Commentary

When it comes to political candidates and psychiatric disorders, the idea of diagnosing from afar is not new. In 1964, Fact magazine published an article called “The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater.” For the article, more than 2,400 psychiatrists responded to a survey, and many described the presidential candidate using a host of diagnostic and symptomatic terms. Mr. Goldwater lost the election in a landslide and successfully sued the magazine for $75,000.

In 1973, nearly a decade later, the American Psychiatric Association specifically noted in its code of ethics that psychiatrists should not offer diagnostic opinions on anyone who has not been personally examined and has not signed the proper authorization for this information to be released. The edict has been informally called The Goldwater Rule.

In the current election cycle, it has been a challenge for some psychiatrists to refrain from making public statements about our presidential candidates. Some have said the Goldwater Rule amounts to a gag order, and that the specifics of this election are different from other elections, and might warrant allowing psychiatrists to issue their professional opinions. The APA has reminded psychiatrists that to do so is unethical, and on Aug. 15, The New York Times ran an article by Benedict Carey titled: “The Psychiatric Question: Is it Fair to Analyze Donald Trump from Afar?”

I want to look at the question from a different stance. In assessing our political candidates, I’d like you to consider this: What difference does it make? Psychiatric diagnostic criteria are determined by consensus opinions of APA workgroup members. They aren’t perfect; they aren’t always accurate even when a patient is evaluated in person and seen over time; they are influenced by culture; and they aren’t always prognostic. One person’s experience of bipolar disorder is not another person’s experience of bipolar disorder, and personality disorders – such as narcissism or antisocial personality disorder – don’t have uniform presentations or outcomes. Some people with these difficulties head corporations and nations, while others wilt in prisons.

Half of the population will suffer from an episode of psychiatric illness at some point in their lives, and one in five people is affected in any given year. While we might all agree that many psychiatric symptoms are not compatible with being president, should the fact that a candidate has had a distant episode of mental illness, either fully resolved or controlled with treatment, disqualify him or her from holding office?

In an article published in the January 2006 issue of the Journal of Nervous and Mental Disease, Jonathan R. Davidson, MD; Kathryn M. Connor, MD; and Marvin Swartz, MD, looked at the biographical data on U.S. presidents from 1776 to 1974 and concluded that 49% met criteria for an Axis I psychiatric disorder. During those cycles, 27% had psychiatric difficulties while in office. Our presidents have suffered from depression and bipolar disorder, anxiety and alcoholism (J Nerv Ment Dis. 2006 Jan;194[1]47-51). No one has publicly attempted to tally personality disorders or use of other addictive substances. It may be safe to say that if the existence of psychiatric pathology had always been a disqualifier for public office, we’d live in a very different country.

Hopefully, when we approach our patients, we do so with warmth, kindness, and a genuine desire to help them heal. Psychiatry, at its best, is about intimacy and trust, and it is in that venue that people share their inner worlds and allow themselves to be vulnerable. Compassion is part of the deal; no one wants to have a mental illness. To refer to an unknown celebrity as “schizophrenic,” “psychotic,” or “having a godlike self-image” – or calling him “a dangerous lunatic,” as Sen. Goldwater was called – is not about careful diagnosis and compassion; it’s simply about name calling. To say that a politician or celebrity’s undesirable behavior is the result of a psychiatric illness based on cavalier observation is an insult to our patients, and it perpetuates stigma.

Psychiatric diagnoses are made by observing a constellation of symptoms that occur together. Mr. Trump has given the whole world years of data – he’s lived his life in a very public way. As a real estate developer, he has had countless employees who all know how they’ve been treated. We’ve seen him through three marriages and watched how he interacts with his children. We’ve seen him take out full-page ads calling for the death penalty for a group of young men who were wrongly convicted in the rape and assault of the Central Park jogger in 1988. If that’s not enough, he has hosted his own reality television show, and we’ve now seen him countless times in debates and rallies. We know how he treats his running mates, journalist Megyn Kelly, a news reporter with a disability, and the parents of a fallen soldier. We’ve watched him assure the nation during a primary debate that his genitals are big enough. Every individual is free to decide if Mr. Trump’s widely viewed patterns of behavior represent much-needed spunk and change with political beliefs that align with their own, or if his words and behaviors represent cruelty, impulsivity, poor judgment, and a pattern of actions that some might not feel is dignified enough for our country’s leader. No degree is required to observe and draw conclusions.

And please, let me be the first to admit that my perspective is biased: I’ve pointed out some of Mr. Trump’s more troubling behaviors and said nothing of the many wonderful things he may have done as both an entrepreneur and as a human being. Those don’t make the headlines or Twitter, and so I’m left with my own observations and those of a liberal press (Of course, there’s a right-wing press, too, but that’s a topic for another time). For voters who align their beliefs with the National Rifle Association, and feel that illegal immigrants are a drain on our country and that people of certain faiths represent a terror threat to Americans, Mr. Trump apparently remains a reasonable candidate.

Is there a role here for living room consults from psychiatrists? Is there something for us as professionals to add to the prediction of Mr. Trump’s behavior if he becomes president? I don’t think so. Every American has ample data, and for those who are curious about Mr. Trump’s psychiatric status, they are free to Google the criteria for psychiatric disorders and see if they believe he meets them. The input of psychiatrists would neither change the election outcome nor accurately predict his behavior if elected. But it might make us look a bit grandiose.

Finally, I’ve focused here on Mr. Trump, while saying nothing about Secretary Hillary Clinton and her psychiatric status. She, too, has lived a public life, and while many of her activities have attracted media attention and scrutiny, I’ve seen nothing that has suggested she suffers from a psychiatric condition. There was, however, an op-ed piece in The New York Times on Aug. 23, 2016, by Frank Bruni, suggesting that Mrs. Clinton may have an 11th toe.

If nothing else, it’s time for this election to be over.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” forthcoming from Johns Hopkins University Press in fall 2016.

When it comes to political candidates and psychiatric disorders, the idea of diagnosing from afar is not new. In 1964, Fact magazine published an article called “The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater.” For the article, more than 2,400 psychiatrists responded to a survey, and many described the presidential candidate using a host of diagnostic and symptomatic terms. Mr. Goldwater lost the election in a landslide and successfully sued the magazine for $75,000.

In 1973, nearly a decade later, the American Psychiatric Association specifically noted in its code of ethics that psychiatrists should not offer diagnostic opinions on anyone who has not been personally examined and has not signed the proper authorization for this information to be released. The edict has been informally called The Goldwater Rule.

In the current election cycle, it has been a challenge for some psychiatrists to refrain from making public statements about our presidential candidates. Some have said the Goldwater Rule amounts to a gag order, and that the specifics of this election are different from other elections, and might warrant allowing psychiatrists to issue their professional opinions. The APA has reminded psychiatrists that to do so is unethical, and on Aug. 15, The New York Times ran an article by Benedict Carey titled: “The Psychiatric Question: Is it Fair to Analyze Donald Trump from Afar?”

I want to look at the question from a different stance. In assessing our political candidates, I’d like you to consider this: What difference does it make? Psychiatric diagnostic criteria are determined by consensus opinions of APA workgroup members. They aren’t perfect; they aren’t always accurate even when a patient is evaluated in person and seen over time; they are influenced by culture; and they aren’t always prognostic. One person’s experience of bipolar disorder is not another person’s experience of bipolar disorder, and personality disorders – such as narcissism or antisocial personality disorder – don’t have uniform presentations or outcomes. Some people with these difficulties head corporations and nations, while others wilt in prisons.

Half of the population will suffer from an episode of psychiatric illness at some point in their lives, and one in five people is affected in any given year. While we might all agree that many psychiatric symptoms are not compatible with being president, should the fact that a candidate has had a distant episode of mental illness, either fully resolved or controlled with treatment, disqualify him or her from holding office?

In an article published in the January 2006 issue of the Journal of Nervous and Mental Disease, Jonathan R. Davidson, MD; Kathryn M. Connor, MD; and Marvin Swartz, MD, looked at the biographical data on U.S. presidents from 1776 to 1974 and concluded that 49% met criteria for an Axis I psychiatric disorder. During those cycles, 27% had psychiatric difficulties while in office. Our presidents have suffered from depression and bipolar disorder, anxiety and alcoholism (J Nerv Ment Dis. 2006 Jan;194[1]47-51). No one has publicly attempted to tally personality disorders or use of other addictive substances. It may be safe to say that if the existence of psychiatric pathology had always been a disqualifier for public office, we’d live in a very different country.

Hopefully, when we approach our patients, we do so with warmth, kindness, and a genuine desire to help them heal. Psychiatry, at its best, is about intimacy and trust, and it is in that venue that people share their inner worlds and allow themselves to be vulnerable. Compassion is part of the deal; no one wants to have a mental illness. To refer to an unknown celebrity as “schizophrenic,” “psychotic,” or “having a godlike self-image” – or calling him “a dangerous lunatic,” as Sen. Goldwater was called – is not about careful diagnosis and compassion; it’s simply about name calling. To say that a politician or celebrity’s undesirable behavior is the result of a psychiatric illness based on cavalier observation is an insult to our patients, and it perpetuates stigma.

Psychiatric diagnoses are made by observing a constellation of symptoms that occur together. Mr. Trump has given the whole world years of data – he’s lived his life in a very public way. As a real estate developer, he has had countless employees who all know how they’ve been treated. We’ve seen him through three marriages and watched how he interacts with his children. We’ve seen him take out full-page ads calling for the death penalty for a group of young men who were wrongly convicted in the rape and assault of the Central Park jogger in 1988. If that’s not enough, he has hosted his own reality television show, and we’ve now seen him countless times in debates and rallies. We know how he treats his running mates, journalist Megyn Kelly, a news reporter with a disability, and the parents of a fallen soldier. We’ve watched him assure the nation during a primary debate that his genitals are big enough. Every individual is free to decide if Mr. Trump’s widely viewed patterns of behavior represent much-needed spunk and change with political beliefs that align with their own, or if his words and behaviors represent cruelty, impulsivity, poor judgment, and a pattern of actions that some might not feel is dignified enough for our country’s leader. No degree is required to observe and draw conclusions.

And please, let me be the first to admit that my perspective is biased: I’ve pointed out some of Mr. Trump’s more troubling behaviors and said nothing of the many wonderful things he may have done as both an entrepreneur and as a human being. Those don’t make the headlines or Twitter, and so I’m left with my own observations and those of a liberal press (Of course, there’s a right-wing press, too, but that’s a topic for another time). For voters who align their beliefs with the National Rifle Association, and feel that illegal immigrants are a drain on our country and that people of certain faiths represent a terror threat to Americans, Mr. Trump apparently remains a reasonable candidate.

Is there a role here for living room consults from psychiatrists? Is there something for us as professionals to add to the prediction of Mr. Trump’s behavior if he becomes president? I don’t think so. Every American has ample data, and for those who are curious about Mr. Trump’s psychiatric status, they are free to Google the criteria for psychiatric disorders and see if they believe he meets them. The input of psychiatrists would neither change the election outcome nor accurately predict his behavior if elected. But it might make us look a bit grandiose.

Finally, I’ve focused here on Mr. Trump, while saying nothing about Secretary Hillary Clinton and her psychiatric status. She, too, has lived a public life, and while many of her activities have attracted media attention and scrutiny, I’ve seen nothing that has suggested she suffers from a psychiatric condition. There was, however, an op-ed piece in The New York Times on Aug. 23, 2016, by Frank Bruni, suggesting that Mrs. Clinton may have an 11th toe.

If nothing else, it’s time for this election to be over.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” forthcoming from Johns Hopkins University Press in fall 2016.

When it comes to political candidates and psychiatric disorders, the idea of diagnosing from afar is not new. In 1964, Fact magazine published an article called “The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater.” For the article, more than 2,400 psychiatrists responded to a survey, and many described the presidential candidate using a host of diagnostic and symptomatic terms. Mr. Goldwater lost the election in a landslide and successfully sued the magazine for $75,000.

In 1973, nearly a decade later, the American Psychiatric Association specifically noted in its code of ethics that psychiatrists should not offer diagnostic opinions on anyone who has not been personally examined and has not signed the proper authorization for this information to be released. The edict has been informally called The Goldwater Rule.

In the current election cycle, it has been a challenge for some psychiatrists to refrain from making public statements about our presidential candidates. Some have said the Goldwater Rule amounts to a gag order, and that the specifics of this election are different from other elections, and might warrant allowing psychiatrists to issue their professional opinions. The APA has reminded psychiatrists that to do so is unethical, and on Aug. 15, The New York Times ran an article by Benedict Carey titled: “The Psychiatric Question: Is it Fair to Analyze Donald Trump from Afar?”

I want to look at the question from a different stance. In assessing our political candidates, I’d like you to consider this: What difference does it make? Psychiatric diagnostic criteria are determined by consensus opinions of APA workgroup members. They aren’t perfect; they aren’t always accurate even when a patient is evaluated in person and seen over time; they are influenced by culture; and they aren’t always prognostic. One person’s experience of bipolar disorder is not another person’s experience of bipolar disorder, and personality disorders – such as narcissism or antisocial personality disorder – don’t have uniform presentations or outcomes. Some people with these difficulties head corporations and nations, while others wilt in prisons.

Half of the population will suffer from an episode of psychiatric illness at some point in their lives, and one in five people is affected in any given year. While we might all agree that many psychiatric symptoms are not compatible with being president, should the fact that a candidate has had a distant episode of mental illness, either fully resolved or controlled with treatment, disqualify him or her from holding office?

In an article published in the January 2006 issue of the Journal of Nervous and Mental Disease, Jonathan R. Davidson, MD; Kathryn M. Connor, MD; and Marvin Swartz, MD, looked at the biographical data on U.S. presidents from 1776 to 1974 and concluded that 49% met criteria for an Axis I psychiatric disorder. During those cycles, 27% had psychiatric difficulties while in office. Our presidents have suffered from depression and bipolar disorder, anxiety and alcoholism (J Nerv Ment Dis. 2006 Jan;194[1]47-51). No one has publicly attempted to tally personality disorders or use of other addictive substances. It may be safe to say that if the existence of psychiatric pathology had always been a disqualifier for public office, we’d live in a very different country.

Hopefully, when we approach our patients, we do so with warmth, kindness, and a genuine desire to help them heal. Psychiatry, at its best, is about intimacy and trust, and it is in that venue that people share their inner worlds and allow themselves to be vulnerable. Compassion is part of the deal; no one wants to have a mental illness. To refer to an unknown celebrity as “schizophrenic,” “psychotic,” or “having a godlike self-image” – or calling him “a dangerous lunatic,” as Sen. Goldwater was called – is not about careful diagnosis and compassion; it’s simply about name calling. To say that a politician or celebrity’s undesirable behavior is the result of a psychiatric illness based on cavalier observation is an insult to our patients, and it perpetuates stigma.

Psychiatric diagnoses are made by observing a constellation of symptoms that occur together. Mr. Trump has given the whole world years of data – he’s lived his life in a very public way. As a real estate developer, he has had countless employees who all know how they’ve been treated. We’ve seen him through three marriages and watched how he interacts with his children. We’ve seen him take out full-page ads calling for the death penalty for a group of young men who were wrongly convicted in the rape and assault of the Central Park jogger in 1988. If that’s not enough, he has hosted his own reality television show, and we’ve now seen him countless times in debates and rallies. We know how he treats his running mates, journalist Megyn Kelly, a news reporter with a disability, and the parents of a fallen soldier. We’ve watched him assure the nation during a primary debate that his genitals are big enough. Every individual is free to decide if Mr. Trump’s widely viewed patterns of behavior represent much-needed spunk and change with political beliefs that align with their own, or if his words and behaviors represent cruelty, impulsivity, poor judgment, and a pattern of actions that some might not feel is dignified enough for our country’s leader. No degree is required to observe and draw conclusions.

And please, let me be the first to admit that my perspective is biased: I’ve pointed out some of Mr. Trump’s more troubling behaviors and said nothing of the many wonderful things he may have done as both an entrepreneur and as a human being. Those don’t make the headlines or Twitter, and so I’m left with my own observations and those of a liberal press (Of course, there’s a right-wing press, too, but that’s a topic for another time). For voters who align their beliefs with the National Rifle Association, and feel that illegal immigrants are a drain on our country and that people of certain faiths represent a terror threat to Americans, Mr. Trump apparently remains a reasonable candidate.

Is there a role here for living room consults from psychiatrists? Is there something for us as professionals to add to the prediction of Mr. Trump’s behavior if he becomes president? I don’t think so. Every American has ample data, and for those who are curious about Mr. Trump’s psychiatric status, they are free to Google the criteria for psychiatric disorders and see if they believe he meets them. The input of psychiatrists would neither change the election outcome nor accurately predict his behavior if elected. But it might make us look a bit grandiose.

Finally, I’ve focused here on Mr. Trump, while saying nothing about Secretary Hillary Clinton and her psychiatric status. She, too, has lived a public life, and while many of her activities have attracted media attention and scrutiny, I’ve seen nothing that has suggested she suffers from a psychiatric condition. There was, however, an op-ed piece in The New York Times on Aug. 23, 2016, by Frank Bruni, suggesting that Mrs. Clinton may have an 11th toe.

If nothing else, it’s time for this election to be over.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” forthcoming from Johns Hopkins University Press in fall 2016.

As summer winds down, it is routine for children and adolescents to feel a little melancholy or even worried about the approaching start of school. But for some students, anxiety about school is more than routine; it is insurmountable. School refusal is a serious behavioral problem: without assertive management, it can become a pattern which is very difficult to alter. Whether a child is complaining of vague somatic concerns or is explicitly refusing to go to school, the pediatrician’s office is often the first place a parent will turn to for help. If you can recognize the true nature of the problem, help to determine its cause, and facilitate the needed management, you will have effectively treated what can become a disabling problem for vulnerable young people.

School refusal is happening when a child has major difficulty attending school, associated with intense emotional distress. It can be a refusal to attend school or difficulty remaining in school for an entire day. It is distinct (but not mutually exclusive) from truancy, which is a failure to attend school associated with antisocial behavior or other conduct problems. In the pediatrician’s office, school refusal sounds like, “He was moaning about a stomachache yesterday, I kept him home, but he had no fever and ate okay. Then it all repeated again this morning.” Or you might hear, “She was whining about a headache, but when I said she had to go to school, she started crying and couldn’t stop. She was hysterical!” In teenagers, there may be somatic complaints or just a sleepy, sulky refusal to get out of bed. Children with truancy might fake illness (as compared with feeling sick), or simply leave school. Truant children often want to be out of school doing other things, and may keep their whereabouts a secret from their parents. While it might seem like just one tough morning that can be shrugged off, true school refusal will continue or escalate unless it is properly managed.

School refusal affects approximately 5% of all children annually, affecting girls and boys in equal numbers and with peaks in incidence at the ages of 5 to 6 years and again at 10 to 11 years. Approximately half of children and teenagers with school refusal have a treatable psychiatric illness. In the Great Smoky Mountain Study of 2003, where more than 1,400 children were observed, they categorized children as being anxious school refusers, truant, or “mixed school refusers,” with features of both truancy and anxiety. In children with truancy or anxious school refusal, 25% had a psychiatric illness. In the mixed school refusers, they found 88% had at least one psychiatric diagnosis and 42% had somatic complaints. While pure truancy will require different management strategies from school and parents, those young people who display features of both anxiety and truancy around school attendance are most likely to be suffering from a psychiatric illness. Those illnesses most commonly associated with difficulty attending school include anxiety disorders (separation anxiety, social phobia, generalized anxiety disorder) and depression.

While psychiatric illness is a common factor, there is also always a behavioral component to school refusal. This simply means that children are either avoiding unpleasant feelings associated with school, such as anxiety, or escaping uncomfortable situations, such as bullying or the stress of performance. On the positive side, children may be refusing school because they are pursuing the attention of important people (parents, peers) or pursuing pleasurable activities (playing video games, surfing the web or hanging out in town). Beyond an internal anxiety disorder, some children may be facing bullying or threats at school or may have to walk through a dangerous neighborhood to get to school. Some children may be missing school because of significant stress or transitions at home, such as financial difficulties or divorce. Other children may be staying home to take care of younger siblings because of a parent’s medical illness or substance abuse problem. Children who are being abused may be kept home to prevent suspicion about bruises. Lastly, some children feel they have to stay home to be with a lonely or depressed parent. Gently asking about these very real concerns will help determine the necessary course of action.

Pediatricians can play a central role in the management of school refusal. Often, the most important step is helping parents to understand that there is not an insidious medical problem driving the morning stomachaches and headaches. It is critical to clarify that (usually) their child is not feigning illness, but that there is significant distress around school that has led to this behavioral problem. Even children who have a genuine medical problem also can have school refusal. Once parents understand that without proper management, this behavior will continue or worsen, they usually are ready to collaborate on effective management. Their child may need a thorough psychiatric evaluation to rule out a treatable underlying psychiatric diagnosis, particularly if they have both anxious and truant behaviors. Most of the psychiatric problems associated with school refusal will require therapy and some may require medications for effective treatment.

Successfully getting children back to school will require a behavior plan that is agreed upon by the parents and the school, and then used consistently. This plan will simply detail strategies to “demagnetize” the home and “remagnetize” the school. Such strategies might include ensuring that children are not allowed “screen time” when home from school, and that their homework expectations continue. It should support healthy routines, including a regular sleep schedule and exercise. It should facilitate their being able to gradually manage any anxiety associated with school (shorter days initially, the option to have time-outs in a favorite part of the school or with a favorite teacher). A behavior plan should detail strategies for the child to manage stress (relaxation strategies, connecting with supportive individuals, even singing a favorite song). This plan can detail reasonable accommodations for a medical or psychiatric condition and appropriate rewards for regular attendance, such as being able to go on a class trip.

Through all of this, the pediatrician is in a uniquely authoritative position to provide support and reassurance to parents of a school refusing child. The pediatrician has a unique ability to clarify for parents the seriousness of the behavioral problem, even if there is no medical problem. Compassionately acknowledging how much a child is suffering (and the parents, as well) is powerful. Remind parents that accommodating anxiety only shows a child you don’t think they can master it, and often keeps them from trying. Express confidence that this is a relatively common and treatable phenomenon. If a pediatrician’s and parents’ efforts do not work quickly, in a matter of a few days, urgent referral to a mental health consultant is indicated, as falling behind in school and any acceptance of staying home makes return to school more difficult every day.

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.

As summer winds down, it is routine for children and adolescents to feel a little melancholy or even worried about the approaching start of school. But for some students, anxiety about school is more than routine; it is insurmountable. School refusal is a serious behavioral problem: without assertive management, it can become a pattern which is very difficult to alter. Whether a child is complaining of vague somatic concerns or is explicitly refusing to go to school, the pediatrician’s office is often the first place a parent will turn to for help. If you can recognize the true nature of the problem, help to determine its cause, and facilitate the needed management, you will have effectively treated what can become a disabling problem for vulnerable young people.

School refusal is happening when a child has major difficulty attending school, associated with intense emotional distress. It can be a refusal to attend school or difficulty remaining in school for an entire day. It is distinct (but not mutually exclusive) from truancy, which is a failure to attend school associated with antisocial behavior or other conduct problems. In the pediatrician’s office, school refusal sounds like, “He was moaning about a stomachache yesterday, I kept him home, but he had no fever and ate okay. Then it all repeated again this morning.” Or you might hear, “She was whining about a headache, but when I said she had to go to school, she started crying and couldn’t stop. She was hysterical!” In teenagers, there may be somatic complaints or just a sleepy, sulky refusal to get out of bed. Children with truancy might fake illness (as compared with feeling sick), or simply leave school. Truant children often want to be out of school doing other things, and may keep their whereabouts a secret from their parents. While it might seem like just one tough morning that can be shrugged off, true school refusal will continue or escalate unless it is properly managed.

School refusal affects approximately 5% of all children annually, affecting girls and boys in equal numbers and with peaks in incidence at the ages of 5 to 6 years and again at 10 to 11 years. Approximately half of children and teenagers with school refusal have a treatable psychiatric illness. In the Great Smoky Mountain Study of 2003, where more than 1,400 children were observed, they categorized children as being anxious school refusers, truant, or “mixed school refusers,” with features of both truancy and anxiety. In children with truancy or anxious school refusal, 25% had a psychiatric illness. In the mixed school refusers, they found 88% had at least one psychiatric diagnosis and 42% had somatic complaints. While pure truancy will require different management strategies from school and parents, those young people who display features of both anxiety and truancy around school attendance are most likely to be suffering from a psychiatric illness. Those illnesses most commonly associated with difficulty attending school include anxiety disorders (separation anxiety, social phobia, generalized anxiety disorder) and depression.

While psychiatric illness is a common factor, there is also always a behavioral component to school refusal. This simply means that children are either avoiding unpleasant feelings associated with school, such as anxiety, or escaping uncomfortable situations, such as bullying or the stress of performance. On the positive side, children may be refusing school because they are pursuing the attention of important people (parents, peers) or pursuing pleasurable activities (playing video games, surfing the web or hanging out in town). Beyond an internal anxiety disorder, some children may be facing bullying or threats at school or may have to walk through a dangerous neighborhood to get to school. Some children may be missing school because of significant stress or transitions at home, such as financial difficulties or divorce. Other children may be staying home to take care of younger siblings because of a parent’s medical illness or substance abuse problem. Children who are being abused may be kept home to prevent suspicion about bruises. Lastly, some children feel they have to stay home to be with a lonely or depressed parent. Gently asking about these very real concerns will help determine the necessary course of action.

Pediatricians can play a central role in the management of school refusal. Often, the most important step is helping parents to understand that there is not an insidious medical problem driving the morning stomachaches and headaches. It is critical to clarify that (usually) their child is not feigning illness, but that there is significant distress around school that has led to this behavioral problem. Even children who have a genuine medical problem also can have school refusal. Once parents understand that without proper management, this behavior will continue or worsen, they usually are ready to collaborate on effective management. Their child may need a thorough psychiatric evaluation to rule out a treatable underlying psychiatric diagnosis, particularly if they have both anxious and truant behaviors. Most of the psychiatric problems associated with school refusal will require therapy and some may require medications for effective treatment.

Successfully getting children back to school will require a behavior plan that is agreed upon by the parents and the school, and then used consistently. This plan will simply detail strategies to “demagnetize” the home and “remagnetize” the school. Such strategies might include ensuring that children are not allowed “screen time” when home from school, and that their homework expectations continue. It should support healthy routines, including a regular sleep schedule and exercise. It should facilitate their being able to gradually manage any anxiety associated with school (shorter days initially, the option to have time-outs in a favorite part of the school or with a favorite teacher). A behavior plan should detail strategies for the child to manage stress (relaxation strategies, connecting with supportive individuals, even singing a favorite song). This plan can detail reasonable accommodations for a medical or psychiatric condition and appropriate rewards for regular attendance, such as being able to go on a class trip.

Through all of this, the pediatrician is in a uniquely authoritative position to provide support and reassurance to parents of a school refusing child. The pediatrician has a unique ability to clarify for parents the seriousness of the behavioral problem, even if there is no medical problem. Compassionately acknowledging how much a child is suffering (and the parents, as well) is powerful. Remind parents that accommodating anxiety only shows a child you don’t think they can master it, and often keeps them from trying. Express confidence that this is a relatively common and treatable phenomenon. If a pediatrician’s and parents’ efforts do not work quickly, in a matter of a few days, urgent referral to a mental health consultant is indicated, as falling behind in school and any acceptance of staying home makes return to school more difficult every day.

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.

As summer winds down, it is routine for children and adolescents to feel a little melancholy or even worried about the approaching start of school. But for some students, anxiety about school is more than routine; it is insurmountable. School refusal is a serious behavioral problem: without assertive management, it can become a pattern which is very difficult to alter. Whether a child is complaining of vague somatic concerns or is explicitly refusing to go to school, the pediatrician’s office is often the first place a parent will turn to for help. If you can recognize the true nature of the problem, help to determine its cause, and facilitate the needed management, you will have effectively treated what can become a disabling problem for vulnerable young people.

School refusal is happening when a child has major difficulty attending school, associated with intense emotional distress. It can be a refusal to attend school or difficulty remaining in school for an entire day. It is distinct (but not mutually exclusive) from truancy, which is a failure to attend school associated with antisocial behavior or other conduct problems. In the pediatrician’s office, school refusal sounds like, “He was moaning about a stomachache yesterday, I kept him home, but he had no fever and ate okay. Then it all repeated again this morning.” Or you might hear, “She was whining about a headache, but when I said she had to go to school, she started crying and couldn’t stop. She was hysterical!” In teenagers, there may be somatic complaints or just a sleepy, sulky refusal to get out of bed. Children with truancy might fake illness (as compared with feeling sick), or simply leave school. Truant children often want to be out of school doing other things, and may keep their whereabouts a secret from their parents. While it might seem like just one tough morning that can be shrugged off, true school refusal will continue or escalate unless it is properly managed.

School refusal affects approximately 5% of all children annually, affecting girls and boys in equal numbers and with peaks in incidence at the ages of 5 to 6 years and again at 10 to 11 years. Approximately half of children and teenagers with school refusal have a treatable psychiatric illness. In the Great Smoky Mountain Study of 2003, where more than 1,400 children were observed, they categorized children as being anxious school refusers, truant, or “mixed school refusers,” with features of both truancy and anxiety. In children with truancy or anxious school refusal, 25% had a psychiatric illness. In the mixed school refusers, they found 88% had at least one psychiatric diagnosis and 42% had somatic complaints. While pure truancy will require different management strategies from school and parents, those young people who display features of both anxiety and truancy around school attendance are most likely to be suffering from a psychiatric illness. Those illnesses most commonly associated with difficulty attending school include anxiety disorders (separation anxiety, social phobia, generalized anxiety disorder) and depression.

While psychiatric illness is a common factor, there is also always a behavioral component to school refusal. This simply means that children are either avoiding unpleasant feelings associated with school, such as anxiety, or escaping uncomfortable situations, such as bullying or the stress of performance. On the positive side, children may be refusing school because they are pursuing the attention of important people (parents, peers) or pursuing pleasurable activities (playing video games, surfing the web or hanging out in town). Beyond an internal anxiety disorder, some children may be facing bullying or threats at school or may have to walk through a dangerous neighborhood to get to school. Some children may be missing school because of significant stress or transitions at home, such as financial difficulties or divorce. Other children may be staying home to take care of younger siblings because of a parent’s medical illness or substance abuse problem. Children who are being abused may be kept home to prevent suspicion about bruises. Lastly, some children feel they have to stay home to be with a lonely or depressed parent. Gently asking about these very real concerns will help determine the necessary course of action.

Pediatricians can play a central role in the management of school refusal. Often, the most important step is helping parents to understand that there is not an insidious medical problem driving the morning stomachaches and headaches. It is critical to clarify that (usually) their child is not feigning illness, but that there is significant distress around school that has led to this behavioral problem. Even children who have a genuine medical problem also can have school refusal. Once parents understand that without proper management, this behavior will continue or worsen, they usually are ready to collaborate on effective management. Their child may need a thorough psychiatric evaluation to rule out a treatable underlying psychiatric diagnosis, particularly if they have both anxious and truant behaviors. Most of the psychiatric problems associated with school refusal will require therapy and some may require medications for effective treatment.

Successfully getting children back to school will require a behavior plan that is agreed upon by the parents and the school, and then used consistently. This plan will simply detail strategies to “demagnetize” the home and “remagnetize” the school. Such strategies might include ensuring that children are not allowed “screen time” when home from school, and that their homework expectations continue. It should support healthy routines, including a regular sleep schedule and exercise. It should facilitate their being able to gradually manage any anxiety associated with school (shorter days initially, the option to have time-outs in a favorite part of the school or with a favorite teacher). A behavior plan should detail strategies for the child to manage stress (relaxation strategies, connecting with supportive individuals, even singing a favorite song). This plan can detail reasonable accommodations for a medical or psychiatric condition and appropriate rewards for regular attendance, such as being able to go on a class trip.

Through all of this, the pediatrician is in a uniquely authoritative position to provide support and reassurance to parents of a school refusing child. The pediatrician has a unique ability to clarify for parents the seriousness of the behavioral problem, even if there is no medical problem. Compassionately acknowledging how much a child is suffering (and the parents, as well) is powerful. Remind parents that accommodating anxiety only shows a child you don’t think they can master it, and often keeps them from trying. Express confidence that this is a relatively common and treatable phenomenon. If a pediatrician’s and parents’ efforts do not work quickly, in a matter of a few days, urgent referral to a mental health consultant is indicated, as falling behind in school and any acceptance of staying home makes return to school more difficult every day.

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.

It is important to step back occasionally to survey where one has been and to plot a new heading. In an online Aug. 10, 2016, release, the New England Journal of Medicine posted two opinion pieces that provide perspective on hospital medicine. As is often the case when journalism presents two opinions, the viewpoints represent opposite ends of a spectrum and the truth lies somewhere in between.

In one essay, Robert Wachter, MD, and Lee Goldman, MD, highlight the successful growth of hospital medicine (N Eng J Med. 2016, Aug 10. doi: 10.1056/NEJMp1607958). In just 2 decades, more than 50,000 physicians have changed their focus to the care of inpatients. The authors state that “many stars had to align” for hospital medicine to grow as rapidly as it has. I would argue instead that many talented leaders of the field have moved heaven and earth to create that alignment and birth this field.

In the other essay, Richard Gunderman, MD, focuses on what he sees as having been lost in this evolution (N Eng J Med. 2016, Aug 10. doi: 10.1056/NEJMp1608289). I believe Dr. Gunderman’s viewpoint nostalgically longs for the good old days and a model of an interpersonal doctor-patient relationship that never really existed for a large portion of the population. If you were wealthy, lived most of your life in one location, and had only intermittent or common diseases, then perhaps you had a trusted general internist to provide your medical care and provide the emotional reassurance that nourished both patient and doctor. But in modern medicine, that scenario is uncommon. With large group practices, there is only a small chance that your personal physician will be on call on the night of your admission to a hospital. The next day, as test results and specialty consults trickle in, that personal physician will be trapped in a busy outpatient clinic and not truly available at hospital bedside in “your moment of greatest need,” as Dr. Gunderman phrased it. When your personal physician finally does make rounds, s/he will find the hospital environment inefficient and repeating the same small mistakes that happened to his/her last patient.

I’ve been writing about and teaching professionalism for years. I agree with Dr. Gunderman about the importance of a doctor-patient relationship. I believe reducing physicians to being automatons in a hospital assembly line would be a bad idea. But this essay’s rose-colored and sienna-colored portrait of that relationship is not helpful guidance in the modern world. Surveyors and navigators need sharp, clear vision.

Trade-offs are being made. Many pediatricians in affluent communities do have the opportunity to establish long-term relationships with families, sometimes for multiple generations of children. Those relationships attract medical students into pediatrics and family medicine. I was fortunate enough to establish many of those relationships when I practiced outpatient pediatrics. During my last interstate move, the man packing the picture frames was amused to find amidst my many diplomas a framed crayon drawing. It was a gift to me from a young patient. I told the mover that I would be sadder to have that drawing damaged than if a diploma was damaged in the move. So he wrapped it with extra padding.

Those bonds established with families make up the emotional sustenance throughout a career that justifies the years of sacrifice spent becoming a physician. There is no doubt that it is easier to form those bonds in outpatient pediatrics. At a community hospital, with 7 days on/7 days off scheduling, I usually provide care for the entire hospitalization of a child. That provides emotional satisfaction for both the parents and for me as a physician in ways that 12-hour shifts usually don’t.

The diminishment of those relationships needs to be acknowledged, but not to the exclusion of what a hospitalist can provide. When I practiced general pediatrics and only admitted 1 or 2 children each week, I was often frustrated by inefficiency and errors in the hospital, but I had little recourse for changing it. As a hospitalist admitting 500 patients per year, I can perform problem solving and devote resources to continuously improve the quality and safety of inpatient care. I provide those improvements to all patients admitted to the hospital, whether they have a medical home or not. That fosters social justice. As a function-over-fashion person, that success is emotionally rewarding, too.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

It is important to step back occasionally to survey where one has been and to plot a new heading. In an online Aug. 10, 2016, release, the New England Journal of Medicine posted two opinion pieces that provide perspective on hospital medicine. As is often the case when journalism presents two opinions, the viewpoints represent opposite ends of a spectrum and the truth lies somewhere in between.

In one essay, Robert Wachter, MD, and Lee Goldman, MD, highlight the successful growth of hospital medicine (N Eng J Med. 2016, Aug 10. doi: 10.1056/NEJMp1607958). In just 2 decades, more than 50,000 physicians have changed their focus to the care of inpatients. The authors state that “many stars had to align” for hospital medicine to grow as rapidly as it has. I would argue instead that many talented leaders of the field have moved heaven and earth to create that alignment and birth this field.

In the other essay, Richard Gunderman, MD, focuses on what he sees as having been lost in this evolution (N Eng J Med. 2016, Aug 10. doi: 10.1056/NEJMp1608289). I believe Dr. Gunderman’s viewpoint nostalgically longs for the good old days and a model of an interpersonal doctor-patient relationship that never really existed for a large portion of the population. If you were wealthy, lived most of your life in one location, and had only intermittent or common diseases, then perhaps you had a trusted general internist to provide your medical care and provide the emotional reassurance that nourished both patient and doctor. But in modern medicine, that scenario is uncommon. With large group practices, there is only a small chance that your personal physician will be on call on the night of your admission to a hospital. The next day, as test results and specialty consults trickle in, that personal physician will be trapped in a busy outpatient clinic and not truly available at hospital bedside in “your moment of greatest need,” as Dr. Gunderman phrased it. When your personal physician finally does make rounds, s/he will find the hospital environment inefficient and repeating the same small mistakes that happened to his/her last patient.

I’ve been writing about and teaching professionalism for years. I agree with Dr. Gunderman about the importance of a doctor-patient relationship. I believe reducing physicians to being automatons in a hospital assembly line would be a bad idea. But this essay’s rose-colored and sienna-colored portrait of that relationship is not helpful guidance in the modern world. Surveyors and navigators need sharp, clear vision.

Trade-offs are being made. Many pediatricians in affluent communities do have the opportunity to establish long-term relationships with families, sometimes for multiple generations of children. Those relationships attract medical students into pediatrics and family medicine. I was fortunate enough to establish many of those relationships when I practiced outpatient pediatrics. During my last interstate move, the man packing the picture frames was amused to find amidst my many diplomas a framed crayon drawing. It was a gift to me from a young patient. I told the mover that I would be sadder to have that drawing damaged than if a diploma was damaged in the move. So he wrapped it with extra padding.

Those bonds established with families make up the emotional sustenance throughout a career that justifies the years of sacrifice spent becoming a physician. There is no doubt that it is easier to form those bonds in outpatient pediatrics. At a community hospital, with 7 days on/7 days off scheduling, I usually provide care for the entire hospitalization of a child. That provides emotional satisfaction for both the parents and for me as a physician in ways that 12-hour shifts usually don’t.

The diminishment of those relationships needs to be acknowledged, but not to the exclusion of what a hospitalist can provide. When I practiced general pediatrics and only admitted 1 or 2 children each week, I was often frustrated by inefficiency and errors in the hospital, but I had little recourse for changing it. As a hospitalist admitting 500 patients per year, I can perform problem solving and devote resources to continuously improve the quality and safety of inpatient care. I provide those improvements to all patients admitted to the hospital, whether they have a medical home or not. That fosters social justice. As a function-over-fashion person, that success is emotionally rewarding, too.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

It is important to step back occasionally to survey where one has been and to plot a new heading. In an online Aug. 10, 2016, release, the New England Journal of Medicine posted two opinion pieces that provide perspective on hospital medicine. As is often the case when journalism presents two opinions, the viewpoints represent opposite ends of a spectrum and the truth lies somewhere in between.

In one essay, Robert Wachter, MD, and Lee Goldman, MD, highlight the successful growth of hospital medicine (N Eng J Med. 2016, Aug 10. doi: 10.1056/NEJMp1607958). In just 2 decades, more than 50,000 physicians have changed their focus to the care of inpatients. The authors state that “many stars had to align” for hospital medicine to grow as rapidly as it has. I would argue instead that many talented leaders of the field have moved heaven and earth to create that alignment and birth this field.

In the other essay, Richard Gunderman, MD, focuses on what he sees as having been lost in this evolution (N Eng J Med. 2016, Aug 10. doi: 10.1056/NEJMp1608289). I believe Dr. Gunderman’s viewpoint nostalgically longs for the good old days and a model of an interpersonal doctor-patient relationship that never really existed for a large portion of the population. If you were wealthy, lived most of your life in one location, and had only intermittent or common diseases, then perhaps you had a trusted general internist to provide your medical care and provide the emotional reassurance that nourished both patient and doctor. But in modern medicine, that scenario is uncommon. With large group practices, there is only a small chance that your personal physician will be on call on the night of your admission to a hospital. The next day, as test results and specialty consults trickle in, that personal physician will be trapped in a busy outpatient clinic and not truly available at hospital bedside in “your moment of greatest need,” as Dr. Gunderman phrased it. When your personal physician finally does make rounds, s/he will find the hospital environment inefficient and repeating the same small mistakes that happened to his/her last patient.

I’ve been writing about and teaching professionalism for years. I agree with Dr. Gunderman about the importance of a doctor-patient relationship. I believe reducing physicians to being automatons in a hospital assembly line would be a bad idea. But this essay’s rose-colored and sienna-colored portrait of that relationship is not helpful guidance in the modern world. Surveyors and navigators need sharp, clear vision.

Trade-offs are being made. Many pediatricians in affluent communities do have the opportunity to establish long-term relationships with families, sometimes for multiple generations of children. Those relationships attract medical students into pediatrics and family medicine. I was fortunate enough to establish many of those relationships when I practiced outpatient pediatrics. During my last interstate move, the man packing the picture frames was amused to find amidst my many diplomas a framed crayon drawing. It was a gift to me from a young patient. I told the mover that I would be sadder to have that drawing damaged than if a diploma was damaged in the move. So he wrapped it with extra padding.

Those bonds established with families make up the emotional sustenance throughout a career that justifies the years of sacrifice spent becoming a physician. There is no doubt that it is easier to form those bonds in outpatient pediatrics. At a community hospital, with 7 days on/7 days off scheduling, I usually provide care for the entire hospitalization of a child. That provides emotional satisfaction for both the parents and for me as a physician in ways that 12-hour shifts usually don’t.

The diminishment of those relationships needs to be acknowledged, but not to the exclusion of what a hospitalist can provide. When I practiced general pediatrics and only admitted 1 or 2 children each week, I was often frustrated by inefficiency and errors in the hospital, but I had little recourse for changing it. As a hospitalist admitting 500 patients per year, I can perform problem solving and devote resources to continuously improve the quality and safety of inpatient care. I provide those improvements to all patients admitted to the hospital, whether they have a medical home or not. That fosters social justice. As a function-over-fashion person, that success is emotionally rewarding, too.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

At the summer meetings of the American Academy of Dermatology, AAD President Abel Torres screened a video of members responding to the question, “What keeps you up at night?” A recurring refrain in many of their responses was, “loss of autonomy.”

Many physicians feel they are losing autonomy. No doubt they are right. But physicians are not alone in their loss.

A young academic friend of mine had a similar lament. “Some assistant dean sent me an email ordering me to grade my students in a way that made no sense,” he said. “I challenged him to explain why. He answered that my school was following the guidelines of some organization I’d never heard of.”

“Academics used to be autonomous,” he said. “No more.”

Another professor friend decided to retire. “Forty years in the department,” he said, “10 as chair. Now a junior administrator tells me that I have to spend more hours on campus, even though I don’t have anything useful to do when I’m there. She said there are new rules for more academic efficiency.”

New administrators. Guidelines. Efficiency. Experienced hands dropping out or retiring out of frustration. Any of these sound familiar?

Teachers also complain to me about their loss of autonomy. “I used to be able to use judgment,” said one. “I knew what worked for a specific student. Now I just teach to the standardized test.

“For every one of my 23 kindergartners, I spent 1 hour filling out an iPad questionnaire on reading readiness. I’ve had it.”

“What will you do instead?” I asked him.

“Something with dogs,” he said.

And so it goes. Accountants and attorneys complain about heavy reporting regulations, with new ones added each year. Judges in Wisconsin make sentencing decisions using proprietary algorithms that no one outside the company that sells the algorithms has validated. Financial advisers have clients sign boilerplate statements documenting that they accept a certain level of risk. These clients may or may not understand what “level of risk” really implies, but either way they must sign a form, and the form must be filed. If you didn’t document it, you didn’t do it. If you documented it, you did it, even though you may not have really done anything meaningful.

An internist told me how things are in her new dispensation.

“They allow 15 minutes for a physical,” she said, “which is not enough anyway. But I also have to check off boxes for the EMR that add nothing to patient care. Last year we had to start asking about gender status. ‘What was your gender assignment at birth?’ ‘What is it now?’ We have to ask that every year – and click the box that says we did it.

“Several docs in our group retired. Another bunch went concierge. They couldn’t deal with it anymore.”

Metrics. Algorithms. Higher authorities who tell professionals what to do, how to do it, how to record it, business quants with scant understanding of what professionals actually profess. All so familiar and tiresome. It’s everywhere, and it’s bigger than any of us.

Loss of autonomy by professionals across the board reflects a changed understanding by society at large of what quality service is and how it should be judged. Numbers are in. Personal judgment – in our case, clinical judgment – is out. Since judgment can’t be measured, it cannot be trusted.

To a certain extent, autonomy is an illusion. We can do what we want as long as powers larger than we are – natural, social, political – let us do it. Those powers may lie dormant for a while, but they’re always there, and always have been. When they wake up and change the rules of the game, everyone has to adapt. New burdens in the practice of medicine are just one instance of a much broader trend.

Our professional organizations know this well. They are hard at work giving the authorities, government, and insurance administrators what they demand: data showing that what we do is useful, in the quantitative terms the authorities will accept.

To the extent that they succeed, we will be able to do some of what we want to do. Young people entering the medical field will expect nothing more. Some of their older colleagues will be satisfied that they are autonomous enough. The rest will have to find something else to do.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years.

At the summer meetings of the American Academy of Dermatology, AAD President Abel Torres screened a video of members responding to the question, “What keeps you up at night?” A recurring refrain in many of their responses was, “loss of autonomy.”

Many physicians feel they are losing autonomy. No doubt they are right. But physicians are not alone in their loss.

A young academic friend of mine had a similar lament. “Some assistant dean sent me an email ordering me to grade my students in a way that made no sense,” he said. “I challenged him to explain why. He answered that my school was following the guidelines of some organization I’d never heard of.”

“Academics used to be autonomous,” he said. “No more.”

Another professor friend decided to retire. “Forty years in the department,” he said, “10 as chair. Now a junior administrator tells me that I have to spend more hours on campus, even though I don’t have anything useful to do when I’m there. She said there are new rules for more academic efficiency.”

New administrators. Guidelines. Efficiency. Experienced hands dropping out or retiring out of frustration. Any of these sound familiar?

Teachers also complain to me about their loss of autonomy. “I used to be able to use judgment,” said one. “I knew what worked for a specific student. Now I just teach to the standardized test.

“For every one of my 23 kindergartners, I spent 1 hour filling out an iPad questionnaire on reading readiness. I’ve had it.”

“What will you do instead?” I asked him.

“Something with dogs,” he said.

And so it goes. Accountants and attorneys complain about heavy reporting regulations, with new ones added each year. Judges in Wisconsin make sentencing decisions using proprietary algorithms that no one outside the company that sells the algorithms has validated. Financial advisers have clients sign boilerplate statements documenting that they accept a certain level of risk. These clients may or may not understand what “level of risk” really implies, but either way they must sign a form, and the form must be filed. If you didn’t document it, you didn’t do it. If you documented it, you did it, even though you may not have really done anything meaningful.

An internist told me how things are in her new dispensation.

“They allow 15 minutes for a physical,” she said, “which is not enough anyway. But I also have to check off boxes for the EMR that add nothing to patient care. Last year we had to start asking about gender status. ‘What was your gender assignment at birth?’ ‘What is it now?’ We have to ask that every year – and click the box that says we did it.

“Several docs in our group retired. Another bunch went concierge. They couldn’t deal with it anymore.”

Metrics. Algorithms. Higher authorities who tell professionals what to do, how to do it, how to record it, business quants with scant understanding of what professionals actually profess. All so familiar and tiresome. It’s everywhere, and it’s bigger than any of us.

Loss of autonomy by professionals across the board reflects a changed understanding by society at large of what quality service is and how it should be judged. Numbers are in. Personal judgment – in our case, clinical judgment – is out. Since judgment can’t be measured, it cannot be trusted.

To a certain extent, autonomy is an illusion. We can do what we want as long as powers larger than we are – natural, social, political – let us do it. Those powers may lie dormant for a while, but they’re always there, and always have been. When they wake up and change the rules of the game, everyone has to adapt. New burdens in the practice of medicine are just one instance of a much broader trend.

Our professional organizations know this well. They are hard at work giving the authorities, government, and insurance administrators what they demand: data showing that what we do is useful, in the quantitative terms the authorities will accept.

To the extent that they succeed, we will be able to do some of what we want to do. Young people entering the medical field will expect nothing more. Some of their older colleagues will be satisfied that they are autonomous enough. The rest will have to find something else to do.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years.

At the summer meetings of the American Academy of Dermatology, AAD President Abel Torres screened a video of members responding to the question, “What keeps you up at night?” A recurring refrain in many of their responses was, “loss of autonomy.”

Many physicians feel they are losing autonomy. No doubt they are right. But physicians are not alone in their loss.

A young academic friend of mine had a similar lament. “Some assistant dean sent me an email ordering me to grade my students in a way that made no sense,” he said. “I challenged him to explain why. He answered that my school was following the guidelines of some organization I’d never heard of.”

“Academics used to be autonomous,” he said. “No more.”

Another professor friend decided to retire. “Forty years in the department,” he said, “10 as chair. Now a junior administrator tells me that I have to spend more hours on campus, even though I don’t have anything useful to do when I’m there. She said there are new rules for more academic efficiency.”

New administrators. Guidelines. Efficiency. Experienced hands dropping out or retiring out of frustration. Any of these sound familiar?

Teachers also complain to me about their loss of autonomy. “I used to be able to use judgment,” said one. “I knew what worked for a specific student. Now I just teach to the standardized test.

“For every one of my 23 kindergartners, I spent 1 hour filling out an iPad questionnaire on reading readiness. I’ve had it.”

“What will you do instead?” I asked him.

“Something with dogs,” he said.

And so it goes. Accountants and attorneys complain about heavy reporting regulations, with new ones added each year. Judges in Wisconsin make sentencing decisions using proprietary algorithms that no one outside the company that sells the algorithms has validated. Financial advisers have clients sign boilerplate statements documenting that they accept a certain level of risk. These clients may or may not understand what “level of risk” really implies, but either way they must sign a form, and the form must be filed. If you didn’t document it, you didn’t do it. If you documented it, you did it, even though you may not have really done anything meaningful.

An internist told me how things are in her new dispensation.

“They allow 15 minutes for a physical,” she said, “which is not enough anyway. But I also have to check off boxes for the EMR that add nothing to patient care. Last year we had to start asking about gender status. ‘What was your gender assignment at birth?’ ‘What is it now?’ We have to ask that every year – and click the box that says we did it.

“Several docs in our group retired. Another bunch went concierge. They couldn’t deal with it anymore.”

Metrics. Algorithms. Higher authorities who tell professionals what to do, how to do it, how to record it, business quants with scant understanding of what professionals actually profess. All so familiar and tiresome. It’s everywhere, and it’s bigger than any of us.

Loss of autonomy by professionals across the board reflects a changed understanding by society at large of what quality service is and how it should be judged. Numbers are in. Personal judgment – in our case, clinical judgment – is out. Since judgment can’t be measured, it cannot be trusted.

To a certain extent, autonomy is an illusion. We can do what we want as long as powers larger than we are – natural, social, political – let us do it. Those powers may lie dormant for a while, but they’re always there, and always have been. When they wake up and change the rules of the game, everyone has to adapt. New burdens in the practice of medicine are just one instance of a much broader trend.

Our professional organizations know this well. They are hard at work giving the authorities, government, and insurance administrators what they demand: data showing that what we do is useful, in the quantitative terms the authorities will accept.

To the extent that they succeed, we will be able to do some of what we want to do. Young people entering the medical field will expect nothing more. Some of their older colleagues will be satisfied that they are autonomous enough. The rest will have to find something else to do.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years.

Current treatment strategies for chronic hepatitis B virus (HBV) infection seek to suppress viral replication by blocking HBV reverse transcription. When circulating HBV viremia is suppressed, clinical outcomes improve, with slowing of fibrosis and reduced rates of hepatocellular carcinoma. However, when treatment is discontinued, viral replication typically rebounds. This is because nucleos(t)ide (NUC) therapy has no effect on existing HBV cccDNA (covalently closed circular DNA) reservoirs.

A functional cure is defined as the absence of HBV DNA and hepatitis B surface antigen (HBsAg), in the absence of antiviral therapy, with or without the development of protective hepatitis B surface antibody (HBsAb). However, rates of viral clearance are extremely low after therapy with IFN and NUC analogs. Strategies to control HBV replication, purge covalently closed circular DNA (cccDNA) reservoirs, and develop long-lasting protective immunity in patients with chronic HBV infection are desperately needed to achieve a functional cure.

Current investigational approaches to curing HBV fall into two different strategies: targeting the virus directly or manipulating the host immune response to aid in clearance.

Targeting the virus

One of the challenges of treating HBV is the stability of HBV DNA inside infected hepatocytes; supercoiled and sequestered in the host cell nucleus, HBV cccDNA is protected from cellular DNA-sensing machinery. Hepatocytes infected with HBV have a long half-life, serving as a reservoir for HBV reactivation. In addition to preventing, inactivating, or disrupting cccDNA, investigational approaches to target the virus also focus on blocking specific steps in viral replication, including viral transcription, entry into uninfected hepatocytes, capsid assembly, and antigen secretion.

Gene therapy approaches, including zinc finger nucleases (ZFNs), transcription activator-like effector nucleases (TALENs), clustered regularly interspaced palindromic repeat (CRISP-R) applications, and RNA interference (RNAi) technology may be able to inactivate target cccDNA, silencing or disrupting this viral reservoir.

Various investigational drugs are being studied for their ability to interfere with viral entry, encapsidation, or antigen release. Specific interactions between viral membrane proteins and cellular receptors are attractive targets for blocking HBV entry into host cells. Agents that interfere with assembly of the virus particle may prevent the production of infectious virus. Some innovative therapeutic strategies also seek to block the secretion of HBsAg; chronic exposure to HBsAg can lead to T-cell exhaustion, so this strategy may allow the host to develop a more effective anti-HBV adaptive immune response.

Manipulating host response

The second major strategy of novel HBV therapies involves mediating the host response, reversing immune exhaustion, selectively activating innate and/or adaptive immunity through therapeutic vaccination or passive transfer in order to produce a more effective response that results in viral clearance.

The innate immune response, the first line of defense against viral infections, is activated when toll-like receptors (TLRs) on the surface of innate immune cells are engaged, but TLR signaling is downregulated in chronic HBV infection. Stimulating innate immune cells by activating TLRs may accelerate HBV-specific immune reconstitution and help clear HBV in chronically infected individuals. Likewise, blocking the interaction of PD-1 with its ligands (PD-L1/2) may improve the antiviral function of exhausted T cells.

Reversing immune exhaustion will not work if there are no HBV-specific T cells present. Studies have pointed to the clonal deletion of HBV-specific CD8+ T cells as a mechanism of HBV persistence. T-cell responses may be “trained” to recognize infected cells by expressing HBV-specific chimeric antigen receptors (CARs), which are synthetic engineered receptors that can engage cell-surface molecules.

Therapeutic vaccination additionally presents a promising strategy to address HBV-specific T-cell exhaustion by inducing a potent CD4 T-cell response and counteracting immune tolerance against HBV antigens. Yeast-based vaccines, adenovirus vector and engineered vesicular stomatitis virus vectors have shown to be promising platforms that may be capable of eliciting a functional adaptive immune response in patients with chronic HBV, but their use is often limited by preexisting host immunity.

In summary, current therapies for HBV rarely clear or cure infection. A two-pronged approach of targeting viral and host factors may offer the best chance to reverse the immune tolerance, T-cell exhaustion, and persistent viral reservoir associated with chronic HBV infection.

Rebecca Lee is a second-year medical student at the University of Maryland School of Medicine. Eleanor Wilson, MD, is assistant professor in the Institute of Human Virology at the University of Maryland School of Medicine. Shyam Kottilil, MBBS, PhD, is professor of medicine in the Institute of Human Virology at the University of Maryland School of Medicine.

Current treatment strategies for chronic hepatitis B virus (HBV) infection seek to suppress viral replication by blocking HBV reverse transcription. When circulating HBV viremia is suppressed, clinical outcomes improve, with slowing of fibrosis and reduced rates of hepatocellular carcinoma. However, when treatment is discontinued, viral replication typically rebounds. This is because nucleos(t)ide (NUC) therapy has no effect on existing HBV cccDNA (covalently closed circular DNA) reservoirs.

A functional cure is defined as the absence of HBV DNA and hepatitis B surface antigen (HBsAg), in the absence of antiviral therapy, with or without the development of protective hepatitis B surface antibody (HBsAb). However, rates of viral clearance are extremely low after therapy with IFN and NUC analogs. Strategies to control HBV replication, purge covalently closed circular DNA (cccDNA) reservoirs, and develop long-lasting protective immunity in patients with chronic HBV infection are desperately needed to achieve a functional cure.

Current investigational approaches to curing HBV fall into two different strategies: targeting the virus directly or manipulating the host immune response to aid in clearance.

Targeting the virus

One of the challenges of treating HBV is the stability of HBV DNA inside infected hepatocytes; supercoiled and sequestered in the host cell nucleus, HBV cccDNA is protected from cellular DNA-sensing machinery. Hepatocytes infected with HBV have a long half-life, serving as a reservoir for HBV reactivation. In addition to preventing, inactivating, or disrupting cccDNA, investigational approaches to target the virus also focus on blocking specific steps in viral replication, including viral transcription, entry into uninfected hepatocytes, capsid assembly, and antigen secretion.

Gene therapy approaches, including zinc finger nucleases (ZFNs), transcription activator-like effector nucleases (TALENs), clustered regularly interspaced palindromic repeat (CRISP-R) applications, and RNA interference (RNAi) technology may be able to inactivate target cccDNA, silencing or disrupting this viral reservoir.

Various investigational drugs are being studied for their ability to interfere with viral entry, encapsidation, or antigen release. Specific interactions between viral membrane proteins and cellular receptors are attractive targets for blocking HBV entry into host cells. Agents that interfere with assembly of the virus particle may prevent the production of infectious virus. Some innovative therapeutic strategies also seek to block the secretion of HBsAg; chronic exposure to HBsAg can lead to T-cell exhaustion, so this strategy may allow the host to develop a more effective anti-HBV adaptive immune response.

Manipulating host response

The second major strategy of novel HBV therapies involves mediating the host response, reversing immune exhaustion, selectively activating innate and/or adaptive immunity through therapeutic vaccination or passive transfer in order to produce a more effective response that results in viral clearance.

The innate immune response, the first line of defense against viral infections, is activated when toll-like receptors (TLRs) on the surface of innate immune cells are engaged, but TLR signaling is downregulated in chronic HBV infection. Stimulating innate immune cells by activating TLRs may accelerate HBV-specific immune reconstitution and help clear HBV in chronically infected individuals. Likewise, blocking the interaction of PD-1 with its ligands (PD-L1/2) may improve the antiviral function of exhausted T cells.

Reversing immune exhaustion will not work if there are no HBV-specific T cells present. Studies have pointed to the clonal deletion of HBV-specific CD8+ T cells as a mechanism of HBV persistence. T-cell responses may be “trained” to recognize infected cells by expressing HBV-specific chimeric antigen receptors (CARs), which are synthetic engineered receptors that can engage cell-surface molecules.

Therapeutic vaccination additionally presents a promising strategy to address HBV-specific T-cell exhaustion by inducing a potent CD4 T-cell response and counteracting immune tolerance against HBV antigens. Yeast-based vaccines, adenovirus vector and engineered vesicular stomatitis virus vectors have shown to be promising platforms that may be capable of eliciting a functional adaptive immune response in patients with chronic HBV, but their use is often limited by preexisting host immunity.

In summary, current therapies for HBV rarely clear or cure infection. A two-pronged approach of targeting viral and host factors may offer the best chance to reverse the immune tolerance, T-cell exhaustion, and persistent viral reservoir associated with chronic HBV infection.

Rebecca Lee is a second-year medical student at the University of Maryland School of Medicine. Eleanor Wilson, MD, is assistant professor in the Institute of Human Virology at the University of Maryland School of Medicine. Shyam Kottilil, MBBS, PhD, is professor of medicine in the Institute of Human Virology at the University of Maryland School of Medicine.

Current treatment strategies for chronic hepatitis B virus (HBV) infection seek to suppress viral replication by blocking HBV reverse transcription. When circulating HBV viremia is suppressed, clinical outcomes improve, with slowing of fibrosis and reduced rates of hepatocellular carcinoma. However, when treatment is discontinued, viral replication typically rebounds. This is because nucleos(t)ide (NUC) therapy has no effect on existing HBV cccDNA (covalently closed circular DNA) reservoirs.

A functional cure is defined as the absence of HBV DNA and hepatitis B surface antigen (HBsAg), in the absence of antiviral therapy, with or without the development of protective hepatitis B surface antibody (HBsAb). However, rates of viral clearance are extremely low after therapy with IFN and NUC analogs. Strategies to control HBV replication, purge covalently closed circular DNA (cccDNA) reservoirs, and develop long-lasting protective immunity in patients with chronic HBV infection are desperately needed to achieve a functional cure.

Current investigational approaches to curing HBV fall into two different strategies: targeting the virus directly or manipulating the host immune response to aid in clearance.

Targeting the virus

One of the challenges of treating HBV is the stability of HBV DNA inside infected hepatocytes; supercoiled and sequestered in the host cell nucleus, HBV cccDNA is protected from cellular DNA-sensing machinery. Hepatocytes infected with HBV have a long half-life, serving as a reservoir for HBV reactivation. In addition to preventing, inactivating, or disrupting cccDNA, investigational approaches to target the virus also focus on blocking specific steps in viral replication, including viral transcription, entry into uninfected hepatocytes, capsid assembly, and antigen secretion.

Gene therapy approaches, including zinc finger nucleases (ZFNs), transcription activator-like effector nucleases (TALENs), clustered regularly interspaced palindromic repeat (CRISP-R) applications, and RNA interference (RNAi) technology may be able to inactivate target cccDNA, silencing or disrupting this viral reservoir.

Various investigational drugs are being studied for their ability to interfere with viral entry, encapsidation, or antigen release. Specific interactions between viral membrane proteins and cellular receptors are attractive targets for blocking HBV entry into host cells. Agents that interfere with assembly of the virus particle may prevent the production of infectious virus. Some innovative therapeutic strategies also seek to block the secretion of HBsAg; chronic exposure to HBsAg can lead to T-cell exhaustion, so this strategy may allow the host to develop a more effective anti-HBV adaptive immune response.

Manipulating host response

The second major strategy of novel HBV therapies involves mediating the host response, reversing immune exhaustion, selectively activating innate and/or adaptive immunity through therapeutic vaccination or passive transfer in order to produce a more effective response that results in viral clearance.

The innate immune response, the first line of defense against viral infections, is activated when toll-like receptors (TLRs) on the surface of innate immune cells are engaged, but TLR signaling is downregulated in chronic HBV infection. Stimulating innate immune cells by activating TLRs may accelerate HBV-specific immune reconstitution and help clear HBV in chronically infected individuals. Likewise, blocking the interaction of PD-1 with its ligands (PD-L1/2) may improve the antiviral function of exhausted T cells.

Reversing immune exhaustion will not work if there are no HBV-specific T cells present. Studies have pointed to the clonal deletion of HBV-specific CD8+ T cells as a mechanism of HBV persistence. T-cell responses may be “trained” to recognize infected cells by expressing HBV-specific chimeric antigen receptors (CARs), which are synthetic engineered receptors that can engage cell-surface molecules.

Therapeutic vaccination additionally presents a promising strategy to address HBV-specific T-cell exhaustion by inducing a potent CD4 T-cell response and counteracting immune tolerance against HBV antigens. Yeast-based vaccines, adenovirus vector and engineered vesicular stomatitis virus vectors have shown to be promising platforms that may be capable of eliciting a functional adaptive immune response in patients with chronic HBV, but their use is often limited by preexisting host immunity.

In summary, current therapies for HBV rarely clear or cure infection. A two-pronged approach of targeting viral and host factors may offer the best chance to reverse the immune tolerance, T-cell exhaustion, and persistent viral reservoir associated with chronic HBV infection.

Rebecca Lee is a second-year medical student at the University of Maryland School of Medicine. Eleanor Wilson, MD, is assistant professor in the Institute of Human Virology at the University of Maryland School of Medicine. Shyam Kottilil, MBBS, PhD, is professor of medicine in the Institute of Human Virology at the University of Maryland School of Medicine.

The importance of postpartum depression, both in terms of its prevalence and the need for appropriate screening and effective treatments, has become an increasingly important area of focus for clinicians, patients, and policymakers. This derives from more than a decade of data on the significant prevalence of the condition, with roughly 10% of women meeting the criteria for major or minor depression during the first 3-6 months post partum.

Over the last 5 years, interest has centered around establishing mechanisms for appropriate perinatal depression screening, most notably the January 2016 recommendation from the U.S. Preventive Services Task Force that all adults should be screened for depression, including the at-risk populations of pregnant and postpartum women. In 2015, the American College of Obstetricians and Gynecologists endorsed screening women for depression and anxiety symptoms at least once during the perinatal period using a validated tool. Unfortunately, we still lack data to support whether screening is effective in getting patients referred for treatment and if it leads to women accessing therapies that will actually get them well.

As we wait for that data and consider ways to best implement enhanced screening, it’s important to take stock of the available treatments for postpartum depression.

Seeking a rapid treatment

The current literature supports efficacy for nonpharmacologic therapies, such as interpersonal psychotherapy and cognitive-behavioral therapy, as well as several antidepressants. The efficacy of antidepressants – such as selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors – has been demonstrated for postpartum depression, but these agents carry the typical limitations and concerns in terms of side effects and the amount of time required to ascertain if there is benefit. While these are the same challenges seen in treating depression in general, the time to response – often 4-8 weeks – is particularly problematic for postpartum women where the impact of depression on maternal morbidity and child development is so critical.

The field has been clamoring for agents that work more quickly. One possibility in that area is ketamine, which is being studied as a rapid treatment in major depression. The National Institutes of Health also has an initiative underway called RAPID (Rapidly Acting Treatments for Treatment-Resistant Depression), aimed at identifying and testing pharmacologic and nonpharmacologic treatments that produce a response within days rather than weeks.

Recently, considerable interest has focused on SAGE-547, manufactured by Sage Therapeutics, which is a different type of antidepressant. The so-called neurosteriod is an allosteric modulator of the GABA_A (gamma-aminobutyric acid type A) receptors. The product was granted fast-track status by the Food and Drug Administration to speed its development as a possible treatment for superrefractory status epilepticus, but it also is being studied for its potential in treating severe postpartum depression.

Approximately a year ago, there was preliminary evidence from an open-label study suggesting rapid response to SAGE-547 for women who received this medicine intravenously in a controlled hospital environment. And in July 2016, the manufacturer announced in a press release unpublished positive results from a small phase II controlled trial of SAGE-547 for the treatment of severe postpartum depression.

Specifically, this was a placebo-controlled, double-blind randomized trial for 21 women who had severe depressive symptoms with a baseline score of at least 26 on the Hamilton Rating Scale for Depression (HAM-D). For some of the women, postpartum depression was not of new onset, but rather was an extension of depression that had manifested no earlier than the third trimester of pregnancy. A total of 10 women received the drug, while 11 received placebo. Both groups received continuous intravenous infusion over a 60-hour period.

Consistent with the earlier report, participants receiving the active agent had a statistically significant reduction in HAM-D scores at 24 hours, compared with women who received the placebo. Seven out of 10 women who received the active drug achieved remission from depression at 60 hours, compared with only 1 of the 11 patients who received placebo. Even though the results derived from an extremely small sample, the signal for efficacy appears promising.

Of particular interest, there appeared to be a duration of benefit at 30 days’ follow-up. The medicine was well tolerated with no discontinuations due to adverse events, which were most commonly dizziness, sedation, or somnolence. The adverse events were about the same in both the drug and placebo groups.

Next steps

These early results have generated excitement, if not a “buzz,” in the field, given the rapid onset of antidepressant benefit and the apparent duration of the effect. But readers should be mindful that to date, the findings have not been peer reviewed and are available only through a company-issued press release. It is also noteworthy that on clinicaltrials.gov, the projected enrollment was 32, but 21 women enrolled. This may speak to the great difficulty in enrolling the sample and may ultimately reflect on the generalizability of the findings.

One significant challenge with SAGE-547 is the formulation. It’s hardly feasible for severely ill postpartum women to come to the hospital for 60 hours of treatment. The manufacturer will have to produce a reformulated compound that is able to sustain the efficacy signaled in this proof of concept study.

But even more importantly, we will need to see how the drug performs in a larger, rigorous phase IIB or phase III study to know if the signal of promise really translates into a potential viable treatment option for women with severe postpartum depression. When we have results from a randomized controlled trial with a substantially larger number of patients, then we’ll know whether the excitement is justified. It would be a significant advance for the field if this were to be the case.

The field of depression, in general, has been seeking an effective, rapid treatment for some time, and the role of neurosteriods has been spoken about for more than 2 decades. If postpartum women are in fact a subgroup who respond to this class of agents, then that would be an example of truly personalized medicine. But we won’t know that until the manufacturer does an appropriate large trial, which could take 2-4 years.

Dr. Cohen is the director of the Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information and resources and conducts clinical care and research in reproductive mental health. He has no financial relationship with SAGE Therapeutics, but he has been a consultant to manufacturers of psychiatric medications.

The importance of postpartum depression, both in terms of its prevalence and the need for appropriate screening and effective treatments, has become an increasingly important area of focus for clinicians, patients, and policymakers. This derives from more than a decade of data on the significant prevalence of the condition, with roughly 10% of women meeting the criteria for major or minor depression during the first 3-6 months post partum.

Over the last 5 years, interest has centered around establishing mechanisms for appropriate perinatal depression screening, most notably the January 2016 recommendation from the U.S. Preventive Services Task Force that all adults should be screened for depression, including the at-risk populations of pregnant and postpartum women. In 2015, the American College of Obstetricians and Gynecologists endorsed screening women for depression and anxiety symptoms at least once during the perinatal period using a validated tool. Unfortunately, we still lack data to support whether screening is effective in getting patients referred for treatment and if it leads to women accessing therapies that will actually get them well.

As we wait for that data and consider ways to best implement enhanced screening, it’s important to take stock of the available treatments for postpartum depression.

Seeking a rapid treatment

The current literature supports efficacy for nonpharmacologic therapies, such as interpersonal psychotherapy and cognitive-behavioral therapy, as well as several antidepressants. The efficacy of antidepressants – such as selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors – has been demonstrated for postpartum depression, but these agents carry the typical limitations and concerns in terms of side effects and the amount of time required to ascertain if there is benefit. While these are the same challenges seen in treating depression in general, the time to response – often 4-8 weeks – is particularly problematic for postpartum women where the impact of depression on maternal morbidity and child development is so critical.

The field has been clamoring for agents that work more quickly. One possibility in that area is ketamine, which is being studied as a rapid treatment in major depression. The National Institutes of Health also has an initiative underway called RAPID (Rapidly Acting Treatments for Treatment-Resistant Depression), aimed at identifying and testing pharmacologic and nonpharmacologic treatments that produce a response within days rather than weeks.

Recently, considerable interest has focused on SAGE-547, manufactured by Sage Therapeutics, which is a different type of antidepressant. The so-called neurosteriod is an allosteric modulator of the GABA_A (gamma-aminobutyric acid type A) receptors. The product was granted fast-track status by the Food and Drug Administration to speed its development as a possible treatment for superrefractory status epilepticus, but it also is being studied for its potential in treating severe postpartum depression.

Approximately a year ago, there was preliminary evidence from an open-label study suggesting rapid response to SAGE-547 for women who received this medicine intravenously in a controlled hospital environment. And in July 2016, the manufacturer announced in a press release unpublished positive results from a small phase II controlled trial of SAGE-547 for the treatment of severe postpartum depression.

Specifically, this was a placebo-controlled, double-blind randomized trial for 21 women who had severe depressive symptoms with a baseline score of at least 26 on the Hamilton Rating Scale for Depression (HAM-D). For some of the women, postpartum depression was not of new onset, but rather was an extension of depression that had manifested no earlier than the third trimester of pregnancy. A total of 10 women received the drug, while 11 received placebo. Both groups received continuous intravenous infusion over a 60-hour period.

Consistent with the earlier report, participants receiving the active agent had a statistically significant reduction in HAM-D scores at 24 hours, compared with women who received the placebo. Seven out of 10 women who received the active drug achieved remission from depression at 60 hours, compared with only 1 of the 11 patients who received placebo. Even though the results derived from an extremely small sample, the signal for efficacy appears promising.

Of particular interest, there appeared to be a duration of benefit at 30 days’ follow-up. The medicine was well tolerated with no discontinuations due to adverse events, which were most commonly dizziness, sedation, or somnolence. The adverse events were about the same in both the drug and placebo groups.

Next steps

These early results have generated excitement, if not a “buzz,” in the field, given the rapid onset of antidepressant benefit and the apparent duration of the effect. But readers should be mindful that to date, the findings have not been peer reviewed and are available only through a company-issued press release. It is also noteworthy that on clinicaltrials.gov, the projected enrollment was 32, but 21 women enrolled. This may speak to the great difficulty in enrolling the sample and may ultimately reflect on the generalizability of the findings.

One significant challenge with SAGE-547 is the formulation. It’s hardly feasible for severely ill postpartum women to come to the hospital for 60 hours of treatment. The manufacturer will have to produce a reformulated compound that is able to sustain the efficacy signaled in this proof of concept study.

But even more importantly, we will need to see how the drug performs in a larger, rigorous phase IIB or phase III study to know if the signal of promise really translates into a potential viable treatment option for women with severe postpartum depression. When we have results from a randomized controlled trial with a substantially larger number of patients, then we’ll know whether the excitement is justified. It would be a significant advance for the field if this were to be the case.

The field of depression, in general, has been seeking an effective, rapid treatment for some time, and the role of neurosteriods has been spoken about for more than 2 decades. If postpartum women are in fact a subgroup who respond to this class of agents, then that would be an example of truly personalized medicine. But we won’t know that until the manufacturer does an appropriate large trial, which could take 2-4 years.

Dr. Cohen is the director of the Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information and resources and conducts clinical care and research in reproductive mental health. He has no financial relationship with SAGE Therapeutics, but he has been a consultant to manufacturers of psychiatric medications.

The importance of postpartum depression, both in terms of its prevalence and the need for appropriate screening and effective treatments, has become an increasingly important area of focus for clinicians, patients, and policymakers. This derives from more than a decade of data on the significant prevalence of the condition, with roughly 10% of women meeting the criteria for major or minor depression during the first 3-6 months post partum.

Over the last 5 years, interest has centered around establishing mechanisms for appropriate perinatal depression screening, most notably the January 2016 recommendation from the U.S. Preventive Services Task Force that all adults should be screened for depression, including the at-risk populations of pregnant and postpartum women. In 2015, the American College of Obstetricians and Gynecologists endorsed screening women for depression and anxiety symptoms at least once during the perinatal period using a validated tool. Unfortunately, we still lack data to support whether screening is effective in getting patients referred for treatment and if it leads to women accessing therapies that will actually get them well.

As we wait for that data and consider ways to best implement enhanced screening, it’s important to take stock of the available treatments for postpartum depression.

Seeking a rapid treatment

The current literature supports efficacy for nonpharmacologic therapies, such as interpersonal psychotherapy and cognitive-behavioral therapy, as well as several antidepressants. The efficacy of antidepressants – such as selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors – has been demonstrated for postpartum depression, but these agents carry the typical limitations and concerns in terms of side effects and the amount of time required to ascertain if there is benefit. While these are the same challenges seen in treating depression in general, the time to response – often 4-8 weeks – is particularly problematic for postpartum women where the impact of depression on maternal morbidity and child development is so critical.

The field has been clamoring for agents that work more quickly. One possibility in that area is ketamine, which is being studied as a rapid treatment in major depression. The National Institutes of Health also has an initiative underway called RAPID (Rapidly Acting Treatments for Treatment-Resistant Depression), aimed at identifying and testing pharmacologic and nonpharmacologic treatments that produce a response within days rather than weeks.

Recently, considerable interest has focused on SAGE-547, manufactured by Sage Therapeutics, which is a different type of antidepressant. The so-called neurosteriod is an allosteric modulator of the GABA_A (gamma-aminobutyric acid type A) receptors. The product was granted fast-track status by the Food and Drug Administration to speed its development as a possible treatment for superrefractory status epilepticus, but it also is being studied for its potential in treating severe postpartum depression.

Approximately a year ago, there was preliminary evidence from an open-label study suggesting rapid response to SAGE-547 for women who received this medicine intravenously in a controlled hospital environment. And in July 2016, the manufacturer announced in a press release unpublished positive results from a small phase II controlled trial of SAGE-547 for the treatment of severe postpartum depression.

Specifically, this was a placebo-controlled, double-blind randomized trial for 21 women who had severe depressive symptoms with a baseline score of at least 26 on the Hamilton Rating Scale for Depression (HAM-D). For some of the women, postpartum depression was not of new onset, but rather was an extension of depression that had manifested no earlier than the third trimester of pregnancy. A total of 10 women received the drug, while 11 received placebo. Both groups received continuous intravenous infusion over a 60-hour period.

Consistent with the earlier report, participants receiving the active agent had a statistically significant reduction in HAM-D scores at 24 hours, compared with women who received the placebo. Seven out of 10 women who received the active drug achieved remission from depression at 60 hours, compared with only 1 of the 11 patients who received placebo. Even though the results derived from an extremely small sample, the signal for efficacy appears promising.

Of particular interest, there appeared to be a duration of benefit at 30 days’ follow-up. The medicine was well tolerated with no discontinuations due to adverse events, which were most commonly dizziness, sedation, or somnolence. The adverse events were about the same in both the drug and placebo groups.

Next steps

These early results have generated excitement, if not a “buzz,” in the field, given the rapid onset of antidepressant benefit and the apparent duration of the effect. But readers should be mindful that to date, the findings have not been peer reviewed and are available only through a company-issued press release. It is also noteworthy that on clinicaltrials.gov, the projected enrollment was 32, but 21 women enrolled. This may speak to the great difficulty in enrolling the sample and may ultimately reflect on the generalizability of the findings.

One significant challenge with SAGE-547 is the formulation. It’s hardly feasible for severely ill postpartum women to come to the hospital for 60 hours of treatment. The manufacturer will have to produce a reformulated compound that is able to sustain the efficacy signaled in this proof of concept study.

But even more importantly, we will need to see how the drug performs in a larger, rigorous phase IIB or phase III study to know if the signal of promise really translates into a potential viable treatment option for women with severe postpartum depression. When we have results from a randomized controlled trial with a substantially larger number of patients, then we’ll know whether the excitement is justified. It would be a significant advance for the field if this were to be the case.

The field of depression, in general, has been seeking an effective, rapid treatment for some time, and the role of neurosteriods has been spoken about for more than 2 decades. If postpartum women are in fact a subgroup who respond to this class of agents, then that would be an example of truly personalized medicine. But we won’t know that until the manufacturer does an appropriate large trial, which could take 2-4 years.

Dr. Cohen is the director of the Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information and resources and conducts clinical care and research in reproductive mental health. He has no financial relationship with SAGE Therapeutics, but he has been a consultant to manufacturers of psychiatric medications.

The struggles with the State of Ohio Board of Pharmacy continue. The pharmacy board reopened its comment period for 2 weeks and received many comments from multiple physicians, organizations, and patients who would be adversely affected by the Board’s move to hold physicians’ offices to the same standard as compounding pharmacies. This was the topic of my recent column, in which I pointed out that as a result, “any practitioners who reconstitute any drug in their offices is considered to be a compounding pharmacy, ordered to pay compounding pharmacy registration fees ($112 yearly), and to undergo the same inspections as compounding pharmacies”.

At their last meeting, the pharmacy board members made a few minor changes, but practitioners will still have to throw out their neurotoxins after 1-6 hours (the exact time is still under debate). Incidentally, I have spoken to all three neurotoxin manufacturers, and they have no interest in adding preservative to their products or in bringing out smaller unit dose packaging. These regulations will have broad impact across the house of medicine because many specialties use neurotoxin.

You should know the back story behind all of this, and how the house of medicine came to this sad place.

About 20 years ago, pain control became a cause célèbre in medicine championed by no less than the World Health Organization. Numerous publications, thought leaders, and policy wonks decried the inadequacy of pain control both in and out of the hospital. It was explained loud and long that patients should have their pain controlled and that physicians fell short if they did not do so, never mind that there is no quantifiable way to measure pain. Further, it was explained that patients in severe pain did not become addicted to narcotics. And the Joint Commission heralded pain control as “the fifth vital sign.”

Where are these thought leaders now?

Graded on responsiveness to patients’ pain and the results of patient surveys on pain control, physicians grudgingly opened the narcotic floodgates and large quantities of prescription narcotics hit the streets. Admittedly, some were written by bad doctors running “pill mills,” but other supplies were diverted by producers, pharmacists, pharmacies, and pharmacy technicians. Hundreds of thousands of Americans became addicted to prescription narcotics, but overdoses were infrequent because there was a unit dose on the street.

Then the medical pendulum swung back, and it was decided that there was too much pain medicine on the streets. The narcotic supply spigots were tightened sharply by the Drug Enforcement Administration, medical boards, and legislatures. It became hard for drug-seeking patients to fill multiple prescriptions, pill mills were shut down, doctors were encouraged to prescribe minimum dosages of narcotic pain relievers, and the price of the unit dose shot up on the street. The patterns of abuse and addiction shifted as heroin became cheaper and more readily available, but hard to dose, particularly when Mexican fentanyl was being sold as “heroin.” Unable to judge the dose of illicitly obtained drugs, addicts began overdosing and dying all over America.

Angry, bereaved family members demanded an accounting for the addiction and deaths of their relatives. Heat was applied to politicians, and a “culprit” was found, physicians! Physicians had made these drugs available and caused all of these people to be addicted!

And thus began the political ascendancy of the pharmacy board, whose members claimed clean hands in this affair. Keen to expand their scope of practice, pharmacists have been trying to find a way into clinical medicine for years. The pharmacy board offered their expertise, and politicians angry at doctors were willing to give the pharmacists’ recommendations a try.

Last year in Ohio, the legislature passed a huge budget reconciliation bill with language tucked in it that authorized the pharmacy board to regulate buprenorphine and other dangerous drugs. The obvious reading of this authority would be that pharmacists were supposed to regulate compounding pharmacies, like the one that produced tainted steroid injections that resulted in 64 deaths in 2012.The regulation is so vague, however, that it could be construed that pharmacists were supposed to regulate everyone in the state, especially since the pharmacy board unilaterally moved to define “dangerous” as any prescription drug. This puts all of medicine in play. The board then declared that it would apply U.S. Pharmacopeial Convention standards (those used for compounding pharmacies) to all physician offices and declared that reconstitution of any drug is considered to be compounding.

To consider physician’s offices as compounding pharmacies is absurd and will degrade patient care by increasing expense and denying access to treatments. Physicians have made and applied individual customized medications to their patients since Galen. It is an integral part of the practice of medicine and has not suddenly become the practice of pharmacy. Using this logic, pharmacists, who have recently won the right to administer vaccinations, should obtain special licenses from the state medical board, since injecting medications is clearly in the purview of medical practice. Physicians have not been killing patients by running dirty compounding pharmacies, pharmacists have. Good, clean up the compounding pharmacies! But applying these compounding rules to physicians’ offices will not save any lives.

This battle has just been joined. The American Medical Association recently passed a resolution declaring that physician compounding should be regulated by state medical boards. This action is most helpful, and another reason for you to join and support the AMA. If you practice in Ohio, you should join the Ohio State Medical Association post haste. They are a big dog in the Ohio legislature, and your membership will influence their efforts.

I hope the Ohio governor’s Common Sense Initiative Office will convene a joint meeting that allows physicians, especially dermatologists, to demonstrate the absurdity of these rules, and their potentially destructive effects on patient care. However, I do not expect the pharmacy board to readily give up this power. Ultimately, the language in the legislative code must add two words after the word “compounding.” The words to be added are “by pharmacists.”

These rules may have to be stayed by a legal injunction. If the legislation is not clarified, a lawsuit against the pharmacy board based on restraint of trade should be successful.

Be vigilant, and watch your state legislatures. Just recently, the pharmacy board of North Dakota has made the same power grab. Stay tuned, as this struggle has national implications.

Dr. Coldiron is past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Write to him at [email protected].

The struggles with the State of Ohio Board of Pharmacy continue. The pharmacy board reopened its comment period for 2 weeks and received many comments from multiple physicians, organizations, and patients who would be adversely affected by the Board’s move to hold physicians’ offices to the same standard as compounding pharmacies. This was the topic of my recent column, in which I pointed out that as a result, “any practitioners who reconstitute any drug in their offices is considered to be a compounding pharmacy, ordered to pay compounding pharmacy registration fees ($112 yearly), and to undergo the same inspections as compounding pharmacies”.

At their last meeting, the pharmacy board members made a few minor changes, but practitioners will still have to throw out their neurotoxins after 1-6 hours (the exact time is still under debate). Incidentally, I have spoken to all three neurotoxin manufacturers, and they have no interest in adding preservative to their products or in bringing out smaller unit dose packaging. These regulations will have broad impact across the house of medicine because many specialties use neurotoxin.

You should know the back story behind all of this, and how the house of medicine came to this sad place.

About 20 years ago, pain control became a cause célèbre in medicine championed by no less than the World Health Organization. Numerous publications, thought leaders, and policy wonks decried the inadequacy of pain control both in and out of the hospital. It was explained loud and long that patients should have their pain controlled and that physicians fell short if they did not do so, never mind that there is no quantifiable way to measure pain. Further, it was explained that patients in severe pain did not become addicted to narcotics. And the Joint Commission heralded pain control as “the fifth vital sign.”

Where are these thought leaders now?

Graded on responsiveness to patients’ pain and the results of patient surveys on pain control, physicians grudgingly opened the narcotic floodgates and large quantities of prescription narcotics hit the streets. Admittedly, some were written by bad doctors running “pill mills,” but other supplies were diverted by producers, pharmacists, pharmacies, and pharmacy technicians. Hundreds of thousands of Americans became addicted to prescription narcotics, but overdoses were infrequent because there was a unit dose on the street.

Then the medical pendulum swung back, and it was decided that there was too much pain medicine on the streets. The narcotic supply spigots were tightened sharply by the Drug Enforcement Administration, medical boards, and legislatures. It became hard for drug-seeking patients to fill multiple prescriptions, pill mills were shut down, doctors were encouraged to prescribe minimum dosages of narcotic pain relievers, and the price of the unit dose shot up on the street. The patterns of abuse and addiction shifted as heroin became cheaper and more readily available, but hard to dose, particularly when Mexican fentanyl was being sold as “heroin.” Unable to judge the dose of illicitly obtained drugs, addicts began overdosing and dying all over America.

Angry, bereaved family members demanded an accounting for the addiction and deaths of their relatives. Heat was applied to politicians, and a “culprit” was found, physicians! Physicians had made these drugs available and caused all of these people to be addicted!

And thus began the political ascendancy of the pharmacy board, whose members claimed clean hands in this affair. Keen to expand their scope of practice, pharmacists have been trying to find a way into clinical medicine for years. The pharmacy board offered their expertise, and politicians angry at doctors were willing to give the pharmacists’ recommendations a try.

Last year in Ohio, the legislature passed a huge budget reconciliation bill with language tucked in it that authorized the pharmacy board to regulate buprenorphine and other dangerous drugs. The obvious reading of this authority would be that pharmacists were supposed to regulate compounding pharmacies, like the one that produced tainted steroid injections that resulted in 64 deaths in 2012.The regulation is so vague, however, that it could be construed that pharmacists were supposed to regulate everyone in the state, especially since the pharmacy board unilaterally moved to define “dangerous” as any prescription drug. This puts all of medicine in play. The board then declared that it would apply U.S. Pharmacopeial Convention standards (those used for compounding pharmacies) to all physician offices and declared that reconstitution of any drug is considered to be compounding.

To consider physician’s offices as compounding pharmacies is absurd and will degrade patient care by increasing expense and denying access to treatments. Physicians have made and applied individual customized medications to their patients since Galen. It is an integral part of the practice of medicine and has not suddenly become the practice of pharmacy. Using this logic, pharmacists, who have recently won the right to administer vaccinations, should obtain special licenses from the state medical board, since injecting medications is clearly in the purview of medical practice. Physicians have not been killing patients by running dirty compounding pharmacies, pharmacists have. Good, clean up the compounding pharmacies! But applying these compounding rules to physicians’ offices will not save any lives.

This battle has just been joined. The American Medical Association recently passed a resolution declaring that physician compounding should be regulated by state medical boards. This action is most helpful, and another reason for you to join and support the AMA. If you practice in Ohio, you should join the Ohio State Medical Association post haste. They are a big dog in the Ohio legislature, and your membership will influence their efforts.

I hope the Ohio governor’s Common Sense Initiative Office will convene a joint meeting that allows physicians, especially dermatologists, to demonstrate the absurdity of these rules, and their potentially destructive effects on patient care. However, I do not expect the pharmacy board to readily give up this power. Ultimately, the language in the legislative code must add two words after the word “compounding.” The words to be added are “by pharmacists.”

These rules may have to be stayed by a legal injunction. If the legislation is not clarified, a lawsuit against the pharmacy board based on restraint of trade should be successful.

Be vigilant, and watch your state legislatures. Just recently, the pharmacy board of North Dakota has made the same power grab. Stay tuned, as this struggle has national implications.

Dr. Coldiron is past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Write to him at [email protected].

The struggles with the State of Ohio Board of Pharmacy continue. The pharmacy board reopened its comment period for 2 weeks and received many comments from multiple physicians, organizations, and patients who would be adversely affected by the Board’s move to hold physicians’ offices to the same standard as compounding pharmacies. This was the topic of my recent column, in which I pointed out that as a result, “any practitioners who reconstitute any drug in their offices is considered to be a compounding pharmacy, ordered to pay compounding pharmacy registration fees ($112 yearly), and to undergo the same inspections as compounding pharmacies”.

At their last meeting, the pharmacy board members made a few minor changes, but practitioners will still have to throw out their neurotoxins after 1-6 hours (the exact time is still under debate). Incidentally, I have spoken to all three neurotoxin manufacturers, and they have no interest in adding preservative to their products or in bringing out smaller unit dose packaging. These regulations will have broad impact across the house of medicine because many specialties use neurotoxin.

You should know the back story behind all of this, and how the house of medicine came to this sad place.

About 20 years ago, pain control became a cause célèbre in medicine championed by no less than the World Health Organization. Numerous publications, thought leaders, and policy wonks decried the inadequacy of pain control both in and out of the hospital. It was explained loud and long that patients should have their pain controlled and that physicians fell short if they did not do so, never mind that there is no quantifiable way to measure pain. Further, it was explained that patients in severe pain did not become addicted to narcotics. And the Joint Commission heralded pain control as “the fifth vital sign.”

Where are these thought leaders now?

Graded on responsiveness to patients’ pain and the results of patient surveys on pain control, physicians grudgingly opened the narcotic floodgates and large quantities of prescription narcotics hit the streets. Admittedly, some were written by bad doctors running “pill mills,” but other supplies were diverted by producers, pharmacists, pharmacies, and pharmacy technicians. Hundreds of thousands of Americans became addicted to prescription narcotics, but overdoses were infrequent because there was a unit dose on the street.

Then the medical pendulum swung back, and it was decided that there was too much pain medicine on the streets. The narcotic supply spigots were tightened sharply by the Drug Enforcement Administration, medical boards, and legislatures. It became hard for drug-seeking patients to fill multiple prescriptions, pill mills were shut down, doctors were encouraged to prescribe minimum dosages of narcotic pain relievers, and the price of the unit dose shot up on the street. The patterns of abuse and addiction shifted as heroin became cheaper and more readily available, but hard to dose, particularly when Mexican fentanyl was being sold as “heroin.” Unable to judge the dose of illicitly obtained drugs, addicts began overdosing and dying all over America.

Angry, bereaved family members demanded an accounting for the addiction and deaths of their relatives. Heat was applied to politicians, and a “culprit” was found, physicians! Physicians had made these drugs available and caused all of these people to be addicted!

And thus began the political ascendancy of the pharmacy board, whose members claimed clean hands in this affair. Keen to expand their scope of practice, pharmacists have been trying to find a way into clinical medicine for years. The pharmacy board offered their expertise, and politicians angry at doctors were willing to give the pharmacists’ recommendations a try.

Last year in Ohio, the legislature passed a huge budget reconciliation bill with language tucked in it that authorized the pharmacy board to regulate buprenorphine and other dangerous drugs. The obvious reading of this authority would be that pharmacists were supposed to regulate compounding pharmacies, like the one that produced tainted steroid injections that resulted in 64 deaths in 2012.The regulation is so vague, however, that it could be construed that pharmacists were supposed to regulate everyone in the state, especially since the pharmacy board unilaterally moved to define “dangerous” as any prescription drug. This puts all of medicine in play. The board then declared that it would apply U.S. Pharmacopeial Convention standards (those used for compounding pharmacies) to all physician offices and declared that reconstitution of any drug is considered to be compounding.

To consider physician’s offices as compounding pharmacies is absurd and will degrade patient care by increasing expense and denying access to treatments. Physicians have made and applied individual customized medications to their patients since Galen. It is an integral part of the practice of medicine and has not suddenly become the practice of pharmacy. Using this logic, pharmacists, who have recently won the right to administer vaccinations, should obtain special licenses from the state medical board, since injecting medications is clearly in the purview of medical practice. Physicians have not been killing patients by running dirty compounding pharmacies, pharmacists have. Good, clean up the compounding pharmacies! But applying these compounding rules to physicians’ offices will not save any lives.

This battle has just been joined. The American Medical Association recently passed a resolution declaring that physician compounding should be regulated by state medical boards. This action is most helpful, and another reason for you to join and support the AMA. If you practice in Ohio, you should join the Ohio State Medical Association post haste. They are a big dog in the Ohio legislature, and your membership will influence their efforts.

I hope the Ohio governor’s Common Sense Initiative Office will convene a joint meeting that allows physicians, especially dermatologists, to demonstrate the absurdity of these rules, and their potentially destructive effects on patient care. However, I do not expect the pharmacy board to readily give up this power. Ultimately, the language in the legislative code must add two words after the word “compounding.” The words to be added are “by pharmacists.”

These rules may have to be stayed by a legal injunction. If the legislation is not clarified, a lawsuit against the pharmacy board based on restraint of trade should be successful.

Be vigilant, and watch your state legislatures. Just recently, the pharmacy board of North Dakota has made the same power grab. Stay tuned, as this struggle has national implications.

Dr. Coldiron is past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Write to him at [email protected].

In preparation for a presentation at the 58th Annual Meeting of the Noah Worcester Dermatological Society (April 6-10, 2016; Marana, Arizona) entitled “Burnout: The New Epidemic,” I sent out a brief survey with 4 questions, one of which asked what changes members planned to make to deal with burnout symptoms. I offered the following list of possibilities: retire early, go to more dermatology meetings, work fewer hours, see fewer patients, change jobs, leave dermatology, leave the profession of medicine altogether, restrict practice to previous patients, restrict patients to certain types of insurances only, restrict practice to self-pay patients only, and hire additional help. One of my colleagues tested the survey and suggested that I add both practicing mindfulness at work and volunteering in underprivileged settings. Mindfulness? Interesting, but it seemed unlikely that anyone would select that answer. Needing some filler answers, I added both to the list on the final survey.

Burnout is defined by episodes of emotional fatigue; development of a negative, callous, or cynical attitude toward patients; and a decreased sense of personal accomplishment.¹ Survey responses showed that 58% of 48 respondents indicated that they experienced a symptom of burnout and stated that their primary issues were helplessness in the ability to shape their role or their practice, difficulty in obtaining medications that they prescribed for their patients, and too many hours at work. What did they choose as their primary actions to deal with burnout? Forty-two percent of respondents said they would work fewer hours, 38% said they would retire early, and a startling 35% said they would practice mindfulness at work.² Because one-third of these practicing dermatologists thought they would find value in practicing mindfulness, I decided to explore this topic for its relevance in our work lives.

Mindfulness is a purposeful activity that involves being acutely aware of what is happening now as opposed to thinking about the past or worrying about the future. Jon Kabat-Zinn, PhD, developer of the practice called mindfulness-based stress reduction, phrases it this way: “Mindfulness is awareness, cultivated by paying attention in a sustained and particular way: on purpose, in the present moment, and non-judgmentally.”³ It is being rather than becoming; it is noticing internal experiences and external events rather than reacting; and it is intentional, not accidental.

Mindfulness practices include meditation, yoga, and tai chi. Buddhist monks listen to bells chime, Sufis spin by putting one foot in front of the other, and fly fishermen watch the ripples in the river. My son, a jazz musician, gets into the zone playing his bass and even senses color changes while completely losing track of time and space. I enjoy walking with my camera, looking intently for little things in the right light that will make interesting photographs. Then, I work on the right framing for that view before I take the photograph. The process keeps me in the moment, visually appreciating what I see, with no room for anxiety about my long must-do list.

Is mindfulness relevant to our work lives? The Boston Globe highlighted how mindfulness has become mainstream, reporting that major companies including Google, Aetna, the Huffington Post, Eileen Fisher, and the Massachusetts General Hospital build in opportunities during the work day for an employee to utilize practices that promote mindfulness.⁴ In the corporate setting, the stated objective is to contribute to the well-being of the employee, but the major motivation by the company is to reduce stress, which is one of the most costly employee health issues for absenteeism, turnover, and diminished creativity and productivity.

The medical literature supports the worth of mindfulness practices. A study of Brazilian primary care professionals showed a strong negative correlation between mindfulness and perceived stress.⁵ Irving et al⁶ showed that an 8-week formal mindfulness program reduced stress in health care professionals and produced remarkable evidence of better physical and mental health. In Australia, where medical students have much higher levels of depression and anxiety compared to the general adult population, medical students with higher levels of mindfulness traits, especially the nonjudgmental subscale, had lower levels of distress.⁷ Shapiro et al⁸ found notable decreases in distress for medical students who participated in a mindfulness program.

And mindfulness matters to patient care. A multicenter observational study of 45 clinicians caring for patients with human immunodeficiency virus found that clinicians with the highest mindfulness scores displayed a more positive emotional tone with patients and their patients reported higher ratings on clinician communication. The researchers hypothesized that these better clinical interactions may have a profound effect on quality, safety, and efficacy of the patient’s care.⁹

How can we incorporate mindfulness in our daily work lives? For some it is a cognitive style that regularly facilitates nonjudgmental awareness, but there are regular practices that induce mindfulness as temporary states and help build it as a persistent style. A common exercise is to take a raisin, hold it in your hand and appreciate its color and shape, roll it in between your fingers for a tactile sensation that you describe in words to yourself, then put it on your tongue to feel its sensation there, and finally chew it noticing the texture and the taste. Another practice has been highlighted by respected Buddhist monk Thich Nhat Hanh who reminds us to concentrate on our breath, observing what happens as we breathe in and out.¹⁰ Kabat-Zinn³ challenges us to “hear what is here to be heard. . . . letting sounds arrive at our door, letting them come to us.” He points out it is relatively easy to be intently aware of the external and physical world, but the real difficulty is being aware and examining our thoughts and internal experiences without being drawn into judging them, which then leads us to be carried away on an emotional path.³

When I am preoccupied or distracted at work, I find it helpful to stop at the door I am about to enter, hold the knob, and take a deep breath, concentrating on the next single task in front of me. Then I open the door and see a patient or deal with an administrative issue. My mindfulness in action at the workplace, helping me have a good and productive day. Yes, mindfulness is relevant to our work lives.

In preparation for a presentation at the 58th Annual Meeting of the Noah Worcester Dermatological Society (April 6-10, 2016; Marana, Arizona) entitled “Burnout: The New Epidemic,” I sent out a brief survey with 4 questions, one of which asked what changes members planned to make to deal with burnout symptoms. I offered the following list of possibilities: retire early, go to more dermatology meetings, work fewer hours, see fewer patients, change jobs, leave dermatology, leave the profession of medicine altogether, restrict practice to previous patients, restrict patients to certain types of insurances only, restrict practice to self-pay patients only, and hire additional help. One of my colleagues tested the survey and suggested that I add both practicing mindfulness at work and volunteering in underprivileged settings. Mindfulness? Interesting, but it seemed unlikely that anyone would select that answer. Needing some filler answers, I added both to the list on the final survey.

Burnout is defined by episodes of emotional fatigue; development of a negative, callous, or cynical attitude toward patients; and a decreased sense of personal accomplishment.¹ Survey responses showed that 58% of 48 respondents indicated that they experienced a symptom of burnout and stated that their primary issues were helplessness in the ability to shape their role or their practice, difficulty in obtaining medications that they prescribed for their patients, and too many hours at work. What did they choose as their primary actions to deal with burnout? Forty-two percent of respondents said they would work fewer hours, 38% said they would retire early, and a startling 35% said they would practice mindfulness at work.² Because one-third of these practicing dermatologists thought they would find value in practicing mindfulness, I decided to explore this topic for its relevance in our work lives.

Mindfulness is a purposeful activity that involves being acutely aware of what is happening now as opposed to thinking about the past or worrying about the future. Jon Kabat-Zinn, PhD, developer of the practice called mindfulness-based stress reduction, phrases it this way: “Mindfulness is awareness, cultivated by paying attention in a sustained and particular way: on purpose, in the present moment, and non-judgmentally.”³ It is being rather than becoming; it is noticing internal experiences and external events rather than reacting; and it is intentional, not accidental.

Mindfulness practices include meditation, yoga, and tai chi. Buddhist monks listen to bells chime, Sufis spin by putting one foot in front of the other, and fly fishermen watch the ripples in the river. My son, a jazz musician, gets into the zone playing his bass and even senses color changes while completely losing track of time and space. I enjoy walking with my camera, looking intently for little things in the right light that will make interesting photographs. Then, I work on the right framing for that view before I take the photograph. The process keeps me in the moment, visually appreciating what I see, with no room for anxiety about my long must-do list.

Is mindfulness relevant to our work lives? The Boston Globe highlighted how mindfulness has become mainstream, reporting that major companies including Google, Aetna, the Huffington Post, Eileen Fisher, and the Massachusetts General Hospital build in opportunities during the work day for an employee to utilize practices that promote mindfulness.⁴ In the corporate setting, the stated objective is to contribute to the well-being of the employee, but the major motivation by the company is to reduce stress, which is one of the most costly employee health issues for absenteeism, turnover, and diminished creativity and productivity.

The medical literature supports the worth of mindfulness practices. A study of Brazilian primary care professionals showed a strong negative correlation between mindfulness and perceived stress.⁵ Irving et al⁶ showed that an 8-week formal mindfulness program reduced stress in health care professionals and produced remarkable evidence of better physical and mental health. In Australia, where medical students have much higher levels of depression and anxiety compared to the general adult population, medical students with higher levels of mindfulness traits, especially the nonjudgmental subscale, had lower levels of distress.⁷ Shapiro et al⁸ found notable decreases in distress for medical students who participated in a mindfulness program.

And mindfulness matters to patient care. A multicenter observational study of 45 clinicians caring for patients with human immunodeficiency virus found that clinicians with the highest mindfulness scores displayed a more positive emotional tone with patients and their patients reported higher ratings on clinician communication. The researchers hypothesized that these better clinical interactions may have a profound effect on quality, safety, and efficacy of the patient’s care.⁹

How can we incorporate mindfulness in our daily work lives? For some it is a cognitive style that regularly facilitates nonjudgmental awareness, but there are regular practices that induce mindfulness as temporary states and help build it as a persistent style. A common exercise is to take a raisin, hold it in your hand and appreciate its color and shape, roll it in between your fingers for a tactile sensation that you describe in words to yourself, then put it on your tongue to feel its sensation there, and finally chew it noticing the texture and the taste. Another practice has been highlighted by respected Buddhist monk Thich Nhat Hanh who reminds us to concentrate on our breath, observing what happens as we breathe in and out.¹⁰ Kabat-Zinn³ challenges us to “hear what is here to be heard. . . . letting sounds arrive at our door, letting them come to us.” He points out it is relatively easy to be intently aware of the external and physical world, but the real difficulty is being aware and examining our thoughts and internal experiences without being drawn into judging them, which then leads us to be carried away on an emotional path.³

When I am preoccupied or distracted at work, I find it helpful to stop at the door I am about to enter, hold the knob, and take a deep breath, concentrating on the next single task in front of me. Then I open the door and see a patient or deal with an administrative issue. My mindfulness in action at the workplace, helping me have a good and productive day. Yes, mindfulness is relevant to our work lives.

In preparation for a presentation at the 58th Annual Meeting of the Noah Worcester Dermatological Society (April 6-10, 2016; Marana, Arizona) entitled “Burnout: The New Epidemic,” I sent out a brief survey with 4 questions, one of which asked what changes members planned to make to deal with burnout symptoms. I offered the following list of possibilities: retire early, go to more dermatology meetings, work fewer hours, see fewer patients, change jobs, leave dermatology, leave the profession of medicine altogether, restrict practice to previous patients, restrict patients to certain types of insurances only, restrict practice to self-pay patients only, and hire additional help. One of my colleagues tested the survey and suggested that I add both practicing mindfulness at work and volunteering in underprivileged settings. Mindfulness? Interesting, but it seemed unlikely that anyone would select that answer. Needing some filler answers, I added both to the list on the final survey.

Burnout is defined by episodes of emotional fatigue; development of a negative, callous, or cynical attitude toward patients; and a decreased sense of personal accomplishment.¹ Survey responses showed that 58% of 48 respondents indicated that they experienced a symptom of burnout and stated that their primary issues were helplessness in the ability to shape their role or their practice, difficulty in obtaining medications that they prescribed for their patients, and too many hours at work. What did they choose as their primary actions to deal with burnout? Forty-two percent of respondents said they would work fewer hours, 38% said they would retire early, and a startling 35% said they would practice mindfulness at work.² Because one-third of these practicing dermatologists thought they would find value in practicing mindfulness, I decided to explore this topic for its relevance in our work lives.

Mindfulness is a purposeful activity that involves being acutely aware of what is happening now as opposed to thinking about the past or worrying about the future. Jon Kabat-Zinn, PhD, developer of the practice called mindfulness-based stress reduction, phrases it this way: “Mindfulness is awareness, cultivated by paying attention in a sustained and particular way: on purpose, in the present moment, and non-judgmentally.”³ It is being rather than becoming; it is noticing internal experiences and external events rather than reacting; and it is intentional, not accidental.

Mindfulness practices include meditation, yoga, and tai chi. Buddhist monks listen to bells chime, Sufis spin by putting one foot in front of the other, and fly fishermen watch the ripples in the river. My son, a jazz musician, gets into the zone playing his bass and even senses color changes while completely losing track of time and space. I enjoy walking with my camera, looking intently for little things in the right light that will make interesting photographs. Then, I work on the right framing for that view before I take the photograph. The process keeps me in the moment, visually appreciating what I see, with no room for anxiety about my long must-do list.

Is mindfulness relevant to our work lives? The Boston Globe highlighted how mindfulness has become mainstream, reporting that major companies including Google, Aetna, the Huffington Post, Eileen Fisher, and the Massachusetts General Hospital build in opportunities during the work day for an employee to utilize practices that promote mindfulness.⁴ In the corporate setting, the stated objective is to contribute to the well-being of the employee, but the major motivation by the company is to reduce stress, which is one of the most costly employee health issues for absenteeism, turnover, and diminished creativity and productivity.

The medical literature supports the worth of mindfulness practices. A study of Brazilian primary care professionals showed a strong negative correlation between mindfulness and perceived stress.⁵ Irving et al⁶ showed that an 8-week formal mindfulness program reduced stress in health care professionals and produced remarkable evidence of better physical and mental health. In Australia, where medical students have much higher levels of depression and anxiety compared to the general adult population, medical students with higher levels of mindfulness traits, especially the nonjudgmental subscale, had lower levels of distress.⁷ Shapiro et al⁸ found notable decreases in distress for medical students who participated in a mindfulness program.

And mindfulness matters to patient care. A multicenter observational study of 45 clinicians caring for patients with human immunodeficiency virus found that clinicians with the highest mindfulness scores displayed a more positive emotional tone with patients and their patients reported higher ratings on clinician communication. The researchers hypothesized that these better clinical interactions may have a profound effect on quality, safety, and efficacy of the patient’s care.⁹

How can we incorporate mindfulness in our daily work lives? For some it is a cognitive style that regularly facilitates nonjudgmental awareness, but there are regular practices that induce mindfulness as temporary states and help build it as a persistent style. A common exercise is to take a raisin, hold it in your hand and appreciate its color and shape, roll it in between your fingers for a tactile sensation that you describe in words to yourself, then put it on your tongue to feel its sensation there, and finally chew it noticing the texture and the taste. Another practice has been highlighted by respected Buddhist monk Thich Nhat Hanh who reminds us to concentrate on our breath, observing what happens as we breathe in and out.¹⁰ Kabat-Zinn³ challenges us to “hear what is here to be heard. . . . letting sounds arrive at our door, letting them come to us.” He points out it is relatively easy to be intently aware of the external and physical world, but the real difficulty is being aware and examining our thoughts and internal experiences without being drawn into judging them, which then leads us to be carried away on an emotional path.³

When I am preoccupied or distracted at work, I find it helpful to stop at the door I am about to enter, hold the knob, and take a deep breath, concentrating on the next single task in front of me. Then I open the door and see a patient or deal with an administrative issue. My mindfulness in action at the workplace, helping me have a good and productive day. Yes, mindfulness is relevant to our work lives.