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Is bread bad?
My 27-year-old patient with a body mass index of 64 kg/m2 presented to my clinic with back and leg pain. Unfortunately, I was not the least bit surprised.
When bending over, he developed acute onset of back pain, with radiating pain down the lateral side of his right leg to his foot. Exam and history were consistent with lumbar radiculopathy.
Over the next several months, the patient had intractable pain in the presence of escalating opioids. The neurosurgeons said that his weight created too high a risk for intraoperative and postoperative complications, with which I agreed.
And so began the work of titrating his pain-modulating agents, along with the significantly less glamorous and substantially more challenging task of helping him lose weight.
He was staunchly opposed to bariatric surgery and could not afford weight loss medications, presenting a bit of an impasse. To me, the fact that his insurance company would have covered his spinal surgery but not his FDA-approved weight loss medications embodies one of the great medical mysteries of modern times.
His mother accompanied him on one of his several visits and chimed in, “He needs to eat bread, doesn’t he?”
One of my common weight loss counseling mantras is “no whites for breakfast, lunch, or dinner.” These whites would include rice, bread, pasta, and potatoes. The airwaves have been crackling for a while with calls to decrease carbohydrate consumption to combat the obesity epidemic and to eat bread only if you’re a duck. As a result, bread consumption has declined worldwide.
So how bad is bread? Are all breads the same?
Luis Serra-Majem and Inmaculada Bautista-Castano of the University of Las Palmas de Gran Canaria, Spain, conducted a systematic review of the impact of bread consumption on obesity and abdominal adiposity (Br. J. Nutr. 2015;113:S29-S35). The authors concluded that white (refined grain) bread, but not whole-grain bread, may be associated with excess abdominal fat.
Proposed hypotheses for how breads impact adiposity differently are:
1. Whole-grain bread increases satiety more than white bread;
2. Whole-grain bread results in lower plasma glucose and insulin responses than white bread;
3. Higher fiber content of whole-grain bread limits glucose absorption more than white bread; and
4. Whole-grain bread may positively influence gut microbiota through a probiotic effect.
My advice to the patient was to restrict calories, avoid carbohydrates, and if bread must be consumed, then it must be whole grain. Baby steps.
But he found religion in this (and in walking) and lost 200 pounds over the next 5 years. Miracles are still possible.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.
My 27-year-old patient with a body mass index of 64 kg/m2 presented to my clinic with back and leg pain. Unfortunately, I was not the least bit surprised.
When bending over, he developed acute onset of back pain, with radiating pain down the lateral side of his right leg to his foot. Exam and history were consistent with lumbar radiculopathy.
Over the next several months, the patient had intractable pain in the presence of escalating opioids. The neurosurgeons said that his weight created too high a risk for intraoperative and postoperative complications, with which I agreed.
And so began the work of titrating his pain-modulating agents, along with the significantly less glamorous and substantially more challenging task of helping him lose weight.
He was staunchly opposed to bariatric surgery and could not afford weight loss medications, presenting a bit of an impasse. To me, the fact that his insurance company would have covered his spinal surgery but not his FDA-approved weight loss medications embodies one of the great medical mysteries of modern times.
His mother accompanied him on one of his several visits and chimed in, “He needs to eat bread, doesn’t he?”
One of my common weight loss counseling mantras is “no whites for breakfast, lunch, or dinner.” These whites would include rice, bread, pasta, and potatoes. The airwaves have been crackling for a while with calls to decrease carbohydrate consumption to combat the obesity epidemic and to eat bread only if you’re a duck. As a result, bread consumption has declined worldwide.
So how bad is bread? Are all breads the same?
Luis Serra-Majem and Inmaculada Bautista-Castano of the University of Las Palmas de Gran Canaria, Spain, conducted a systematic review of the impact of bread consumption on obesity and abdominal adiposity (Br. J. Nutr. 2015;113:S29-S35). The authors concluded that white (refined grain) bread, but not whole-grain bread, may be associated with excess abdominal fat.
Proposed hypotheses for how breads impact adiposity differently are:
1. Whole-grain bread increases satiety more than white bread;
2. Whole-grain bread results in lower plasma glucose and insulin responses than white bread;
3. Higher fiber content of whole-grain bread limits glucose absorption more than white bread; and
4. Whole-grain bread may positively influence gut microbiota through a probiotic effect.
My advice to the patient was to restrict calories, avoid carbohydrates, and if bread must be consumed, then it must be whole grain. Baby steps.
But he found religion in this (and in walking) and lost 200 pounds over the next 5 years. Miracles are still possible.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.
My 27-year-old patient with a body mass index of 64 kg/m2 presented to my clinic with back and leg pain. Unfortunately, I was not the least bit surprised.
When bending over, he developed acute onset of back pain, with radiating pain down the lateral side of his right leg to his foot. Exam and history were consistent with lumbar radiculopathy.
Over the next several months, the patient had intractable pain in the presence of escalating opioids. The neurosurgeons said that his weight created too high a risk for intraoperative and postoperative complications, with which I agreed.
And so began the work of titrating his pain-modulating agents, along with the significantly less glamorous and substantially more challenging task of helping him lose weight.
He was staunchly opposed to bariatric surgery and could not afford weight loss medications, presenting a bit of an impasse. To me, the fact that his insurance company would have covered his spinal surgery but not his FDA-approved weight loss medications embodies one of the great medical mysteries of modern times.
His mother accompanied him on one of his several visits and chimed in, “He needs to eat bread, doesn’t he?”
One of my common weight loss counseling mantras is “no whites for breakfast, lunch, or dinner.” These whites would include rice, bread, pasta, and potatoes. The airwaves have been crackling for a while with calls to decrease carbohydrate consumption to combat the obesity epidemic and to eat bread only if you’re a duck. As a result, bread consumption has declined worldwide.
So how bad is bread? Are all breads the same?
Luis Serra-Majem and Inmaculada Bautista-Castano of the University of Las Palmas de Gran Canaria, Spain, conducted a systematic review of the impact of bread consumption on obesity and abdominal adiposity (Br. J. Nutr. 2015;113:S29-S35). The authors concluded that white (refined grain) bread, but not whole-grain bread, may be associated with excess abdominal fat.
Proposed hypotheses for how breads impact adiposity differently are:
1. Whole-grain bread increases satiety more than white bread;
2. Whole-grain bread results in lower plasma glucose and insulin responses than white bread;
3. Higher fiber content of whole-grain bread limits glucose absorption more than white bread; and
4. Whole-grain bread may positively influence gut microbiota through a probiotic effect.
My advice to the patient was to restrict calories, avoid carbohydrates, and if bread must be consumed, then it must be whole grain. Baby steps.
But he found religion in this (and in walking) and lost 200 pounds over the next 5 years. Miracles are still possible.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.
Why, oh why, won’t she go to bed?!
To weary parents, the fact that their child does not want to go to bed at night is both puzzling and exasperating. No matter what age, it is important to have a healthy bedtime for the child’s well-being as well as their caregiver’s!
Sleep, like the “canary in the mine,” is vulnerable to disruption by anything from minor illness to changes in schedule, things viewed on media, or emotions in the home, to life changes such as a new sibling, toilet training, or a new school year. In patients on stimulant medicine resisting bedtime, consider the need to finally eat. Asking about these specifically will help you plan an appropriate time to successfully address bedtime conflicts.
Knowing some basic principles about falling asleep can help your counseling. “Sleep drive” builds up over the day like a coiled spring, making falling asleep easier initially than for wakings later in the night. It also means that a nap too close to bedtime reduces the drive. Avoiding any naps (after age 4 years) and naps lasting past 4 p.m. for children under 4, even in car rides, is crucial. Beware of teens “having trouble falling asleep” who have sneaked in a nap after school!
To optimize sleep drive, calculate age-related sleep needs and, ideally, ask parents to keep a sleep diary for 1-2 weeks, especially checking on naps at daycare. Updated sleep duration standards (preschool 10-13 hours; school age 9-11 hours; teens 8-10 hours (see sleepfoundation.org) show that ranges of total sleep are remarkably stable, but may not meet parents’ ideals for time “off duty.”
If placed in bed when not yet tired, anyone will have trouble falling asleep (phase shift). For a child, lying awake in the dark alone is time for active imaginations to conjure fear of separation (> 4-6 months), monsters (for preschoolers), burglars (for anxious school-aged children), or the next day’s social or academic stresses (for school-aged children to teens). Children with anxiety disorders even worry that they may not get enough sleep! A soothing routine with a story in their bed (not media), a spritzing of “monster spray” or a “bedtime ticket” to cash in for “one more thing” (for those who beg) will usually suffice for preschoolers. A “magic flashlight” lends the child some control to check for monsters, but an “exorcism ritual” by the all-powerful parent can be added if needed. Teens are never too old for a chance to talk or even a story read by the parent (but they won’t ask for this).
A secret to managing bedtime struggles is to start the routine at the time the child is now falling asleep to avoid resistance, and keeping wake-up time appropriate to the new schedule. Once falling asleep within 10 minutes, move bedtime 15 minutes earlier each night to reach the schedule, then maintain 7 days per week (or within 1 hour) to prevent resetting the biological clock. Sorry, no movie nights until 2 a.m. or “sleeping in” on weekends! Teens who resist bedtime may be napping, socializing at the “only time” peers are up, addicted to media, or avoiding family. Their cooperation must be engaged to make a change by staying up all night once, then setting a new schedule, or staying up 1 hour later each night until the desired bedtime is reached.
Because sleep includes being paralyzed (REM stages), evolution encourages animals to sleep together to protect from predators. Sleeping alone requires a great deal of reassurance, such as from a friendly atmosphere, favorite stuffed toy, and familiar routine that implies safety. Children could use a toy, pet, or even a sibling to feel safe. While body contact is the most reassuring, children may not return to sleep from the many normal night wakings without it. Most can be weaned from this dependence by the parent sitting by the bed silently, moving one foot closer to the door each night. A promise to “check on you” in 5 minutes also helps.
Other factors making sleep easier include avoiding caffeine, stimulating medicines, or nicotine as well as exciting games, media, or exercise within 2 hours of bedtime. A quiet, dark, cool but not damp location used only for sleeping is helpful, but not always possible. A white noise generator, fan, or radio on static can help.
Many parents strangely expect their child to give up the pleasures of the day and take themselves to bed! As for other kinds of limit setting, parental company is typically needed for brushing teeth, pajamas, and a story. Ideally, it can be fun as a race or with songs, not a yelling match, which undermines the sense of safety. Setting rules about no electronics in the bedroom, even for charging, after a certain hour is often the only solution (even for adults) to the common struggle over ending media.
Often the bedtime complaint is “curtain calls” after being settled in bed. For children who call out, advise parents wait a few moments before responding, then reassure verbally without entering their room, waiting longer each time. For the child getting out of bed, one parent should lead them back without talking at all as many times as necessary. A reward for staying in bed without calling or coming out can be an extra story the next night and/or a morning reward. Alternatively, close the door and turn off the light if they come out or call out. After a few moments in the dark, give a “second chance” as long as they are quietly in bed. Gating the doorway works well for toddlers – sleeping on the floor is not dangerous!
Families often are ambivalent about asking for bedtime advice, thinking your solutions might be stressful, harmful to their relationship, or will take up their own precious sleep. For many, a prolonged bedtime is the best part of their day. Special Time earlier is often key to enforcing a healthy bedtime. Reassure them that these solutions usually take less than 3 weeks!
For the child, bedtime means giving up on fun but, more importantly, separation from the parent. This separation is harder if negative emotions are left from a day of behavior struggles or parents are even subtly angry at each other. For parents, bedtime means separating from their main pleasure in life. They also may be regretting their interactions during the day. Ambivalence about parting also may come from fears of being alone with their partner due to marital discord, intimate partner violence, chronic arguing, substance use, or simply depression. When simple advice fails, it is important to explore these meanings with families, encourage positive daytime behavior management methods, and avoid conflict in front of the children to resolve bedtime struggles.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at [email protected].
To weary parents, the fact that their child does not want to go to bed at night is both puzzling and exasperating. No matter what age, it is important to have a healthy bedtime for the child’s well-being as well as their caregiver’s!
Sleep, like the “canary in the mine,” is vulnerable to disruption by anything from minor illness to changes in schedule, things viewed on media, or emotions in the home, to life changes such as a new sibling, toilet training, or a new school year. In patients on stimulant medicine resisting bedtime, consider the need to finally eat. Asking about these specifically will help you plan an appropriate time to successfully address bedtime conflicts.
Knowing some basic principles about falling asleep can help your counseling. “Sleep drive” builds up over the day like a coiled spring, making falling asleep easier initially than for wakings later in the night. It also means that a nap too close to bedtime reduces the drive. Avoiding any naps (after age 4 years) and naps lasting past 4 p.m. for children under 4, even in car rides, is crucial. Beware of teens “having trouble falling asleep” who have sneaked in a nap after school!
To optimize sleep drive, calculate age-related sleep needs and, ideally, ask parents to keep a sleep diary for 1-2 weeks, especially checking on naps at daycare. Updated sleep duration standards (preschool 10-13 hours; school age 9-11 hours; teens 8-10 hours (see sleepfoundation.org) show that ranges of total sleep are remarkably stable, but may not meet parents’ ideals for time “off duty.”
If placed in bed when not yet tired, anyone will have trouble falling asleep (phase shift). For a child, lying awake in the dark alone is time for active imaginations to conjure fear of separation (> 4-6 months), monsters (for preschoolers), burglars (for anxious school-aged children), or the next day’s social or academic stresses (for school-aged children to teens). Children with anxiety disorders even worry that they may not get enough sleep! A soothing routine with a story in their bed (not media), a spritzing of “monster spray” or a “bedtime ticket” to cash in for “one more thing” (for those who beg) will usually suffice for preschoolers. A “magic flashlight” lends the child some control to check for monsters, but an “exorcism ritual” by the all-powerful parent can be added if needed. Teens are never too old for a chance to talk or even a story read by the parent (but they won’t ask for this).
A secret to managing bedtime struggles is to start the routine at the time the child is now falling asleep to avoid resistance, and keeping wake-up time appropriate to the new schedule. Once falling asleep within 10 minutes, move bedtime 15 minutes earlier each night to reach the schedule, then maintain 7 days per week (or within 1 hour) to prevent resetting the biological clock. Sorry, no movie nights until 2 a.m. or “sleeping in” on weekends! Teens who resist bedtime may be napping, socializing at the “only time” peers are up, addicted to media, or avoiding family. Their cooperation must be engaged to make a change by staying up all night once, then setting a new schedule, or staying up 1 hour later each night until the desired bedtime is reached.
Because sleep includes being paralyzed (REM stages), evolution encourages animals to sleep together to protect from predators. Sleeping alone requires a great deal of reassurance, such as from a friendly atmosphere, favorite stuffed toy, and familiar routine that implies safety. Children could use a toy, pet, or even a sibling to feel safe. While body contact is the most reassuring, children may not return to sleep from the many normal night wakings without it. Most can be weaned from this dependence by the parent sitting by the bed silently, moving one foot closer to the door each night. A promise to “check on you” in 5 minutes also helps.
Other factors making sleep easier include avoiding caffeine, stimulating medicines, or nicotine as well as exciting games, media, or exercise within 2 hours of bedtime. A quiet, dark, cool but not damp location used only for sleeping is helpful, but not always possible. A white noise generator, fan, or radio on static can help.
Many parents strangely expect their child to give up the pleasures of the day and take themselves to bed! As for other kinds of limit setting, parental company is typically needed for brushing teeth, pajamas, and a story. Ideally, it can be fun as a race or with songs, not a yelling match, which undermines the sense of safety. Setting rules about no electronics in the bedroom, even for charging, after a certain hour is often the only solution (even for adults) to the common struggle over ending media.
Often the bedtime complaint is “curtain calls” after being settled in bed. For children who call out, advise parents wait a few moments before responding, then reassure verbally without entering their room, waiting longer each time. For the child getting out of bed, one parent should lead them back without talking at all as many times as necessary. A reward for staying in bed without calling or coming out can be an extra story the next night and/or a morning reward. Alternatively, close the door and turn off the light if they come out or call out. After a few moments in the dark, give a “second chance” as long as they are quietly in bed. Gating the doorway works well for toddlers – sleeping on the floor is not dangerous!
Families often are ambivalent about asking for bedtime advice, thinking your solutions might be stressful, harmful to their relationship, or will take up their own precious sleep. For many, a prolonged bedtime is the best part of their day. Special Time earlier is often key to enforcing a healthy bedtime. Reassure them that these solutions usually take less than 3 weeks!
For the child, bedtime means giving up on fun but, more importantly, separation from the parent. This separation is harder if negative emotions are left from a day of behavior struggles or parents are even subtly angry at each other. For parents, bedtime means separating from their main pleasure in life. They also may be regretting their interactions during the day. Ambivalence about parting also may come from fears of being alone with their partner due to marital discord, intimate partner violence, chronic arguing, substance use, or simply depression. When simple advice fails, it is important to explore these meanings with families, encourage positive daytime behavior management methods, and avoid conflict in front of the children to resolve bedtime struggles.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at [email protected].
To weary parents, the fact that their child does not want to go to bed at night is both puzzling and exasperating. No matter what age, it is important to have a healthy bedtime for the child’s well-being as well as their caregiver’s!
Sleep, like the “canary in the mine,” is vulnerable to disruption by anything from minor illness to changes in schedule, things viewed on media, or emotions in the home, to life changes such as a new sibling, toilet training, or a new school year. In patients on stimulant medicine resisting bedtime, consider the need to finally eat. Asking about these specifically will help you plan an appropriate time to successfully address bedtime conflicts.
Knowing some basic principles about falling asleep can help your counseling. “Sleep drive” builds up over the day like a coiled spring, making falling asleep easier initially than for wakings later in the night. It also means that a nap too close to bedtime reduces the drive. Avoiding any naps (after age 4 years) and naps lasting past 4 p.m. for children under 4, even in car rides, is crucial. Beware of teens “having trouble falling asleep” who have sneaked in a nap after school!
To optimize sleep drive, calculate age-related sleep needs and, ideally, ask parents to keep a sleep diary for 1-2 weeks, especially checking on naps at daycare. Updated sleep duration standards (preschool 10-13 hours; school age 9-11 hours; teens 8-10 hours (see sleepfoundation.org) show that ranges of total sleep are remarkably stable, but may not meet parents’ ideals for time “off duty.”
If placed in bed when not yet tired, anyone will have trouble falling asleep (phase shift). For a child, lying awake in the dark alone is time for active imaginations to conjure fear of separation (> 4-6 months), monsters (for preschoolers), burglars (for anxious school-aged children), or the next day’s social or academic stresses (for school-aged children to teens). Children with anxiety disorders even worry that they may not get enough sleep! A soothing routine with a story in their bed (not media), a spritzing of “monster spray” or a “bedtime ticket” to cash in for “one more thing” (for those who beg) will usually suffice for preschoolers. A “magic flashlight” lends the child some control to check for monsters, but an “exorcism ritual” by the all-powerful parent can be added if needed. Teens are never too old for a chance to talk or even a story read by the parent (but they won’t ask for this).
A secret to managing bedtime struggles is to start the routine at the time the child is now falling asleep to avoid resistance, and keeping wake-up time appropriate to the new schedule. Once falling asleep within 10 minutes, move bedtime 15 minutes earlier each night to reach the schedule, then maintain 7 days per week (or within 1 hour) to prevent resetting the biological clock. Sorry, no movie nights until 2 a.m. or “sleeping in” on weekends! Teens who resist bedtime may be napping, socializing at the “only time” peers are up, addicted to media, or avoiding family. Their cooperation must be engaged to make a change by staying up all night once, then setting a new schedule, or staying up 1 hour later each night until the desired bedtime is reached.
Because sleep includes being paralyzed (REM stages), evolution encourages animals to sleep together to protect from predators. Sleeping alone requires a great deal of reassurance, such as from a friendly atmosphere, favorite stuffed toy, and familiar routine that implies safety. Children could use a toy, pet, or even a sibling to feel safe. While body contact is the most reassuring, children may not return to sleep from the many normal night wakings without it. Most can be weaned from this dependence by the parent sitting by the bed silently, moving one foot closer to the door each night. A promise to “check on you” in 5 minutes also helps.
Other factors making sleep easier include avoiding caffeine, stimulating medicines, or nicotine as well as exciting games, media, or exercise within 2 hours of bedtime. A quiet, dark, cool but not damp location used only for sleeping is helpful, but not always possible. A white noise generator, fan, or radio on static can help.
Many parents strangely expect their child to give up the pleasures of the day and take themselves to bed! As for other kinds of limit setting, parental company is typically needed for brushing teeth, pajamas, and a story. Ideally, it can be fun as a race or with songs, not a yelling match, which undermines the sense of safety. Setting rules about no electronics in the bedroom, even for charging, after a certain hour is often the only solution (even for adults) to the common struggle over ending media.
Often the bedtime complaint is “curtain calls” after being settled in bed. For children who call out, advise parents wait a few moments before responding, then reassure verbally without entering their room, waiting longer each time. For the child getting out of bed, one parent should lead them back without talking at all as many times as necessary. A reward for staying in bed without calling or coming out can be an extra story the next night and/or a morning reward. Alternatively, close the door and turn off the light if they come out or call out. After a few moments in the dark, give a “second chance” as long as they are quietly in bed. Gating the doorway works well for toddlers – sleeping on the floor is not dangerous!
Families often are ambivalent about asking for bedtime advice, thinking your solutions might be stressful, harmful to their relationship, or will take up their own precious sleep. For many, a prolonged bedtime is the best part of their day. Special Time earlier is often key to enforcing a healthy bedtime. Reassure them that these solutions usually take less than 3 weeks!
For the child, bedtime means giving up on fun but, more importantly, separation from the parent. This separation is harder if negative emotions are left from a day of behavior struggles or parents are even subtly angry at each other. For parents, bedtime means separating from their main pleasure in life. They also may be regretting their interactions during the day. Ambivalence about parting also may come from fears of being alone with their partner due to marital discord, intimate partner violence, chronic arguing, substance use, or simply depression. When simple advice fails, it is important to explore these meanings with families, encourage positive daytime behavior management methods, and avoid conflict in front of the children to resolve bedtime struggles.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at [email protected].
Water woes: Recognizing and treating recreational water illness
Most of our patients have been or will be exposed to water in a recreational setting this summer. As health care providers, we might not routinely consider illnesses associated with recreational water exposure or discuss preventive strategies; however, the Centers for Disease Control and Prevention has been actively promoting awareness about recreational water illnesses for years. May 18-24, 2015, was the 11th annual observance of Healthy and Safe Swimming Week, formerly known as Recreational Illness and Injury Prevention Week. The focus for 2015 was promoting the role of swimmers, residential pool owners, public health officials, and beach staff in the prevention of drownings, chemical injuries, and outbreaks of illness. One goal was for the swimmer to take a more active role in protecting themselves and preventing the spread of infections to others. For our colleagues, that means educating both parents and children.
To begin our discussion, let’s define recreational water illnesses (RWI). RWIs are caused by a variety of infectious pathogens transmitted by ingestion, inhalation of aerosols or mists, or having contact with contaminated water from both treated (swimming pools, hot tubs, water parks, and fountains) and untreated (lakes, rivers, and oceans) sources of water in recreational venues. RWIs also can be caused by chemicals that have evaporated from water leading to poor indoor air quality. However, I am focusing on the infectious etiologies.
A broad spectrum of infections are associated with RWIs, including infections of the gastrointestinal tract, ear, skin, eye, central nervous system, and wounds. Diarrhea is the most common infection. Implicated pathogens include Giardia, Shigella, norovirus, and Escherichia coli O157:H7, but it is Cryptosporidium that has emerged as the pathogen implicated most often in swimming pool–related outbreaks. Recently published data from the CDC revealed that in 2011-2012, there were 90 recreational-associated outbreaks reported from 32 states and Puerto Rico resulting in 1,788 infections, with 69 outbreaks occurring in treated water venues. Of these, 36 (51%) were caused by Cryptosporidium. Among 21 outbreaks occurring in untreated recreational water, E. coli was responsible for 7 (33%) (MMWR Morb. Mortal. Wkly Rep. 2015;64:668-72)
It’s no surprise diarrhea is the most common illness. Infection can easily occur after swallowing contaminated water. Many erroneously think chlorine kills all pathogens. Cryptosporidium is chlorine tolerant and can persist in treated water with the current recommended levels of chlorine for more than 10 days (J. Water Health 2008;6:513-20). For chlorine-sensitive pathogens, maintenance of the disinfection process must remain intact. What role do swimmers play? Most people have about 0.4 g of feces on their bottoms that can contaminate water when rinsed off. How many people enter a pool with a diarrheal illness? How many may go swimming after having recently recovered from a diarrheal illness and may have asymptomatic shedding? We all have cringed when we see a diapered child in the water. All of these are potential ways for the swimmer to contaminate an adequately treated pool. Additionally, while Cryptosporidium infections are usually self-limited, some individuals, including the immunocompromised host and especially those with advanced HIV and those who are solid organ transplant recipients, may have a protracted course of profuse diarrhea if infected.
While diarrhea maybe the most common RWI, it is not the only one. Acute otitis externa (AOE), more commonly known as “swimmer’s ear,” is one of the most frequent reasons for summer health care encounters. It has been estimated that in the United States in 2007, 2.4 million health care visits resulted in the diagnosis of AOE (MMWR Morb. Mortal. Wkly. Rep. 2011;60:605-9). Visits were highest among children aged 5-9 years; however, adults accounted for 53% of the encounters. Inflammation and infection of the external auditory canal is usually caused by bacteria. Pseudomonas aeruginosa or Staphylococcus aureus are the two most common etiologies. Water is easily introduced into the external auditory canal with recreational water activities, leading to maceration and subsequent infection of the canal. Simply reminding parents to thoroughly dry their child’s ears after water exposure can help prevent AOE.
P. aeruginosa also is the agent causing the self-limiting conditions hot tub folliculitis and hot-foot syndrome. Hot tub folliculitis is characterized by the development of tender, pruritic papules and papulopustules on the hips, buttocks, and axillae, usually developing 8-48 hours after exposure to water that has been contaminated because of inadequate chlorination. Hot-foot syndrome is characterized by painful planter nodules (N. Engl. J. Med. 2001;345:335).
Serious diseases are encountered infrequently, but there are some that require more urgent interventions. Primary amebic meningoencephalitis (PAM) is an extremely rare, progressive, and almost always fatal infection of the brain caused by Naegleria fowleri. The pathogen is found in warm freshwater including lakes, rivers, streams, and hot springs. It enters the body through the nose and travels via the olfactory nerve to the brain. Infection usually occurs when individuals swim or dive in warm freshwater. Most cases have been reported in children from Southern states. In 2010, the first case in a northern state was reported from Minnesota, and three additional cases have since been reported in Kansas and Indiana (J. Ped. Infect. Dis. 2014 [doi: 10.1093/jpids/piu103]). Cases also have been reported in two individuals who were regular users of neti pots for sinus irrigation because the irrigating solution was prepared with contaminated tap water (Clin. Infect. Dis. 2012;55:e79-85). Clinical presentation is similar to bacterial meningitis. Helpful diagnostic clues may come from obtaining a history of swimming in freshwater within the 2 weeks prior to presentation, especially during the summer, or the use of nasal or sinus irrigation with untreated tap water. Consultation with an infectious disease specialist is recommended.
Acanthamoeba keratitis is a potentially blinding infection of the cornea that primarily occurs in individuals who wear contact lenses. Risk factors for the infection include swimming, showering, and use of hot tubs while wearing contact lenses. Improper storage and cleansing contacts with tap water are other risk factors. Anyone with corneal trauma and similar water exposures also would be at risk. Clinically, the history combined with a foreign-body sensation, pain, and decreased visual acuity should make one include this infection in the differential diagnosis. Referral to an ophthalmologist is required.
Finally, swimming with an open wound is a portal of entry for Vibrio vulnificus. It usually is associated with consumption of contaminated seafood, especially oysters. In immunocompromised individuals, especially those with chronic liver disease, this bacteria can cause a life-threatening illness leading to bacteremia, septic shock, and development of blistering skin lesions. Infections are fatal in approximately 50% of cases.
The goal of this brief review was not to discourage swimming, but to make your patients and their families healthy swimmers. Here are a few things the CDC is recommending to help them achieve that goal:
• Shower prior to going swimming.
• Do not swallow or drink pool water.
• Take bathroom breaks every hour and rinse off before going back into the water.
• Do not swim if you have diarrhea.
• Wait at least 2 weeks to go swimming if you have had diarrhea.
• Change swim diapers frequently and away from the water.
• Suggest patients download the free CDC app Healthy Swimming for more detailed information and suggest they visit cdc.gov/healthywater/swimming.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She had no relevant financial disclosures. Write to Dr. Word at [email protected].
Most of our patients have been or will be exposed to water in a recreational setting this summer. As health care providers, we might not routinely consider illnesses associated with recreational water exposure or discuss preventive strategies; however, the Centers for Disease Control and Prevention has been actively promoting awareness about recreational water illnesses for years. May 18-24, 2015, was the 11th annual observance of Healthy and Safe Swimming Week, formerly known as Recreational Illness and Injury Prevention Week. The focus for 2015 was promoting the role of swimmers, residential pool owners, public health officials, and beach staff in the prevention of drownings, chemical injuries, and outbreaks of illness. One goal was for the swimmer to take a more active role in protecting themselves and preventing the spread of infections to others. For our colleagues, that means educating both parents and children.
To begin our discussion, let’s define recreational water illnesses (RWI). RWIs are caused by a variety of infectious pathogens transmitted by ingestion, inhalation of aerosols or mists, or having contact with contaminated water from both treated (swimming pools, hot tubs, water parks, and fountains) and untreated (lakes, rivers, and oceans) sources of water in recreational venues. RWIs also can be caused by chemicals that have evaporated from water leading to poor indoor air quality. However, I am focusing on the infectious etiologies.
A broad spectrum of infections are associated with RWIs, including infections of the gastrointestinal tract, ear, skin, eye, central nervous system, and wounds. Diarrhea is the most common infection. Implicated pathogens include Giardia, Shigella, norovirus, and Escherichia coli O157:H7, but it is Cryptosporidium that has emerged as the pathogen implicated most often in swimming pool–related outbreaks. Recently published data from the CDC revealed that in 2011-2012, there were 90 recreational-associated outbreaks reported from 32 states and Puerto Rico resulting in 1,788 infections, with 69 outbreaks occurring in treated water venues. Of these, 36 (51%) were caused by Cryptosporidium. Among 21 outbreaks occurring in untreated recreational water, E. coli was responsible for 7 (33%) (MMWR Morb. Mortal. Wkly Rep. 2015;64:668-72)
It’s no surprise diarrhea is the most common illness. Infection can easily occur after swallowing contaminated water. Many erroneously think chlorine kills all pathogens. Cryptosporidium is chlorine tolerant and can persist in treated water with the current recommended levels of chlorine for more than 10 days (J. Water Health 2008;6:513-20). For chlorine-sensitive pathogens, maintenance of the disinfection process must remain intact. What role do swimmers play? Most people have about 0.4 g of feces on their bottoms that can contaminate water when rinsed off. How many people enter a pool with a diarrheal illness? How many may go swimming after having recently recovered from a diarrheal illness and may have asymptomatic shedding? We all have cringed when we see a diapered child in the water. All of these are potential ways for the swimmer to contaminate an adequately treated pool. Additionally, while Cryptosporidium infections are usually self-limited, some individuals, including the immunocompromised host and especially those with advanced HIV and those who are solid organ transplant recipients, may have a protracted course of profuse diarrhea if infected.
While diarrhea maybe the most common RWI, it is not the only one. Acute otitis externa (AOE), more commonly known as “swimmer’s ear,” is one of the most frequent reasons for summer health care encounters. It has been estimated that in the United States in 2007, 2.4 million health care visits resulted in the diagnosis of AOE (MMWR Morb. Mortal. Wkly. Rep. 2011;60:605-9). Visits were highest among children aged 5-9 years; however, adults accounted for 53% of the encounters. Inflammation and infection of the external auditory canal is usually caused by bacteria. Pseudomonas aeruginosa or Staphylococcus aureus are the two most common etiologies. Water is easily introduced into the external auditory canal with recreational water activities, leading to maceration and subsequent infection of the canal. Simply reminding parents to thoroughly dry their child’s ears after water exposure can help prevent AOE.
P. aeruginosa also is the agent causing the self-limiting conditions hot tub folliculitis and hot-foot syndrome. Hot tub folliculitis is characterized by the development of tender, pruritic papules and papulopustules on the hips, buttocks, and axillae, usually developing 8-48 hours after exposure to water that has been contaminated because of inadequate chlorination. Hot-foot syndrome is characterized by painful planter nodules (N. Engl. J. Med. 2001;345:335).
Serious diseases are encountered infrequently, but there are some that require more urgent interventions. Primary amebic meningoencephalitis (PAM) is an extremely rare, progressive, and almost always fatal infection of the brain caused by Naegleria fowleri. The pathogen is found in warm freshwater including lakes, rivers, streams, and hot springs. It enters the body through the nose and travels via the olfactory nerve to the brain. Infection usually occurs when individuals swim or dive in warm freshwater. Most cases have been reported in children from Southern states. In 2010, the first case in a northern state was reported from Minnesota, and three additional cases have since been reported in Kansas and Indiana (J. Ped. Infect. Dis. 2014 [doi: 10.1093/jpids/piu103]). Cases also have been reported in two individuals who were regular users of neti pots for sinus irrigation because the irrigating solution was prepared with contaminated tap water (Clin. Infect. Dis. 2012;55:e79-85). Clinical presentation is similar to bacterial meningitis. Helpful diagnostic clues may come from obtaining a history of swimming in freshwater within the 2 weeks prior to presentation, especially during the summer, or the use of nasal or sinus irrigation with untreated tap water. Consultation with an infectious disease specialist is recommended.
Acanthamoeba keratitis is a potentially blinding infection of the cornea that primarily occurs in individuals who wear contact lenses. Risk factors for the infection include swimming, showering, and use of hot tubs while wearing contact lenses. Improper storage and cleansing contacts with tap water are other risk factors. Anyone with corneal trauma and similar water exposures also would be at risk. Clinically, the history combined with a foreign-body sensation, pain, and decreased visual acuity should make one include this infection in the differential diagnosis. Referral to an ophthalmologist is required.
Finally, swimming with an open wound is a portal of entry for Vibrio vulnificus. It usually is associated with consumption of contaminated seafood, especially oysters. In immunocompromised individuals, especially those with chronic liver disease, this bacteria can cause a life-threatening illness leading to bacteremia, septic shock, and development of blistering skin lesions. Infections are fatal in approximately 50% of cases.
The goal of this brief review was not to discourage swimming, but to make your patients and their families healthy swimmers. Here are a few things the CDC is recommending to help them achieve that goal:
• Shower prior to going swimming.
• Do not swallow or drink pool water.
• Take bathroom breaks every hour and rinse off before going back into the water.
• Do not swim if you have diarrhea.
• Wait at least 2 weeks to go swimming if you have had diarrhea.
• Change swim diapers frequently and away from the water.
• Suggest patients download the free CDC app Healthy Swimming for more detailed information and suggest they visit cdc.gov/healthywater/swimming.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She had no relevant financial disclosures. Write to Dr. Word at [email protected].
Most of our patients have been or will be exposed to water in a recreational setting this summer. As health care providers, we might not routinely consider illnesses associated with recreational water exposure or discuss preventive strategies; however, the Centers for Disease Control and Prevention has been actively promoting awareness about recreational water illnesses for years. May 18-24, 2015, was the 11th annual observance of Healthy and Safe Swimming Week, formerly known as Recreational Illness and Injury Prevention Week. The focus for 2015 was promoting the role of swimmers, residential pool owners, public health officials, and beach staff in the prevention of drownings, chemical injuries, and outbreaks of illness. One goal was for the swimmer to take a more active role in protecting themselves and preventing the spread of infections to others. For our colleagues, that means educating both parents and children.
To begin our discussion, let’s define recreational water illnesses (RWI). RWIs are caused by a variety of infectious pathogens transmitted by ingestion, inhalation of aerosols or mists, or having contact with contaminated water from both treated (swimming pools, hot tubs, water parks, and fountains) and untreated (lakes, rivers, and oceans) sources of water in recreational venues. RWIs also can be caused by chemicals that have evaporated from water leading to poor indoor air quality. However, I am focusing on the infectious etiologies.
A broad spectrum of infections are associated with RWIs, including infections of the gastrointestinal tract, ear, skin, eye, central nervous system, and wounds. Diarrhea is the most common infection. Implicated pathogens include Giardia, Shigella, norovirus, and Escherichia coli O157:H7, but it is Cryptosporidium that has emerged as the pathogen implicated most often in swimming pool–related outbreaks. Recently published data from the CDC revealed that in 2011-2012, there were 90 recreational-associated outbreaks reported from 32 states and Puerto Rico resulting in 1,788 infections, with 69 outbreaks occurring in treated water venues. Of these, 36 (51%) were caused by Cryptosporidium. Among 21 outbreaks occurring in untreated recreational water, E. coli was responsible for 7 (33%) (MMWR Morb. Mortal. Wkly Rep. 2015;64:668-72)
It’s no surprise diarrhea is the most common illness. Infection can easily occur after swallowing contaminated water. Many erroneously think chlorine kills all pathogens. Cryptosporidium is chlorine tolerant and can persist in treated water with the current recommended levels of chlorine for more than 10 days (J. Water Health 2008;6:513-20). For chlorine-sensitive pathogens, maintenance of the disinfection process must remain intact. What role do swimmers play? Most people have about 0.4 g of feces on their bottoms that can contaminate water when rinsed off. How many people enter a pool with a diarrheal illness? How many may go swimming after having recently recovered from a diarrheal illness and may have asymptomatic shedding? We all have cringed when we see a diapered child in the water. All of these are potential ways for the swimmer to contaminate an adequately treated pool. Additionally, while Cryptosporidium infections are usually self-limited, some individuals, including the immunocompromised host and especially those with advanced HIV and those who are solid organ transplant recipients, may have a protracted course of profuse diarrhea if infected.
While diarrhea maybe the most common RWI, it is not the only one. Acute otitis externa (AOE), more commonly known as “swimmer’s ear,” is one of the most frequent reasons for summer health care encounters. It has been estimated that in the United States in 2007, 2.4 million health care visits resulted in the diagnosis of AOE (MMWR Morb. Mortal. Wkly. Rep. 2011;60:605-9). Visits were highest among children aged 5-9 years; however, adults accounted for 53% of the encounters. Inflammation and infection of the external auditory canal is usually caused by bacteria. Pseudomonas aeruginosa or Staphylococcus aureus are the two most common etiologies. Water is easily introduced into the external auditory canal with recreational water activities, leading to maceration and subsequent infection of the canal. Simply reminding parents to thoroughly dry their child’s ears after water exposure can help prevent AOE.
P. aeruginosa also is the agent causing the self-limiting conditions hot tub folliculitis and hot-foot syndrome. Hot tub folliculitis is characterized by the development of tender, pruritic papules and papulopustules on the hips, buttocks, and axillae, usually developing 8-48 hours after exposure to water that has been contaminated because of inadequate chlorination. Hot-foot syndrome is characterized by painful planter nodules (N. Engl. J. Med. 2001;345:335).
Serious diseases are encountered infrequently, but there are some that require more urgent interventions. Primary amebic meningoencephalitis (PAM) is an extremely rare, progressive, and almost always fatal infection of the brain caused by Naegleria fowleri. The pathogen is found in warm freshwater including lakes, rivers, streams, and hot springs. It enters the body through the nose and travels via the olfactory nerve to the brain. Infection usually occurs when individuals swim or dive in warm freshwater. Most cases have been reported in children from Southern states. In 2010, the first case in a northern state was reported from Minnesota, and three additional cases have since been reported in Kansas and Indiana (J. Ped. Infect. Dis. 2014 [doi: 10.1093/jpids/piu103]). Cases also have been reported in two individuals who were regular users of neti pots for sinus irrigation because the irrigating solution was prepared with contaminated tap water (Clin. Infect. Dis. 2012;55:e79-85). Clinical presentation is similar to bacterial meningitis. Helpful diagnostic clues may come from obtaining a history of swimming in freshwater within the 2 weeks prior to presentation, especially during the summer, or the use of nasal or sinus irrigation with untreated tap water. Consultation with an infectious disease specialist is recommended.
Acanthamoeba keratitis is a potentially blinding infection of the cornea that primarily occurs in individuals who wear contact lenses. Risk factors for the infection include swimming, showering, and use of hot tubs while wearing contact lenses. Improper storage and cleansing contacts with tap water are other risk factors. Anyone with corneal trauma and similar water exposures also would be at risk. Clinically, the history combined with a foreign-body sensation, pain, and decreased visual acuity should make one include this infection in the differential diagnosis. Referral to an ophthalmologist is required.
Finally, swimming with an open wound is a portal of entry for Vibrio vulnificus. It usually is associated with consumption of contaminated seafood, especially oysters. In immunocompromised individuals, especially those with chronic liver disease, this bacteria can cause a life-threatening illness leading to bacteremia, septic shock, and development of blistering skin lesions. Infections are fatal in approximately 50% of cases.
The goal of this brief review was not to discourage swimming, but to make your patients and their families healthy swimmers. Here are a few things the CDC is recommending to help them achieve that goal:
• Shower prior to going swimming.
• Do not swallow or drink pool water.
• Take bathroom breaks every hour and rinse off before going back into the water.
• Do not swim if you have diarrhea.
• Wait at least 2 weeks to go swimming if you have had diarrhea.
• Change swim diapers frequently and away from the water.
• Suggest patients download the free CDC app Healthy Swimming for more detailed information and suggest they visit cdc.gov/healthywater/swimming.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She had no relevant financial disclosures. Write to Dr. Word at [email protected].
Complementary and alternative approaches in treating ASD
Navigating the world of autism treatments and staying abreast of the evolving evidence base of a wide array of interventions spanning diverse modalities can be overwhelming for even well-trained clinicians. Parents and caregivers for children with an autism spectrum disorder (ASD) equally face troubles reconciling treatment information often obtained not only from their health care providers, but from family members, friends, and the Internet (where thousands of websites promise “cures” or improvements for ASD/ASD-related symptoms). In this context, families are commonly seeking complementary and alternative treatments for their children. Although some of these treatments are relatively benign, key safety and efficacy issues remain, and parents often act with little to no guidance from their child’s primary care provider. With the increasing prevalence of the use of nontraditional treatments used both with and in place of conventional treatments, you should be prepared to counsel families in making the most informed decisions in the best interest of their child.
Case Summary
Adam is a 15-year-old boy who carries a diagnosis of an ASD accompanied by enduring gastrointestinal troubles (constipation), auditory and tactile sensitivities, and episodes of aggression towards himself and others. Adam is essentially nonverbal and enjoys watching children’s videos repeatedly (Thomas the Train); he attends school in an alternative classroom as his hyperactivity, impulsivity, and susceptibility to behaving in an unpredictable physical manner limits his ability to successfully engage with peers without one-on-one supervision.
In an attempt to address Adam’s challenging behaviors (that haven’t responded significantly to a variety of conventional medications and behavioral strategies), his well-meaning and highly educated parents seek advice. They admit they’ve come across websites that offer treatments with a promise to cure their son’s autism symptoms. Adam’s mother has always preferred “a more natural” approach to her son’s treatment, and she still has vivid memories of the side effects her son experienced on past medications, such as akathisia with risperidone.
Discussion
Adam’s case is not an uncommon scenario encountered by many families who may be experiencing increasing desperation to address their child’s autism-related struggles while being disappointed by conventional treatments. Autism is a complex neurobiologic disorder with a heterogeneous presentation for which there are no well-established pharmacologic treatments to address its core symptoms of social-communication impairments and restricted, repetitive behaviors/interests. With this in mind, it’s not surprising that studies indicate that at least 50% of families with an autistic child have tried complementary and alternative medicine (CAM) treatments. Notably, the higher the child-related stress, the more likely the families are to try CAM interventions (J. Child Neurology 2014;29:360-7) and higher use of CAM is associated with coexisting gastrointestinal problems, seizure disorders, and behavioral problems in youth with autism (Pediatrics 2012;130:S77-S82).
CAM treatments are defined by the National Center for Complementary and Integrative Health (nccih.nih.gov) as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be a part of conventional medicine.” They may include biologically based therapies (dietary supplements, chelation, immune-modulating agents, special diets), mind-body medicine (acupuncture, biofeedback), energy medicine, and manipulative and body-based treatments (massage, chiropractic manipulation). Families who choose CAM interventions for their children with autism tend to try natural products, special diets, and/or mind and body practices.
Reviewing the literature surrounding CAM, there are few randomized controlled trials published, and you should be aware that evidence for most of these interventions is insufficient to make strong recommendations for or against their use. Certainly, some treatments considered as CAM can be effective in treating specific target symptoms that often co-occur in individuals with autism (using melatonin to address sleep difficulties) without major safety issues, but others are potentially dangerous and likely ineffective (chelation therapy, hyperbaric oxygen, mineral solutions). The National Autism Center has published a comprehensive analysis of autism interventions (www.nationalautismcenter.org) that can be helpful for parents and practitioners to make informed treatment decisions; their most recent 2015 review categorizes some CAM treatments as having “emerging” evidence for favorable outcomes (music therapy, massage therapy, exercise) and labels some CAM interventions as having little to no evidence to support their efficacy. Interestingly, gluten-free and casein free diets are included in this latter category. Families are frequently curious about such elimination diets, especially given the buzz in both the popular and scientific press about the gut-brain connection. Although these diets do not have strong evidence to support their use in managing core features of autism, investigators are examining whether there may be a subgroup of children with autism (those with gastrointestinal problems) who may achieve potential benefits. All in all, there’s a need for more robust research on this particular set of treatments. Families should be aware that if they chose to pursue an elimination diet, adherence for children who are inherently picky eaters may be challenging. Furthermore, although commonly labeled as safe, these diets could be linked with potentially harmful adverse effects such as nutritional deficits.
To help guide clinical decision making, it may be helpful for you to first consult the American Academy of Pediatrics 2001 policy statement, “Counseling families who choose complementary and alternative medicine for their child with chronic illness or disability” (Pediatrics 2001;107:598-601) and then consider a range of variables when discussing the use of CAM treatments with families. Some authors classify treatments as being safe, easy, cheap, and sensible (SECS) versus being risky, unrealistic, difficult, and expensive (RUDE) (Contemporary Pediatrics 2004;21:61-72), and using these terms when engaging parents in treatment decisions can be instructive for all parties. For example, there is limited high-quality evidence that omega-3 fatty acid supplementation is effective in treating autism symptoms, but the fact that this can be easy, inexpensive, and relatively safe for families to use may ultimately inform your decision to support a family’s trial of this with close monitoring. Additionally, it is important to explore whether families are seeking to replace other therapies with something novel and new, or are they looking for something to complement existing treatments/services? You should always, while being mindful of a family’s needs, values, and resources, consider first and foremost the use of treatments with established efficacy. Certainly CAM treatments – particularly those that are nonbiologic (pet therapy) – may positively augment standard interventions without potential significant harm.
Clinical Pearl
With the increasing number of parents turning to CAM treatments for their children with autism (particularly when the parents themselves use CAM), you should be prepared to talk with families about their decision making and actively ask families if this is something that they’ve considered. Given that the research on many CAM treatments is in early stages, it’s not unique to perhaps feel ill prepared to make CAM recommendations to families. Often it’s helpful to share this “CAM illiteracy” with families and aim to work together in a nonjudgmental manner to evaluate and select individualized treatment programs based on factors of potential efficacy, safety, cost, and family values. Regardless of the intervention, you should establish, with all patients, reliable methods for documenting past trials of all treatments, evaluating target symptoms, monitoring clinical outcomes, and measuring adverse events.
You should work to provide realistic hope to families and acknowledge that some CAM treatments may work better for some children, but we often don’t have a great sense, from the current state-of-the-science of ASD treatment, as to who these kids may be.
Dr. Dickerson, a child and adolescent psychiatrist, is an assistant professor of psychiatry at the University of Vermont. He is the director of the university’s autism diagnostic clinic. Dr. Dickerson said he had no relevant financial disclosures. Contact Dr. Dickerson at [email protected].
Navigating the world of autism treatments and staying abreast of the evolving evidence base of a wide array of interventions spanning diverse modalities can be overwhelming for even well-trained clinicians. Parents and caregivers for children with an autism spectrum disorder (ASD) equally face troubles reconciling treatment information often obtained not only from their health care providers, but from family members, friends, and the Internet (where thousands of websites promise “cures” or improvements for ASD/ASD-related symptoms). In this context, families are commonly seeking complementary and alternative treatments for their children. Although some of these treatments are relatively benign, key safety and efficacy issues remain, and parents often act with little to no guidance from their child’s primary care provider. With the increasing prevalence of the use of nontraditional treatments used both with and in place of conventional treatments, you should be prepared to counsel families in making the most informed decisions in the best interest of their child.
Case Summary
Adam is a 15-year-old boy who carries a diagnosis of an ASD accompanied by enduring gastrointestinal troubles (constipation), auditory and tactile sensitivities, and episodes of aggression towards himself and others. Adam is essentially nonverbal and enjoys watching children’s videos repeatedly (Thomas the Train); he attends school in an alternative classroom as his hyperactivity, impulsivity, and susceptibility to behaving in an unpredictable physical manner limits his ability to successfully engage with peers without one-on-one supervision.
In an attempt to address Adam’s challenging behaviors (that haven’t responded significantly to a variety of conventional medications and behavioral strategies), his well-meaning and highly educated parents seek advice. They admit they’ve come across websites that offer treatments with a promise to cure their son’s autism symptoms. Adam’s mother has always preferred “a more natural” approach to her son’s treatment, and she still has vivid memories of the side effects her son experienced on past medications, such as akathisia with risperidone.
Discussion
Adam’s case is not an uncommon scenario encountered by many families who may be experiencing increasing desperation to address their child’s autism-related struggles while being disappointed by conventional treatments. Autism is a complex neurobiologic disorder with a heterogeneous presentation for which there are no well-established pharmacologic treatments to address its core symptoms of social-communication impairments and restricted, repetitive behaviors/interests. With this in mind, it’s not surprising that studies indicate that at least 50% of families with an autistic child have tried complementary and alternative medicine (CAM) treatments. Notably, the higher the child-related stress, the more likely the families are to try CAM interventions (J. Child Neurology 2014;29:360-7) and higher use of CAM is associated with coexisting gastrointestinal problems, seizure disorders, and behavioral problems in youth with autism (Pediatrics 2012;130:S77-S82).
CAM treatments are defined by the National Center for Complementary and Integrative Health (nccih.nih.gov) as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be a part of conventional medicine.” They may include biologically based therapies (dietary supplements, chelation, immune-modulating agents, special diets), mind-body medicine (acupuncture, biofeedback), energy medicine, and manipulative and body-based treatments (massage, chiropractic manipulation). Families who choose CAM interventions for their children with autism tend to try natural products, special diets, and/or mind and body practices.
Reviewing the literature surrounding CAM, there are few randomized controlled trials published, and you should be aware that evidence for most of these interventions is insufficient to make strong recommendations for or against their use. Certainly, some treatments considered as CAM can be effective in treating specific target symptoms that often co-occur in individuals with autism (using melatonin to address sleep difficulties) without major safety issues, but others are potentially dangerous and likely ineffective (chelation therapy, hyperbaric oxygen, mineral solutions). The National Autism Center has published a comprehensive analysis of autism interventions (www.nationalautismcenter.org) that can be helpful for parents and practitioners to make informed treatment decisions; their most recent 2015 review categorizes some CAM treatments as having “emerging” evidence for favorable outcomes (music therapy, massage therapy, exercise) and labels some CAM interventions as having little to no evidence to support their efficacy. Interestingly, gluten-free and casein free diets are included in this latter category. Families are frequently curious about such elimination diets, especially given the buzz in both the popular and scientific press about the gut-brain connection. Although these diets do not have strong evidence to support their use in managing core features of autism, investigators are examining whether there may be a subgroup of children with autism (those with gastrointestinal problems) who may achieve potential benefits. All in all, there’s a need for more robust research on this particular set of treatments. Families should be aware that if they chose to pursue an elimination diet, adherence for children who are inherently picky eaters may be challenging. Furthermore, although commonly labeled as safe, these diets could be linked with potentially harmful adverse effects such as nutritional deficits.
To help guide clinical decision making, it may be helpful for you to first consult the American Academy of Pediatrics 2001 policy statement, “Counseling families who choose complementary and alternative medicine for their child with chronic illness or disability” (Pediatrics 2001;107:598-601) and then consider a range of variables when discussing the use of CAM treatments with families. Some authors classify treatments as being safe, easy, cheap, and sensible (SECS) versus being risky, unrealistic, difficult, and expensive (RUDE) (Contemporary Pediatrics 2004;21:61-72), and using these terms when engaging parents in treatment decisions can be instructive for all parties. For example, there is limited high-quality evidence that omega-3 fatty acid supplementation is effective in treating autism symptoms, but the fact that this can be easy, inexpensive, and relatively safe for families to use may ultimately inform your decision to support a family’s trial of this with close monitoring. Additionally, it is important to explore whether families are seeking to replace other therapies with something novel and new, or are they looking for something to complement existing treatments/services? You should always, while being mindful of a family’s needs, values, and resources, consider first and foremost the use of treatments with established efficacy. Certainly CAM treatments – particularly those that are nonbiologic (pet therapy) – may positively augment standard interventions without potential significant harm.
Clinical Pearl
With the increasing number of parents turning to CAM treatments for their children with autism (particularly when the parents themselves use CAM), you should be prepared to talk with families about their decision making and actively ask families if this is something that they’ve considered. Given that the research on many CAM treatments is in early stages, it’s not unique to perhaps feel ill prepared to make CAM recommendations to families. Often it’s helpful to share this “CAM illiteracy” with families and aim to work together in a nonjudgmental manner to evaluate and select individualized treatment programs based on factors of potential efficacy, safety, cost, and family values. Regardless of the intervention, you should establish, with all patients, reliable methods for documenting past trials of all treatments, evaluating target symptoms, monitoring clinical outcomes, and measuring adverse events.
You should work to provide realistic hope to families and acknowledge that some CAM treatments may work better for some children, but we often don’t have a great sense, from the current state-of-the-science of ASD treatment, as to who these kids may be.
Dr. Dickerson, a child and adolescent psychiatrist, is an assistant professor of psychiatry at the University of Vermont. He is the director of the university’s autism diagnostic clinic. Dr. Dickerson said he had no relevant financial disclosures. Contact Dr. Dickerson at [email protected].
Navigating the world of autism treatments and staying abreast of the evolving evidence base of a wide array of interventions spanning diverse modalities can be overwhelming for even well-trained clinicians. Parents and caregivers for children with an autism spectrum disorder (ASD) equally face troubles reconciling treatment information often obtained not only from their health care providers, but from family members, friends, and the Internet (where thousands of websites promise “cures” or improvements for ASD/ASD-related symptoms). In this context, families are commonly seeking complementary and alternative treatments for their children. Although some of these treatments are relatively benign, key safety and efficacy issues remain, and parents often act with little to no guidance from their child’s primary care provider. With the increasing prevalence of the use of nontraditional treatments used both with and in place of conventional treatments, you should be prepared to counsel families in making the most informed decisions in the best interest of their child.
Case Summary
Adam is a 15-year-old boy who carries a diagnosis of an ASD accompanied by enduring gastrointestinal troubles (constipation), auditory and tactile sensitivities, and episodes of aggression towards himself and others. Adam is essentially nonverbal and enjoys watching children’s videos repeatedly (Thomas the Train); he attends school in an alternative classroom as his hyperactivity, impulsivity, and susceptibility to behaving in an unpredictable physical manner limits his ability to successfully engage with peers without one-on-one supervision.
In an attempt to address Adam’s challenging behaviors (that haven’t responded significantly to a variety of conventional medications and behavioral strategies), his well-meaning and highly educated parents seek advice. They admit they’ve come across websites that offer treatments with a promise to cure their son’s autism symptoms. Adam’s mother has always preferred “a more natural” approach to her son’s treatment, and she still has vivid memories of the side effects her son experienced on past medications, such as akathisia with risperidone.
Discussion
Adam’s case is not an uncommon scenario encountered by many families who may be experiencing increasing desperation to address their child’s autism-related struggles while being disappointed by conventional treatments. Autism is a complex neurobiologic disorder with a heterogeneous presentation for which there are no well-established pharmacologic treatments to address its core symptoms of social-communication impairments and restricted, repetitive behaviors/interests. With this in mind, it’s not surprising that studies indicate that at least 50% of families with an autistic child have tried complementary and alternative medicine (CAM) treatments. Notably, the higher the child-related stress, the more likely the families are to try CAM interventions (J. Child Neurology 2014;29:360-7) and higher use of CAM is associated with coexisting gastrointestinal problems, seizure disorders, and behavioral problems in youth with autism (Pediatrics 2012;130:S77-S82).
CAM treatments are defined by the National Center for Complementary and Integrative Health (nccih.nih.gov) as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be a part of conventional medicine.” They may include biologically based therapies (dietary supplements, chelation, immune-modulating agents, special diets), mind-body medicine (acupuncture, biofeedback), energy medicine, and manipulative and body-based treatments (massage, chiropractic manipulation). Families who choose CAM interventions for their children with autism tend to try natural products, special diets, and/or mind and body practices.
Reviewing the literature surrounding CAM, there are few randomized controlled trials published, and you should be aware that evidence for most of these interventions is insufficient to make strong recommendations for or against their use. Certainly, some treatments considered as CAM can be effective in treating specific target symptoms that often co-occur in individuals with autism (using melatonin to address sleep difficulties) without major safety issues, but others are potentially dangerous and likely ineffective (chelation therapy, hyperbaric oxygen, mineral solutions). The National Autism Center has published a comprehensive analysis of autism interventions (www.nationalautismcenter.org) that can be helpful for parents and practitioners to make informed treatment decisions; their most recent 2015 review categorizes some CAM treatments as having “emerging” evidence for favorable outcomes (music therapy, massage therapy, exercise) and labels some CAM interventions as having little to no evidence to support their efficacy. Interestingly, gluten-free and casein free diets are included in this latter category. Families are frequently curious about such elimination diets, especially given the buzz in both the popular and scientific press about the gut-brain connection. Although these diets do not have strong evidence to support their use in managing core features of autism, investigators are examining whether there may be a subgroup of children with autism (those with gastrointestinal problems) who may achieve potential benefits. All in all, there’s a need for more robust research on this particular set of treatments. Families should be aware that if they chose to pursue an elimination diet, adherence for children who are inherently picky eaters may be challenging. Furthermore, although commonly labeled as safe, these diets could be linked with potentially harmful adverse effects such as nutritional deficits.
To help guide clinical decision making, it may be helpful for you to first consult the American Academy of Pediatrics 2001 policy statement, “Counseling families who choose complementary and alternative medicine for their child with chronic illness or disability” (Pediatrics 2001;107:598-601) and then consider a range of variables when discussing the use of CAM treatments with families. Some authors classify treatments as being safe, easy, cheap, and sensible (SECS) versus being risky, unrealistic, difficult, and expensive (RUDE) (Contemporary Pediatrics 2004;21:61-72), and using these terms when engaging parents in treatment decisions can be instructive for all parties. For example, there is limited high-quality evidence that omega-3 fatty acid supplementation is effective in treating autism symptoms, but the fact that this can be easy, inexpensive, and relatively safe for families to use may ultimately inform your decision to support a family’s trial of this with close monitoring. Additionally, it is important to explore whether families are seeking to replace other therapies with something novel and new, or are they looking for something to complement existing treatments/services? You should always, while being mindful of a family’s needs, values, and resources, consider first and foremost the use of treatments with established efficacy. Certainly CAM treatments – particularly those that are nonbiologic (pet therapy) – may positively augment standard interventions without potential significant harm.
Clinical Pearl
With the increasing number of parents turning to CAM treatments for their children with autism (particularly when the parents themselves use CAM), you should be prepared to talk with families about their decision making and actively ask families if this is something that they’ve considered. Given that the research on many CAM treatments is in early stages, it’s not unique to perhaps feel ill prepared to make CAM recommendations to families. Often it’s helpful to share this “CAM illiteracy” with families and aim to work together in a nonjudgmental manner to evaluate and select individualized treatment programs based on factors of potential efficacy, safety, cost, and family values. Regardless of the intervention, you should establish, with all patients, reliable methods for documenting past trials of all treatments, evaluating target symptoms, monitoring clinical outcomes, and measuring adverse events.
You should work to provide realistic hope to families and acknowledge that some CAM treatments may work better for some children, but we often don’t have a great sense, from the current state-of-the-science of ASD treatment, as to who these kids may be.
Dr. Dickerson, a child and adolescent psychiatrist, is an assistant professor of psychiatry at the University of Vermont. He is the director of the university’s autism diagnostic clinic. Dr. Dickerson said he had no relevant financial disclosures. Contact Dr. Dickerson at [email protected].
Does mental health influence entry into violent extremism and domestic hate groups?
In the wake of the Charleston, S.C., church massacre, people are asking what led the alleged shooter, Dylann Roof, into the world of hate, extremism, and violence. People also are asking what role, if any, mental health factors played in Roof’s violent radicalization.
At this point, no clear answers are available regarding Roof’s mental health status, nor are we certain about his specific entry into domestic radicalization and violent extremism. It is hoped that further investigation will provide greater clarity about the influences of Roof’s hateful ideology and violent actions, but this tragedy requires a discussion about the potential overlap between domestic radicalization, violent extremism, and mental health issues.
We are currently conducting research funded by the Department of Justice’s research arm, the National Institute of Justice (NIJ), to address this gap in knowledge in an effort to inform prevention and intervention efforts in the area, often referred to as “countering violent extremism,” or CVE.
Several complexities are related to the relationship between mental health and violent extremism, VE, which is defined, in part, as violence motivated by ideological commitments to a political and/or religious cause. In Roof’s case, his violence was quite clearly motivated by a long history of white supremacist ideology that condoned violence, supported hatred, and encouraged extremism. Roof’s actions, therefore, are embedded within a historical context that has traumatized racial/ethnic minorities and other vulnerable populations by individuals aligned, in varying degrees, to a broad cross section of the Ku Klux Klan (KKK), neo-Nazi, Christian Identity, and racist skinhead groups.
Beliefs play a central role in this “world of hate,” where individuals learn about a “white racial genocide,” promoted by a host of “racial enemies” who purportedly control the media, government, and education system. Although these radical ideas are inaccurate, we have to be careful in assuming that collective beliefs such as these that appear delusional, paranoid, and simply “crazy” to an outside observer automatically implicate mental health problems.
More than 50 years of social behavioral research show that even the most “sane” and stable people are susceptible to the pressures of group dynamics and the power of situational forces. In fact, the importance of group dynamics has led many leading scholars who study VE to dismiss the possibility that mental health plays a role in the radicalization process. Instead, these scholars suggest that violent extremists are otherwise well-adjusted people influenced solely by group beliefs and norms that advocate violent tactics to achieve political and/or religious goals. Certainly, this is the case for numerous individuals attracted to VE. Still however, it seems premature to completely discount the role mental health may play in the world of domestic radicalization and violent extremism.
Through the NIJ’s funding, we are engaged in a research collaboration with Life After Hate (LAH), a nongovernmental organization founded by former members of domestic radical groups, and the Anti-Defamation League, the Simon Wiesenthal Center, and the Southern Poverty Law Center. This partnership will result in a comprehensive study of the disengagement and deradicalization processes among members of domestic radical groups. As part of the project, we are conducting 50 in-depth life history interviews with former members of such extremist groups as the KKK, neo-Nazis, and racist skinheads. The findings will inform LAH’s efforts to build a robust prevention and intervention program aimed specifically at domestic radical groups.
LAH’s community intervention program, Exit USA, is modeled after similar programs in Europe, the Middle East, and elsewhere. Exit USA will be a bridge to connect individuals seeking to exit domestic radical groups with needed social and behavioral services as they make their way out of domestic radicalization. Heretofore, intervention and prevention strategies, including the recent White House Summit on CVE, have focused almost exclusively on “violent jihadis.” We suggest this emphasis on foreign terrorism has left many of our communities with little support to dissuade membership and dismantle domestic radical group mobilization. Our research will contribute to Exit USA as a first step toward building community supports.
As part of the interviews, the research team is examining how exposure to various types of risk factors, including mental health problems, are associated with entry into domestic hate groups as well as how these risk factors might impede or create obstacles to leaving violent extremism. Identifying the presence of risk factors and providing opportunities for individuals to access services that might help mitigate these issues is critical, but we do not assume that any one risk factor or even a distinct combination of certain risk factors cause violent extremism in a straightforward way easily detectable through predictive assessment.
We see mental health as one factor that can influence the development of VE. The multidimensional nature of radicalization means there is no single cause of radicalization and no “magic bullet” that guarantees the exit from violent extremist groups. Instead, there are various points along the pathway of entering and leaving VE where intervention strategies such as Exit USA could be successful. Untreated mental health problems, along with the volatile mix of extremist beliefs and associations, destabilize a person and also remove the needed internal constraints that otherwise are likely to reduce the potential of VE.
We expect CVE interventions focused on mental health to be effective in two principal ways. First, individuals at risk of becoming involved or who are at the early stages of entry might benefit from mental health treatment as a means to provide stability and address underlying issues that might be driving the person toward extremism. A growing number of studies underscore that individuals are not necessarily initially motivated by ideology and are often seeking universal needs, such as social support, protection, and excitement. In this sense, mental health treatment could aid the person in addressing these underlying motivations and seeking alternative ways of fulfilling these needs.
Second, mental health treatment should be an important consideration in the design of intervention programs aimed at promoting disengagement and deradicalization. Mental health treatment is especially likely to be helpful in terms of decreasing the likelihood an individual will “relapse” and return to extremism, which our preliminary results suggest is relatively common.
We are seeking firsthand accounts of how trauma, neglect, and other mental health issues are related to domestic radicalization to inform LAH’s Exit USA program. Anyone with an account should send an e-mail to [email protected].
The project was supported by Award No. 2014-ZA-0005, awarded by the NIJ, Office of Justice Programs, U.S. Department of Justice. The opinions, findings, and conclusions or recommendations expressed in this article are those of the author(s) and do not necessarily reflect those of the Department of Justice.
Dr. Simi is with the National Consortium for the Study of Terrorism and Responses to Terrorism and is associate professor at the University of Nebraska, Omaha. Dr. Blee is associate dean for graduate studies, and research and distinguished professor of sociology at the Kenneth P. Dietrich School of Arts and Sciences, University of Pittsburgh. Dr. DeMichele is a research sociologist with the Center for Justice, Safety, and Resilience at RTI International, Research Triangle Park, N.C.*
This article was updated 7/27/2015.
In the wake of the Charleston, S.C., church massacre, people are asking what led the alleged shooter, Dylann Roof, into the world of hate, extremism, and violence. People also are asking what role, if any, mental health factors played in Roof’s violent radicalization.
At this point, no clear answers are available regarding Roof’s mental health status, nor are we certain about his specific entry into domestic radicalization and violent extremism. It is hoped that further investigation will provide greater clarity about the influences of Roof’s hateful ideology and violent actions, but this tragedy requires a discussion about the potential overlap between domestic radicalization, violent extremism, and mental health issues.
We are currently conducting research funded by the Department of Justice’s research arm, the National Institute of Justice (NIJ), to address this gap in knowledge in an effort to inform prevention and intervention efforts in the area, often referred to as “countering violent extremism,” or CVE.
Several complexities are related to the relationship between mental health and violent extremism, VE, which is defined, in part, as violence motivated by ideological commitments to a political and/or religious cause. In Roof’s case, his violence was quite clearly motivated by a long history of white supremacist ideology that condoned violence, supported hatred, and encouraged extremism. Roof’s actions, therefore, are embedded within a historical context that has traumatized racial/ethnic minorities and other vulnerable populations by individuals aligned, in varying degrees, to a broad cross section of the Ku Klux Klan (KKK), neo-Nazi, Christian Identity, and racist skinhead groups.
Beliefs play a central role in this “world of hate,” where individuals learn about a “white racial genocide,” promoted by a host of “racial enemies” who purportedly control the media, government, and education system. Although these radical ideas are inaccurate, we have to be careful in assuming that collective beliefs such as these that appear delusional, paranoid, and simply “crazy” to an outside observer automatically implicate mental health problems.
More than 50 years of social behavioral research show that even the most “sane” and stable people are susceptible to the pressures of group dynamics and the power of situational forces. In fact, the importance of group dynamics has led many leading scholars who study VE to dismiss the possibility that mental health plays a role in the radicalization process. Instead, these scholars suggest that violent extremists are otherwise well-adjusted people influenced solely by group beliefs and norms that advocate violent tactics to achieve political and/or religious goals. Certainly, this is the case for numerous individuals attracted to VE. Still however, it seems premature to completely discount the role mental health may play in the world of domestic radicalization and violent extremism.
Through the NIJ’s funding, we are engaged in a research collaboration with Life After Hate (LAH), a nongovernmental organization founded by former members of domestic radical groups, and the Anti-Defamation League, the Simon Wiesenthal Center, and the Southern Poverty Law Center. This partnership will result in a comprehensive study of the disengagement and deradicalization processes among members of domestic radical groups. As part of the project, we are conducting 50 in-depth life history interviews with former members of such extremist groups as the KKK, neo-Nazis, and racist skinheads. The findings will inform LAH’s efforts to build a robust prevention and intervention program aimed specifically at domestic radical groups.
LAH’s community intervention program, Exit USA, is modeled after similar programs in Europe, the Middle East, and elsewhere. Exit USA will be a bridge to connect individuals seeking to exit domestic radical groups with needed social and behavioral services as they make their way out of domestic radicalization. Heretofore, intervention and prevention strategies, including the recent White House Summit on CVE, have focused almost exclusively on “violent jihadis.” We suggest this emphasis on foreign terrorism has left many of our communities with little support to dissuade membership and dismantle domestic radical group mobilization. Our research will contribute to Exit USA as a first step toward building community supports.
As part of the interviews, the research team is examining how exposure to various types of risk factors, including mental health problems, are associated with entry into domestic hate groups as well as how these risk factors might impede or create obstacles to leaving violent extremism. Identifying the presence of risk factors and providing opportunities for individuals to access services that might help mitigate these issues is critical, but we do not assume that any one risk factor or even a distinct combination of certain risk factors cause violent extremism in a straightforward way easily detectable through predictive assessment.
We see mental health as one factor that can influence the development of VE. The multidimensional nature of radicalization means there is no single cause of radicalization and no “magic bullet” that guarantees the exit from violent extremist groups. Instead, there are various points along the pathway of entering and leaving VE where intervention strategies such as Exit USA could be successful. Untreated mental health problems, along with the volatile mix of extremist beliefs and associations, destabilize a person and also remove the needed internal constraints that otherwise are likely to reduce the potential of VE.
We expect CVE interventions focused on mental health to be effective in two principal ways. First, individuals at risk of becoming involved or who are at the early stages of entry might benefit from mental health treatment as a means to provide stability and address underlying issues that might be driving the person toward extremism. A growing number of studies underscore that individuals are not necessarily initially motivated by ideology and are often seeking universal needs, such as social support, protection, and excitement. In this sense, mental health treatment could aid the person in addressing these underlying motivations and seeking alternative ways of fulfilling these needs.
Second, mental health treatment should be an important consideration in the design of intervention programs aimed at promoting disengagement and deradicalization. Mental health treatment is especially likely to be helpful in terms of decreasing the likelihood an individual will “relapse” and return to extremism, which our preliminary results suggest is relatively common.
We are seeking firsthand accounts of how trauma, neglect, and other mental health issues are related to domestic radicalization to inform LAH’s Exit USA program. Anyone with an account should send an e-mail to [email protected].
The project was supported by Award No. 2014-ZA-0005, awarded by the NIJ, Office of Justice Programs, U.S. Department of Justice. The opinions, findings, and conclusions or recommendations expressed in this article are those of the author(s) and do not necessarily reflect those of the Department of Justice.
Dr. Simi is with the National Consortium for the Study of Terrorism and Responses to Terrorism and is associate professor at the University of Nebraska, Omaha. Dr. Blee is associate dean for graduate studies, and research and distinguished professor of sociology at the Kenneth P. Dietrich School of Arts and Sciences, University of Pittsburgh. Dr. DeMichele is a research sociologist with the Center for Justice, Safety, and Resilience at RTI International, Research Triangle Park, N.C.*
This article was updated 7/27/2015.
In the wake of the Charleston, S.C., church massacre, people are asking what led the alleged shooter, Dylann Roof, into the world of hate, extremism, and violence. People also are asking what role, if any, mental health factors played in Roof’s violent radicalization.
At this point, no clear answers are available regarding Roof’s mental health status, nor are we certain about his specific entry into domestic radicalization and violent extremism. It is hoped that further investigation will provide greater clarity about the influences of Roof’s hateful ideology and violent actions, but this tragedy requires a discussion about the potential overlap between domestic radicalization, violent extremism, and mental health issues.
We are currently conducting research funded by the Department of Justice’s research arm, the National Institute of Justice (NIJ), to address this gap in knowledge in an effort to inform prevention and intervention efforts in the area, often referred to as “countering violent extremism,” or CVE.
Several complexities are related to the relationship between mental health and violent extremism, VE, which is defined, in part, as violence motivated by ideological commitments to a political and/or religious cause. In Roof’s case, his violence was quite clearly motivated by a long history of white supremacist ideology that condoned violence, supported hatred, and encouraged extremism. Roof’s actions, therefore, are embedded within a historical context that has traumatized racial/ethnic minorities and other vulnerable populations by individuals aligned, in varying degrees, to a broad cross section of the Ku Klux Klan (KKK), neo-Nazi, Christian Identity, and racist skinhead groups.
Beliefs play a central role in this “world of hate,” where individuals learn about a “white racial genocide,” promoted by a host of “racial enemies” who purportedly control the media, government, and education system. Although these radical ideas are inaccurate, we have to be careful in assuming that collective beliefs such as these that appear delusional, paranoid, and simply “crazy” to an outside observer automatically implicate mental health problems.
More than 50 years of social behavioral research show that even the most “sane” and stable people are susceptible to the pressures of group dynamics and the power of situational forces. In fact, the importance of group dynamics has led many leading scholars who study VE to dismiss the possibility that mental health plays a role in the radicalization process. Instead, these scholars suggest that violent extremists are otherwise well-adjusted people influenced solely by group beliefs and norms that advocate violent tactics to achieve political and/or religious goals. Certainly, this is the case for numerous individuals attracted to VE. Still however, it seems premature to completely discount the role mental health may play in the world of domestic radicalization and violent extremism.
Through the NIJ’s funding, we are engaged in a research collaboration with Life After Hate (LAH), a nongovernmental organization founded by former members of domestic radical groups, and the Anti-Defamation League, the Simon Wiesenthal Center, and the Southern Poverty Law Center. This partnership will result in a comprehensive study of the disengagement and deradicalization processes among members of domestic radical groups. As part of the project, we are conducting 50 in-depth life history interviews with former members of such extremist groups as the KKK, neo-Nazis, and racist skinheads. The findings will inform LAH’s efforts to build a robust prevention and intervention program aimed specifically at domestic radical groups.
LAH’s community intervention program, Exit USA, is modeled after similar programs in Europe, the Middle East, and elsewhere. Exit USA will be a bridge to connect individuals seeking to exit domestic radical groups with needed social and behavioral services as they make their way out of domestic radicalization. Heretofore, intervention and prevention strategies, including the recent White House Summit on CVE, have focused almost exclusively on “violent jihadis.” We suggest this emphasis on foreign terrorism has left many of our communities with little support to dissuade membership and dismantle domestic radical group mobilization. Our research will contribute to Exit USA as a first step toward building community supports.
As part of the interviews, the research team is examining how exposure to various types of risk factors, including mental health problems, are associated with entry into domestic hate groups as well as how these risk factors might impede or create obstacles to leaving violent extremism. Identifying the presence of risk factors and providing opportunities for individuals to access services that might help mitigate these issues is critical, but we do not assume that any one risk factor or even a distinct combination of certain risk factors cause violent extremism in a straightforward way easily detectable through predictive assessment.
We see mental health as one factor that can influence the development of VE. The multidimensional nature of radicalization means there is no single cause of radicalization and no “magic bullet” that guarantees the exit from violent extremist groups. Instead, there are various points along the pathway of entering and leaving VE where intervention strategies such as Exit USA could be successful. Untreated mental health problems, along with the volatile mix of extremist beliefs and associations, destabilize a person and also remove the needed internal constraints that otherwise are likely to reduce the potential of VE.
We expect CVE interventions focused on mental health to be effective in two principal ways. First, individuals at risk of becoming involved or who are at the early stages of entry might benefit from mental health treatment as a means to provide stability and address underlying issues that might be driving the person toward extremism. A growing number of studies underscore that individuals are not necessarily initially motivated by ideology and are often seeking universal needs, such as social support, protection, and excitement. In this sense, mental health treatment could aid the person in addressing these underlying motivations and seeking alternative ways of fulfilling these needs.
Second, mental health treatment should be an important consideration in the design of intervention programs aimed at promoting disengagement and deradicalization. Mental health treatment is especially likely to be helpful in terms of decreasing the likelihood an individual will “relapse” and return to extremism, which our preliminary results suggest is relatively common.
We are seeking firsthand accounts of how trauma, neglect, and other mental health issues are related to domestic radicalization to inform LAH’s Exit USA program. Anyone with an account should send an e-mail to [email protected].
The project was supported by Award No. 2014-ZA-0005, awarded by the NIJ, Office of Justice Programs, U.S. Department of Justice. The opinions, findings, and conclusions or recommendations expressed in this article are those of the author(s) and do not necessarily reflect those of the Department of Justice.
Dr. Simi is with the National Consortium for the Study of Terrorism and Responses to Terrorism and is associate professor at the University of Nebraska, Omaha. Dr. Blee is associate dean for graduate studies, and research and distinguished professor of sociology at the Kenneth P. Dietrich School of Arts and Sciences, University of Pittsburgh. Dr. DeMichele is a research sociologist with the Center for Justice, Safety, and Resilience at RTI International, Research Triangle Park, N.C.*
This article was updated 7/27/2015.
Cold iron truth: The high value quotient of dermatology
I have been a traveling road show for the last 2 years, explaining the value of dermatology to insurers. It is amazing how poorly understood we are by payers.
Let me give you an example. Currently, dermatologists treat about 70% of all skin cancers. This is up from the 10% we treated 30 years ago, but if you think about it, it should be 98% or 99%. There were 5.4 million skin cancers in the United States in 2012. The great majority were nonmelanoma skin cancers (at an interesting ratio of 1:1 for basal cell carcinoma and squamous cell carcinoma), and only about 75,000 were melanomas. About 80% of all melanomas are less than 1 mm in thickness and undoubtedly appropriate for local excision in the office. Dermatologists treat these skin cancers at less than 1/5 the cost of treatment in a facility. We, and a few primary care physicians, are the only physicians who are not operating room dependent. We can remove these cancers under local anesthesia in the office, without an anesthesiologist, multiple nurses, intravenous lines, preop labs, and the other high fixed costs associated with a hospital procedure, and we can do it promptly. Insurers should be pounding their drums to demand that the vast majority of skin cancers be treated in the office setting, rather than in a hospital. Maybe all skin cancer patients should be required to get “precertified” by a dermatologist before they are sent to a hospital for a procedure. This would improve quality and greatly cut costs.
Insurers always drop their jaws when I explain this to them. They have never matched up the costs of the physicians and the costs of the facilities where procedures are performed. They need to consider the value of the dermatologist in providing an accurate, quick diagnosis, with immediate exclusion of benign lesions and elimination of the long wait times to get a cancer removed. It costs less to get a skin cancer diagnosed and removed by a dermatologist than to get a new set of car tires installed, and we can often do it in about the same amount of time. Compare that with $150,000 spent annually to treat metastatic melanoma.
In addition, fewer dermatologists mean longer wait times to see the dermatologist, causing what I call the “spillover” effect. When patients cannot get in to see the dermatologist, they call their primary care physician, who sends them down to the hospital to see their general surgeon on lumps and bumps day. Everything gets removed, benign or not, in the hospital outpatient department.
That is why it is insane for insurers to be eliminating dermatologists wholesale from their “tight” networks. Their software tells them they will save money in the short term, but they won’t because of the spillover, and it is very foolish in the long term. With the advent of the Affordable Care Act, patients cannot be excluded for preexisting conditions, and these patients all become long-term clients of one insurer or another. What is neglected today becomes a nightmare tomorrow. Dermatology offers an extraordinarily high value quotient, but only if insurers have enough sense to let the patients see us.
Dr. Coldiron is in private practice, but maintains a clinical assistant professorship of dermatology at the University of Cincinnati. Email him at [email protected].
I have been a traveling road show for the last 2 years, explaining the value of dermatology to insurers. It is amazing how poorly understood we are by payers.
Let me give you an example. Currently, dermatologists treat about 70% of all skin cancers. This is up from the 10% we treated 30 years ago, but if you think about it, it should be 98% or 99%. There were 5.4 million skin cancers in the United States in 2012. The great majority were nonmelanoma skin cancers (at an interesting ratio of 1:1 for basal cell carcinoma and squamous cell carcinoma), and only about 75,000 were melanomas. About 80% of all melanomas are less than 1 mm in thickness and undoubtedly appropriate for local excision in the office. Dermatologists treat these skin cancers at less than 1/5 the cost of treatment in a facility. We, and a few primary care physicians, are the only physicians who are not operating room dependent. We can remove these cancers under local anesthesia in the office, without an anesthesiologist, multiple nurses, intravenous lines, preop labs, and the other high fixed costs associated with a hospital procedure, and we can do it promptly. Insurers should be pounding their drums to demand that the vast majority of skin cancers be treated in the office setting, rather than in a hospital. Maybe all skin cancer patients should be required to get “precertified” by a dermatologist before they are sent to a hospital for a procedure. This would improve quality and greatly cut costs.
Insurers always drop their jaws when I explain this to them. They have never matched up the costs of the physicians and the costs of the facilities where procedures are performed. They need to consider the value of the dermatologist in providing an accurate, quick diagnosis, with immediate exclusion of benign lesions and elimination of the long wait times to get a cancer removed. It costs less to get a skin cancer diagnosed and removed by a dermatologist than to get a new set of car tires installed, and we can often do it in about the same amount of time. Compare that with $150,000 spent annually to treat metastatic melanoma.
In addition, fewer dermatologists mean longer wait times to see the dermatologist, causing what I call the “spillover” effect. When patients cannot get in to see the dermatologist, they call their primary care physician, who sends them down to the hospital to see their general surgeon on lumps and bumps day. Everything gets removed, benign or not, in the hospital outpatient department.
That is why it is insane for insurers to be eliminating dermatologists wholesale from their “tight” networks. Their software tells them they will save money in the short term, but they won’t because of the spillover, and it is very foolish in the long term. With the advent of the Affordable Care Act, patients cannot be excluded for preexisting conditions, and these patients all become long-term clients of one insurer or another. What is neglected today becomes a nightmare tomorrow. Dermatology offers an extraordinarily high value quotient, but only if insurers have enough sense to let the patients see us.
Dr. Coldiron is in private practice, but maintains a clinical assistant professorship of dermatology at the University of Cincinnati. Email him at [email protected].
I have been a traveling road show for the last 2 years, explaining the value of dermatology to insurers. It is amazing how poorly understood we are by payers.
Let me give you an example. Currently, dermatologists treat about 70% of all skin cancers. This is up from the 10% we treated 30 years ago, but if you think about it, it should be 98% or 99%. There were 5.4 million skin cancers in the United States in 2012. The great majority were nonmelanoma skin cancers (at an interesting ratio of 1:1 for basal cell carcinoma and squamous cell carcinoma), and only about 75,000 were melanomas. About 80% of all melanomas are less than 1 mm in thickness and undoubtedly appropriate for local excision in the office. Dermatologists treat these skin cancers at less than 1/5 the cost of treatment in a facility. We, and a few primary care physicians, are the only physicians who are not operating room dependent. We can remove these cancers under local anesthesia in the office, without an anesthesiologist, multiple nurses, intravenous lines, preop labs, and the other high fixed costs associated with a hospital procedure, and we can do it promptly. Insurers should be pounding their drums to demand that the vast majority of skin cancers be treated in the office setting, rather than in a hospital. Maybe all skin cancer patients should be required to get “precertified” by a dermatologist before they are sent to a hospital for a procedure. This would improve quality and greatly cut costs.
Insurers always drop their jaws when I explain this to them. They have never matched up the costs of the physicians and the costs of the facilities where procedures are performed. They need to consider the value of the dermatologist in providing an accurate, quick diagnosis, with immediate exclusion of benign lesions and elimination of the long wait times to get a cancer removed. It costs less to get a skin cancer diagnosed and removed by a dermatologist than to get a new set of car tires installed, and we can often do it in about the same amount of time. Compare that with $150,000 spent annually to treat metastatic melanoma.
In addition, fewer dermatologists mean longer wait times to see the dermatologist, causing what I call the “spillover” effect. When patients cannot get in to see the dermatologist, they call their primary care physician, who sends them down to the hospital to see their general surgeon on lumps and bumps day. Everything gets removed, benign or not, in the hospital outpatient department.
That is why it is insane for insurers to be eliminating dermatologists wholesale from their “tight” networks. Their software tells them they will save money in the short term, but they won’t because of the spillover, and it is very foolish in the long term. With the advent of the Affordable Care Act, patients cannot be excluded for preexisting conditions, and these patients all become long-term clients of one insurer or another. What is neglected today becomes a nightmare tomorrow. Dermatology offers an extraordinarily high value quotient, but only if insurers have enough sense to let the patients see us.
Dr. Coldiron is in private practice, but maintains a clinical assistant professorship of dermatology at the University of Cincinnati. Email him at [email protected].
Business associate agreements
Revision of the Health Insurance Portability and Accountability Act (HIPAA) rules has prompted numerous questions about business associates (BAs) and business associate agreements (BAAs). Apparently there is confusion about exactly which businesses qualify as BAs and how your BAAs should be modified to reflect the new provisions.
The criteria for identifying BAs are admittedly vague: The act defines them as nonemployees, performing “functions or activities” on behalf of the “covered entity” (your practice) that involve “creating, receiving, maintaining, or transmitting” personal health information (PHI).
Clearly, answering and billing services, independent transcriptionists, hardware and software companies, and any other vendors involved in creating or maintaining your medical records always qualify as BAs. Other businesses may or may not qualify, depending on whether they need direct access to PHI in order to provide their service. These include practice management consultants, attorneys, companies that store or microfilm medical records, and record-shredding services.
Specialty pharmacies are seldom mentioned in the BA discussion, but they probably should be. Pharmaceutical manufacturers are increasingly using them as intermediaries for their products – particularly the more expensive ones, such as biologics. Many of them ship products directly to patients, for which they require home addresses and other personal information, and in order to file payment paperwork and claim forms, they usually request diagnoses and associated medical information. By any reasonable interpretation of the new rules, this makes them BAs, and you should have BAAs in place before allowing them to fill your prescriptions.
To further complicate the situation, manufacturers and insurers routinely compile information about the real world uses of their products. To that end, they often ask specialty pharmacies to provide them with any patient data that they collect. Under the new rules, patients may restrict any PHI shared with third parties when patients pay for the drugs or services themselves. Your specialty pharmacy BAA should include a provision noting that the pharmacy is forbidden from disclosing any data to pharmaceutical companies or insurers from patients who self-pay and request confidentiality.
Mail carriers, package delivery people, cleaning services, copier repairmen, bank employees, and the like are not considered BAs. While they might conceivably come in contact with PHI on occasion, they don’t need it to do their job. You are required to use “reasonable diligence” in limiting the PHI that these folks may encounter, but you do not need to enter into written BA agreements with them.
Independent contractors who work within your practice – aestheticians and physical therapists, for example – are not considered BAs either, and do not need to sign a BA agreement. Just train them, as you do your employees.
Another source of confusion is the provision in the new rules that makes BAs directly responsible for their own HIPAA violations. While this might seem to eliminate the need for BAAs entirely, unfortunately that is not the case. In fact, even more responsibility has been placed on physicians for confidentiality breaches committed by their BAs. It is not enough to simply have a BAA in place; you are expected to use “reasonable diligence” in monitoring the work of your BAs. While BAs and their subcontractors are responsible for their own actions, the primary responsibility remains with you. Furthermore, you now must assume the worst-case scenario. Previously, when PHI was compromised, you would have to notify affected patients (and the government) only if there was a “significant risk of financial or reputational harm”; but now, any incident involving patient records is assumed to be a breach, and must be reported. Failure to do so could subject your practice, as well as the contractor, to significant fines.
If you haven’t yet revised your Notice of Privacy Practices (NPP) to explain your relationships with BAs, and their status under the new rules, do it now. (You should have done it last September.) You need to explain the breach notification process too, as well as the new patient rights mentioned above. You must post your revised NPP in your office, and make copies available there, but you need not mail a copy to every patient.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News.
Revision of the Health Insurance Portability and Accountability Act (HIPAA) rules has prompted numerous questions about business associates (BAs) and business associate agreements (BAAs). Apparently there is confusion about exactly which businesses qualify as BAs and how your BAAs should be modified to reflect the new provisions.
The criteria for identifying BAs are admittedly vague: The act defines them as nonemployees, performing “functions or activities” on behalf of the “covered entity” (your practice) that involve “creating, receiving, maintaining, or transmitting” personal health information (PHI).
Clearly, answering and billing services, independent transcriptionists, hardware and software companies, and any other vendors involved in creating or maintaining your medical records always qualify as BAs. Other businesses may or may not qualify, depending on whether they need direct access to PHI in order to provide their service. These include practice management consultants, attorneys, companies that store or microfilm medical records, and record-shredding services.
Specialty pharmacies are seldom mentioned in the BA discussion, but they probably should be. Pharmaceutical manufacturers are increasingly using them as intermediaries for their products – particularly the more expensive ones, such as biologics. Many of them ship products directly to patients, for which they require home addresses and other personal information, and in order to file payment paperwork and claim forms, they usually request diagnoses and associated medical information. By any reasonable interpretation of the new rules, this makes them BAs, and you should have BAAs in place before allowing them to fill your prescriptions.
To further complicate the situation, manufacturers and insurers routinely compile information about the real world uses of their products. To that end, they often ask specialty pharmacies to provide them with any patient data that they collect. Under the new rules, patients may restrict any PHI shared with third parties when patients pay for the drugs or services themselves. Your specialty pharmacy BAA should include a provision noting that the pharmacy is forbidden from disclosing any data to pharmaceutical companies or insurers from patients who self-pay and request confidentiality.
Mail carriers, package delivery people, cleaning services, copier repairmen, bank employees, and the like are not considered BAs. While they might conceivably come in contact with PHI on occasion, they don’t need it to do their job. You are required to use “reasonable diligence” in limiting the PHI that these folks may encounter, but you do not need to enter into written BA agreements with them.
Independent contractors who work within your practice – aestheticians and physical therapists, for example – are not considered BAs either, and do not need to sign a BA agreement. Just train them, as you do your employees.
Another source of confusion is the provision in the new rules that makes BAs directly responsible for their own HIPAA violations. While this might seem to eliminate the need for BAAs entirely, unfortunately that is not the case. In fact, even more responsibility has been placed on physicians for confidentiality breaches committed by their BAs. It is not enough to simply have a BAA in place; you are expected to use “reasonable diligence” in monitoring the work of your BAs. While BAs and their subcontractors are responsible for their own actions, the primary responsibility remains with you. Furthermore, you now must assume the worst-case scenario. Previously, when PHI was compromised, you would have to notify affected patients (and the government) only if there was a “significant risk of financial or reputational harm”; but now, any incident involving patient records is assumed to be a breach, and must be reported. Failure to do so could subject your practice, as well as the contractor, to significant fines.
If you haven’t yet revised your Notice of Privacy Practices (NPP) to explain your relationships with BAs, and their status under the new rules, do it now. (You should have done it last September.) You need to explain the breach notification process too, as well as the new patient rights mentioned above. You must post your revised NPP in your office, and make copies available there, but you need not mail a copy to every patient.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News.
Revision of the Health Insurance Portability and Accountability Act (HIPAA) rules has prompted numerous questions about business associates (BAs) and business associate agreements (BAAs). Apparently there is confusion about exactly which businesses qualify as BAs and how your BAAs should be modified to reflect the new provisions.
The criteria for identifying BAs are admittedly vague: The act defines them as nonemployees, performing “functions or activities” on behalf of the “covered entity” (your practice) that involve “creating, receiving, maintaining, or transmitting” personal health information (PHI).
Clearly, answering and billing services, independent transcriptionists, hardware and software companies, and any other vendors involved in creating or maintaining your medical records always qualify as BAs. Other businesses may or may not qualify, depending on whether they need direct access to PHI in order to provide their service. These include practice management consultants, attorneys, companies that store or microfilm medical records, and record-shredding services.
Specialty pharmacies are seldom mentioned in the BA discussion, but they probably should be. Pharmaceutical manufacturers are increasingly using them as intermediaries for their products – particularly the more expensive ones, such as biologics. Many of them ship products directly to patients, for which they require home addresses and other personal information, and in order to file payment paperwork and claim forms, they usually request diagnoses and associated medical information. By any reasonable interpretation of the new rules, this makes them BAs, and you should have BAAs in place before allowing them to fill your prescriptions.
To further complicate the situation, manufacturers and insurers routinely compile information about the real world uses of their products. To that end, they often ask specialty pharmacies to provide them with any patient data that they collect. Under the new rules, patients may restrict any PHI shared with third parties when patients pay for the drugs or services themselves. Your specialty pharmacy BAA should include a provision noting that the pharmacy is forbidden from disclosing any data to pharmaceutical companies or insurers from patients who self-pay and request confidentiality.
Mail carriers, package delivery people, cleaning services, copier repairmen, bank employees, and the like are not considered BAs. While they might conceivably come in contact with PHI on occasion, they don’t need it to do their job. You are required to use “reasonable diligence” in limiting the PHI that these folks may encounter, but you do not need to enter into written BA agreements with them.
Independent contractors who work within your practice – aestheticians and physical therapists, for example – are not considered BAs either, and do not need to sign a BA agreement. Just train them, as you do your employees.
Another source of confusion is the provision in the new rules that makes BAs directly responsible for their own HIPAA violations. While this might seem to eliminate the need for BAAs entirely, unfortunately that is not the case. In fact, even more responsibility has been placed on physicians for confidentiality breaches committed by their BAs. It is not enough to simply have a BAA in place; you are expected to use “reasonable diligence” in monitoring the work of your BAs. While BAs and their subcontractors are responsible for their own actions, the primary responsibility remains with you. Furthermore, you now must assume the worst-case scenario. Previously, when PHI was compromised, you would have to notify affected patients (and the government) only if there was a “significant risk of financial or reputational harm”; but now, any incident involving patient records is assumed to be a breach, and must be reported. Failure to do so could subject your practice, as well as the contractor, to significant fines.
If you haven’t yet revised your Notice of Privacy Practices (NPP) to explain your relationships with BAs, and their status under the new rules, do it now. (You should have done it last September.) You need to explain the breach notification process too, as well as the new patient rights mentioned above. You must post your revised NPP in your office, and make copies available there, but you need not mail a copy to every patient.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News.
The outlander’s tale
“Alien Physician” – thus am I ordained by the document that allows me to train in America. I am the International Medical Graduate. This is my story.
I came from poverty and hardship. In other cases, I came from wealth and privilege. Regardless, I clawed my way over staggering numbers of competitors to earn my shot at a medical education. Back home, I was top of my class, fresh out of medical school. In other cases, I was a respected practitioner with a wealth of experience. Now I am a blank slate.
I am here because I heard of a place where questions were encouraged and boundaries pushed. Or I am here because I learned of the American dream. They told me I would be judged for my merit here and nothing else. I have escaped persecution, war, nepotism, or perhaps just a bogged-down system to get here.
Although I have taken the same tests as you, my resume comes with an asterisk. I have had to prove myself by rising to a standard higher than that expected of my peers. Much of my time and peace of mind are consumed jumping through bureaucratic hoops in order to continue my stay. For every one of me you see, there is at least one more who was forced to give up on his or her dream midway.
Know this, however – I appreciate working in a system where the team is greater than the individual, where no job is menial, where the ability to make choices about your health is yours alone, to be shared should you need to.
Know that I am good company, although my jokes sometimes fall flat in the space between our two cultures. Learning new things about your country and its people makes me feel young again.
Know that I have a keen appreciation of how important cultural nuance is to the doctor-patient relationship, even if I come across as ignorant. I have gained this understanding not by reading about it in a book, but by living it.
Know that nothing is more important to me than the health of my patients, and that my being a foreigner does not mean your child will receive anything less than my very best.
Most importantly, know that I feel blessed to be here. While my journey is still uphill, I have no regrets. If I were not made of hard stuff, I would not be here. Although I may grumble, I shall endeavor to accept my lot with grace and humility in the knowledge that I have earned the right to practice the subject that I love and the cognizance that not everyone would open their arms to outsiders the way you have. It has meant the world to me. Working with you has opened my eyes to things I did not see before and has inspired me to be a better doctor. I hope in some small way my presence here affords you that same inspiration.
Dr. Behere was a pediatric resident at the Children’s Hospital at Dartmouth, Lebanon, N.H. when he wrote this article. He is currently a first-year fellow in pediatric cardiology at the Nemours Cardiac Center at the Nemours/Alfred I. duPont Hospital for Children, Wilmington, Del.
“Alien Physician” – thus am I ordained by the document that allows me to train in America. I am the International Medical Graduate. This is my story.
I came from poverty and hardship. In other cases, I came from wealth and privilege. Regardless, I clawed my way over staggering numbers of competitors to earn my shot at a medical education. Back home, I was top of my class, fresh out of medical school. In other cases, I was a respected practitioner with a wealth of experience. Now I am a blank slate.
I am here because I heard of a place where questions were encouraged and boundaries pushed. Or I am here because I learned of the American dream. They told me I would be judged for my merit here and nothing else. I have escaped persecution, war, nepotism, or perhaps just a bogged-down system to get here.
Although I have taken the same tests as you, my resume comes with an asterisk. I have had to prove myself by rising to a standard higher than that expected of my peers. Much of my time and peace of mind are consumed jumping through bureaucratic hoops in order to continue my stay. For every one of me you see, there is at least one more who was forced to give up on his or her dream midway.
Know this, however – I appreciate working in a system where the team is greater than the individual, where no job is menial, where the ability to make choices about your health is yours alone, to be shared should you need to.
Know that I am good company, although my jokes sometimes fall flat in the space between our two cultures. Learning new things about your country and its people makes me feel young again.
Know that I have a keen appreciation of how important cultural nuance is to the doctor-patient relationship, even if I come across as ignorant. I have gained this understanding not by reading about it in a book, but by living it.
Know that nothing is more important to me than the health of my patients, and that my being a foreigner does not mean your child will receive anything less than my very best.
Most importantly, know that I feel blessed to be here. While my journey is still uphill, I have no regrets. If I were not made of hard stuff, I would not be here. Although I may grumble, I shall endeavor to accept my lot with grace and humility in the knowledge that I have earned the right to practice the subject that I love and the cognizance that not everyone would open their arms to outsiders the way you have. It has meant the world to me. Working with you has opened my eyes to things I did not see before and has inspired me to be a better doctor. I hope in some small way my presence here affords you that same inspiration.
Dr. Behere was a pediatric resident at the Children’s Hospital at Dartmouth, Lebanon, N.H. when he wrote this article. He is currently a first-year fellow in pediatric cardiology at the Nemours Cardiac Center at the Nemours/Alfred I. duPont Hospital for Children, Wilmington, Del.
“Alien Physician” – thus am I ordained by the document that allows me to train in America. I am the International Medical Graduate. This is my story.
I came from poverty and hardship. In other cases, I came from wealth and privilege. Regardless, I clawed my way over staggering numbers of competitors to earn my shot at a medical education. Back home, I was top of my class, fresh out of medical school. In other cases, I was a respected practitioner with a wealth of experience. Now I am a blank slate.
I am here because I heard of a place where questions were encouraged and boundaries pushed. Or I am here because I learned of the American dream. They told me I would be judged for my merit here and nothing else. I have escaped persecution, war, nepotism, or perhaps just a bogged-down system to get here.
Although I have taken the same tests as you, my resume comes with an asterisk. I have had to prove myself by rising to a standard higher than that expected of my peers. Much of my time and peace of mind are consumed jumping through bureaucratic hoops in order to continue my stay. For every one of me you see, there is at least one more who was forced to give up on his or her dream midway.
Know this, however – I appreciate working in a system where the team is greater than the individual, where no job is menial, where the ability to make choices about your health is yours alone, to be shared should you need to.
Know that I am good company, although my jokes sometimes fall flat in the space between our two cultures. Learning new things about your country and its people makes me feel young again.
Know that I have a keen appreciation of how important cultural nuance is to the doctor-patient relationship, even if I come across as ignorant. I have gained this understanding not by reading about it in a book, but by living it.
Know that nothing is more important to me than the health of my patients, and that my being a foreigner does not mean your child will receive anything less than my very best.
Most importantly, know that I feel blessed to be here. While my journey is still uphill, I have no regrets. If I were not made of hard stuff, I would not be here. Although I may grumble, I shall endeavor to accept my lot with grace and humility in the knowledge that I have earned the right to practice the subject that I love and the cognizance that not everyone would open their arms to outsiders the way you have. It has meant the world to me. Working with you has opened my eyes to things I did not see before and has inspired me to be a better doctor. I hope in some small way my presence here affords you that same inspiration.
Dr. Behere was a pediatric resident at the Children’s Hospital at Dartmouth, Lebanon, N.H. when he wrote this article. He is currently a first-year fellow in pediatric cardiology at the Nemours Cardiac Center at the Nemours/Alfred I. duPont Hospital for Children, Wilmington, Del.
Commentary: A modern epidemic – the case for addiction medicine
Imagine a disease killing nearly 1,500 Americans every day and sending an additional 6,748 people to our nation’s emergency departments on a daily basis.1, 2 Imagine 22.7 million people in our country needing treatment for this disease, and only 2.5 million being able to access lifesaving care.3
Imagine the outrage if, in an unfortunate reminder of the early years of HIV/AIDS, patients were blamed for their disease and received stigma instead of compassion.
In such a drastic context, one might expect academic medical centers and medical schools to be clamoring to train physicians to provide evidence-based prevention, diagnosis, and treatment; researchers lining up to develop new treatments; public health experts developing urgent new approaches; and affected communities advocating for change.
Unfortunately, this is far from a hypothetical scenario. The disease is substance use disorder (SUD), and we are in the midst of an epidemic. Our patients are dying – and we, as internists, should be concerned, prepared, and ready to join the fight.
Alcohol, tobacco, and drug use disorders affect 40 million Americans, or 15.9% of the population – more than heart conditions, diabetes, or cancer – and cost society $559 billion each year.4, 5 Unintentional drug overdose is the leading cause of accidental death in the United States.2
Yet, most primary care physicians do not feel competent diagnosing or treating alcohol and drug use disorders.6, 7 Similarly, a survey of internal medicine residents found a majority felt unprepared to treat SUD and rated the quality of education and training they received in addiction medicine poorly.
I received very little formal education about SUD in my own training and received exposure to addictions primarily through work in a state prison, where I saw firsthand the consequences of untreated addiction and was fortunate to meet a mentor who cared deeply about this disease. However, most medical students are not so fortunate, and inadequate training and limited faculty role models contribute to the lack of physician preparedness to care for patients with SUD.6, 8, 9
Rapid access to effective treatment, particularly to agonist medication treatment for opioid use disorder, is the single greatest intervention we have to stem the tide of deaths. Increased treatment with buprenorphine and methadone was associated with reduced heroin overdose death by 50% in Maryland, and by 79% in France.10, 11
And yet, because of both stigma and a limited number of trained physicians to prescribe, access to these treatments remains limited and wait lists remain long.
As the National Center on Addiction and Substance Abuse at Columbia University, New York, reported, “Most of those who are providing addiction treatment are not medical professionals and are not equipped with the knowledge, skills, or credentials necessary to provide the full range of evidence-based services to address addiction effectively.”4
The good news is that addiction medicine is now a multidisciplinary subspecialty, which has its own specialty board, the American Board of Addiction Medicine (ABAM). The formal process to make addiction medicine a recognized subspecialty within the American Board of Medical Specialties may be completed within the next year. Although there are 27 ABAM Foundation–accredited fellowship programs across the country, the credentialing exam is still open to any licensed physician with at least 1,920 hours over the last 5 years caring for patients at risk for, or with, addiction, and 50 hours of addiction CME.12
Significantly, several years ago, the credentialing committee of ABAM noted that at least 20% of the average internist’s time is spent caring for a patient with addiction or its complications. Thus, many internists will meet the exam’s eligibility requirements. Like me, many of those who become certified by ABAM work in a primary care setting and do their initial training in internal medicine.
Increasing the number of addiction medicine specialists is necessary to reduce the addiction treatment gap, elevate the quality of addiction care available, and work toward reducing stigma.
With other similar chronic diseases, specialty consultation is available. While general internists can and do effectively manage diabetes, cardiovascular disease, and asthma, they appropriately have access to endocrinologists, cardiologists, and pulmonologists.
Drawing again on the comparison to HIV, research has found that physician experience with HIV/AIDS and specialty training improves patient outcomes. Similarly, access to specialty consultation with addiction experts should be an option available for all patients with SUD and the doctors caring for them. Many of us are already providing the care. Getting certified provides an opportunity to consolidate one’s knowledge of addictions.
Science has shown that there is no longer any question about the nature of addiction – it is a chronic disease with genetic vulnerability, pathophysiological changes, and environmental contributors. Continuing to marginalize this illness as a social problem out of the domain of physicians will only worsen the stigmatization of affected patients and increase the deadly impact of this epidemic.
Addiction medicine certification and specialization offer physicians an opportunity to demonstrate excellence and competence in the field, serve as expert consultants for colleagues, and provide patients and families with quality and equitable health care.
It is also a dynamic and exciting field to practice in right now, one in which we can make a significant impact on the nation’s number one public health problem.
Dr. Wakeman is medical director of the Substance Use Disorder Initiative at Massachusetts General Hospital/Harvard Medical School, Boston. She is a diplomate of both the American Board of Internal Medicine and American Board of Addiction Medicine. For more information on the ABAM certification exam, visit www.abam.net.
References
2. CDC. Prescription Drug Overdose in the United States: Fact Sheet. Available online at www.cdc.gov/drugoverdose/index.html.
3. The NSDUH Report: Substance Use and Mental Health Estimates from the 2013 National Survey on Drug Use and Health: Overview of Findings.
4. CASA Columbia. Addiction Medicine: Closing the Gap between Science and Practice. Available online at www.casacolumbia.org/addiction-research/reports/addiction-medicine.
5. NIDA. Addiction Science: From Molecules to Managed Care. July, 2008. Available online at www.drugabuse.gov/publications/addiction-science/introduction.
7. CASA Columbia. Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse. April, 2000. Available online at www.casacolumbia.org/addiction-research/reports/national-survey-primary-care-physicians-patients-substance-abuse.
8. Ann. Intern. Med. 2011;154:56-59.
9. Subst. Abus. 2013;34:363-70.
10. Am. J. Public Health 2013;103:917-22.
Imagine a disease killing nearly 1,500 Americans every day and sending an additional 6,748 people to our nation’s emergency departments on a daily basis.1, 2 Imagine 22.7 million people in our country needing treatment for this disease, and only 2.5 million being able to access lifesaving care.3
Imagine the outrage if, in an unfortunate reminder of the early years of HIV/AIDS, patients were blamed for their disease and received stigma instead of compassion.
In such a drastic context, one might expect academic medical centers and medical schools to be clamoring to train physicians to provide evidence-based prevention, diagnosis, and treatment; researchers lining up to develop new treatments; public health experts developing urgent new approaches; and affected communities advocating for change.
Unfortunately, this is far from a hypothetical scenario. The disease is substance use disorder (SUD), and we are in the midst of an epidemic. Our patients are dying – and we, as internists, should be concerned, prepared, and ready to join the fight.
Alcohol, tobacco, and drug use disorders affect 40 million Americans, or 15.9% of the population – more than heart conditions, diabetes, or cancer – and cost society $559 billion each year.4, 5 Unintentional drug overdose is the leading cause of accidental death in the United States.2
Yet, most primary care physicians do not feel competent diagnosing or treating alcohol and drug use disorders.6, 7 Similarly, a survey of internal medicine residents found a majority felt unprepared to treat SUD and rated the quality of education and training they received in addiction medicine poorly.
I received very little formal education about SUD in my own training and received exposure to addictions primarily through work in a state prison, where I saw firsthand the consequences of untreated addiction and was fortunate to meet a mentor who cared deeply about this disease. However, most medical students are not so fortunate, and inadequate training and limited faculty role models contribute to the lack of physician preparedness to care for patients with SUD.6, 8, 9
Rapid access to effective treatment, particularly to agonist medication treatment for opioid use disorder, is the single greatest intervention we have to stem the tide of deaths. Increased treatment with buprenorphine and methadone was associated with reduced heroin overdose death by 50% in Maryland, and by 79% in France.10, 11
And yet, because of both stigma and a limited number of trained physicians to prescribe, access to these treatments remains limited and wait lists remain long.
As the National Center on Addiction and Substance Abuse at Columbia University, New York, reported, “Most of those who are providing addiction treatment are not medical professionals and are not equipped with the knowledge, skills, or credentials necessary to provide the full range of evidence-based services to address addiction effectively.”4
The good news is that addiction medicine is now a multidisciplinary subspecialty, which has its own specialty board, the American Board of Addiction Medicine (ABAM). The formal process to make addiction medicine a recognized subspecialty within the American Board of Medical Specialties may be completed within the next year. Although there are 27 ABAM Foundation–accredited fellowship programs across the country, the credentialing exam is still open to any licensed physician with at least 1,920 hours over the last 5 years caring for patients at risk for, or with, addiction, and 50 hours of addiction CME.12
Significantly, several years ago, the credentialing committee of ABAM noted that at least 20% of the average internist’s time is spent caring for a patient with addiction or its complications. Thus, many internists will meet the exam’s eligibility requirements. Like me, many of those who become certified by ABAM work in a primary care setting and do their initial training in internal medicine.
Increasing the number of addiction medicine specialists is necessary to reduce the addiction treatment gap, elevate the quality of addiction care available, and work toward reducing stigma.
With other similar chronic diseases, specialty consultation is available. While general internists can and do effectively manage diabetes, cardiovascular disease, and asthma, they appropriately have access to endocrinologists, cardiologists, and pulmonologists.
Drawing again on the comparison to HIV, research has found that physician experience with HIV/AIDS and specialty training improves patient outcomes. Similarly, access to specialty consultation with addiction experts should be an option available for all patients with SUD and the doctors caring for them. Many of us are already providing the care. Getting certified provides an opportunity to consolidate one’s knowledge of addictions.
Science has shown that there is no longer any question about the nature of addiction – it is a chronic disease with genetic vulnerability, pathophysiological changes, and environmental contributors. Continuing to marginalize this illness as a social problem out of the domain of physicians will only worsen the stigmatization of affected patients and increase the deadly impact of this epidemic.
Addiction medicine certification and specialization offer physicians an opportunity to demonstrate excellence and competence in the field, serve as expert consultants for colleagues, and provide patients and families with quality and equitable health care.
It is also a dynamic and exciting field to practice in right now, one in which we can make a significant impact on the nation’s number one public health problem.
Dr. Wakeman is medical director of the Substance Use Disorder Initiative at Massachusetts General Hospital/Harvard Medical School, Boston. She is a diplomate of both the American Board of Internal Medicine and American Board of Addiction Medicine. For more information on the ABAM certification exam, visit www.abam.net.
References
2. CDC. Prescription Drug Overdose in the United States: Fact Sheet. Available online at www.cdc.gov/drugoverdose/index.html.
3. The NSDUH Report: Substance Use and Mental Health Estimates from the 2013 National Survey on Drug Use and Health: Overview of Findings.
4. CASA Columbia. Addiction Medicine: Closing the Gap between Science and Practice. Available online at www.casacolumbia.org/addiction-research/reports/addiction-medicine.
5. NIDA. Addiction Science: From Molecules to Managed Care. July, 2008. Available online at www.drugabuse.gov/publications/addiction-science/introduction.
7. CASA Columbia. Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse. April, 2000. Available online at www.casacolumbia.org/addiction-research/reports/national-survey-primary-care-physicians-patients-substance-abuse.
8. Ann. Intern. Med. 2011;154:56-59.
9. Subst. Abus. 2013;34:363-70.
10. Am. J. Public Health 2013;103:917-22.
Imagine a disease killing nearly 1,500 Americans every day and sending an additional 6,748 people to our nation’s emergency departments on a daily basis.1, 2 Imagine 22.7 million people in our country needing treatment for this disease, and only 2.5 million being able to access lifesaving care.3
Imagine the outrage if, in an unfortunate reminder of the early years of HIV/AIDS, patients were blamed for their disease and received stigma instead of compassion.
In such a drastic context, one might expect academic medical centers and medical schools to be clamoring to train physicians to provide evidence-based prevention, diagnosis, and treatment; researchers lining up to develop new treatments; public health experts developing urgent new approaches; and affected communities advocating for change.
Unfortunately, this is far from a hypothetical scenario. The disease is substance use disorder (SUD), and we are in the midst of an epidemic. Our patients are dying – and we, as internists, should be concerned, prepared, and ready to join the fight.
Alcohol, tobacco, and drug use disorders affect 40 million Americans, or 15.9% of the population – more than heart conditions, diabetes, or cancer – and cost society $559 billion each year.4, 5 Unintentional drug overdose is the leading cause of accidental death in the United States.2
Yet, most primary care physicians do not feel competent diagnosing or treating alcohol and drug use disorders.6, 7 Similarly, a survey of internal medicine residents found a majority felt unprepared to treat SUD and rated the quality of education and training they received in addiction medicine poorly.
I received very little formal education about SUD in my own training and received exposure to addictions primarily through work in a state prison, where I saw firsthand the consequences of untreated addiction and was fortunate to meet a mentor who cared deeply about this disease. However, most medical students are not so fortunate, and inadequate training and limited faculty role models contribute to the lack of physician preparedness to care for patients with SUD.6, 8, 9
Rapid access to effective treatment, particularly to agonist medication treatment for opioid use disorder, is the single greatest intervention we have to stem the tide of deaths. Increased treatment with buprenorphine and methadone was associated with reduced heroin overdose death by 50% in Maryland, and by 79% in France.10, 11
And yet, because of both stigma and a limited number of trained physicians to prescribe, access to these treatments remains limited and wait lists remain long.
As the National Center on Addiction and Substance Abuse at Columbia University, New York, reported, “Most of those who are providing addiction treatment are not medical professionals and are not equipped with the knowledge, skills, or credentials necessary to provide the full range of evidence-based services to address addiction effectively.”4
The good news is that addiction medicine is now a multidisciplinary subspecialty, which has its own specialty board, the American Board of Addiction Medicine (ABAM). The formal process to make addiction medicine a recognized subspecialty within the American Board of Medical Specialties may be completed within the next year. Although there are 27 ABAM Foundation–accredited fellowship programs across the country, the credentialing exam is still open to any licensed physician with at least 1,920 hours over the last 5 years caring for patients at risk for, or with, addiction, and 50 hours of addiction CME.12
Significantly, several years ago, the credentialing committee of ABAM noted that at least 20% of the average internist’s time is spent caring for a patient with addiction or its complications. Thus, many internists will meet the exam’s eligibility requirements. Like me, many of those who become certified by ABAM work in a primary care setting and do their initial training in internal medicine.
Increasing the number of addiction medicine specialists is necessary to reduce the addiction treatment gap, elevate the quality of addiction care available, and work toward reducing stigma.
With other similar chronic diseases, specialty consultation is available. While general internists can and do effectively manage diabetes, cardiovascular disease, and asthma, they appropriately have access to endocrinologists, cardiologists, and pulmonologists.
Drawing again on the comparison to HIV, research has found that physician experience with HIV/AIDS and specialty training improves patient outcomes. Similarly, access to specialty consultation with addiction experts should be an option available for all patients with SUD and the doctors caring for them. Many of us are already providing the care. Getting certified provides an opportunity to consolidate one’s knowledge of addictions.
Science has shown that there is no longer any question about the nature of addiction – it is a chronic disease with genetic vulnerability, pathophysiological changes, and environmental contributors. Continuing to marginalize this illness as a social problem out of the domain of physicians will only worsen the stigmatization of affected patients and increase the deadly impact of this epidemic.
Addiction medicine certification and specialization offer physicians an opportunity to demonstrate excellence and competence in the field, serve as expert consultants for colleagues, and provide patients and families with quality and equitable health care.
It is also a dynamic and exciting field to practice in right now, one in which we can make a significant impact on the nation’s number one public health problem.
Dr. Wakeman is medical director of the Substance Use Disorder Initiative at Massachusetts General Hospital/Harvard Medical School, Boston. She is a diplomate of both the American Board of Internal Medicine and American Board of Addiction Medicine. For more information on the ABAM certification exam, visit www.abam.net.
References
2. CDC. Prescription Drug Overdose in the United States: Fact Sheet. Available online at www.cdc.gov/drugoverdose/index.html.
3. The NSDUH Report: Substance Use and Mental Health Estimates from the 2013 National Survey on Drug Use and Health: Overview of Findings.
4. CASA Columbia. Addiction Medicine: Closing the Gap between Science and Practice. Available online at www.casacolumbia.org/addiction-research/reports/addiction-medicine.
5. NIDA. Addiction Science: From Molecules to Managed Care. July, 2008. Available online at www.drugabuse.gov/publications/addiction-science/introduction.
7. CASA Columbia. Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse. April, 2000. Available online at www.casacolumbia.org/addiction-research/reports/national-survey-primary-care-physicians-patients-substance-abuse.
8. Ann. Intern. Med. 2011;154:56-59.
9. Subst. Abus. 2013;34:363-70.
10. Am. J. Public Health 2013;103:917-22.
‘Choosing Wisely’: Canada vs. U.S.
In 2011, the American Board of Internal Medicine started the Choosing Wisely campaign, a subtly subversive call to curb health care spending. As part of that campaign, the American College of Rheumatology published its own list of five “tests, treatments, or services … whose necessity or value should be questioned” in March 2013.
As it turns out, Canada has also started a Choosing Wisely Canada campaign, and in February of this year the Canadian Rheumatology Association published their list of five. Though the methodology for coming up with the list was the same in these two very similar populations, there is surprisingly little overlap between the two lists. It is likely that the differences are partly explained by how medicine is practiced and paid for in the two countries. How invested physicians are in their respective professional societies may play a role, too. As part of the methodology, surveys were sent out to membership: At the time of the study the ACR had 6,188 members and a 17% response rate, while the CRA had a membership of 484 and a 35% response rate.
The ACR publication reminds us that the initiative is in part a response to a physician charter for medical professionalism, drafted in 2002 by a collaboration of physician organizations, including the ABIM Foundation and the American College of Physicians, outlining principles of professionalism, “including patient welfare, patient autonomy, and social justice” (Ann. Intern. Med. 2002;136:143-6).
Social justice, according to the ACR, “calls on the profession to promote a fair distribution of health care resources and to engage in collective efforts to improve the health care system for the welfare of society.” I wonder if the gap between the survey response rates of the American and the Canadian groups reflects greater indifference to societal welfare, but I certainly hope not.
In any event, I would like to devote some space to reviewing these two lists. They are worth revisiting often. I’ve included some clarifying statements from each publication that I thought were helpful.
The ACR list (Arthritis Care Res. 2013;65:329-39)
• Do not test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease. Exceptions include anti-Jo1, which can be positive in some forms of myositis, or occasionally, anti-SSA in the setting of lupus or Sjögren syndrome.
• Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate examination findings. Diffuse arthralgias, myalgias, or fibromyalgia alone are not criteria for musculoskeletal Lyme disease.
• Do not perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.
• Do not prescribe biologic agents for RA before a trial of methotrexate (or another conventional nonbiologic DMARD)
• Do not routinely repeat DXA scans more often than once every 2 years. DXA scans should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected.
The CRA list (J. Rheumatol. 2015;42:682-9)
• Do not order ANA as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus or other connective tissue disease. At one center in Canada, ANA testing was positive only 15% of the time and cost more than $800,000 over 3 years when combined with ENA and anti-dsDNA. … An ANA test should be ordered only if the clinician feels there is reasonable clinical suspicion of SLE or CTD based on historical information, physical findings and results of other laboratory tests.
• Do not order an HLA-B27 unless spondyloarthritis is suspected based on specific signs or symptoms. There is no clinical utility to ordering an HLA-B27 in the absence of positive imaging or the minimally required SpA signs or symptoms.
• Do not repeat DXA scans more often than every 2 years. If BMD are stable and/or individuals are at low risk of fracture, then less frequent monitoring up to an interval of 5-10 years can be considered.
• Do not prescribe bisphosphonates for patients at low risk of fracture.
• Do not perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in the adult population.
Dr. Chan practices rheumatology in Pawtucket, R.I.
In 2011, the American Board of Internal Medicine started the Choosing Wisely campaign, a subtly subversive call to curb health care spending. As part of that campaign, the American College of Rheumatology published its own list of five “tests, treatments, or services … whose necessity or value should be questioned” in March 2013.
As it turns out, Canada has also started a Choosing Wisely Canada campaign, and in February of this year the Canadian Rheumatology Association published their list of five. Though the methodology for coming up with the list was the same in these two very similar populations, there is surprisingly little overlap between the two lists. It is likely that the differences are partly explained by how medicine is practiced and paid for in the two countries. How invested physicians are in their respective professional societies may play a role, too. As part of the methodology, surveys were sent out to membership: At the time of the study the ACR had 6,188 members and a 17% response rate, while the CRA had a membership of 484 and a 35% response rate.
The ACR publication reminds us that the initiative is in part a response to a physician charter for medical professionalism, drafted in 2002 by a collaboration of physician organizations, including the ABIM Foundation and the American College of Physicians, outlining principles of professionalism, “including patient welfare, patient autonomy, and social justice” (Ann. Intern. Med. 2002;136:143-6).
Social justice, according to the ACR, “calls on the profession to promote a fair distribution of health care resources and to engage in collective efforts to improve the health care system for the welfare of society.” I wonder if the gap between the survey response rates of the American and the Canadian groups reflects greater indifference to societal welfare, but I certainly hope not.
In any event, I would like to devote some space to reviewing these two lists. They are worth revisiting often. I’ve included some clarifying statements from each publication that I thought were helpful.
The ACR list (Arthritis Care Res. 2013;65:329-39)
• Do not test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease. Exceptions include anti-Jo1, which can be positive in some forms of myositis, or occasionally, anti-SSA in the setting of lupus or Sjögren syndrome.
• Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate examination findings. Diffuse arthralgias, myalgias, or fibromyalgia alone are not criteria for musculoskeletal Lyme disease.
• Do not perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.
• Do not prescribe biologic agents for RA before a trial of methotrexate (or another conventional nonbiologic DMARD)
• Do not routinely repeat DXA scans more often than once every 2 years. DXA scans should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected.
The CRA list (J. Rheumatol. 2015;42:682-9)
• Do not order ANA as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus or other connective tissue disease. At one center in Canada, ANA testing was positive only 15% of the time and cost more than $800,000 over 3 years when combined with ENA and anti-dsDNA. … An ANA test should be ordered only if the clinician feels there is reasonable clinical suspicion of SLE or CTD based on historical information, physical findings and results of other laboratory tests.
• Do not order an HLA-B27 unless spondyloarthritis is suspected based on specific signs or symptoms. There is no clinical utility to ordering an HLA-B27 in the absence of positive imaging or the minimally required SpA signs or symptoms.
• Do not repeat DXA scans more often than every 2 years. If BMD are stable and/or individuals are at low risk of fracture, then less frequent monitoring up to an interval of 5-10 years can be considered.
• Do not prescribe bisphosphonates for patients at low risk of fracture.
• Do not perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in the adult population.
Dr. Chan practices rheumatology in Pawtucket, R.I.
In 2011, the American Board of Internal Medicine started the Choosing Wisely campaign, a subtly subversive call to curb health care spending. As part of that campaign, the American College of Rheumatology published its own list of five “tests, treatments, or services … whose necessity or value should be questioned” in March 2013.
As it turns out, Canada has also started a Choosing Wisely Canada campaign, and in February of this year the Canadian Rheumatology Association published their list of five. Though the methodology for coming up with the list was the same in these two very similar populations, there is surprisingly little overlap between the two lists. It is likely that the differences are partly explained by how medicine is practiced and paid for in the two countries. How invested physicians are in their respective professional societies may play a role, too. As part of the methodology, surveys were sent out to membership: At the time of the study the ACR had 6,188 members and a 17% response rate, while the CRA had a membership of 484 and a 35% response rate.
The ACR publication reminds us that the initiative is in part a response to a physician charter for medical professionalism, drafted in 2002 by a collaboration of physician organizations, including the ABIM Foundation and the American College of Physicians, outlining principles of professionalism, “including patient welfare, patient autonomy, and social justice” (Ann. Intern. Med. 2002;136:143-6).
Social justice, according to the ACR, “calls on the profession to promote a fair distribution of health care resources and to engage in collective efforts to improve the health care system for the welfare of society.” I wonder if the gap between the survey response rates of the American and the Canadian groups reflects greater indifference to societal welfare, but I certainly hope not.
In any event, I would like to devote some space to reviewing these two lists. They are worth revisiting often. I’ve included some clarifying statements from each publication that I thought were helpful.
The ACR list (Arthritis Care Res. 2013;65:329-39)
• Do not test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease. Exceptions include anti-Jo1, which can be positive in some forms of myositis, or occasionally, anti-SSA in the setting of lupus or Sjögren syndrome.
• Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate examination findings. Diffuse arthralgias, myalgias, or fibromyalgia alone are not criteria for musculoskeletal Lyme disease.
• Do not perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.
• Do not prescribe biologic agents for RA before a trial of methotrexate (or another conventional nonbiologic DMARD)
• Do not routinely repeat DXA scans more often than once every 2 years. DXA scans should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected.
The CRA list (J. Rheumatol. 2015;42:682-9)
• Do not order ANA as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus or other connective tissue disease. At one center in Canada, ANA testing was positive only 15% of the time and cost more than $800,000 over 3 years when combined with ENA and anti-dsDNA. … An ANA test should be ordered only if the clinician feels there is reasonable clinical suspicion of SLE or CTD based on historical information, physical findings and results of other laboratory tests.
• Do not order an HLA-B27 unless spondyloarthritis is suspected based on specific signs or symptoms. There is no clinical utility to ordering an HLA-B27 in the absence of positive imaging or the minimally required SpA signs or symptoms.
• Do not repeat DXA scans more often than every 2 years. If BMD are stable and/or individuals are at low risk of fracture, then less frequent monitoring up to an interval of 5-10 years can be considered.
• Do not prescribe bisphosphonates for patients at low risk of fracture.
• Do not perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in the adult population.
Dr. Chan practices rheumatology in Pawtucket, R.I.
