Commentary

On March 23, 2016, we recognized the sixth anniversary of the signing of the Patient Protection and Affordable Care Act (ACA), a law designed to increase the number of Americans covered by health insurance and decrease the cost of health care. Prior to and since its passage, many have criticized the ACA as too costly and too quickly implemented (indeed, some would say, implemented without much planning or thought). Others have denigrated it as a step toward “socialized medicine” or as “big government”—a historically distrusted approach to solving problems.

As a student of health policy, I have watched the yarn of attempts to enact a comprehensive health insurance system ravel and unravel with each administration. Yes, for decades, political parties have staunchly opposed this type of program to reform our ailing system. But why is there such resistance to government involvement in health care reform?

This hasn’t been limited to insurance. Since the mid-1800s, despite the known dangers (including death) of various contagious diseases (eg, smallpox, malaria), people have resisted, even vehemently opposed, government-initiated regulations intended to combat such illnesses.¹ Yet, today, we recognize that many improvements in the health of our communities and ourselves are founded on the infrastructure of the public health system. In most cities and states, the public health department responds to everyday health threats and emergencies through programs and initiatives that are government sponsored and funded—and accepted (one might even say expected) by most of us. Dare I point out that these are part of a “social insurance” program?

The idea of a comprehensive approach to health care coverage is not new. One of the earliest government interventions toward social insurance was the 1921 Sheppard-Towner Act, which provided matching funds to states for prenatal and child health centers. Regrettably, it was viewed by the AMA as “excessive federal interference in local health concerns” and discontinued a mere six years later.¹

A later intervention, the Hill-Burton Act (passed in 1946) provided hospitals, nursing homes, and other health facilities with grants and loans for construction and modernization.² An obligation tied to receiving funds was the requirement that administrators of the facilities “provide a reasonable volume of services to persons unable to pay and to make their services available to all persons residing in the facility’s area.”² One could posit that these two policies influenced the movement toward national insurance in the United States.

We have a patchwork quilt of a health insurance system that includes social insurance programs: Social Security and Medicare. Generations of Americans have contributed to those programs through taxes and expect to benefit from them. And for generations—actually a century—there have been attempts to establish national health insurance (NHI) in the US. In the early 1900s, after Germany and England established health insurance for industrial workers, progressive social reformers attempted to secure similar protection for American workers but were unsuccessful.³ Repeated efforts in 1948, 1965, 1974, 1978, and 1994 also failed to institute an NHI program.

But why? There has been public support for some form of comprehensive NHI since the 1930s. The percentage of Americans expressing support for more government intervention on health care delivery has not fallen below 60% since 1937.⁴ This disconnect between the people’s desires and politics has been analyzed extensively and written about in many health policy texts.

So when did the idea of NHI become palatable? The notion came closer to reality during the Clinton administration. As the political parties began to fragment, they lost their power over health care politics. With more than 30 million Americans either without health insurance, or in jeopardy of losing what they had, the push for reform was stronger than ever before. We came close, but the scare tactics by NHI opponents about cost, decreased benefits, and increased risk (remember the Harry and Louise commercials?) quickly put the kibosh on that attempt at reform.

Continue forward to 2009 >>

Fast forward to 2009: Barack Obama is elected president and upholds his stance on health care reform, with a vow to institute a universal or near-universal health insurance program during his administration. As he said in his remarks to Congress, “I am not the first President to take up this cause [the issue of health care], but I am determined to be the last.”⁵ Hearing that an NHI program would cost $900 billion over 10 years was a bitter pill to swallow for some.⁵ But we couldn’t afford not to undertake it.

Since the enactment of the ACA, 18 million uninsured people have gained health coverage.⁶ The law has also improved access to health care services provided by NPs and PAs, evidenced by the nondiscrimination provision acknowledging us as primary care providers. The shortage of physicians and the increase in the number of newly insured persons seeking health care created an unprecedented opportunity to increase the utilization of NPs and PAs throughout the health care system.

Reflecting on the cost of the ACA, I have always maintained two positions: First, we pay for health care at often the most expensive place (the ED) or time (end-stage disease) … so it is a case of “pay me now or pay me later.” Second, we must gain control over the overall cost of health care. Providing access to primary care services for everyone is a step toward getting that control.

I have been a supporter of an NHI system all my adult life. I consider myself lucky to have had continuous access to health care. But I have cared for many who have not been so fortunate, and I have seen a minor illness become a major event because the family has no access to care. Without universal access to care, these cases increase—and with them, the cost of care.

Is the ACA the perfect solution? Even six years later, I think the jury is still out. But what I know for sure is that it was the first step in the right direction. You no doubt have opinions on this topic; please share them with me at [email protected].

References
1. Heinrich J. Organization and delivery of health care in the United States: the health care system that isn’t. In: Mason DJ, Leavitt JK, eds. Policy and Politics in Nursing and Health Care. 3rd ed. Philadelphia: Saunders; 1998:59-79.
2. US Department of Health and Human Services, Health Resources and Services Administration. Hill-Burton Program (July 2010). www.hrsa.gov/gethealthcare/affordable/hillburton/hillburton.pdf. Accessed April 11, 2016.
3. Altman S, Schactman D. Power, Politics, and Universal Health Care: The Inside Story of a Century-long Battle. Amherst, NY: Prometheus Books; 2011.
4. Steinmo S, Watts J. It’s the institutions, stupid: why comprehensive national health insurance always fails in America. In: Harrington C, Estes CL, eds. Health Policy: Crisis and Reform in the US Health Care Delivery System. 5th ed. Burlington, MA: Jones and Bartlett; 2008:30-36.
5. White House Office of the Press Secretary. Remarks by the President to a Joint Session of Congress on Health Care, September 9, 2009. www.whitehouse.gov/the-press-office/remarks-president-a-joint-session-congress-health-care. Accessed April 11, 2016.
6. US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Health insurance coverage and the Affordable Care Act, September 2015. https://aspe.hhs.gov/pdf-report/health-insurance-coverage-and-affordable-care-act-september-2015. Accessed April 11, 2016.

On March 23, 2016, we recognized the sixth anniversary of the signing of the Patient Protection and Affordable Care Act (ACA), a law designed to increase the number of Americans covered by health insurance and decrease the cost of health care. Prior to and since its passage, many have criticized the ACA as too costly and too quickly implemented (indeed, some would say, implemented without much planning or thought). Others have denigrated it as a step toward “socialized medicine” or as “big government”—a historically distrusted approach to solving problems.

As a student of health policy, I have watched the yarn of attempts to enact a comprehensive health insurance system ravel and unravel with each administration. Yes, for decades, political parties have staunchly opposed this type of program to reform our ailing system. But why is there such resistance to government involvement in health care reform?

This hasn’t been limited to insurance. Since the mid-1800s, despite the known dangers (including death) of various contagious diseases (eg, smallpox, malaria), people have resisted, even vehemently opposed, government-initiated regulations intended to combat such illnesses.¹ Yet, today, we recognize that many improvements in the health of our communities and ourselves are founded on the infrastructure of the public health system. In most cities and states, the public health department responds to everyday health threats and emergencies through programs and initiatives that are government sponsored and funded—and accepted (one might even say expected) by most of us. Dare I point out that these are part of a “social insurance” program?

The idea of a comprehensive approach to health care coverage is not new. One of the earliest government interventions toward social insurance was the 1921 Sheppard-Towner Act, which provided matching funds to states for prenatal and child health centers. Regrettably, it was viewed by the AMA as “excessive federal interference in local health concerns” and discontinued a mere six years later.¹

A later intervention, the Hill-Burton Act (passed in 1946) provided hospitals, nursing homes, and other health facilities with grants and loans for construction and modernization.² An obligation tied to receiving funds was the requirement that administrators of the facilities “provide a reasonable volume of services to persons unable to pay and to make their services available to all persons residing in the facility’s area.”² One could posit that these two policies influenced the movement toward national insurance in the United States.

We have a patchwork quilt of a health insurance system that includes social insurance programs: Social Security and Medicare. Generations of Americans have contributed to those programs through taxes and expect to benefit from them. And for generations—actually a century—there have been attempts to establish national health insurance (NHI) in the US. In the early 1900s, after Germany and England established health insurance for industrial workers, progressive social reformers attempted to secure similar protection for American workers but were unsuccessful.³ Repeated efforts in 1948, 1965, 1974, 1978, and 1994 also failed to institute an NHI program.

But why? There has been public support for some form of comprehensive NHI since the 1930s. The percentage of Americans expressing support for more government intervention on health care delivery has not fallen below 60% since 1937.⁴ This disconnect between the people’s desires and politics has been analyzed extensively and written about in many health policy texts.

So when did the idea of NHI become palatable? The notion came closer to reality during the Clinton administration. As the political parties began to fragment, they lost their power over health care politics. With more than 30 million Americans either without health insurance, or in jeopardy of losing what they had, the push for reform was stronger than ever before. We came close, but the scare tactics by NHI opponents about cost, decreased benefits, and increased risk (remember the Harry and Louise commercials?) quickly put the kibosh on that attempt at reform.

Continue forward to 2009 >>

Fast forward to 2009: Barack Obama is elected president and upholds his stance on health care reform, with a vow to institute a universal or near-universal health insurance program during his administration. As he said in his remarks to Congress, “I am not the first President to take up this cause [the issue of health care], but I am determined to be the last.”⁵ Hearing that an NHI program would cost $900 billion over 10 years was a bitter pill to swallow for some.⁵ But we couldn’t afford not to undertake it.

Since the enactment of the ACA, 18 million uninsured people have gained health coverage.⁶ The law has also improved access to health care services provided by NPs and PAs, evidenced by the nondiscrimination provision acknowledging us as primary care providers. The shortage of physicians and the increase in the number of newly insured persons seeking health care created an unprecedented opportunity to increase the utilization of NPs and PAs throughout the health care system.

Reflecting on the cost of the ACA, I have always maintained two positions: First, we pay for health care at often the most expensive place (the ED) or time (end-stage disease) … so it is a case of “pay me now or pay me later.” Second, we must gain control over the overall cost of health care. Providing access to primary care services for everyone is a step toward getting that control.

I have been a supporter of an NHI system all my adult life. I consider myself lucky to have had continuous access to health care. But I have cared for many who have not been so fortunate, and I have seen a minor illness become a major event because the family has no access to care. Without universal access to care, these cases increase—and with them, the cost of care.

Is the ACA the perfect solution? Even six years later, I think the jury is still out. But what I know for sure is that it was the first step in the right direction. You no doubt have opinions on this topic; please share them with me at [email protected].

References
1. Heinrich J. Organization and delivery of health care in the United States: the health care system that isn’t. In: Mason DJ, Leavitt JK, eds. Policy and Politics in Nursing and Health Care. 3rd ed. Philadelphia: Saunders; 1998:59-79.
2. US Department of Health and Human Services, Health Resources and Services Administration. Hill-Burton Program (July 2010). www.hrsa.gov/gethealthcare/affordable/hillburton/hillburton.pdf. Accessed April 11, 2016.
3. Altman S, Schactman D. Power, Politics, and Universal Health Care: The Inside Story of a Century-long Battle. Amherst, NY: Prometheus Books; 2011.
4. Steinmo S, Watts J. It’s the institutions, stupid: why comprehensive national health insurance always fails in America. In: Harrington C, Estes CL, eds. Health Policy: Crisis and Reform in the US Health Care Delivery System. 5th ed. Burlington, MA: Jones and Bartlett; 2008:30-36.
5. White House Office of the Press Secretary. Remarks by the President to a Joint Session of Congress on Health Care, September 9, 2009. www.whitehouse.gov/the-press-office/remarks-president-a-joint-session-congress-health-care. Accessed April 11, 2016.
6. US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Health insurance coverage and the Affordable Care Act, September 2015. https://aspe.hhs.gov/pdf-report/health-insurance-coverage-and-affordable-care-act-september-2015. Accessed April 11, 2016.

On March 23, 2016, we recognized the sixth anniversary of the signing of the Patient Protection and Affordable Care Act (ACA), a law designed to increase the number of Americans covered by health insurance and decrease the cost of health care. Prior to and since its passage, many have criticized the ACA as too costly and too quickly implemented (indeed, some would say, implemented without much planning or thought). Others have denigrated it as a step toward “socialized medicine” or as “big government”—a historically distrusted approach to solving problems.

As a student of health policy, I have watched the yarn of attempts to enact a comprehensive health insurance system ravel and unravel with each administration. Yes, for decades, political parties have staunchly opposed this type of program to reform our ailing system. But why is there such resistance to government involvement in health care reform?

This hasn’t been limited to insurance. Since the mid-1800s, despite the known dangers (including death) of various contagious diseases (eg, smallpox, malaria), people have resisted, even vehemently opposed, government-initiated regulations intended to combat such illnesses.¹ Yet, today, we recognize that many improvements in the health of our communities and ourselves are founded on the infrastructure of the public health system. In most cities and states, the public health department responds to everyday health threats and emergencies through programs and initiatives that are government sponsored and funded—and accepted (one might even say expected) by most of us. Dare I point out that these are part of a “social insurance” program?

The idea of a comprehensive approach to health care coverage is not new. One of the earliest government interventions toward social insurance was the 1921 Sheppard-Towner Act, which provided matching funds to states for prenatal and child health centers. Regrettably, it was viewed by the AMA as “excessive federal interference in local health concerns” and discontinued a mere six years later.¹

A later intervention, the Hill-Burton Act (passed in 1946) provided hospitals, nursing homes, and other health facilities with grants and loans for construction and modernization.² An obligation tied to receiving funds was the requirement that administrators of the facilities “provide a reasonable volume of services to persons unable to pay and to make their services available to all persons residing in the facility’s area.”² One could posit that these two policies influenced the movement toward national insurance in the United States.

We have a patchwork quilt of a health insurance system that includes social insurance programs: Social Security and Medicare. Generations of Americans have contributed to those programs through taxes and expect to benefit from them. And for generations—actually a century—there have been attempts to establish national health insurance (NHI) in the US. In the early 1900s, after Germany and England established health insurance for industrial workers, progressive social reformers attempted to secure similar protection for American workers but were unsuccessful.³ Repeated efforts in 1948, 1965, 1974, 1978, and 1994 also failed to institute an NHI program.

But why? There has been public support for some form of comprehensive NHI since the 1930s. The percentage of Americans expressing support for more government intervention on health care delivery has not fallen below 60% since 1937.⁴ This disconnect between the people’s desires and politics has been analyzed extensively and written about in many health policy texts.

So when did the idea of NHI become palatable? The notion came closer to reality during the Clinton administration. As the political parties began to fragment, they lost their power over health care politics. With more than 30 million Americans either without health insurance, or in jeopardy of losing what they had, the push for reform was stronger than ever before. We came close, but the scare tactics by NHI opponents about cost, decreased benefits, and increased risk (remember the Harry and Louise commercials?) quickly put the kibosh on that attempt at reform.

Continue forward to 2009 >>

Fast forward to 2009: Barack Obama is elected president and upholds his stance on health care reform, with a vow to institute a universal or near-universal health insurance program during his administration. As he said in his remarks to Congress, “I am not the first President to take up this cause [the issue of health care], but I am determined to be the last.”⁵ Hearing that an NHI program would cost $900 billion over 10 years was a bitter pill to swallow for some.⁵ But we couldn’t afford not to undertake it.

Since the enactment of the ACA, 18 million uninsured people have gained health coverage.⁶ The law has also improved access to health care services provided by NPs and PAs, evidenced by the nondiscrimination provision acknowledging us as primary care providers. The shortage of physicians and the increase in the number of newly insured persons seeking health care created an unprecedented opportunity to increase the utilization of NPs and PAs throughout the health care system.

Reflecting on the cost of the ACA, I have always maintained two positions: First, we pay for health care at often the most expensive place (the ED) or time (end-stage disease) … so it is a case of “pay me now or pay me later.” Second, we must gain control over the overall cost of health care. Providing access to primary care services for everyone is a step toward getting that control.

I have been a supporter of an NHI system all my adult life. I consider myself lucky to have had continuous access to health care. But I have cared for many who have not been so fortunate, and I have seen a minor illness become a major event because the family has no access to care. Without universal access to care, these cases increase—and with them, the cost of care.

Is the ACA the perfect solution? Even six years later, I think the jury is still out. But what I know for sure is that it was the first step in the right direction. You no doubt have opinions on this topic; please share them with me at [email protected].

References
1. Heinrich J. Organization and delivery of health care in the United States: the health care system that isn’t. In: Mason DJ, Leavitt JK, eds. Policy and Politics in Nursing and Health Care. 3rd ed. Philadelphia: Saunders; 1998:59-79.
2. US Department of Health and Human Services, Health Resources and Services Administration. Hill-Burton Program (July 2010). www.hrsa.gov/gethealthcare/affordable/hillburton/hillburton.pdf. Accessed April 11, 2016.
3. Altman S, Schactman D. Power, Politics, and Universal Health Care: The Inside Story of a Century-long Battle. Amherst, NY: Prometheus Books; 2011.
4. Steinmo S, Watts J. It’s the institutions, stupid: why comprehensive national health insurance always fails in America. In: Harrington C, Estes CL, eds. Health Policy: Crisis and Reform in the US Health Care Delivery System. 5th ed. Burlington, MA: Jones and Bartlett; 2008:30-36.
5. White House Office of the Press Secretary. Remarks by the President to a Joint Session of Congress on Health Care, September 9, 2009. www.whitehouse.gov/the-press-office/remarks-president-a-joint-session-congress-health-care. Accessed April 11, 2016.
6. US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Health insurance coverage and the Affordable Care Act, September 2015. https://aspe.hhs.gov/pdf-report/health-insurance-coverage-and-affordable-care-act-september-2015. Accessed April 11, 2016.

Research shows that the foundation of lifelong health is established during a child’s earliest years, including the prenatal period, and is also determined by the health of the future mother before she becomes pregnant. Much like the foundation of a house, if a child’s early years are filled with nurturing experiences and limited exposure to toxic stress, a child is set to succeed and withstand future challenges. However, adverse childhood experiences and toxic stress can disproportionately derail a child’s developmental growth and can lead to negative impacts throughout the lifespan, including social, emotional, and cognitive impairment; adoption of health risk behaviors; disease, disability, and social problems; and potentially early death.

Furthermore, data from the National Comorbidity Survey–Replication Sample (NCS-R) found that the prevalence of various mental health disorders – including disorders related to mood, anxiety, impulse control, and substance abuse – increases with the cumulative number of adverse childhood experiences. Persons with four or more childhood adversities had an odds ratio of 7.3 for four disorder categories.

Combined with recent data from the World Health Organization suggesting that the global cost of untreated mental health disorders is approximately $1 trillion, there is a clear public health crisis on our doorstep. Seeing our vulnerable patient population in the Bronx, family after family struggling to cope, I asked myself – is the solution on our doorstep too?

The role of the pediatrician

During a child’s early years, a pediatrician’s role is to identify signs of early childhood adversity and toxic stress, and to provide targeted support for parents and caregivers (Pediatrics. 2012 Jan. doi: 10.1542/peds.2011-2662). Given this, child primary care providers face the following challenges:

• Is there an opportunity for us to identify children at risk of developing mental health problems within the primary care setting?

• If so, how early can we identify children who would benefit from specific preventive or therapeutic interventions to optimize their developmental and behavioral potential?

• What tools are available in primary care to accomplish this function, and how should we administer them?

Healthy Steps program evaluation

At Montefiore Medical Group, we have developed a program that helps pediatricians overcome these challenges. Based on the national Healthy Steps program, Montefiore offers integrated mental health services in pediatric primary care settings, and provides universal screening, assessment, and treatment of young children and their caregivers.

A quasiexperimental longitudinal study was conducted, involving follow-up of 124 children enrolled in Healthy Steps at their primary care pediatric setting and a comparison group from a clinic that did not receive this intervention. The aim of the study was to determine the relationship between maternal adverse childhood experiences (ACES) and child social-emotional development, as measured via the Ages and States Questionnaire: Social Emotional (ASQ:SE) at age 36 months.

Social-emotional development is thought to be critical in terms of a child’s ability to learn and get along with others. It is also a precursor to mental health. Our results showed that, without intervention, there was a dramatic link between maternal ACES score and at-risk social-emotional development for children at age 3 years. However, our Healthy Steps program appeared to moderate this otherwise powerful link, as children who received Healthy Steps, even if their mother had experienced abuse or neglect in her own childhood, had healthy social-emotional development at age 3 years.

As a result of the success of Healthy Steps at Montefiore, in 2014 we expanded our pediatric integrated behavioral health program to also include school age and adolescent patients. Today, we are serving approximately 90,000 pediatric patients at more than 21 sites in the Bronx and surrounding area. We provide universal behavioral health screening, including for autism and maternal depression, at well-child visits. We provide parental mental health services, within pediatrics, to parents of infants and toddlers struggling with perinatal mental health challenges, and we devote significant time to education of our primary care providers, to increase their confidence and competence regarding pediatric behavioral health.

Initial results for school age, adolescent program

Our early results regarding feasibility are promising. We found that more than 26% of children presenting to the primary care practices, well beyond national averages, were referred to our program during a 6-month study period. And while a referral unfortunately rarely leads to actual treatment in mental health, we found that more than half of referred patients attended at least one therapy session, and a warm hand-off (a unique feature of integrated care in which psychologists meet with a referred patient during the well-child visit in order to establish a level of trust between patient and provider) increased this to 63%.

Future steps

Our efforts suggest that integration of pediatric behavioral health specialists into primary care is feasible, efficacious, and beneficial to children and parents. We have had success at identifying children at risk for exposure to toxic stress early in their lifetimes and providing multigenerational treatment to these children to ensure healthy social-emotional development. We have shown that when we offer mental health treatment within primary care, even in an urban setting where stigma around mental illness runs high, we almost triple the national average of successful linkage to mental health services for school age and adolescent children. However, payment reform is needed to truly achieve population health. We must ensure preventive and multigenerational services are covered so that we may continue to treat children and families within the nonstigmatized and universally accessed setting of primary care.

Dr. Briggs is director of pediatric behavioral health services and Healthy Steps at Montefiore Medical Group and associate professor of clinical pediatrics at Albert Einstein College of Medicine, both in New York.

Research shows that the foundation of lifelong health is established during a child’s earliest years, including the prenatal period, and is also determined by the health of the future mother before she becomes pregnant. Much like the foundation of a house, if a child’s early years are filled with nurturing experiences and limited exposure to toxic stress, a child is set to succeed and withstand future challenges. However, adverse childhood experiences and toxic stress can disproportionately derail a child’s developmental growth and can lead to negative impacts throughout the lifespan, including social, emotional, and cognitive impairment; adoption of health risk behaviors; disease, disability, and social problems; and potentially early death.

Furthermore, data from the National Comorbidity Survey–Replication Sample (NCS-R) found that the prevalence of various mental health disorders – including disorders related to mood, anxiety, impulse control, and substance abuse – increases with the cumulative number of adverse childhood experiences. Persons with four or more childhood adversities had an odds ratio of 7.3 for four disorder categories.

Combined with recent data from the World Health Organization suggesting that the global cost of untreated mental health disorders is approximately $1 trillion, there is a clear public health crisis on our doorstep. Seeing our vulnerable patient population in the Bronx, family after family struggling to cope, I asked myself – is the solution on our doorstep too?

The role of the pediatrician

During a child’s early years, a pediatrician’s role is to identify signs of early childhood adversity and toxic stress, and to provide targeted support for parents and caregivers (Pediatrics. 2012 Jan. doi: 10.1542/peds.2011-2662). Given this, child primary care providers face the following challenges:

• Is there an opportunity for us to identify children at risk of developing mental health problems within the primary care setting?

• If so, how early can we identify children who would benefit from specific preventive or therapeutic interventions to optimize their developmental and behavioral potential?

• What tools are available in primary care to accomplish this function, and how should we administer them?

Healthy Steps program evaluation

At Montefiore Medical Group, we have developed a program that helps pediatricians overcome these challenges. Based on the national Healthy Steps program, Montefiore offers integrated mental health services in pediatric primary care settings, and provides universal screening, assessment, and treatment of young children and their caregivers.

A quasiexperimental longitudinal study was conducted, involving follow-up of 124 children enrolled in Healthy Steps at their primary care pediatric setting and a comparison group from a clinic that did not receive this intervention. The aim of the study was to determine the relationship between maternal adverse childhood experiences (ACES) and child social-emotional development, as measured via the Ages and States Questionnaire: Social Emotional (ASQ:SE) at age 36 months.

Social-emotional development is thought to be critical in terms of a child’s ability to learn and get along with others. It is also a precursor to mental health. Our results showed that, without intervention, there was a dramatic link between maternal ACES score and at-risk social-emotional development for children at age 3 years. However, our Healthy Steps program appeared to moderate this otherwise powerful link, as children who received Healthy Steps, even if their mother had experienced abuse or neglect in her own childhood, had healthy social-emotional development at age 3 years.

As a result of the success of Healthy Steps at Montefiore, in 2014 we expanded our pediatric integrated behavioral health program to also include school age and adolescent patients. Today, we are serving approximately 90,000 pediatric patients at more than 21 sites in the Bronx and surrounding area. We provide universal behavioral health screening, including for autism and maternal depression, at well-child visits. We provide parental mental health services, within pediatrics, to parents of infants and toddlers struggling with perinatal mental health challenges, and we devote significant time to education of our primary care providers, to increase their confidence and competence regarding pediatric behavioral health.

Initial results for school age, adolescent program

Our early results regarding feasibility are promising. We found that more than 26% of children presenting to the primary care practices, well beyond national averages, were referred to our program during a 6-month study period. And while a referral unfortunately rarely leads to actual treatment in mental health, we found that more than half of referred patients attended at least one therapy session, and a warm hand-off (a unique feature of integrated care in which psychologists meet with a referred patient during the well-child visit in order to establish a level of trust between patient and provider) increased this to 63%.

Future steps

Our efforts suggest that integration of pediatric behavioral health specialists into primary care is feasible, efficacious, and beneficial to children and parents. We have had success at identifying children at risk for exposure to toxic stress early in their lifetimes and providing multigenerational treatment to these children to ensure healthy social-emotional development. We have shown that when we offer mental health treatment within primary care, even in an urban setting where stigma around mental illness runs high, we almost triple the national average of successful linkage to mental health services for school age and adolescent children. However, payment reform is needed to truly achieve population health. We must ensure preventive and multigenerational services are covered so that we may continue to treat children and families within the nonstigmatized and universally accessed setting of primary care.

Dr. Briggs is director of pediatric behavioral health services and Healthy Steps at Montefiore Medical Group and associate professor of clinical pediatrics at Albert Einstein College of Medicine, both in New York.

Research shows that the foundation of lifelong health is established during a child’s earliest years, including the prenatal period, and is also determined by the health of the future mother before she becomes pregnant. Much like the foundation of a house, if a child’s early years are filled with nurturing experiences and limited exposure to toxic stress, a child is set to succeed and withstand future challenges. However, adverse childhood experiences and toxic stress can disproportionately derail a child’s developmental growth and can lead to negative impacts throughout the lifespan, including social, emotional, and cognitive impairment; adoption of health risk behaviors; disease, disability, and social problems; and potentially early death.

Furthermore, data from the National Comorbidity Survey–Replication Sample (NCS-R) found that the prevalence of various mental health disorders – including disorders related to mood, anxiety, impulse control, and substance abuse – increases with the cumulative number of adverse childhood experiences. Persons with four or more childhood adversities had an odds ratio of 7.3 for four disorder categories.

Combined with recent data from the World Health Organization suggesting that the global cost of untreated mental health disorders is approximately $1 trillion, there is a clear public health crisis on our doorstep. Seeing our vulnerable patient population in the Bronx, family after family struggling to cope, I asked myself – is the solution on our doorstep too?

The role of the pediatrician

During a child’s early years, a pediatrician’s role is to identify signs of early childhood adversity and toxic stress, and to provide targeted support for parents and caregivers (Pediatrics. 2012 Jan. doi: 10.1542/peds.2011-2662). Given this, child primary care providers face the following challenges:

• Is there an opportunity for us to identify children at risk of developing mental health problems within the primary care setting?

• If so, how early can we identify children who would benefit from specific preventive or therapeutic interventions to optimize their developmental and behavioral potential?

• What tools are available in primary care to accomplish this function, and how should we administer them?

Healthy Steps program evaluation

At Montefiore Medical Group, we have developed a program that helps pediatricians overcome these challenges. Based on the national Healthy Steps program, Montefiore offers integrated mental health services in pediatric primary care settings, and provides universal screening, assessment, and treatment of young children and their caregivers.

A quasiexperimental longitudinal study was conducted, involving follow-up of 124 children enrolled in Healthy Steps at their primary care pediatric setting and a comparison group from a clinic that did not receive this intervention. The aim of the study was to determine the relationship between maternal adverse childhood experiences (ACES) and child social-emotional development, as measured via the Ages and States Questionnaire: Social Emotional (ASQ:SE) at age 36 months.

Social-emotional development is thought to be critical in terms of a child’s ability to learn and get along with others. It is also a precursor to mental health. Our results showed that, without intervention, there was a dramatic link between maternal ACES score and at-risk social-emotional development for children at age 3 years. However, our Healthy Steps program appeared to moderate this otherwise powerful link, as children who received Healthy Steps, even if their mother had experienced abuse or neglect in her own childhood, had healthy social-emotional development at age 3 years.

As a result of the success of Healthy Steps at Montefiore, in 2014 we expanded our pediatric integrated behavioral health program to also include school age and adolescent patients. Today, we are serving approximately 90,000 pediatric patients at more than 21 sites in the Bronx and surrounding area. We provide universal behavioral health screening, including for autism and maternal depression, at well-child visits. We provide parental mental health services, within pediatrics, to parents of infants and toddlers struggling with perinatal mental health challenges, and we devote significant time to education of our primary care providers, to increase their confidence and competence regarding pediatric behavioral health.

Initial results for school age, adolescent program

Our early results regarding feasibility are promising. We found that more than 26% of children presenting to the primary care practices, well beyond national averages, were referred to our program during a 6-month study period. And while a referral unfortunately rarely leads to actual treatment in mental health, we found that more than half of referred patients attended at least one therapy session, and a warm hand-off (a unique feature of integrated care in which psychologists meet with a referred patient during the well-child visit in order to establish a level of trust between patient and provider) increased this to 63%.

Future steps

Our efforts suggest that integration of pediatric behavioral health specialists into primary care is feasible, efficacious, and beneficial to children and parents. We have had success at identifying children at risk for exposure to toxic stress early in their lifetimes and providing multigenerational treatment to these children to ensure healthy social-emotional development. We have shown that when we offer mental health treatment within primary care, even in an urban setting where stigma around mental illness runs high, we almost triple the national average of successful linkage to mental health services for school age and adolescent children. However, payment reform is needed to truly achieve population health. We must ensure preventive and multigenerational services are covered so that we may continue to treat children and families within the nonstigmatized and universally accessed setting of primary care.

Dr. Briggs is director of pediatric behavioral health services and Healthy Steps at Montefiore Medical Group and associate professor of clinical pediatrics at Albert Einstein College of Medicine, both in New York.

Thomas M. DeBerardino, MD

Associate Editor for Sports Medicine

Dr. DeBerardino is an orthopedic surgeon specializing in sports medicine and arthroscopic surgery of the knee, hip, and shoulder; and team physician for the University of Connecticut athletic teams, including football and the men’s and women’s basketball programs. He attended the United States Military Academy, West Point as an undergraduate, completed medical school at the New York Medical College, and completed his residency at Tripler Army Medical Center. He also completed a John A. Feagin, Jr, Sports Medicine Fellowship at Keller Army Hospital, West Point. Previously he was head team physician for the collegiate athletic teams at the United States Military Academy, and Director of the Sports Medicine Fellowship. He is a member of many professional societies, including the American Orthopaedic Society for Sports Medicine (AOSSM), the International ACL Study Group, and the Herodicus Society.

Patrick J. Denard, MD

Associate Editor for Shoulder

Dr. Denard is a shoulder specialist at Southern Oregon Orthopedics in Medford, OR and a clinical instructor at Oregon Health & Science University. He attended college at the University of Puget Sound. He obtained his medical degree at Dartmouth College in New Hampshire. He completed his orthopedic residency training at Oregon Health & Science University, where he received the research award as a chief resident. After residency, he completed specialized fellowship training in shoulder arthroscopy in San Antonio, TX under Dr. Stephen Burkhart. Dr. Denard completed a fellowship in shoulder replacement surgery in Lyon, France under Dr. Gilles Walch, one of the developers of the current prosthesis used in reverse shoulder replacement. He has co-authored a textbook on the shoulder, and contributed to 15 book chapters and over 60 research papers. He was recently elected to the American Shoulder and Elbow Surgeons (ASES).

Anand M. Murthi, MD

Associate Editor for Shoulder

Dr. Murthi is attending orthopedic surgeon; chief, shoulder and elbow service; and fellowship director at MedStar Union Memorial Hospital in Baltimore, MD. He received his undergraduate degree in Chemistry and Psychology and his doctorate degree from Case Western Reserve University. He completed an internship in general surgery, residency in orthopedic surgery, and was a chief resident in orthopedic surgery at George Washington University Medical Center. He also completed a fellowship in shoulder and elbow surgery at Columbia-Presbyterian Medical Center. He is a member of numerous societies, including the American Academy of Orthopaedic Surgeons (AAOS), American Medical Association (AMA), and American Shoulder and Elbow Surgeons (ASES).

Jose B. Toro, MD

Associate Editor for Trauma

Dr. Toro is director for orthopaedic trauma at Peconic Bay Medical Center. He obtained his medical degree from Pontifical Xavier University in Bogota, Colombia, where he also trained in the specialty of orthopedic surgery. Dr. Toro started his fellowship training at the Hospital for Special Surgery, where he completed a fellowship in orthopedic traumatology under the tutelage of Dr. David L. Helfet and a fellowship in metabolic bone disease under the supervision of Dr. Joseph Lane. Dr. Toro started his professional career as an attending orthopaedic surgeon at the Veterans Affairs administration of the James J. Peters Bronx VA Medical Center. He also has served as director of orthopaedic trauma and assistant professor in orthopaedic surgery at the Albert Einstein College of Medicine, Jacobi Medical Center, Bronx, New York.

Thomas M. DeBerardino, MD

Associate Editor for Sports Medicine

Dr. DeBerardino is an orthopedic surgeon specializing in sports medicine and arthroscopic surgery of the knee, hip, and shoulder; and team physician for the University of Connecticut athletic teams, including football and the men’s and women’s basketball programs. He attended the United States Military Academy, West Point as an undergraduate, completed medical school at the New York Medical College, and completed his residency at Tripler Army Medical Center. He also completed a John A. Feagin, Jr, Sports Medicine Fellowship at Keller Army Hospital, West Point. Previously he was head team physician for the collegiate athletic teams at the United States Military Academy, and Director of the Sports Medicine Fellowship. He is a member of many professional societies, including the American Orthopaedic Society for Sports Medicine (AOSSM), the International ACL Study Group, and the Herodicus Society.

Patrick J. Denard, MD

Associate Editor for Shoulder

Dr. Denard is a shoulder specialist at Southern Oregon Orthopedics in Medford, OR and a clinical instructor at Oregon Health & Science University. He attended college at the University of Puget Sound. He obtained his medical degree at Dartmouth College in New Hampshire. He completed his orthopedic residency training at Oregon Health & Science University, where he received the research award as a chief resident. After residency, he completed specialized fellowship training in shoulder arthroscopy in San Antonio, TX under Dr. Stephen Burkhart. Dr. Denard completed a fellowship in shoulder replacement surgery in Lyon, France under Dr. Gilles Walch, one of the developers of the current prosthesis used in reverse shoulder replacement. He has co-authored a textbook on the shoulder, and contributed to 15 book chapters and over 60 research papers. He was recently elected to the American Shoulder and Elbow Surgeons (ASES).

Anand M. Murthi, MD

Associate Editor for Shoulder

Dr. Murthi is attending orthopedic surgeon; chief, shoulder and elbow service; and fellowship director at MedStar Union Memorial Hospital in Baltimore, MD. He received his undergraduate degree in Chemistry and Psychology and his doctorate degree from Case Western Reserve University. He completed an internship in general surgery, residency in orthopedic surgery, and was a chief resident in orthopedic surgery at George Washington University Medical Center. He also completed a fellowship in shoulder and elbow surgery at Columbia-Presbyterian Medical Center. He is a member of numerous societies, including the American Academy of Orthopaedic Surgeons (AAOS), American Medical Association (AMA), and American Shoulder and Elbow Surgeons (ASES).

Jose B. Toro, MD

Associate Editor for Trauma

Dr. Toro is director for orthopaedic trauma at Peconic Bay Medical Center. He obtained his medical degree from Pontifical Xavier University in Bogota, Colombia, where he also trained in the specialty of orthopedic surgery. Dr. Toro started his fellowship training at the Hospital for Special Surgery, where he completed a fellowship in orthopedic traumatology under the tutelage of Dr. David L. Helfet and a fellowship in metabolic bone disease under the supervision of Dr. Joseph Lane. Dr. Toro started his professional career as an attending orthopaedic surgeon at the Veterans Affairs administration of the James J. Peters Bronx VA Medical Center. He also has served as director of orthopaedic trauma and assistant professor in orthopaedic surgery at the Albert Einstein College of Medicine, Jacobi Medical Center, Bronx, New York.

Thomas M. DeBerardino, MD

Associate Editor for Sports Medicine

Dr. DeBerardino is an orthopedic surgeon specializing in sports medicine and arthroscopic surgery of the knee, hip, and shoulder; and team physician for the University of Connecticut athletic teams, including football and the men’s and women’s basketball programs. He attended the United States Military Academy, West Point as an undergraduate, completed medical school at the New York Medical College, and completed his residency at Tripler Army Medical Center. He also completed a John A. Feagin, Jr, Sports Medicine Fellowship at Keller Army Hospital, West Point. Previously he was head team physician for the collegiate athletic teams at the United States Military Academy, and Director of the Sports Medicine Fellowship. He is a member of many professional societies, including the American Orthopaedic Society for Sports Medicine (AOSSM), the International ACL Study Group, and the Herodicus Society.

Patrick J. Denard, MD

Associate Editor for Shoulder

Dr. Denard is a shoulder specialist at Southern Oregon Orthopedics in Medford, OR and a clinical instructor at Oregon Health & Science University. He attended college at the University of Puget Sound. He obtained his medical degree at Dartmouth College in New Hampshire. He completed his orthopedic residency training at Oregon Health & Science University, where he received the research award as a chief resident. After residency, he completed specialized fellowship training in shoulder arthroscopy in San Antonio, TX under Dr. Stephen Burkhart. Dr. Denard completed a fellowship in shoulder replacement surgery in Lyon, France under Dr. Gilles Walch, one of the developers of the current prosthesis used in reverse shoulder replacement. He has co-authored a textbook on the shoulder, and contributed to 15 book chapters and over 60 research papers. He was recently elected to the American Shoulder and Elbow Surgeons (ASES).

Anand M. Murthi, MD

Associate Editor for Shoulder

Dr. Murthi is attending orthopedic surgeon; chief, shoulder and elbow service; and fellowship director at MedStar Union Memorial Hospital in Baltimore, MD. He received his undergraduate degree in Chemistry and Psychology and his doctorate degree from Case Western Reserve University. He completed an internship in general surgery, residency in orthopedic surgery, and was a chief resident in orthopedic surgery at George Washington University Medical Center. He also completed a fellowship in shoulder and elbow surgery at Columbia-Presbyterian Medical Center. He is a member of numerous societies, including the American Academy of Orthopaedic Surgeons (AAOS), American Medical Association (AMA), and American Shoulder and Elbow Surgeons (ASES).

Jose B. Toro, MD

Associate Editor for Trauma

Dr. Toro is director for orthopaedic trauma at Peconic Bay Medical Center. He obtained his medical degree from Pontifical Xavier University in Bogota, Colombia, where he also trained in the specialty of orthopedic surgery. Dr. Toro started his fellowship training at the Hospital for Special Surgery, where he completed a fellowship in orthopedic traumatology under the tutelage of Dr. David L. Helfet and a fellowship in metabolic bone disease under the supervision of Dr. Joseph Lane. Dr. Toro started his professional career as an attending orthopaedic surgeon at the Veterans Affairs administration of the James J. Peters Bronx VA Medical Center. He also has served as director of orthopaedic trauma and assistant professor in orthopaedic surgery at the Albert Einstein College of Medicine, Jacobi Medical Center, Bronx, New York.

What is causing the alarming increase in suicides in the United States, and what can psychiatrists do to help?

The Centers for Disease Control and Prevention recently reported that the suicide rate in 2014 was 13/100,000, a 24% increase from the 1999 rate of 10.5/100,000. Every age group from 10 to 74 had an increase in suicides; people over age 75 had a decrease. The suicide rate increased by 1% yearly from 1999 through 2006 and then by 2% per year from 2006 through 2014.

It’s hard to find a single explanation for the increased suicide rates, since so many events have rocked our country since 1999. You could talk about 9/11 and the wars that followed, you could mention the Great Recession of 2007-2009 and its anemic recovery, and you could note the growing disparity between the rich and the poor as placing immeasurable stress on this country.

The economy and war do not explain the most startling statistic: The suicide rate for girls aged 10-14 tripled from 1999 to 2014. I can only speculate on the cause of this rise, but I believe social media play a role. Facebook was launched in 2004, and there are now dozens of social media sites that adolescent girls use, despite age restrictions. The bullying and sexual harassment that have always been part of the adolescent years now can be amplified when a message or post goes viral. Cyberbullying has been linked to some high-profile adolescent suicides. While researching this topic, I learned about a book, “American Girls: Social Media and the Secret Lives of Teenagers” (New York: Knopf, 2016) by Nancy Jo Sales, which highlights the harm of unmonitored social media use on girls’ psyches.

While women had a larger increase than men in suicide rates, men’s rates continue to exceed women’s rates. The ratio of male to female suicides was 3.6 in 2014, a decrease from a rate of 4.5 in 1999. Possible explanations for men’s continued higher suicide rates include their decreased likelihood of seeking help for mental health issues and increased likelihood of using more lethal means (firearms) in suicide attempts.

Most psychiatrists may not be surprised to learn that suicide rates have steadily risen from 1999 to 2014. In my own work as a university counseling center psychiatrist, I see a student population with increased rates of anxiety, depression, and suicidal thoughts and behaviors. Suicide is now the second-leading cause of death for people aged 15-24.

Whenever I hear about a suicide, I lament that the individual either did not seek treatment or lost faith in the treatment they were in. Tragically, it is estimated that 2 out of 3 of people who killed themselves suffered from depression, and the majority of them were not receiving treatment. If they only knew what we have seen as psychiatrists – amazing recoveries in people who had nearly given up hope.

How do we engage people who are depressed and suicidal into believing they can get help and feel good again?

We have to start young, by educating parents about the warning signs of depression and suicide in their children. For the last few years, I have written parenting articles, given talks, and done radio shows on mental health. Psychiatrists can teach parents through writing and speaking in their local communities. Parents should be encouraged to monitor their child’s social media use. Parents should urge both girls and boys to talk openly about their feelings and not be afraid to ask for help.

We have to encourage people of all ages to recognize and get early treatment for mental health problems. We need to get the word out that there is strength in seeking help. We have to fight the stigma that continues to accompany mental health treatment.

We also need to loudly support more funding for mental health. Too many of my patients who need intensive levels of treatment for psychosis, severe depression, or borderline personality disorder lack access to care; some have no insurance or insurance with limited coverage. Write your congressman, senator, or local representative to support bills that increase mental health coverage. Promote groups like NAMI, National Alliance on Mental Illness, and the Depression and Bipolar Support Alliance that provide support and advocacy.

Over the next few months, there may be explanations for the increased suicide rates and a public health approach to this problem. There is one fact we know: Many people with mental health issues are not getting treatment. Now more than ever, psychiatrists need to go beyond the walls of their office to educate the public about the benefits of treatment, and to advocate for greater access to care.

Dr. Morris is a psychiatrist at the University of Florida Counseling and Wellness Center in Gainesville and has provided clinical care to University of Florida students for the last 20 years. Her areas of specialty include depression, eating disorders, and anxiety disorders.

What is causing the alarming increase in suicides in the United States, and what can psychiatrists do to help?

The Centers for Disease Control and Prevention recently reported that the suicide rate in 2014 was 13/100,000, a 24% increase from the 1999 rate of 10.5/100,000. Every age group from 10 to 74 had an increase in suicides; people over age 75 had a decrease. The suicide rate increased by 1% yearly from 1999 through 2006 and then by 2% per year from 2006 through 2014.

It’s hard to find a single explanation for the increased suicide rates, since so many events have rocked our country since 1999. You could talk about 9/11 and the wars that followed, you could mention the Great Recession of 2007-2009 and its anemic recovery, and you could note the growing disparity between the rich and the poor as placing immeasurable stress on this country.

The economy and war do not explain the most startling statistic: The suicide rate for girls aged 10-14 tripled from 1999 to 2014. I can only speculate on the cause of this rise, but I believe social media play a role. Facebook was launched in 2004, and there are now dozens of social media sites that adolescent girls use, despite age restrictions. The bullying and sexual harassment that have always been part of the adolescent years now can be amplified when a message or post goes viral. Cyberbullying has been linked to some high-profile adolescent suicides. While researching this topic, I learned about a book, “American Girls: Social Media and the Secret Lives of Teenagers” (New York: Knopf, 2016) by Nancy Jo Sales, which highlights the harm of unmonitored social media use on girls’ psyches.

While women had a larger increase than men in suicide rates, men’s rates continue to exceed women’s rates. The ratio of male to female suicides was 3.6 in 2014, a decrease from a rate of 4.5 in 1999. Possible explanations for men’s continued higher suicide rates include their decreased likelihood of seeking help for mental health issues and increased likelihood of using more lethal means (firearms) in suicide attempts.

Most psychiatrists may not be surprised to learn that suicide rates have steadily risen from 1999 to 2014. In my own work as a university counseling center psychiatrist, I see a student population with increased rates of anxiety, depression, and suicidal thoughts and behaviors. Suicide is now the second-leading cause of death for people aged 15-24.

Whenever I hear about a suicide, I lament that the individual either did not seek treatment or lost faith in the treatment they were in. Tragically, it is estimated that 2 out of 3 of people who killed themselves suffered from depression, and the majority of them were not receiving treatment. If they only knew what we have seen as psychiatrists – amazing recoveries in people who had nearly given up hope.

How do we engage people who are depressed and suicidal into believing they can get help and feel good again?

We have to start young, by educating parents about the warning signs of depression and suicide in their children. For the last few years, I have written parenting articles, given talks, and done radio shows on mental health. Psychiatrists can teach parents through writing and speaking in their local communities. Parents should be encouraged to monitor their child’s social media use. Parents should urge both girls and boys to talk openly about their feelings and not be afraid to ask for help.

We have to encourage people of all ages to recognize and get early treatment for mental health problems. We need to get the word out that there is strength in seeking help. We have to fight the stigma that continues to accompany mental health treatment.

We also need to loudly support more funding for mental health. Too many of my patients who need intensive levels of treatment for psychosis, severe depression, or borderline personality disorder lack access to care; some have no insurance or insurance with limited coverage. Write your congressman, senator, or local representative to support bills that increase mental health coverage. Promote groups like NAMI, National Alliance on Mental Illness, and the Depression and Bipolar Support Alliance that provide support and advocacy.

Over the next few months, there may be explanations for the increased suicide rates and a public health approach to this problem. There is one fact we know: Many people with mental health issues are not getting treatment. Now more than ever, psychiatrists need to go beyond the walls of their office to educate the public about the benefits of treatment, and to advocate for greater access to care.

Dr. Morris is a psychiatrist at the University of Florida Counseling and Wellness Center in Gainesville and has provided clinical care to University of Florida students for the last 20 years. Her areas of specialty include depression, eating disorders, and anxiety disorders.

What is causing the alarming increase in suicides in the United States, and what can psychiatrists do to help?

The Centers for Disease Control and Prevention recently reported that the suicide rate in 2014 was 13/100,000, a 24% increase from the 1999 rate of 10.5/100,000. Every age group from 10 to 74 had an increase in suicides; people over age 75 had a decrease. The suicide rate increased by 1% yearly from 1999 through 2006 and then by 2% per year from 2006 through 2014.

It’s hard to find a single explanation for the increased suicide rates, since so many events have rocked our country since 1999. You could talk about 9/11 and the wars that followed, you could mention the Great Recession of 2007-2009 and its anemic recovery, and you could note the growing disparity between the rich and the poor as placing immeasurable stress on this country.

The economy and war do not explain the most startling statistic: The suicide rate for girls aged 10-14 tripled from 1999 to 2014. I can only speculate on the cause of this rise, but I believe social media play a role. Facebook was launched in 2004, and there are now dozens of social media sites that adolescent girls use, despite age restrictions. The bullying and sexual harassment that have always been part of the adolescent years now can be amplified when a message or post goes viral. Cyberbullying has been linked to some high-profile adolescent suicides. While researching this topic, I learned about a book, “American Girls: Social Media and the Secret Lives of Teenagers” (New York: Knopf, 2016) by Nancy Jo Sales, which highlights the harm of unmonitored social media use on girls’ psyches.

While women had a larger increase than men in suicide rates, men’s rates continue to exceed women’s rates. The ratio of male to female suicides was 3.6 in 2014, a decrease from a rate of 4.5 in 1999. Possible explanations for men’s continued higher suicide rates include their decreased likelihood of seeking help for mental health issues and increased likelihood of using more lethal means (firearms) in suicide attempts.

Most psychiatrists may not be surprised to learn that suicide rates have steadily risen from 1999 to 2014. In my own work as a university counseling center psychiatrist, I see a student population with increased rates of anxiety, depression, and suicidal thoughts and behaviors. Suicide is now the second-leading cause of death for people aged 15-24.

Whenever I hear about a suicide, I lament that the individual either did not seek treatment or lost faith in the treatment they were in. Tragically, it is estimated that 2 out of 3 of people who killed themselves suffered from depression, and the majority of them were not receiving treatment. If they only knew what we have seen as psychiatrists – amazing recoveries in people who had nearly given up hope.

How do we engage people who are depressed and suicidal into believing they can get help and feel good again?

We have to start young, by educating parents about the warning signs of depression and suicide in their children. For the last few years, I have written parenting articles, given talks, and done radio shows on mental health. Psychiatrists can teach parents through writing and speaking in their local communities. Parents should be encouraged to monitor their child’s social media use. Parents should urge both girls and boys to talk openly about their feelings and not be afraid to ask for help.

We have to encourage people of all ages to recognize and get early treatment for mental health problems. We need to get the word out that there is strength in seeking help. We have to fight the stigma that continues to accompany mental health treatment.

We also need to loudly support more funding for mental health. Too many of my patients who need intensive levels of treatment for psychosis, severe depression, or borderline personality disorder lack access to care; some have no insurance or insurance with limited coverage. Write your congressman, senator, or local representative to support bills that increase mental health coverage. Promote groups like NAMI, National Alliance on Mental Illness, and the Depression and Bipolar Support Alliance that provide support and advocacy.

Over the next few months, there may be explanations for the increased suicide rates and a public health approach to this problem. There is one fact we know: Many people with mental health issues are not getting treatment. Now more than ever, psychiatrists need to go beyond the walls of their office to educate the public about the benefits of treatment, and to advocate for greater access to care.

Dr. Morris is a psychiatrist at the University of Florida Counseling and Wellness Center in Gainesville and has provided clinical care to University of Florida students for the last 20 years. Her areas of specialty include depression, eating disorders, and anxiety disorders.

In May, Rebecca (Becky) Maron CAE, the first Executive Director of the Society for Vascular Surgery, is retiring. Becky played a pivotal role in setting the stage for the exponential growth and success of the SVS we know today. Her leadership ability, strategic planning acumen and management style were a perfect fit with the visionary SVS voluntary leadership. This has continued to be true throughout her 13-year tenure with the Society.

I am certain that every SVS President and committee member who has worked with Becky over the years will agree that she has a wonderful “board side” manner – she is a true partner, always providing support and guidance to ensure that each leader is able to achieve the Society’s goals and objectives during their term of office. Patricia Burton, Deputy Executive Director and Executive Director of the SVS Foundation, writes that “Staff would agree that Becky is a wonderful leader as well, always providing just the right amount of oversight and direction needed.” Becky has also been instrumental in the growth of the SVS through the addition of new programs and services, the most notable of which are the SVS PSO and VQI. We will definitely miss her guidance.

I asked Becky if I could interview her for this editorial but she respectfully declined stating “I prefer to stay a behind the scenes person.” Come to think of it, I would expect nothing more of this demure person who has been both a good friend and mentor to me in my position as medical editor of Vascular Specialist. Becky oversees my editorials and makes sure that I do not embarrass myself or the Society, and she frequently has provided me with important direction in developing these opinion pieces.

However, her reluctance to being feted made me realize that there are many others who work for the Society yet gain little or no recognition. These include our excellent paid fulltime staff but more significantly the “Silent Minority,” the members who serve on SVS committees. There are 36 committees including the various Councils and the Board of the SVS, requiring the work of over 500 volunteers. Currently, at least 100 members serve on at least two, and many serve on a multitude of committees. Almost all of these volunteers are also “behind the scenes persons” garnering little recognition from the general membership. They are, for the most part, busy clinical surgeons during the day but willing to devote countless hours, usually at night and on weekends, to their committee work. Yes, “Silent” they may be but why do I refer to them as the “Minority”? After all, isn’t 400 a large number? Well, not really. The SVS has over 5,000 members of whom 2,200 are active. So only about 20% of active members participate in its organizational activities. Further, many of these are a dedicated cadre who have been involved year after year. Perhaps the real “silent minority” are the limited number of members who contribute to the SVS PAC. I gather that no more than 10% are donors and once again it is that small group who pledge year in and year out. Yet the PAC is so critical to all vascular surgeons. It is one of our most important methods of assuring the survival of our specialty and our ability to serve vascular patients.

So why are so few members willing to contribute time or money to further the functions of the SVS? Perhaps it is because many members still do not realize just how our Society has evolved since Becky became its first Executive Director. Thirteen years ago, two predominantly academic vascular societies merged into one, becoming the preeminent Society for all U.S. vascular surgeons. Originally, its dominant function was to put on a premier vascular meeting. Of course this is still a major function of our Society and most would agree that the annual VAM is the foremost meeting of its kind in the world. This year’s upcoming meeting organized by Ron Dalman and his committee may be the best ever. However, over the ensuing years, the SVS has become involved not only in the academic arena but in government relations, patient education, training of future vascular surgeons, postgraduate education, research, quality assessment, and all aspects of vascular and endovascular surgery. It argues on our behalf for improved payment for our services. It funds research enterprises and trains future leaders. It provides courses on coding vascular and endovascular surgeries. It now provides the essential tool for quality initiatives. There is representation on it from regional, other national, and many international vascular societies. It produces the Journal of Vascular Surgery, the Journal of Venous and Lymphatic Disorders, the Journal of Vascular Cases, Rutherford’s textbook of Vascular Surgery and, of course, this newspaper -Vascular Specialist.

Furthermore, it authors authoritative manuscripts and position papers on current diagnostics and therapies for vascular disorders.

Let me assure you, the Society for Vascular Surgery bears little resemblance to that original Society Becky inherited. Through her efforts, and the tireless silent work of many vascular surgeons and office staff, we are now the beneficiaries of this amazing organization. But it still has much more to offer and more goals to achieve. Most importantly it needs to increase public recognition of what we do as vascular surgeons and why patients should entrust their vascular health to us rather than some of the other specialists involved in delivering vascular care.

In the ensuing months Ron Fairman, Clem Darling, and Bruce Perler, three of our most tireless “minority” will select volunteers to serve on the various SVS committees. Many members have already volunteered but I urge all to consider helping. If not now, perhaps next year. And please consider making a donation to our Political Action Committee. It may be true that many practitioners either don’t have the time or the interest to pursue such positions. Some may feel that even if they serve they will not have the power to make a significant change that could positively affect our lives or those of our patients. I fervently believe that is not the case! The more volunteers and donors, the better the chance that vascular surgeons will no longer be seen as a silent minority but rather the outspoken leaders in the field. n

In May, Rebecca (Becky) Maron CAE, the first Executive Director of the Society for Vascular Surgery, is retiring. Becky played a pivotal role in setting the stage for the exponential growth and success of the SVS we know today. Her leadership ability, strategic planning acumen and management style were a perfect fit with the visionary SVS voluntary leadership. This has continued to be true throughout her 13-year tenure with the Society.

I am certain that every SVS President and committee member who has worked with Becky over the years will agree that she has a wonderful “board side” manner – she is a true partner, always providing support and guidance to ensure that each leader is able to achieve the Society’s goals and objectives during their term of office. Patricia Burton, Deputy Executive Director and Executive Director of the SVS Foundation, writes that “Staff would agree that Becky is a wonderful leader as well, always providing just the right amount of oversight and direction needed.” Becky has also been instrumental in the growth of the SVS through the addition of new programs and services, the most notable of which are the SVS PSO and VQI. We will definitely miss her guidance.

I asked Becky if I could interview her for this editorial but she respectfully declined stating “I prefer to stay a behind the scenes person.” Come to think of it, I would expect nothing more of this demure person who has been both a good friend and mentor to me in my position as medical editor of Vascular Specialist. Becky oversees my editorials and makes sure that I do not embarrass myself or the Society, and she frequently has provided me with important direction in developing these opinion pieces.

However, her reluctance to being feted made me realize that there are many others who work for the Society yet gain little or no recognition. These include our excellent paid fulltime staff but more significantly the “Silent Minority,” the members who serve on SVS committees. There are 36 committees including the various Councils and the Board of the SVS, requiring the work of over 500 volunteers. Currently, at least 100 members serve on at least two, and many serve on a multitude of committees. Almost all of these volunteers are also “behind the scenes persons” garnering little recognition from the general membership. They are, for the most part, busy clinical surgeons during the day but willing to devote countless hours, usually at night and on weekends, to their committee work. Yes, “Silent” they may be but why do I refer to them as the “Minority”? After all, isn’t 400 a large number? Well, not really. The SVS has over 5,000 members of whom 2,200 are active. So only about 20% of active members participate in its organizational activities. Further, many of these are a dedicated cadre who have been involved year after year. Perhaps the real “silent minority” are the limited number of members who contribute to the SVS PAC. I gather that no more than 10% are donors and once again it is that small group who pledge year in and year out. Yet the PAC is so critical to all vascular surgeons. It is one of our most important methods of assuring the survival of our specialty and our ability to serve vascular patients.

So why are so few members willing to contribute time or money to further the functions of the SVS? Perhaps it is because many members still do not realize just how our Society has evolved since Becky became its first Executive Director. Thirteen years ago, two predominantly academic vascular societies merged into one, becoming the preeminent Society for all U.S. vascular surgeons. Originally, its dominant function was to put on a premier vascular meeting. Of course this is still a major function of our Society and most would agree that the annual VAM is the foremost meeting of its kind in the world. This year’s upcoming meeting organized by Ron Dalman and his committee may be the best ever. However, over the ensuing years, the SVS has become involved not only in the academic arena but in government relations, patient education, training of future vascular surgeons, postgraduate education, research, quality assessment, and all aspects of vascular and endovascular surgery. It argues on our behalf for improved payment for our services. It funds research enterprises and trains future leaders. It provides courses on coding vascular and endovascular surgeries. It now provides the essential tool for quality initiatives. There is representation on it from regional, other national, and many international vascular societies. It produces the Journal of Vascular Surgery, the Journal of Venous and Lymphatic Disorders, the Journal of Vascular Cases, Rutherford’s textbook of Vascular Surgery and, of course, this newspaper -Vascular Specialist.

Furthermore, it authors authoritative manuscripts and position papers on current diagnostics and therapies for vascular disorders.

Let me assure you, the Society for Vascular Surgery bears little resemblance to that original Society Becky inherited. Through her efforts, and the tireless silent work of many vascular surgeons and office staff, we are now the beneficiaries of this amazing organization. But it still has much more to offer and more goals to achieve. Most importantly it needs to increase public recognition of what we do as vascular surgeons and why patients should entrust their vascular health to us rather than some of the other specialists involved in delivering vascular care.

In the ensuing months Ron Fairman, Clem Darling, and Bruce Perler, three of our most tireless “minority” will select volunteers to serve on the various SVS committees. Many members have already volunteered but I urge all to consider helping. If not now, perhaps next year. And please consider making a donation to our Political Action Committee. It may be true that many practitioners either don’t have the time or the interest to pursue such positions. Some may feel that even if they serve they will not have the power to make a significant change that could positively affect our lives or those of our patients. I fervently believe that is not the case! The more volunteers and donors, the better the chance that vascular surgeons will no longer be seen as a silent minority but rather the outspoken leaders in the field. n

In May, Rebecca (Becky) Maron CAE, the first Executive Director of the Society for Vascular Surgery, is retiring. Becky played a pivotal role in setting the stage for the exponential growth and success of the SVS we know today. Her leadership ability, strategic planning acumen and management style were a perfect fit with the visionary SVS voluntary leadership. This has continued to be true throughout her 13-year tenure with the Society.

I am certain that every SVS President and committee member who has worked with Becky over the years will agree that she has a wonderful “board side” manner – she is a true partner, always providing support and guidance to ensure that each leader is able to achieve the Society’s goals and objectives during their term of office. Patricia Burton, Deputy Executive Director and Executive Director of the SVS Foundation, writes that “Staff would agree that Becky is a wonderful leader as well, always providing just the right amount of oversight and direction needed.” Becky has also been instrumental in the growth of the SVS through the addition of new programs and services, the most notable of which are the SVS PSO and VQI. We will definitely miss her guidance.

I asked Becky if I could interview her for this editorial but she respectfully declined stating “I prefer to stay a behind the scenes person.” Come to think of it, I would expect nothing more of this demure person who has been both a good friend and mentor to me in my position as medical editor of Vascular Specialist. Becky oversees my editorials and makes sure that I do not embarrass myself or the Society, and she frequently has provided me with important direction in developing these opinion pieces.

However, her reluctance to being feted made me realize that there are many others who work for the Society yet gain little or no recognition. These include our excellent paid fulltime staff but more significantly the “Silent Minority,” the members who serve on SVS committees. There are 36 committees including the various Councils and the Board of the SVS, requiring the work of over 500 volunteers. Currently, at least 100 members serve on at least two, and many serve on a multitude of committees. Almost all of these volunteers are also “behind the scenes persons” garnering little recognition from the general membership. They are, for the most part, busy clinical surgeons during the day but willing to devote countless hours, usually at night and on weekends, to their committee work. Yes, “Silent” they may be but why do I refer to them as the “Minority”? After all, isn’t 400 a large number? Well, not really. The SVS has over 5,000 members of whom 2,200 are active. So only about 20% of active members participate in its organizational activities. Further, many of these are a dedicated cadre who have been involved year after year. Perhaps the real “silent minority” are the limited number of members who contribute to the SVS PAC. I gather that no more than 10% are donors and once again it is that small group who pledge year in and year out. Yet the PAC is so critical to all vascular surgeons. It is one of our most important methods of assuring the survival of our specialty and our ability to serve vascular patients.

So why are so few members willing to contribute time or money to further the functions of the SVS? Perhaps it is because many members still do not realize just how our Society has evolved since Becky became its first Executive Director. Thirteen years ago, two predominantly academic vascular societies merged into one, becoming the preeminent Society for all U.S. vascular surgeons. Originally, its dominant function was to put on a premier vascular meeting. Of course this is still a major function of our Society and most would agree that the annual VAM is the foremost meeting of its kind in the world. This year’s upcoming meeting organized by Ron Dalman and his committee may be the best ever. However, over the ensuing years, the SVS has become involved not only in the academic arena but in government relations, patient education, training of future vascular surgeons, postgraduate education, research, quality assessment, and all aspects of vascular and endovascular surgery. It argues on our behalf for improved payment for our services. It funds research enterprises and trains future leaders. It provides courses on coding vascular and endovascular surgeries. It now provides the essential tool for quality initiatives. There is representation on it from regional, other national, and many international vascular societies. It produces the Journal of Vascular Surgery, the Journal of Venous and Lymphatic Disorders, the Journal of Vascular Cases, Rutherford’s textbook of Vascular Surgery and, of course, this newspaper -Vascular Specialist.

Furthermore, it authors authoritative manuscripts and position papers on current diagnostics and therapies for vascular disorders.

Let me assure you, the Society for Vascular Surgery bears little resemblance to that original Society Becky inherited. Through her efforts, and the tireless silent work of many vascular surgeons and office staff, we are now the beneficiaries of this amazing organization. But it still has much more to offer and more goals to achieve. Most importantly it needs to increase public recognition of what we do as vascular surgeons and why patients should entrust their vascular health to us rather than some of the other specialists involved in delivering vascular care.

In the ensuing months Ron Fairman, Clem Darling, and Bruce Perler, three of our most tireless “minority” will select volunteers to serve on the various SVS committees. Many members have already volunteered but I urge all to consider helping. If not now, perhaps next year. And please consider making a donation to our Political Action Committee. It may be true that many practitioners either don’t have the time or the interest to pursue such positions. Some may feel that even if they serve they will not have the power to make a significant change that could positively affect our lives or those of our patients. I fervently believe that is not the case! The more volunteers and donors, the better the chance that vascular surgeons will no longer be seen as a silent minority but rather the outspoken leaders in the field. n

I have been an RN for about 30 years and an NP for the past seven years. In the busy and intense internal medicine practice where I am employed, I have had the pleasure of precepting five or six students in the past six years. I am currently taking a break and am not sure if I will ever precept again.

You are so right in regard to having the time to precept students with the issues of productivity, etc. The hospital group that I am employed by actually encourages precepting, however the extra time that is needed to teach a student usually leads to later evenings trying to catch up. Beyond those issues, the last student I had has been an RN for about a year and is totally unprepared for the rigors and responsibilities of being an NP. I actually could not pass this person in certain areas, such as pharmacology, due to concerns I had with safety and lack of a strong knowledge base. This person had a very poor understanding of the basics of pharmacology; I really could not believe that this student had taken a pharmacology class at an APN level or even in basic RN courses. A preceptor is a person who is willing to teach and guide another person; I do not feel the responsibility is that of a classroom instructor. We should be building on their classroom knowledge.

Another frustrating issue is that there was absolutely no contact with the college until I reached out to them two weeks after the internship ended.  It was also difficult to obtain a certificate stating I had precepted to receive CME credit.

The paperwork from the three universities I have precepted for has been manageable. However, each time I sign up to help out a student at a new school, I have to resubmit all of my information (my resume, etc.) I have found other groups within the medical practice that have contracted with one college only. I now understand why! I see reason to submit my license data, but beyond that am not sure why so much is necessary.  I feel the schools of nursing have no idea what it is like to work 10-hour days with very little free time.

I am very concerned with the quality of the current programs; I am hoping that schools are not lowering their admission standards, since this will greatly affect the profession as a whole, specifically the respect of and employment by the medical community.

Name Withheld by Request

FOR MORE LETTERS TO THE EDITOR:
Do Veteran PAs Care Less, Or Are New PA Students Careless?
Insurance and Billing Qualms Double the Work
Precepting: I Love It, But ...
Preceptor Tax Incentive Program: The Realities

I have been an RN for about 30 years and an NP for the past seven years. In the busy and intense internal medicine practice where I am employed, I have had the pleasure of precepting five or six students in the past six years. I am currently taking a break and am not sure if I will ever precept again.

You are so right in regard to having the time to precept students with the issues of productivity, etc. The hospital group that I am employed by actually encourages precepting, however the extra time that is needed to teach a student usually leads to later evenings trying to catch up. Beyond those issues, the last student I had has been an RN for about a year and is totally unprepared for the rigors and responsibilities of being an NP. I actually could not pass this person in certain areas, such as pharmacology, due to concerns I had with safety and lack of a strong knowledge base. This person had a very poor understanding of the basics of pharmacology; I really could not believe that this student had taken a pharmacology class at an APN level or even in basic RN courses. A preceptor is a person who is willing to teach and guide another person; I do not feel the responsibility is that of a classroom instructor. We should be building on their classroom knowledge.

Another frustrating issue is that there was absolutely no contact with the college until I reached out to them two weeks after the internship ended.  It was also difficult to obtain a certificate stating I had precepted to receive CME credit.

The paperwork from the three universities I have precepted for has been manageable. However, each time I sign up to help out a student at a new school, I have to resubmit all of my information (my resume, etc.) I have found other groups within the medical practice that have contracted with one college only. I now understand why! I see reason to submit my license data, but beyond that am not sure why so much is necessary.  I feel the schools of nursing have no idea what it is like to work 10-hour days with very little free time.

I am very concerned with the quality of the current programs; I am hoping that schools are not lowering their admission standards, since this will greatly affect the profession as a whole, specifically the respect of and employment by the medical community.

Name Withheld by Request

FOR MORE LETTERS TO THE EDITOR:
Do Veteran PAs Care Less, Or Are New PA Students Careless?
Insurance and Billing Qualms Double the Work
Precepting: I Love It, But ...
Preceptor Tax Incentive Program: The Realities

I have been an RN for about 30 years and an NP for the past seven years. In the busy and intense internal medicine practice where I am employed, I have had the pleasure of precepting five or six students in the past six years. I am currently taking a break and am not sure if I will ever precept again.

You are so right in regard to having the time to precept students with the issues of productivity, etc. The hospital group that I am employed by actually encourages precepting, however the extra time that is needed to teach a student usually leads to later evenings trying to catch up. Beyond those issues, the last student I had has been an RN for about a year and is totally unprepared for the rigors and responsibilities of being an NP. I actually could not pass this person in certain areas, such as pharmacology, due to concerns I had with safety and lack of a strong knowledge base. This person had a very poor understanding of the basics of pharmacology; I really could not believe that this student had taken a pharmacology class at an APN level or even in basic RN courses. A preceptor is a person who is willing to teach and guide another person; I do not feel the responsibility is that of a classroom instructor. We should be building on their classroom knowledge.

Another frustrating issue is that there was absolutely no contact with the college until I reached out to them two weeks after the internship ended.  It was also difficult to obtain a certificate stating I had precepted to receive CME credit.

The paperwork from the three universities I have precepted for has been manageable. However, each time I sign up to help out a student at a new school, I have to resubmit all of my information (my resume, etc.) I have found other groups within the medical practice that have contracted with one college only. I now understand why! I see reason to submit my license data, but beyond that am not sure why so much is necessary.  I feel the schools of nursing have no idea what it is like to work 10-hour days with very little free time.

I am very concerned with the quality of the current programs; I am hoping that schools are not lowering their admission standards, since this will greatly affect the profession as a whole, specifically the respect of and employment by the medical community.

Name Withheld by Request

FOR MORE LETTERS TO THE EDITOR:
Do Veteran PAs Care Less, Or Are New PA Students Careless?
Insurance and Billing Qualms Double the Work
Precepting: I Love It, But ...
Preceptor Tax Incentive Program: The Realities

Precepting is a valuable part of practice for both the active clinician and the student. I believe I would be more inclined to take students on, but I work in a very rural location and my small, personal office is already shared with another provider. Adding a third person to the mix just isn’t feasible. I was approached by my alma mater two days ago, requesting that I take on a student for four months, beginning next week. REALLY???!! I feel bad for that student, I truly do; but I can’t just “fit them in.” 

Personally, I think part of the issue is the number of schools trying to provide PA education. You have a glut of students out there, so time and space for preceptorships is diminishing. I don’t have to get paid to be a preceptor. I just feel that there are too many programs that haven’t done the footwork to establish relationships with their graduates or local/regional PAs and get them invested in precepting the future generations of PAs. Programs add students without maintaining contact with former graduates; it’s important to keep lines of communication open to foster goodwill so we will take on their students.

Fortunately, the students I have precepted were prepared when they came into rotations. However, I have had the displeasure of meeting many twenty-something PA students who do not have a clue how to interact appropriately with patients and are very arrogant in their demeanor. The difference between baby PAs with zero life/medical experience compared to us life veterans who did health care in some other field before becoming PAs is grossly obvious. I’m not a fan of the undergrad-to-PA certification; I would much rather see a PA who has some background in health care and some life/work experience over a newly minted PA without any experience.

I do not think PAs “care less.” We still care a great deal, and more of us would probably precept, but between intense patient caseloads and demand for our time in a multitude of ways, it becomes difficult to “give” that much more. 

Jennifer Strine, PA-C
Thompson Falls, MT

FOR MORE LETTERS TO THE EDITOR:
Has the Bar Been Lowered for RN/NP Programs?
Insurance and Billing Qualms Double the Work
Precepting: I Love It, But ...
Preceptor Tax Incentive Program: The Realities

Precepting is a valuable part of practice for both the active clinician and the student. I believe I would be more inclined to take students on, but I work in a very rural location and my small, personal office is already shared with another provider. Adding a third person to the mix just isn’t feasible. I was approached by my alma mater two days ago, requesting that I take on a student for four months, beginning next week. REALLY???!! I feel bad for that student, I truly do; but I can’t just “fit them in.” 

Personally, I think part of the issue is the number of schools trying to provide PA education. You have a glut of students out there, so time and space for preceptorships is diminishing. I don’t have to get paid to be a preceptor. I just feel that there are too many programs that haven’t done the footwork to establish relationships with their graduates or local/regional PAs and get them invested in precepting the future generations of PAs. Programs add students without maintaining contact with former graduates; it’s important to keep lines of communication open to foster goodwill so we will take on their students.

Fortunately, the students I have precepted were prepared when they came into rotations. However, I have had the displeasure of meeting many twenty-something PA students who do not have a clue how to interact appropriately with patients and are very arrogant in their demeanor. The difference between baby PAs with zero life/medical experience compared to us life veterans who did health care in some other field before becoming PAs is grossly obvious. I’m not a fan of the undergrad-to-PA certification; I would much rather see a PA who has some background in health care and some life/work experience over a newly minted PA without any experience.

I do not think PAs “care less.” We still care a great deal, and more of us would probably precept, but between intense patient caseloads and demand for our time in a multitude of ways, it becomes difficult to “give” that much more. 

Jennifer Strine, PA-C
Thompson Falls, MT

FOR MORE LETTERS TO THE EDITOR:
Has the Bar Been Lowered for RN/NP Programs?
Insurance and Billing Qualms Double the Work
Precepting: I Love It, But ...
Preceptor Tax Incentive Program: The Realities

Precepting is a valuable part of practice for both the active clinician and the student. I believe I would be more inclined to take students on, but I work in a very rural location and my small, personal office is already shared with another provider. Adding a third person to the mix just isn’t feasible. I was approached by my alma mater two days ago, requesting that I take on a student for four months, beginning next week. REALLY???!! I feel bad for that student, I truly do; but I can’t just “fit them in.” 

Personally, I think part of the issue is the number of schools trying to provide PA education. You have a glut of students out there, so time and space for preceptorships is diminishing. I don’t have to get paid to be a preceptor. I just feel that there are too many programs that haven’t done the footwork to establish relationships with their graduates or local/regional PAs and get them invested in precepting the future generations of PAs. Programs add students without maintaining contact with former graduates; it’s important to keep lines of communication open to foster goodwill so we will take on their students.

Fortunately, the students I have precepted were prepared when they came into rotations. However, I have had the displeasure of meeting many twenty-something PA students who do not have a clue how to interact appropriately with patients and are very arrogant in their demeanor. The difference between baby PAs with zero life/medical experience compared to us life veterans who did health care in some other field before becoming PAs is grossly obvious. I’m not a fan of the undergrad-to-PA certification; I would much rather see a PA who has some background in health care and some life/work experience over a newly minted PA without any experience.

I do not think PAs “care less.” We still care a great deal, and more of us would probably precept, but between intense patient caseloads and demand for our time in a multitude of ways, it becomes difficult to “give” that much more. 

Jennifer Strine, PA-C
Thompson Falls, MT

FOR MORE LETTERS TO THE EDITOR:
Has the Bar Been Lowered for RN/NP Programs?
Insurance and Billing Qualms Double the Work
Precepting: I Love It, But ...
Preceptor Tax Incentive Program: The Realities