pain management, I feel there is a lot being overlooked in this crusade and would like to suggest alternative evidence-based methods that don’t involve prescription narcotics.
I have extensive training in energy therapy, guided imagery, and ozonotherapy. Healing touch is one well-researched energy therapy that has been shown to reduce pain. I have performed and published research demonstrating its efficacy (see http://healingbeyondborders.org/index.php/research-integrative-health/research); patients’ functional abilities improve, and they are able to decrease or eliminate use of pain medication. Providers from many disciplines, including MDs, DOs, NPs, and DCs, practice healing touch. Training for healing touch is available worldwide. The certification process is similar to masters-level education, including both classroom and hands-on clinical practice experience. My practice uses healing touch for patients, and I teach classes using the international curriculum.
In addition to the research published on the efficacy of guided imagery (another method of pain relief therapy), I have personally witnessed and been part of several successful examples in my clinical practice. In the burn unit, Dr. Jean Achterberg Lawlis and I used guided imagery to relieve pain in patients with third- and fourth-degree burns over 70% or more of their body. We performed tanking and dressing changes without narcotic pain medications; patients were comfortable during treatment and slept peacefully after. In another instance, a 23-year-old man presented with major chest and spine injuries after a motorcycle accident. Morphine (100 mg IV) did nothing to relieve his pain. But guided imagery of racing his stock car around a racetrack eliminated any need for narcotics during dressing changes. I’ve also worked with women prenatally, teaching guided imagery for smooth, successful deliveries without pain medications or epidural.
Ozonotherapy has an extensive international evidence base, and many studies show that it relieves pain without the need for narcotics (see http://aaot.us/?page=Literature). I have seen many cases of chronic pain relieved by major autohemolytic therapy and prolozone injection therapies. Here, too, patients are able to decrease and eventually stop their narcotic medications. Some patients are able to avoid joint replacement surgery, achieving improved function and comfort without the adverse effects of steroids.
An effective way to release muscle tension and relieve pain from injury (eg, low back pain, plantar fasciitis, whiplash, carpal tunnel) is through massage therapy. Providers who refer patients to massage practitioners can avoid narcotic medication prescriptions by addressing the problem that is causing the pain. Chiropractic care is a standard care for low back pain; it can also resolve problems that cause migraines, trigeminal neuralgia, and Bell’s palsy without narcotics, steroids, or the sedating muscle relaxants and seizure medications. Yet several veterans in my community were denied chiropractic care until they had tried narcotics and physical therapy (which involved a four-hour roundtrip car ride, no less). Oh, and in the meantime, they were prescribed an additional narcotic!
By focusing only on narcotics, we miss out on other options to treat pain. If we overlook the full range of evidence, then the “evidence-based” mantra isn’t truthful, nor is it useful. To follow the pledge to “do no harm,” we must treat the causes of pain. Of the Surgeon General, I request: Please don’t just send us a teaching card on how to prescribe narcotics. Get providers involved in seeking continuing education credits in therapies that help us avoid prescribing them in the first place.
Susan Peck, PhD, GNP-BC, APNP, FAAO, APT, CHTP/I
Eau Claire, WI
I recently received the letter and instruction card for prescribing narcotic analgesics from US Surgeon General Vice Admiral Vivek H. Murthy, MD, MBA. While I agree in principle with the movement to improve pain management, I feel there is a lot being overlooked in this crusade and would like to suggest alternative evidence-based methods that don’t involve prescription narcotics.
I have extensive training in energy therapy, guided imagery, and ozonotherapy. Healing touch is one well-researched energy therapy that has been shown to reduce pain. I have performed and published research demonstrating its efficacy (see http://healingbeyondborders.org/index.php/research-integrative-health/research); patients’ functional abilities improve, and they are able to decrease or eliminate use of pain medication. Providers from many disciplines, including MDs, DOs, NPs, and DCs, practice healing touch. Training for healing touch is available worldwide. The certification process is similar to masters-level education, including both classroom and hands-on clinical practice experience. My practice uses healing touch for patients, and I teach classes using the international curriculum.
In addition to the research published on the efficacy of guided imagery (another method of pain relief therapy), I have personally witnessed and been part of several successful examples in my clinical practice. In the burn unit, Dr. Jean Achterberg Lawlis and I used guided imagery to relieve pain in patients with third- and fourth-degree burns over 70% or more of their body. We performed tanking and dressing changes without narcotic pain medications; patients were comfortable during treatment and slept peacefully after. In another instance, a 23-year-old man presented with major chest and spine injuries after a motorcycle accident. Morphine (100 mg IV) did nothing to relieve his pain. But guided imagery of racing his stock car around a racetrack eliminated any need for narcotics during dressing changes. I’ve also worked with women prenatally, teaching guided imagery for smooth, successful deliveries without pain medications or epidural.
Ozonotherapy has an extensive international evidence base, and many studies show that it relieves pain without the need for narcotics (see http://aaot.us/?page=Literature). I have seen many cases of chronic pain relieved by major autohemolytic therapy and prolozone injection therapies. Here, too, patients are able to decrease and eventually stop their narcotic medications. Some patients are able to avoid joint replacement surgery, achieving improved function and comfort without the adverse effects of steroids.
An effective way to release muscle tension and relieve pain from injury (eg, low back pain, plantar fasciitis, whiplash, carpal tunnel) is through massage therapy. Providers who refer patients to massage practitioners can avoid narcotic medication prescriptions by addressing the problem that is causing the pain. Chiropractic care is a standard care for low back pain; it can also resolve problems that cause migraines, trigeminal neuralgia, and Bell’s palsy without narcotics, steroids, or the sedating muscle relaxants and seizure medications. Yet several veterans in my community were denied chiropractic care until they had tried narcotics and physical therapy (which involved a four-hour roundtrip car ride, no less). Oh, and in the meantime, they were prescribed an additional narcotic!
By focusing only on narcotics, we miss out on other options to treat pain. If we overlook the full range of evidence, then the “evidence-based” mantra isn’t truthful, nor is it useful. To follow the pledge to “do no harm,” we must treat the causes of pain. Of the Surgeon General, I request: Please don’t just send us a teaching card on how to prescribe narcotics. Get providers involved in seeking continuing education credits in therapies that help us avoid prescribing them in the first place.
Susan Peck, PhD, GNP-BC, APNP, FAAO, APT, CHTP/I
Eau Claire, WI
I recently received the letter and instruction card for prescribing narcotic analgesics from US Surgeon General Vice Admiral Vivek H. Murthy, MD, MBA. While I agree in principle with the movement to improve pain management, I feel there is a lot being overlooked in this crusade and would like to suggest alternative evidence-based methods that don’t involve prescription narcotics.
I have extensive training in energy therapy, guided imagery, and ozonotherapy. Healing touch is one well-researched energy therapy that has been shown to reduce pain. I have performed and published research demonstrating its efficacy (see http://healingbeyondborders.org/index.php/research-integrative-health/research); patients’ functional abilities improve, and they are able to decrease or eliminate use of pain medication. Providers from many disciplines, including MDs, DOs, NPs, and DCs, practice healing touch. Training for healing touch is available worldwide. The certification process is similar to masters-level education, including both classroom and hands-on clinical practice experience. My practice uses healing touch for patients, and I teach classes using the international curriculum.
In addition to the research published on the efficacy of guided imagery (another method of pain relief therapy), I have personally witnessed and been part of several successful examples in my clinical practice. In the burn unit, Dr. Jean Achterberg Lawlis and I used guided imagery to relieve pain in patients with third- and fourth-degree burns over 70% or more of their body. We performed tanking and dressing changes without narcotic pain medications; patients were comfortable during treatment and slept peacefully after. In another instance, a 23-year-old man presented with major chest and spine injuries after a motorcycle accident. Morphine (100 mg IV) did nothing to relieve his pain. But guided imagery of racing his stock car around a racetrack eliminated any need for narcotics during dressing changes. I’ve also worked with women prenatally, teaching guided imagery for smooth, successful deliveries without pain medications or epidural.
Ozonotherapy has an extensive international evidence base, and many studies show that it relieves pain without the need for narcotics (see http://aaot.us/?page=Literature). I have seen many cases of chronic pain relieved by major autohemolytic therapy and prolozone injection therapies. Here, too, patients are able to decrease and eventually stop their narcotic medications. Some patients are able to avoid joint replacement surgery, achieving improved function and comfort without the adverse effects of steroids.
An effective way to release muscle tension and relieve pain from injury (eg, low back pain, plantar fasciitis, whiplash, carpal tunnel) is through massage therapy. Providers who refer patients to massage practitioners can avoid narcotic medication prescriptions by addressing the problem that is causing the pain. Chiropractic care is a standard care for low back pain; it can also resolve problems that cause migraines, trigeminal neuralgia, and Bell’s palsy without narcotics, steroids, or the sedating muscle relaxants and seizure medications. Yet several veterans in my community were denied chiropractic care until they had tried narcotics and physical therapy (which involved a four-hour roundtrip car ride, no less). Oh, and in the meantime, they were prescribed an additional narcotic!
By focusing only on narcotics, we miss out on other options to treat pain. If we overlook the full range of evidence, then the “evidence-based” mantra isn’t truthful, nor is it useful. To follow the pledge to “do no harm,” we must treat the causes of pain. Of the Surgeon General, I request: Please don’t just send us a teaching card on how to prescribe narcotics. Get providers involved in seeking continuing education credits in therapies that help us avoid prescribing them in the first place.
Susan Peck, PhD, GNP-BC, APNP, FAAO, APT, CHTP/I
Eau Claire, WI
Staring down the opioid epidemic
Nearly 80 people die every day in America from an opioid overdose.1 At the same time, sales of prescription painkillers have increased 4-fold since 1999.2 My own medical assistant was given an unsolicited prescription for 40 oxycodone after a wisdom tooth extraction.
Meanwhile, about 80% of the country’s 2 million opioid-dependent patients are not receiving the treatment they need.3,4 In Vermont, for example, more than 500 patients are on waiting lists to receive buprenorphine (the partial opioid agonist used to treat opioid addiction)—a wait that for many of them will last for more than a year and may cost them their life.5
Buprenorphine makes good sense. Fortunately, buprenorphine can reverse opioid cravings within minutes. Medication-assisted treatment with buprenorphine derivatives allows patients to lead normal, productive, and stable lives. Every dollar invested in treating opioid addiction saves society $7 in drug-related crime and criminal justice costs.6 In addition, 50% to 80% of opioid-dependent patients remain opioid-free for 12 months while taking buprenorphine.7
Steps we can take. As family physicians (FPs), we are frequently overwhelmed by regulatory concerns, overhead expenses, and providing meaningful use data to third-party payers. And we sometimes take the easy route of simply prescribing or refilling scheduled drugs. Instead, we should educate ourselves and our patients about alternative therapeutic interventions for pain control and addiction.
To that end, I encourage all FPs to take the 8-hour online course provided by the American Society of Addiction Medicine to obtain a US Drug Enforcement Administration waiver for prescribing buprenorphine (available at: http://www.asam.org/education/live-online-cme/buprenorphine-course). It costs less than $200 and successful completion of this CME program allows FPs to deliver office-based opioid dependency interventions as per the Drug Addiction Treatment Act of 2000.
Right now, monthly patient censuses indicate that there are about 3234 buprenorphine prescribers providing care for 245,016 opioid-dependent patients, and fewer than 20% of those prescribers are FPs.8 We need to change that. We have an opportunity to invest in the future of these high-risk patients. Let’s not let them down.
1. Democratic staff of the senate committee on finance. Dying waiting for treatment: the opioid use disorder treatment gap and the need for funding. October 10, 2016. Available at: https://www.finance.senate.gov/imo/media/doc/101116%20Opioid%20Treatment%20Gap%20Report%20Final.pdf. Accessed December 14, 2016.
2. Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60:1487-1492.
3. Saloner B, Karthikeyan S. Changes in substance abuse treatment use among individuals with opioid use disorders in the United States. JAMA. 2015;314:1515-1517.
4. Substance Abuse and Mental Health Services Administration. Opioids. Available at: https://www.samhsa.gov/atod/opioids. Accessed December 14, 2016.
5. Vestal C. Waiting lists grow for medicine to fight opioid addiction. Stateline. February 11, 2016. Available at: http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/02/11/waiting-lists-grow-for-medicine-to-fight-opioid-addiction. Accessed December 14, 2016.
6. National Institute on Drug Abuse. Principles of drug addiction treatment: a research-based guide (third edition). Is drug addiction treatment worth its cost? Available at: https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/drug-addiction-treatment-worth-its-cost. Accessed December 14, 2016.
7. Kleber HD. Pharmacologic treatments for opioid dependence: detoxification and maintenance options. Dialogues Clin Neurosci. 2007; 9:455-470.
8. Stein BD, Sorbero MJ, Dick AW, et al. Physician capacity to treat opioid use disorder with buprenorphine-assisted treatment. JAMA. 2016;316:1211-1212.
Unger Primary Care Concierge Medical Group, Rancho Cucamonga, Calif. Dr. Unger is a member of JFP’s editorial board. He reported no potential conflict of interest relevant to this article.
Unger Primary Care Concierge Medical Group, Rancho Cucamonga, Calif. Dr. Unger is a member of JFP’s editorial board. He reported no potential conflict of interest relevant to this article.
Unger Primary Care Concierge Medical Group, Rancho Cucamonga, Calif. Dr. Unger is a member of JFP’s editorial board. He reported no potential conflict of interest relevant to this article.
Nearly 80 people die every day in America from an opioid overdose.1 At the same time, sales of prescription painkillers have increased 4-fold since 1999.2 My own medical assistant was given an unsolicited prescription for 40 oxycodone after a wisdom tooth extraction.
Meanwhile, about 80% of the country’s 2 million opioid-dependent patients are not receiving the treatment they need.3,4 In Vermont, for example, more than 500 patients are on waiting lists to receive buprenorphine (the partial opioid agonist used to treat opioid addiction)—a wait that for many of them will last for more than a year and may cost them their life.5
Buprenorphine makes good sense. Fortunately, buprenorphine can reverse opioid cravings within minutes. Medication-assisted treatment with buprenorphine derivatives allows patients to lead normal, productive, and stable lives. Every dollar invested in treating opioid addiction saves society $7 in drug-related crime and criminal justice costs.6 In addition, 50% to 80% of opioid-dependent patients remain opioid-free for 12 months while taking buprenorphine.7
Steps we can take. As family physicians (FPs), we are frequently overwhelmed by regulatory concerns, overhead expenses, and providing meaningful use data to third-party payers. And we sometimes take the easy route of simply prescribing or refilling scheduled drugs. Instead, we should educate ourselves and our patients about alternative therapeutic interventions for pain control and addiction.
To that end, I encourage all FPs to take the 8-hour online course provided by the American Society of Addiction Medicine to obtain a US Drug Enforcement Administration waiver for prescribing buprenorphine (available at: http://www.asam.org/education/live-online-cme/buprenorphine-course). It costs less than $200 and successful completion of this CME program allows FPs to deliver office-based opioid dependency interventions as per the Drug Addiction Treatment Act of 2000.
Right now, monthly patient censuses indicate that there are about 3234 buprenorphine prescribers providing care for 245,016 opioid-dependent patients, and fewer than 20% of those prescribers are FPs.8 We need to change that. We have an opportunity to invest in the future of these high-risk patients. Let’s not let them down.
Nearly 80 people die every day in America from an opioid overdose.1 At the same time, sales of prescription painkillers have increased 4-fold since 1999.2 My own medical assistant was given an unsolicited prescription for 40 oxycodone after a wisdom tooth extraction.
Meanwhile, about 80% of the country’s 2 million opioid-dependent patients are not receiving the treatment they need.3,4 In Vermont, for example, more than 500 patients are on waiting lists to receive buprenorphine (the partial opioid agonist used to treat opioid addiction)—a wait that for many of them will last for more than a year and may cost them their life.5
Buprenorphine makes good sense. Fortunately, buprenorphine can reverse opioid cravings within minutes. Medication-assisted treatment with buprenorphine derivatives allows patients to lead normal, productive, and stable lives. Every dollar invested in treating opioid addiction saves society $7 in drug-related crime and criminal justice costs.6 In addition, 50% to 80% of opioid-dependent patients remain opioid-free for 12 months while taking buprenorphine.7
Steps we can take. As family physicians (FPs), we are frequently overwhelmed by regulatory concerns, overhead expenses, and providing meaningful use data to third-party payers. And we sometimes take the easy route of simply prescribing or refilling scheduled drugs. Instead, we should educate ourselves and our patients about alternative therapeutic interventions for pain control and addiction.
To that end, I encourage all FPs to take the 8-hour online course provided by the American Society of Addiction Medicine to obtain a US Drug Enforcement Administration waiver for prescribing buprenorphine (available at: http://www.asam.org/education/live-online-cme/buprenorphine-course). It costs less than $200 and successful completion of this CME program allows FPs to deliver office-based opioid dependency interventions as per the Drug Addiction Treatment Act of 2000.
Right now, monthly patient censuses indicate that there are about 3234 buprenorphine prescribers providing care for 245,016 opioid-dependent patients, and fewer than 20% of those prescribers are FPs.8 We need to change that. We have an opportunity to invest in the future of these high-risk patients. Let’s not let them down.
1. Democratic staff of the senate committee on finance. Dying waiting for treatment: the opioid use disorder treatment gap and the need for funding. October 10, 2016. Available at: https://www.finance.senate.gov/imo/media/doc/101116%20Opioid%20Treatment%20Gap%20Report%20Final.pdf. Accessed December 14, 2016.
2. Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60:1487-1492.
3. Saloner B, Karthikeyan S. Changes in substance abuse treatment use among individuals with opioid use disorders in the United States. JAMA. 2015;314:1515-1517.
4. Substance Abuse and Mental Health Services Administration. Opioids. Available at: https://www.samhsa.gov/atod/opioids. Accessed December 14, 2016.
5. Vestal C. Waiting lists grow for medicine to fight opioid addiction. Stateline. February 11, 2016. Available at: http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/02/11/waiting-lists-grow-for-medicine-to-fight-opioid-addiction. Accessed December 14, 2016.
6. National Institute on Drug Abuse. Principles of drug addiction treatment: a research-based guide (third edition). Is drug addiction treatment worth its cost? Available at: https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/drug-addiction-treatment-worth-its-cost. Accessed December 14, 2016.
7. Kleber HD. Pharmacologic treatments for opioid dependence: detoxification and maintenance options. Dialogues Clin Neurosci. 2007; 9:455-470.
8. Stein BD, Sorbero MJ, Dick AW, et al. Physician capacity to treat opioid use disorder with buprenorphine-assisted treatment. JAMA. 2016;316:1211-1212.
1. Democratic staff of the senate committee on finance. Dying waiting for treatment: the opioid use disorder treatment gap and the need for funding. October 10, 2016. Available at: https://www.finance.senate.gov/imo/media/doc/101116%20Opioid%20Treatment%20Gap%20Report%20Final.pdf. Accessed December 14, 2016.
2. Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60:1487-1492.
3. Saloner B, Karthikeyan S. Changes in substance abuse treatment use among individuals with opioid use disorders in the United States. JAMA. 2015;314:1515-1517.
4. Substance Abuse and Mental Health Services Administration. Opioids. Available at: https://www.samhsa.gov/atod/opioids. Accessed December 14, 2016.
5. Vestal C. Waiting lists grow for medicine to fight opioid addiction. Stateline. February 11, 2016. Available at: http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/02/11/waiting-lists-grow-for-medicine-to-fight-opioid-addiction. Accessed December 14, 2016.
6. National Institute on Drug Abuse. Principles of drug addiction treatment: a research-based guide (third edition). Is drug addiction treatment worth its cost? Available at: https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/drug-addiction-treatment-worth-its-cost. Accessed December 14, 2016.
7. Kleber HD. Pharmacologic treatments for opioid dependence: detoxification and maintenance options. Dialogues Clin Neurosci. 2007; 9:455-470.
8. Stein BD, Sorbero MJ, Dick AW, et al. Physician capacity to treat opioid use disorder with buprenorphine-assisted treatment. JAMA. 2016;316:1211-1212.
Revisiting delirious mania; Correcting an error
Revisiting delirious mania
After treating a young woman with delirious mania, we were compelled to comment on the case report “Confused and nearly naked after going on spending sprees” (Cases That Test Your Skills,
A young woman with bipolar I disorder and mild intellectual disability was brought to our inpatient psychiatric unit after she disappeared from her home. Her family reported she was not compliant with her medications, and she recently showed deterioration marked by bizarre and violent behaviors for the previous month.
Although her presentation was consistent with earlier manic episodes, additional behaviors indicated an increase in severity. The patient was only oriented to name, was disrobing, had urinary and fecal incontinence, and showed purposeless hyperactivity such as continuously dancing in circles.
Because we thought she was experiencing a severe exacerbation of bipolar disorder, the patient was started on 4 different antipsychotic trials (typical and atypical) and 2 mood stabilizers, all of which did not produce adequate response. Even after augmentation with nightly long-acting benzodiazepines, the patient’s symptoms remained unchanged.
The patient received a diagnosis of delirious mania, with the underlying mechanism being severe catatonia. A literature search revealed electroconvulsive therapy (ECT) and benzodiazepines as first-line treatments, and discouraged use of typical antipsychotics because of an increased risk of neuroleptic malignant syndrome and malignant delirious mania.1 Because ECT was not available at our facility, we initiated benzodiazepines,
We agree it is prudent to rule out any medical illnesses that could cause delirium. Interestingly, in our patient a head CT revealed small calcifications suggestive of cysticercosis, which have been seen on imaging since age 13. We suggest that this finding contributed to her disinhibition, prolonged her recovery, and could explain why she did not respond adequately to medications.
Diagnosing and treating delirious mania in our patient was challenging. As mentioned by Davis et al, there is no classification of delirious mania in DSM-5. In addition, there are no large-scale studies to educate psychiatrists about the prevalence and appropriate treatment of this disorder.
Our treatment approach differed from that of Davis et al in that we chose scheduled benzodiazepines rather than antipsychotics to target the patient’s catatonia. However, both patients improved, prompting us to further question the mechanism behind this presentation.
We encourage the addition of delirious mania to the next edition of DSM. Without classification and establishment of this diagnosis, psychiatrists are unlikely to consider this serious and potentially fatal syndrome. Delirious mania is mysterious and rare and its inner workings are not fully elucidated.
Sabina Bera, MD MSc
PGY-2 Psychiatry Resident
Mohammed Molla, MD, DFAPA
Interim Joint Chair and Program Director
University of California Los Angeles-Kern
Psychiatry Training Program
Bakersfield, California
Reference
1. Jacobowski NL, Heckers S, Bobo WV. Delirious mania: detection, diagnosis, and clinical management in the acute setting. J Psychiatr Pract. 2013;19(1):15-28.
Correcting an error
In his informative guest editorial "
David A. Gorelick, MD, PhD
Professor of Psychiatry
Maryland Psychiatric Research Center
University of Maryland
Baltimore, Maryland
Revisiting delirious mania
After treating a young woman with delirious mania, we were compelled to comment on the case report “Confused and nearly naked after going on spending sprees” (Cases That Test Your Skills,
A young woman with bipolar I disorder and mild intellectual disability was brought to our inpatient psychiatric unit after she disappeared from her home. Her family reported she was not compliant with her medications, and she recently showed deterioration marked by bizarre and violent behaviors for the previous month.
Although her presentation was consistent with earlier manic episodes, additional behaviors indicated an increase in severity. The patient was only oriented to name, was disrobing, had urinary and fecal incontinence, and showed purposeless hyperactivity such as continuously dancing in circles.
Because we thought she was experiencing a severe exacerbation of bipolar disorder, the patient was started on 4 different antipsychotic trials (typical and atypical) and 2 mood stabilizers, all of which did not produce adequate response. Even after augmentation with nightly long-acting benzodiazepines, the patient’s symptoms remained unchanged.
The patient received a diagnosis of delirious mania, with the underlying mechanism being severe catatonia. A literature search revealed electroconvulsive therapy (ECT) and benzodiazepines as first-line treatments, and discouraged use of typical antipsychotics because of an increased risk of neuroleptic malignant syndrome and malignant delirious mania.1 Because ECT was not available at our facility, we initiated benzodiazepines,
We agree it is prudent to rule out any medical illnesses that could cause delirium. Interestingly, in our patient a head CT revealed small calcifications suggestive of cysticercosis, which have been seen on imaging since age 13. We suggest that this finding contributed to her disinhibition, prolonged her recovery, and could explain why she did not respond adequately to medications.
Diagnosing and treating delirious mania in our patient was challenging. As mentioned by Davis et al, there is no classification of delirious mania in DSM-5. In addition, there are no large-scale studies to educate psychiatrists about the prevalence and appropriate treatment of this disorder.
Our treatment approach differed from that of Davis et al in that we chose scheduled benzodiazepines rather than antipsychotics to target the patient’s catatonia. However, both patients improved, prompting us to further question the mechanism behind this presentation.
We encourage the addition of delirious mania to the next edition of DSM. Without classification and establishment of this diagnosis, psychiatrists are unlikely to consider this serious and potentially fatal syndrome. Delirious mania is mysterious and rare and its inner workings are not fully elucidated.
Sabina Bera, MD MSc
PGY-2 Psychiatry Resident
Mohammed Molla, MD, DFAPA
Interim Joint Chair and Program Director
University of California Los Angeles-Kern
Psychiatry Training Program
Bakersfield, California
Reference
1. Jacobowski NL, Heckers S, Bobo WV. Delirious mania: detection, diagnosis, and clinical management in the acute setting. J Psychiatr Pract. 2013;19(1):15-28.
Correcting an error
In his informative guest editorial "
David A. Gorelick, MD, PhD
Professor of Psychiatry
Maryland Psychiatric Research Center
University of Maryland
Baltimore, Maryland
Revisiting delirious mania
After treating a young woman with delirious mania, we were compelled to comment on the case report “Confused and nearly naked after going on spending sprees” (Cases That Test Your Skills,
A young woman with bipolar I disorder and mild intellectual disability was brought to our inpatient psychiatric unit after she disappeared from her home. Her family reported she was not compliant with her medications, and she recently showed deterioration marked by bizarre and violent behaviors for the previous month.
Although her presentation was consistent with earlier manic episodes, additional behaviors indicated an increase in severity. The patient was only oriented to name, was disrobing, had urinary and fecal incontinence, and showed purposeless hyperactivity such as continuously dancing in circles.
Because we thought she was experiencing a severe exacerbation of bipolar disorder, the patient was started on 4 different antipsychotic trials (typical and atypical) and 2 mood stabilizers, all of which did not produce adequate response. Even after augmentation with nightly long-acting benzodiazepines, the patient’s symptoms remained unchanged.
The patient received a diagnosis of delirious mania, with the underlying mechanism being severe catatonia. A literature search revealed electroconvulsive therapy (ECT) and benzodiazepines as first-line treatments, and discouraged use of typical antipsychotics because of an increased risk of neuroleptic malignant syndrome and malignant delirious mania.1 Because ECT was not available at our facility, we initiated benzodiazepines,
We agree it is prudent to rule out any medical illnesses that could cause delirium. Interestingly, in our patient a head CT revealed small calcifications suggestive of cysticercosis, which have been seen on imaging since age 13. We suggest that this finding contributed to her disinhibition, prolonged her recovery, and could explain why she did not respond adequately to medications.
Diagnosing and treating delirious mania in our patient was challenging. As mentioned by Davis et al, there is no classification of delirious mania in DSM-5. In addition, there are no large-scale studies to educate psychiatrists about the prevalence and appropriate treatment of this disorder.
Our treatment approach differed from that of Davis et al in that we chose scheduled benzodiazepines rather than antipsychotics to target the patient’s catatonia. However, both patients improved, prompting us to further question the mechanism behind this presentation.
We encourage the addition of delirious mania to the next edition of DSM. Without classification and establishment of this diagnosis, psychiatrists are unlikely to consider this serious and potentially fatal syndrome. Delirious mania is mysterious and rare and its inner workings are not fully elucidated.
Sabina Bera, MD MSc
PGY-2 Psychiatry Resident
Mohammed Molla, MD, DFAPA
Interim Joint Chair and Program Director
University of California Los Angeles-Kern
Psychiatry Training Program
Bakersfield, California
Reference
1. Jacobowski NL, Heckers S, Bobo WV. Delirious mania: detection, diagnosis, and clinical management in the acute setting. J Psychiatr Pract. 2013;19(1):15-28.
Correcting an error
In his informative guest editorial "
David A. Gorelick, MD, PhD
Professor of Psychiatry
Maryland Psychiatric Research Center
University of Maryland
Baltimore, Maryland
Patient Satisfaction: Within Arm’s Reach, or Bending Over Backward?
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 ha
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].
1. Prakash B. Patient satisfaction. J Cutan Aesthet Surg. 2010; 3(3):151-155.
2. Jackson JL,Chamberlin J, Kroenke K. Predictors of patient satisfaction. Soc Sci Med. 2001;52(4):609-620.
3. Linder-Pelz SU. Toward a theory of patient satisfaction. Soc Sci Med. 1982;16(5):577-582.
4. Onieal ME. The paradox of pain management. Clinician Reviews. 2016;26(11):12,16.
5. Rickert J. Measuring patient satisfaction: a bridge between patient and physician perceptions of care. http://healthaffairs.org/blog/2014/05/09/measuring-patient-satisfaction-a-bridge-between-patient-and-physician-perceptions-of-care. Accessed December 1, 2016.
6. Centers for Medicare & Medicaid Services. Hospital Consumer Assessment of Healthcare Providers and Systems CAHPS® Hospital Survey. www.hcahpsonline.org/home.aspx. Accessed December 1, 2016.
7. Agency for Healthcare Research and Quality. Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey. www.ahrq.gov/cahps/surveys-guidance/cg/index.html. Accessed December 1, 2016.
8. Haas JS, Cook EF, Puopolo AL, et al. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med. 2000;15(2):122-128.
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 ha
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 ha
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].
1. Prakash B. Patient satisfaction. J Cutan Aesthet Surg. 2010; 3(3):151-155.
2. Jackson JL,Chamberlin J, Kroenke K. Predictors of patient satisfaction. Soc Sci Med. 2001;52(4):609-620.
3. Linder-Pelz SU. Toward a theory of patient satisfaction. Soc Sci Med. 1982;16(5):577-582.
4. Onieal ME. The paradox of pain management. Clinician Reviews. 2016;26(11):12,16.
5. Rickert J. Measuring patient satisfaction: a bridge between patient and physician perceptions of care. http://healthaffairs.org/blog/2014/05/09/measuring-patient-satisfaction-a-bridge-between-patient-and-physician-perceptions-of-care. Accessed December 1, 2016.
6. Centers for Medicare & Medicaid Services. Hospital Consumer Assessment of Healthcare Providers and Systems CAHPS® Hospital Survey. www.hcahpsonline.org/home.aspx. Accessed December 1, 2016.
7. Agency for Healthcare Research and Quality. Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey. www.ahrq.gov/cahps/surveys-guidance/cg/index.html. Accessed December 1, 2016.
8. Haas JS, Cook EF, Puopolo AL, et al. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med. 2000;15(2):122-128.
1. Prakash B. Patient satisfaction. J Cutan Aesthet Surg. 2010; 3(3):151-155.
2. Jackson JL,Chamberlin J, Kroenke K. Predictors of patient satisfaction. Soc Sci Med. 2001;52(4):609-620.
3. Linder-Pelz SU. Toward a theory of patient satisfaction. Soc Sci Med. 1982;16(5):577-582.
4. Onieal ME. The paradox of pain management. Clinician Reviews. 2016;26(11):12,16.
5. Rickert J. Measuring patient satisfaction: a bridge between patient and physician perceptions of care. http://healthaffairs.org/blog/2014/05/09/measuring-patient-satisfaction-a-bridge-between-patient-and-physician-perceptions-of-care. Accessed December 1, 2016.
6. Centers for Medicare & Medicaid Services. Hospital Consumer Assessment of Healthcare Providers and Systems CAHPS® Hospital Survey. www.hcahpsonline.org/home.aspx. Accessed December 1, 2016.
7. Agency for Healthcare Research and Quality. Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey. www.ahrq.gov/cahps/surveys-guidance/cg/index.html. Accessed December 1, 2016.
8. Haas JS, Cook EF, Puopolo AL, et al. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med. 2000;15(2):122-128.
It’s working! (No it’s not! Yes it is!)
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!”
Even saying that sounds strange. Don’t we physicians apply the evidence-based fruits of science? What does the patient’s mind have to do with that?
Yesterday we saw Emma, who spent 5 years in Austria. On her back was perfectly circular purpura.
“Who does your cupping?” I asked her.
“My acupuncturist,” said Emma. “He does cupping too.”
“What’s it for?”
“Aches and pains, stress, that sort of thing.”
“Does it help?”
“It seems to,” said Emma. Sometimes, anyway.”
Later I asked my student what she thought Emma meant. “What did Emma see or feel to make her conclude that cupping was working, at least sometimes? Did she feel better Tuesday than Monday? What if she felt worse again Wednesday? Would that mean the treatment wasn’t working anymore? That it works some days and not others?”
If you think this line of analysis applies only to exotic forms of alternative medicine, consider how often we could ask the same questions about the medically approved treatments we prescribe every day.
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!”
Even saying that sounds strange. Don’t we physicians apply the evidence-based fruits of science? What does the patient’s mind have to do with that?
Yesterday we saw Emma, who spent 5 years in Austria. On her back was perfectly circular purpura.
“Who does your cupping?” I asked her.
“My acupuncturist,” said Emma. “He does cupping too.”
“What’s it for?”
“Aches and pains, stress, that sort of thing.”
“Does it help?”
“It seems to,” said Emma. Sometimes, anyway.”
Later I asked my student what she thought Emma meant. “What did Emma see or feel to make her conclude that cupping was working, at least sometimes? Did she feel better Tuesday than Monday? What if she felt worse again Wednesday? Would that mean the treatment wasn’t working anymore? That it works some days and not others?”
If you think this line of analysis applies only to exotic forms of alternative medicine, consider how often we could ask the same questions about the medically approved treatments we prescribe every day.
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!”
Even saying that sounds strange. Don’t we physicians apply the evidence-based fruits of science? What does the patient’s mind have to do with that?
Yesterday we saw Emma, who spent 5 years in Austria. On her back was perfectly circular purpura.
“Who does your cupping?” I asked her.
“My acupuncturist,” said Emma. “He does cupping too.”
“What’s it for?”
“Aches and pains, stress, that sort of thing.”
“Does it help?”
“It seems to,” said Emma. Sometimes, anyway.”
Later I asked my student what she thought Emma meant. “What did Emma see or feel to make her conclude that cupping was working, at least sometimes? Did she feel better Tuesday than Monday? What if she felt worse again Wednesday? Would that mean the treatment wasn’t working anymore? That it works some days and not others?”
If you think this line of analysis applies only to exotic forms of alternative medicine, consider how often we could ask the same questions about the medically approved treatments we prescribe every day.
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] .
FOUND IN TRANSLATION Minimal nomenclature and maximum sensitivity complicate MRD measures
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
These patients, now more appropriately stratified for risk of recurrence, are in desperate need of better care algorithms. Standard MRD assessment by flow cytometric analysis is able to detect less than 1 x 10-4 cells. While it can be applied to most patients, its sensitivity will likely be surpassed by new and emerging genomic assays. Real time quantitative polymerase chain reaction (RT-qPCR) and next generation sequencing (NGS) require a leukemia-specific abnormality but have the potential for far greater sensitivity with deeper sequencing techniques.
Long-term follow up data in acute promyelocytic leukemia (APL) provides the illustrative example where morphologic remission is not durable in the setting of a persistent PML-RARa transcript and therapeutic goals for PCR negativity irrespective of morphology are standard. Pathologic fusion proteins are ideal for marker-driven therapy, but are found in only about 50% of patients, mainly those with APL and Philadelphia chromosome-positive leukemias.
With driver mutations identified in the majority of patients, we can be hopeful that NGS negativity may be a useful clinical endpoint. In work presented at ASH 2016 by Bartlomiej M Getta, MBBS, of Memorial Sloan Kettering Cancer Center, New York, and his colleagues, patients with concordant MRD positivity by flow cytometry and NGS had inferior outcomes, even after allogeneic transplant, compared to patients with MRD positivity on one assay but not both.5 Nonetheless, caution should be taken in early adoption of NGS as a independent marker of MRD status for two main reasons: 1) False positives and lack of standardization make current interpretation difficult. 2) The presence of “preleukemic” clones remains enigmatic – and no matter the nomenclature used, can a DNMT3A or IDH-mutant clone really be deemed “clonal hematopoiesis of indeterminate potential” when a patient has already had clonal transformation?
Conversely, not all patients reported in the work by Klco2 and Getta ultimately relapse. Thus, while it would be preferred to clear all mutant clones, as a therapeutic goal this likely would subject many patients to unnecessary toxicity. One half of the patients reported by Getta were disease free at a year with concordant flow and NGS positive MRD while patients with NGS positivity alone had outcomes equivalent to those of MRD-negative patients, highlighting that certain persistent clones in NGS-only, MRD-positive patients might be amenable to immunotherapy, either with checkpoint inhibitors or allogeneic transplant. Insight into which clones remain quiescent and which are more sinister will require more investigation, but there does seem to be an additive role to NGS-positivity, whereby all MRD is not created equal and the precision and clinical utility of MRD status will likely take on nuanced nomenclature.
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
These patients, now more appropriately stratified for risk of recurrence, are in desperate need of better care algorithms. Standard MRD assessment by flow cytometric analysis is able to detect less than 1 x 10-4 cells. While it can be applied to most patients, its sensitivity will likely be surpassed by new and emerging genomic assays. Real time quantitative polymerase chain reaction (RT-qPCR) and next generation sequencing (NGS) require a leukemia-specific abnormality but have the potential for far greater sensitivity with deeper sequencing techniques.
Long-term follow up data in acute promyelocytic leukemia (APL) provides the illustrative example where morphologic remission is not durable in the setting of a persistent PML-RARa transcript and therapeutic goals for PCR negativity irrespective of morphology are standard. Pathologic fusion proteins are ideal for marker-driven therapy, but are found in only about 50% of patients, mainly those with APL and Philadelphia chromosome-positive leukemias.
With driver mutations identified in the majority of patients, we can be hopeful that NGS negativity may be a useful clinical endpoint. In work presented at ASH 2016 by Bartlomiej M Getta, MBBS, of Memorial Sloan Kettering Cancer Center, New York, and his colleagues, patients with concordant MRD positivity by flow cytometry and NGS had inferior outcomes, even after allogeneic transplant, compared to patients with MRD positivity on one assay but not both.5 Nonetheless, caution should be taken in early adoption of NGS as a independent marker of MRD status for two main reasons: 1) False positives and lack of standardization make current interpretation difficult. 2) The presence of “preleukemic” clones remains enigmatic – and no matter the nomenclature used, can a DNMT3A or IDH-mutant clone really be deemed “clonal hematopoiesis of indeterminate potential” when a patient has already had clonal transformation?
Conversely, not all patients reported in the work by Klco2 and Getta ultimately relapse. Thus, while it would be preferred to clear all mutant clones, as a therapeutic goal this likely would subject many patients to unnecessary toxicity. One half of the patients reported by Getta were disease free at a year with concordant flow and NGS positive MRD while patients with NGS positivity alone had outcomes equivalent to those of MRD-negative patients, highlighting that certain persistent clones in NGS-only, MRD-positive patients might be amenable to immunotherapy, either with checkpoint inhibitors or allogeneic transplant. Insight into which clones remain quiescent and which are more sinister will require more investigation, but there does seem to be an additive role to NGS-positivity, whereby all MRD is not created equal and the precision and clinical utility of MRD status will likely take on nuanced nomenclature.
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
These patients, now more appropriately stratified for risk of recurrence, are in desperate need of better care algorithms. Standard MRD assessment by flow cytometric analysis is able to detect less than 1 x 10-4 cells. While it can be applied to most patients, its sensitivity will likely be surpassed by new and emerging genomic assays. Real time quantitative polymerase chain reaction (RT-qPCR) and next generation sequencing (NGS) require a leukemia-specific abnormality but have the potential for far greater sensitivity with deeper sequencing techniques.
Long-term follow up data in acute promyelocytic leukemia (APL) provides the illustrative example where morphologic remission is not durable in the setting of a persistent PML-RARa transcript and therapeutic goals for PCR negativity irrespective of morphology are standard. Pathologic fusion proteins are ideal for marker-driven therapy, but are found in only about 50% of patients, mainly those with APL and Philadelphia chromosome-positive leukemias.
With driver mutations identified in the majority of patients, we can be hopeful that NGS negativity may be a useful clinical endpoint. In work presented at ASH 2016 by Bartlomiej M Getta, MBBS, of Memorial Sloan Kettering Cancer Center, New York, and his colleagues, patients with concordant MRD positivity by flow cytometry and NGS had inferior outcomes, even after allogeneic transplant, compared to patients with MRD positivity on one assay but not both.5 Nonetheless, caution should be taken in early adoption of NGS as a independent marker of MRD status for two main reasons: 1) False positives and lack of standardization make current interpretation difficult. 2) The presence of “preleukemic” clones remains enigmatic – and no matter the nomenclature used, can a DNMT3A or IDH-mutant clone really be deemed “clonal hematopoiesis of indeterminate potential” when a patient has already had clonal transformation?
Conversely, not all patients reported in the work by Klco2 and Getta ultimately relapse. Thus, while it would be preferred to clear all mutant clones, as a therapeutic goal this likely would subject many patients to unnecessary toxicity. One half of the patients reported by Getta were disease free at a year with concordant flow and NGS positive MRD while patients with NGS positivity alone had outcomes equivalent to those of MRD-negative patients, highlighting that certain persistent clones in NGS-only, MRD-positive patients might be amenable to immunotherapy, either with checkpoint inhibitors or allogeneic transplant. Insight into which clones remain quiescent and which are more sinister will require more investigation, but there does seem to be an additive role to NGS-positivity, whereby all MRD is not created equal and the precision and clinical utility of MRD status will likely take on nuanced nomenclature.
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].
Stress management for ambitious students
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].